Knee Surgery, Sports Traumatology, Arthroscopy

https://doi.org/10.1007/s00167-018-4950-2

KNEE

Greater fear of reinjury is related to stiffened jump-landing

biomechanics and muscle activation in women after ACL
reconstruction
Stephanie M. Trigsted1   · Dane B. Cook2 · Kristen A. Pickett2 · Lisa Cadmus‑Bertram2 · Warren R. Dunn3 ·
David R. Bell2

Received: 28 August 2017 / Accepted: 16 April 2018

© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2018

Abstract
Purpose  Fear of reinjury is an important factor in determining who returns to sport following anterior cruciate ligament
reconstruction (ACLR). Evidence from other musculoskeletal injuries indicates fear of reinjury may be related to stiffened
movement patterns observed in individuals following ACLR. The relationship between fear of reinjury and performance on
dynamic tasks, however, has not been investigated. Therefore, the purpose of this study was to investigate the relationship
between fear of reinjury and jump-landing biomechanics.
Methods  Thirty-six females (height = 168.7 ± 6.5 cm, body mass = 67.2 ± 10.0 kg, age = 18.9 ± 1.5 years) with a history of
ACLR (time from surgery = 26.1 ± 13.3 months) participated in the study. Each participant performed five trials of a standard
jump-landing task. 3D motion capture and surface electromyography was used to record peak kinematics and lower extremity
muscle activation on the injured limb during the jump landings. Spearman’s rank correlations established the relationship
between TSK-11 scores and each biomechanical variable of interest.
Results  There was a significant, negative relationship between fear of reinjury (TSK-11: 19.9 ± 4.5) and knee (p = 0.006),
hip (p = 0.003), and trunk flexion (p = 0.013). There was also a significant, positive relationship between hip adduction
(p = 0.007), and gluteus maximus preparatory activation (p = 0.001).
Conclusions  The results of this study indicate that higher fear of reinjury is associated with stiffened movement patterns that
are associated with increased risk of a second ACL injury. Similar movement patterns have been observed in patients with
low back pain. Clinicians should evaluate psychological and emotional consequences of injury in addition to the physical
consequences as they appear to be related.
Level of evidence III.

Keywords  TSK-11 · Fear avoidance · Jump landing · Kinesiophobia

* Stephanie M. Trigsted David R. Bell

strigste@highpoint.edu drbell2@wisc.edu
Dane B. Cook 1
High Point University, One University Parkway, High Point,
dcook@education.wisc.edu
NC 27268, USA
Kristen A. Pickett 2
University of Wisconsin Madison, 2000 Observatory Dr,
kpickett2@wisc.edu
Madison, WI 53706, USA
Lisa Cadmus‑Bertram 3
Sports Medicine Reedsburg, 1104 21st St Ste A, Reedsburg,
cadmusbertra@wisc.edu
WI 53959, USA
Warren R. Dunn
dunnwr@me.com

