Relationship Between Kinesiophobia and Biomechanical,Postural,and Neuromuscular Parameters of the Lower Limbs: A Systematic Review

Abstract

Context:

Musculoskeletal injuries are common and often result in behaviors such as kinesiophobia. Kinesiophobia is defined as an irrational fear of movement due to the concern about exacerbating an existing injury or causing a new one, which can lead to various changes in posture, neuromuscular function, and biomechanics in affected people.

Objective:

To determine the relationship between kinesiophobia and the biomechanical, postural, and neuromuscular parameters of the lower limbs.

Data Sources:

A systematic review of the literature from the years 2000 to 2024 was performed using 3 electronic databases: PubMed, Scopus, and Web of Science.

Study Selection:

Article selection was conducted by 2 reviewers, initially screening articles by title and abstract, followed by full-text reading, applying eligibility criteria, and assessing methodological quality.

Study Design:

Systematic review.

Level of Evidence:

Level 4.

Data Extraction:

Data were extracted from 10 studies. This systematic review was conducted following the Preferred Reporting Items for Systematic reviews and Meta-Analyses 2020 guidelines. Study methodology quality was evaluated using the Methodological Index for Non-Randomized Studies scale.

Results:

Of 1998 studies analyzed, 10 were included in the review. Data were collected on postural control, static and dynamic balance, neuromuscular parameters, and biomechanics.

Conclusion:

Elevated levels of kinesiophobia are associated directly with impaired postural control, neuromuscular alterations, and changes in the biomechanical patterns of the lower limbs during various activities, except during walking.

Keywords

biomechanics fear of movement kinesiophobia muscle strength musculoskeletal injuries postural balance

Musculoskeletal injuries are highly prevalent, the second leading cause of disability,^17,41,44 and often become chronic.¹⁵ Inadequate management of these injuries can lead to behaviors such as catastrophizing or kinesiophobia, resulting in poor interpretation and management of pain.³⁷ Catastrophizing is understood as an exaggerated negative response to a potentially or actually painful experience, while kinesiophobia is an irrational fear of movement stemming from a perceived of vulnerability to new or worsening injuries.^8,9,37

The most commonly used diagnostic tool for assessing kinesiophobia is the Tampa Scale for Kinesiophobia (TSK),²⁴ a self-report measure evaluating fear of movement-related pain in patients with musculoskeletal pain.¹⁶ The original version contains 17 items,⁴⁷ but a shorter 11-item version (TSK-11) has also been developed and validated. The TSK is often used in conjunction with other questionnaires for the diagnosis of kinesiophobia,^14,16,33 such as the Fear-Avoidance Beliefs Questionnaire (FABQ),⁴⁵ the Pain Catastrophizing Scale (PCS),³⁶ the Fear of Pain Questionnaire III (FPQ-III), and the Athlete Fear Avoidance Questionnaire (AFAQ).¹²

Prolonged behaviors associated with kinesiophobia can lead to adverse biopsychosocial changes and functional impairment.^9,42 These behaviors may cause various motor adaptations, including muscle protection, altered muscle synchronization and movement, reduced range and variability of regional movement, and altered spatiotemporal movement characteristics,^25,40 potentially resulting in biomechanical, neuromuscular, and postural changes.

Although studies have identified motor adaptations related to different musculoskeletal injuries,²⁹ such as alterations in static and dynamic balance, center of pressure deviations, or Y-balance test outcomes,^1,6 few have focused on the relationship between kinesiophobia and postural, neuromuscular, and biomechanical changes. Most existing studies have assessed the functional capacity and psychosocial changes in patients with kinesiophobia subjectively using PROMS, examining primarily knee and foot-ankle conditions.^2,8,19,43,46 These studies demonstrate a negative relationship between kinesiophobia, functional capacity, and quality of life. However, few studies have quantified this impairment by evaluating muscle capacity, joint range of motion, or postural control in patients. This highlights the need to explore the relationship between these parameters and kinesiophobia to gain a better understanding, and this information may be of great interest to therapists in managing their patient’s injuries.

