The relationship between kinesiophobia and return to sport after shoulder surgery for recurrent anterior instability

Key points

1. 01Only 47% of the 66 patients returned to their pre-injury sport level at a mean follow-up of 61.1 months
2. 02Kinesiophobia (TSK) correlated moderately with return to sport outcome (rho = 0.505, p < 0.001)
3. 03Patients who did not return to sport had significantly higher TSK scores than those who did (30.1 vs 23.4, p = 0.006)
4. 04TSK was the only independent predictor of return to sport in the multivariate model (coefficient 0.146, p = 0.025)
5. 05Perceived shoulder function (WOSI) did not independently predict return to sport in the multivariate model

How it was conducted

Design

Retrospective questionnaire-based case series

Participants

66 patients (mean age 35.5 years, SD 9.9) treated for recurrent anterior shoulder instability at a single centre

Surgery types

Arthroscopic Bankart repair (n=52, 78.8%) or open Bristow-Latarjet procedure (n=14, 21.2%)

Follow-up

Mean 61.1 months (SD 37.5, range 12-156 months)

Primary outcome

Difference between pre-injury and postoperative DOSIS score (D-DOSIS); predictor was Tampa Scale for Kinesiophobia (TSK)

Secondary outcome

Western Ontario Shoulder Instability Index (WOSI) for perceived shoulder function

What they found

• 47.0% of patients (31/66) returned to pre-injury sport activity (D-DOSIS <= 0)
• TSK correlated with D-DOSIS: rho = 0.505, p < 0.001; TSK1 subscale rho = 0.485, p < 0.001; TSK2 subscale rho = 0.402, p < 0.001
• TSK correlated with WOSI: rho = 0.589, p < 0.001; TSK1 rho = 0.619, p < 0.001; TSK2 rho = 0.484, p < 0.001
• Mean TSK score was 23.4 (SD 7.4) in patients who returned vs 30.1 (SD 9.6) in those who did not (p = 0.006, FDR q = 0.0075)
• Mean WOSI score was 1.9 (SD 1.8) in those who returned vs 4.5 (SD 2.7) in those who did not (p = 0.0001, FDR q = 0.00025)
• Multivariate model: TSK was an independent predictor of D-DOSIS (coefficient 0.146, SE 0.063, p = 0.025, 95% CI 0.019-0.273); model F = 6.799, p < 0.001, R2 = 0.374
• WOSI did not independently predict D-DOSIS in the multivariate model (coefficient 0.228, p = 0.263)

Limitations

• Retrospective design with wide follow-up range (1-10 years) introduces recall bias for baseline sport activity levels
• No a priori power calculation; small sample size (n=66) limits subgroup analyses and generalizability
• Participation bias: only 67% of eligible respondents completed the questionnaire, and non-responders may differ systematically
• Single-centre study with two surgeons limits external validity

Why it matters

For patients

Patients who feel fearful of re-injury after shoulder surgery may be less likely to return to their previous sport, suggesting that addressing psychological readiness is as important as physical recovery.

For clinicians

Routine screening for kinesiophobia using tools like the TSK after shoulder stabilization surgery could identify patients who may benefit from targeted psychological support or cognitive-behavioral interventions to facilitate return to sport.

For readers

This study adds shoulder surgery to the list of orthopaedic conditions where kinesiophobia independently predicts return to sport, strengthening the case for bio-psychosocial rehabilitation models.