Rethinking the Tampa scale of kinesiophobia as a measure of re-injury worries after anterior cruciate ligament injury - PMC Skip to main content An official website of the United States government Here's how you know Here's how you know Official websites use .gov A .gov website belongs to an official government organization in the United States. Secure .gov websites use HTTPS A lock ( Lock Locked padlock icon ) or https:// means you've safely connected to the .gov website. Share sensitive information only on official, secure websites. Search Log in Dashboard Publications Account settings Log out Search… Search NCBI Primary site navigation Search Logged in as: Dashboard Publications Account settings Log in Search PMC Full-Text Archive Search in PMC Journal List User Guide PERMALINK Copy As a library, NLM provides access to scientific literature. Inclusion in an NLM database does not imply endorsement of, or agreement with, the contents by NLM or the National Institutes of Health. Learn more: PMC Disclaimer | PMC Copyright Notice BMC Sports Sci Med Rehabil . 2026 Apr 6;18:196. doi: 10.1186/s13102-026-01684-y Search in PMC Search in PubMed View in NLM Catalog Add to search Rethinking the Tampa scale of kinesiophobia as a measure of re-injury worries after anterior cruciate ligament injury Adam Grinberg Adam Grinberg 1 Department of Community Medicine and Rehabilitation, Umeå University, Umeå, SE-901 87 Sweden Find articles by Adam Grinberg 1, ✉ , Martin Björklund Martin Björklund 1 Department of Community Medicine and Rehabilitation, Umeå University, Umeå, SE-901 87 Sweden 2 Department for Occupational Health, Psychology and Sports Sciences, Faculty of Health and Occupational Studies, University of Gävle, Gävle, Sweden Find articles by Martin Björklund 1, 2 , Charlotte K Häger Charlotte K Häger 1 Department of Community Medicine and Rehabilitation, Umeå University, Umeå, SE-901 87 Sweden 3 Department of Diagnostics and Intervention, Clinics of Orthopaedics, University Hospital of Umeå, Umeå, Sweden Find articles by Charlotte K Häger 1, 3 Author information Article notes Copyright and License information 1 Department of Community Medicine and Rehabilitation, Umeå University, Umeå, SE-901 87 Sweden 2 Department for Occupational Health, Psychology and Sports Sciences, Faculty of Health and Occupational Studies, University of Gävle, Gävle, Sweden 3 Department of Diagnostics and Intervention, Clinics of Orthopaedics, University Hospital of Umeå, Umeå, Sweden ✉ Corresponding author. Received 2025 Sep 22; Accepted 2026 Apr 1; Collection date 2026. © The Author(s) 2026 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . PMC Copyright notice PMCID: PMC13081327 PMID: 41943059 Abstract Background The term kinesiophobia originates in the context of the cognitive fear-avoidance model of pain. The Tampa Scale of Kinesiophobia (TSK) is frequently used to assess this construct, notably among populations for which it was not designed, including athletes with anterior cruciate ligament (ACL) injury, for whom pain is not a major concern. The objective of this study was to determine the suitability of the TSK for evaluating re-injury worries in ACL-injured persons with and without pain, by assessing key psychometric properties. Methods Ninety-two individuals post-ACL reconstruction (ACLR) were included and divided into PAIN and NO-PAIN subgroups, based on a 90% cutoff on the pain subscale of the Knee Injury and Osteoarthritis Outcome Score. Correlation analyses were employed to assess the contribution of pain-specific TSK items to the total score. Criterion validity (Cohen’s-kappa) was evaluated between an established TSK total cutoff and classification based on the re-injury fear-specific TSK Q9 , with an optimal cutoff further explored via receiver operating characteristic (ROC) analysis. The TSK’s internal consistency was tested on subgroup level, using Chronbach’s-α. Finally, in a subset of participants, the TSK’s discriminant validity was assessed through correlation with the ACL Return-to-Sport-after-Injury survey (ACL-RSI) of psychological readiness. Results Pain-specific TSK items correlated strongly with TSK total (r s =0.85). Classification based on a previously recommended TSK total cutoff (38-point) demonstrated fair agreement with TSK Q9 (K = 0.31), with low sensitivity and high specificity. An optimal cutoff of 33.5 for TSK total had a sensitivity of 70.6% and specificity of 87.8%. The TSK’s internal consistency was poor ( α = 0.65) for NO-PAIN and acceptable ( α = 0.77) for the PAIN subgroup. The TSK total and ACL-RSI scores were not correlated. Conclusion The TSK may have limited suitability for individuals after ACLR due to poor internal consistency when pain is not a concern and limited relationship to re-injury fear, regardless of selected cutoff, and psychological readiness. The construct of kinesiophobia is likely less relevant in this population while other more suitable constructs could provide more meaningful assessment of psychological aspects affecting athletic recovery. Clinicians should consider prioritising more efficient, population-specific tools for detecting re-injury worries, over commonly-used but less-fitting tools like the TSK. Supplementary Information The online version contains supplementary material available at 10.1186/s13102-026-01684-y. Keywords: Fear of re-injury, TSK, ACL, Anxiety, Psychological readiness, Pain, Psychometric properties Introduction Kinesiophobia (from Greek: Kinesis-phobos; literally fear of movement) was defined by Kori, Miller and Todd in 1990 as “an