Fear-avoidance beliefs influence preoperative but not postoperative outcomes after arthroscopic rotator cuff repair

Purpose Fear-avoidance beliefs (FAB) may influence pain perception and functional limitation, yet their prognostic relevance in rotator cuff surgery remains unclear. This study examined nonlinear and threshold-dependent relationships between preoperative FAB and both preoperative and 12-month postoperative outcomes following arthroscopic rotator cuff repair. Methods A prospectively collected cohort of 281 patients undergoing arthroscopic rotator cuff repair was retrospectively analyzed. Preoperative FABQ-PA and FABQ-W scores were assessed along with ASES, SANE, and VAS scores. Nonlinear associations were examined using maximal information coefficient analysis with Bayesian probability estimates. An XGBoost model with SHAP values was used to estimate the independent contribution of FAB while adjusting for demographic and surgical variables. Results FABQ-PA and FABQ-W demonstrated weak but detectable nonlinear associations with preoperative ASES scores (MIC 0.15 and 0.14), supported by Bayesian analysis. Machine-learning modeling identified model-derived inflection points at FABQ-PA ≥ 17.5 and FABQ-W ≥ 28.5. No meaningful associations were observed between FAB and preoperative VAS or SANE, nor with any 12-month postoperative outcomes. Conclusion Fear-avoidance beliefs independently influenced preoperative shoulder function but did not predict postoperative recovery. FAB appear to influence patients’ perceptions before surgery but have limited prognostic value for long-term outcomes after arthroscopic rotator cuff repair. Level of Evidence Level III – Retrospective cohort study