Association between landing biomechanics, knee pain, and kinesiophobia in athletes following anterior cruciate ligament reconstruction: A cross-sectional study

The relationship between fear of movement and ankle biomechanical strategies in a 180° change of direction task

OBJECTIVE

To assess the association between fear of movement and ankle biomechanics and timed performance in a 505 agility change of direction (COD) test, and to assess the association between the biomechanical indices with timed performance.

METHODS

Twenty participants, who play football at a university level or higher, with a history of ankle injuries were recruited. All participants performed three maximal effort 505 agility COD tests. Three-dimensional ankle range of motion (ROM, measured using inertial measurement units) and the average ankle muscle co-activation (tibialis anterior, soleus, and peroneus longus muscles of the affected limb, measured using bipolar surface electromyography) were extracted from the stance phase of the final cutting step. Fear of movement was assessed using the Tampa Scale of Kinesiophobia 11-item (TSK-11) questionnaire.

RESULTS

TSK-11 significantly correlated with ankle transverse plane ROM: r = -0.53 (95 %CI -0.79 to -0.11), t = -2.63, P = 0.017. There was no significant association between the COD timed performance and the four ankle biomechanical indices.

CONCLUSIONS

Greater fear of movement may result in a stiffer turning strategy, which may reduce the risk of injury to the ankle. However, fear of movement is less likely to moderate ankle kinematic and muscle activation strategies that give rise to a performance-injury conflict.

Kinesiophobia Associates With Physical Performance in Patients With ACL Reconstruction: A Critically Appraised Topic

CLINICAL SCENARIO

Anterior cruciate ligament (ACL) injuries remain one of the most common and debilitating injuries that physically active individuals experience. Pain-related fear of movement and/or reinjury, or kinesiophobia, is the most frequently cited reason for not returning to sport after ACL reconstruction. Understanding how kinesiophobia may impact recovery of physical performance is essential to guide targeted rehabilitation.

CLINICAL QUESTION

Does kinesiophobia associate with physical performance in patients with a history of ACL reconstruction?

SUMMARY OF KEY FINDINGS

Five cross-sectional studies investigating bivariate relationships between kinesiophobia and metrics of physical performance among individuals with a history of primary, unilateral ACL reconstruction were included. From a strength perspective, greater kinesiophobia associated with lesser isometric knee flexion torque (n = 1, negligible association) but did not associate with isokinetic or isometric knee extension torque (n = 2). In terms of functional movement, greater kinesiophobia associated with asymmetric single-leg step-down performance (n = 1, high association) and shorter single-leg hop distance (n = 1, negligible association). Biomechanically, greater kinesiophobia associated with worse drop jump landing, characterized by greater frontal plane motion and lesser sagittal plane motion at the hip and knee joints (n = 1, low to high association).

CLINICAL BOTTOM LINE

Very low-quality evidence suggests a muscle-specific association between kinesiophobia and strength. Low- to moderate-quality evidence suggests that greater kinesiophobia associates with worse functional movement and landing biomechanics.

STRENGTH OF RECOMMENDATION

Considering the consistency and level of evidence among the included studies, we offer the following grades for each construct of physical performance evaluated: strength, D; functional movement, B; and biomechanics, B.

The impact of pain from medial meniscus injuries on walking movement patterns

Background

Existing literature provides inconclusive evidence regarding the impact of pain on movement patterns, especially in medial meniscus injuries. This study investigated how pain induced by medial meniscus injuries affects walking movement patterns, focusing on the biomechanical mechanisms. The goal was to develop targeted rehabilitation.

Methods

Thirty control participants (15 male, 15 female), 23 individuals with medial meniscus injury but no pain (11 male, 12 female), and 51 individuals with medial meniscus injury and pain (24 male, 27 female) were recruited. Gait data was collected using eight inertial measurement units and a video camera. Pain characteristics were assessed using the Visual Analog Scale (VAS) score, Tampa Scale for Kinesiophobia (TSK), Pain Catastrophizing Scale, and pain duration score. Statistical analyses were conducted using a one-way ANOVA to compare movement patterns among the three groups. Bivariate correlation analyses were performed within the pain group to examine the relationship between pain characteristics and movement patterns. The p was set at 0.05.

Results

(1) ANOVA among the groups revealed significant differences (p < 0.05) in several parameters: a shorter swing phase, reduced hip and knee angles, increased variability index, increased calf-foot mean absolute relative phase (MARP) during the support phase, and decreased calf-foot MARP during the swing phase were associated with pain. (2) Within the pain group, pain in knee extension (PKE) was negatively correlated with hip and ankle angles, stride length, and thigh-calf MARP during the support phase (p < 0.05). The VAS exhibited a negative correlation with knee angle and stride length, and a positive correlation with shock attenuation (p < 0.05). The TSK showed a positive correlation with hip and knee angles, and calf-foot MARP during the swing phase, while it was negatively correlated with stride length (p < 0.05).