Due to the important role of the lower limbs in human biomechanics, the primary objective of this review was to determine the relationship between kinesiophobia and the biomechanical, postural, and neuromuscular parameters of the lower limbs. Our hypothesis suggests that high levels of kinesiophobia are associated with deficits in postural and muscular control and alterations in the biomechanical patterns of the lower limbs during various activities, but not during walking.

Methods

This systematic review was conducted following the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) 2020 guidelines²⁸ and was registered in PROSPERO. Literature searches were performed between November 2023 and April 2025 using the Web of Science, Scopus, and PubMed databases. Table 1 details the search equations and filters used in each database. Longitudinal or cross-sectional studies were included if they: (1) evaluated kinesiophobia levels in adult patients with a history of musculoskeletal injury, and (2) measured biomechanical, postural, or neuromuscular variables of the lower limbs. Experimental studies evaluating the influence of interventions on biomechanical, postural, or neuromuscular variables in kinesiophobic samples and studies assessing the effect of kinesiophobia on lower limb function through patient-reported outcome measures (PROMS) were excluded.

Table 1.

Search equation and filters

Database	Search equation	Filters
Pubmed	(Low Limb Pain[tiab] OR Lower Limb Pain[tiab] OR Leg Pain[tiab] OR Low Limb Ache[tiab] OR Lower Limb Ache[tiab] OR Leg Ache[tiab] OR Kinesiophobia[tiab] OR Fear of fall[tiab] OR Fear of Move[tiab] OR Fear adj2 avoidance[tiab] OR Pain Catastrophizing[tiab]) AND (Neuromuscular[tiab] OR Muscular perform[tiab] OR Biomechanics[tiab] OR Postur[tiab] OR Kinematics[tiab] OR Kinetics[tiab] OR Spatiotemporal[tiab]) AND (knee[tiab] OR hip[tiab] OR ankle[tiab] OR foot[tiab] OR leg[tiab] OR lower limb[tiab] OR leg OR lower leg[tiab])	2000-2024
Web of Science	TS=(Low Limb Pain OR Lower Limb Pain OR Leg Pain OR Low Limb Ache OR Lower Limb Ache OR Leg Ache OR Kinesiophobia OR Fear of fall* OR Fear of Move* OR Fear avoidance OR Pain Catastrophizing) AND TS=(Neuromuscular OR Muscular perform* OR Biomechanics OR Postur* OR Kinematics OR Kinetics OR Spatiotemporal) AND TS=(knee OR hip OR ankle OR foot OR leg OR lower limb OR leg OR lower leg)	2000-2024 Clinical Trial
Scopus	(kinesiophobia OR fear of movement) AND (neuromuscular OR muscular AND perform OR biomechanics OR postural OR kinematics OR kinetics OR spatiotemporal) AND (knee OR hip OR ankle OR foot OR leg OR lower AND limb OR leg OR lower AND leg)	2000-2024 Article Human English

Article selection was conducted by 2 reviewers, initially screening articles by title and abstract, followed by full-text reading, applying eligibility criteria, and assessing methodological quality. The level of agreement between the 2 primary reviewers was calculated using Cohen’s kappa coefficient, interpreted according to Landis and Koch’s criteria. A kappa value >0.60 was considered an acceptable level of agreement. The variable used to evaluate inter-rater agreement was the score obtained from the Methodological Index for Non-Randomized Studies (MINORS) scale. Initially, each reviewer completed the review independently, and the information was shared subsequently in a meeting between the two. Data extraction was performed by 2 reviewers, gathering information on the study reference, objective, type (longitudinal or cross-sectional), sample, study variables, kinesiophobia assessment instruments, and results. The same process was repeated as in the selection of articles. They first carried out the extraction independently and later put the data together. Any discrepancy between reviewers in both processes was resolved by a third reviewer.