13
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Introduction
Anterior cruciate ligament (ACL) injuries are among the
most common sport-related orthopedic injuries that result
in surgical reconstruction and lengthy rehabilitation [12].
Fear of reinjury is the most commonly cited reason for
patients choosing not to return to sport [17], and the fear-
avoidance model may help to explain the patient’s deci-
sion not to return to sport. ACL injuries, reconstruction,
and early rehabilitation are commonly painful experi-
ences. Some patients may associate the pain with certain
movements or activities and begin to avoid them. Alter-
natively, they may employ compensatory techniques or
alter movement patterns in an attempt to avoid pain and
reinjury [33]. This theoretical model is supported in the
previous research in patients with other orthopedic inju-
ries. For example, high fear of reinjury was associated
with decreased sagittal plane motion and increased muscle
guarding in patients with low back pain [35]. While the
model is supported with the previous work, it has not yet
been explored in an ACLR population.
The Tampa Scale of Kinesiophobia-11 (TSK-11) has been
used in patients with ACL injuries to investigate fear of rein-
jury before, immediately after, and up to 20 years following
ACLR [2, 7, 8, 17, 19]. High fear of reinjury has been linked
to low rates of return to sport [2, 3, 7, 8, 11, 19, 31] and self-
reported activity [24], lower self-reported knee function [7,
8, 17], lower quadriceps strength [19, 24], worse hop per-
formance [24], and greater risk of reinjury [24]. In a recent
study, a group of patients after ACLR that did not return to
sport due to fear of reinjury or lack of confidence demon-
strated higher TSK-11 scores, lower quadriceps strength, and
reduced self-reported knee function than the group that had
returned to sport [19]. This study provided evidence that fear
of reinjury may be related to objective measures of function,
such as strength, in addition to subjective measures of knee
function. However, it remains unknown how fear of reinjury
might be related to movement patterns in individuals with
a history of ACLR.
Patients with ACLR exhibit a multitude of biomechani-
cal deficits during functional tasks, like landing from a
jump, cutting tasks, or jump stops when compared to
healthy individuals, including decreased hip and knee
flexion during landing [9, 32] and increased hip adduc-
tion and lateral trunk flexion [6, 26]. Finally, various stud-
ies have concluded that patients shift demands away from
their injured limb and towards their healthy limb during
functional tasks [4, 32]. Because these tasks replicate
common injury mechanisms, they can be useful in inves-
tigating relationships between fear and movement patterns.
Fear of reinjury is a powerful emotion that appears to
play a role in return to sport and activity after ACLR.
13
Knee Surgery, Sports Traumatology, Arthroscopy
Despite preliminary evidence from related studies in
low back pain literature, the relationship between fear
of reinjury and altered biomechanics during functional
tasks has not been fully explored in ACLR populations.
There is a substantial gap in the literature regarding the
potential relationship between fear of reinjury and hip,
knee, and trunk biomechanics and lower extremity mus-
cle activation. Therefore, the purpose of this study was to
investigate the relationship between fear of reinjury and
jump-landing biomechanics. Specifically, the relationship
between fear of reinjury and three-dimensional hip, knee,
and trunk motion and forces and muscle activation during
the preparatory, and landing phases of the jump landing
was explored. It was hypothesized that higher levels of
fear of reinjury would be associated with decreased sag-
ittal plane movements and greater frontal plane motion
on the reconstructed limb. A secondary analysis was per-
formed to investigate the relationship between fear of rein-
jury and lower extremity muscle activation on the injured
limb. It was hypothesized that greater fear of reinjury
would be associated with greater quadriceps activation
and decreased gluteus medius activation during the jump
landing. This study is clinically important, because it may
provide a link between fear of reinjury and movement pat-
terns commonly observed after ACLR. Ultimately, this
information could be used by clinicians to improve reha-
bilitation and identify areas, where interventions can be
implemented.
Materials and methods
This study used a cross-sectional design in which data were
collected during a single study visit to the laboratory. Each
participant provided informed written consent, completed
patient reported outcomes, and performed the jump-land-
ing task. A sample of 36 female participants with unilateral
ACLR was recruited from the university and surrounding
communities. To be eligible for the study, each participant
had to meet the following criteria: (1) a female who experi-
enced a primary unilateral ACLR; (2) self-report of being
cleared by physician or rehabilitation specialist to return to
sport; (3) less than 4 years from the time of surgery; (4)
18–27 years of age; (5) have no history of multiple ligament
reconstructions (MCL, PCL, and LCL); and (6) report no
lower extremity injuries in the past 3 months (hip, knee,
ankle, or foot). Participants were not restricted based on
surgeon, graft type, or surgical method to increase the gen-
