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Mind, Stress and Recovery

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

Overview

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 [1]. Anxiety and depression symptoms are associated with inferior outcomes in patients undergoing total hip arthroplasty, with recovery trajectories differing from those without these symptoms [7]. Mental health status shows the strongest association with baseline patient-reported outcome measures in patients undergoing revision rotator cuff repairs [10]. Patients developing new-onset anxiety or depression after arthroscopic shoulder stabilization surgery have a significantly increased risk of 90-day readmission [8].

Commonly collected data from routine preoperative clinical care show promise for predicting psychological distress after total joint arthroplasty [2]. The Patient-Reported Outcomes Measurement Information System Global Health Instrument Mental Health T-Score has superior performance and integration within standard outcome frameworks compared to the Brief Resiliency Scale for identifying the potential for poor outcomes following elective total knee and hip arthroplasty [6]. Central sensitization in chronic nonspecific low back pain 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 [13].

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 [5]. 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 [3]. 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 [4].

Background & Causes

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 [1]. Anxiety and depression symptoms are associated with inferior outcomes in patients undergoing total hip arthroplasty, with recovery trajectories differing despite major clinical improvement [7]. 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 [16].

Preoperative Screening: The Patient-Reported Outcomes Measurement Information System Global Health Instrument Mental Health T-Score has superior performance and integration within standard outcome frameworks for preoperative psychosocial screening compared to the Brief Resiliency Scale [6]. Commonly collected data from routine preoperative clinical care show promise for predicting psychological distress after total joint arthroplasty [2]. Mental health status shows the strongest association with baseline patient-reported outcomes in patients undergoing revision rotator cuff repairs [10].

Specific Surgical Populations: Patients with major depressive disorder and undiagnosed depression are at risk for inferior outcomes after patellar stabilization surgery, reporting worse pre- and post-operative PROMIS scores despite significant benefit compared to unaffected counterparts [15]. Patients developing new-onset anxiety or depression after arthroscopic shoulder stabilization surgery have a significantly increased risk of 90-day readmission [8]. Kinesiophobia is a critical psychological factor that adversely affects functional recovery and return to sport following arthroscopic Bankart repair for glenohumeral instability [12]. 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 [5].

Chronic Pain and Neuromuscular Conditions: Central sensitization in chronic nonspecific low back pain 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 [13]. Patients with lower preoperative mental health scores reported similar or greater pain improvements and similar functional improvements following regenerative peripheral nerve interface surgery for upper-extremity neuromas [9]. 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 [3]. Adolescent adolescent idiopathic scoliosis patients' anxiety levels are stable and independent of received therapeutic support [11].

Intervention Efficacy: 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 [4].

Symptoms & Presentation

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 outcomes [1]. Anxiety and depression symptoms are associated with inferior outcomes in patients undergoing total hip arthroplasty, with recovery trajectories differing from those without these symptoms [7]. Patients developing new-onset anxiety or depression after arthroscopic shoulder stabilization surgery have a significantly increased risk of 90-day readmission [8].

Preoperative Screening Tools: The Patient-Reported Outcomes Measurement Information System Global Health Instrument Mental Health T-Score has superior performance and integration within standard outcome frameworks for preoperative psychosocial screening compared to the Brief Resiliency Scale [6]. Commonly collected data from routine preoperative clinical care show promise for predicting psychological distress after total joint arthroplasty [2]. Mental health status shows the strongest association with baseline patient-reported outcome measures in patients undergoing revision rotator cuff repairs [10].

Psychological Factors and Recovery: Kinesiophobia is a critical psychological factor that adversely affects functional recovery and return to sport following arthroscopic Bankart repair for glenohumeral instability [12]. 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 [20]. 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 [5].

Chronic Pain and Central Sensitization: Central sensitization in chronic nonspecific low back pain 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 [13]. 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 [3]. 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 [4].

