Psychological Measures for Return to Play Following ACLR, Part 1

According to a 2012 study in the American Journal of Sports Medicine, 20% of athletes who return to play following ACLR re-injure within the first 2 years. Further, Wiggins et al Am J Sport Med 2016 showed that one in four youths who tear their ACL will suffer another ACL injury at some point throughout their athletic career. With odds like this, we have to do something to help improve the odds and, more importantly, protect our athletes as they prepare to return to play.

Traditionally and in a majority of athletic settings, return to play means just assessing the athlete’s strength and endurance and maybe performing some movement or functional assessments. But all too often we forget about the psychological factors associated with return to play. In the last couple of years, however, there has been a tremendous amount of work done in this area.

One of the most common aspects talked about when determining return to play is kinesiophobia or fear of movement. Many times, as the result of the athlete’s initial injury, there is a lack of confidence in the injured limb and therefore a fear of reinjuring upon return to play. There have been several studies in the last couple of years that show that athletes who have higher levels of kinesiophobia are in fact at greater risk of injury.

In a systematic review done by Everhart et al in Knee Surg Sports Traum Artho 2015, the authors showed a high correlation to kinesiophobia and re-injury rates in ACLR patients. In a recent study by Noehren et al Orth J Sport Med 2017 the authors looked at athletes who were returning to sport and for those who demonstrated kinesiophobia if there was any correlation to the way they moved and potential injury risk. What the authors found was that athletes who demonstrated higher levels of kinesiophobia demonstrated lower weight-bearing in the reconstructed limb.

Although assessed differently than in this study, this is a similar pattern we see, especially when assessing an athlete’s squatting motion. What is demonstrated is a significant lateral shift to the contralateral limb (uninvolved side) and away from the involved side. The authors of this study found similar results where the athlete was shifting their weight to the uninvolved side during vertical jumping and landing activities. The authors compared these results to a measure of kinesiophobia and found a strong correlation between the two. Meaning athletes that shifted weight away from the involved side scored high on the kinesiophobia scale.

With all the studies coming out showing similar correlations with risk and kinesiophobia, then how do we measure this in our athletes? Is this an overly complex measure and is this something that requires a psychologist to do? The answer to both those questions is no. Simply, we can implement at Tampa Kinesiophobia Form as a part of our evaluation process. For those that have not seen it, the Tampa Scale is below is scored on a 1-4 scale for each question. A total score is calculated after inverting the individual scores on 4, 8, 12, and 16.

Adding up all the scores and dividing by the total possible score (68) points. Higher the percentage the higher the individual’s kinesiophobia or fear of movement. Paterno et al Sport Health 2018 showed that athletes who have a score of 19 (27.9%) or greater at the time of RTPlay are 13 times more likely to suffer a second ACL injury. Based on the findings of Noehren et al, that makes sense. Based on those studies, one could hypothesize that the higher the percentage of kinesiophobia then the greater the displacement would be to the contralateral or non-involved limb.

Based on these results, it is high suggestive that this type of form be used in helping us make a return to play decision for our athlete.


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