Methodological quality was assessed independently by 2 reviewers using the MINORS tool. This scale includes 12 items for comparative studies (maximum score of 24) and 8 items for noncomparative studies (maximum score of 16), each scored from 0 to 2. Final scores were interpreted as follows: 20 to 24 points (comparative) or 13 to 16 points (noncomparative) indicated high methodological quality, 14 to 19 points, or 9 to 12 points indicated moderate quality, and lower scores indicated low quality.³⁴ Discrepancies between reviewers were resolved through discussion and consensus.

Results

The initial searches identified a total of 1998 possible articles. After removing duplicates and conducting a preliminary selection based on titles and abstracts, 48 potential articles remained. After full-text reading, applying inclusion and exclusion criteria, and assessing methodological quality, 10 articles were selected (Figure 1).

Complete concordance was observed between the 2 reviewers, who assigned identical scores to all evaluated articles. This resulted in a weighted Cohen’s kappa coefficient of 1.0, indicating almost perfect inter-rater agreement according to the criteria established by Landis and Koch.

Extracted information from the included articles is presented in Annexes 1 and 2 (available in the online version of this article). The results from the methodological quality assessment are presented in Annex 3 (available online). All data referring to the P value are based on individual results of the studies included in the review.

Methodological Quality Assessment

The methodological quality of the included studies was assessed using the MINORS scale with predefined and consistently applied scoring criteria. Noncomparative studies achieved mean scores ranging from 10 to 11 out of 16, whereas comparative studies reached scores between 15 and 17 out of 24, indicating overall moderate-to-good methodological quality. Considering the maximum possible scores for noncomparative (16 points) and comparative (24 points) designs, the included studies demonstrated acceptable methodological rigor.

Evaluation of Postural Control Through Static and Dynamic Balance

In the static balance evaluation, people with chronic ankle instability and kinesiophobia showed significantly higher Romberg indices in the range of displacement and mediolateral center of pressure velocity (P < 0.05) compared with those without kinesiophobia.^2,19,43

Dynamic balance evaluation using the Y-balance test revealed reduced anterior displacements in people with chronic ankle instability and kinesiophobia compared with healthy subjects (P < 0.05).^19,32 Similarly, analysis in people with patellofemoral syndrome showed reduced anterior, mediolateral, and posterior displacements in those with higher kinesiophobia indices compared with lower indices in healthy subjects (P < 0.05).³²

Neuromuscular Parameters

Alterations in selective muscle control were observed in muscles involved in the load acceptance (gluteus medius [GM]) and propulsion, vastus medialis (VM), and medial gastrocnemius (MG)) phases of gait in patients with chronic low back pain and kinesiophobia. Significant associations were found between kinesiophobia and muscular correlation (r = 0.63; P = 0.005) and muscular coactivation (r = 0.69; P = 0.001) between VM and MG, and moderate associations between kinesiophobia and muscular correlation (r = 0.58; P = 0.01) and muscular coactivation (r = 0.55; P = 0.02) between GM and MG.²⁷ In addition, asymmetry in muscle activation of the rectus femoris (r = 0.460; P = 0.007) and biceps femoris (r = 0.429; P = 0.01) was observed during the contact phase of gait between limbs in patients with anterior cruciate ligament reconstruction.³⁹

Biomechanical Parameters

Biomechanical parameter studies reported reduced knee flexion ranges (r = −0.76; P < 0.001) and cadence (r = −0.62; P < 0.001) during stair descent in patients with patellofemoral pain and kinesiophobia. However, this was not related to a loss of knee extensor muscle strength.¹⁰

In various jump tests, biomechanical deficiencies were found in the affected limb of patients with a history of anterior cruciate ligament injury. During the drop jump task, deficits in knee flexion (r = 0.592; P = 0.20) and trunk flexion (r = 0.724; P = 0.002) were reported, while the single-leg hop test revealed limitations in hip flexion (r = 0.560; P = 0.03).¹³

