Kinesiophobia Is Associated with Peak Knee Abduction Angle during Jump Landing after ACL Reconstruction

Stepping into a safer movement: The relationship between foot progression angle and lower extremity biomechanics during a 45-degree run-cut maneuver

BACKGROUND

Anterior cruciate ligament injury rates are high and often associated with change-of-direction movements. Analysis of youth movement patterns is critical for avoiding injury and foot progression angle affects lower extremity kinematics during cutting movements. Knee abduction and hip adduction are known predictors of anterior cruciate ligament injury. The relationship between foot progression angle and lower extremity biomechanics lacks exploration in youth athletes following anterior cruciate ligament reconstruction. This study aimed to assess the relationship between foot progression angle at max knee flexion, and mechanics predictive of anterior cruciate ligament injury during a change-of-direction task in youth athletes following anterior cruciate ligament reconstruction.

METHODS

Thirty-four participants (12 m, 15.0 ± 2.5 years) who previously underwent anterior cruciate ligament reconstruction participated in the study. Participants performed a 45-degree run cut task on both affected and unaffected limbs. Trunk and lower extremity biomechanics were collected using 3D motion capture and force plates.

FINDINGS

Moderate correlations were observed on the affected limb for trunk, pelvis, hip, knee, and ankle angles, as well as ankle moments (r = -0.34-0.52). On the unaffected limb, moderate correlations were seen in pelvis, hip, and ankle angles (r = 0.41-0.44). Significant differences exist between limbs for pelvis, hip and knee angles, as well as knee moments (p ≤ 0.038).

INTERPRETATION

Youth athletes appear to exhibit cutting movement patterns following anterior cruciate ligament reconstruction that may increase their risk of anterior cruciate ligament reinjury. Foot progression angle is a potential component of cutting tasks that clinicians and coaches can use to reduce an athlete's injury risk.

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.

Relationships between Patient-Reported Outcomes and Predictors of Second ACL Injuries during Unanticipated Jump Landings

BACKGROUND

Reactive and external visual-cognitive demands are prevalent in sport and likely contribute to anterior cruciate ligament (ACL) injury scenarios. However, these demands are absent in common return-to-sport assessments. This disconnect leaves a blind spot for determining when an athlete can return to sport with mitigated re-injury risk.

PURPOSE

To characterize relationships between patient-reported outcome measures (PROMs) and cognitive-task interference (i.e., cognitive demands exacerbating neuromuscular impairments) for biomechanical predictors of second ACL injuries during jump landings that involved rapid unanticipated decision making.

METHODS

Thirty-six persons following primary ACL reconstruction (ACLR; 26 females/10 males, 19.8 ± 1.8 yr; 1.71 ± 0.1 m; 69.6 ± 12.8 kg, 1.5 ± 0.6 yr post-ACLR; Tegner: 6.8 ± 1.8) participated. PROMs of ACL-RSI and the Forgotten Joint Score-12 Knee (FJS-12) were selected to assess altered psychological state (e.g., confidence, attention toward knee). Jumping tasks under anticipated and unanticipated secondary jump directions were performed. Biomechanical variables were dual-task changes (unanticipated - anticipated) in 1) uninvolved limb hip rotator impulse (DTC_Uni-HRot_Imp), 2) asymmetry of knee extensor moment at initial contact (DTC_KEM_Asym), and 3) range of involved knee abduction angle (DTC_KAbA_Range). Regression models tested for relationships between PROMs and the dual-task change in biomechanical variables.

RESULTS

ACL-RSI (DTC_Uni-HRot_Imp ( P < 0.001)) and FJS-12 (DTC_KAbA_Range ( P = 0.001)) had significant relationships with dual-task change in the opposite direction as expected (worse PROM ➔ less dual-task change). A follow-up analysis indicated that dual-task change was inversely correlated with the baseline estimates for kinetic biomechanical variables (less risky single-task biomechanics ➔ greater dual-task change for Uni-HRot_Imp and KEM_Asym).

