Clin Orthop Relat Res (2018) 476:754-763

DOI 10.1007/s11999.0000000000000085

Comprehensive Orthopaedic Care

What Is the Relationship of Fear Avoidance to Physical Function

and Pain Intensity in Injured Athletes?
Stefan F. Fischerauer MD, PhD, Mojtaba Talaei-Khoei MD, Rens Bexkens MD, David C. Ring MD, PhD,
Luke S. Oh MD, Ana-Maria Vranceanu PhD

Received: 27 February 2017 / revised: 15 June 2017 / Accepted: 20 November 2017 / Published online: 16 February 2018
Copyright © 2018 by the Association of Bone and Joint Surgeons

Abstract weekly engagement in sport activities, participation in

Background Fear avoidance can play a prominent role in competitive events as part of a team or club, self-
maladaptive responses to an injury. In injured athletes, such identification as an athlete, and a desire to return to sport
pain-related fear or fear avoidance behavior may have after recovery—from an orthopaedic sports medicine
a substantial influence on the recovery process. Specifically, center at a major urban university hospital. Of 130
it may explain why some are able to reach their preinjury approached patients, 102 (84% men; mean 6 SD age 25
abilities, whereas others are unable to return to sport. 6 8.5 years) met the inclusion criteria. Participants
Questions/purposes (1) Is fear avoidance in athletes as- completed a demographic questionnaire, the Athlete Fear
sociated with decreased physical function after injury? (2) Avoidance Questionnaire, which assesses injury-related fear
To what degree is fear avoidance associated with athletes’ and avoidance behavior specifically in an athletic population,
pain intensity? the Pain Catastrophizing Scale, the Hospital Anxiety and
Methods In a cross-sectional study, we recruited injured Depression Scale, and two Patient-Reported Outcomes
athletes—defined as patients with sports-related injury, Measurement Information System measures: Physical

Each author certifies that neither he or she, nor any member of his or her immediate family, have funding or commercial associations
(consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection
with the submitted article.
All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file
with the publication and can be viewed on request.
Clinical Orthopaedics and Related Research® neither advocates nor endorses the use of any treatment, drug, or device. Readers are
encouraged to always seek additional information, including FDA-approval status, of any drug or device prior to clinical use.
Each author certifies that his or her institution approved the human protocol for this investigation, that all investigations were
conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained.
This work was performed at Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.

S. F. Fischerauer, M. Talaei-Khoei, Orthopaedic Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical
School, Boston, MA, USA

S. F. Fischerauer, Department of Orthopaedics and Trauma, Medical University of Graz, Graz, Austria

R. Bexkens, L. S. Oh, Sports Medicine Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA

R. Bexkens, Department of Orthopaedic Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands

D. C. Ring, Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, TX, USA

A.-M. Vranceanu, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA

A.-M. Vranceanu (✉), Integrated Brain Health Clinical and Research Program, Massachusetts General Hospital One Bowdoin Square 7th
Floor Boston, MA 02114, USA email: avranceanu@mgh.harvard.edu

Copyright Ó 2018 by the Association of Bone and Joint Surgeons. Unauthorized reproduction of this article is prohibited.
 Volume 476, Number 4 Fear Avoidance in Injured Athletes 755