eralizability of this study.
Knee Surgery, Sports Traumatology, Arthroscopy
Procedures
Patient reported outcomes
Participants were interviewed to collect demographic infor-
mation including height, mass, age, and information regard-
ing their injury and surgery. Participants completed a packet
of surveys that included the TSK-11, International Knee
Document Committee (IKDC) subjective form, and the Teg-
ner activity scale. The TSK-11 is an 11-item questionnaire
with a 4-point Likert scale. The total score is calculated by
summing responses from the 11 items, with possible scores
ranging from 11 to 44. Higher scores on the TSK-11 indicate
greater fear of movement and reinjury. The TSK-11 has good
internal consistency (Chronbachs α = 0.79) and test–retest
reliability (ICC 0.81, SEM = 2.54) [36]. The International
Knee Document Committee (IKDC) Subjective Knee Form,
was used to assess symptoms and knee function during tasks
in daily living and sport/activity [15] and Tegner activity
scale was used to determine current level of physical activity.
Jump landing
Participants performed five successful trials of a standard-
ized jump-landing task [23]. Each participant jumped from
a 30 cm box to embedded force plates which were located
half of the participant’s height from the box. Participants
jumped forward from the box to force plates and upon land-
ing immediately jumped for maximal height. Practice trials
were allowed until the participant could perform the task
comfortably. A trial was considered successful if the partici-
pant performed the task fluidly and landing with each foot
completely on the force plates.
Instrumentation
Nonconductive in-floor force plates (Bertec Corporation,
Columbus, OH) measured ground reaction forces (sam-
pling rate 2000 Hz) during the jump landing and were used
to define the phases of the task. Lower extremity kinemat-
ics were collected via an electromagnetic tracking system
(sampling rate 100  Hz) (Ascension Technologies, Inc.,
Burlington, VT), and all data were recorded by the Motion
Monitor software system (Innovative Sports Training, Inc.,
Chicago, IL, USA) and synchronized via electronic pulse.
The previous investigations into the accuracy of electromag-
netic sensor systems used to assess joint motion report high
reliability and positional and rotational errors of less than
2% [1, 21]. An embedded right-hand Cartesian coordinate
system defined for the shank, thigh, hip, and trunk was used
to describe the three-dimensional position and orientation
of these segments. Electromagnetic tracking sensors were
secured to each subject over the spinous process of C7, apex
of the sacrum, midpoint of the lateral thigh, and shank of
the tibia. Bony landmarks were digitized and included the
spinous process of T12, medial and lateral femoral condyles,
medial and lateral malleoli, left and right anterior superior
iliac spine. Digitization of bony landmarks was used to esti-
mate or identify the segment end-points and joint centers.
Joint centers of the ankle and knee were defined via centroid.
The hip joint center was determined by the Bell method [5].
A surface electromyographic (EMG) (Delsys Trigno
Wireless, Boston, MA, USA) system with four bar surface
EMG sensors was used to measure muscle activity ampli-
tude of lower extremity muscle activity of the reconstructed
limb throughout the jump landing. The sensors were placed
over the muscle belly for each separate muscle according
to expert recommendations [14]. The muscles recorded
include: vastus lateralis, (VL), rectus femoris (RF), gluteus
maximus (Gmax), gluteus medius (Gmed), biceps femoris
(biceps), semimembranosus (semi), lateral gastrocnemius
(latG) and medial gastrocnemius (medG). Data were col-
lected with a gain of 1000 and sampling rate of 2000 Hz. A
manual muscle test was performed to ensure placement over
the muscle belly prior to the jumping task.
Data filtering and reduction
Euler angles were used to calculate the knee joint angle
between the shank and thigh, the hip joint angle between
the thigh and pelvis, and the trunk relative to the world, in
an order of rotations of (1) sagittal plane motion (Y-axis), (2)
frontal plane (X-axis), and (3) transverse plane (Z-axis). The
y-axis was associated with flexion (+) and extension (−),
the x-axis adduction (+) and abduction (−), and the z-axis
was associated with internal (+) and external (−) rotation.
Kinematic data was filtered using a 4th order zero-phase-lag
Butterworth low-pass filter at 14.5 Hz [37]. Initial contact
was defined as the point at which the ground reaction forces
exceeded 10 N. Peak kinematics were calculated during the
loading phase of the jump landing, between initial contact
and peak knee flexion.
Each EMG signal was (1) band-pass filtered at 20–350 Hz
with a 4th-order, zero-phase-lag Butterworth filter and (2)
smoothed using root-mean-squared sliding window function
with a 50 ms time constant. Peak muscle activation values
were obtained for each muscle 50 ms prior to initial contact
(pre-activation) and between initial contact and peak knee
flexion (loading phase) [30]. Jump-landing EMG data was
normalized to the average peak value throughout the entire
jump-landing motion over the five trials [28]. This approach
was used because EMG activity during a dynamic task often
exceeds isometric efforts as isometric testing does not take
into account length–tension or force–velocity relationships
[28].
13
 Knee Surgery, Sports Traumatology, Arthroscopy