Conclusion

Medial meniscus injury-induced pain has several adverse effects, including prolonged walking swing periods, reduced angulation, and increased variability while positively influencing coordination and shock attenuation. Pain intensity, kinesiophobia, and pain freedom contribute to these changes. Therapists should focus on pain management and movement pattern retraining to develop personalized rehabilitation. The angle of the swing phase should be emphasized during retraining.

Clinical Trial Registration

https://www.chictr.org.cn/showproj.html?proj=65961, identifier ChiCTR2000041087.

Interventions to Modify Psychological Processes in Patients Undergoing Spine Surgery: A Systematic Review

OBJECTIVES

Among patients undergoing elective spine surgery, psychological processes such as kinesiophobia and pain catastrophizing are associated with postoperative disability and poor quality of life. These represent risk factors which could be modified to improve surgical outcomes. We reviewed perioperative interventions to modify psychological processes and their effects on psychological and surgery-related outcomes.

METHODS

We searched MEDLINE, EMBASE, and Cochrane databases for studies examining any interventions for modifying psychological processes in adult patients undergoing spine surgery. Two reviewers screened studies for eligibility, extracted data in duplicate, and performed risk of bias assessments. Outcomes included pain, disability, quality of life, kinesiophobia, self-efficacy, and pain catastrophizing.

RESULTS

368 titles and abstracts were retrieved, of which 27 studies underwent full-text screening. We included 12 studies which reported on 1263 patients. Eight were randomized controlled trials. Interventions included preoperative and postoperative cognitive behavioural therapy, cognitive-behavioural-based physical therapy, a web-based interactive platform, an information booklet, and music therapy. The psychological and surgery-related outcomes of interventions were variable, with some studies reporting significant benefits and others reporting no differences between groups. The greatest potential benefits were found in studies of post-operative cognitive-behavioural-based physical therapy. Risk of bias among studies was high due primarily to lack of blinding and limited standardization of interventions.

CONCLUSIONS

Several interventions to potentially modify psychological processes in patients undergoing spine surgery have been reported. Post-operative cognitive-behavioural-based physical therapy might be associated with improved outcomes, but confidence is limited by inconsistency, risk of bias, and limited long-term follow-up.

Pain-related fear induces aberrant drop jump landing biomechanics in healthy and anterior cruciate ligament reconstructed females

PURPOSE

Rupture of the anterior cruciate ligament (ACL) is a prevalent and debilitating injury typically arising from aberrant biomechanics during landing or deceleration tasks. Pain-related fear, a component of kinesiophobia, has been associated with poor functional outcomes and altered movement patterns in individuals with ACL reconstruction (ACLr), however, the influence of pain-related fear on landing mechanics remains unclear. The purpose of this investigation was to examine the effects of pain-related fear on landing movement patterns in a population of ACLr and healthy females.

METHODS

Thirty-two females (15 recreationally active with a history of ACLr and 17 recreationally active with no history of ACLr) took part. Participants performed five trials of a drop jump (DJ) task (Baseline), underwent a pain stimulus (PS) familiarization task utilizing an electrical stimulus to induce pain-related fear, and performed a subsequent round of DJs while under threat of PS (PS-threat). Lower extremity and trunk kinematics, ground reaction force (GRF) data and muscle activation were analyzed.

RESULTS

At baseline, ACLr participants scored higher (21 ± 5.5) on the TSK-11 compared to healthy participants (17 ± 3.4) (p = 0.007). For both groups, the PS intervention significantly increased pain-related fear (ACLr p < 0.001; Healthy p < 0.001). When comparing baseline to PS-threat trials, ACLr participants experienced a significant increase in peak GRF (p = 0.005), decreases in hip (p = 0.003) and knee (p = 0.005) flexion, decreased contact time (p = 0.006) and decreased muscle preactivation for all muscles tested (p < 0.05). Healthy participants experienced significant increases in peak GRF (p = 0.014) and decreased hip (p = 0.005) and trunk peak (p = 0.004) flexion.

CONCLUSIONS

Pain-related fear alters landing biomechanics in healthy and ACLr females. This may implicate pain-related fear as a contributor to movement alterations commonly associated with ACL injury risk.

LEVEL OF EVIDENCE

Level III.

Relationship Between Single-Leg Vertical Jump and Drop Jump Performance, and Return to Sports After Primary Anterior Cruciate Ligament Reconstruction Using Hamstring Graft

Background

After anterior cruciate ligament reconstruction (ACLR), asymmetry is likely to persist in single-leg (SL) vertical jump and drop jump performance than in SL hop distance. However, its relationship with the return to sport (RTS) remains unclear.