Function Computerized Adaptive Testing (CAT) and Pain some individuals who experience pain recover, whereas
Intensity CAT. others develop chronic pain and disability. The model
Results After controlling for age, injury region (upper ver- depicts fear avoidance as a critical factor in whether
sus lower extremity), catastrophic thinking, and emotional patients adjust to their injury and recover or engage in
distress, we found that an increase in athletes’ fear avoidance a pattern of avoidance behaviors that impede recovery [19,
was associated with a decrease in physical function (b = 32, 58]. The original fear avoidance questionnaire [59] has
-0.32; p = 0.002). The model explained 30% of the variation been developed and validated in the working population
in physical function with 7.3% explained uniquely by fear with lower back pain to detect fear avoidance beliefs and
avoidance. After controlling for initial appointment/ predict return to work. Its wording has been adapted in
followup, surgery for the current condition, multiple pain some studies for applications in other body regions and
conditions, history of prior sport-related injury/surgery, pain injured patients [40, 43, 56], but the questionnaire does not
medication prescription, catastrophic thinking, and emo- account for circumstances that are specific to athletes. For
tional distress, athletes’ fear avoidance was not associated instance, athletes may not only have concerns about pain
with pain (b = -0.14; p = 0.249). The model explained 40% of and time to return to sport, but also about the risk of rein-
the variation in pain intensity and pain catastrophizing (b = jury, expectations of peers and trainers, and losing their
0.30; p = 0.001) uniquely explained 7.1% of this variation. athletic identity if the injury jeopardizes their future career.
Conclusions In injured athletes, fear avoidance is in- The Athletes Fear Avoidance Questionnaire [20] was de-
dependently associated with decreased physical function, veloped to assess these specific fears associated with ath-
whereas pain catastrophizing is associated with high pain letes’ injuries and return to sports.
intensity. Both level of an athlete’s fear avoidance and cat- To our knowledge, no prior studies have investigated if
astrophic thinking about pain should be accounted for in athletes’ specific fear avoidance is associated with pain
clinical interventions aimed at helping athletes improve re- intensity and physical function during the recovery process
covery and return to sport. of injured athletes. The purpose of this study was to de-
Level of Evidence Level II, prognostic study. termine to what extent athletes’ fear avoidance is associ-
ated with physical function and pain intensity in athletes
presenting to an orthopaedic sports medicine clinic. In
conducting this study, we intend to extend prior research on
Introduction psychosocial factors in injured athletes [3, 5, 15, 16, 30-32,
37, 41, 42, 46, 47, 53].
Psychosocial factors play an important role in the recovery Therefore, we asked: (1) Is fear avoidance in athletes
process of injured athletes [42, 46, 48] and explain why associated with decreased physical function after injury?
some athletes are able to reach their preinjury level of (2) To what degree is fear avoidance associated with ath-
function, whereas others are unable to return to sport. letes’ pain intensity?
Among these factors, emotional distress (such as symp-
toms of depression and anxiety) [2, 26, 47, 61] and mal-
adaptive coping styles (like catastrophic thinking about
pain) [51] have been consistently depicted as pivotal in Patients and Methods
their association with decreased physical function and in-
creased pain in this population. These factors are also as- This was a descriptive, cross-sectional study, which took
sociated with prolonged recovery and higher risk of place in a sports medicine center within the Department of
reinjury [10, 53]. Although athletes typically are consid- Orthopedic Surgery at a major medical center in Boston,
ered to better endure pain during competition, when it MA, USA, between January and August 2016. A research
comes to injury, they tend to experience higher levels of assistant rounded in the sports clinic 2 days a week and
emotional distress and catastrophic thinking than the gen- approached prospective patients for participation. Enroll-
eral population as a result of perceived external (coaches, ment, inclusion and exclusion criteria, and questionnaire
peers, family, and media) or internal (athletic identity, fi- completion occurred in the examination room before the
nancial pressures, guilt) pressures [6, 9, 31, 48]. meeting with the physician. Participants completed ques-
In addition to emotional distress and coping, athletes’ tionnaires on an encrypted iPad® (Apple Inc, Cupertino,
fear avoidance—a set of pain-related fear or fear avoidance CA, USA) using Assessment Center [25]. Our institutional
behaviors in response to a sport injury—may be an im- review board had approved the study and its procedures
portant predictor of recovery [15, 30, 43, 53]. The Fear before enrollment commenced.
Avoidance Model, originally developed by Lethem et al. The study inclusion criteria were: (1) age 18 years or
[33] in 1983 and expanded by Vlaeyen et al. [57] in 1995, is older; (2) sports-related injury; (3) English fluency and
a cognitive-behavioral model developed to understand why literacy; (4) ability to provide informed consent; (5) being

