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Kinesiophobia, Knee Self-Efficacy, and Fear Avoidance Beliefs in People with ACL Injury: A Systematic Review and Meta-Analysis

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Abstract

Background

To improve the understanding of the psychological impacts of anterior cruciate ligament (ACL) injury, a systematic review synthesizing the evidence on knee self-efficacy, fear avoidance beliefs and kinesiophobia following ACL injury is needed.

Objective

The aim of this systematic review was to investigate knee self-efficacy, fear avoidance beliefs and kinesiophobia following ACL injury, and compare these outcomes following management with rehabilitation alone, early and delayed ACL reconstruction (ACLR).

Methods

Seven databases were searched from inception to April 14, 2022. Articles were included if they assessed Tampa Scale of Kinesiophobia (TSK), Knee Self-Efficacy Scale (KSES), or Fear Avoidance Beliefs Questionnaire (FABQ). Risk of bias (RoB) was assessed using domain-based RoB tools (ROBINS-1, RoB 2, RoBANS), and GRADE-assessed certainty of evidence. Random-effects meta-analyses pooled outcomes, stratified by time post-injury (pre-operative, 3–6 months, 7–12 months, > 1–2 years, > 2–5 years, > 5 years).

Results

Seventy-three studies (70% high RoB) were included (study outcomes: TSK: 55; KSES: 22; FABQ: 5). Meta-analysis demonstrated worse kinesiophobia and self-efficacy pre-operatively (pooled mean [95% CI], TSK-11: 23.8 [22.2–25.3]; KSES: 5.0 [4.4–5.5]) compared with 3–6 months following ACLR (TSK-11: 19.6 [18.7–20.6]; KSES: 19.6 [18.6–20.6]). Meta-analysis suggests similar kinesiophobia > 3–6 months following early ACLR (19.8 [4.9]) versus delayed ACLR (17.2 [5.0]). Only one study assessed outcomes comparing ACLR with rehabilitation only.

Conclusions

Knee self-efficacy and kinesiophobia improved from pre-ACLR to 3–6 months following ACLR, with similar outcomes after 6 months. Since the overall evidence was weak, there is a need for high-quality observational and intervention studies focusing on psychological outcomes following ACL injury.

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Authors and Affiliations

  1. Department of Orthopaedic Surgery, Wake Forest School of Medicine, Charlotte, NC, USA

    Garrett S. Bullock

  2. Centre for Sport, Exercise and Osteoarthritis Research-Versus Arthritis, University of Oxford, Oxford, UK

    Garrett S. Bullock

  3. Atrium Health, Charlotte, NC, USA

    Timothy C. Sell, Ryan Zarega, Victoria King, Hailey Wrona & Nilani Mills

  4. University of New South Wales, Sydney, NSW, Australia

    Nilani Mills

  5. Swinborne University of Technology, Melbourne, VIC, Australia

    Charlotte Ganderton

  6. Griffith Centre of Biomedical and Rehabilitation Engineering (GCORE), Menzies Health Institute Queensland, Griffith University, Gold Coast Campus, Gold Coast, Australia

    Steven Duhig

  7. Department of Physical Therapy, Western University of Health Sciences, Lebanon, OR, USA

    Anu Räisäsen

  8. Department of Kinesiology, University of Calgary, Calgary, AB, Canada

    Anu Räisäsen

  9. Medical Libraries, Duke School of Medicine, Durham, NC, USA

    Leila Ledbetter

  10. Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, UK

    Gary S. Collins

  11. Oxford University Hospitals NHS Foundation Trust, Oxford, UK

    Gary S. Collins

  12. Unit of Physiotherapy, Department of Health, Medicine, and Caring Medicine, Linkoping University, Linköping, Sweden

    Joanna Kvist

  13. Stockholm Sports Trauma Research Center, Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden

    Joanna Kvist

  14. Centre of Health, Exercise, and Sport Medicine, University of Melbourne, Melbourne, VIC, Australia

    Stephanie R. Filbay

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  1. Garrett S. Bullock
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Corresponding author

Correspondence to Garrett S. Bullock.

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Funding

GSC was supported by the NIHR Biomedical Research Centre, Oxford, and Cancer Research UK (programme grant: C49297/A27294). SRF is funded by a National Health and Medical Research Council (NHMRC) Investigator Grant (#1194428).

Conflicts of interests and competing interests

Garrett Scott Bullock, Tim Sell, Ryan Zerega, Charles Reiter, Victoria King, Hailey Wrona, Nilani Mills, Charlotte Ganderton, Steven Duhig, Anu Räisäsen, Leila Ledbetter, Gary S. Collins, Joanna Kvist and Stephanie R. Filbay declare that they have no conflicts of interest relevant to the content of this review.

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Authors’ contributions

GSB, TCS, JK, SRF conceived the study idea. GSB, TCS, GSC, LL, JK, SRF were involved in design and planning. GB, RZ, CR, VK, SD, HW, NM, CG, AR screened articles and assessed risk of bias. GB, RZ, CR, VK, HW, SD, NM, CG, AR performed data extraction. GSB, SRF wrote the first draft of the manuscript. GSB, TCS, RZ, CR, VK, HW, NM, CG, SD, AR, LL, GSC, JK, SRF critically revised the manuscript. GSB, TCS, RZ, CR, VK, HW, NM, CG, SD, AR, LL, GSC, JK, SRF approved the final version of the manuscript. All authors read and approved the final manuscript.

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Patient public involvement

Five authors are researchers and clinicians who treat anterior cruciate ligament (ACL) injury patients, and four authors are researchers who have sustained ACL injuries and have undergone ACL rehabilitation and surgery. A series of symposiums are planned at various sports medicine conferences to help further educate clinicians on this topic.

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Bullock, G.S., Sell, T.C., Zarega, R. et al. Kinesiophobia, Knee Self-Efficacy, and Fear Avoidance Beliefs in People with ACL Injury: A Systematic Review and Meta-Analysis. Sports Med 52, 3001–3019 (2022). https://doi.org/10.1007/s40279-022-01739-3

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