Hypothesis/Purpose

This study aimed to determine the association between vertical jump performance after primary ACLR using hamstring tendon autograft and RTS at a pre-injury competitive level.

Study design

Cross-sectional study.

Methods

Patients who underwent primary ACLR using hamstring tendon autograft were recruited for this study. Participants who returned to pre-injury competition after ACLR were recruited at least eight months postoperatively. Knee condition was assessed, including joint laxity, range of motion, muscle strength, and knee pain intensity during sports activities. Performance variables were also assessed, including SL hop distance, jump height in SL vertical jump, and reactive strength index (RSI; jump height/contact time) in SL drop jump. Participants were asked to subjectively report whether they had returned to the same level of competition as pre-injury and their perceived sport performance intensity. Those who answered "Yes" to the dichotomous question and had a postoperative subjective athletic performance of > 80% were categorized into the Yes-RTS group. The primary outcome was the ability to achieve RTS at the preinjury level.

Results

Sixty-five patients (female, 35; male, 30) at 13.0 (13.0) [median (interquartile)] months after ACLR participated in this study. Thirty-nine (60%) were assigned to the Yes-RTS group. Regarding knee conditions, the No-RTS group had a significantly higher knee pain intensity, as assessed using a numerical rating scale (p<0.001, effect size -0.45). In the performance tests, the No-RTS group exhibited a significantly lower limb symmetry index of RSI during the SL drop jump compared to the Yes-RTS group (p=0.002, effect size 0.81).

Conclusion

Patients unable to achieve RTS after primary ACLR using hamstring grafts are more likely to exhibit asymmetric performance during the SL drop jump test, suggesting the significance of assessing jump symmetry when evaluating post-ACLR rehabilitation success.

Level of Evidence

3c.

Concussion History Moderates Trunk Motion and Lower Extremity Biomechanical Relationships During Jump Landing and Cutting

Concussion history, trunk motion, and lower extremity biomechanics associate with musculoskeletal injury risk. We aimed to examine the interaction between concussion history and trunk motion as possible modifiable factors for injury risk biomechanics during jump landing and cutting. Division I female athletes (24 with, 20 without concussion history) performed jump landings and jump-to-cuts at 45° in the opposite direction of the landing limb. We used multiple linear regressions with interaction terms to examine ankle dorsiflexion angle, knee flexion and abduction angle, and external knee flexion and abduction moment. We observed a group by trunk flexion interaction for nondominant external knee flexion moment (P = .042) during jump landing. Concussion history associated with increased external knee flexion moment as trunk flexion increased. We observed a group by trunk flexion interaction for the dominant limb dorsiflexion angle (P = .044), and group by trunk lateral bending interactions for the dominant (P = .039) and nondominant limb (P = .016) external knee flexion moment during cutting. During cutting, concussion history associated with decreased dominant dorsiflexion angles as trunk flexion increased, and decreased dominant and nondominant external knee flexion moment as lateral bending toward the planted limb increased. Concussion history associated with atypical biomechanics as trunk flexion and lateral bending increased.

Kinesiophobia in Injured Athletes: A Systematic Review

Athletes have a high risk of injury. Kinesiophobia is a condition in which an individual experiences a fear of physical movement and activity after an injury occurs. Our purpose was to systematically review the literature about Kinesiophobia in athletes. A systematic review was conducted in February 2023 using PubMed, CINAHL, SPORTDiscus, Web of Science, Cochrane Library, and Medline. Studies were included if they were peer-reviewed, in English, within the last 20 years and included athletes who had been injured and tracked Kinesiophobia. Articles were checked for quality via the modified Downs and Black checklist. Fourteen studies were included in the review and had an average "fair" quality score. Authors examined Kinesiophobia in injured athletes with mostly lower-extremity injuries. Kinesiophobia was associated with lower physical and mental outcomes. Kinesiophobia exists in athletes and can affect both physical and mental factors. The Tampa Scale of Kinesiophobia (TSK) was the most common tool used to examine Kinesiophobia. Common mental factors associated with Kinesiophobia include anxiety, low confidence, and fear avoidance.

Effect of meditation music and comedy movie interventions on postoperative kinesiophobia and pain in patients undergoing total knee arthroplasty

BACKGROUND

This study aimed to investigate the effects of music and comedy movie interventions on postoperative pain and kinesiophobia in patients who underwent total knee arthroplasty.

METHODS

This randomized-controlled study was carried out with the participation of patients who underwent total knee arthroplasty. The patients were divided into three groups. To reduce surgical pain and kinesiophobia, the patients in group 1 watched a comedy movie, those in group 2 listened to music, and those in group 3 did not participate in any intervention other than the routine practices of the clinic.