excessive, irrational, and debilitating fear of physical movement and activity resulting from a feeling of vulnerability due to painful injury or re-injury” [ 1 ]. This psychological construct has since been widely addressed in the context of the cognitive fear avoidance model of pain [ 2 ], a framework adopted by researchers and clinicians over the last four decades. Briefly, the model outlines two potential trajectories patients might take when experiencing a painful injury or musculoskeletal condition. In an optimal scenario, the patient confronts their pain and accepts physical activity as a successful pathway to recovery. In the more sinister trajectory, the cognitive and emotional components predominantly exacerbate the patient’s pain experience [ 2 ]. They may develop catastrophising thoughts, possibly leading to pain anxiety, avoidance behaviour and to disability and depression [ 3 ]. The Tampa Scale of Kinesiophobia (TSK), originally with 17 items (TSK-17) [ 4 ] has been used since 1991 as the predominant tool for assessing kinesiophobia among patients with pain-dominating conditions, including chronic low back pain [ 5 ], total knee arthroplasty [ 6 ], patellofemoral pain [ 7 ] and fibromyalgia [ 8 ]. Sports researchers and clinical practitioners have however extended the use of kinesiophobia measures to populations for which pain is not a primary concern. Specifically, athletes who have suffered anterior cruciate ligament (ACL) injury are commonly administered the TSK to evaluate fear of re-injury [ 9 ]. Re-injury worries (anxiety and fear) are indeed frequent after ACL injury and considered the main reason for not returning to pre-injury activity level [ 10 , 11 ]. The psychological response to an athletic injury may also subconsciously influence movement patterns [ 12 , 13 ] and be associated with secondary injuries [ 14 , 15 ]. The concept of kinesiophobia thus seems appropriate in this context given the risk of potentially hazardous movements as the trigger for a secondary injury. However, fear of re-injury and kinesiophobia are not identical as the latter involves pain as the fear-relevant threat associated with movements. This distinction is critical because in the TSK more than 50% of the items explicitly refer to pain as the major deterrent [ 4 ]. The population for which the TSK was developed, patients suffering from musculoskeletal chronic pain, is inherently different from sportspeople recovering from an injury, who generally aspire to resume physical activity or preferably return to their respective sport. Re-injury anxiety among ACL-injured persons is complex, involving many emotions related to a life-changing experience [ 16 , 17 ], and not limited to worries about the acute injury pain [ 17 – 19 ]. Kvist et al. were the first who administered the TSK to ACL-injured individuals [ 20 ]. Notably, they adapted the instrument to the target population, with the word ‘pain’ replaced by ‘knee trouble’ in most instances, among other relevant modifications. The use of the unmodified TSK for the ACL-injured athletic population has however since then become increasingly common, with the number of published papers rising from one in 2005 to a total of 111 in 2025. Furthermore, while the TSK includes several items reflecting different sub-constructs [ 21 ] the overall score is predominantly used to quantify an athlete’s worries of re-injury [ 9 ]. A recent study [ 12 ] employed a reductionistic approach to assessing re-injury fear by stratifying individuals following ACL reconstruction (ACLR) into high or low fear subgroups based on a single item from the TSK-17. The ninth statement from the TSK – “ I am afraid that I might injure myself accidentally ” (TSK Q9 ) – was selected as it explicitly refers to re-injury worries. Individuals classified as “High-fear” exhibited greater muscle co-activation, suggesting a protective strategy during side-hops which challenge knee stability [ 12 ]. A classification based on TSK Q9 , albeit simplistic, may therefore provide a crude estimate of a person’s worries about being re-injuried. Recognising that the TSK may not fully align with the psychological profile of ACL-injured athletes, the overall purpose of the present study was to empirically evaluate the suitability of the TSK for evaluating re-injury worries in this population. The five specific objectives were to: (1) determine the extent to which the TSK pain-specific items contribute to the total score, whereasa strong contribution was hypothesised, indicating that pain-related information heavily influences the score; (2) evaluate whether any existing ACLR pain translates into kinesiophobia, with be a weak relationship between pain and TSK scores was hypothesised, suggesting that the presence of pain does not necessarily correspond to kinesiophobia in this population; (3) evaluate the criterion validity of the TSK by exploring the agreement between a standard TSK total score cutoff for kinesiophobia [ 5 ] and re-injury worries, as determined by TSK Q9 cutoff [ 12 , 22 ], and to explore an optimal TSK cutoff that best distinguishes between individuals with high and low worries. A low agreement between the measures was hypothesised considering that the cutoffs were established for two distinct populations; (4) assess the internal consistency of the TSK among individuals following ACLR with and without pain. Given the construct’s strong dependency on presence of pain, a poor internal consistency was hypothesised, particularly in pain-free individuals; and finally, (5) evaluate the discriminant