Impact of preoperative kinesiophobia on early rehabilitation compliance and functional recovery after arthroscopic meniscal repair

Abstract

BACKGROUND

Meniscal injury is a common orthopedic condition significantly affecting knee function and quality of life. While arthroscopic meniscal repair has become the preferred treatment, postoperative rehabilitation adherence remains crucial for optimal functional recovery. Kinesiophobia, defined as excessive fear of movement due to concerns about pain or re-injury, has been shown to negatively impact rehabilitation outcomes in various orthopedic conditions. However, its specific impact on rehabilitation compliance and functional recovery after arthroscopic meniscal repair remains inadequately investigated.

AIM

To investigate the impact of preoperative kinesiophobia on early rehabilitation adherence and functional recovery following arthroscopic meniscal repair.

METHODS

A retrospective analysis was conducted on clinical data from 269 patients who underwent arthroscopic meniscal repair between January 2021 and June 2024. Based on preoperative Tampa Scale for Kinesiophobia (TSK) scores, patients were divided into a kinesiophobia group (120 cases, TSK ≥ 37) and a non-kinesiophobia group (149 cases, TSK < 37). The Modified Exercise Adherence Rating Scale (MEARS) was used to assess rehabilitation adherence at 1 month, 3 months, and 6 months postoperatively. Lysholm score, range of motion, and Visual Analogue Scale were used to evaluate knee function recovery and pain status. Pearson correlation analysis was employed to explore the correlation between TSK scores and rehabilitation adherence and functional recovery indicators. Multiple linear regression analysis was used to investigate factors influencing rehabilitation adherence at 3 months postoperatively.

RESULTS

The TSK total score of the kinesiophobia group was (42.8 ± 4.2) points, higher than the non-kinesiophobia group’s (30.5 ± 3.8) points. At 1 month, 3 months, and 6 months postoperatively, the MEARS scores of the kinesiophobia group were lower than those of the non-kinesiophobia group. The excellent adherence rate at 3 months postoperatively was 26.7% in the kinesiophobia group and 54.4% in the non-kinesiophobia group. At 6 months postoperatively, the Lysholm score of the kinesiophobia group was (84.7 ± 9.8) points, lower than the non-kinesiophobia group’s (91.2 ± 7.6) points. Range of motion in the kinesiophobia group was (128.4° ± 10.5°), less than the non-kinesiophobia group’s (135.8° ± 9.3°). Preoperative TSK total score was negatively correlated with MEARS score at 3 months postoperatively and negatively correlated with Lysholm score. Multiple linear regression analysis showed that preoperative TSK score (β = -0.512, P < 0.001), education level (β = 0.186, P = 0.002), and disease duration (β = -0.152, P = 0.012) were independent factors influencing rehabilitation adherence at 3 months postoperatively. Binary logistic regression analysis showed that preoperative TSK score (odds ratio = 1.082, 95% confidence interval: 1.032-1.134, P = 0.001) was an independent risk factor for postoperative complications.

CONCLUSION

Preoperative kinesiophobia is an important factor affecting early rehabilitation adherence, functional recovery, and pain control following arthroscopic meniscal repair. It is recommended to routinely conduct kinesiophobia screening preoperatively and implement early psychological interventions for high-risk patients to improve rehabilitation adherence and promote knee function recovery.

Key Words: Kinesiophobia; Meniscal injury; Arthroscopy; Rehabilitation adherence; Functional recovery; Tampa Scale for Kinesiophobia

Core Tip: Preoperative kinesiophobia significantly impairs early rehabilitation adherence and delays functional recovery after arthroscopic meniscal repair. Higher Tampa Scale for Kinesiophobia scores predict poorer Modified Exercise Adherence Rating Scale performance, slower improvement in Lysholm scores, limited knee range of motion, and higher postoperative pain levels. Kinesiophobia is also an independent risk factor for postoperative complications. Routine preoperative screening and early psychological intervention may effectively improve adherence and enhance postoperative outcomes.

INTRODUCTION

Meniscal injury is one of the most common sports injuries in orthopedic clinical practice, frequently occurring in young and middle-aged active populations, and significantly affecting patients’ joint function and quality of life[1]. With the continuous development and improvement of arthroscopic techniques, arthroscopic meniscal repair has become the preferred treatment method for meniscal injuries due to its advantages of minimal trauma, reduced bleeding, and rapid recovery[2]. However, surgical success does not equate to complete restoration of knee function; systematic and standardized postoperative rehabilitation training is crucial for knee function recovery[3]. Clinical practice has shown that postoperative rehabilitation adherence is a key factor affecting knee function recovery, and patients’ psychological state is one of the important factors influencing rehabilitation adherence[4].

Kinesiophobia refers to the excessive, irrational, and debilitating fear of movement and physical activity that patients develop due to concerns that exercise will lead to pain exacerbation or re-injury[5]. The Tampa Scale for Kinesiophobia (TSK) is currently the most commonly used and internationally validated assessment tool for evaluating kinesiophobia with good reliability and validity. Recent studies have found that kinesiophobia is prevalent among postoperative orthopedic patients and may have significant negative impacts on postoperative rehabilitation progress[6]. In conditions such as chronic low back pain, anterior cruciate ligament reconstruction, and rotator cuff injuries, kinesiophobia has been confirmed to be closely associated with decreased rehabilitation training adherence, delayed functional recovery, prolonged pain duration, and reduced quality of life[6].

However, specific research on the impact of preoperative kinesiophobia on rehabilitation adherence and functional recovery following arthroscopic meniscal repair is relatively limited, lacking systematic clinical data support and quantitative analysis. Based on this, this study retrospectively analyzed clinical data from 269 patients who underwent arthroscopic meniscal repair to systematically evaluate the correlation between preoperative kinesiophobia and early postoperative rehabilitation adherence, knee function recovery indicators, and pain control effectiveness, and to explore multifactorial analysis of factors influencing postoperative rehabilitation adherence. The aim is to provide scientific evidence and theoretical support for developing individualized, targeted perioperative psychological intervention programs in clinical practice, thereby improving postoperative rehabilitation adherence, promoting early comprehensive recovery of knee function, and ultimately improving patients’ clinical prognosis and long-term outcomes[7].

