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Eighty-three per cent of elite athletes return to preinjury sport after anterior cruciate ligament reconstruction: a systematic review with meta-analysis of return to sport rates, graft rupture rates and performance outcomes
  1. Courtney C H Lai1,
  2. Clare L Ardern1,2,3,
  3. Julian A Feller4,
  4. Kate E Webster1
  1. 1 School of Allied Health, La Trobe University, Melbourne, Australia
  2. 2 Division of Physiotherapy, Linköping University, Linköping, Sweden
  3. 3 Aspetar Orthopaedic & Sports Medicine Hospital, Doha, Qatar
  4. 4 OrthoSport Victoria, Melbourne, Australia
  1. Correspondence to Dr Courtney C H Lai, Level 4, Health Sciences 3 Building, La Trobe University, Bundoora, Victoria 3086 Australia; lai.c{at}


Objectives The primary objective was to calculate the rate of return to sport (RTS) following anterior cruciate ligament (ACL) reconstruction in elite athletes. Secondary objectives were to estimate the time taken to RTS, calculate rates of ACL graft rupture, evaluate postsurgical athletic performance and identify determinants of RTS.

Design Pooled RTS and graft rupture rates were calculated using random effects proportion meta-analysis. Time to RTS, performance data and determinants of RTS were synthesised descriptively.

Data sources MEDLINE, EMBASE, AMED, CINAHL, AMI, PEDro, SPORTDiscus and The Cochrane Library were searched from inception to 19 January 2016. Hand searching of 10 sports medicine journals and reference checking were also performed.

Eligibility criteria for selecting studies Studies were included if they reported the ratio of elite athletes who returned to their preinjury level of sport following ACL reconstruction. Twenty-four studies were included.

Results The pooled RTS rate was 83% (95% CI 77% to 88%). The mean time to RTS ranged from 6 to 13 months. The pooled graft rupture rate was 5.2% (95% CI 2.8% to 8.3%). Six out of nine studies that included a noninjured control group found no significant deterioration in athletic performance following ACL reconstruction. Indicators of greater athletic skill or value to the team were associated with RTS.

Summary and conclusions Eighty-three per cent of elite athletes returned to sport following ACL reconstruction, while 5.2% sustained a graft rupture. Most athletes who returned to sport performed comparably with matched, uninjured controls. This information may assist in guiding expectations of athletes and clinicians following ACL reconstruction.

  • anterior cruciate ligament
  • anterior cruciate ligament reconstruction
  • sport re-entry
  • elite athletes

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  • Publication embargo This work has been presented at the following conferences:

    •The 2016 Sports Medicine Australia Conference, 14 October 2016, as a free paper.

    •The 17th European Society of Sports Traumatology, Knee Surgery & Arthroscopy (ESSKA) Congress, 4 to 7 May 2016, as an electronic poster.

    Return to sport following anterior cruciate ligament reconstruction in elite athletes: a systematic review and meta-analysis

    1. Jessica Thompson is a 28-year-old avid netball fan. She ruptured the anterior cruciate ligament of her left knee 10 years ago while playing nonelite netball for her club. Despite undergoing an anterior cruciate ligament reconstruction, Jessica did not return to sport, which she attributes to a significant fear of reinjuring her knee. Which of the following is most likely to be correct?

    (a) Elite athletes place greater demands on their knees than nonelite athletes, so it is unlikely that being in an elite sporting environment would have increased Jessica’s odds of returning to sport.

    (b) Even though nearly one out of five elite athletes who undergo anterior cruciate ligament reconstruction never return to their previous level of sport, elite athletes have a greater chance of returning to their preinjury level of sport than nonelite athletes.

    (c) Physical attributes alone explain the differing return to sport rates between elite and nonelite athletes following anterior cruciate ligament reconstruction.

    (d) Jessica would have been more likely to return to sport if she were playing soccer or football instead of netball.

    Answer: (b) This meta-analysis found that 83% of elite athletes return to their preinjury level of sport, which is higher than previously reported rates in nonelite athletes.

