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Received: 1 August 2024
|
Accepted: 9 September 2024
DOI: 10.1002/jeo2.70077
ORIGINAL PAPER
Fear of reinjury after acute Achilles tendon rupture is
related to poorer recovery and lower physical activity
postinjury
Elin Larsson
1
|Agnes LeGreves
1
|Annelie Brorsson
2,3
|
Pernilla Eliasson
1
|Christer Johansson
1
|Michael R. Carmont
3,4
|
Katarina Nilsson Helander
1
1
The Department of Orthopaedics,
Sahlgrenska University Hospital Mölndal,
Institute of Clinical Sciences at Sahlgrenska
Academy, Gothenburg University,
Gothenburg, Sweden
2
IFK Kliniken Rehab, Gothenburg, Sweden
3
The Department of Orthopaedics, Institute of
Clinical Science at Sahlgrenska Academy,
Gothenburg University, Gothenburg, Sweden
4
The Department of Trauma & Orthopaedic
Surgery, Princess Royal Hospital, Shrewsbury
& Telford Hospital NHS Trust, Shropshire, UK
Correspondence
Elin Larsson and Katarina Nilsson Helander
Email: elin.larsson.2@gu.se and katarina.
nilsson.helander@gu.se
Funding information
Doctor Felix Neubergh Foundation
Abstract
Purpose: The aim of this study was to investigate how fear of reinjury to the
Achilles tendon affects return to previous levels of physical activity and self‐
reported Achilles tendon Total Rupture Score (ATRS) outcomes.
Methods: Data were collected from a large cohort of patients treated for an
acute Achilles tendon rupture at Sahlgrenska University Hospital Mölndal
between 2015 and 2020. The ATRS and additional questions concerning
fear of reinjury, treatment modality, satisfaction of treatment and recovery
were analyzed 1–6 years postinjury. Analysis was performed to determine
the impact of fear of reinjury on patient‐reported recovery and physical
activity.
Results: Of a total of 856 eligible patients, 550 (64%) answered the self‐
reported questionnaire and participated in the follow‐up. Of the participants,
425 (77%) were men and 125 (23%) were women. ATRS, recovery in
percentage, satisfaction of treatment, recovery on a 5‐point scale and
physical activity level post‐versus preinjury were significantly related to fear
of reinjury (p< 0.001). Of the nonsurgically treated patients, 59% reported
fear of reinjury compared to 48% of the surgically treated patients
(p= 0.024) Patients that reported fear of reinjury had a 15‐point lower
median ATRS score than those who did not (p< 0.001).
Conclusion: More than half of patients who have suffered an Achilles
tendon rupture are afraid of reinjuring their tendon. Patients who reported
fear of reinjury exhibited a significantly lower ATRS score. This indicates the
importance of addressing psychological aspects in the treatment after this
injury.
Level of Evidence: Level II.
KEYWORDS
Achilles tendon rupture, Achilles tendon Total Rupture Score, fear of reinjury
J Exp Orthop. 2024;11:e70077. wileyonlinelibrary.com/journal/jeo2
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https://doi.org/10.1002/jeo2.70077
This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium,
provided the original work is properly cited.
© 2024 The Author(s). Journal of Experimental Orthopaedics published by John Wiley & Sons Ltd on behalf of European Society of Sports Traumatology, Knee
Surgery and Arthroscopy.
Abbreviations: ATR, Achilles tendon rupture; ATRS, Achilles tendon Total Rupture Score; IQR, interquartile ranges; SD, standard deviation; SU/Mölndal, Sahl-
grenska University Hospital Mölndal.
INTRODUCTION
The incidence of acute Achilles tendon rupture (ATR) is
increasing, with a particularly higher risk of injury
among those who are middle‐aged, male and under-
take a more active lifestyle [3]. Huttunen et al. pre-
sented that men are four times more likely to suffer
from acute ATR than women [6]. The choice of treat-
ment for ATR varies between hospitals, regions and
countries and opinions are divided as to whether sur-
gical or nonsurgical treatment is recommended. It is
generally agreed from intervention studies that surgical
repair reduces the risk of rerupture over nonsurgical
treatment by approximately two to four times, although
the magnitude of risk reduction may vary between
studies [10, 11, 13]. However, surgical treatment can
lead to a number of complications, including adhesions,
iatrogenic nerve injury, pain, cosmetically unappealing
scars, infection or other wound problems. It must also
be considered that surgical repair does not eliminate
the risk of rerupture [8]. A rupture of one's Achilles
tendon can mean long sick leave with financial losses
for the individual patient [16]. Furthermore, a long
rehabilitation awaits and despite this, many do not
regain full function [1].