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 756 Fischerauer et al. Clinical Orthopaedics and Related Research®

an athlete, which we defined as an individual with par- was your average pain?”; and “What is your level of pain
ticipation in sports activities on a regular basis before right now?” Each question has five response options
injury (minimum once per week), participation in com- ranging from “no pain” to “very severe.” The final score is
petitive team/group events or individual sport competi- represented as a T-score, which is weighted based on
tion as a member of a team/club (such as running, or a mean of 50 and a SD of 10 for all samples derived from
triathlons, cycling team), and self-identification as an the US general population. Therefore, a score of 60 indi-
athlete; and (6) desire to return to sport. Exclusion criteria cates a level of pain intensity that is 1 SD higher than the
per our institutional review board included (1) pregnant average of the US general population.
women; or (2) self-reported severe and untreated mental The Athlete Fear Avoidance Questionnaire (AFAQ)
health conditions such as bipolar disorder, schizophrenia, was used to measure sports injury-related fear avoidance in
or psychotic symptoms. athletes. The AFAQ consists of 10 items assessing an
Demographic information included age, gender, race, athlete’s perceptions regarding an injury (eg, “I will never
years of education, marital status, sports-related information be able to play as I did before my injury” or “I worry if I go
such as level of participation in sports, number of competitive back to play too soon I will make my injury worse”) [20].
sports events during the past year, current injury specifics Answer options range from 1 being “not at all” to 5 being
(traumatic versus nontraumatic, upper extremity injury [eg, “completely agree” with the total score ranging from 10 to
shoulder, elbow] versus lower extremity injury [eg, knee]), 50. Higher scores represent a greater degree of sport-
sports-related medical history (prior sports-related injuries, specific fear and avoidance. The scale has been validated
prior sports-related surgeries), surgery status (having had by correlation analysis with the Pain Catastrophizing Scale
prior surgery for the current injury), time since injury/ (PCS) [50] and the Fear-Avoidance Beliefs Questionnaire
surgery, and prescription of pain medication. (FABQ) [59] in a set of athletes and showed good psy-
We used the Tegner Activity Scale [52] to assess self- chometric properties in measuring athletes’ fear avoid-
reported preinjury level of activity. The scale provides ance [20].
a measure of working and sporting activity levels, ranging The PCS is a self-assessment scale to measure cata-
from 0 “sick leave/disability” to 10 “participation in na- strophic thinking about pain [50]. Participants have the
tional and international elite competitive sports.” option to choose on a range between 0 being “not at all” and
We used the Patient Reported Outcomes Measurement 4 being “all the time” on 13 items (eg, “I can’t seem to keep
Information System (PROMIS) Item Bank—Physical it out of my mind”; “I wonder whether something serious
Function Version 1.2 with Computer Adaptive Testing may happen”; “It’s terrible and I think it’s never going to
(CAT) to assess patients’ self-reported level of physical get any better”). The PCS has demonstrated good reliability
function. The PROMIS Item Banks have been developed and construct validity in the general as well as athletic
for a standardized assessment of health outcomes from the population [50]. Scores below 13 translate into low, from
patient’s perspective [22]. Response items are related to 13 to 30 into moderate, and above 30 into high clinically
participants’ perception of their ability to perform physical relevant levels of catastrophizing [50].
activities (eg, “Are you able to exercise for an hour?” or The Hospital Anxiety and Depression Scale (HADS)
“Does your health now limit you in doing vigorous activ- was used to measure the symptoms of depression and
ities such as running, lifting heavy objects, or participating anxiety [62]. The scale consists of 14 items with responses
in strenuous sports?”). Response options on abilities and being scored on a scale from 0 to 3 with higher scores
limitations range on a 5-point scale from 1 being "unable to indicating a higher level of symptom frequency [60]. The
do/cannot do" to 5 being “[able to do] without any questionnaire comprises the two subscales of anxiety (eg,
difficulty/not at all [limited].” Using CAT, item selection “I get a sort of frightened feeling like ‘butterflies’ in the
from the full item bank (121 items) followed a dynamic stomach”) and depression (eg, “I have lost interest in my
algorithm in response to the participant’s answers [12, 14, appearance”). The combined scale (emotional distress)
23]. PROMIS scores are rescaled as T-scores representing ranges from 0 to 42 with scores of 15 or higher indicating
a standardized mean of 50–equaling the US general a clinically significant mood disorder [17, 28, 62]. The
population–and a SD of 10 [12, 34]. Therefore, a person HADS has shown good psychometric properties [38].
who has a T-score of 40 has a physical function 1 SD below
the US general population mean. PROMIS Physical
Function CAT is a reliable and valid instrument with low Statistical Analysis
floor or ceiling effects [22, 27].
PROMIS Pain Intensity scale 3a (Version 1.0) was used We present patients’ characteristics by measures of central
to measure the perceived intensity of pain. It consists of tendencies (eg, proportion, mean, median) as appropriate.
three questions asking “In the past 7 days, how intense was Bivariate relations among continuous variables (eg,
your pain at its worst?”; “In the past 7 days, how intense AFAQ, HADS, PCS, and PROMIS scores) were tested