Procedure-Specific Presentations: Patients with lower preoperative mental health scores reported similar or greater pain improvements and similar functional improvements following regenerative peripheral nerve interface surgery for upper-extremity neuromas [9]. Adolescent adolescent idiopathic scoliosis patients' anxiety levels are stable and independent of received therapeutic support [11]. Longer symptom duration is an independent predictor of postoperative dissatisfaction in patients with cervical disc herniation [21].

Management

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 outcomes [1]. Anxiety and depression symptoms are associated with inferior outcomes in patients undergoing total hip arthroplasty, with recovery trajectories differing from those without these symptoms [7]. Patients developing new-onset anxiety or depression after arthroscopic shoulder stabilization surgery have a significantly increased risk of 90-day readmission [8].

Preoperative Screening: Commonly collected data from routine preoperative clinical care show promise for predicting psychological distress after total joint arthroplasty [2]. The Patient-Reported Outcomes Measurement Information System Global Health Instrument Mental Health T-Score has superior performance and integration within standard outcome frameworks compared to the Brief Resiliency Scale for identifying the potential for poor outcomes following elective total knee and hip arthroplasty [6]. Patients with major depressive disorder and undiagnosed depression report worse pre- and post-operative PROMIS scores after patellar stabilization surgery but may still significantly benefit from the procedure compared to unaffected counterparts [15].

Pharmacologic and Psychological Interventions: Administration of duloxetine to patients with anxiety or depression undergoing arthroscopic rotator cuff repair improved anxiety and distress, as well as active range of motion, ASES, and SST scores in the first 3 months postoperatively [18]. However, administration of duloxetine to patients undergoing arthroscopic rotator cuff repair resulted in 16% experiencing nausea and vomiting [18]. 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 [4]. Patients receiving music therapy intervention had a significantly greater reduction in pain and anxiety scores compared to controls during total shoulder arthroplasty [17].

Condition-Specific Considerations: Kinesiophobia is a critical psychological factor that adversely affects functional recovery and return to sport following arthroscopic Bankart repair for glenohumeral instability [12]. 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 [5]. 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 [3]. Adolescent adolescent idiopathic scoliosis patients' anxiety levels are stable, independent of received therapeutic support [11].

Rehabilitation and Adjuncts: Adding motor imagery to conservative treatment after distal radius fracture improved function, wrist extension, and hand grip strength compared to conventional treatment alone [19]. Patients with lower preoperative mental health scores reported similar or greater pain improvements and similar functional improvements following regenerative peripheral nerve interface surgery for upper-extremity neuromas [9]. Comprehensive rehabilitation programs for lower limb amputees in post-conflict settings should prioritize effective pain management, social support, and personalized care [14].

Key Considerations

Preoperative Psychosocial Screening: The Patient-Reported Outcomes Measurement Information System Global Health Instrument Mental Health T-Score demonstrates superior performance and integration within standard outcome frameworks for preoperative psychosocial screening compared to the Brief Resiliency Scale [6]. Commonly collected data from routine preoperative clinical care show promise for predicting psychological distress after total joint arthroplasty [2].

Impact of Mental Health History on Surgical Outcomes: 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 [1]. Anxiety and depression symptoms are associated with inferior outcomes in patients undergoing total hip arthroplasty, with recovery trajectories differing despite major clinical improvement [7]. A history of anxiety and/or depression is consistently associated with poorer outcomes after arthroscopic hip surgery at 2-year follow-up [16]. Mental health status shows the strongest association with baseline patient-reported outcomes in patients undergoing revision rotator cuff repairs [10]. Patients developing new-onset anxiety or depression after arthroscopic shoulder stabilization surgery have a significantly increased risk of 90-day readmission [8].

Variable Associations and Specific Procedures: Resilience demonstrates a less consistent and variable association with outcomes after arthroscopic hip surgery compared to anxiety and depression history [16]. Patients with lower preoperative mental health scores reported similar or greater pain improvements and similar functional improvements following regenerative peripheral nerve interface surgery for upper-extremity neuromas, suggesting benefits regardless of mental health status [9]. A history of depression may not adversely affect patient-reported outcomes following thumb carpometacarpal arthroplasty [22].

