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Mind, Stress and Recovery

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How stress, low mood, anxiety and worry about pain affect recovery and surgical outcomes — and what helps.

Updated Sep 202613 citations

Mind, Stress and Recovery Kieran Hirpara 4.0

Pain and mood travel together. Anyone who has had a bad week and noticed their shoulder hurting more already knows this. It does not mean the pain is imagined, and it does not mean it is your fault. It means the nervous system that carries pain and the part of you that worries are the same system, and it is worth understanding how they interact before an operation rather than discovering it afterwards.

What stress does to pain

Think of your nervous system as an alarm. Its job is to tell you when something is wrong. In a calm, rested body the alarm is sensitive but accurate: a real injury sets it off, ordinary movement does not.

When you have been in pain for months, sleeping badly, or under strain at home or at work, the alarm gets turned up. It starts going off for things that are not dangerous: a light touch, a small movement, the weight of a blanket. The pain is real, but it is now bigger than the injury causing it. Doctors call this central sensitisation. In plain terms, the wiring has become over-sensitive, and worry, poor sleep and fear all turn the dial further.

This is why two people with the same operation, done the same way, can have very different first weeks. The repair is the same; the alarm settings are not.

Why it matters for your operation

If you are living with anxiety or low mood, your recovery is likely to follow a different path from the textbook one. You will probably report more pain in the early weeks, and your scores on the questionnaires we use may climb more slowly. You will still get most of the benefit of the operation; you may just feel it later, and feel less sure of it along the way.

Two specific things deserve a mention:

• Fear of moving the arm is the single thing most likely to hold a recovery back. It is completely understandable. The arm hurts, it has just been operated on, and moving it feels like it must be doing harm. But a repair that is not moved stiffens, and stiffness is much harder to undo than it is to prevent. The exercises you are given are the treatment, not an optional extra.
• Worry that starts after surgery is worth telling us about. People who become newly anxious or low in the weeks after a shoulder operation are more likely to end up back in hospital, usually over pain they were not expecting. Expecting it, and having a plan for it, is most of the answer.

None of this changes whether you should have the operation. It changes how we prepare you for it.

The habit that helps most: moving, gently, every day

The exercises from your surgeon or hand therapist are deliberately small and deliberately boring. They are meant to be done several times a day, within the limits you have been given, whether or not you feel like it. Some tips that make it easier:

• Do them by the clock, not by how you feel. Tie them to something you already do: after each meal, or each time you make a cup of tea.
• Expect some discomfort and know the difference. A stretch that eases as you settle into it is fine. Sharp pain that gets worse, or pain that stays raised for hours afterwards, is not, and means you should ease off and let us know.
• Rehearse the movement in your head. Sitting quietly and imagining the wrist bending, in detail, several times a day, sounds odd, but it has been shown to improve movement, grip and function after a wrist fracture [10]. The brain practises the movement even when the joint cannot yet. Try it before each set of exercises.
• Keep the rest of you moving. Walk every day. The arm is in a sling; you are not.

Simple things that help

• Protect your sleep. Poor sleep and pain feed each other, and after shoulder surgery in particular sleep is hard. The sleep, pain and recovery page has practical steps.
• Use your pain relief as prescribed in the first days, rather than waiting until pain is severe and then chasing it. See managing pain after surgery.
• Keep a routine. Get up at the usual time, get dressed, eat at normal times. Days without shape are days when pain fills the space.
• Listen to music you like. This is not a platitude. In a randomised trial, patients who had music therapy during shoulder replacement surgery had a greater fall in pain and anxiety scores than those who did not [11]. Headphones in the waiting area and at home cost nothing.
• Slow breathing. Four seconds in, six seconds out, for a couple of minutes, several times a day and whenever pain spikes. It is the quickest way to turn the alarm down a notch.
• Stay connected. Being one-handed is isolating. Say yes to visits and lifts, and let people help with the things that need two hands.
• Go easy on alcohol and caffeine, both of which make sleep worse and anxiety louder.
• Judge progress over weeks, not days. Recovery is not a straight line. A bad day in week three is not a failed operation.

If you already live with anxiety or depression

Tell us. It is common, it is not a reason to avoid surgery, and knowing about it lets us plan around it.

• Keep taking your medication. Do not stop antidepressants or anxiety medication before surgery unless the doctor who prescribed them tells you to. Stopping suddenly makes the days around an operation harder.
• Line up your supports before the day. If you see a psychologist or counsellor, let them know your surgery date. If you do not, and you would like to, your GP can arrange it.
• Treating the anxiety helps the arm. In patients with anxiety or depression having a rotator cuff repair, treating the mood problem in the weeks around surgery improved not only distress but also shoulder movement and function in the first three months [12]. Your mind and your shoulder are not separate projects.

When to seek help

Call the rooms if:

• pain is far worse than you were told to expect, or is not improving at all by the time you were told it should
• you find yourself unable to do your exercises because of fear rather than because of pain
• you notice new anxiety or low mood after your operation that is not lifting

See your GP if low mood or worry lasts more than a couple of weeks, if you are not sleeping at all, or if you have stopped doing the things you normally enjoy.

If you have thoughts of harming yourself, do not wait for an appointment. Call Lifeline on 13 11 14, any time, or 000 in an emergency.