CONCLUSIONS

The collective results are consistent with higher functioning participants (better PROMs) who also demonstrate desirable biomechanics during single-task conditions being prone to demonstrating the greatest risk-associated DTC in unanticipated scenarios.

Kinesiophobia is associated with lower extremity landing biomechanics in individuals with ACL reconstruction

OBJECTIVES

To evaluate relationships between patient-reported outcomes and lower extremity biomechanics associated with risk for second ACL injury among individuals with ACL reconstruction (ACLR).

DESIGN

Cross-sectional study.

SETTING

Research laboratory.

PARTICIPANTS

20 individuals with primary, unilateral ACLR (10 female, age = 20.1 ± 2.0 years, median time from surgery = 29.6 [IQR = 9.1-53.3] months).

MAIN OUTCOME MEASURES

Participants completed the International Knee Documentation Committee Subjective Knee Evaluation, Tampa Scale of Kinesiophobia (TSK-11), and Veterans RAND 12-Item Health Survey. Three-dimensional biomechanics were evaluated at peak vertical ground reaction force (vGRF) and as peak kinematic and kinetics within the first 100 ms of landing from a drop vertical jump.

RESULTS

Higher TSK-11 scores associated with lesser hip flexion angles (r = -.723, P < .001), lesser knee flexion angles (r = .561, P = .010), and greater internal knee abduction moments (ρ = -.606, P = .005) at peak vGRF. These relationships remained significant when correcting for multiple tests and controlling for time from surgery and biological sex.

CONCLUSIONS

Kinesiophobia, but not self-reported knee function or health-related quality of life, is associated with aberrant landing biomechanics when the largest magnitudes of vertical force were applied to the knee. Individuals with greater kinesiophobia may adopt a stiffer landing profile with increased medial knee compartment loading, potentially increasing risk for second ACL injury.

Patients With a Quadriceps Tendon Autograft Demonstrate Greater Asymmetry in Landing Kinetics Than Patients With a Bone-Patellar Tendon-Bone Autograft 6 Months After Anterior Cruciate Ligament Reconstruction

BACKGROUND

Asymmetric landing kinetics 6 months after anterior cruciate ligament reconstruction (ACLR) are associated with higher risk of second anterior cruciate ligament injury. Little is known about landing kinetics after ACLR with an all-soft tissue quadriceps tendon (QT) autograft despite its increasingly common use in young, active patients.

PURPOSE/HYPOTHESIS

The purpose of this study was to compare landing kinetics during a bilateral drop vertical jump (DVJ) 6 months after ACLR in participants who had undergone primary ACLR with a QT or bone-patellar tendon-bone (BTB) autograft. The hypothesis was that patients with a QT autograft will experience more asymmetry during a bilateral DVJ than patients with a BTB autograft 6 months after ACLR. In addition, greater impact force asymmetry will be associated with worse patient-reported outcome measures.

STUDY DESIGN

Controlled laboratory study.

METHODS

Participants who underwent primary unilateral ACLR with a QT or BTB autograft between May 2022 and December 2023 were prospectively recruited to undergo DVJ assessment and patient-reported outcome measures 6 months after ACLR. DVJ assessment was completed using force-sensing insoles. Peak impact force, average loading rate, and impulse data were collected at 100 Hz.

RESULTS

Forty-four participants (22 BTB, 22 QT) completed DVJ assessment and International Knee Documentation Committee (IKDC) and Anterior Cruciate Ligament-Return to Sport After Injury (ACL-RSI) surveys at 6 ± 1 months after ACLR. Graft source groups did not differ by age (P = .884), sex (P = .531), mass (P = .872), height (P = .572), months since surgery (P = .683), or lateral (P = .637) or medial (P = .416) meniscal tear treatment rate. On average, participants with a QT autograft demonstrated 26.2% greater contralateral limb peak impact force (P = .004), 18.4% lower peak impact force limb symmetry index (P = .009), 18.5% lower involved limb impulse (P < .001), and 15.1% lower impulse limb symmetry index (P < .001) when compared with participants with a BTB autograft. Graft source groups did not differ in IKDC score (P = .333) or ACL-RSI score (P = .070). Neither IKDC nor ACL-RSI score was strongly associated with any kinetic variables.