MATERIALS AND METHODS

Study subjects

A retrospective analysis was conducted on clinical data from patients who underwent arthroscopic meniscal repair in the orthopedics department of our hospital between January 2021 and June 2024.

Inclusion criteria: (1) Age 18-65 years; (2) Meniscal injury confirmed by magnetic resonance imaging and arthroscopic examination; (3) Treatment with arthroscopic meniscal repair; (4) Completion of preoperative kinesiophobia assessment; and (5) Complete clinical data with postoperative follow-up time ≥ 6 months.

Exclusion criteria: (1) Concurrent serious knee pathology (such as severe osteoarthritis, ligament rupture, etc.) requiring simultaneous surgery; (2) Previous ipsilateral knee surgery history; (3) Concurrent severe cardiopulmonary disease, psychiatric disorders, or cognitive dysfunction; (4) Incomplete adherence assessment data; and (5) Loss to follow-up or missing follow-up data.

This retrospective study was approved by the Ethics Committee of the First Affiliated Hospital of Henan Medical University (Approval No. EC-2025-717). Due to the retrospective nature of the study, patient informed consent was waived. Initially, 312 patients met the inclusion criteria; 18 patients who did not complete preoperative TSK assessment, 19 lost to follow-up, and 6 with incomplete data were excluded, ultimately including 269 patients.

Surgical method

All surgeries were performed by the same group of senior orthopedic surgeons. Patients were placed in supine position under combined spinal-epidural anesthesia or general anesthesia, with a tourniquet applied at the thigh root. Standard anteromedial and anterolateral portals were established, saline was injected to expand the joint cavity, and intra-articular structures were systematically examined. After determining the type, location, and extent of meniscal injury, suturing techniques were selected based on the injury: Red-red zone injuries were treated with inside-out suturing technique, red-white zone injuries were treated with all-inside suturing technique, and longitudinal tears with length > 10 mm were treated with inside-out suturing technique. During surgery, injury margins were thoroughly debrided to ensure fresh suture surfaces. All-inside suturing spacing was approximately 3-4 mm, inside-out suturing spacing was approximately 4-6 mm, and inside-out suturing spacing was approximately 5-6 mm. After surgery, the joint cavity was irrigated, a drain was routinely placed, and sterile dressings were applied.

Assessment indicators

General data: Patient gender, age, body mass index (BMI), injury side, injury type (categorized by arthroscopic examination as longitudinal tear, transverse tear, horizontal tear, complex tear), disease duration, and education level (junior high school and below, high school/technical secondary school, college and above) were collected from the medical record system as baseline data.

Preoperative kinesiophobia assessment: The TSK was used for assessment. This scale was developed by Miller et al[8] in 1991 to evaluate patients’ fear of movement and re-injury. The Chinese version has been validated for reliability and validity with a Cronbach’s α coefficient of 0.82. The scale contains 17 items, which according to Roelofs et al’s research[9], are divided into two dimensions: Somatic focus (items 1, 2, 3, 7, 9, 10, 13, 14, 15, 17, totaling 10 items) and activity avoidance (items 4, 5, 6, 8, 11, 12, 16, totaling 7 items). Each item uses a 4-point Likert scale (1 point = strongly disagree, 2 points = disagree, 3 points = agree, 4 points = strongly agree), with items 4, 8, 12, and 16 being reverse-scored (i.e., original scores of 4, 3, 2, 1 points are converted to 1, 2, 3, 4 points respectively before being included in the total score). The total score ranges from 17-68 points, with higher scores indicating more severe kinesiophobia. Patients were divided into two groups: Kinesiophobia group (TSK ≥ 37 points) and non-kinesiophobia group (TSK < 37 points). Since 2020, our hospital has routinely conducted preoperative TSK assessments for all patients scheduled for knee surgery. The assessment was completed by trained rehabilitation therapists 1-3 days before surgery during hospitalization, and assessment data were extracted from the medical record system.

Primary outcome measures: Early rehabilitation adherence (3 months postoperatively): The Modified Exercise Adherence Rating Scale (MEARS) was used to assess rehabilitation adherence at 1 month, 3 months, and 6 months postoperatively. The MEARS was adapted from the original Exercise Adherence Rating Scale developed by Newman-Beinart et al[10] for chronic musculoskeletal pain populations. The Chinese version of MEARS was validated by Cai et al[11] in patients undergoing orthopedic surgery, demonstrating good internal consistency (Cronbach’s α = 0.87), test-retest reliability (intraclass correlation coefficient = 0.92), and construct validity through significant correlations with patient-reported functional outcomes. The scale includes 4 dimensions: (1) Training frequency (0-25 points): Scored based on the number of rehabilitation training sessions completed per week, 0 sessions = 0 points, 1-2 sessions = 10 points, 3-4 sessions = 18 points, ≥ 5 sessions = 25 points; (2) Training duration (0-25 points): Scored based on duration per training session, < 10 minutes = 0 points, 10-20 minutes = 10 points, 20-30 minutes = 18 points, ≥ 30 minutes = 25 points; (3) Training intensity (0-25 points): Scored based on whether prescribed intensity was achieved, not completed = 0 points, completed < 50% = 8 points, completed 50%-80% = 16 points, completed > 80% = 25 points; and (4) Medical advice compliance (0-25 points): Scored based on adherence to medical instructions, never compliant = 0 points, occasionally compliant = 8 points, often compliant = 16 points, fully compliant = 25 points. Total score ranges from 0-100 points, with higher scores indicating better adherence. Adherence grading criteria: Excellent (≥ 80 points), good (60-79 points), fair (40-59 points), poor (< 40 points).