In more depth

Advanced reading: the deeper science (optional)

This section is for the reader who wants the evidence rather than the summary. The research on mind and orthopaedic recovery has grown quickly, and the honest picture is more nuanced, and more hopeful, than "anxious people do worse".

Mental health shapes where you start, not only where you finish

In patients undergoing revision rotator cuff repair, pre-operative mental health status showed the strongest association of any factor with baseline pain, function and satisfaction scores, before anything had been operated on [1]. That matters for interpreting everything that follows: if you begin from a lower score, a smaller final score can still represent the same amount of improvement.

Anxiety and depression change the path, less so the destination

A prospective cohort study of hip replacement found that anxiety and depression symptoms were associated with inferior outcomes, with recovery trajectories that differed from those of patients without such symptoms, despite major clinical improvement in both groups [2]. After patellar stabilisation surgery, patients with major depressive disorder, or with depression that had never been diagnosed, reported worse scores before and after surgery, but still benefited significantly from the operation [3]. At two years after hip arthroscopy, a history of anxiety or depression was consistently associated with poorer patient-reported outcomes, whereas resilience showed a weaker and less consistent association [4].

The repeated pattern is a shifted curve rather than a flat one: the benefit is real, and it is measured from a lower starting point.

It is not a rule

Two upper-limb studies push back on any simple story. After thumb base arthroplasty, a history of depression did not appear to worsen patient-reported outcomes [5]. And in surgery for painful nerve endings (neuromas) in the arm, patients with lower pre-operative mental health scores reported similar or greater improvements in pain, and similar improvements in function, to everyone else [6]. Mood is a factor, not a verdict.

The modifiable part is fear of movement

The psychological factor with the clearest mechanical consequence is kinesiophobia, the fear that movement will cause harm. After arthroscopic stabilisation of a dislocating shoulder, kinesiophobia adversely affected functional recovery and return to sport [7]. A related trait, pain catastrophising (the habit of expecting the worst from pain), predicted dissatisfaction six months after spinal surgery [8]. And in the weeks after arthroscopic shoulder stabilisation, patients who developed new anxiety or depression had a significantly higher risk of readmission within 90 days [9].

These are the findings behind the advice on this page to move by the clock, to expect discomfort, and to tell us about new worry rather than sit on it.

What actually helps, tested properly

Three properly randomised comparisons are worth knowing about. Adding motor imagery (structured mental rehearsal of the movement) to standard treatment after a distal radius fracture improved function, wrist extension and grip strength compared with standard treatment alone [10]. Music therapy during shoulder replacement produced a significantly greater reduction in pain and anxiety scores than usual care [11]. And in patients with anxiety or depression undergoing rotator cuff repair, treatment with duloxetine, an antidepressant also used for pain, improved anxiety and distress and also range of motion and functional scores over the first three months, at the cost of nausea or vomiting in about one patient in six [12].

None of these is a cure and the last is a prescribing decision for your GP or psychiatrist, not something to start yourself. But together they show the same thing from three directions: the mind is not a bystander in recovery, and it can be worked with.

A note on the questionnaires

You may be asked to fill in a short mental health questionnaire before surgery. This is not a test you can fail. A study comparing screening tools before joint replacement found that a brief standard mental health score performed better than a resilience questionnaire at identifying patients at risk of a poorer result [13]. The point of asking is to plan support, not to decide who is operated on.

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Reviewed by Dr Kieran Hirpara · 9 September 2026.

Want the clinical detail? Read the clinician version.

Talk to your treating clinician for advice specific to you.

For an appointment with the CQ Hand + Upper Limb team, ask your GP about a referral or visit www.cqupperlimb.com.

