Rethinking the Tampa scale of kinesiophobia as a measure of re-injury worries after anterior cruciate ligament injury

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.