Secondary outcome measures: (1) Lysholm knee score: Assesses knee functional status. The scale includes 8 items: Limping (0-5 points: No limping 5 points, mild or intermittent limping 3 points, persistent limping 0 points). Support (0-5 points: No support needed 5 points, cannot weight-bear with crutch 2 points, cannot weight-bear 0 points). Locking (0-15 points: No locking 15 points, catching sensation but no true locking 10 points, occasional locking 6 points, frequent locking 2 points, persistent locking 0 points). Instability (0-25 points: No instability 25 points, instability during vigorous activity 20 points, instability during general activity 15 points, occasional instability during daily activities 10 points, frequent instability during daily activities 5 points, instability with every step 0 points). Pain (0-25 points: No pain 25 points, mild and intermittent pain 20 points, pain during vigorous activity 15 points, pain when walking over 2 km 10 points, pain when walking less than 2 km 5 points, persistent pain 0 points). Swelling (0-10 points: No swelling 10 points, swelling during vigorous activity 6 points, swelling during general activity 2 points, persistent swelling 0 points). Stair climbing (0-10 points: No difficulty 10 points, mild discomfort 6 points, one step at a time 2 points, cannot climb stairs 0 points). Squatting (0-5 points: No difficulty 5 points, mild difficulty 4 points, cannot exceed 90° 2 points, cannot squat 0 points). Total score ranges from 0-100 points, with higher scores indicating better knee function. Assessments were conducted preoperatively and at 1 month, 3 months, and 6 months postoperatively, with data extracted from outpatient follow-up records; (2) Range of motion (ROM): Active flexion angle of the affected knee measured with a goniometer was obtained from medical records. Measurements were taken with the patient in supine position, using the greater trochanter of the femur as the axis, the femoral shaft as the fixed arm, and the fibula as the moving arm. Flexion angles were recorded preoperatively and at 1 month, 3 months, and 6 months postoperatively, with larger angles indicating better ROM; and (3) Visual Analogue Scale (VAS): Evaluates knee pain intensity using a 0-10 numerical rating scale, where 0 indicates no pain and 10 indicates the most severe pain, with higher scores indicating more severe pain. Resting state pain scores (at rest) and pain scores after daily activities (after daily activities) were recorded preoperatively and at 1 month, 3 months, and 6 months postoperatively, with data extracted from follow-up records.

Postoperative rehabilitation protocol

All patients followed the standardized rehabilitation protocol developed by our hospital’s orthopedics department. Rehabilitation therapists made appropriate adjustments based on individual patient recovery status without violating basic rehabilitation principles. Postoperative days 1-3: Ankle pump exercises, isometric quadriceps contractions, 3-5 times daily, 15-20 minutes each session; passive knee flexion-extension activities, angle 0°-90°. Postoperative days 4-14 (weeks 1-2): Gradually increase knee ROM to 120°, strengthen quadriceps strengthening training. Postoperative weeks 3-6: Progressive weight-bearing ambulation, increase proprioceptive training. Postoperative weeks 7-12 (months 2-3): Comprehensive functional recovery training, including muscle strength, balance, and coordination training. Postoperative months 4-6: Gradually resume daily activities and sports based on recovery status. During rehabilitation, rehabilitation therapists conducted regular assessments. If the following conditions occurred, rehabilitation progress needed to be slowed: (1) Resting VAS pain score increased ≥ 2 points from baseline; (2) Joint swelling circumference increased ≥ 1cm from baseline; (3) ROM decreased ≥ 10° from baseline; and (4) Joint locking or obvious instability occurred. Rehabilitation protocol compliance was recorded and assessed through outpatient follow-up and structured telephone interviews. The structured telephone interviews were conducted by two trained rehabilitation therapists at predetermined time points (1 month, 3 months, and 6 months post-surgery) using a standardized protocol. Each interview lasted approximately 15-20 minutes and followed a semi-structured script to assess the four MEARS dimensions systematically. For training frequency, patients were asked: “In the past week, how many days did you complete your prescribed rehabilitation exercises?”. For training duration, they were asked: “On the days you exercised, how long did each session typically last?”. For training intensity, the therapist asked patients to describe their exercise routine in detail and then determined whether they achieved < 50%, 50%-80%, or > 80% of the prescribed intensity based on comparison with the standardized rehabilitation protocol. For medical advice compliance, patients were asked about their adherence to weight-bearing restrictions, use of assistive devices, medication schedules, and attendance at follow-up appointments. To enhance reliability, 20% of telephone interviews were randomly selected for dual assessment by both therapists, showing excellent inter-rater agreement [intraclass correlation coefficient = 0.91, 95% confidence interval (CI): 0.85-0.95]. Patients who could not be reached by telephone after three attempts on different days were classified as lost to follow-up.

Statistical analysis

SPSS 26.0 statistical software was used for data analysis. Continuous variables were first tested for normality using the Shapiro-Wilk test. Normally distributed data were expressed as mean ± SD, and independent samples t-tests were used for between-group comparisons. Non-normally distributed data were expressed as median (interquartile range), and Mann-Whitney U tests were used for between-group comparisons. Categorical variables were expressed as n (%), and χ² tests or Fisher’s exact test were used for between-group comparisons. Bonferroni correction was used for comparisons between different time groups. Pearson or Spearman correlation analysis was used to explore correlations between TSK scores and rehabilitation adherence and functional recovery indicators. Post hoc power analyses were conducted using G*Power 3.1 software to confirm adequate statistical power for primary outcomes. For the comparison of MEARS scores at 3 months postoperatively between the two groups (13.8 ± 13.5 points), with α = 0.05 and total sample size of 269, the achieved power was 0.996. For the multiple linear regression analysis with three significant predictors (preoperative TSK score, education level, and disease duration) and an observed R² of 0.315, the achieved power was 0.999. These calculations confirmed that our sample size was sufficient to detect the observed effects with high statistical power. P < 0.05 was considered statistically significant.

