Statistics show that women are two to eight times more likely to tear their ACL than men.
Statistics show that women are two to eight times more likely to tear their ACL than men. (Photo: AlexSava/iStock)

Your Fear of Reinjury Could Get You Hurt Again

And new research shows it may be one reason why women tear their ACLs more often than men

Statistics show that women are two to eight times more likely to tear their ACL than men.

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Peering over the cornice at the top of Deer Valley’s Daly Chutes in February, I tightened my knee brace and questioned if I was a little out of my league. All morning I had been feeling awkward and tentative on my skis, like I couldn’t quite get my legs underneath me. I looked for the most welcoming entry, then carefully dropped in. 

I had torn the ACL in my right knee twice and my right medial meniscus once. And I’m not an anomaly: statistics show that women are two to eight times more likely to tear their ACL than men, and they’re 15 percent more likely to re-tear the ligament, too. Every time I get ready to ski, hike, run, or even lift weights, I think about how easy it would be to injure myself again. For every ache and twinge, real or phantom, my mind starts looping the phrase Don’t hurt your knee, like a scratch in a record.

After two turns in the chutes, I stopped and retightened my brace, as if the Velcro and hard frame could magically make my wobbly knee invincible. But as I made my way into a mellow section in the trees, the tips of my skis crossed, and I fell in what felt like slow motion. When I stood up, something was clearly off. An MRI two weeks later confirmed that I had torn my meniscus for the second time. Thankfully, my ACL was intact, but I wondered if my lack of confidence in my joint somehow made me more prone to hurting myself. 

Many write off fear of reinjury as just another mental barrier to overcome during recovery, but physicians have long thought that it may actually impact post-injury outcomes. Now a new body of research is examining how this anxiety affects rehabilitation and a return to sports. It turns out, being afraid of hurting your knee actually increases your chances of getting injured again. And while research has pinpointed physiological aspects that lead women to tear their ACLs more often—including limb alignment, ligament laxity, muscle strength, and hormonal and genetic factors—psychological factors may be another key reason.

The emotional trauma of getting injured doesn’t end as soon as you’re back on the horse, especially after a long, slow recovery from an ACL tear. Fear and anxiety can affect motivation, confidence, and body mechanics, even in patients who have made a full recovery, says Dr. Melissa Christino, an orthopedic surgeon at Boston Children’s Hospital.

According to a 2018 study published in the Journal of Athletic Training, both men and women are more conscious of and less confident in their injured joint following an ACL reconstruction and are hesitant when it comes to resuming physical activity, leading to self-limiting behaviors. Those who experienced the greatest levels of fear—measured by a self-assessment called the Tampa Scale for Kinesiophobia—were 13 times more likely to suffer a second ACL injury within two years. Critically, women diagnosed with an ACL tear endure greater emotional trauma compared to men with the same injury. A 2018 study in the Orthopaedic Journal of Sports Medicine found that women were more likely to experience symptoms consistent with post-traumatic stress disorder, such as trouble sleeping or concentrating, flashbacks, and feeling jumpy or on guard.

Dr. Cordelia Carter, director of the Center for Women’s Sports Health at New York University Langone, believes that the higher ACL re-tear rates in women could also be due partly to the fact that women are generally more risk-averse than men. (This difference has been supported by research.) Injury-related fear impacts muscle recruitment, knee stability, and range of motion in men and women alike, but women experience this anxiety at higher rates. “ACL tears happen in a nanosecond,” Carter says. “If you don’t trust your knee, if you have that feeling in the back of your mind, it’s going to prevent you from moving fluidly, and that’s a problem.” A 2018 study in the journal Knee Surgery, Sports Traumatology, Arthroscopy looked specifically at women post knee injury and found that caution led to poorer biomechanics—like landing stiffly when jumping, which is associated with an increased risk of injury.

Fortunately, physicians and rehabilitation specialists are working on ways to overcome injury-related anxiety. Christino of Boston Children’s Hospital makes a point of evaluating and treating emotional trauma while she’s helping her patients heal physically. “The mental side of recovery is underappreciated,” she says. “Struggling emotionally affects the way that patients perform in their rehab. They think they can’t do it, and it makes everything harder.”

During office visits, Christino asks her patients how they’re handling the recovery process. She connects those who need support to a mental-skills coach, like Kelsey Griffith, a performance and rehabilitation specialist at the Micheli Center, to help with motivation, self-esteem, and fear. Though Christino regularly refers both men and women for this kind of care, it may be particularly useful in shrinking the number of women who reinjure their knees. “We’re trying to figure out how to help people heal from this injury. Looking at it from multiple perspectives, the physical and emotional, is the best chance we have,” Christino says.

Griffith strives to help patients view injury rehabilitation as just another part of being an athlete, something to approach with the same tenacity as they do their training. She uses tools like goal setting, stress management, and cognitive restructuring to help patients reframe their situation and cope with the ups and downs of rehab. Imagery and visualization can help reduce fear and build confidence, too.

Carter also encourages patients to better advocate for themselves and their needs during recovery. “Tell your physical therapist what type of activities you want to go back to and what you’re scared of,” she says. “Practice those skills in a safe environment so you can then take them out into the real world.” 

Griffith is optimistic about the future of treatment. “My hope is to help normalize the psychological aspects of injury,” she says. “It’s not about erasing fear so much as acknowledging and accepting that it very well could be there, and what you can do about it.” This attention to emotional trauma may have the potential to help women—who experience more ACL tears, more related emotional trauma, and greater fear upon reentering sports—the most.