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 Volume 476, Number 4 Fear Avoidance in Injured Athletes 757

using Spearman’s rs and Pearson’s r, between continuous each individual variable. All analyses were performed us-
and dichotomous variables (eg, gender, surgery status, ing Stata/MP 13.0 (Stata Corp, College Station, TX, USA).
upper/lower injury region, narcotics) using independent t- Ross reported that fear avoidance explained 12% of the
test, and between continuous and categorical variables (eg, variance in physical function after anterior cruciate liga-
marital status, work status) using one-way independent ment reconstruction [43]. We a priori calculated that 93
analysis of variance. Small, medium, and large effect sizes patients are needed to gain 0.80 power in detecting a R2
were distinguished by Pearson r values of 6 0.10, 6 0.30, increase of 8% in adding a single factor (athlete fear
and 6 0.50, respectively [18]. Visualization tools were avoidance) to a hierarchical linear multiple regression
used to objectify the relationship among multiple variables model with a total of 10 predictors to explain physical
(Note: to ease the readability of Figure 1, HADS and PCS function on the basis of a two-tailed type I error probability
scores are displayed after transformation into clinically of 0.05.
relevant categories.). To estimate whether fear avoidance Of the 130 patients approached, one patient refused
has an association with physical function above and beyond participation and 129 (99%) consented to participate. Of
relevant demographic and clinical variables, we conducted these, 27 (21%) were not included as a result of one of the
a hierarchical linear regression. In step 1, we included rel- following reasons: (1) no sports-related injury; (2) not in-
evant demographic variables with a strong association to volved in competition; (3) no regular participation in
physical function in bivariate analysis, intensity in bivariate sports; or (4) not part of a team. One hundred two patients
analysis, in step 2 relevant modifiable psychologic varia- (78%) were fully enrolled in the study.
bles, and in step 3 fear avoidance. We conducted a similar The majority of enrolled patients (N = 102) were in their
analysis for pain intensity. We report significance using an early 20s (mean 6 SD age, 25 6 8.5 years), men (n = 86
a level of 0.05. We report the percent of variance explained [84%]), white (n = 99 [97%]), and single (n = 84 [82%]).
by the entire model, the percent of variance explained in Approximately two-thirds of the sample reported a history
each step as well as the percent of variance explained by of involvement in national elite (n = 15 [15%]) or lower

Fig. 1 The sum of graphs visualizes the relationships of athlete fear avoidance and psy-
chosocial variables with physical function (left column) and pain intensity (right column).