Few studies have been published regarding the
psychological well‐being and attitudes of patients to-
ward recovery after an ATR and the impacts of these
factors on return to physical activity [7, 14]. Jónsdóttir
et al. presented that n= 25 patients (50%) with acute
ATR, refrained from physical activity due to fear of re-
injury to the Achilles tendon [7]. Patients who were
afraid of new injuries had a significantly greater differ-
ence in strength between their injured leg and healthy
leg compared with those who did not [7]. Olsson et al.
showed that patients reporting fear had significantly
worse self‐reported outcomes and physical activity
3 months after an ATR [14].
Fear of reinjury is a well‐documented concept in
sports medicine as a barrier to rehabilitation. In a clin-
ical review, Hsu et al. identified that fear of reinjury can
have a negative impact on rehabilitation, recovery and
subsequent successful return to sports participation [5].
The authors proposed that athletes with a high fear of
reinjury would benefit most from psychologically in-
formed practice to enhance rehabilitation. Psychologi-
cally informed practice, as described in the article,
includes measuring fear of reinjury using PROM to
monitor during rehabilitation [5].
The aim of this study was to investigate how fear of
reinjury to the Achilles tendon affects return to previous
physical activity in a large cohort. The specific ques-
tions of interest were how fear affects recovery after
acute ATR and return to previous activity. The hypoth-
esis was that a greater proportion of patients treated
nonsurgically would refrain from physical activity due to
fear of reinjury.
MATERIALS AND METHODS
The study was approved by the Swedish Ethical
Review Authority (dnr 2021‐01779).
This retrospective cross‐sectional study compiled
the medical records for all patients who visited the
emergency department with an acute ATR at Sahl-
grenska University Hospital Mölndal (SU/Mölndal)
between 1 January 2015 and 31 December 2020 and
received the main diagnosis of S86.0 (damage to the
Achilles tendon). Patients meeting these inclusion
criteria were then contacted by mail 1–6 years after
their initial injury.
Eight‐hundred‐and‐fifty‐six patients were invited to
the study and 550 patients (64.3%) were enroled in the
study. Patient demographic is presented in Table 1. The
letter contained information about the study and an
offer to participate. They were asked to self‐report
using the Achilles tendon Total Rupture Score (ATRS)
questionnaire [12], a patient‐reported outcome mea-
sure with high reliability and validity for measure out-
come after treatment for an ATR. Patients were also
provided additional questions regarding physical
activity levels pre‐and postinjury, treatment satisfac-
tion, recovery (both in percent and on a Likert scale)
TAB LE 1 Patient demographics.
Total (n= 550) Women (n= 125) Men (n= 425) pValue
Age, years, mean (SD) 48 (14.9) 45 (14.7) 49 (14.9) 0.006
a
BMI, mean (SD) 26 (3.8) 25.3 (4.3) 26.5 (3.6) 0.002
a
Treatment, n(%) n.s.
b
Nonsurgery 395 (72%) 86 (69%) 309 (73%)
Surgery 155 (28%) 39 (31%) 116 (27%)
Note: Bold values are statistically significant.
Abbreviations: BMI, body mass index; n, number of patients; n.s., not significant; SD, standard deviation.
a
Student's ttest.
b
Pearson's χ
2
test.
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and fear of reinjuring their Achilles tendon. When re-
viewing medical records, the following parameters
were documented: age, sex, date of injury, date of
admission to the emergency department and treatment
modality.
Statistical analysis
Descriptive statistics for patient demographics and
outcomes were reported as counts and proportions for
categorical variables. Continuous variables were re-
ported as means with standard deviations for normally
distributed data and medians with interquartile ranges
(IQR) for nonnormally distributed data. Distribution of
variables was examined by visual inspection of histo-
grams. For comparison between the two groups of
patients indicating the presence or absence of fear of
reinjury (yes/no), the Pearson χ
2
test was used for
categorical variables. The Mann–Whitney U‐test was
used to compare ATRS scores and recovery in per-
centage between the two groups. All tests were two‐
sided, and the significance level was set at 0.05. IBM
SPSS Statistics for Mac, version 28 (IBM Corp.) was
used for all statistical tests.