Statistical analysis Institutional Review Board at the University of Wisconsin

Madison (ID #2015-1211).
Demographic data were summarized using frequencies
(%) and proportions and means and standard deviations
(SD), when appropriate. Spearman Rank tests (rs) were Results
calculated to determine the relationships between TSK-11
scores and the kinematic and activation variables of inter- Thirty-six female participants completed the protocol and
est. Relationships were interpreted as: trivial (r < 0.10), had complete data sets for the kinematic variables of inter-
low (r = 0.10–0.29), moderate (r = 0.30–0.49), high est. EMG data collection malfunctioned during one subject,
(r = 0.50–0.69), or very high (r = 0.70–0.89), or nearly leaving only 35 participants with complete muscle activ-
perfect to perfect (0.90–1.00) [16]. All analyses were per- ity data. Table 1 presents demographic information and
formed in SPSS statistical software (version 22.0, SPSS descriptive statistics for all participants. The relationships
Inc., Chicago, IL, USA) and all p values were set a priori at between the TSK-11 total score and kinematic variables can
p ≤ 0.05. A power analysis revealed a minimum of 34 sub- be found in Table 2. Fear had a significant, negative relation-
jects were needed to detect a meaningful correlation between ship with knee flexion (p = 0.006), hip flexion (p = 0.003),
the TSK-11 and primary variables of interest (power = 0.95, trunk flexion (p = 0.013) and a positive relationship with
effect size = 0.05, α = 0.05). This study was approved by the hip adduction (p = 0.007). Relationships between TSK-11
scores and muscle activation can be found in Tables 3 and
4. Fear of reinjury had a significant, positive relationship
Table 1  Demographics of study participants with gluteus max pre-activation (p = 0.001) and moderate,
though non-significant, association with vastus lateralis and
Count (% Median (IQR) Range
of total) or rectus femoris pre-activation. There were not any significant
Mean ± SD relationships between fear of reinjury and muscle activation
during the landing phase of the jump landing.
Height (cm) 168 ± 7 170 (9.5) 154–182
Mass (kg) 67 ± 10 66 (10.5) 50–98
Age (years) 19 ± 1.5 18.0 (2) 18–26
Discussion
Tegner 6 ± 2 6 (1.5) 3–10
Months from surgery 26 ± 13 22 (24) 7–47
The most important finding of this study is that greater fear
TSK-11 score 20 ± 4.5 20 (7) 12–31
of reinjury is associated with stiffened movement patterns
IKDC score 85 ± 10 87 (15) 58–100
in the sagittal and transverse planes, greater motion in the
Mechanism of injury
frontal plane, and greater preparatory muscle activation.
 Non-contact 20 (55.5%)
The main hypotheses were supported as individuals with
 Indirect contact 11 (30.6%)
higher fear of reinjury demonstrated lower peak knee, hip,
 Direct contact 5 (13.9%)
and trunk flexion and greater peak hip adduction during the

Table 2  Correlations between TSK-11

TSK-11 total score and peak Total score
hip, knee, and trunk kinematics
Mean ± SD Median (IQR) p value Correlation Strength of
coefficient relationship

Hip
 Flexion − 89.4 ± 15.8 − 92.4 (15.3) 0.003 0.479 Moderate
 Adduction − 1.3 ± 5.5 − 1.1 (10.3) 0.007 0.445 Moderate
 Rotation 11.3 ± 9.9 12.9 (14.4) n.s. 0.027 Trivial
Knee
 Flexion 97.0 ± 12.9 98.9 (17.7) 0.006 − 0.452 Moderate
 Valgus − 4.7 ± 8.0 − 3.6 (11.6) n.s. 0.001 Trivial
 Rotation 4.8 ± 7.8 4.1 (8.9) 0.005 − 0.456 Moderate
Trunk
 Flexion 44.5 ± 10.2 44.2 (11.0) 0.013 − 0.411 Moderate
 Lateral flexion 3.9 ± 3.5 3.8 (5.4) n.s. 0.051 Trivial

13
Knee Surgery, Sports Traumatology, Arthroscopy

Table 3  Preparatory activation TSK-11

Total score
Mean ± SD Median (IQR) p value Correlation Interpretation
coefficient of relationship