Recovery Disparities and Interventions: 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 [5]. 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 [4]. 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 [3]. Comprehensive rehabilitation programs for lower limb amputees in post-conflict settings should prioritize effective pain management, social support, and personalized care [14].

Key Evidence

  • [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. (10.1002/arj.70034)
  • [L4] Commonly collected data from routine preoperative clinical care show promise for predicting psychological distress after TJA. (10.1016/j.arth.2026.05.039)
  • [L4] Despite being in a mild activity or remission stage, RFM patients experience more severe symptoms and poorer QOL than RRA patients. (10.1186/s12891-025-08323-6)
  • [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. (10.1097/corr.0000000000003410)
  • [L2] This study demonstrates the disparity between sexes in physical and psychological recovery, as well as RTS status, in community-level patients undergoing ACLR. (10.1177/2325967125s00328)
  • [L3] Its superior performance and integration within standard outcome frameworks make it a valuable tool for preoperative psychosocial screening. (10.1016/j.arth.2025.09.034)
  • [L2] While these patients experience major clinical improvement after THA, their recovery trajectories differ, emphasizing the need for tailored perioperative counseling and psychological support. (10.1016/j.arth.2025.06.013)
  • [L3] Patients developing new-onset anxiety or depression have a significantly increased risk of 90-day readmission. (10.1016/j.jseint.2025.101413)
  • [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. (10.1016/j.jhsg.2026.100985)
  • [L3] Both general patient and disease-specific factors were associated with baseline PROMs in patients undergoing revision RCR, with mental health status showing the strongest association. (10.1016/j.jse.2026.05.007)
  • [L3] AIS patients' anxiety levels are stable, independent of received therapeutic support. (10.1186/s12891-026-09645-9)
  • [L3] Kinesiophobia is a critical psychological factor that adversely affects functional recovery and return to sport following arthroscopic Bankart repair. (10.1186/s12891-026-09567-6)
  • [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. (10.3390/jcm14020577)
  • [L4] The study highlights the importance of developing comprehensive rehabilitation programs that prioritize effective pain management, social support, and personalized care. (10.1186/s12891-026-09654-8)
  • [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. (10.1016/j.jisako.2026.101080)
  • [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. (10.1177/23259671251407329)
  • [L2] Patients receiving music therapy intervention had a significantly greater reduction in pain and anxiety scores compared to the control. (10.1016/j.jseint.2025.101438)
  • [L2] Administration of duloxetine to ARCR patients with anxiety and/or depressive distress not only improved anxiety and distress but also enhanced active ROM, ASES, and SST in the first 3 months postoperatively, although 16% of patients experienced nausea and vomiting. (10.1177/03635465261430918)
  • [L1] Adding motor imagery to conservative treatment after distal radius fracture improved function, wrist extension, and hand grip strength compared to conventional treatment alone. (10.1016/j.jht.2025.02.018)
  • [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. (10.1002/ksa.70349)
  • [L3] Additionally, longer symptom duration was identified as an independent predictor of postoperative dissatisfaction. (10.1186/s12891-026-09541-2)
  • [L4] These findings suggest that a history of depression may not adversely affect patient-reported outcomes after thumb CMC arthroplasty. (10.1016/j.jhsg.2026.100989)

References

[1] Editorial Commentary : Anxiety and Depression May Be More Important Than the Alpha Angle or Suction Seal in Hip Preservation Surgery Outcomes. Arthroscopy. 2026. DOI: 10.1002/arj.70034

[2] Development of Machine Learning Algorithms Predicting Psychological Distress After Total Joint Arthroplasty. The Journal of Arthroplasty. 2026. DOI: 10.1016/j.arth.2026.05.039

[3] Quality of life, pain, depression, fatigue and sleep in patients with remission or mild fibromyalgia: a comparison with remission or low disease activity rheumatoid arthritis and healthy controls. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-08323-6

[4] CORR Insights®: Risk-stratified Care Improves Pain-related Knowledge and Reduces Psychological Distress for Low Back Pain: A Secondary Analysis of a Randomized Trial. Clinical Orthopaedics & Related Research. 2025. DOI: 10.1097/corr.0000000000003410