RESULTS
Of the 856 eligible patients, 550 (64.3%) answered the
question of whether they refrained from physical
activity due to fear of Achilles tendon reinjury. Of these,
56% reported a fear of reinjury to the Achilles tendon,
as shown in Table 2.
Treatment, ATRS, satisfaction, recovery and
current activity compared to before were significantly
relatedtofear(Figure1,Table3). There was no
significant difference between women and men re-
porting fear of reinjury as seen in Figure 2. The group
of patients that reported fear of reinjury had a
15‐point lower ATRS score compared to the group
that did not report fear of reinjury. Recovery ex-
pressed, as a percentage from 0% to 100%, was
significantly lower among patients experiencing fear
of reinjury (Table 3).
There was a significant association between re-
ported fear of reinjury and the age categories
(p= 0.008). The largest proportion reporting fear of re-
injuring the Achilles tendon was found in the 30–39 and
40–49 age categories. The lowest proportion who re-
ported fear of reinjuring the Achilles tendon was among
patients aged 70 years or older (Figure 3).
DISCUSSION
The most important finding of this cross‐sectional
cohort study is that 56% of the 550 patients who suf-
fered from an acute ATR reported a fear of reinjuring
their Achilles tendon. Most patients who experienced
fear of reinjury did not return to the same level of
physical activity as before their injury, were less satis-
fied with treatment, and had worse recovery and ATRS
outcomes compared to those reporting no fear of re-
injury. Furthermore, a larger proportion of nonsurgically
treated patients reported fear of reinjury. The results of
the present study are in line with previous studies that
investigated the frequency of fear of reinjury among
patients suffering from a musculoskeletal injury [7, 9].
However, the present study is based on a larger cohort
than previously published reports. Jónsdóttir et al. re-
ported that 50% out of 25 included patients with an ATR
felt such a high level of fear of rerupture that they
refrained from physical activity [7]. Similarly, Kvist et al.
found that 53% of the 62 who had sustained an injury to
the ACL of the knee returned to their previous activity
levels. Of those who did not return, the primary reason
was fear of reinjury [9].
The findings of the present study indicate that the
majority of the patients expressed satisfaction with the
treatment of their injured Achilles tendon. However, it
was observed that patients who resumed participation
in sports activities without reporting a fear of reinjury
demonstrated a higher level of satisfaction than those
who did report such a fear. Moreover, there was a
significant correlation between fear of reinjury and
recovery. There was a large, significant difference of 15
points in ATRS scores between patients who reported
fear of reinjury and those who did not. Similarly, pa-
tients who felt fear of reinjury had 10% lower median
recovery scores than those who did not. Consistent
with ATRS findings, only 27% of patients with fear of
reinjury reported a return to the same preinjury activity
level compared with 52% of those without fear
(p< 0.001). The reasons for these large differences
require further investigation. In future studies, it is of
interest to gain patient perspectives regarding fear to
better understand impact on daily life due to insufficient
recovery.
The present study showed significant discrepancy
in the prevalence of fear of reinjury between patients
who underwent nonsurgical and surgical treatment
TAB LE 2 Fear of reinjury.
Total
(n= 550)
Women
(n= 125) Men (n= 425) pValue
Fear, n(%) n.s.
a
Yes 308 (56%) 71 (57%) 237 (56%)
No 242 (44%) 54 (43%) 188 (44%)
Abbreviation: n, number of patients.
a
Pearson's χ
2
test.
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(59% vs. 48%; p= 0.024). Previously, Grevnerts et al.
found that the inability to perform physical activity and
fear of increased symptoms are strong factors in the
patient's choice of surgical treatment over nonsurgical
treatment for ACL rupture [4]. These factors could be
influenced by a patient's belief that surgery entails a
lower risk of future problems with pain and a lower risk
of reinjury. Filbay et al. found that patients who pro-
ceeded to surgical treatment of ACL ruptures reported
greater fear of reinjury before treatment compared with
nonsurgically treated patients [2]. The results of our
study, in alignment with those of Grevnerts et al. [4] and
Filbay et al. [2], indicate that fear plays a significant role
in both treatment selection and the return to baseline
function and daily activities. With surgery, patients may
feel less afraid of rerupturing their Achilles tendon due
to the fact that the tendon ends are surgically repaired
together, and the strength of the tendon is thus stron-
ger. This psychological effect makes surgical treatment
a predictor of less fear. Nevertheless, there is no strong
evidence that suggests surgical treatment provides a
better functional outcome [10].