RESULTS

Comparison of general data

A total of 269 patients were included, including 156 males and 113 females, aged 18-65 years. Based on preoperative TSK scores, patients were divided into a kinesiophobia group of 120 cases (TSK ≥ 37 points) and a non-kinesiophobia group of 149 cases (TSK < 37 points). There were no statistically significant differences in baseline characteristics including gender, age, BMI, injury side, injury type, disease duration, and education level between the two groups (P > 0.05), making them comparable (Table 1).

Table 1 Comparison of general data between two groups, n (%)/mean ± SD.

Item	Kinesiophobia group (n = 120)	Non-kinesiophobia group (n = 149)	Statistic	P value
Gender			χ2 = 0.142	0.706
Male	68 (56.7)	88 (59.1)
Female	52 (43.3)	61 (40.9)
Age (years)	38.2 ± 11.5	36.8 ± 12.1	t = 0.974	0.331
BMI (kg/m2)	24.3 ± 3.2	23.9 ± 3.4	t = 0.996	0.32
Injury side			χ2 = 0.028	0.868
Left	58 (48.3)	73 (49.0)
Right	62 (51.7)	76 (51.0)
Injury type			χ2 = 2.156	0.54
Longitudinal tear	47 (39.2)	65 (43.6)
Transverse tear	28 (23.3)	38 (25.5)
Horizontal tear	26 (21.7)	27 (18.1)
Complex tear	19 (15.8)	19 (12.8)
Disease duration (months)	5.8 ± 3.2	5.4 ± 3.0	t = 1.064	0.288
Education level			χ2 = 1.824	0.402
Junior high school and below	38 (31.7)	42 (28.2)
High school/technical secondary school	45 (37.5)	63 (42.3)
College and above	37 (30.8)	44 (29.5)

BMI: Body mass index.

Comparison of preoperative TSK scores

The total TSK score of the kinesiophobia group was (42.8 ± 4.2) points, and the non-kinesiophobia group was (30.5 ± 3.8) points, with a statistically significant difference between the two groups (t = 25.463, P < 0.001). The somatic focus dimension score of the kinesiophobia group was (25.6 ± 2.8) points, and the activity avoidance dimension score was (17.2 ± 2.1) points; the somatic focus dimension score of the non-kinesiophobia group was (18.4 ± 2.5) points, and the activity avoidance dimension score was (12.1 ± 1.9) points. The differences in both dimension scores between the two groups were statistically significant (P < 0.001; Table 2).

Table 2 Comparison of preoperative Tampa Scale for kinesiophobia scores between two groups, mean ± SD (points).

Item	Kinesiophobia group (n = 120)	Non-kinesiophobia group (n = 149)	t value	P value
TSK total score	42.8 ± 4.2	30.5 ± 3.8	25.463	< 0.001
Somatic focus dimension	25.6 ± 2.8	18.4 ± 2.5	22.118	< 0.001
Activity avoidance dimension	17.2 ± 2.1	12.1 ± 1.9	21.015	< 0.001

TSK: Tampa Scale for Kinesiophobia.

Comparison of rehabilitation adherence

MEARS scores at 1 month, 3 months, and 6 months postoperatively in the kinesiophobia group were lower than those in the non-kinesiophobia group. After Bonferroni correction (α = 0.0167), the differences were all statistically significant (P < 0.001; Table 3). Results of rehabilitation adherence grading at 3 months postoperatively showed that the excellent rate was 26.7% in the kinesiophobia group and 54.4% in the non-kinesiophobia group, with a statistically significant difference in adherence grade distribution between the two groups (χ² = 24.186, P < 0.001; Table 4).

Table 3 Comparison of Modified Exercise Adherence Rating Scale scores at different time points between two groups, mean ± SD (points).

Time	Kinesiophobia group (n = 120)	Non-kinesiophobia group (n = 149)	t value	P value	Corrected P value
1 month postoperatively	52.4 ± 12.6	64.8 ± 11.3	8.625	< 0.001	< 0.001
3 months postoperatively	64.7 ± 14.2	78.5 ± 12.8	8.517	< 0.001	< 0.001
6 months postoperatively	75.3 ± 13.5	85.2 ± 11.6	6.531	< 0.001	< 0.001

Bonferroni correction was applied, α = 0.0167.

Table 4 Comparison of rehabilitation adherence grading at 3 months postoperatively between two groups, n (%).

Adherence grade	Kinesiophobia group (n = 120)	Non-kinesiophobia group (n = 149)	χ2 value	P value
Excellent (≥ 80 points)	32 (26.7)	81 (54.4)	24.186	< 0.001
Good (60-79 points)	45 (37.5)	52 (34.9)
Fair (40-59 points)	32 (26.7)	14 (9.4)
Poor (< 40 points)	11 (9.1)	2 (1.3)

Comparison of knee function recovery

Comparison of Lysholm scores: There was no statistically significant difference in preoperative Lysholm scores between the two groups (P > 0.05). At 1 month, 3 months, and 6 months postoperatively, Lysholm scores in the kinesiophobia group were lower than those in the non-kinesiophobia group. After Bonferroni correction (α = 0.0167), the differences were all statistically significant (P < 0.001; Figure 1; Table 5).

Figure 1 Lysholm knee score over time after arthroscopic meniscal repair. Comparison of functional scores between non-kinesiophobia and kinesiophobia groups at different postoperative time points. Both groups showed progressive improvement from preoperative baseline through 1 month, 3 months, and 6 months post-surgery. The non-kinesiophobia group (blue) consistently demonstrated higher scores than the kinesiophobia group (orange) at all time points, with the between-group difference increasing over time. Error bars represent SE.

Table 5 Comparison of Lysholm scores at different time points between two groups, mean ± SD (points).

Time	Kinesiophobia group (n = 120)	Non-kinesiophobia group (n = 149)	t value	P value	Corrected P value
Preoperatively	48.5 ± 8.3	49.2 ± 8.7	0.677	0.499
1 month postoperatively	62.8 ± 9.6	68.4 ± 8.5	5.154	< 0.001	< 0.001
3 months postoperatively	75.3 ± 10.2	83.6 ± 9.1	7.096	< 0.001	< 0.001
6 months postoperatively	84.7 ± 9.8	91.2 ± 7.6	6.026	< 0.001	< 0.001

Bonferroni correction was applied, α = 0.0167.