validity of the TSK by comparison with the ACL Return to Sports after Injury survey (ACL-RSI) [ 23 ], a population-specific measure of psychological readiness. Given that the TSK and ACL-RSI assess related yet distinct constructs, a weak to no relationghip was anticipated between the measures. Methods This was a cross-sectional study performed at the Department of Community Medicine and Rehabilitation, at Umeå University, Sweden. Participant data were collected between 2015 and 2024, in two separate projects involving series of functional testing for individuals who had suffered a unilateral ACL injury. The present study is a secondary analysis of self-reported outcomes, which were administered prior to any testing. All participants provided written informed consent according to the declaration of Helsinki and the research was approved by the Swedish Ethical Review Authority (Project No. 2015/67 − 31; 2021–03860). Sample size justification An a-priori power calculation was performed for Cronbach’s α testing based on a formula introduced by Bonett., 2002 [ 24 ]. For testing of a 17-item questionnaire, with the null hypothesis of internal consistency comparable to that for chronic pain patients [ 25 ] and an alternate hypothesis of a non-satisfactory α of 0.65 (i.e., effect size of 0.2), we estimated a required sample size of 37 participants to achieve 80% power [ 24 ]. For construct validity, we followed a recommendation of 50 participants as the minimal sample size [ 26 ]. Participants and subgrouping All participants for the two primary projects were recruited using a convenience sampling approach. Individuals who had suffered a unilateral ACL injury were recruited from an orthopaedic clinic at the regional hospital, from a private sports medicine clinic, via ads spread around the university campus, social media platforms and word-of-mouth. Inclusion criteria included: 15–35 years of age who suffered a unilateral ACL injury treated with reconstructive surgery with hamstring autograft, which is the most common practice in Sweden [ 27 ]. For the present study, only participants whose injury occurred during sport participation (either recreational or competitive, during training or competition) were included. Participants were excluded if one or more of their questionnaire responses had irregularities (e.g., missing item, marking a midpoint between two response alternatives or marking two instead of one alternative). Out of 97 potential participants, one individual was excluded as his injury occurred in non-sport-related circumstances and four more were excluded due to irregularities in their forms. Specifically, one participant had eight missing items due to a skipped questionnaire page, another had three instances of double marking, a third marked a midpoint between response alternatives and a fourth participant misunderstood the questionnaires, rendering their data unreliable. A final sample of 92 participants was thus used for the analysis (Fig. 1 ). Subgroup allocation was then performed based on the Pain subscale of the KOOS pain . The KOOS is commonly used to evaluate both short and long-term knee injury-associated outcomes [ 28 ], and was considered a relevant patient-reported outcome measure for individuals in the non-acute stages after ACL injury [ 29 ]. It consists of five subscales: Symptoms, Pain, Activities of Daily Living, Sports and Recreation function, and Quality of Life. The Pain subscale is comprised of nine items, one referring to general knee pain and eight that refer to functional pain during the last week (i.e., each refers to a different function). Scoring is summed into percentage, with 100% indicating absence of pain. A previous study investigating the development of post-injury osteoarthritis [ 30 ] used a KOOS pain threshold of 86.1% to define symptomatic knees. For the present study, a more conservative cutoff of 90% was selected to account for minor residual injury/surgery pain, while providing a stringent basis for subgroup comparisons, particularly given a young active population in the present study. Participants who scored 90–100% were allocated to the NO-PAIN subgroup ( N = 46) and participants who scored 0–90% were allocated to the PAIN subgroup ( N = 46). Furthermore, a subset analysis of 30 participants (i.e., only from one of the two projects) was conducted to determine the discriminant validity of the TSK – the degree to which it diverges from another measure of a different construct. For this purpose, we tested the relationship between the TSK and the ACL-RSI questionnaire [ 23 ], a condition-specific measure for psychological readiness to return to sports after ACL injury that includes 12 items covering injury-relevant psychological aspects including fear, confidence and nervousness regarding their rehabilitation and returning to their respective sports. This was an exploratory analysis given that the subset completing the ACL-RSI ( n = 30) was below the recommended minimum of 50 participants [ 26 ]. Participant characteristics, including pre-injury and current activity levels (Tegner scores [ 31 ]) and time since surgery, are presented in Table 1 . Fig. 1. Open in a new tab Flowchart of the study design. Abbreviations : KOOS, Knee Injury and Osteoarthritis Outcome Score; ACL-RSI, Anterior Cruciate Ligament Return to Sport after Injury Survey Table 1. Participants’ background characteristics with groups (PAIN vs. NO PAIN) determined based on a 90% cutoff on the Knee Injury and Osteoarthritis Outcome Score, Pain subscale. Values are presented as median (interquartile range), unless otherwise stated Total ( n = 92) NO-PAIN ( n = 46) PAIN ( n = 46) P (Subgroup) Subset ( n = 30) P (Subset) Sex (M/F) 31/61 15/31 16/30 NS 5/25 NS Age (yrs); mean (SD) 24.9 (4.7) 24.2 (4.7) 25.6 (4.6) NS 24.0 (4.9) NS Time post-surgery (months) 13.5 (14.2) 16.4 (15.7) 12.3 (10.8) 0.013 18.1 (12.2) NS Pre-injury activity (Tegner, 1–10) 8 (2) 9 (2) 8 (2) NS 9 (3) 0.007 Current activity (Tegner, 1–10) 6 (3) 6.5 (3) 6 (4) NS 7 (4.3) NS Open in a new tab NS Non-Significant Tampa scale of kinesiophobia (TSK)-derived outcomes All questionnaires across both projects were identically worded and organised across projects and administered before any physical test occurred. However, the order of administration and data collection delivery formats differed slightly. The Swedish version of the TSK-17 was administered to all participants, either in paper form or using an electronic data capturing tool (REDCap) [ 32 ]. Based on participants’ data and after questions 4, 8, 12 and 16 had been given reverse scoring [ 4 ], several variables were extracted: 1 ) TSK total score, (TSK total ) reflecting the general construct of Kinesiophobia. (2) TSK pain , a subscore comprised of the ten items (Q2, Q4, Q7, Q8, Q10, Q11, Q12, Q13, Q16, Q17) in which pain is explicitly referred to. (3) Item 9 from the TSK-17 (TSK Q9 ) which specifically addresses being afraid of a future injury [ 12 , 22 ]. Statistical analysis All statistical tests were performed with the Statistical Package for the Social Sciences software (version 28.0, IBM SPSS statistics, Armonk, New York, USA). All questionnaire data, being ordinal in nature, were analysed using non-parametric statistics to provide appropriate and accurate estimates without assuming interval scaling or normal distribution. Descriptive statistics were computed for demographics and main outcome variables for both the entire cohort and per subgroup (NO-PAIN / PAIN; Tables 1 and 2 ), followed by Mann-Whitney U tests to detect subgroup differences and ηp 2 for effect sizes. Guided by the five objectives, statistical analyses were performed either on the entire cohort (primary analyses; objectives 1–3) , subgroup analysis (objective 4) and subset analysis, performed on a subset of 30 individuals (objective 5) . In the primary analyses , Spearman correlations were calculated between TSK total and TSK pain (objective 1) and between TSK total and KOOS pain scores (objective 2) . Correlation coefficients were interpreted as negligible (0–0.3), weak (0.3–0.5), moderate (0.5–0.7), strong (0.7–0.9) or very strong (0.9–1) [ 33 ]. To account for multiple correlations, Bonferroni corrections were applied to all p-values. For the analysis of criterion validity, the extent to which the TSK agrees with an external criterion of a phenomenon [ 34 ], the agreement between TSK total and TSK Q9 dichotomisations was tested (objective 3) . The TSK total cutoff for kinesiophobia was set at ≥ 38 based on Vlaeyen et al., 1995 [ 5 ]. It was then tested for agreement against the TSK Q9 cutoff (response alternatives 1–2 = No fear; 3–4 = fear), which has previously been established [ 12 , 22 ]. Pearson Chi-square test was applied on both grouping assignments to assess them for association, with Cramer V test for measurement of association effect size. The 95% confidence interval (CI) for Cramer’s V was estimated using a non-parametric bootstrap procedure with 5,000 resamples. Effect sizes were interpreted as negligible (0.1 to 0.3), medium (0.3 to 0.5) and large (> 0.5) [ 35 ]. Additionally, Cohen’s Kappa was calculated to determine the level of agreement between the two classification methods, and interpreted as poor (0–0.2), fair (0.21–0.4), moderate (0.41–0.6), substantial (0.61–0.8) and strong (0.81–1) [ 36 ]. TSK total sensitivity (i.e., number of true-positives – based on TSK Q9 classification – divided by all positives) and specificity (i.e., number of true-negatives divided by all negatives) were correspondingly calculated. To further assess the criterion validity of the TSK (objective 3) , a receiver operating characteristic (ROC) analysis was employed. The diagnostic performance was evaluated using the area under the curve (AUC), with values interpreted as poor (0.6 ≤ AUC < 0.7), fair (0.7 ≤ AUC < 0.8), considerable (0.8 ≤ AUC < 0.9) or excellent (AUC ≥ 0.9) [ 37 ]. An optimal TSK total cutoff was determined according on the maximal Youden J statistic [ 37 ]. For the subgroup analysis , based on the 90% cutoff in the KOOS pain subscale, the TSK’s internal consistency was assessed using Cronbach’s α separately for each subgroup (objective 4) . To confirm that the findings were not dependent on this threshold, a supplementary analysis was performed ( supplementary material ) using the previously published 86.1% cutoff [ 30 ]. Values considered acceptable for internal consistency ranged from 0.70 to 0.90 [ 38 ]. For the subset analysis , between the TSK and the ACL-RSI questionnaire, Spearman correlation was calculated between the two scores (objective 5) . For all the comparisons, statistical significance was set to p < 0.05. Table 2. Participants’ questionnaire data and group comparisons (PAIN vs. NO-PAIN). Values are presented as median (interquartile range). Effect sizes are presented for significant results Total ( n = 92) NO-PAIN ( n = 46) PAIN ( n = 46) (Subgroup) Effect size (ηp 2 ) Subset ( n = 30) p (Subset) Tampa Scale of Kinesiophobia Total (17–68) 33 (9) 31 (8.3) 34 (10) NS 33.5 (7.8) NS Pain (10–40) 18.5 (6) 18 (6) 19 (7) NS 18.5 (5.3) NS Q9 (1–4) 3 (1) 2.5 (1) 3 (2) NS 3 (2) NS Knee Injury and Osteoarthritis Outcome Score (KOOS, 0-100%) Symptoms 78.6 (17.9) 85.7 (17.8) 71.4 (20.4) < 0.001 0.25 78.8 (17.0) NS Pain 90.3 (11.1) 94.4 (6.2) 83.3 (13.9) < 0.001 0.76 91.7 (12.5) NS Activities of Daily Living 100.0 (5.2) 100.0 (0.0) 97.1 (8.1) < 0.001 0.35 100.0 (5.9) NS Sports/recreation 80.0 (30.0) 87.5 (21.3) 65.0 (35.0) < 0.001 0.30 80.0 (26.3) NS Quality of Life 62.5 (18.8) 68.8 (25.0) 56.3 (25.0) < 0.001 0.16 62.5 (14.1) NS ACL-Return to Sport after Injury survey (0-100) – – 44.6 (30.2) – Open in a new tab Q9, Question 9 (“I am afraid I might injure myself accidentally”) Subgrouping was determined based on a 90% cutoff on the KOOS Pain subscale Results Descriptives There were significant differences between NO-PAIN and PAIN subgroups in all KOOS subscales ( p < 0.001, ηp 2 ≥ 0.16), with the PAIN subgroup demonstrating worse overall scores. No subgroup differences were detected in any of the TSK-derived outcomes (Table 2 ; Fig. 2 ). The subset of 30 participants used for the discriminant validity analysis was comparable to the rest of the cohort with respect to demographic and clinical characteristics ( p ≥ 0.080), with only the pre-injury Tegner scorefound to be slightly higher in the subset (median [min-max]: 9 [ 7 – 10 ]) compared to the rest of the participants (8 [ 4 – 10 ]; P = 0.007). Fig. 2. Open in a new tab Subgroup comparisons of kinesiophobia and pain-related measures. Boxplots illustrate the distribution of three key scores based on NO-PAIN/PAIN subgroups. The boxes represent interquartile range with median values indicated by horizontal lines. Minimum/maximum values indicated by the whiskers. a Tampa scale of kinesiophobia (TSK) total score (TSK total ; Score range: 17–68, with higher score representing greater kinesiophobia); b Summation of the 10 pain-specific items from the TSK (Score range: 17–40, with higher score representing greater kinesiophobia); c The Pain subscale of the Knee Injury and Osteoarthritis Outcome Score (KOOS pain ; used to define the subgroups; lower percentage representing more pain) TSK correlations – Objectives 1, 2 TSK total strongly correlated with TSK pain (r s = 0.85, 95% CI: [0.78–0.90], p < 0.001; Fig. 3 a) while a weak negative correlation was observed between TSK total and KOOS pain (r s = -0.35, 95% CI: [-0.52 – -0.19], p = 0.002; Fig. 3 b). Fig. 3. Open in a new tab TSK Correlations. a Correlation between TSK total score (TSK total ; Score range: 17–68, with higher score representing greater kinesiophobia) and TSK pain-specific items (TSK pain ); b Correlation between TSK total and self-reported pain level, evaluated using the KOOS pain subscale (TSK pain ; lower percentage representing more pain) c Subset ( N = 30) analysis – correlation between TSK total and the ACL-RSI measure for psychological readiness. Abbreviations : TSK, Tampa Scale of Kinesiophobia; KOOS, Knee Injury an Osteoarthritis Outcome Score; Q9, Question 9; ACL-RSI, Anterior Cruciate Ligament Return to Sport After Injury Survey Criterion validity – Objective 3 Comparing the TSK total and TSK Q9 binary classifications (Fig. 4 a) revealed a significant association (χ² = 18.790, p < 0.001) between the two measures, though with a medium effect size (Cramer’s V = 0.452, 95% CI: [0.308–0.575], p < 0.001). Based on a cutoff score of 38 for kinesiophobia [ 5 ], the TSK total had a sensitivity of 37.25% (95% CI: 23.99% − 50.52%) and specificity of 97.50% (95% CI: 88.53% − 100%) against the TSK Q9 classification. The Kappa statistic indicated a fair level of agreement between the two classifications. (K = 0.313; 95% CI: [0.172–0.454], p < 0.001). ROC analysis on our cohort instead demonstrated a considerable diagnostic performance of the TSK total (AUC = 0.802, 95% CI: 0.712–0.891; Fig. 4 b). The maximum Youden (J = 0.584) corresponded to an optimal cutoff of 33.5, yielding sensitivity of 70.6% and specificity of 87.8%. Fig. 4. Open in a new tab Criterion validity of the TSK. a Agreement between binary classifications based on TSK total and TSK Q9 is shown, with the TSK total classification (based on a cutoff of 38 for kinesiophobia [ 5 ]) demonstrating a sensitivity of 37.25% and specificity of 97.5%. b Receiver operating characteristic (ROC) curve representing the classification performance of the TSK-17 total score, against TSK Q9 -based dichotomisation. The X-axis indicates 1-specificity, (i.e., false positive rate) and the Y-axis indicates sensitivity (true positive rate). The blue diagonal line represents the performance of a random classifier, where the true positive rate equals the false positive rate. The optimal cutoff, the point on the ROC curve with the best sensitivity and specificity (70.6% and 87.8%, respectively), based on the maximum Youden J statistic is indicated. Abbreviations : TSK, Tampa Scale of Kinesiophobia; Q9, Question 9 Internal Consistency (subgroup analysis) – Objective 4 The TSK Cronbach’s α for the NO-PAIN subgroup (KOOS pain ≥ 90%) was 0.652, indicating a non-satisfactory internal consistency for individuals with minimal or no pain. For the PAIN subgroup, (KOOS pain < 90%), α = 0.769 was observed, indicating satisfactory internal consistency. Discriminant validity (subset analysis) – Objective 5 For the subset of 30 participants, no significant correlation was observed between TSK total and ACL-RSI scores (Fig. 3 d). Discussion The overarching purpose of this study was to establish whether the TSK was a suitable tool to assess re-injury worries among individuals after ACLR, either with or without current pain. The