References for the advanced reading

1. Streubel PN, Sahoo S, Zhang C, Cogan CJ, Farrow LD, Gilot GJ, et al. Associations of preoperative patient mental health status, sociodemographic and clinical characteristics with baseline pain, function and satisfaction in patients undergoing revision rotator cuff repairs. J Shoulder Elbow Surg. 2026.
2. Aalders MB, Ligthart MJ, Temmerman OP, Benner JL, van der List JP, Kerkhoffs GM, et al. Anxiety and depression symptoms are associated with inferior outcomes in patients undergoing total hip arthroplasty: a prospective cohort study. J Arthroplasty. 2026;41(1):132-40.e4.
3. Greif DN, Castle P, Jain S, Ramirez G, Mannava S, Maloney M, et al. Patients with major depressive disorder and undiagnosed depression are at risk for inferior outcomes after patellar stabilization surgery. J ISAKOS. 2026;18:101080.
4. Quinn M, Morrissey P, Pisani C, Marquez-Garcia J, Ahn B, Zhang H, et al. Effect of a history of anxiety and depression on patient-reported outcomes after hip arthroscopy at 2-year follow-up. Orthop J Sports Med. 2026;14(2).
5. Mohamed OM, Duggan JL, Hines KE, Harper CM, Rozental TD, Shoji MM. The impact of depression and antidepressant treatment on patient-reported outcomes following thumb carpometacarpal arthroplasty. J Hand Surg Glob Online. 2026;8(3):100989.
6. Manzoor A, Khan M, Macaraeg C, Yohe G, Giladi AM. Outcomes following regenerative peripheral nerve interface surgery and associations with preoperative mental health: a retrospective analysis of upper-extremity neuromas. J Hand Surg Glob Online. 2026;8(3):100985.
7. Altay N, Özdemir E, Topsakal FE, Şahbat Y, Demirel E. The impact of kinesiophobia on rehabilitation and return to sport following arthroscopic Bankart repair for glenohumeral instability: a minimum 1-year follow-up. BMC Musculoskelet Disord. 2026;27(1).
8. Mao-jiang Y, Xian Q, Han-feng Y, Xiao-xue X, Al-Goshae HAA. Pain catastrophizing and postoperative satisfaction in cervical disc herniation: a 6-month prospective cohort study. BMC Musculoskelet Disord. 2026;27(1).
9. Lutati DC, Brennan JC, Johnson AH, Peterman MA, Redziniak DE, Lashgari CJ, et al. Risk factors for new-onset anxiety and depression after arthroscopic shoulder stabilization surgery. JSES Int. 2026;10(2):101413.
10. Kalaycı MG, Analay Akbaba Y, Güven MF. The effect of motor imagery on functionality, pain, kinesiophobia, and quality of life in patients with distal radius fractures: a randomized controlled double-blind study. J Hand Ther. 2025;38(4):726-35.
11. Kim RY, Nam HH, Stouffer JW, Myers CA, Hassenbein SE, Updegrove GF, et al. A prospective randomized controlled trial on the effect of music therapy intervention on pain and anxiety in adult patients undergoing total shoulder arthroplasty. JSES Int. 2026;10(2):101438.
12. Han SC, Han J, Min YK, Han JW, Jeong HJ, Oh JH. Duloxetine improves early clinical outcomes including range of motion, functional scores, pain, and psychological distress after arthroscopic rotator cuff repair in patients with anxiety or depression: prospective randomized controlled trial. Am J Sports Med. 2026;54(6):1333-43.
13. Megafu M, Solomito MJ, Carangelo R, Makanji H. The effectiveness of the Patient-Reported Outcomes Measurement Information System Global Health Instrument Mental Health T-Score versus the Brief Resiliency Scale at identifying the potential for poor outcomes following elective total knee and hip arthroplasty. J Arthroplasty. 2026;41(5):1384-90.

Evidence & references

This is the clinical evidence summary written for health professionals. It is technical, and it lists the research this page was built from. You do not need to read it to understand your treatment or to make a decision about it.

Overview

• Psychological outlook is a modifiable determinant of recovery after orthopaedic trauma [1].
• Machine learning models can support early identification of patients at risk for postoperative psychological distress after total joint arthroplasty [2].
• Early identification of patients at risk for postoperative psychological distress enables targeted behavioral health referral or psychologically informed physical therapy prior to surgery [2].
• Patients with anxiety and depression symptoms undergoing total hip arthroplasty experience major clinical improvement but have differing recovery trajectories [3].
• Patients with anxiety and depression symptoms undergoing total hip arthroplasty require tailored perioperative counseling and psychological support [3].
• Patients with lower preoperative mental health scores report similar or greater pain improvements following regenerative peripheral nerve interface surgery [4].
• Patients with lower preoperative mental health scores report similar functional improvements following regenerative peripheral nerve interface surgery [4].
• Regenerative peripheral nerve interface surgery benefits patients regardless of mental health status [4].
• Unaddressed mental health disorders likely account for the persistent inability to achieve high rates of minimal clinically important difference and substantial clinical benefit in hip preservation surgery [5].
• Patients with higher social deprivation experience increased postoperative pain and anxiety in distal femur fractures [7].
• Patients with higher social deprivation experience increased postoperative pain and anxiety despite similar objective outcomes in distal femur fractures [7].
• Achieving the WHO recommendation of 450 MET-min/week is not mandatory to elicit improvements in depressive symptoms in patients with chronic illness and comorbid depression [12].
• Preoperative pain and functional impairment are closely related to preoperative mental health status in adolescents with polydactyly/syndactyly [14].
• The direct impact of preoperative mental health status on surgical outcomes is limited in adolescents with polydactyly/syndactyly [14].
• Evidence suggests that patients receiving early psychological intervention after road traffic accidents may have done worse than those in the control group [15].
• Comparisons regarding the effect of early psychological intervention after road traffic accidents are confounded by higher Injury Severity Scores in the intervention group [15].
• The Patient-Reported Outcomes Measurement Information System Global Health Instrument Mental Health T-Score has superior performance for identifying the potential for poor outcomes following elective total knee and hip arthroplasty [16].
• The Patient-Reported Outcomes Measurement Information System Global Health Instrument Mental Health T-Score is a valuable tool for preoperative psychosocial screening due to its integration within standard outcome frameworks [16].
• Patients with major depressive disorder and undiagnosed depression are at risk for inferior outcomes after patellar stabilization surgery [48].
• Patients with underlying mental health disorders may still significantly benefit from medial patellofemoral ligament reconstruction compared to their unaffected counterparts [48].
• Patients with underlying mental health disorders report worse pre- and post-operative PROMIS scores after medial patellofemoral ligament reconstruction [48].