RESULTS

The personal and medical characteristics of the patients in all groups were similar. The patients in all three groups were kinesiophobic, and their surgical pain levels were moderate despite pharmaceutical interventions. Groups 1 and 2 had a statistically significant decrease in kinesiophobia and pain scores after the interventions. The effects of having patients watch a comedy movie and having them listen to meditation music were not significantly different.

CONCLUSIONS

The results of the study showed that listening to meditation music or watching comedy movie scenes had significant positive effects in alleviating postoperative pain and kinesiophobia after TKA. Based on the results of this study, it is recommended that patients watch comedy movies and listen to meditation music to alleviate their postoperative pain and kinesiophobia.

TRIAL REGISTRATION

NCT, NCT05471778. The study was registered at ClinicalTrials.gov.

Fear of reinjury following primary anterior cruciate ligament reconstruction: a systematic review

PURPOSE

This review aims to elucidate the most commonly reported method to quantify fear of reinjury or kinesiophobia and to identify key variables that influence the degree of kinesiophobia following primary anterior cruciate ligament reconstruction (ACLR).

METHODS

A systematic search across three databases (Pubmed, Ovid (MEDLINE), and EMBASE) was conducted from database inception to August 7th, 2022. The authors adhered to the PRISMA guidelines and the Cochrane Handbook for Systematic Reviews of Interventions. Quality assessment of the included studies was conducted according to the Methodological Index for Non-Randomized Studies (MINORS) criteria.

RESULTS

Twenty-six studies satisfied the inclusion criteria and resulted in 2,213 total patients with a mean age of 27.6 years and a mean follow-up time of 36.7 months post-surgery. The mean MINORS score of the included studies was 11 out of 16 for non-comparative studies and 18 out of 24 for comparative studies. Eighty-eight percent of included studies used variations of the Tampa Scale of Kinesiophobia (TSK) to quantify kinesiophobia and 27.0% used Anterior Cruciate Ligament Return to Sport After Injury (ACL-RSI). The results of this study shows a common association between higher kinesiophobia and poor patient-reported functional status measured using International Knee Documentation Committee (IKDC) Scores, Activity of Daily Living (ADL), Quality of Life (QOL), and Sports/Recreation (S/R) subscales of Knee Osteoarthritis and Outcome Score (KOOS) and Lysholm scores. Postoperative symptoms and pain catastrophizing measured using the KOOS pain and symptom subscales and Pain Catastrophizing Score (PCS) also influenced the degree of kinesiophobia following ACLR. Patients with an increased injury to surgery time and being closer to the date of surgery postoperatively demonstrated higher levels of kinesiophobia. Less common variables included being a female patient, low preoperative and postoperative activity status and low self-efficacy.

CONCLUSION

The most common methods used to report kinesiophobia following primary ACLR were variations of the TSK scale followed by ACL-RSI. The most commonly reported factors influencing higher kinesiophobia in this patient population include lower patient-reported functional status, more severe postoperative symptoms such as pain, increased injury to surgery time, and being closer to the date of surgery postoperatively. Kinesiophobia following primary ACLR is a critical element affecting post-surgical outcomes, and screening should be implemented postoperatively to potentially treat in rehabilitation and recovery.

LEVEL OF EVIDENCE

IV.

Semitendinosus muscle morphology in relation to surface electrode placement in anterior cruciate ligament reconstructed and contralateral legs

The semitendinosus tendon is commonly harvested as graft tissue for anterior cruciate ligament reconstruction (ACLR). Although the semitendinosus tendon can regenerate following harvesting, ACLR results in substantial reductions in semitendinosus muscle size and length, potentially complicating electrode placement for electromyography. The purpose of this study was to assess whether the most commonly used electrode placement [recommended by the "Surface Electromyography for Non-Invasive Assessment of Muscles" (SENIAM) project] is appropriate for measuring semitendinosus electromyograms after ACLR. In nine participants (unilateral ACLR with a semitendinosus graft), B-mode ultrasonography was used to bilaterally determine (i) the semitendinosus muscle-tendon junction position and the state of tendon regeneration (latter for the ACLR leg only) and (ii) the anatomical cross-sectional area (ACSA) of the semitendinosus muscle at the SENIAM-recommended electrode placement site at rest and during isometric maximal voluntary contraction (MVC) at two knee joint angles. Depending on the contraction state and joint angle, the semitendinosus muscle had retracted past the recommended placement site in 33-78% of ACLR legs, but not in any contralateral legs. The ACSA of semitendinosus was smaller both at rest and MVC in the ACLR compared to contralateral leg. The ACSA for both legs decreased at MVC compared to rest and at deep compared to shallow knee flexion angles, likely due to sliding of the muscle under the skin. These results suggest SENIAM guidelines are likely unsuitable for recording surface electromyograms from the semitendinosus muscle after tendon harvesting for ACLR as the muscle of interest may not be within the electrode detection volume.