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 758 Fischerauer et al. Clinical Orthopaedics and Related Research®

division (n = 52 [51%]) competitive sports before the injury Table 1. Characteristics of the study population (N = 102)
with an overall median of 50 competitive games/events per Number (%) or
year. The majority of injuries was trauma-related (n = 64 Characteristics mean 6 SD
[63%]), involved the upper extremity (n = 83 [81%]), and Age (years)* 25 6 8.5
occurred approximately 4 months before enrollment. There Gender
was an equal split between those who have been treated
Women 16 (16)
with surgery (n = 51 [50%]) and those who were treated
Men 86 (84)
nonoperatively or did not receive treatment yet. Seventy-two
Race
percent (n = 73) of patients reported that this was not their
White 99 (97)
first sport-related injury, and 33% (n = 34) had already
Black 1 (1.0)
undergone a prior sport-related surgery in their career.
Twenty-two percent (n = 22) of patients reported additional Latino 1 (1.0)
painful comorbidities to their primary injury at the time of Asian 1 (1.0)
enrollment, and approximately 58% (n = 59) were pre- Education (years) 15 6 2.3
scribed a nonnarcotic, narcotic, or a combination of these Marital status
medications (Table 1). Single 84 (82)
Married/couple 18 (18)
Tegner score before injury 8.4 6 1.3
Descriptive Analyses Games per year* 60 6 48
Primary purpose for sports
In our sample of 102 athletes, the average level of physical Recreation 59 (58)
function (mean = 49) was slightly below the average score Employment/scholarship 43 (42)
of the general US population. Ten patients (10%) scored 1 Visit type
or more SDs below and eight (7.8%) 1 or more SDs above First 38 (37)
the general US population. The mean patient-reported pain
Followup 64 (63)
intensity was distinctively lower than in the general US
Injury region
population (mean = 47) with 19 (19%) patients scoring 1 or
Upper extremity 83 (81)
more SDs below and three (2.9%) above the general US
Lower extremity 19 (19)
population (Table 2).
Injury condition
AFAQ scores ranged from 12 to 46 with a mean of 26
Nontraumatic 38 (37)
(Table 2). Compared with a previously reported mean by
Dover and Amar [20], the AFAQ mean in our sample was Traumatic 64 (63)
higher than in an uninjured/injured mixed athlete pop- Months since injury/surgery* 12 6 23
ulation (mean difference = 1.8, p = 0.023). Sixty-eight Surgery
patients (67%) scored a low, 26 (25%) a moderate, and Yes 51 (50)
eight (7.8%) a high level of catastrophizing about pain. A No 51 (50)
clinically meaningful increased level of emotional distress Other pain conditions
(HADS $ 15) was measured in 17 of 102 patients (17%). Yes 22 (22)
No 80 (78)
Prior sport-related injury
Yes 73 (72)
Results No 29 (28)
Prior sport-related surgery
Fear Avoidance and Decreased Physical Function
Yes 34 (33)
After controlling for potential confounding variables like age,
No 68 (67)
injury region, catastrophic thinking, and emotional distress,
Pain medication
an increase in athletes’ fear avoidance was associated with
None 43 (42)
a decrease in physical function (b = -0.32; p = 0.002).
Narcotics 43 (42)
Older age was associated with lower physical function
Nonnarcotics 5 (5)
(rs = -0.20; p = 0.044), and patients with an injury of the
upper extremity reported higher physical function than Both 11 (11)
patients with a lower extremity injury (mean difference = *Skewed distribution.
6.5; p < 0.001). High fear avoidance was associated with median (interquartile range): age: 22 years (7.8); games per
lower physical function. As fear avoidance decreased, year: 50 (60); months since injury/surgery: 4.0 (10.6).

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 Volume 476, Number 4 Fear Avoidance in Injured Athletes 759

Table 2. Descriptive analysis of measurements

Variable* Mean (SD) Median Range
PROMIS Physical Function 49 (6.9) 50 32-70
Athlete Fear Avoidance Questionnaire 26 (8.0) 25 12-46
(AFAQ)
Pain Catastrophizing Scale (PCS) 11 (11) 8 0-49
Hospital Anxiety and Depression Scale 8.2 (6.3) 6 0-25
(HADS)
PROMIS Pain Intensity 47 (8.3) 48 31-64
*PROMIS scores are rescaled to a mean of 50 and a SD of 10 of the general population.
AFAQ ranges from 10 to 50 with higher scores indicating greater fear avoidance.
PCS ranges from 0 to 52 with > 30 indicating severe catastrophizing.
HADS ranges from 0 to 42, with scores $ 15 indicating clinically significant mood disorder.
PROMIS = Patient Reported Outcomes Measurement Information System.