Anatomy & Pathophysiology

Psychological Stress and Recovery

• Most injuries are associated with some kind of psychological stress [10].
• The psychological response to injury is modified by the nature of the injury, the manner in which it occurs, the parts of the body damaged, and the current life circumstances of the patient [10].
• Baseline level of pain is associated with pain following injury to the extremities [52].
• Patient-specific psychological characteristics and personality structure significantly affect functional outcomes after arthroscopically assisted acromioclavicular joint stabilization for acute and chronic injuries at mid-term follow-up [23].
• Kinesiophobia is a critical psychological factor that adversely affects functional recovery and return to sport following arthroscopic Bankart repair [49].
• Lower Injury Psychological Readiness to Return to Sport (IPRRS) ratings are associated with longer symptom resolution time and the occurrence of subsequent injury [13].
• Anxiety and depression symptoms are associated with inferior outcomes in patients undergoing total hip arthroplasty [3].
• New-onset anxiety and depression occur in 5.1% of patients within 1 year following arthroscopic shoulder stabilization surgery [8].
• Sex-based disparities exist in physical and psychological recovery, as well as return to sport status, in community-level patients undergoing anterior cruciate ligament reconstruction [9].
• Poor compliance with a brace protocol is associated with poorer quality of life, with noncompliant patients lacking vitality and functioning poorly physically, emotionally, and socially [11].

Nerve Injury Pathophysiology

• Peripheral nerves consist of motor, sensory, and postganglionic autonomic nerve fibers arranged into groups by connective tissues that provide protection and maintain specialized compartmental environments [33].
• The endoneurium surrounds individual nerve fibers, the perineurium encloses groups of nerve fibers to form fascicles, and the epineurium encloses groups of fascicles to form nerve trunks [33].
• Compressive and tensile forces sustained by nerves can impact blood flow, axonal transport, and conduction of action potentials [33].
• Neurapraxia is a conduction block that occurs without axonal disruption, with recovery usually complete within days to a few months [41].
• Axonotmesis describes an injury in which axonal disruption occurs with the endoneurial tube remaining in continuity, providing a well-defined path for regenerating sprouting axons [41].
• Neurotmesis describes the situation when a nerve trunk has been divided or so seriously disrupted that spontaneous recovery cannot occur [27].
• In neurotmesis, all connective tissue layers of the nerve are affected as well as the axons, and Wallerian degeneration occurs [27].
• Recovery after neurotmesis is only possible by axonal regeneration after surgical repair of the nerve, with function returning in a proximal to distal pattern [27].
• The quality of functional recovery is never normal after neurotmesis, partly because of the failure of correct "rewiring" [27].
• After a nerve is injured, the somatosensory cortex reorganizes so the area represented by the injured nerve diminishes [41].
• Within 24 hours of injury, axonal sprouting occurs from the proximal stump [41].
• Longitudinal growth of the regenerating nerve depends on the ability of the axons to adhere to trophic factors in the basal lamina of the Schwann cell [41].
• At the motor endplate, muscle fibers atrophy and the sensitivity and number of acetylcholine receptors increase as their location expands from pits to the entire length of the muscle fiber [41].
• Muscle reinnervation occurs only if the axon reaches the muscle within a year [41].
• Sensory receptors may be effectively reinnervated years after injury [41].
• Axonal regeneration occurs from proximal to distal, and the signs of sensory recovery precede those of voluntary motor activity [22].
• Tinel's sign is the first detectable clinical sign of recovery, produced by percutaneous percussion of the nerve trunk distal to the lesion [22].
• The "pins and needles" sensation resulting from Tinel's sign is caused by regeneration of the sensory axons, which are very sensitive to pressure [22].
• Axonal regrowth usually occurs at a rate of 1–2 mm per day after nerve suturing [22].
• Nerve-fiber regeneration occurs at the rate of approximately 1 mm/day following a latent period of 30 days [32].
• Evidence of reinnervation on electromyography may precede the clinical appearance of motor function by approximately 4 weeks [32].
• In the first few days or weeks after injury, the autonomous zone of sensory loss becomes smaller long before regeneration is possible [36].
• Pinprick is the first perception to return after median and ulnar nerve injury, followed by 30 cycles/s vibratory stimulus, then moving touch [36].
• The perception of constant touch and the perception of a 256 cycles/s vibratory stimulus are the last to return after median and ulnar nerve injury [36].
• The early return of pain perception results from the faster regeneration of the small-diameter pain fibers [36].
• The return of moving touch perception before constant touch is explained by differential maturation of the respective receptors rather than by the diameter of the fibers alone [36].
• Axons exhibit a high degree of spontaneous activity and mechanosensitivity, accounting in part for the ubiquity of episodic lancinating pain and for the physiologic basis of the Hoffman-Tinel sign [38].
• Regenerated axons remain abnormal with reduced fiber diameters and hence conduction velocity [38].
• The number of axons re-innervating a muscle is reduced as a result of neuronal loss, and hence fewer but larger motor units will be formed [38].
• Neurobiologic changes pertaining to the quality of nerve regeneration after a repair exhibit a profound deterioration when the delay from injury to repair is extended beyond 1 to 2 months [38].
• Neuronal death is a fundamental issue that requires timely nerve repair and/or pharmacologic intervention [29].
• The repair site environment is not adequately conducive to bridging by neurite growth, with the result that many axons are lost [29].
• Nerve regeneration is far too slow for optimal salvage of much of the distal nerve, target muscles, and higher-order sensory organs from irreversible denervation atrophy [29].
• Plasticity is initially disadvantageous during denervation and subsequently inadequate to make best use of what re-innervation occurs [29].
• Neurorrhaphy is never followed by full return of motor and sensory function [30].
• Recovery of function of the limb as a whole is not proportionate to neurologic recovery [30].

