Document Type : Original Articles


1 Department of motor behavior and biomechanics, Faculty of Physical Education and Sports Sciences, University of Mazandaran, Mazandaran, Babolsar, Iran

2 2. Department of motor behavior and biomechanics, Faculty of Physical Education and Sports Sciences, University of Mazandaran, Mazandaran, Babolsar, Iran.

3 3. Department of Health and Corrective Exercise, School of Physical Education and Sport Sciences, Shahrood University of Technology, Shahrood, Semnan, Iran


Background: The effect of kinesiophobia (fear of movement) following an anterior cruciate ligament injury (ACL) has recently received great attention. However, the relationship between kinesiophobia and peak vertical ground reaction force (VGRF) in ACL reconstructed (ACLR) and deficient (ACLD) individuals has not been investigated.
Methods: Forty male patients (20 ACLR and 20 ACLD), 24 months post-ACL injury, who had completed post-injury/operative rehabilitation, participated in this cross-sectional study. Participants completed a drop vertical landing task on force plate while the VGRF was recorded. Participants also completed the TSK-11 (kinesiophobia) questionnaire.
Results: Associations between peak VGRF and the TSK scale were made with Pearson correlation coefficients; significant relationships were defined as p ≤0.05. The average peak VGRF was 2.67 ± 0.28 and 2.68 ± 0.17 (mean±SD) %bodyweight and the TSK value was 33.45 ± 4.6 and 31.60 ± 3.40 (mean±SD) for ACLD and ACLR groups, respectively. There was a significant negative association between poorer responses on the TSK scale and peak VGRF in the ACLD group (r=-0.58, p=0.007) but not in the ACLR group (r=-0.31, p=0.17).
Conclusion: This study found greater kinesiophobia to be associated with a lower peak VGRF in the ACLD group during the landing task. It seems that ACLD individuals unload their injured limb because of fear of movement. These results suggest that in ACLD individuals with high kinesiophobia, cognitive training should be incorporated into their rehabilitation program to improve landing mechanics. Future studies are needed to assess whether these relationships play a role in developing osteoarthritis over time