[5] Sex-based differences in physical and psychological recovery, and return to sport, following anterior cruciate ligament reconstruction. Orthopaedic Journal of Sports Medicine. 2026. DOI: 10.1177/2325967125s00328

[6] 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. The Journal of Arthroplasty. 2026. DOI: 10.1016/j.arth.2025.09.034

[7] Anxiety and Depression Symptoms Are Associated With Inferior Outcomes in Patients Undergoing Total Hip Arthroplasty: A Prospective Cohort Study. The Journal of Arthroplasty. 2026. DOI: 10.1016/j.arth.2025.06.013

[8] Risk factors for new-onset anxiety and depression after arthroscopic shoulder stabilization surgery. JSES International. 2026. DOI: 10.1016/j.jseint.2025.101413

[9] Outcomes Following Regenerative Peripheral Nerve Interface Surgery and Associations With Preoperative Mental Health: A Retrospective Analysis of Upper-Extremity Neuromas. Journal of Hand Surgery Global Online. 2026. DOI: 10.1016/j.jhsg.2026.100985

[10] Associations of preoperative patient mental health status, sociodemographic and clinical characteristics with baseline pain, function and satisfaction in patients undergoing revision rotator cuff repairs. Journal of Shoulder and Elbow Surgery. 2026. DOI: 10.1016/j.jse.2026.05.007

[11] Pre- and postsurgical anxiety and body perception: the significance of cognitive-behavioral therapy in scoliosis adolescents. BMC Musculoskeletal Disorders. 2026. DOI: 10.1186/s12891-026-09645-9

[12] The impact of kinesiophobia on rehabilitation and return to sport following arthroscopic Bankart repair for glenohumeral instability: a minimum 1-year follow-up. BMC Musculoskeletal Disorders. 2026. DOI: 10.1186/s12891-026-09567-6

[13] Is the Central Sensitization in Chronic Nonspecific Low Back Pain Structural Phenomenon or Psychological Reaction? A Narrative Review. Journal of Clinical Medicine. 2025. DOI: 10.3390/jcm14020577

[14] Physical and mental health outcomes in Syrian lower limb amputees: the impact of prosthetic rehabilitation in post-conflict settings. BMC Musculoskeletal Disorders. 2026. DOI: 10.1186/s12891-026-09654-8

[15] Patients with major depressive disorder and undiagnosed depression are at risk for inferior outcomes after patellar stabilization surgery. Journal of ISAKOS. 2026. DOI: 10.1016/j.jisako.2026.101080

[16] Effect of A History of Anxiety and Depression on Patient-Reported Outcomes After Hip Arthroscopy at 2-Year Follow-up. Orthopaedic Journal of Sports Medicine. 2026. DOI: 10.1177/23259671251407329

[17] A prospective randomized controlled trial on the effect of music therapy intervention on pain and anxiety in adult patients undergoing total shoulder arthroplasty. JSES International. 2026. DOI: 10.1016/j.jseint.2025.101438

[18] 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. The American Journal of Sports Medicine. 2026. DOI: 10.1177/03635465261430918

[19] 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. Journal of Hand Therapy. 2025. DOI: 10.1016/j.jht.2025.02.018

[20] Patient‐specific psychological characteristics and personality structure affect functional outcomes after surgical stabilization of acute and chronic acromioclavicular joint injuries. Knee Surgery, Sports Traumatology, Arthroscopy. 2026. DOI: 10.1002/ksa.70349

[21] Pain catastrophizing and postoperative satisfaction in cervical disc herniation: a 6-month prospective cohort study. BMC Musculoskeletal Disorders. 2026. DOI: 10.1186/s12891-026-09541-2

[22] The Impact of Depression and Antidepressant Treatment on Patient-Reported Outcomes Following Thumb Carpometacarpal Arthroplasty. Journal of Hand Surgery Global Online. 2026. DOI: 10.1016/j.jhsg.2026.100989

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a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

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