Classification

• Machine learning models can support early identification of patients at risk for postoperative psychological distress following total joint arthroplasty [2].
• Patients with remission or mild fibromyalgia experience more severe symptoms and poorer quality of life than patients with remission or low disease activity rheumatoid arthritis [6].
• Sex-based disparities exist in physical and psychological recovery and return to sport status following anterior cruciate ligament reconstruction [9].
• Poor compliance with a brace protocol in adolescents with idiopathic scoliosis is associated with poorer quality of life [11].
• Noncompliant patients with idiopathic scoliosis lack vitality and function poorly physically, emotionally, and socially [11].
• Lower Injury Psychological Readiness to Return to Sport ratings are associated with longer symptom resolution time following concussion [13].
• Lower Injury Psychological Readiness to Return to Sport ratings are associated with the occurrence of subsequent injury following concussion [13].
• Evidence suggests that patients receiving early psychological intervention after road traffic accidents may have done worse than those in the control group, although comparisons are confounded by higher Injury Severity Scores [15].
• The Patient-Reported Outcomes Measurement Information System Global Health Instrument Mental Health T-Score has superior performance for preoperative psychosocial screening compared to the Brief Resiliency Scale [16].
• Physical activity should be a mainstay approach in the management of depression, anxiety, and psychological distress [24].
• Patients undergoing revision rotator cuff repairs have lower mental health status compared to patients undergoing primary rotator cuff repairs [25].
• Five distinct patient typologies were identified among fibromyalgia patients: Category 1 (Worst), Category 2 (Phys. poor), Category 3 (Ment. poor), Category 4 (Moderate), and Category 5 (Best) [50].
• Suicidal ideation and suicidal behaviour can be aggravated by injury or failure to meet performance goals in elite athletes [55].
• The incidence of suicidal ideation and suicidal behaviour peaks among adolescents and young adults [55].
• The global prevalence of lifetime suicidal ideation is between 12% and 33% [55].
• The global prevalence of lifetime suicidal behaviour is between 4% and 9% [55].
• Emergency room visits for injury are events indicating increased suicide risk [55].
• The overall global suicide rate is estimated at 11/100,000 per year [55].
• The suicide rate for collegiate sports in the USA is 1/100,000 per year [55].
• The suicide rate of 1/100,000 per year in USA collegiate sports represents about 7% of all-cause mortality among student athletes [55].
• The occupational category identified with the highest women's suicide rates in the USA in 2015 was professional athletes, at 16/100,000 [55].
• Among men in the professional athlete occupational category in the USA, suicide rates showed the largest increase of 47% from 2012 [55].
• Participation in football, repeated concussions, and chronic traumatic encephalopathy have been associated with increased risk of suicide among male elite athletes in the USA [55].
• Central sensitization can be seen as an excessive reactivity of nociceptive neurons in the central nervous system to normal or subthreshold afferent chronic stimuli in people with certain mental predispositions [58].

Clinical Presentation

• Patients with anxiety and depression undergoing total hip arthroplasty experience major clinical improvement but have differing recovery trajectories [3].
• Patients with higher social deprivation experience increased pain and anxiety despite similar objective outcomes in distal femur fractures [7].
• Patients with lower preoperative mental health scores report similar or greater pain improvements and similar functional improvements following regenerative peripheral nerve interface surgery [4].
• Revision rotator cuff repair patients have lower mental health status compared to primary rotator cuff repair patients [25].
• There is a disparity between sexes in physical and psychological recovery following anterior cruciate ligament reconstruction [9].
• There is a disparity between sexes in return to sport status following anterior cruciate ligament reconstruction [9].
• Lower Injury Psychological Readiness to Return to Sport ratings are associated with longer symptom resolution time after concussion [13].
• Lower Injury Psychological Readiness to Return to Sport ratings are associated with the occurrence of subsequent injury after concussion [13].
• Anxiety levels in adolescents with idiopathic scoliosis are stable and independent of received therapeutic support [18].
• Deterioration or decompensation in complex or worklike settings refers to an individual's repeated failure to adapt to stressful circumstances [31].
• In the face of stressful circumstances, an individual may withdraw from the situation or experience exacerbation of signs and symptoms of a mental disorder [31].
• Patients with post-traumatic stress disorder may require a prophylactic preclusion from jobs involving contact with the general public or handling large sums of money [31].
• Depression, occupational mental stress, job satisfaction, intensity of concentration, anxiety, and marital status are factors revealed in studies of occupational back pain [37].
• Psychologic stresses occur before complaints of pain in some patients with back pain [37].
• Experienced spinal surgeons were able to identify distressed patients only 26% of the time based on patient interviews [37].
• Physicians have difficulty detecting psychosocial factors in patients with back pain without using specific instruments designed for this purpose [37].
• The first detectable clinical sign of neural regeneration is Tinel's sign [22].
• Percutaneous percussion of the nerve trunk distal to the lesion produces a "pins and needles" sensation distally in the territory of distribution of the cutaneous nerve [22].
• Tinel's sign signifies a favorable prognosis and enables one to follow the progress of the regenerating nerve [22].
• Tinel's sign is absent in the early stages following injury or nerve suturing [22].
• Tinel's sign appears only four to six weeks after the injury [22].
• The time of appearance of Tinel's sign is roughly proportional to the severity of the lesion [22].
• Tinel's sign may be difficult to elicit if the nerve lies deep to a large mass of muscle [22].
• Tinel's sign cannot be demonstrated when the lesion is proximal to the posterior root ganglion [22].
• A false positive result for Tinel's sign is elicited when sensory fibers grow into motor sheaths [22].
• Tinel's sign has no quantitative value and can be positive with only a few fibers regenerating [22].
• Steady distal progression of Tinel's sign suggests a good prognosis [22].
• Interrupted progress of Tinel's sign must be regarded as alarming [22].
• Recovery of neural regeneration occurs from proximal to distal [22].
• The signs of sensory recovery precede those of voluntary motor activity in neural regeneration [22].

