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 R² 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. Cite this article: Bone Joint J 2026;108-B(3):431–438.
Bretherton et al. (Sun,) studied this question.