present findings indicate that the pain-specific items of the TSK substantially drive the total score, while at the same time, kinesiophobia and reported pain show a negligible relationship. The TSK had acceptable internal consistency in individuals with pain, but not in those without pain. The TSK’s criterion validity based on an established cutoff-score of 38, had fair agreement with a classification based on TSK Q9 , while even an optimal cutoff was shown to have a limited capability to detect fearful individuals. Finally, for the subset of 30 participants, the TSK was not associated with the ACL-RSI, reinforcing that the two instruments assess distinct constructs. Collectively, these findings suggest that the TSK may not be the most suitable measure to use with athletic individuals after ACLR, for evaluation of their re-injury worries. The construct of kinesiophobia relates mainly to other types of musculoskeletal concerns, with its target population being comprised of individuals suffering from pain-dominating conditions [ 1 , 39 ]. Indeed, the ten items containing an explicit mentioning of pain significantly contributed to the total score. Although half the participants were allocated to a PAIN subgroup based on their KOOS pain scores, the level of their self-reported pain was slightly higher than the cutoff value previously established for symptomatic knees [ 30 ]. Moreover, the PAIN subgroup had statistically shorter times from surgery, making the presence of residual surgery pain, as well as lower scores in all other subscales of the KOOS, somewhat expected. This did not influence their kinesiophobia, given similar scores in TSK-derived outcomes, with both groups’ median TSK total scores being below the cutoff for kinesiophobia used for other populations [ 5 ]. In addition, the associations between KOOS pain and TSK total scores were low, whereas patients with chronic pain conditions have been shown to have strong associations between kinesiophobia and pain-related outcomes [ 40 ]. Together, these findings suggest that subacute pain after ACLR may not translate into anxiety regarding future injuries and instead may be perceived as a natural consequence to the recent trauma. However, given the cross-sectional nature of the present study, no causal relationship can be inferred. For the NO-PAIN subgroup, the internal consistency of the TSK was low and below the acceptable threshold [ 38 ], which raises concerns about its applicability for assessing re-injury worries in this population. Further, although the PAIN subgroup had an acceptable internal consistency, it was considerably lower than α values reported in individuals suffering from chronic pain [ 25 ]. This suggests that, particularly for those whose primary concern is not pain, the TSK may not fully capture a single consistent construct and that there may be conceptual differences or lower relevance of certain items. In previous work [ 12 , 22 ], which also included individuals after ACLR, the inherent heterogeneity of the TSK items motivated the use of a single question (TSK Q9 ) specifically referring to being afraid of accidently getting injured. With no gold-standard measure for re-injury worries, establishing a cutoff for fear in any questionnaire is problematic. TSK Q9 allowed for a simple dichotomisation of participants’ worries, and indeed those classified as “high-fear” demonstrated distinct biomechanics when performing an injury-relevant functional hop task [ 12 , 22 ]. The present findings indicate that using the TSK total score as a classifier for kinesiophobia among individuals after ACLR is likely going to fail in identifying individuals with re-injury worries, at least with the use of the previously established cutoff [ 5 ]. The ROC analysis determined a more sensitive cutoff of 33.5, although with a sensitivity of 70.6% a substantial number of fearful patients would remain unidentified. This is further supported by the observed reduction in activity levels among our participants, as evident by their pre-injury and current Tegner scores. Despite being on average at a stage of returning to sport (mean time post-surgery: 13.5 months), many participants had not resumed their previous activity level, a tendency often related to re-injury worries [ 10 , 11 , 41 ] . To the authors’ knowledge, no previous study has provided a TSK-17 cutoff recommendation for individuals following ACL injury. Shortened versions of the TSK are frequently used instead of the original 17 items version. Particularly, in the TSK-11, items with low internal consistency have been removed, resulting in a concise version with comparable psychometric properties to the longer version, notably among patients with low back pain [ 42 ]. However, pilot work by Paterno et al. [ 14 ] did define a TSK-11 cutoff for ACL injured persons, with scores ≥ 17 interpreted as high kinesiophobia. This cutoff, equivalent to 26.5 on the TSK-17, is considerably lower than the established 38 for chronic pain [ 5 ]. Based on the ROC analysis, applying such a cutoff would have yielded 92.2% sensitivity and 36.6% specificity, resulting in many participants being incorrectly classified as having high re-injury worries despite low kinesiophobia. Moreover, it may be inadvisable to apply a TSK-11-based cutoff for TSK-17. Doing so would overlook six additional items that contribute to the TSK-17 score, combined with the limited internal consistency in the current sample. Moreover, the TSK-11 does not contain the fear-specific Q9 and thus lacks an explicit measure of fear of re-injury