Injury-Related Fear in Individuals With and Without Chronic Ankle Instability: A Systematic Review

Abstract

Context: Injury-related fear has recently been recognized to exist in ankle sprain populations. It is unclear, however, if injury-related fear levels differ between those who develop chronic ankle instability (CAI) and those who do not and the best tools for assessing these differences. Objective: The purpose of this study was to conduct a comprehensive systematic review investigating differences in injury-related fear between individuals with and without CAI. Evidence Acquisition: Relevant studies from CINAHL Plus with full text, PubMed, and SPORTDiscus through November 2020 were included. All studies used the Tampa Scale of Kinesiophobia, Fear-Avoidance Beliefs Questionnaire, or Athlete Fear Avoidance Questionnaire as either a descriptor or a main outcome and provided comparison data between a CAI group and ankle sprain copers (COP) or controls (CON). The authors independently assessed methodological quality using the modified Downs and Black Quality Index. Studies were then grouped by between-group comparisons including CAI and CON, CAI and COP, and COP and CON. The authors calculated Hedge g effect sizes and 95% confidence intervals to examine group differences. Evidence Synthesis: A total of 11 studies were included in this review. In total, 8 studies provided data for the CAI and CON comparison, 7 for CAI and COP comparisons, and 4 for COP and CON comparisons. Methodological quality scores ranged from 60.0% to 86.7%, with 2 high-, and 9 moderate-quality studies. Overall, the evidence suggests that physically active individuals with CAI report higher levels of injury-related fear when compared with both COP and CON. Although limited, ankle sprain COP do not seem to differ from CON. Conclusion: Available evidence emphasizes the importance of injury-related fear in individuals who develop chronicity after ankle sprain injury. The Fear-Avoidance Beliefs Questionnaire and Tampa Scale of Kinesiophobia are useful for the identification of injury-related fear in individuals after sustaining an ankle sprain and should be used to inform rehabilitation strategies and to monitor efficacy in fear reduction.

Perceived Instability, Pain, and Psychological Factors for Prediction of Function and Disability in Individuals With Chronic Ankle Instability

“…Others studying these variables have produced similar findings to ours. 13,18 Further, as injury-related fear is an established factor related to CAI, 11 this relationship does suggest that pain catastrophizing may be another cognitive-affective variable warranting further investigation in the ankle sprain population.…”

“…10 Injury-related fear is a cognitive-affective factor that has been identified in O n l i n e F i r s t individuals who develop CAI. 11 Injury-related fear has shown associations to negative outcomes after injury regarding physical impairments, recovery, and function in other musculoskeletal conditions through use of the fear-avoidance model (FAM). [12][13][14] The FAM is a cognitive-behavioral model that postulates that exaggerated negative beliefs about pain, known as pain catastrophizing, can lead patients into a cycle of fear and activity avoidance.…”

Effect of Chronic Ankle Instability on Functionality, Mental and Physical Health Among Elite Athletes: A Case-Control Study

“…25 When comparing ankle sprain copers and CAI groups, CAI groups showed a higher level of fear-avoidance behavior. 26 The clinicians should be aware of all appropriate outcome measures before returning to sports activities. 27 It is recommended that a FAAM-ADL score below 75.6 and FAAM-sports subscale score below 25.6 can be one of the inclusion criteria for CAI studies.…”

Perceived ankle instability and cutaneous reflex modulation during gait

“…Perceived instability is typically intermittent rather than occurring during every bout of physical activity and is often reported during specific tasks that require more frontal plane movement or in environments with uneven surfaces (Attenborough et al., 2014; Donovan et al., 2020). Though this symptom is not consistent, the unpredictable nature of perceived instability likely contributes to the fear of re‐injury and subsequent reduced physical activity over time seen in individuals with CAI (Houston et al., 2014; Hubbard‐Turner & Turner, 2015; Suttmiller & McCann, 2021). From both a patient and public health perspective, it is important to curtail these sequelae as they contribute to poorer overall health‐related quality of life and incur financial burdens (Feger et al., 2017; Houston et al., 2014).…”