Comparison of knee ROM: There was no statistically significant difference in preoperative ROM between the two groups (P > 0.05). At 1 month postoperatively, ROM in both groups decreased compared to preoperative levels, which is a normal physiological response due to early postoperative pain, swelling, and protective immobilization. At 1 month, 3 months, and 6 months postoperatively, ROM in the kinesiophobia group was smaller than that in the non-kinesiophobia group. After Bonferroni correction (α = 0.0167), the differences were all statistically significant (P < 0.001; Table 6). As rehabilitation progressed, ROM in both groups gradually recovered and exceeded preoperative levels, but the recovery rate in the kinesiophobia group was significantly slower than in the non-kinesiophobia group.

Table 6 Comparison of knee range of motion at different time points between two groups, mean ± SD (degree).

Time	Kinesiophobia group (n = 120)	Non-kinesiophobia group (n = 149)	t value	P value	Corrected P value
Preoperatively	118.3 ± 12.5	119.6 ± 11.8	0.896	0.371
1 month postoperatively	95.6 ± 10.3	102.8 ± 9.5	6.062	< 0.001	< 0.001
3 months postoperatively	115.2 ± 11.7	124.5 ± 10.2	7.038	< 0.001	< 0.001
6 months postoperatively	128.4 ± 10.5	135.8 ± 9.3	6.258	< 0.001	< 0.001

Bonferroni correction was applied, α = 0.0167.

Comparison of VAS pain scores: There were no statistically significant differences in preoperative VAS scores (resting and after activities) between the two groups (P > 0.05). At 1 month postoperatively, resting VAS scores in both groups increased compared to preoperative levels, which is a normal response to surgical trauma and early rehabilitation training. At 1 month, 3 months, and 6 months postoperatively, both resting VAS scores and VAS scores after activities in the kinesiophobia group were higher than those in the non-kinesiophobia group. After Bonferroni correction (α = 0.0167), the differences were all statistically significant (P < 0.001; Table 7). As postoperative time progressed, pain scores in both groups showed a decreasing trend, but pain relief in the kinesiophobia group was slower than in the non-kinesiophobia group, suggesting that kinesiophobia may delay pain improvement by affecting rehabilitation adherence.

Table 7 Comparison of Visual Analogue Scale pain scores at different time points between two groups, mean ± SD (points).

Time	VAS score type	Kinesiophobia group (n = 120)	Non-kinesiophobia group (n = 149)	t value	P value	Corrected P value
Preoperatively	Resting	2.8 ± 1.2	2.7 ± 1.1	0.717	0.474
	After activities	5.6 ± 1.4	5.5 ± 1.3	0.619	0.536
1 month postoperatively	Resting	3.2 ± 1.1	2.9 ± 0.9	2.428	0.016	0.048
	After activities	4.8 ± 1.3	3.9 ± 1.1	6.177	< 0.001	< 0.001
3 months postoperatively	Resting	1.8 ± 0.9	1.2 ± 0.7	6.234	< 0.001	< 0.001
	After activities	3.2 ± 1.1	2.3 ± 0.9	7.428	< 0.001	< 0.001
6 months postoperatively	Resting	1.1 ± 0.7	0.6 ± 0.5	6.878	< 0.001	< 0.001
	After activities	2.1 ± 0.9	1.3 ± 0.7	8.275	< 0.001	< 0.001

Bonferroni correction was applied, α = 0.0167. Bonferroni correction was only applied for different time points, and the two Visual Analogue Scale score types (resting and after activities) at each time point are presented separately as descriptive indicators. VAS: Visual Analogue Scale.

Correlation analysis

Pearson correlation analysis showed that preoperative TSK total score was negatively correlated with MEARS score at 3 months postoperatively (r = -0.518, P < 0.001), negatively correlated with Lysholm score at 3 months postoperatively (r = -0.463, P < 0.001), negatively correlated with ROM at 3 months postoperatively (r = -0.441, P < 0.001), positively correlated with resting VAS score at 3 months postoperatively (r = 0.398, P < 0.001), and positively correlated with VAS score after activities at 3 months postoperatively (r = 0.456, P < 0.001). Both TSK somatic focus dimension and activity avoidance dimension scores were correlated with the above indicators (P < 0.001; Figure 2; Table 8). The correlation analysis results indicate that the higher the degree of preoperative kinesiophobia, the poorer the early postoperative rehabilitation adherence, the slower the knee function recovery, and the less ideal the pain control effect.

Figure 2 Correlation between preoperative Tampa Scale for Kinesiophobia scores and postoperative 3-month rehabilitation and functional outcomes: Correlation analysis between kinesiophobia scores and clinical outcomes. Tampa Scale for Kinesiophobia total score (dark blue), somatic focus subscale (gray), and activity avoidance subscale (teal) showed negative correlations with functional scores (Modified Exercise Adherence Rating Scale, Lysholm, range of motion) and positive correlations with pain scores (resting Visual Analogue Scale and post-activity Visual Analogue Scale). Pearson correlation coefficients (r) are labeled on each bar, with all correlations reaching statistical significance (P = 0.001). TSK: Tampa Scale for Kinesiophobia; MEARS: Modified Exercise Adherence Rating Scale; ROM: Range of motion; VAS: Visual Analogue Scale.

Table 8 Correlation analysis of preoperative Tampa Scale for Kinesiophobia scores with rehabilitation and functional indicators at 3 months postoperatively.