In our cohort, the largest proportion of patients who
reported a fear of reinjury was observed in the 30–39
and 40–49 age groups, while the 70+ age group ex-
hibited the smallest proportion of patients fearful of
reinjury. This trend could be because the elderly usually
have lower demands and lower levels of physical
activity, and, therefore, fewer opportunities to abstain
from physical activity. In addition, the elderly may be
more concerned about other more serious diseases
than reinjury to their Achilles tendon. Another ex-
planation could be that most patients aged 30–49 years
are employed and/or have children and, therefore, feel
that they cannot afford to lose time due to reinjury,
hence they might experience greater fear.
There is a need to determine why such a large
percentage of patients feel afraid of injuring themselves
again and, therefore, avoid physical activity. And sev-
eral questions remain as to why and when fear of re-
injury arises after an acute ATR. There is also a need to
FIGURE 1 Distribution of patients treated with surgery (left) and nonsurgical treatments (right) reporting fear and no fear of Achilles tendon
reinjury. Pearson's χ
2
test.
TAB LE 3 Treatment, recovery, activity and satisfaction
outcomes.
Fear (n= 308)
a
No fear
(n= 242)
b
pValue
ATRS score,
median (IQR)
76 (55–90) 91 (78–97) <0.001
a
Recovery, median
% (IQR)
80 (70–90) 90 (82–98) <0.001
a
Treatment satisfaction, n(%) <0.001
b
Completely
satisfied
109 (35.4%) 146 (60.3%)
Somewhat
satisfied
112 (36.4%) 69 (28.5%)
Neither satisfied
nor dissatisfied
52 (16.9%) 19 (7.9%)
Somewhat
dissatisfied
22 (7.1%) 4 (1.7%)
Dissatisfied 13 (4.2%) 4 (1.7%)
Recovery, n(%) <0.001
b
To full extent 48 (16%) 106 (44%)
To a large extent 183 (59%) 110 (45%)
Neither 27 (8.8%) 11 (4.5%)
To a small extent 48 (16%) 15 (6.2%)
Not at all 2 (0.6%) 0 (0%)
Current activity compared to before <0.001
b
Much more
active
11 (3.6%) 8 (3.3%)
Somewhat more 21 (6.8%) 26 (11%)
Same 83 (27%) 126 (52%)
Somewhat less 142 (46%) 64 (26%)
Much less active 51 (17%) 18 (7.4%)
Note: Bold values are statistically significant.
Abbreviations: ATRS, Achilles tendon Total Rupture Score; IQR, interquartile range.
a
Mann–Whitney U test.
b
Pearson's χ
2
test.
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characterize the degree to which patients are affected
in their everyday life because of their fear and whether
they have stopped doing certain activities compared to
preinjury simply because of fear. In addition to patient‐
related factors (e.g., personality traits), fear of reinjury
may, unfortunately, be supported or even amplified by
comments and mannerisms of treating clinicians during
the recovery process. Collectively, the results of this
study emphasize the importance of treating clinicians in
encouraging patients to not be afraid of pursuing
physical activity or sports. In their investigation of
psychological factors during the rehabilitation of ATR,
Slagers et al. [15] showed that fear of movement
decreased and readiness to return to sport improved
over time. This is in line with our interpretation that
psychological factors could affect rehabilitation, where
physiotherapists have an essential role in terms of
screening for and addressing fear. Going forward,
rehabilitation that includes psychological aspects could
be a valuable addition to physical rehabilitation to
overcome fear and encourage physical activity after
injury, thus, preventing patients from getting stuck in a
vicious cycle of fear and lack of physical activity. In the
orthopaedic community, individualized ‘treatment’is
commonly seen as an approach to optimize outcomes
after an injury. Fear of reinjury could be an important
component of an individualized choice of treatment
during the rehabilitation process for acute ATR.