CONCLUSION/CLINICAL RELEVANCE

Participants with a QT autograft exhibit greater asymmetry in landing kinetics when compared with participants with a BTB autograft 6 months after ACLR, and landing kinetics were not associated with IKDC or ACL-RSI score.

Investigating the Impact of Preoperative Kinesiophobia and Pain on Postoperative Gait Biomechanics Following Anterior Cruciate Ligament Injury

Background

Aberrant gait biomechanics-ie, lower knee abduction moment (KAM) impulse- are linked to the development of posttraumatic osteoarthritis after anterior cruciate ligament (ACL) injury and ACL reconstruction (ACLR). There is a clinical need to identify modifiable factors, such as kinesiophobia and pain, that may contribute to aberrant gait development after ACLR to advance multimodal rehabilitation strategies.

Purpose/Hypothesis

This study aimed to determine associations between preoperative kinesiophobia and pain and gait biomechanics linked to posttraumatic osteoarthritis development at 2 and 4 months after ACLR. We hypothesized that worse preoperative kinesiophobia and pain would be associated with lower KAM impulses in the ACLR limb but not the uninjured limb at 2 and 4 months after ACLR.

Study Design

Cohort study; Level of evidence, 2.

Methods

Patients within 6 weeks of ACL injury and planning to undergo ACLR with bone-patellar tendon-bone autografts were recruited for the study. Preoperatively, participants completed the Tampa Scale of Kinesiophobia (TSK-11) and Knee injury and Osteoarthritis Outcome Score Pain (KOOS Pain) subscale surveys to assess kinesiophobia (ie, psychological component to pain) and knee pain, respectively. Participants returned at 2 and 4 months after ACLR to complete a 3-dimensional gait biomechanics analysis. KAM impulses during the stance phase were calculated (N*m*s/N*m) for both limbs. Associations of preoperative TSK-11 and KOOS Pain scores with KAM impulses in ACLR and uninjured limbs were analyzed using separate linear regressions.

Results

A total of 36 participants (58% women; mean age, 21.4 ± 4.31 years; body mass index, 24.1 ± 3.59 kg/m2 ) completed 3 study visits. Higher preoperative kinesiophobia was associated with lower KAM impulses in the ACLR limb (R 2 = 0.14; P = .02) but not the uninjured limb (R 2 = 0.01; P = .58) at 4 months after ACLR. Preoperative KOOS Pain scores were not associated with KAM impulses in the ACLR and uninjured limbs at 2 and 4 months after ACLR (ΔR 2 range, <0.01-0.02; P range = .53-.90).

Conclusion

Preoperative kinesiophobia, but not pain, was weakly associated with lower KAM impulses during early to midphases of clinical recovery at 4 months after ACLR.

The Influence of Kinesiophobia on Time to Clinical Recovery in Collegiate Athletes with Concussion

BACKGROUND

Several factors such as acute symptom severity, premorbid anxiety, and depression have been associated with concussion recovery. Elevated kinesiophobia has been associated with recovery from musculoskeletal conditions, as well as increased reaction time and vestibular-ocular motor dysfunction following concussion. However, kinesiophobia has yet to be evaluated as a modifier of concussion recovery time.

OBJECTIVES

This study was designed to evaluate the role of acute kinesiophobia levels on days until clinical recovery in collegiate athletes with concussion. We hypothesized that collegiate athletes with elevated Tampa Scale of Kinesiophobia (TSK) scores would take a greater number of days to achieve clinical recovery compared with athletes with lower values.

