Positive reframing: an important but underutilized coping strategy in athletes undergoing sport-related knee surgery

Key points

1. 01Positive reframing was used least often by athletes under age 20, despite being the group that benefited most from it.
2. 02In athletes under 32, higher positive reframing scores were associated with greater odds of returning to prior sport (OR 2.36, 95% CI 1.12-5.10, P=.009).
3. 03Athletes under 20 who used more positive reframing had higher satisfaction (OR 6.21, 95% CI 1.29-11.5, P=.02) and lower kinesiophobia scores.
4. 04Male athletes who relied more on self-distraction had lower satisfaction after surgery (OR 0.53, 95% CI 0.30-0.89, P=.02).
5. 05Athletes over 40 who used greater instrumental support had less fear of reinjury (mean 2.0-point decrease in kinesiophobia per point increase, r=-0.48, P=.01).

How it was conducted

Design

Prospective case series, single center

Participants

184 athletes (104 men, 80 women) aged over 14 years who underwent outpatient sport-related knee surgery between 2014 and 2016

Coping assessment

Brief-COPE inventory administered preoperatively; 6 subscales assessed: self-distraction, venting, acceptance, positive reframing, emotional support, and instrumental support

Primary outcomes

Return to prior sport level, postoperative satisfaction, IKDC-Subjective score, and Tampa Scale for Kinesiophobia (TSK-11) at median 10.7 months follow-up

Procedures

Arthroscopy/meniscectomy (35%), ACL reconstruction (33%), cartilage restoration (18%), meniscus repair (9%), other repair (3%)

Analysis

Logistic and linear regression stratified by age group (under 20, 20-25, 26-31, 32-40, over 40 years) and sex

What they found

• Overall return to prior sport level was 72%; rates ranged from 50% in athletes under 20 to 90% in athletes over 40 (P<.001).
• Overall satisfaction was 86%; athletes over 40 had 100% satisfaction versus 83% in those under 40 (P=.004).
• Positive reframing was used less frequently in athletes under 20 (mean 3.9/8, SD 1.1) versus those 20 and older (mean 4.6/8, SD 0.9; P=.001).
• Per 1-point increase in positive reframing score, odds of return to sport in athletes under 32 increased: OR 2.36 (95% CI 1.12-5.10, P=.009).
• Per 1-point increase in positive reframing score, odds of satisfaction in athletes under 20 increased: OR 6.21 (95% CI 1.29-11.5, P=.02).
• Per 1-point increase in positive reframing, mean kinesiophobia score decreased by 2.9 points in athletes under 20 (r=-0.53, P=.02).
• Per 1-point increase in instrumental support, mean kinesiophobia score decreased by 2.0 points in athletes over 40 (r=-0.48, P=.01).
• Self-distraction was used more by men than women (mean 5.7 vs 5.3, P=.03); greater self-distraction was associated with lower satisfaction in men (OR 0.53, 95% CI 0.30-0.89, P=.02).
• No coping strategy predicted IKDC-Subjective scores at follow-up.
• Surgical procedure and follow-up length were not significant interaction terms in any analysis (all P>.25).

Limitations

• Follow-up ranged from 3 to 21 months, which may have introduced variability in satisfaction ratings depending on where in recovery an athlete was assessed.
• The study was observational, so it cannot confirm that coaching athletes toward positive reframing would change outcomes.
• Preoperative activity level scales such as Tegner scores were not routinely collected, limiting understanding of baseline function.
• Findings may not generalize to athletes younger than 14 or older than 60, or to non-English-speaking populations without further validation.

Why it matters

For patients

Young athletes recovering from knee surgery may benefit from learning positive reframing techniques before or early after their operation, as this mindset was linked to higher chances of returning to sport and less fear of reinjury.

For clinicians

Athletic trainers and sports medicine teams should screen for coping style preoperatively and consider referring young athletes to sports psychology or cognitive behavioral therapy to build positive reframing skills before surgery.

For readers

This study highlights a gap between which coping strategies benefit younger athletes most and which they actually use, suggesting targeted psychological support during surgical planning could improve rehabilitation outcomes.