physical function increased; this association was strong (r = controlling for a potential confounder; however, fear
-0.39; p < 0.01; Table 3) and the effect size seemed to avoidance was not associated with pain intensity (b = -0.14;
further increase when clinically relevant emotional distress p = 0.249).
(HADS $ 15) was present (Fig. 1). Pain catastrophizing (rs Followup patients reported lower pain levels than first
= -0.26; p < 0.05) and emotional distress (rs = -0.33; p < visit patients (mean difference = -4.5; p = 0.002) and
0.05) were also associated with lower physical function. patients who have had surgery for their chief complaint
After accounting for all potential confounders, athletes’ reported lower pain levels (mean difference = -7.6; p <
fear avoidance and injury region remained the two varia- 0.001). Patients receiving narcotics or a combination of
bles associated with physical function (Table 4). With each narcotic and nonnarcotic pain medication reported lower
unit increase in AFAQ, PROMIS physical function scores pain levels than their nonmedicated counterparts (mean
dropped by 0.32 points (p = 0.002) and having an upper difference = -3.9; p = 0.019). Patients with additional pain
rather than a lower extremity injury was associated with conditions reported higher pain levels (mean difference =
a 6.2-point increase in PROMIS physical function (p < 3.4; p = 0.026), and patients with prior sport-related injury
0.001). The entire model accounted for 30% in the variation (mean difference = 6.0; p = 0.002) or prior sport-related
of physical function. Of these, athletes’ fear avoidance surgery (mean difference = 5.0; p = 0.001) also reported
uniquely explained 7.3% in physical function. higher pain levels. An increase in pain catastrophizing (rs =
0.44; p < 0.001), emotional distress (rs = 0.29; p = 0.004),
and athlete fear avoidance (r = 0.27; p = 0.006) was also
Fear Avoidance and Pain Intensity found to be associated with higher pain (Table 3). How-
ever, the association of athlete fear avoidance with pain
Only having had surgery for the current condition (b = -5.3; was weak (Fig. 1).
p = 0.010) and low pain catastrophizing (b = 0.30; p = After controlling for potential confounders such as ini-
0.001) were associated with lower pain intensity after tial appointment/followup, surgery for the current

Table 3. Bivariate correlation coefficients between measurement variables

PROMIS PROMIS
Physical Pain
Instrument Function AFAQ PCS HADS Intensity
PROMIS Physical Function 1
AFAQ -0.39* 1
PCS -0.26* 0.69* 1
HADS -0.33* 0.48* 0.54* 1
PROMIS Pain Intensity -0.06 0.27* 0.44* 0.29* 1
*p < 0.01.
PROMIS = Patient Reported Outcomes Measurement Information System; AFAQ = Athlete Fear Avoidance Questionnaire; PCS =
Depression and Anxiety Scale; HADS = Hospital Depression and Anxiety Scale.

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 760 Fischerauer et al. Clinical Orthopaedics and Related Research®

Table 4. Hierarchical regression analysis for variables predicting physical function

Step
Variable b (SE) b t p value partial R2 DR2 DF(df) p value
Step 1 (demographics) 0.15 8.8 (2,99) < 0.001
Age -0.10 (0.08) -0.12 -1.3 0.202 0.01
Upper extremity injury 6.4 (1.6) 0.36 3.9 < 0.001 0.13
Step 2 (catastrophizing, depression, and anxiety) 0.08 5.1 (2,97) 0.008
Age -0.07 (0.07) -0.08 -0.90 0.371 0.01
Upper extremity injury 7.0 (1.6) 0.40 4.4 < 0.001 0.16
PCS -0.05 (0.07) -0.09 -0.82 0.415 0.01
HADS -0.26 (0.12) -0.23 -2.2 0.030 0.04
Step 3 (fear and avoidance) 0.07 10 (1,96) 0.002
Age -0.06 (0.07) -0.08 -0.91 0.363 0.01
Upper extremity injury 6.2 (1.5) 0.35 4.0 < 0.001 0.12
PCS 0.08 (0.08) 0.12 1.0 0.306 0.01
HADS -0.18 (0.11) -0.16 -1.5 0.127 0.02
AFAQ -0.32 (0.10) -0.37 -3.2 0.002 0.07
Constant (full model) 55 (3.1) 17 < 0.001
PCS = Pain Catastrophizing Scale; HADS = Hospital Depression and Anxiety Scale; AFAQ = Athlete Fear Avoidance Questionnaire.