METHODS

Division I collegiate athletes diagnosed with a concussion (N = 113, 19.9 ± 1.5 years, 42% female) participated in this descriptive laboratory study. Participants were assigned to high [≥ 37 (H-TSK, n = 54)] or low [< 37 (L-TSK, n = 59)] TSK groups on the basis of the first TSK values recorded within 72 h of their concussion. Participants were also administered the Revised Head Injury Scale (HIS-r) to assess symptom severity within 72 h of injury. The Immediate Postconcussion and Cognitive Test (ImPACT) battery was administered at baseline and used to gather demographic variables such as biological sex, age, history of anxiety/depression, and concussion history, and as part of the athletes' symptom-free assessment. Days until clinical recovery between H-TSK and L-TSK groups were compared using a Mann-Whitney U test. Spearman's rank correlation coefficients were calculated to determine the relationship between TSK and days until clinical recovery in addition to other modifiers of recovery. Multiple linear regression was used to evaluate days until clinical recovery as a function of the TSK total score, controlling for the HIS-r and ImPACT variables.

RESULTS

Days until clinical recovery was significantly longer in the H-TSK group (median difference = 2.5 days, p < 0.001) compared with the L-TSK group. A significant, moderate positive correlation between the TSK score and days to clinical recovery (ρ = 0.45, p < 0.001) was observed, which was also the strongest correlation among all variables. Our regression model demonstrated that for every point increase on the TSK, days until clinical recovery increased by 0.23 while controlling for total symptom severity, age, concussion history, psychiatric history, and biological sex (β = 0.23, p = 0.018). All other variables entered into the regression were not statistically significant.

CONCLUSIONS

Our data suggest that athletes with TSK scores above 37 within 72 h of a concussion had a greater number of days until clinical recovery when compared with athletes with TSK values below 37. The TSK score had the highest correlation with days until clinical recovery when compared with other known modifiers of recovery, including total symptom severity. The TSK score was also the strongest predictor of days until clinical recovery. Collectively, these findings suggest that the TSK score should be considered by healthcare professionals to help inform effective management strategies for collegiate athletes with concussion.

Are the Cross-Culturally Adapted Versions of the Tampa Scale for Kinesiophobia 11-Item Valid, Reliable, and Responsive? A COSMIN-Informed Systematic Review of Measurement Properties

Numerous cultural adaptations of the Tampa Scale of Kinesiophobia 11-item version (TSK-11) scale have emerged since the original version was introduced. We conducted a (COnsensus-based Standards for the selection of health Measurement INstruments) COSMIN-informed systematic review of measurement properties to identify the cross-cultural adaptation of the TSK-11 and report, critically appraise, and systematize its measurement properties. Six databases were searched for studies published since 2005. Studies reporting on the measurement properties of culturally adapted versions of the TSK-11, published in English, Portuguese, and Spanish, were considered for inclusion. The results were synthesized by measurement properties and rated against the COSMIN criteria for good measurement properties. The quality of the evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation approach and presented in a summary of findings table. Twenty-three studies were included, and cultural adaptations for 15 languages were identified: English, Chinese, Cantonese, Swedish, German, Dutch, Arabic, Turkish, Danish, Spanish, Japanese, Brazilian Portuguese, Marathi, Thai, and Persian. There is "high" certainty in the evidence for "sufficient" criterion validity (TSK-17, r = .84) and "insufficient" measurement error (small detectable change range 5.6-6.16). "Moderate" certainty in the evidence for "sufficient" construct validity (87.8% of hypotheses confirmed), test-retest reliability (intraclass correlation coefficient2,1 = .747-.87), and "low" certainty in evidence for "sufficient" responsiveness. The numerous sources of heterogeneity prevent conclusions from being drawn regarding structural validity. Measurement error, responsiveness, and structural validity of the TSK-11 require further investigation. Clinicians should complement the use of TSK-11 with other instruments. Future studies on the structural validity of the questionnaire should standardize the data analysis methods. PERSPECTIVE: This article presents the measurement properties of the cross-cultural adaptations of the TSK-11. Clinicians should be aware that cultural and clinical aspects may influence the structural validity of the questionnaire. Using the TSK-11 as a stand-alone instrument may omit relevant clinical progression in the patient's condition.

Adolescent Athletes with Stronger Athletic Identity Perceptions Have Weaker Fear Avoidance Perceptions During Musculoskeletal Injury Rehabilitation Return to Sports Preparation

BACKGROUND

Adolescent athletes who sustain a musculoskeletal sports injury are at high re-injury risk. This prospective study evaluated athletic identity perception and fear avoidance perception relationships during the return to sport preparation phase of musculoskeletal injury rehabilitation.