TSK score	MEARS score	Lysholm score	ROM	Resting VAS	VAS after activities
TSK total score	r = -0.518; P < 0.001	r = -0.463; P < 0.001	r = -0.441; P < 0.001	r = 0.398; P < 0.001	r = 0.456; P < 0.001
Somatic focus dimension	r = -0.492; P < 0.001	r = -0.445; P < 0.001	r = -0.418; P < 0.001	r = 0.376; P < 0.001	r = 0.431; P < 0.001
Activity avoidance dimension	r = -0.487; P < 0.001	r = -0.432; P < 0.001	r = -0.421; P < 0.001	r = 0.383; P < 0.001	r = 0.428; P < 0.001

TSK: Tampa Scale for Kinesiophobia; MEARS: Modified Exercise Adherence Rating Scale; ROM: Range of motion; VAS: Visual Analogue Scale.

Multiple linear regression analysis of factors influencing rehabilitation adherence at 3 months postoperatively

Using MEARS score at 3 months postoperatively as the dependent variable, and preoperative TSK score, age, gender (male = 1, female = 2), BMI, education level (junior high school and below = 1, high school/technical secondary school = 2, college and above = 3), injury type (longitudinal tear = 1, transverse tear = 2, horizontal tear = 3, complex tear = 4), and disease duration as independent variables, multiple linear regression analysis was performed. Results showed that preoperative TSK score (β = -0.512, P < 0.001), education level (β = 0.186, P = 0.002), and disease duration (β = -0.152, P = 0.012) were independent factors influencing rehabilitation adherence at 3 months postoperatively, with an adjusted R² = 0.315 for the model (Table 9). Multiple regression analysis indicates that after controlling for other confounding factors, preoperative kinesiophobia remains the most important factor affecting postoperative rehabilitation adherence, with higher education levels associated with better adherence and longer disease duration associated with relatively poorer adherence.

Table 9 Multiple linear regression analysis of factors influencing rehabilitation adherence at 3 months postoperatively.

Variable	B	SE	β	t value	P value	95%CI
Constant	98.452	8.763		11.235	< 0.001	81.181-115.723
Preoperative TSK score	-0.812	0.096	-0.512	-8.458	< 0.001	-1.001 to -0.623
Education level	4.235	1.358	0.186	3.118	0.002	1.561-6.909
Disease duration	-0.683	0.27	-0.152	-2.53	0.012	-1.215 to -0.151

Adjusted R² = 0.315, F = 41.562, P < 0.001. TSK: Tampa Scale for Kinesiophobia; CI: Confidence interval.

Binary logistic regression analysis of risk factors for postoperative complications

Using whether postoperative complications occurred as the dependent variable (no occurrence = 0, occurrence = 1), and preoperative TSK score, age, gender, BMI, injury type, disease duration, and MEARS score at 3 months postoperatively as independent variables, binary logistic regression analysis was performed. Results showed that preoperative TSK score [odds ratio (OR) = 1.082, 95%CI: 1.032-1.134, P = 0.001] and MEARS score at 3 months postoperatively (OR = 0.961, 95%CI: 0.941-0.981, P < 0.001) were independent risk factors for postoperative complications (Table 10). Logistic regression analysis indicates that the higher the preoperative TSK score, the greater the risk of postoperative complications (for every 1-point increase, complication risk increases by 8.2%); while better rehabilitation adherence at 3 months postoperatively is associated with lower complication risk (for every 1-point increase in MEARS score, complication risk decreases by 3.9%). In our study, postoperative complications within the 6-month follow-up period included: Joint stiffness requiring manipulation under anesthesia (n = 8), persistent joint effusion requiring aspiration (n = 12), superficial wound infection treated with antibiotics (n = 6), symptomatic deep vein thrombosis confirmed by ultrasound (n = 3), and re-injury requiring revision surgery (n = 5). The kinesiophobia group demonstrated significantly higher rates of joint stiffness (10.0% vs 2.0%, χ² = 8.946, P = 0.003) and persistent effusion (15.0% vs 4.7%, χ² = 8.221, P = 0.004) compared to the non-kinesiophobia group (Table 11).

Table 10 Binary logistic regression analysis of risk factors for postoperative complications.

Variable	B	SE	Wald χ2	P value	OR	95%CI
Preoperative TSK score	0.079	0.024	10.823	0.001	1.082	1.032-1.134
MEARS score at 3 months postoperatively	-0.04	0.01	15.362	< 0.001	0.961	0.941-0.981
Constant	-2.156	1.124	3.681	0.055	0.116

Model χ² =43.728, P < 0.001; Hosmer-Lemeshow test χ² =6.842, P = 0.553. TSK: Tampa Scale for Kinesiophobia; MEARS: Modified Exercise Adherence Rating Scale; OR: Odds ratio; CI: Confidence interval.

Table 11 Detailed distribution of postoperative complications between two groups, n (%).

Complication type	Kinesiophobia group (n = 120)	Non-kinesiophobia group (n = 149)	χ2 value	P value
Joint stiffness requiring MUA	12 (10.0)	3 (2.0)	8.946	0.003
Persistent joint effusion	18 (15.0)	7 (4.7)	8.221	0.004
Superficial wound infection	4 (3.3)	2 (1.3)	1.345	0.246
Symptomatic DVT	2 (1.7)	1 (0.7)	0.673	0.412
Re-injury requiring revision	3 (2.5)	2 (1.3)	0.552	0.458
Total complications	39 (32.5)	15 (10.1)	21.758	< 0.001

MUA: Manipulation under anesthesia; DVT: Deep vein thrombosis.

Comparison of rehabilitation progression slowdown between groups

Retrospective review of rehabilitation records revealed that rehabilitation progression was slowed significantly more frequently in the kinesiophobia group compared to the non-kinesiophobia group (42.5% vs 18.1%, χ² = 18.734, P < 0.001). Specifically, the kinesiophobia group more frequently experienced: Increased resting VAS pain scores ≥ 2 points (28.3% vs 10.1%, χ² = 13.872, P < 0.001), joint swelling circumference increase ≥ 1cm (18.3% vs 8.7%, χ² = 5.624, P = 0.018), and ROM decrease ≥ 10° from baseline (15.0% vs 5.4%, χ² = 7.285, P = 0.007). Interestingly, the occurrence of joint locking or obvious instability - which might represent true pathological concerns - did not differ significantly between groups (5.0% vs 3.4%, χ² = 0.402, P = 0.527). This pattern suggests that patients with kinesiophobia may have heightened sensitivity to normal postoperative discomfort, leading to more frequent modifications of the rehabilitation protocol even when objective clinical indicators did not necessarily warrant such changes (Table 12).