condition, multiple pain conditions, history of prior sport- cannot conclude whether athletes’ fear avoidance was the
related injury/surgery, pain medication prescription, cata- reason or the result of reduced physical function. Third,
strophic thinking, and emotional distress, we found that physical function, as assessed by patient-reported outcomes,
athletes’ fear avoidance was not associated with level of represents a patient’s perception of what they can or cannot do
pain (b = -0.14; p = 0.249) (Table 5). Prior surgery for the (eg, subjective rating) rather than actual impairment (eg, ob-
current condition (b = -5.3; p = 0.010) and pain cata- jective rating). This subjective report is influenced by level of
strophizing (b = 0.30; p = 0.001) were associated with impairment and psychosocial factors, in this case, athletes’
higher pain. The whole model explained 40% of the vari- fear avoidance. In this study, demographic and psychosocial
ation of pain intensity with surgery uniquely accounting for variables were associated with approximately 30% variance
4.5% pain catastrophizing for 7.1% of the total variance in in physical function, suggesting that other factors (psycho-
pain. logic, physical, etc) remain unexplained within the current
model. Fourth, although the AFAQ [20] and the PCS [51]
have been specifically validated for athletes, others have not.
However, good applicability of PROMIS and HADS in an
Discussion athletic patient population has already been reported [11, 35].
Fifth, because the definition of an athlete varies, we set a list of
In injured athletes, psychosocial factors, eg, emotional external (eg, regular participation in competition) as well as
distress, anxiety, catastrophic thinking, and fear, are fre- internal factors (self-identification as an athlete) as inclusion
quently associated with prolonged recovery and lower criteria. Because the AFAQ includes team-relevant questions
return to sport rates. The AFAQ was developed to identify (eg, “I am worried about my role with the team changing”),
athletes’ specific fearful cognition and avoidance behavior we excluded athletes who do not practice or compete in
as negative responses to an injury. We conducted this study a team. This, however, further limits the generalizability of
to assess whether athletes’ fear avoidance is associated our results to patients who fit this definition of an “athlete.”
with reduced physical function and higher pain during the Sixth, our sample size limited our ability to test whether fear
recovery process. avoidance, physical function, or pain varies with different
Results of this study need to be interpreted in light of injuries or surgery types. Larger studies and subgroup anal-
several limitations. First, data were collected in a single ysis would be required to address injury-specific inves-
urban academic hospital in the United States, which may tigations. Seventh, our study population was predominantly
limit generalizability. Second, the cross-sectional design of male and white with upper extremity injuries. This may have
the study precludes us from drawing absolute conclusions affected power to find a significant difference in lower ex-
about the causal directionality of our findings. Thus, we tremity injuries or in other populations. Future longitudinal

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 Volume 476, Number 4 Fear Avoidance in Injured Athletes 761

Table 5. Hierarchical regression analysis for variables predicting pain intensity