METHODS

From 140 consecutive physical therapy outpatients, 50 (26 females, 24 males) adolescent athletes (mean age 16.8, range 14 to 22 y) completed the 7-item Athletic Identity Measurement Scale (AIMS), the 10-item Athletic Fear Avoidance Questionnaire (AFAQ), and the AFAQ with 2 additional movement-related fear and pain questions (AFAQ+). Correlational analysis was performed of overall AIMS and AIMS subscale scores (social identity, exclusivity, negative affectivity), with AFAQ and AFAQ+ scores ( P ≤0.05).

RESULTS

Adolescent athletes were receiving treatment for musculoskeletal injuries sustained during soccer (n=10), lacrosse (n=7), baseball (n=6), basketball (n=5), volleyball (n=5), track or cross country (n=4), American football (n=4), field hockey or ice hockey (n=3), softball (n=2), tennis (n=2), and gymnastics (n=2). Lower extremity conditions included anterior cruciate ligament reconstruction (n=23) or other lower extremity conditions (n=17). Upper extremity conditions included shoulder dislocation or labral repair (n=6), elbow sprain or fracture (n=3), and clavicle fracture (n=1). The AIMS score displayed moderate inverse relationships with AFAQ ( r =-0.40, P =0.008) and AFAQ+ ( r =-0.41, P <0.004) scores. The "social identity" AIMS subscale score displayed a moderate inverse relationship with AFAQ ( r =- 0.48, P <0.001) and AFAQ+ ( r =-0.46, P =0.001) scores. The "exclusivity" AIMS subscale score displayed moderate inverse relationships with AFAQ ( r =-0.40, P =0.005) and AFAQ+ ( r =-0.46, P =0.001) scores. The "negative affectivity" subscale did not display significant relationships with AFAQ or AFAQ+ scores. Subject age displayed moderate inverse relationships with the AIMS "social identity" ( r =-0.56, P <0.001) and "exclusivity" ( r =-0.42, P =0.004) subscale scores and weak direct relationships with AFAQ (r=0.30, P =0.04) and AFAQ+ (r=0.32, P =0.02) scores.

CONCLUSION

Adolescent athletes with stronger athletic identity perceptions during the return to the sports preparation phase of musculoskeletal injury rehabilitation had weaker fear avoidance perceptions. As age increased from early to late adolescence, athletic identity perceptions became weaker, and fear avoidance perceptions became stronger. To decrease re-injury rates, early identification and surveillance of injured adolescent athletes with stronger, more exclusive athletic identity perceptions and weaker fear avoidance perceptions may influence rehabilitation progression and return to play decisions.

LEVEL OF EVIDENCE

Level-II, prospective cohort, correlational study.

Trends and associations between kinesiophobia and knee function from preoperatively to three and six months postoperatively in patients post-ACL reconstruction surgery

OBJECTIVE

This study aimed to clarify the relationship between the transition of kinesiophobia and knee joint function from the preoperative period to three months postoperative, the time to resume running, six months post-ACLR, and the goal time to resume sports.

METHODS

54 patients who underwent initial ACLR were included in this study. The Tampa Scale for Kinesiophobia-11 (TSK-11) was used to assess kinesiophobia. One-way ANOVA was performed for the preoperative, three-month postoperative, and six-month postoperative endpoints. To examine changes in knee function associated with changes in TSK-11, we calculated correlations between the differences at each time point.

RESULTS

TSK-11 decreased significantly at both three and six months postoperatively compared with the preoperative level, but there was no significant change between three months and six months postoperatively. Similar to the decrease in TSK-11 from preoperatively to three and six months postoperatively, there was an improvement in flexion ROM, Pain, Subjective knee function, but none of these changed significantly from three to six months postoperatively.

CONCLUSION

There may be significant improvements in knee function associated with TSK-11 reduction up to three months postoperatively.