Investigations

• Patients with lower preoperative mental health scores reported similar or greater pain improvements and similar functional improvements following regenerative peripheral nerve interface surgery [4].
• Patients with higher social deprivation experienced increased pain and anxiety despite similar objective outcomes in distal femur fractures [7].
• There is a disparity between sexes in physical and psychological recovery, as well as return to sport status, in community-level patients undergoing anterior cruciate ligament reconstruction [9].
• Lower Injury Psychological Readiness to Return to Sport ratings were associated with longer symptom resolution time and the occurrence of subsequent injury following post-concussion exercise [13].
• The Patient-Reported Outcomes Measurement Information System Global Health Instrument Mental Health T-Score is a valuable tool for preoperative psychosocial screening due to its superior performance and integration within standard outcome frameworks [16].
• Anxiety levels in adolescent idiopathic scoliosis patients are stable and independent of received therapeutic support [18].

Treatment

Psychological Interventions and Therapeutic Relationships

• A substantive relationship with one’s surgeon is often sufficient psychological support, but sometimes expert support is helpful [28].
• Traditional supportive therapy might best be thought of as a compassionate interchange that fosters robustness [28].
• Motivational interviewing addresses the inner obstacles that interfere with desired behavior change [28].
• Psychodynamic therapy is about the self-knowledge that leads to personal freedom [28].
• Acceptance and commitment therapy cites personal values and fosters flexible thinking to create growth [28].
• Cognitive-behavioral treatments help one change thoughts and behaviors to change mindset and mood [28].
• Group therapy can help people feel less alone and more understood [28].
• Designing a self-care contract together with the patient says “We are in this together” and can make a monumental difference for mood and compliance [28].
• Treatments that are tailored for the needs of individual patients and are delivered in the acute phase of symptoms are more effective than those that start after symptoms have become persistent [28].
• A 60-second, personalized mindfulness intervention delivered to patients waiting for their surgeon was feasible, accepted by patients, and associated with immediate decrease in pain, anger, anxiety, and depression [28].
• A four-session intervention called Toolkit for Optimal Recovery that combined mind body skills with cognitive-behavioral approaches decreased pain intensity and limitations among patients recovering from injury or surgery who score high on catastrophic thinking about pain or pain anxiety [28].
• Relaxation and mindfulness skills, cognitive-behavioral skills, and activity pacing can help challenge negative myths associated with recovery [28].
• Videos and decision aides can provide helpful information on optimal recovery and serve as tools for training people to develop effective coping strategies [28].
• Empowering patients to ask for skills training rather than waiting for provider referrals may bypass some barriers to care [28].
• Compassion is defined as sympathetic awareness of the pain or distress of others combined with the wish to alleviate that suffering [35].
• An injured person is more likely to trust an expert, receive information, think objectively about their condition, and work on stress, distress, and optimal coping strategies if they trust their surgeon and feel valued as an individual [35].
• A positive clinical interaction may even circumvent the need for a psychological referral [35].
• Feeling valued via a compassionate exchange can prime a person to practice self-care and prosocial behavior [35].
• Trust allows people to do stretching exercises even when they are painful because they more readily question intuitive yet nonadaptive thoughts triggered by injury and pain [35].
• The act of talking or even writing about the emotional aspects of illness can decrease symptoms and limitations [35].
• A compassionate and emotionally connected conversation can be the first step to eliciting an individual's particular coping capacities [35].
• In the context of the placebo effect, evidence shows that it is the interaction of the clinician with the patient, not specific patient factors or belief systems, that diminishes symptoms and limitations and can even—in some instances—affect pathophysiology [35].
• Stigma is reduced when we acknowledge that stress and distress are expected aspects of recovery from injury [35].
• Interventions that address the fears that accompany injury and help develop natural coping strategies can seed positive adjustment and an optimal life [35].

Patient Engagement and Education

• Patient engagement is paramount to complete recovery [34].
• Initial engagement is hampered by altered consciousness, severe pain, and poor recall [34].
• Over time, pain is a major driving factor to increase anxiety, and to foster catastrophizing and mental illness, particularly anxiety, depression, and post-traumatic stress disorder [34].
• Early iterative communication by all providers regarding the nature of injuries and projected treatment course and framing of expectations are essential to achieving patient education and engagement [34].
• Baseline chronic pain with prescription and/or recreational opioid use as well as other forms of substance abuse and mental illness is common in trauma patients [34].
• Baseline chronic pain, substance abuse, and mental illness are associated with poor self-efficacy and support systems, and place patients at even greater risk for poor outcome [34].
• Initial strategies to manage pain including education and setting of expectations; multimodal pain medications; counseling; and alternative therapies such as aromatherapy, cryotherapy, and other nontraditional methods may be effective [34].
• The Trauma Survivor Network has shown promise by providing an online community of support and various educational materials [34].
• Initial reports of such interventions, coupled with counseling and peer visitor support, are valuable in promoting patient and provider satisfaction and in minimizing complications related to nonadherence to treatment recommendations [34].
• Good organization makes assessment a continuous process which everybody who deals with the patient performs every day [19].
• Frequent case conferences pool the knowledge gained by individuals, so that trends can be anticipated, corrected, or augmented as necessary [19].
• A system of recording ability or disability and then matching it against the requirements of different types of employment is being experimented with for return to work assessment [19].