1. Rousseau R, Labruyere C, Kajetanek C, Deschamps O, Makridis KG, Djian P. Complications after anterior cruciate ligament reconstruction and their relation to the type of graft: a prospective study of 958 cases. Am J Sports Med. 2019;47(11):2543-9.
2. Bisciotti GN, Chamari K, Cena E, Bisciotti A, Corsini A, Volpi P. Anterior cruciate ligament injury risk factors in football. J Sports Med Phys Fitness. 2019;59(10):1724-38.
3. Shen L, Jin Z-G, Dong Q-R, Li L-B. Anatomical risk factors of anterior cruciate ligament Injury. Chin Med J. 2018;131(24):2960.
4. Hoogeslag RA, Brouwer RW, Boer BC, de Vries AJ, Huis in ‘t Veld R. Acute anterior cruciate ligament rupture: repair or reconstruction? Two-year results of a randomized controlled clinical trial. Am J Sports Med. 2019;47(3):567-77.
5. Grindem H, Wellsandt E, Failla M, Snyder-Mackler L, Risberg MA. Anterior Cruciate Ligament Injury—Who Succeeds Without Reconstructive Surgery? The Delaware-Oslo ACL Cohort Study. Orthop. J. Sports Med. 2018;6(5):2325967118774255.
6.Wilk KE, Arrigo CA. Rehabilitation principles of the anterior cruciate ligament reconstructed knee: twelve steps for successful progression and return to play. Clin Sports Med. 2017;36(1):189-232.
7. Kvist J, Ek A, Sporrstedt K, Good L. Fear of re-injury: a hindrance for returning to sports after anterior cruciate ligament reconstruction. Knee Surg. Sports Traumatol. Arthrosc. 2005;13(5):393-7.
8. Kvist J. Rehabilitation following anterior cruciate ligament injury. Sports Med. 2004;34(4):269-80.
9. Bjordal JM, Arnøy F, Hannestad B, Strand T. Epidemiology of anterior cruciate ligament injuries in soccer. Am J Sports Med. 1997;25(3):341-5.
10. Mikkelsen C, Werner S, Eriksson E. Closed kinetic chain alone compared to combined open and closed kinetic chain exercises for quadriceps strengthening after anterior cruciate ligament reconstruction with respect to return to sports: a prospective matched follow-up study. Knee Surg Sports Traumatol. 2000;8(6):337-42.
11. Tichonova A, Rimdeikienė I, Petruševičienė D, Lendraitienė E. The relationship between pain catastrophizing, kinesiophobia and subjective knee function during rehabilitation following anterior cruciate ligament reconstruction and meniscectomy: A pilot study. Medicina. 2016;52(4):229-37.
12.  Verbrugghe J, Agten A, Stevens S, Eijnde BO, Vandenabeele F, Roussel N, et al. Disability, kinesiophobia, perceived stress, and pain are not associated with trunk muscle strength or aerobic capacity in chronic nonspecific low back pain. Phys Ther Sport. 2020;43:77-83.
13.Kiapour A, Murray M. Basic science of anterior cruciate ligament injury and repair. Bone Joint J. 2014;3(2):20-31.
14.Chmielewski TL, Zeppieri Jr G, Lentz TA, Tillman SM, Moser MW, Indelicato PA, et al. Longitudinal changes in psychosocial factors and their association with knee pain and function after anterior cruciate ligament reconstruction. Phys Ther. 2011;91(9):1355-66.
15. Lentz TA, Tillman SM, Indelicato PA, Moser MW, George SZ, Chmielewski TL. Factors associated with function after anterior cruciate ligament reconstruction. Sports health. 2009;1(1):47-53.
16. Lentz TA, Zeppieri Jr G, George SZ, Tillman SM, Moser MW, Farmer KW, et al. Comparison of physical impairment, functional, and psychosocial measures based on fear of reinjury/lack of confidence and return-to-sport status after ACL reconstruction. Am J Sports Med. 2015;43(2):345-53.
17.Chmielewski TL, Jones D, Day T, Tillman SM, Lentz TA, George SZ. The association of pain and fear of movement/reinjury with function during anterior cruciate ligament reconstruction rehabilitation. J Orthop Sports Phys Ther. 2008;38(12):746-53.
18. Norte GE, Solaas H, Saliba SA, Goetschius J, Slater LV, Hart JM. The relationships between kinesiophobia and clinical outcomes after ACL reconstruction differ by self-reported physical activity engagement. Phys Ther Sport. 2019;40:1-9.
19.Paterno MV, Flynn K, Thomas S, Schmitt LC. Self-reported fear predicts functional performance and second ACL injury after ACL reconstruction and return to sport: a pilot study. Sports Health. 2018;10(3):228-33.
20.Trigsted SM, Cook DB, Pickett KA, Cadmus-Bertram L, Dunn WR, Bell DR. Greater fear of reinjury is related to stiffened jump-landing biomechanics and muscle activation in women after ACL reconstruction. Knee Surg. Sports Traumatol. Arthrosc. 2018;26(12):3682-9.
21. Theunissen W, van der Steen MC, Liu WY, Janssen R. Timing of anterior cruciate ligament reconstruction and preoperative pain are important predictors for postoperative kinesiophobia. Knee Surg. Sports Traumatol. Arthrosc. 2020;28(8):2502-10.
22. Lepley AS, Kuenze CM. Hip and knee kinematics and kinetics during landing tasks after anterior cruciate ligament reconstruction: a systematic review and meta-analysis. J Athl Train. 2018;53(2):144-59.
23. Rudolph KS, Axe MJ, Buchanan TS, Scholz JP, Snyder-Mackler L. Dynamic stability in the anterior cruciate ligament deficient knee. Knee Surg. Sports Traumatol. Arthrosc. 2001;9(2):62-71.
24. Gardinier ES, Manal K, Buchanan TS, Snyder‐Mackler L. Altered loading in the injured knee after ACL rupture. J Orthop Res. 2013;31(3):458-64.
25. Wellsandt E, Gardinier ES, Manal K, Axe MJ, Buchanan TS, Snyder-Mackler L. Decreased knee joint loading associated with early knee osteoarthritis after anterior cruciate ligament injury. Am J Sports Med. 2016;44(1):143-51.
26. Berchuck M, Andriacchi T, Bach B, Reider B. Gait adaptations by patients who have a deficient anterior cruciate ligament. J Bone Joint Surg. 1990:871-7.
27.Vairo GL, Myers JB, Sell TC, Fu FH, Harner CD, Lephart SM. Neuromuscular and biomechanical landing performance subsequent to ipsilateral semitendinosus and gracilis autograft anterior cruciate ligament reconstruction. Knee Surg. Sports Traumatol Arthrosc. 2008;16(1):2-14.
28. Faul F, Erdfelder E, Lang A-G, Buchner A. G* Power 3: A flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behavior research methods. 2007;39(2):175-91.
29. Piercy KL, Troiano RP, Ballard RM, Carlson SA, Fulton JE, Galuska DA, et al. The physical activity guidelines for Americans. JAMA. 2018;320(19):2020-8.
30. Elias AR, Hammill CD, Mizner RL. Changes in quadriceps and hamstring cocontraction following landing instruction in patients with anterior cruciate ligament reconstruction. JOrthop Sports Phys. Ther. 2015;45(4):273-80.
31. George SZ, Lentz TA, Zeppieri Jr G, Lee D, Chmielewski TL. Analysis of shortened versions of the Tampa Scale for Kinesiophobia and Pain Catastrophizing Scale for patients following anterior cruciate ligament reconstruction. Clin J Pain. 2012;28(1):73.
32. Woby SR, Roach NK, Urmston M, Watson PJ. Psychometric properties of the TSK-11: a shortened version of the Tampa Scale for Kinesiophobia. Pain. 2005;117(1-2):137-44.
33.Lachenbruch PA. Statistical power analysis for the behavioral sciences. JASA 1989;84(408):1096-7.
34.Leeuw M, Goossens ME, Linton SJ, Crombez G, Boersma K, Vlaeyen JW. The fear-avoidance model of musculoskeletal pain: current state of scientific evidence. J. Behav. Med. 2007;30(1):77-94.
35. Oberländer KD, Brüggemann G-P, Höher J, Karamanidis K. Reduced knee joint moment in ACL deficient patients at a cost of dynamic stability during landing. J Biomech. 2012;45(8):1387-92.
36. Petersen W, Taheri P, Forkel P, Zantop T. Return to play following ACL reconstruction: a systematic review about strength deficits. Arch Orthop Trauma Surg. 2014;134(10):1417-28.
37. Harilainen A, Alaranta H, Sandelin J, Vanhanen I. Good muscle performance does not compensate instability symptoms in chronic anterior cruciate ligament deficiency. Knee Surg. Sports Traumatol Arthrosc. 1995;3(3):135-7.
38.Luc-Harkey BA, Franz JR, Losina E, Pietrosimone B. Association between kinesiophobia and walking gait characteristics in physically active individuals with anterior cruciate ligament reconstruction. Gait Posture. 2018;64:220-5.
39.Hartigan EH, Lynch AD, Logerstedt DS, Chmielewski TL, Snyder-Mackler L. Kinesiophobia after anterior cruciate ligament rupture and reconstruction: noncopers versus potential copers. J Orthop Sports PhysTher. 2013;43(11):821-32.