that does not refer to pain or general exercise as the cause of a potential future injury. Kvist et al. [ 20 ] were the first to apply the TSK on individuals after ACL injury in 2005. However, the authors used an adapted version, in which multiple relevant modifications were made to better suit the ACL-injured athletic population [ 20 ]. The modified version, despite lacking formal evaluation of its psychometric properties, can be expected to better reflect re-injury worries in this population, given that the wording (e.g., “knee trouble” instead of “pain”) is more relatable. This version has been used in at least three other studies since then [ 17 , 41 , 43 ] and could potentially serve as a viable option for practitioners opting for continuity with the original instrument while maintaining its relevance for athletes. Kvist et al., 2013 [ 43 ] reported a moderate correlation between their modified TSK-17 and the ACL-RSI measure of psychological readiness, indicating that the two constructs are related to each other. In the present study, however, we found no significant correlations between the ACL-RSI and the original TSK version, indicating strong discriminant validity, confirming that the two measures address distinct constructs with limited overlap. The ACL-RSI, designed particularly for ACL-injured persons, contains items related to fear of re-injury, confidence and sport-specific risk appraisal, as well as references to worries regarding prolonged rehabilitation. While elements such as confidence and risk appraisal are reflected in the TSK as well, it is the context that is inherently different. Confidence in the TSK relates to general aversion of physical activity (e.g., “ I’m afraid that I injure myself if I exercise ” (Q1), “ No one should have to exercise when he/she is in pain ”) (Q17), which is less of a concern to athletes for whom physical activity may be a way of life [ 44 ]. Risk appraisal is deeply connected to pain and naturally feeds into catastrophizing thoughts due to statements such as: “ I wouldn’t have this much pain if there weren’t something potentially dangerous going on in my body ”. There are also statements concerning how “ people with a condition like mine ” should behave, which are absent from the ACL-RSI. Therefore, the lack of association between the measures, observed in the present study was not surprising. It has been reported that athletes often struggle with frustration [ 45 – 47 ], anger [ 46 ], anxiety [ 45 , 47 ] and depression [ 45 – 47 ] during the recovery process. These emotions are intensified by the realisation of how the injury has disrupted the athlete’s sports participation, along with the feeling of missing out on opportunities as their teammates continue to play [ 47 ]. Throughout the recovery process, pain (among other factors) may contribute to the athlete’s appraisal of the severity of their injury [ 48 ]. However, when the injury/surgery pain subsides, other factors affect their re-injury fear [ 17 , 19 ], which can manifest particularly when required to perform risk-associated movements related to the injury context [ 47 ]. This is again fundamentally different from patients experiencing chronic pain, whose catastrophising thoughts may lead to avoidance behaviour [ 49 ]. The pain experience in those patients is central to the anxiety and behavioural change, which may manifest in avoiding movement in general, rather than in an injury-specific context [ 3 ]. Tissot et al., 2023 [ 50 ] demonstrated that the TSK (the 11-item version) underestimated task-specific fear even in individuals with low back pain. Questionnaires that target specific fears, regarding injury-specific situations, are seldom applied in research/clinical context. One example is an eight-item questionnaire proposed by Ardern et al., 2012 [ 51 ], which has shown high internal consistency and includes a question related to “ injury-provoking situations when playing your spor t”, as well as referring to environmental conditions such as a wet playing field or the type of gym floor. Another injury anxiety assessment tool, the Japanese ACL-25 (JACL-25) questionnaire [ 52 ], contains task-specific items that refer to worries, fear and hesitation during e.g., hopping, changing direction, landing. Huang et al., 2019 [ 53 ] reported that the TSK only moderately correlated to the JACL-25, and was thus interpreted as having insufficient validity for individuals after ACL injury. Similarly, a lack of associations between the TSK to the ACL-RSI in the present study does not support administering the TSK to ACL-injured persons when there are other more relevant questionnaires. Clinicians and researchers have at hand questionnaires which are more population-specific, such as the ACL-RSI 54, which has also a short 6-item version [ 54 ]. Although short, it captures the same concepts as the longer version and unlike the TSK, does not focus on pain or general exercise. Another tool when it comes to sports injuries, particularly among competitive athletes, is the re-injury anxiety inventory (RIAI) [ 55 ], which highlights the psychological state of an athlete in relation both to their rehabilitation and to future reintegration into competitive sports. However, the RIAI would not be suitable for recreational, non-competitive athletes as it has many items referring explicitly to return to competition. Clinicians may therefore benefit from selecting questionnaires that align with their patients’ needs, rather than defaulting to tools that are commonly used in studies. On that note, the authors