An Investigation of the Nature of Fear within ACL-Injured Subjects When Exposed to Provocative Videos: A Concurrent Qualitative and Quantitative Study

Fear is a factor contributing to poor return to sport after an anterior cruciate (ACL) injury, however the identification and assessment of fear is challenging. To improve understanding of fear, this study qualitatively and quantitatively assessed responses to videos depicting threat to knee stability in people who had experienced an ACL injury. ACL-injured participants who had above average fear on the Tampa Scale of Kinesiophobia and were at least 1-year post-injury/surgery were eligible. Participants were shown four videos depicting sequentially increasing threat to their knee stability (running, cut-and-pivot, feigned knee injury during cut-and-pivot, series of traumatic knee injuries). Qualitative interviews explored participants feeling related to viewing the videos. Participants quantitatively self-rated fear and distress in response to each video. Seventeen participants were included in this study (71% female, with an average time since last ACL injury of 5 ½ years). Five themes were identified: (1) Evoked physiological responses, (2) Deeper contextualisation of the meaning of an ACL injury influencing bodily confidence, (3) Recall of psychological difficulties, (4) Negative implications of a re-injury, and (5) Change to athletic identity. Quantitatively, direct proportionality was noticed between threat level and reported fear and distress. Specifically, participants reported increasing levels of fear and distress as the videos progressed in threat level, with the largest increase seen between a cut-and-pivot movement to a feigned injury during a cut and pivot. The results support the notion that in addition to being a physical injury, an ACL injury has more complex neurophysiological, psychological, and social characteristics which should be considered in management. Using video exposure in the clinic may assist identification of underlying psychological barriers to recovery following an ACL injury, facilitating person-centred care.