The impact of unhelpful pain beliefs on patient outcomes after surgically managed ankle fractures: an embedded observational study
The impact of unhelpful pain beliefs on patient outcomes after surgically managed ankle fractures: an embedded observational study
Aims: to determine the distribution of unhelpful pain beliefs in patients after ankle fracture surgery and investigate their impact, along with other demographic characteristics, on postoperative recovery.
Methods: this was an observational cohort study embedded within the Weightbearing in Ankle Fractures (WAX) trial. Adults (≥ 18 years) who underwent operative fixation of unstable ankle fractures were recruited from 23 UK hospitals two weeks post-surgery. Pain beliefs were measured at baseline using the Pain Self-Efficacy Questionnaire (PSEQ-2) and Tampa Scale of Kinesiophobia (TSK-11). Outcomes were the Olerud-Molander Ankle Score (OMAS) and EuroQol five-dimension questionnaire (EQ-5D) index at four months. Associations between pain beliefs and outcomes were examined using multivariable linear regression models adjusted for age, sex, BMI, comorbidity, occupation, and weightbearing allocation.
Results: of 795 eligible patients, 561 were recruited between February 2020 and October 2021 (mean age 48 years, 64% female). At four months, higher BMI, manual labour occupation, and greater kinesiophobia (TSK-11) were associated with poorer OMAS and EQ-5D outcomes, whereas male sex and higher pain self-efficacy (PSEQ-2) predicted better outcomes. Pain beliefs accounted for roughly twice the variability in outcomes compared with other factors. The adjusted R 2 for the OMAS and EQ-5D models was 0.15, indicating that other unexplored factors contribute to recovery.
Conclusion : unhelpful pain beliefs measured two weeks after ankle fracture surgery were consistently associated with poorer function and quality of life up to 12 months. Pain self-efficacy and fear of movement emerged as stronger predictors than most demographic or clinical factors, highlighting their value as early screening targets. These findings support the integration of biopsychosocial interventions to improve recovery following ankle fracture surgery.
Adult, Aged, Ankle Fractures/surgery, Female, Fracture Fixation, Internal, Humans, Male, Middle Aged, Pain Measurement, Postoperative Pain/psychology, Self Efficacy, Surveys and Questionnaires, Treatment Outcome
431-438
Bretherton, Christopher Patrick
84103205-3d15-4774-a085-f19971e4111d
Al-Saadawi, Ahmed
d7122d1c-9d04-4203-8453-050a28f36261
Sandhu, Harbinder
b58b0cec-4f88-4ce1-9841-20a39a0f6fdd
Baird, Janis
f4bf2039-6118-436f-ab69-df8b4d17f824
Griffin, Xavier L.
95c2a79c-af80-47c8-9475-338eb506aa7a
1 March 2026
Bretherton, Christopher Patrick
84103205-3d15-4774-a085-f19971e4111d
Al-Saadawi, Ahmed
d7122d1c-9d04-4203-8453-050a28f36261
Sandhu, Harbinder
b58b0cec-4f88-4ce1-9841-20a39a0f6fdd
Baird, Janis
f4bf2039-6118-436f-ab69-df8b4d17f824
Griffin, Xavier L.
95c2a79c-af80-47c8-9475-338eb506aa7a
Bretherton, Christopher Patrick, Al-Saadawi, Ahmed, Sandhu, Harbinder, Baird, Janis and Griffin, Xavier L.
(2026)
The impact of unhelpful pain beliefs on patient outcomes after surgically managed ankle fractures: an embedded observational study.
The Bone & Joint Journal, 108-B (3), .
(doi:10.1302/0301-620X.108B3.BJJ-2025-1321.R1).
Abstract
Aims: to determine the distribution of unhelpful pain beliefs in patients after ankle fracture surgery and investigate their impact, along with other demographic characteristics, on postoperative recovery.
Methods: this was an observational cohort study embedded within the Weightbearing in Ankle Fractures (WAX) trial. Adults (≥ 18 years) who underwent operative fixation of unstable ankle fractures were recruited from 23 UK hospitals two weeks post-surgery. Pain beliefs were measured at baseline using the Pain Self-Efficacy Questionnaire (PSEQ-2) and Tampa Scale of Kinesiophobia (TSK-11). Outcomes were the Olerud-Molander Ankle Score (OMAS) and EuroQol five-dimension questionnaire (EQ-5D) index at four months. Associations between pain beliefs and outcomes were examined using multivariable linear regression models adjusted for age, sex, BMI, comorbidity, occupation, and weightbearing allocation.
Results: of 795 eligible patients, 561 were recruited between February 2020 and October 2021 (mean age 48 years, 64% female). At four months, higher BMI, manual labour occupation, and greater kinesiophobia (TSK-11) were associated with poorer OMAS and EQ-5D outcomes, whereas male sex and higher pain self-efficacy (PSEQ-2) predicted better outcomes. Pain beliefs accounted for roughly twice the variability in outcomes compared with other factors. The adjusted R 2 for the OMAS and EQ-5D models was 0.15, indicating that other unexplored factors contribute to recovery.
Conclusion : unhelpful pain beliefs measured two weeks after ankle fracture surgery were consistently associated with poorer function and quality of life up to 12 months. Pain self-efficacy and fear of movement emerged as stronger predictors than most demographic or clinical factors, highlighting their value as early screening targets. These findings support the integration of biopsychosocial interventions to improve recovery following ankle fracture surgery.
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WAX_Pain_Beliefs_Manuscript_BJJ_V2.0_10Oct2025 (1)
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e-pub ahead of print date: 1 March 2026
Published date: 1 March 2026
Keywords:
Adult, Aged, Ankle Fractures/surgery, Female, Fracture Fixation, Internal, Humans, Male, Middle Aged, Pain Measurement, Postoperative Pain/psychology, Self Efficacy, Surveys and Questionnaires, Treatment Outcome
Identifiers
Local EPrints ID: 511320
URI: http://eprints.soton.ac.uk/id/eprint/511320
ISSN: 2049-4394
PURE UUID: 61e5d5b4-49f7-4a27-9187-529e7eaa4d21
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Date deposited: 12 May 2026 16:31
Last modified: 13 May 2026 01:39
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Contributors
Author:
Christopher Patrick Bretherton
Author:
Ahmed Al-Saadawi
Author:
Harbinder Sandhu
Author:
Xavier L. Griffin
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