Knee Surgery, Sports Traumatology, Arthroscopy

, Volume 27, Issue 2, pp 397–404 | Cite as

Fear avoidance and self-efficacy at 4 weeks after ACL reconstruction are associated with early impairment resolution and readiness for advanced rehabilitation

  • Terese L. ChmielewskiEmail author
  • Steven Z. George



To examine the association of fear avoidance and self-efficacy psychological factors within 4 weeks after anterior cruciate ligament (ACL) reconstruction with knee impairment resolution and readiness for advanced rehabilitation at 12 weeks post-surgery.


Seventy-five patients participated. Data collection included demographics; questionnaires on fear avoidance (Pain Catastrophizing Scale, PCS; shortened Tampa Scale for Kinesiophobia, TSK-11) and self-efficacy (modified Self-Efficacy for Rehabilitation Outcome Scale, SER; Knee Activity Self-Efficacy, KASE) at 1, 4, and 12 weeks post-surgery; and knee impairment measures (pain intensity, range of motion, and quadriceps symmetry index) at 12 weeks post-surgery. Readiness for advanced rehabilitation (READY or NOT READY) was determined by knee impairment resolution criteria; demographics and questionnaire scores were compared between groups. Questionnaire scores at 1 and 4 weeks post-surgery and the change between time points were examined for association with knee impairment measures and group assignment.


READY included 32 patients; NOT READY included 43 patients. Questionnaire scores improved in both groups over time. Significant correlations across groups were: PCS scores at 1 and 4 weeks post-surgery with pain intensity at 12 weeks post-surgery (r = 0.24 and 0.29, respectively) and KASE score 4 weeks post-surgery with range of motion deficit at 12 weeks post-surgery (r = − 0.26). Contact injury was more prevalent in READY. After accounting for mechanism of injury, higher TSK-11 and fear of re-injury subscale scores at 4 weeks post-surgery increased the odds of NOT READY assignment at 12 weeks post-surgery (odds ratios 1.10 and 1.31, respectively).


Lower pain catastrophizing and higher knee activity self-efficacy levels 4 weeks after ACL reconstruction were associated with better knee impairment resolution at 12 weeks post-surgery, whereas lower kinesiophobia at 4 weeks post-surgery increased the odds of meeting advanced rehabilitation criteria at 12 weeks post-surgery. The clinical implication of these findings is that measuring pain catastrophizing, knee activity self-efficacy and kinesiophobia at 4 weeks post-surgery may improve prediction of patients at risk for delayed rehabilitation progression 12 weeks post-surgery.

Level of evidence



Anterior cruciate ligament Outcomes Confidence Pain catastrophizing Kinesiophobia Fear of re-injury 



The authors acknowledge Trevor Lentz and Giorgio Zeppieri Jr for their assistance with data collection and Ariel Botwin for his assistance with data preparation.



Compliance with ethical standards

Conflict of interest

The authors certify that they have no commercial association that might pose a conflict of interest in connection with this article.

Ethical approval

The study protocol was approved by the University of Florida Institutional Review Board (IRB Project #548-2006).


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Copyright information

© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2018

Authors and Affiliations

  1. 1.TRIA Orthopaedic CenterBloomingtonUSA
  2. 2.Duke Clinical Research Institute and Department of Orthopaedic SurgeryDuke UniversityDurhamUSA

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