In single-leg vertical drop jump tests in patients with patellofemoral pain, a negative association was found between kinesiophobia and maximal internal hip rotation (r = 0.43; P = 0.02), as well as between maximal knee extensor torque and maximal knee flexion (r = 0.41; P = 0.02). A moderate to good correlation was also observed between hip abductor torque and maximal contralateral pelvic drop (r = 0.52; P = 0.003).³⁵

Regarding gait biomechanics, no significant relationship was found between kinesiophobia and gait characteristics (walking speed, vertical ground reaction force [vGRF], joint ranges, etc) in physically active people with a history of anterior cruciate ligament injury,²³ except for an association between kinesiophobia and asymmetry of the second peak of vGRF (r = 0.531; P = 0.002) during walking, but not with the first peak.³⁹

Discussion

The results indicate that patients with high levels of kinesiophobia (identified using the TSK or TSK-11) exhibit deficits in postural control (static and dynamic balance), neuromuscular alterations, and changes in the biomechanical patterns of the lower limbs. However, information on biomechanical gait changes is limited despite known neuromuscular changes in the involved musculature.

Several authors have found a relationship between kinesiophobia and alterations in postural control. Alshahrani and Reddy² reported impairments in postural control of ankle position in patients with chronic ankle instability. This could be a consequence of an impairment of the extrinsic ankle musculature caused by both the injury and the movement limitation associated with kinesiophobia. The extrinsic foot-ankle musculature, regardless of its force-generating capacity, is also an important proprioceptive input and therefore plays a significant role in postural control.⁷

Asiri et al³ reported postural control impairments during standing in people with fibromyalgia and kinesiophobia, noting that this impairment was greater in the nondominant limb during single-leg support. These findings suggest a possible relationship between kinesiophobia and altered trunk muscle activation involved in maintaining an upright and stable posture.^4,26

Similarly, various authors have found a direct relationship between kinesiophobia and poorer static and dynamic balance outcomes in patients with chronic ankle instability and a history of knee pathology. Damage to mechanoreceptors after injury may cause this loss of balance, resulting in an inability to effectively weigh sensory information.³⁰ In addition, increased reliance on vision to maintain static balance has been reported.¹⁹ The cause is unclear, although several possibilities exist, including the development dependence on vision as a compensatory mechanism for the deterioration of the somatosensory system.^18,21,22 Other studies suggest that it could be due to neuroplastic changes in the temporal lobe after damage to sensory communication, although this evidence is still limited.³⁰

Dynamic balance was assessed in all cases using the Y-balance test. However, each study reported different displacement alterations in their results. In patients with chronic ankle instability, this limitation was found only in anterior displacement,¹⁹ while in patients with knee pathology it was found in all directions (anterior, posterior, and mediolateral),³² due primarily to differences in the pathomechanics of the injuries analyzed, as they involve different muscle groups.²²

Regarding neuromuscular parameters, several articles have shown selective alterations in muscle control of the posterior chain muscles of the lower limbs in patients with kinesiophobia during gait, especially in the muscles involved in the initial contact and propulsion phases.^27,39 These alterations in the medium/long term would generate a series of asymmetric gait patterns that could trigger disorders. However, there are currently no findings that confirm this.

The association between kinesiophobia and selective motor control can be explained by different mechanisms. One is that neuromuscular control is essentially modulated at the supraspinal level, and coactivation could be a strategy to help protect the most painful area.²⁰ In addition, it is believed that fear can cause a change in the subject’s attention, triggering more conscious protective movement strategies.³¹ Furthermore, fear and increased attention could lead to an altered inhibitory/excitatory response at the supraspinal level to protect the most painful area.^5,38 Nevertheless, there is still no clear evidence of brain activity in regions related to attention and pain, indicating the need for further investigation for better understanding. Any of these mechanisms could result in a compensatory movement strategy that causes asymmetries between limbs, leading to a potentially harmful movement pattern for that person.