Muscle activation (%)

 Gluteus maximus 20.9 ± 13.0 18.6 (14.5) 0.001 0.517 High
 Gluteus medius 36.4 ± 16.1 37.3 (19.7) n.s 0.137 Trivial
 Vastus lateralis 30.5 ± 12.6 30.4 (33.5) n.s 0.317 Moderate
 Rectus femoris 35.5 ± 16.6 31.4 (28.4) n.s 0.301 Moderate
 Biceps femoris 36.6 ± 20.8 30.0 (21.5) n.s 0.315 Moderate
 Semimembranosus 54.5 ± 28.2 49.4 (34.5) n.s 0.016 Trivial
 Lateral gastrocnemius 40.4 ± 18.4 35.7 (22.4) n.s − 0.044 Trivial
 Medial gastrocnemius 57.5 ± 28.1 50.7 (27.4) n.s 0.275 Low

Relationships between TSK-11 total score and peak muscle activation during the preparatory phase of
landing

Table 4  Landing Phase TSK-11

Total Score
Mean ± SD Median (IQR) p value Correlation Strength of
coefficient relationship

Muscle activation (%)

 Gluteus Maximus 57.5 ± 7.8 57.2 (10.8) n.s 0.201 Low
 Gluteus Medius 60.3 ± 6.2 59.9 (9.1) n.s 0.023 Trivial
 Vastus Lateralis 62.8 ± 6.7 63.2 (8.6) n.s 0.039 Trivial
 Rectus Femoris 64.8 ± 8.2 65.7 (10.8) n.s 0.029 Trivial
 Biceps Femoris 59.1 ± 8.9 59.7 (10.0) n.s 0.089 Trivial
 Semimembranosus 60.1 ± 9.4 61.5 (10.4) n.s 0.164 Low
 Lateral Gastrocnemius 60.7 ± 7.5 63.2 (8.7) n.s − 0.143 Low
 Medial Gastrocnemius 60.6 ± 9.0 63.3 (13.2) n.s 0.273 Low

Relationships between TSK-11 total score and peak muscle activation during the landing phase of landing

jump landing. In addition, the secondary hypotheses were
partially supported. Greater fear of reinjury was associated
with greater quadriceps pre-activation but was not associ-
ated with lower gluteus medius activation. The results of this
study are important because they indicate fear of reinjury is
related to stiffened movement patterns which are associated
with fear-avoidance behaviors and potential risk factors of
secondary ACL injury.
The relationships observed in this study in individuals
with a history of ACLR are similar to published results from
a different patient population. In patients with low back pain,
fear of reinjury was linked to decreased sagittal plane kin-
ematics and increased activation, or guarding, of the erector
spinae muscles during a functional task [35]. The truncated
movement patterns were attributed to fear-avoidance beliefs
rather than pain or level of disability [35]. Similarly, in the
present study, lower peak sagittal plane movements and
increased preparatory muscle activation of the quadriceps
and gluteus maximus were associated with greater fear of
reinjury. It is notable that a similar relationship between fear
of reinjury and guarded movement and activation patterns
has been observed in patients with high fear of reinjury with
two different pathologies.
Guarded movement patterns have been previously
reported in the ACLR literature. During low demand
tasks, such as gait, and more demanding tasks like uni-
lateral hopping and bilateral jump landings, patients shift
biomechanical demands away from their injured limb
towards their healthy limb [4, 10, 22, 32] and away from
their injured knee and towards proximal (hip) or distal
(ankle) joints [9]. Investigators occasionally attribute these
compensations to quadriceps avoidance strategies associ-
ated with decreased quadriceps strength; a problem that
can persist for years following ACLR and successful reha-
bilitation [27]. Quadriceps strength deficits are associated
with poor knee function and increased reports of disability

