What Is the Relationship of Fear Avoidance to Physical Function and Pain Intensity in Injured Athletes?

Clin Orthop Relat Res. 2018 Apr;476(4):754-763. doi: 10.1007/s11999.0000000000000085.


Background: Fear avoidance can play a prominent role in maladaptive responses to an injury. In injured athletes, such pain-related fear or fear avoidance behavior may have a substantial influence on the recovery process. Specifically, it may explain why some are able to reach their preinjury abilities, whereas others are unable to return to sport.

Questions/purposes: (1) Is fear avoidance in athletes associated with decreased physical function after injury? (2) To what degree is fear avoidance associated with athletes' pain intensity?

Methods: In a cross-sectional study, we recruited injured athletes-defined as patients with sports-related injury, weekly engagement in sport activities, participation in competitive events as part of a team or club, self-identification as an athlete, and a desire to return to sport after recovery-from an orthopaedic sports medicine center at a major urban university hospital. Of 130 approached patients, 102 (84% men; mean ± SD age 25 ± 8.5 years) met the inclusion criteria. Participants completed a demographic questionnaire, the Athlete Fear Avoidance Questionnaire, which assesses injury-related fear and avoidance behavior specifically in an athletic population, the Pain Catastrophizing Scale, the Hospital Anxiety and Depression Scale, and two Patient-Reported Outcomes Measurement Information System measures: Physical Function Computerized Adaptive Testing (CAT) and Pain Intensity CAT.

Results: After controlling for age, injury region (upper versus lower extremity), catastrophic thinking, and emotional distress, we found that an increase in athletes' fear avoidance was associated with a decrease in physical function (b = -0.32; p = 0.002). The model explained 30% of the variation in physical function with 7.3% explained uniquely by fear avoidance. After controlling for initial appointment/followup, surgery for the current condition, multiple pain conditions, history of prior sport-related injury/surgery, pain medication prescription, catastrophic thinking, and emotional distress, athletes' fear avoidance was not associated with pain (b = -0.14; p = 0.249). The model explained 40% of the variation in pain intensity and pain catastrophizing (b = 0.30; p = 0.001) uniquely explained 7.1% of this variation.

Conclusions: In injured athletes, fear avoidance is independently associated with decreased physical function, whereas pain catastrophizing is associated with high pain intensity. Both level of an athlete's fear avoidance and catastrophic thinking about pain should be accounted for in clinical interventions aimed at helping athletes improve recovery and return to sport.

Level of evidence: Level II, prognostic study.

MeSH terms

  • Adolescent
  • Adult
  • Athletes / psychology*
  • Athletic Injuries / diagnosis
  • Athletic Injuries / physiopathology
  • Athletic Injuries / psychology*
  • Athletic Injuries / rehabilitation
  • Avoidance Learning*
  • Catastrophization
  • Cross-Sectional Studies
  • Fear*
  • Female
  • Humans
  • Male
  • Musculoskeletal Pain / diagnosis
  • Musculoskeletal Pain / physiopathology
  • Musculoskeletal Pain / psychology*
  • Musculoskeletal Pain / rehabilitation
  • Pain Measurement
  • Pain Perception
  • Pain Threshold
  • Patient Reported Outcome Measures
  • Recovery of Function
  • Return to Sport
  • Risk Factors
  • Young Adult