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  • Infographic. High rate of second ACL injury following ACL reconstruction in male professional footballers: an updated longitudinal analysis from 118 players in the UEFA Elite Club Injury Study

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Infographic. High rate of second ACL injury following ACL reconstruction in male professional footballers: an updated longitudinal analysis from 118 players in the UEFA Elite Club Injury Study
  1. Francesco Della Villa1,
  2. Martin Hägglund2,3,
  3. Stefano Della Villa1,
  4. Jan Ekstrand2,4,
  5. Markus Waldén2,4,5
  1. 1 Education and Research Department, Isokinetic Medical Group, FIFA Medical Centre of Excellence, Bologna, Italy
  2. 2 Football Research Group, Linköping University, Linkoping, Sweden
  3. 3 Unit of Physiotherapy, Department of Health, Medicine and Caring Sciences, Linköping University, Linkoping, Sweden
  4. 4 Unit of Community Medicine, Department of Health, Medicine and Caring Sciences, Linköping University, Linkoping, Sweden
  5. 5 Department of Orthopaedics, Hässleholm-Kristianstad Hospitals, Hässleholm, Sweden
  1. Correspondence to Dr Francesco Della Villa, Education and Research Department, Isokinetic Medical Group, FIFA Medical Centre of Excellence, Bologna, Italy; f.dellavilla{at}isokinetic.com

https://doi.org/10.1136/bjsports-2021-104508

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    ACL injury is a serious concern for the professional football player.1 Studies about second ACL injury rate and career length after ACL reconstruction (ACLR) in male professional football players are scarce in the current literature.

    We studied 118 top-level professional football players who sustained an ACL injury and subsequent ACLR over the course of 19 seasons as part of a substudy2 of the Elite Club Injury Study. The players were tracked prospectively for second ACL injuries as well for the career length following ACL injury and related treatment. Analysis of potential predictors of subsequent ACL injury (to either knee) was carried out using a stepwise Cox Regression model.

    All players returned to training (RTT) following ACLR and were evaluated at a median follow-up of 4.3 (IQR 4.6) years after ACLR. For the index ACL injury, 45 players (38%) had sustained an isolated ACL injury and 73 (62%) had at least one associated injury. Regarding injury mechanism, 67 (57%) had sustained an index noncontact ACL injury and 51 (43%) an indirect or direct contact injury.2

    Among the 118 included players, there were 21 subsequent ACL injuries after RTT (figure 1). The cumulative second ACL injury incidence was 17.8% (21/118), with 9.3% (11/118) ipsilateral graft ruptures and 8.5% (10/118) contralateral ruptures.2

    Figure 1
    Figure 1

    Infographic.

    Having sustained a noncontact or isolated index ACL injury were independent risk factors for a second ACL injury with a sevenfold and threefold increased risk, respectively.2 Combined, 11 of the 26 players who sustained a noncontact isolated index ACL injury had a second ACL injury compared with 9 of the other 92 players (42.3% vs 9.8%, p<0.001). None of the 32 players who sustained a contact and non isolated ACL injury sustained a second ACL injury.2

    Time to RTT was not an independent predictor of second ACL injury in the multivariable analysis (HR: 0.87; p=0.446). However, none of the 13 players who had their RTT after 8 months sustained a second ACL injury, whereas 10 of 49 players (20%) with RTT within 6 months sustained a second ACL injury.2

    The median top-level career length was 4.1 (IQR 4.0) years after ACLR and 3.4 (IQR 3.9) years after RTT. The proportion of players still playing at the highest level 5 years after ACLR was 60%.2

    Even in top-level professional footballers, the second ACL injury rate was 18% after RTT, underlying the importance of continuous secondary prevention, also after the formal return to play. Moreover, suffering a pure non-contact index ACL injury (44%–66% in professional footballers3 4 or an isolated index ACL injury are important risk factors, with a sevenfold and threefold increase in second ACL injury risk, respectively. The athlete sustaining a noncontact isolated ACL injury (high risk) should be appropriately counselled and treated carefully to potentially decrease the second ACL injury risk. Finally, considering only players who quit top-level football in the study period, top-level football career length was 3.4 years after formal RTT, suggesting an important effect of ACL injury even at top-level European football.

    To reduce the impact of ACL injuries on football players’ career and life, alongside the implementation of primary reduction programmes,5 an optimisation of knowledge translation on postoperative rehabilitation pathway and continuous secondary prevention are warranted.

    Ethics statements

    Patient consent for publication

    Ethics approval

    The study protocols were approved by the UEFA Football Development Division and the UEFA Medical Committee.

    Acknowledgments

    The authors would like to thank Adam Virgile for the important work in making the infographic.

    References

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    Footnotes

    • Twitter @fdellavilla, @MHgglund, @JanEkstrand, @MarkusWalden

    • Contributors FDV, MH, SDV, JE and MW were responsible for the conception of the study. FDV wrote the first draft of the paper that was critically revised by MH, SDV, JE and MW. The final manuscript has been approved by all authors. MW is the study guarantor.

    • Funding This study was funded by grants from the Union of European Football Associations.

    • Competing interests None declared.

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