13

[27]; however, quadriceps strength alone does not account
for similar compensation strategies utilized by individuals
who have torn their ACL but have not had an ACLR [13].
The fear-avoidance model may help to explain compen-
satory movement patterns in patients without quadriceps
strength deficits. After ACL injury, fear or anxiety has
been shown to be high prior to surgery and then decrease
throughout rehabilitation, with an increase in some
individuals around return to sport [7]. Even though our
patients were, on average, 2 years from surgery, we still
observed a relationship between fear and landing patterns.
Patients may experience pain during certain movements
or feel certain movements put them at risk of injury early
in rehabilitation. As a result, they begin to predict pain
and risk and avoid these positions of perceived harm by
avoiding activities or restricting motion to protect the body
part [33]. These avoidance or movement restrictions seem
to have lasting consequences as the injury in our sam-
ple occurred more than 2 years ago. More than 85% of
the females in our study injured their ACL during a non-
contact or indirect contact mechanism, such as landing
from a jump, cutting, or abruptly stopping, so the jump-
landing task mimicked a common mechanism of injury
for our subject pool. If an individual perceives a dynamic
task might put them at risk of reinjury, they may utilize
stiffened or restricted movement and activation patterns to
help protect their knee from the perceived harm because
they cannot avoid the task they associate with their injury.
The results of the present study indicate that quadriceps
and gluteus maximus activation prior to contacting the
ground may occur in an attempt to restrict joint motion and
to protect the knee from perceived danger [33]. Although
not statistically significant, potentially due to sample size
limitations, greater fear of reinjury was moderately asso-
ciated with greater preparatory activation in the vastus
lateralis and the rectus femoris. Higher quadriceps activa-
tion with lower knee flexion angles have been observed in
healthy female participants during three different sport-
related activities, including cutting tasks [20]. Pain alone
is not an explanation for these modifications in function
and activity because individuals who chose not to return
to sport after ACLR due to fear of reinjury had higher
fear of movement/reinjury and lower self-reported knee
function but similar overall pain intensity as those who
had returned to sport [19]. Reducing level of function and
activity participation is similar to the response of individu-
als with other musculoskeletal injuries [18, 33, 34]. The
combination of low flexion angles with high quadriceps
contraction during functional tasks in individuals with
high fear of reinjury are comparable to movement patterns
that have previously been linked to secondary injuries.
Paterno et al., observed that individuals who went on to
suffer a second ACL injury demonstrated increased frontal
13
Knee Surgery, Sports Traumatology, Arthroscopy
plane and decreased sagittal plane displacement during a
functional task [25, 26].
There are several limitations associated with this study.
The cross-sectional design of the present study leaves us
unable to determine whether fear of reinjury affects move-
ment or whether movement affects fear. It is important
for clinicians to address aspects of both fear and move-
ment to optimize outcomes following ACLR. Patients
with high fear of reinjury should be identified during the
rehabilitation process using readily available tools such
as the TSK-11 which is specific to patients after ACLR.
Once individuals who have high fear have been identified,
interventions such as goal setting and positive self-talk
can be implemented to improve outcomes [29]. In addi-
tion, movement patterns during functional tasks should
be evaluated and deficits or abnormal movements should
be addressed during rehabilitation. This blended approach
may be important to help address failure to return to sport
or activity as well as future injury risk.
The sample of participants included in this study was
limited to recreationally active females only who were on
average 2 years from surgery. The relationships observed
in this study may differ if examined closer to return to
sport. In addition, our results cannot be applied to males or
competitive athletes following ACLR. Graft type, surgeon,
operative technique, and rehabilitation protocol were not
controlled during this study. While this increased the gen-
eralizability, it may also impact the results. Future studies
should investigate the relationship between fear of rein-
jury and movement patterns in these populations. Finally,
additional investigations are needed to determine how fear
of reinjury might affect or be affected by movement pat-
terns so that interventions can be investigated and imple-
mented clinically. It is important for clinicians to evaluate
and address psychological or emotional consequences of
injury in addition to physical rehabilitation. By practic-
ing whole-person healthcare, the clinician can intervene
to address concerns before the patient is discharged from
care to optimize outcomes.
Conclusions
Fear of reinjury appears to be related to movement patterns
in females with a history of ACLR. Individuals with greater
fear demonstrated stiffer landings in the sagittal plane and
increased frontal plane motions. Fear is important in deter-
mining which patients will return to sport but may also be
related to stiffened movement patterns during a jump land-
ing. Further investigations are needed to explore these rela-
tionships in individuals who are closer to surgery and return
to sport.
Knee Surgery, Sports Traumatology, Arthroscopy

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