Results on lower limb biomechanics have documented changes in range of motion, especially in the knee and hip, during various activities such as stair descent or different jump tests. However, no clear relationship has been found between loss of mobility and a decrease in muscle strength.^10,13,27 A possible explanation for the lack of relationship between the 2 variables is that the study protocols may not have been broad enough to detect a relationship between them, or that the impaired movement is caused by a psychological limitation due to kinesiophobia without the development of atrophy and/or muscle degeneration leading to a loss of mobility.¹¹

Regarding gait biomechanics, no relevant findings were identified that recognize kinesiophobia as a key factor generating direct modifications in any of its phases. However, at the neuromuscular level, as mentioned earlier, changes have been found in the muscles involved, especially in the initial contact and propulsion phases.^27,39 These results may indicate that the study protocols and/or the instruments used in the analyses were inadequate, highlighting the need for future research to delve deeper into the topic using more advanced study protocols and specialized measurement tools. This would help to provide more robust and meaningful conclusions in this area of research.

These findings furnish clinicians with critical insights into the multifaceted influence of kinesiophobia across biomechanical, neuromuscular, and postural domains. Recognition of these multilevel effects underscores the necessity of an integrated, multidisciplinary management strategy for patients exhibiting elevated kinesiophobia.

Limitations

This review has several limitations that should be acknowledged. First, the available literature on this topic remains limited, and, although many studies assess functional capacity in people with kinesiophobia, most rely on self-report questionnaires, which reduces the objectivity of the findings. In addition, the included studies present heterogeneous samples in terms of clinical conditions, symptom severity, functional status, and biomechanical assessment protocols, which substantially limits comparability across studies.

Importantly, all included studies were observational in nature, which precludes causal inference. Therefore, the associations identified between kinesiophobia and biomechanical, neuromuscular, or postural control parameters should be interpreted with caution. Kinesiophobia may represent a marker, mediator, or consequence of these alterations rather than a direct cause.

The methodological quality assessment was also challenging due to the limited availability of validated tools specifically designed for cross-sectional analytical observational studies. In addition, methodological heterogeneity (particularly regarding biomechanical outcome measures and assessment protocols) further limits the strength and generalizability of the conclusions. Finally, most of the included studies focused on knee-related conditions, which restricts the applicability of the findings to other clinical populations. Future research should prioritize the development and use of standardized assessment protocols, include more diverse and homogeneous clinical subgroups, and incorporate objective outcome measures to enhance the robustness and clinical relevance of the evidence.

Conclusion

The findings of this review consistently indicate an association between higher levels of kinesiophobia and impairments in postural control, including changes in static and dynamic balance, neuromuscular alterations in the posterior muscle chain of the lower limbs, and modifications in joint mobility during various functional activities, although not during gait.

However, as the available evidence is derived exclusively from observational studies, these findings should be interpreted with caution and do not allow causal inferences. In this context, kinesiophobia may be considered a marker, mediator, or consequence of the observed biomechanical alterations rather than their direct cause.

Future high-quality longitudinal and experimental studies are warranted to clarify the directionality of these associations, particularly in gait biomechanics, where current evidence remains limited and heterogeneous.

Supplemental Material

sj-docx-1-sph-10.1177_19417381261429492 – Supplemental material for Relationship Between Kinesiophobia and Biomechanical, Postural, and Neuromuscular Parameters of the Lower Limbs: A Systematic Review

Supplemental material, sj-docx-1-sph-10.1177_19417381261429492 for Relationship Between Kinesiophobia and Biomechanical, Postural, and Neuromuscular Parameters of the Lower Limbs: A Systematic Review by Juan García-Castillo, Javier Benítez-Porres, Jerónimo García-Romero and Alejandro Castillo-Domínguez in Sports Health

Footnotes

The author(s) report(s) no potential conflicts of interest in the development and publication of this article.

ORCID iDs

Juan García-Castillo

Javier Benítez-Porres

Jerónimo García-Romero

Alejandro Castillo-Domínguez

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