Pharmacological and Non-Pharmacological Adjuncts

• Patients receiving music therapy intervention had a significantly greater reduction in pain and anxiety scores compared to the control in adult patients undergoing total shoulder arthroplasty [47].

Risk Stratification and Monitoring

• Machine learning models could support early identification of patients at risk for postoperative psychological distress, enabling targeted behavioral health referral or psychologically informed physical therapy prior to surgery [2].
• While patients with anxiety and depression symptoms experience major clinical improvement after total hip arthroplasty, their recovery trajectories differ, emphasizing the need for tailored perioperative counseling and psychological support [3].
• This study demonstrates the disparity between sexes in physical and psychological recovery, as well as return to sport status, in community-level patients undergoing anterior cruciate ligament reconstruction [9].
• Patients with lower preoperative mental health scores reported similar or greater pain improvements and similar functional improvements, suggesting regenerative peripheral nerve interface surgery benefits patients regardless of mental health status [4].
• Poor compliance with a brace protocol is associated with poorer quality of life, with noncompliant patients lacking vitality and functioning poorly physically, emotionally and socially in adolescents with idiopathic scoliosis [11].

Efficacy and Limitations of Specific Interventions

• Although comparisons are confounded by their higher Injury Severity Score, the evidence suggests that those trauma patients receiving an early psychological intervention may have done worse than those in the control group [15].
• A cognitive-behavioral therapy-based intervention resulted in marginal improvements in pain knowledge and psychological distress at 6 weeks, but did not yield meaningful benefits in pain and function out to 1 year for low back pain [17].
• Adolescent idiopathic scoliosis patients' anxiety levels are stable, independent of received therapeutic support [18].

Complications

• Patients with remission or mild fibromyalgia experience more severe symptoms than patients with remission or low disease activity rheumatoid arthritis [6].
• Patients with remission or mild fibromyalgia experience poorer quality of life than patients with remission or low disease activity rheumatoid arthritis [6].
• Patients with higher social deprivation experience increased postoperative pain in distal femur fractures [7].
• Patients with higher social deprivation experience increased postoperative anxiety in distal femur fractures [7].
• The psychological response to injury is modified by the nature of injury, manner in which it occurs, parts of the body damaged, and current life circumstances of the patient [10].
• Evidence suggests that patients receiving an early psychological intervention may have done worse than those in the control group, although comparisons are confounded by their higher ISS [15].
• A CBT-based intervention resulted in marginal improvements in pain knowledge and psychological distress at 6 weeks for low back pain [17].
• A CBT-based intervention did not yield meaningful benefits in pain and function out to 1 year for low back pain [17].
• A history of anxiety and/or depression is consistently associated with poorer outcomes after arthroscopic hip surgery [26].
• Resilience demonstrates a less consistent and variable association with outcomes after arthroscopic hip surgery [26].

Recovery

• Patients with lower preoperative mental health scores reported similar or greater pain improvements following regenerative peripheral nerve interface surgery [4].
• Patients with lower preoperative mental health scores reported similar functional improvements following regenerative peripheral nerve interface surgery [4].
• Patients with higher social deprivation experienced increased pain following distal femur fracture surgery [7].
• Patients with higher social deprivation experienced increased anxiety following distal femur fracture surgery [7].
• Patients with higher social deprivation experienced increased pain and anxiety despite similar objective outcomes following distal femur fracture surgery [7].
• There is a disparity between sexes in physical recovery following anterior cruciate ligament reconstruction [9].
• There is a disparity between sexes in psychological recovery following anterior cruciate ligament reconstruction [9].
• Lower Injury Psychological Readiness to Return to Sport ratings were associated with longer symptom resolution time after concussion [13].
• Lower Injury Psychological Readiness to Return to Sport ratings were associated with the occurrence of subsequent injury after concussion [13].
• Preoperative pain is closely related to preoperative mental health status in adolescents with polydactyly or syndactyly [14].
• Preoperative functional impairment is closely related to preoperative mental health status in adolescents with polydactyly or syndactyly [14].
• The direct impact of preoperative mental health status on surgical outcomes is limited in adolescents with polydactyly or syndactyly [14].
• A CBT-based intervention for low back pain resulted in marginal improvements in pain knowledge at 6 weeks [17].
• A CBT-based intervention for low back pain resulted in marginal improvements in psychological distress at 6 weeks [17].
• A CBT-based intervention for low back pain did not yield meaningful benefits in pain out to 1 year [17].
• A CBT-based intervention for low back pain did not yield meaningful benefits in function out to 1 year [17].