The large cohort size is one of the strengths of this
study. Previous studies in the same field have been
FIGURE 2 Distribution of women (left) and men (right) reporting fear and no fear of Achilles tendon reinjury. Pearson's χ
2
test.
FIGURE 3 Proportion of patients reporting fear of Achilles tendon reinjury within each age category. The percentages reporting yes/no sum
up to 100% in each age category. A χ
2
test for association indicates an association between fear and age categories (p= 0.008).
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carried out on much smaller cohorts. Another strength
was the use of the ATRS, an injury‐specific, validated
and reliability‐tested patient‐reported outcomes mea-
sure, to evaluate recovery in patients treated for a total
ATR. Furthermore, all patients included in the present
study were managed at one centre, which means that
the same local guidelines were followed regarding the
assessment of injury, ATRS and treatment choice
reducing the heterogeneity of the cohort. But this can
also be regarded as a limitation since the results could
be less generalizable and applicable to other settings
and in other countries with different working methods
and guidelines. Another limitation is the retrospective
nature of this study and the effect of recall bias. The
questionnaire was sent to patients so that at least
1 year had passed since injury, and the period
between the injury and questionnaire completion var-
ied from 1 to 6 years. Recall bias can affect the pa-
tients' answers as it can be difficult to remember the
time before injury. Nevertheless, previous studies
identified no significant differences in ATRS scores
2 years after injury or several years after injury [1].
Related to the long study period, only 66% of patients
who were invited accepted and participated in the
follow‐up study and answered the questionnaires. The
moderate response rate could pose a risk of selection
bias in that patients who felt completely satisfied with
their treatment and recovery chose to answer the
questionnaire to a greater extent than those who did
not feel satisfied. Finally, the study questionnaire
included only one question related to fear of reinjury.
This question was a yes/no question, and there was
no possibility for patient reporting the level of fear.
Future studies could ask more questions regarding
fear and the reasons for perceived fear. Studies where
patients are interviewed could help explore the topic
further.
The findings of this study highlight the crucial
importance of inquiring about the potential fear
of reinjury during the course of both medical
consultations—with the orthopaedic surgeon and the
physiotherapist—and of addressing this issue in a
comprehensive and sensitive manner.
CONCLUSIONS
More than half of patients affected by acute ATR are
afraid of reinjuring their Achilles tendon. Patients who
experienced fear of reinjury have a significantly worse
self‐estimated recovery as measured by the ATRS. The
findings of this study emphasize the importance of
taking patients' fear of injury seriously.
AUTHOR CONTRIBUTIONS
Elin Larsson, Agnes LeGreves, Annelie Brorsson,
Pernilla Eliasson, Christer Johansson, Michael R.
Carmont and Katarina Nilsson Helander participated in
the design of the study. Elin Larsson, Katarina Nilsson
Helander and Christer Johansson performed the data
processing and statistical analysis. All of the authors
have contributed to the manuscript.
ACKNOWLEDGEMENTS
Doctor Felix Neubergh Foundation.
CONFLICT OF INTEREST STATEMENT
The authors declare no conflict of interest.
DATA AVAILABILITY STATEMENT
The data sets generated and/or analyzed during the
current study are not publicly available due to confi-
dential information but are available from the corre-
sponding author on reasonable request.
ETHICS STATEMENT
Approval was provided by the Swedish Ethical Review
Authority, dnr 2021‐01779. All patients that were
included in the study provided written consent for
enrolment.
ORCID
Elin Larsson http://orcid.org/0009-0006-3064-6146
Annelie Brorsson http://orcid.org/0000-0002-
9099-9529
Pernilla Eliasson http://orcid.org/0000-0001-
6718-034X
Christer Johansson http://orcid.org/0000-0002-
3707-9766
Michael R. Carmont http://orcid.org/0000-0002-
7472-6280
Katarina Nilsson Helander https://orcid.org/0000-
0002-1292-5102
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How to cite this article: Larsson, E., LeGreves,
A., Brorsson, A., Eliasson, P., Johansson, C.,
Carmont, M.R. et al. (2024) Fear of reinjury after
acute Achilles tendon rupture is related to poorer
recovery and lower physical activity postinjury.
Journal of Experimental Orthopaedics,11,
e70077. https://doi.org/10.1002/jeo2.70077
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