Step
Variable b (SE) b t p value partial R2 DR2 DF(df) p value
Step 1 (demographics) 0.29 6.4 (6,95) < 0.001
Followup 0.23 (2.1) 0.01 0.11 0.912 < 0.01
Surgery -6.4 (2.1) -0.39 -3.0 0.003 0.05
Other pain condition 0.90 (1.9) 0.05 0.48 0.630 < 0.01
Prior sport-related injury 2.7 (1.7) 0.15 1.6 0.119 0.01
Prior sport-related surgery 3.2 (1.7) 0.19 1.9 0.064 0.02
Narcotics -0.32 (1.9) -0.02 -0.17 0.867 < 0.01
Step 2 (catastrophizing, depression, and anxiety) 0.10 7.5 (2,93) 0.001
Followup 0.24 (2.0) 0.01 0.12 0.903 < 0.01
Surgery -5.3 (2.0) -0.32 -2.6 0.011 0.04
Other pain condition 0.55 (1.8) 0.03 0.31 0.757 < 0.01
Prior sport-related injury 1.9 (1.6) 0.10 1.2 0.254 0.01
Prior sport-related surgery 2.9 (1.6) 0.16 1.8 0.084 0.02
Narcotics 0.06 (1.8) < 0.01 0.04 0.971 < 0.01
PCS 0.25 (0.08) 0.32 3.1 0.002 0.06
HADS 0.04 (0.13) 0.03 0.34 0.732 < 0.01
Step 3 (fear and avoidance) 0.01 1.4 (1,92) 0.249
Followup -0.04 (2.0) < -0.01 -0.02 0.984 < 0.01
Surgery -5.3 (2.0) -0.32 -2.6 0.010 0.05
Other pain condition 0.26 (1.8) 0.01 0.15 0.884 < 0.01
Prior sport-related injury 2.0 (1.6) 0.11 1.2 0.237 0.01
Prior sport-related surgery 3.0 (1.6) 0.17 1.8 0.069 0.02
Narcotics 0.24 (1.8) 0.01 0.14 0.892 < 0.01
PCS 0.30 (0.09) 0.39 3.3 0.001 0.07
HADS 0.08 (0.13) 0.06 0.61 0.547 < 0.01
AFAQ -0.14 (0.12) -0.13 -1.2 0.249 0.01
Constant (full model) 47 (3.0) 16 < 0.001

PCS = Pain Catastrophizing Scale; HADS = Hospital Depression and Anxiety Scale; AFAQ = Athlete Fear Avoidance Questionnaire.

studies with larger samples are warranted to bypass these fear of reinjury predicts return to a previous level of sport
limitations. activities [53], whereas decreased fear of movement/
We found that demographic, clinical, and psychosocial reinjury contributes to improved knee function [16]. Our
factors explain a large proportion of variance in physical results are also in alignment with previous studies that
function. Our findings add to the current understanding by investigated the effect of fear-related thoughts on func-
showing that athlete-specific fear avoidance is the most tional outcomes with different questionnaires. In athletes
important factor, explaining 7.3% of the unique variation with anterior cruciate ligament (ACL) reconstruction,
in physical function. This reasonably large single-factor concerns about painful sensations resulting from physical
association occurred negatively proportional: the higher activity–assessed by the physical activity subscale of the
athletes scored in fear avoidance, the lower their physical FABQ, modified for the knee–contributed to explaining
function. This is of particular importance, because factors residual physical impairment [43]. Similarly, fear of
previously reported as associated with physical function movement/reinjury–measured by The Tampa Scale of
(older age [1, 21], higher emotional distress, and higher Kinesiophobia–was found to be a major contributor to not
catastrophic thinking about pain [37, 45, 49]) were returning to preinjury sport activity levels [30, 53]. In
outreached by athletes’ fear avoidance in our sample. The a retrospective interview, 53% of high school players and
central role of fear avoidance in reports of physical 50% of collegiate players who did not return to play after
function is consistent with prior research that assessed ACL reconstruction identified fear as the major contrib-
general fear avoidance or aspects of fear avoidance in uting factor to their decision [36]. A systematic review
athletes [16, 43, 53, 57]. Longitudinal studies showed that revealed that fear of reinjury was the most common reason

Copyright Ó 2018 by the Association of Bone and Joint Surgeons. Unauthorized reproduction of this article is prohibited.
 762 Fischerauer et al. Clinical Orthopaedics and Related Research®

cited for a postoperative reduction in sports participa- 5. Ardern CL, Taylor NF, Feller JA, Whitehead TS, Webster KE.
tion [4]. Psychological responses matter in returning to preinjury level of
sport after anterior cruciate ligament reconstruction surgery. Am J
Catastrophic thinking was independently associated with
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