Key Evidence

• [Paper] Psychological outlook is a modifiable determinant of recovery after orthopaedic trauma. [1] (10.1016/j.injury.2026.113389)
• [L4] Such models could support early identification of patients at risk for postoperative psychological distress, enabling targeted behavioral health referral or psychologically informed physical therapy prior to surgery. [2] (10.1016/j.arth.2026.05.039)
• [L2] While these patients experience major clinical improvement after THA, their recovery trajectories differ, emphasizing the need for tailored perioperative counseling and psychological support. [3] (10.1016/j.arth.2025.06.013)
• [L4] Patients with lower preoperative mental health scores reported similar or greater pain improvements and similar functional improvements, suggesting RPNI benefits patients regardless of mental health status. [4] (10.1016/j.jhsg.2026.100985)
• [L5] Unaddressed mental health disorders likely account for the persistent inability to achieve high rates of minimal clinically important difference and substantial clinical benefit in hip preservation surgery. [5] (10.1002/arj.70034)
• [L4] Despite being in a mild activity or remission stage, RFM patients experience more severe symptoms and poorer QOL than RRA patients. [6] (10.1186/s12891-025-08323-6)
• [L3] Patients with higher social deprivation experienced increased pain and anxiety despite similar objective outcomes. [7] (10.5435/jaaosglobal-d-25-00066)
• [L3] New-onset anxiety and depression occur in 5.1% of patients within 1 year following arthroscopic shoulder stabilization surgery. [8] (10.1016/j.jseint.2025.101413)
• [L2] This study demonstrates the disparity between sexes in physical and psychological recovery, as well as RTS status, in community-level patients undergoing ACLR. [9] (10.1177/2325967125s00328)
• [Paper] [10] (10.1016/s0020-1383(02)00377-7)
• [L4] Poor compliance with a brace protocol is associated with poorer QOL, with noncompliant patients lacking vitality and functioning poorly physically, emotionally and socially. [11] (10.1186/1471-2474-10-5)
• [L1] It informs stakeholders that achieving the WHO recommendation of 450 MET-min/week is not mandatory to elicit improvements in depressive symptoms. [12] (10.1136/bjsports-2025-110371)
• [L3] Lower Injury Psychological Readiness to Return to Sport (IPRRS) ratings were associated with longer symptom resolution time and the occurrence of subsequent injury. [13] (10.1177/2325967126s00178)
• [L4] Preoperative pain and functional impairment are closely related to preoperative mental health status, whereas the direct impact of preoperative mental health status on surgical outcomes is limited. [14] (10.1186/s13018-026-07014-9)
• [L1] Although comparisons are confounded by their higher ISS, the evidence suggests that those patients receiving an early psychological intervention may have done worse than those in the control group. [15] (10.1016/0020-1383(96)86862-8)
• [L3] Its superior performance and integration within standard outcome frameworks make it a valuable tool for preoperative psychosocial screening. [16] (10.1016/j.arth.2025.09.034)
• [Paper] This CORR Insights commentary discusses a secondary analysis of a randomized trial, noting that while a CBT-based intervention resulted in marginal improvements in pain knowledge and psychological distress at 6 weeks, it did not yield meaningful benefits in pain and function out to 1 year. [17] (10.1097/corr.0000000000003410)
• [L3] AIS patients' anxiety levels are stable, independent of received therapeutic support. [18] (10.1186/s12891-026-09645-9)
• [L4] [19] (10.1016/s0020-1383(69)80092-6)
• [L4] Patient-specific psychological characteristics and personality structure significantly affect functional outcomes after arthroscopically assisted ACJ stabilization for acute and chronic ACJ injuries at mid-term follow-up. [23] (10.1002/ksa.70349)
• [L1] Physical activity should be a mainstay approach in the management of depression, anxiety and psychological distress. [24] (10.1136/bjsports-2022-106195)
• [L3] Compared to primary RCR patients, the revision cohort were more commonly White, had lower mental health status and more severe rotator cuff pathology, though tear severity was not associated with baseline PROMs. [25] (10.1016/j.jse.2026.05.007)
• [L3] The present study suggests that a history of anxiety and/or depression is consistently associated with poorer outcomes after arthroscopic hip surgery, whereas resilience demonstrates a less consistent and variable association. [26] (10.1177/23259671251407329)
• [L2] Patients receiving music therapy intervention had a significantly greater reduction in pain and anxiety scores compared to the control. [47] (10.1016/j.jseint.2025.101438)
• [L3] Patients with underlying mental health disorders may still significantly benefit from MPFL-R compared to their unaffected counterparts but will nonetheless report worse pre- and post-operative PROMIS scores. [48] (10.1016/j.jisako.2026.101080)
• [L3] Kinesiophobia is a critical psychological factor that adversely affects functional recovery and return to sport following arthroscopic Bankart repair. [49] (10.1186/s12891-026-09567-6)
• [L2] The study identified five distinct patient typologies (clusters) among fibromyalgia patients: Category 1 (Worst), Category 2 (Phys. poor), Category 3 (Ment. poor), Category 4 (Moderate), and Category 5 (Best). [50] (10.1186/1471-2474-15-450)
• [L3] Baseline level of pain is associated with pain following injury to the extremities. [52] (10.1016/s0020-1383(99)00090-x)
• [L4] [55] (10.1136/bjsports-2019-101386)
• [L5] Central sensitization can be seen as an excessive reactivity of nociceptive neurons in the central nervous system to normal or subthreshold afferent chronic stimuli in people with certain mental predispositions. [58] (10.3390/jcm14020577)

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