Unfortunately, injuries cause more than pain and lost playing time for athletes. In many cases, an injury negatively impacts self-esteem and creates fear and anxiety. For competitive athletes, the injury often separates them from their familiar role and identity with respect to their teammates, coaches and peers.

It seems rather obvious that injured athletes would want to return to sport as soon as possible, right? Based on my clinical observations and experience, most athletes are motivated to return after their first injury. The more serious the injury (e.g. ACL tear, Achilles tendon rupture or UCL tear), the longer the road to get back. The speed and ease of the process is affected by the patient’s response to injury and surgery (coper vs. non-coper), degree of injury, skill of the surgeon, effectiveness of rehab, and patient compliance.

Much of the research done to date with fear of re-injury has centered on athletes undergoing ACL reconstruction. Over the last decade, methods for measuring kinesiophobia (fear of movement associated with sport/injury) such as the Tampa Scale of Kinesiophobia. I routinely use the TSK-11 with my athletes. In addition, the ACL-RSI is another tool for evaluating psychosocial readiness to return to sport. As sports medicine practitioners, we must pay attention to our clients’ fears and mental status.

Invariably, not all athletes want to return to sport. Factors that may hinder return to sport are:

  • Chronic pain
  • Fear of re-injury
  • Fear or anxiety about long term pain, injury or future disability (such as osteoarthritis)
  • Anxiety about not being able to return to their prior level of performance

A recent review (1) shows that 2 in every 3 patients after ACL reconstruction report psychological factors as the reason for not returning to sports, and 77% of them reported fear of reinjury as the most important psychological factor. Evidence also suggests 1 in every 3 athletes sustains a new ACL injury (to the same or contralateral knee) within 3.5 years from ACLR if they return to contact sports. (2) So, fear of re-injury is warranted in this patient population, and it is important to measure this during rehab and support the athlete with interventions aimed at diminishing this fear.

Open conversations about it with the athlete and their family are helpful in setting rehab timelines and expectations. It is also important to point out that this level of fear will likely be much higher after a second ACL injury. The athlete knows firsthand how long and arduous the recovery process is. In many cases, the athlete wants to go slower and shows more indifference toward going back to his/her sport.

At times, athletes may feel pressure from coaches and family to return to sport. This pressure may be in direct conflict with their apprehension about playing again. Parents may opt for fast surgical treatment assuming the most important thing to the child is getting back to sports. Allowing the athlete to weigh in and participate in the decision making process is critical for mental and physical success.

Athletes with low levels of fear of re-injury progress easier to more advanced phases of rehabilitation (3). As rehab advances, increased strength and function as well as more time from the injury build additional self-confidence. Throughout the rehab process, clinicians should measure kinesiophobia and physical outcomes through testing. In some cases, the physical gains outpace the mental recovery and vice-versa.

I have had patients pass all return to sport testing after ACL reconstruction (dynamometer strength, single leg hop testing, FMS, YBT, etc) while their ACL-RSI score falls well below 90%. In these cases, I have legitimate concerns about clearing the athlete for return to sport, as I worry he/she may hesitate or perform at a lower levels due to fear or anxiety. Graded exposure, slower, longer ramp-up protocols and allowing more time to pass after surgery may help in situations like this. I counsel patients that waiting is not a bad thing, and there is no guarantee they will not suffer a future injury.

In the end, there is no quick fix if fear of re-injury is hindering an athlete. Perhaps, changing sports or not returning may be the best outcome for the athlete in the short and/or long term. I want my patients to feel safe in the clinic and comfortable confiding in me, even if that means telling me they do not want to play their sport again. The end goal is to help the patient heal mentally, physically and emotionally. Therefore, listen and recognize signs of fear/anxiety, assess psychosocial factors, and be willing to engage with other medical professionals (e.g. sports psychologists) as needed to deliver the best care.


  1. Nwachukwu BU, Adjei J, Rauck RC, et al. How much do psychological factors affect lack of return to play after anterior cruciate ligament reconstruction? A systematic review. Orthop J Sports
    Med. 2019;7:2325967119845313.
  2. Faltstrom A, Kvist J, Gauffin H, Hagglund M. Female soccer players with anterior cruciate ligament reconstruction have a higher risk of new knee injuries and quit soccer to a higher degree than knee-healthy controls. Am J Sports Med. 2019;47:31–40.
  3. Chmielewski TL, George SZ. Fear avoidance and self-efficacy at 4 weeks after ACL reconstruction are associated with early impairment resolution and readiness for advanced rehabilitation. Knee Surg Sports Traumatol Arthrosc. 2019;27:397–404.