Psychological correlates of pain catastrophizing and disability in patients with Achilles tendinopathy: The roles of resilience and psychological inflexibility

Objective: This study aimed to clarify the contribution of psychological factors to pain adjustment in patients with Achilles tendinopathy. It specifically investigated the associations of psychological inflexibility, distress, and resilience with pain catastrophizing, and their indirect associations between pain intensity and pain disability.

Methods: A total of 120 participants (65% female; mean age = 49.17 years, SD = 12.06) completed validated measures of visual analog scales for pain level, psychological distress, psychological inflexibility, resilience, pain disability index, and pain catastrophizing. Hierarchical regressions identified correlates of pain catastrophizing. Bootstrapped mediation analyses (5000 samples) tested indirect effects of psychological variables on the pain intensity–disability relationship.

Results: Pain catastrophizing was most strongly associated with psychological inflexibility (β = 0.413, P < .001) and distress (β = 0.284, P < .001); resilience also showed a significant inverse association (β = −0.181, P = .021). Pain intensity had a weaker yet significant association with catastrophizing in both final steps. Mediation models revealed an indirect-only pattern of association between pain intensity and disability through both pain catastrophizing and psychological inflexibility, as the direct effects were not statistically significant (c′ = 0.044, 95% CI [−0.092, 0.180]; 0.143, 95% CI [−0.014, 0.301], respectively). Resilience partially mediated this relationship (c’ = 0.207, 95% CI [0.044, 0.370]), while distress was not a significant mediator.

Conclusion: Psychological processes, particularly catastrophizing and inflexibility, are strongly associated with the extent to which pain is linked to disability. These findings support the integration of psychological assessment into routine musculoskeletal rehabilitation in orthopedic practice. Addressing emotional processes and promoting psychological flexibility may improve treatment outcomes and prevent long-term disability.

Cite this article as: Akça E, Kart H, Demir U, Akpınar F. Psychological correlates of pain catastrophizing and disability in patients with Achilles tendinopathy: the roles of resilience and psychological inflexibility. Acta Orthop Traumatol Turc. 2026, 60 (1), 0477, doi: 10.5152/j.aott.2026.25477.