would like to highlight the importance of delving into scientific methods when citing articles. Historically, this has been overlooked, resulting in a widespread use of the classic TSK on ACL-injured persons [ 9 ], instead of the modified version used by Kvist et al. [ 20 ]. Study limitations First, although the sex distribution was similar across subgroups, the overall sample included a higher proportion of females. Therefore, we cannot rule out possible gender-related differences in kinesiophobia reporting. Second, only a subset ( n = 30) completed the ACL-RSI, which is below the recommended n = 50 [ 26 ], limiting the analysis of the TSK’s discriminant validity and its relationship with a more ACL-specific measure of psychological readiness across the entire cohort. A third limitation concerns the subgrouping, which was based on an arbitrary cutoff value of the KOOS pain subscale. In the present study, a stringent 90% cutoff was used, which incidentally resulted in a balanced subgroup distribution. However, as this threshold was not empirically derived, we also repeated the analysis using the 86.1% cutoff reported in the literature [ 30 ], yielding comparable results (supplementary material) and thus supporting the robustness of our findings. Fourth, given that data from two separate projects were combined, differences in the order of how questionnaires were completed and their format (paper vs. digital) could potentially have introduced variability in their scores [ 56 ]. Finally, the use of convenience sampling may further limit the generalisability of the findings to other populations, e.g., older athletes. Conclusion and recommendations The present findings indicate that the TSK may have limited suitability for assessing re-injury worries in active individuals after ACL reconstruction. The total score’s strong dependence on pain-specific items and limited internal consistency in pain-free individuals raise concerns about its use in this population. Furthermore, the TSK’s non-satisfying sensitivity compared with a more direct measure of re-injury worries and its divergence from the ACL-RSI highlight potential conceptual and psychometric limitations. From a research perspective, inclusion of the TSK in future data collections of ACL-injured persons should be carefully considered. Existing registries or datasets may also consider inspecting their TSK data alongside other measures of related constructs to explore, among other properties, the between-measurement relationships. Then, a more informed decision can be made regarding the interpretation of TSK scores for individuals after ACL injury. From a clinical perspective, clinicians and researchers may benefit from considering adopting more population-specific instruments when addressing re-injuries worries among ACL-injured persons, to better describe the psychological dimensions of this injury. Supplementary Information Supplementary Material 1. (42.7KB, docx) Acknowledgements We gratefully acknowledge Jonas Markström, Andrew Strong, Heidi Nedergård and Yevgenia Grinberg for their role in participant recruitment and data collection. We also extend our gratitude to all the study participants and fund givers. Clinical trial number Not applicable. Authors’ contributions A.G. conceptualised the study, obtained the data, designed and performed the main analysis, interpreted the results, drafted and revised the manuscript. M.B. contributed to the conceptualisation and methodology, interpreted the results and contributed to the writing of the manuscript. C.K.H. acquired funding, contributed to the conceptualisation and methodology, recruited participants, interpreted the results and contributed to the writing of the manuscript. All authors read and approved the final manuscript. Funding Open access funding provided by Umea University. This study has received funding from the Swedish Scientific Research Council (Grant No. K2014-99X-21876-04-4; 2017 − 00892 2016-02763; 2022 − 00774), Region Västerbotten (Grant No. ALF VLL548501, VLL838421and Strategic funding VLL-358901; Project No. 7002795; Cutting Edge funding RV966109 and 2022–2024; ALF funding RV 967112 and 2022–2024), the Swedish Research Council for Sports Science (Grant No. CIF 2017/8 P2018-0104, FO-2018-0034; FO-2019-00082; 2020/9; P2020-0035; 2021/9 P2022; 2022/10; P2023-0030), Umeå University School of Sport Science (Grant No. IH 5.3-13-2017; IH 5.2–25-2021), Umeå University Foundation for Medical Research (Sandströms foundation 20–22) and King Gustaf V and Queen Victoria’s Foundation of Freemasons. Data availability Data will be available from the authors upon reasonable request and in accordance with GDPR regulations. Declarations Ethics approval and consent to participate This study was conducted in accordance with the Declaration of Helsinki and approved by the Swedish Ethical Review Authority (Projects No. 2015/67 − 31; 2021–03860). All participants provided written informed consent to participate. All processed and published data were anonymised. Consent for publication Not applicable. Competing interests The authors declare no competing interests. Footnotes Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. References 1. Kori SHM, Miller P, Todd DD. Kinesiophobia: a new view of chronic pain behavior. Pain Manage. 1990:35–43. 2. Lethem J, Slade P, Troup J, Bentley G. Outline of a fear-avoidance model of exaggerated pain perception—I. Behav Res Ther. 1983;21(4):401–8. [ DOI ] [ PubMed ] [ Google Scholar ] 3. Vlaeyen JW, Linton SJ. 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