Table 12 Comparison of rehabilitation progression slowdown criteria between two groups, n (%).

Criteria for slowing progression	Kinesiophobia group (n = 120)	Non-kinesiophobia group (n = 149)	χ2 value	P value
Any criterion met	51 (42.5)	27 (18.1)	18.734	< 0.001
Resting VAS increase ≥ 2 points	34 (28.3)	15 (10.1)	13.872	< 0.001
Joint swelling increase ≥ 1 cm	22 (18.3)	13 (8.7)	5.624	0.018
ROM decrease ≥ 10°	18 (15.0)	8 (5.4)	7.285	0.007
Joint locking or instability	6 (5.0)	5 (3.4)	0.402	0.527

VAS: Visual Analogue Scale; ROM: Range of motion.

DISCUSSION

This study found that MEARS scores at 1 month, 3 months, and 6 months postoperatively in the kinesiophobia group were significantly lower than those in the non-kinesiophobia group, with the excellent adherence rate at 3 months postoperatively being only 26.7%, far lower than the 54.4% in the non-kinesiophobia group. Multiple linear regression analysis showed that preoperative TSK score was the most important independent factor influencing rehabilitation adherence at 3 months postoperatively (β = -0.512, P < 0.001). This result is consistent with previous research conclusions in orthopedic surgeries such as anterior cruciate ligament reconstruction[12], rotator cuff repair[13], and total knee arthroplasty[14], suggesting that kinesiophobia plays an important negative role in rehabilitation after different types of orthopedic surgeries.

The mechanism by which kinesiophobia affects rehabilitation adherence may be multifaceted[15]. First, the fear-avoidance model theory suggests that patients’ excessive fear of pain and re-injury leads them to actively avoid rehabilitation training, forming a vicious cycle of “pain-fear-avoidance-disuse-pain exacerbation”[16]. Second, patients with kinesiophobia often pay excessive attention to bodily sensations, interpreting normal postoperative discomfort as signs of worsening injury, thereby interrupting or reducing rehabilitation training intensity[17]. Additionally, kinesiophobia may decrease patients’ self-efficacy, reducing their confidence and motivation toward rehabilitation goals, ultimately leading to decreased adherence[18]. In this study, both TSK dimensions (somatic focus and activity avoidance) were significantly negatively correlated with rehabilitation adherence, supporting the existence of these mechanisms.

It is noteworthy that this study also found that education level and disease duration were independent factors affecting rehabilitation adherence. Patients with higher education levels may have better understanding of disease and rehabilitation knowledge, better recognizing the importance of standardized rehabilitation training[19]. Patients with longer disease duration may develop negative psychology due to prolonged pain and functional limitations, lacking confidence in rehabilitation training, leading to decreased adherence[20]. This suggests that clinical healthcare providers need to fully consider patients’ individualized characteristics when developing rehabilitation programs, adopting differentiated health education and psychological intervention strategies for different populations.

The adjusted R² of 0.315 in our multiple linear regression model indicates that while preoperative TSK score, education level, and disease duration are important predictors, they collectively explain only about one-third of the variance in 3-month rehabilitation adherence. This substantial unexplained variance (approximately 68.5%) strongly suggests that other unmeasured factors play crucial roles in determining adherence outcomes. These likely include general anxiety and depression levels, pain catastrophizing tendencies, social support networks, financial constraints affecting access to rehabilitation services, and possibly individual differences in pain tolerance, motivation, and health literacy. Additionally, environmental factors such as distance to rehabilitation facilities, work-related time constraints, and family caregiving responsibilities may contribute substantially to adherence but were not captured in our model. This moderate R² value, while statistically significant, highlights the multifactorial nature of rehabilitation adherence and the need for comprehensive, holistic assessment approaches that extend beyond kinesiophobia alone. Future prospective studies should employ more comprehensive psychosocial assessments and potentially use machine learning approaches to identify additional predictive factors and their interactions. The results of this study have important clinical application value. First, routine preoperative TSK assessment can identify high-risk populations for kinesiophobia early, creating opportunities for targeted interventions. For patients with TSK scores ≥ 37 points, preoperative psychological assessment and intervention are recommended. Several evidence-based intervention modalities have demonstrated efficacy in reducing kinesiophobia in musculoskeletal populations: Cognitive behavioral therapy: Recent systematic reviews have shown that cognitive behavioral therapy effectively reduces kinesiophobia by challenging catastrophic thinking patterns and maladaptive pain beliefs. We recommend 4-8 preoperative sessions focusing on identifying and restructuring fear-related cognitions, developing adaptive coping strategies, and setting realistic recovery expectations. Pain neuroscience education (PNE): Studies have demonstrated that PNE - which teaches patients about pain physiology, the distinction between hurt and harm, and the neurobiological basis of pain - can reduce kinesiophobia and improve outcomes after rotator cuff repair and other orthopedic surgeries (Ponce-Fuentes et al[13]). We suggest incorporating 2-3 preoperative PNE sessions using visual aids and metaphors to enhance patient understanding. Graded exposure therapy: Drawing on the fear-avoidance model, graded in vivo exposure is a behavioral intervention where patients progressively engage in feared movements within a safe, supervised environment. Evidence from anterior cruciate ligament reconstruction populations shows that systematic desensitization to movement can significantly reduce TSK scores and improve functional outcomes.

