Fear avoidance: 4 ways to address fear of pain and re-injury

2019; Michigan State Spartans forward Nick Ward (44) in pain. Credit: Joe Maiorana-USA TODAY Sports

Fear is an emotional response to a threat, either real or perceived. It is a great motivator and rapidly modifies behavior. Fear avoidance is making behavioral choices to avoid that which instills fear, like taking a circuitous route to keep from driving down a street you know is a police speed trap.

As discussed in last week’s newsletter, injured athletes can begin to catastrophize about their injury. They can’t stop thinking about the pain of injury (rumination); they might think it’s the worst possible injury and that it will end their sports career (magnification); or that nothing can be done about their pain or injury and they will never recover (helplessness). All this negative thinking can lead to fear of pain or further injury, and avoidance of anything that might cause pain, make the injury worse, or result in another injury.

This negative-feedback loop results in constant monitoring of physical status and hyper vigilance toward anything that causes discomfort, even training. Athletes may begin to avoid cross training that doesn’t even relate to the initial injury. The decreased physical activity results in deconditioning and further negative thoughts, which can ultimately lead to depression and disability(1). Fear avoidance behaviors can take on a life of their own, existing long after the initial injury has healed and function should return to normal. In fact, measurements of fear avoidance may be a better prognosticator of return to sport than biometric factors such as healing and strength(2).

Fear avoidance can be measured using such tests as the Fear-Avoidance Pain Scale (FAPS), Pain Anxiety Symptom Scale (PASS), The Tampa Scale of Kinesiophobia (TSK), or the Fear-Avoidance Beliefs Questionnaire (FABQ). To specifically target athletes, researchers in Quebec developed the Athlete Fear Avoidance Questionnaire (AFAQ), which measures fear avoidance related to sports injuries. A Linkoping University study using the TSK found that 53% of the 62 patients surveyed three to four years after anterior cruciate ligament (ACL) repair, returned to prior level of sport(3). The remainder demonstrated more fear of re-injury on the TSK than the group that resumed their previous activities.

Another study from the University of Florida found that almost one-fourth of the 73 participants surveyed with the TSK at six months and one-year post ACL repair, didn’t return to their prior level of sport because of fear of re-injury or lack of confidence(4). In addition, these subjects also demonstrated greater quadriceps weakness and lower overall knee function scores. The authors of this study suggest that in addition to the regular physiological return to sport post-ACL repair criteria, practitioners add a fear of re-injury assessment along with a self-reported knee function measure to identify those at risk for not returning to prior level of play.

Don’t fear the fear

Skirting around the issue and plodding through rehab hoping it will go away isn’t the right way to address an athlete’s hesitancy to do the hard activities. Neither is the ‘just suck it up’ approach. Here’s four ways based on cognitive behavioral treatment, to address fear avoidance with an athlete(1):

  1. Education – Once an athlete knows that lack of confidence and fear can make their pain worse and actually effect their ability to return to sport, they become more aware of it within themselves.
  2. Identification – Broaden their awareness by helping athletes identify their own feelings and the situations that provoke them.
  3. Develop a hierarchy – Once they identify situational triggers, have them rate them from least fearful to most fearful. For instance, post-ACL repair, stair climbing might be slightly fear producing, while the athlete may shudder at the thought of running again.
  4. Graded exposure – Beginning with the least feared activity, have the athlete perform the activities in a controlled environment with safe boundaries. Gradually remove safeguards until they can perform the activity in real time without worry. Progress along the hierarchy as tolerated.


  1. JOSPT.2016 Feb;46(2):38
  2. J Athl Train. 2015;50(6):634
  3. Knee Surg Sports Traumatol Arthrosc. 2005;13:393
  4. Amer J Sports Med. 2015 Feb;43(2):345


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