    2. John Smith is a 24-year-old male professional rugby player who plays at the fullback position. He sustained a direct contact injury to his right knee while being tackled in a match and was subsequently diagnosed with a ruptured anterior cruciate ligament and a lateral meniscal tear. Having undergone an anterior cruciate ligament reconstruction with a hamstrings tendon autograft together with a repair of his lateral meniscus, which of the following statements is true?

    (a) The presence of a concomitant injury to his medial meniscus will substantially reduce John’s chances of returning to professional rugby.

    (b) There is currently strong evidence to suggest that John, being a fullback, John is more likely to return to sport than a forward would be if they were to sustain a similar injury.

    (c) The hamstrings tendon autograft is a better choice than the bone-patellar tendon-bone autograft for elite athletes due to the lower incidence of donor site complications.

    (d) If John sustained this injury as a 20-year-old, with less professional rugby experience, he would have been less likely to return to professional rugby.

    Answer: (d) The majority of studies in this systematic review did not find that concomitant meniscal injuries, playing position or graft choices were strongly associated with different return to sport rates. Two studies of elite football players of various codes found that greater playing experience was associated with a higher rate of return to sport.

    3. Jack Watson is a 28-year-old male professional basketball player in the National Basketball Association. He sustained a left anterior cruciate ligament injury while changing direction 12 months ago. Prior to his injury, he was an All-Star guard. His career is about to resume. Which of the following statements regarding his upcoming performances is most likely to be true?

    (a) Given that Jack has taken a full 12 months to return to sport, Jack is likely to return to his preinjury levels of performance within one season on measures including games played per season and shooting percentage.

    (b) Very few elite basketball players ever regain their preinjury level of form and Jack should learn to play different roles within the team immediately in order to continue his career.

    (c) Jack will find it challenging to add to his previous All-Star selection, but if he can remain on the court, his career trajectory is likely to remain comparable to players with similar experience and playing characteristics.

    (d) Guards return to their preinjury level of form more frequently than forwards and centres in the National Basketball Association.

    Answer: (c) Studies of elite basketball players have reported that players returning to sport following anterior cruciate ligament reconstruction, on average, do not return to preinjury levels of performance, but these declines are not statistically significant compared with matched control groups.

    4. Which of the following rates is closest to the risk of a graft rupture across a career for an elite athlete?

    (a) One in 50(2%).

    (b) One in 20(5%).

    (c) One in five (20%).

    (d) One in two (50%).

    Answer: (b) The pooled graft rupture rate in elite athletes following anterior cruciate ligament reconstruction was 5.2%.

    5. The Australian Rules football season is typically between April and September. Peter Wood is a 23-year-old professional Australian Rules football player who sustained an isolated anterior cruciate ligament injury early in April. Mark’s 25-year-old brother, Andrew, who plays in an amateur nonelite competition, sustained a similar injury one week earlier. Both have elected to undergo ACL reconstruction with hamstrings tendon autografts, and they aim to returning to sport. Which of the following statements is most likely to be correct?

    (a) Peter is more likely to return to sport, and a realistic goal is to be ready to play early in the next season.

    (b) Peter is more likely to return to sport, and he is a good chance of playing in the finals in September if he undergoes surgery immediately.

    (c) Peter is more likely to return to sport, but it is unlikely that he will return until late in the following season (ie, approximately 15 months out of sport).

    (d) Andrew is likely to return to sport earlier than his brother because the lower demands of amateur Australian football allow athletes to return to sport earlier on average than those in the high-demand elite environment.

    Answer: (a) Elite athletes return to sport more frequently than nonelite athletes, and the majority of studies have reported that elite athletes take between 6 and 13 months on average to return to sport.

  • Contributors All authors contributed to the conception and design of the review. CCHL and CLA applied the search strategy, applied the selection criteria and completed the risk of bias assessment. CCHL and KEW extracted and synthesised the data. All authors contributed to the analysis and interpretation of data. CCHL wrote the manuscript. CLA, JAF and KEW critically revised the manuscript for important intellectual content. CCHL is responsible for the overall content as guarantor. All authors approved of the final version published.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Full outputs of meta-analyses performed using StatsDirect V.2.8 (Altrincham, UK) are available from the corresponding author on reasonable request.

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