This study’s results show that Lysholm scores and ROM at all postoperative time points in the kinesiophobia group were significantly lower than those in the non-kinesiophobia group, with correlation analysis further confirming that preoperative TSK scores had moderate negative correlations with knee function indicators at 3 months postoperatively. This is consistent with previous research reporting that kinesiophobia can delay knee function recovery[21,22]. Some studies indicate that knee function scores in patients with kinesiophobia at 6 months postoperatively are approximately 10-15 points lower than those in patients without kinesiophobia[23]. In this study, the difference in Lysholm scores between the two groups at 6 months postoperatively was 6.5 points. Although the difference was statistically significant, the clinical significance is relatively small, which may be related to the relatively short follow-up time in this study. Long-term functional outcomes still require further observation.

The pathway by which kinesiophobia affects functional recovery is primarily through reducing rehabilitation adherence[24]. Adequate rehabilitation training is key to knee function recovery, including muscle strength training, ROM training, proprioceptive training, and other aspects[25]. When patients reduce or interrupt rehabilitation training due to kinesiophobia, muscle strength cannot effectively recover, joint stiffness risk increases, ultimately leading to delayed functional recovery[26]. In this study, ROM at all postoperative time points in the kinesiophobia group was significantly smaller than in the non-kinesiophobia group, suggesting that kinesiophobia may lead to slow joint ROM recovery by reducing joint mobility training. Additionally, some studies indicate that kinesiophobia may directly affect functional recovery through mechanisms such as neuromuscular control disorders and decreased proprioception[27]. This mechanism was not explored in depth in this study and awaits further research in the future.

This study found that both resting and post-activity VAS scores at all postoperative time points in the kinesiophobia group were significantly higher than those in the non-kinesiophobia group, with preoperative TSK scores positively correlated with pain scores at 3 months postoperatively. This result is highly consistent with research in the field of pain psychology[28]. There is a bidirectional relationship between pain and kinesiophobia: On one hand, pain experience is an important trigger for kinesiophobia; on the other hand, kinesiophobia exacerbates pain perception through multiple mechanisms[29].

Pain catastrophizing thinking is a typical cognitive characteristic of patients with kinesiophobia. Patients tend to exaggerate pain severity and develop feelings of helplessness and rumination about pain, and this negative pain coping style enhances pain perception[30]. Additionally, reduced activity and muscle disuse caused by kinesiophobia may cause local metabolic disorders, microcirculation disorders, and inflammatory factor accumulation, thereby aggravating pain[31]. Some studies indicate that patients with kinesiophobia have abnormal central pain modulation functions, manifested as weakened descending pain inhibition system function, leading to pain sensitization and pain chronicity[32]. In this study, pain relief in the kinesiophobia group was slower than in the non-kinesiophobia group, suggesting that early identification and intervention for kinesiophobia is of great significance for improving postoperative pain control.

Binary logistic regression analysis in this study showed that preoperative TSK score was an independent risk factor for postoperative complications (OR = 1.082), while rehabilitation adherence at 3 months postoperatively was a protective factor (OR = 0.961). This suggests that kinesiophobia not only affects functional recovery but may also increase the risk of postoperative complications. Although this study did not analyze complication types and incidence in detail, previous research indicates that poor rehabilitation adherence is closely related to postoperative complications such as joint stiffness, muscle atrophy, and deep vein thrombosis[33]. Reduced activity and prolonged bed rest caused by kinesiophobia increase thrombosis risk, while insufficient rehabilitation training may lead to joint adhesion and muscle atrophy. Therefore, preoperative assessment of kinesiophobia not only helps predict rehabilitation adherence and functional recovery but may also provide important reference for complication prevention.

The results of this study have important clinical application value. First, routine preoperative TSK assessment can identify high-risk populations for kinesiophobia early, creating opportunities for targeted interventions. For patients with TSK scores ≥ 37 points, preoperative psychological assessment and intervention are recommended, including cognitive behavioral therapy, progressive exposure therapy, and pain education[34], helping patients rebuild correct cognition about movement and reduce fear levels. Second, during postoperative rehabilitation, psychological support and rehabilitation guidance for patients with kinesiophobia should be strengthened. By setting reasonable rehabilitation goals, providing positive feedback, and establishing peer support networks, patients’ self-efficacy and rehabilitation confidence can be enhanced. Additionally, healthcare providers should emphasize pain management, adopting multimodal analgesia protocols to avoid exacerbating kinesiophobia due to poor pain control.

This study has the following limitations: First, the retrospective study design cannot completely eliminate the impact of selection bias and confounding factors. Prospective cohort studies or randomized controlled trials are needed in the future to further validate the conclusions. Second, the follow-up time was relatively short (6 months), making it impossible to assess the impact of kinesiophobia on long-term functional recovery and quality of life. Long-term follow-up studies need to be conducted. Third, while we controlled for several key demographic and clinical variables, this study did not include assessment of other important psychosocial factors such as general anxiety (e.g., Generalized Anxiety Disorder-7), depression (e.g., Patient Health Questionnaire-9), pain catastrophizing (e.g., Pain Catastrophizing Scale), or social support levels, all of which have been shown in previous literature to correlate with both kinesiophobia and rehabilitation outcomes. The absence of these measures represents a potential source of residual confounding that may partially explain the observed associations. Our findings regarding the impact of kinesiophobia should be interpreted in the context of these unmeasured psychosocial factors, and the true effect size may be moderated by these variables. Future prospective studies should employ comprehensive psychological assessment batteries to better disentangle the independent contributions of these interrelated constructs. Fourth, although we provided detailed information on postoperative complications including specific types and frequencies in each group, further analysis of complication severity and their long-term impact on patient outcomes is still needed.

CONCLUSION

In conclusion, preoperative kinesiophobia is an important factor affecting early rehabilitation adherence, functional recovery, and pain control following arthroscopic meniscal repair. Clinical practice should emphasize preoperative screening and assessment of kinesiophobia, implementing early, systematic psychological interventions for high-risk patients to improve rehabilitation adherence, promote comprehensive recovery of knee function, and improve patients’ clinical prognosis. Future research should further explore the underlying mechanisms by which kinesiophobia affects rehabilitation and develop and validate effective psychological intervention programs to provide more comprehensive theoretical guidance and practical evidence for postoperative orthopedic rehabilitation.