Most Soccer Players Return to Play After ACL Reconstructive Surgery, Study Finds

Most soccer players are able to return to play after anterior cruciate ligament reconstruction surgery (ACLR), but one in eight who return end up having additional ACLR, with females and those whose first surgery was on their non-dominant leg most at risk, a new study¹ finds.

Researchers at the Washington University School of Medicine, the Cleveland Clinic and Vanderbilt University Medical Center followed 100 soccer players (55 male, 45 female) after ACLR to find out the rate at which they returned to play, and whether outcomes were effected by gender, the leg which was injured (dominant v. non-dominant), graft choice, and to determine the risk factors for further ACL surgery.

They found that:

• 72% of soccer players returned to soccer at an average of 12 to 14 months after ACLR, with 85% of those returning to soccer getting back to the same or higher level of play as before their injury; 
• younger and male soccer athletes were more likely to return to soccer after ACL reconstruction than older and female athletes, but men (56%) were more than twice as likely as women (26%) to attribute their ACL injury as the primary reason for quitting the sport;
• the type of graft (bone-patellar-tendon-bone (BPTB) autograft (69% of athletes) v. hamstring tendon autograft (28%) v. BPTB allograft (4%)) had no significant effect on return to play, consistent with previous studies;
• neither rate of return to or time to return to play were affected by which leg (dominant v. non-dominant) was injured; and
• one out of eight (12%) had undergone further ACLR, with almost four times more subsequent ACL surgery in females (20%) compared with males (5.5%); 
• soccer athletes who injured their nondominant limb had a much higher rate of ACL reconstruction on in their dominant limb (16%) than soccer athletes who underwent ACL reconstruction on their dominant limb (3.5%).  Although the reasons for this relationship were not clear, the author suggested that the injury and reconstruction perhaps create or increase neuromuscular differences between the limbs, with injury to the nondominant limb possibly leading to an even greater dependence on the dominant limb during play, potentially increasing the risk for future injury). 

The study is published in the American Journal of Sports Medicine.

Gender differences

The study found that female soccer athletes were less likely to get back to soccer than their male counterparts, but only one in four women, as compared to a majority of men, attributed their ACL injury as the primary reason they did not return.  The authors suggested that there were a number of possible explanations for this discrepancy, such as that men may find that the injury and surgery more traumatic and/or painful and be more averse to repeating the experience, while women may be more likely to limit their participation because of external factors such as graduating from a certain level of schooling or starting a career or family.  While the reasons are probably complex, lead author Robert H. Brophy, MD, of the Department of Orthopaedic Surgery at Washington University School of Medicine in St. Louis, nevertheless suggested that female soccer players be "made aware of this information before surgery, particularly if return to play is a primary motivation for the surgery."

The findings that there were almost five times as many subsequent ACL surgeries in females as in males, and of increased risk of such surgeries to athletes who previously injured their nondominant leg, the authors suggested, may make participation in an ACL injury prevention program - which a growing body of evidence has found effective in soccer athletes - particularly important for soccer players who have already undergone ACL reconstruction.  

ACL injuries common

Here are some facts about soccer injuries: 

• The overall incidence of soccer-related injuries is estimated to be 10 to 35 per 1000 playing hours in adult male players and is often higher in younger and less skilled players; 
• Approximately sixty to eighty percent of severe injuries in soccer occur to in the lower extremities, most commonly at the knee (29%) or ankle (19%);
• the ACL injury rate in women's college soccer is 1.0 injury per 100 athlete game exposures compared with .10 per 1000 athlete practice exposures; and
• the ACL injury rate in men's college soccer is much lower (.19 ACL injuries per 1000 athletic game exposures and .04 ACL injuries per 1000 athlete practice exposures.

Soccer has consistently emerged as one of the most popular sports among female athletes, with participation in high school girls' soccer more than tripling between 1990 and 2010, jumping from 111,711 to 356,116 participants,² and the number of NCAA schools participating in women's soccer increasing by 617 programs, the most of any sport played by college women.³

1. Brophy R, Schmitz L, Wright R, et. al. Return to Play and Furture ACL Injury Risk After ACL Reconstruction in Soccer Athletes From the Multicenter Orthopaedic Outcomes Network (MOON) Group.  Am. J. Sports Med. 2012;20(10), DOI: 10.1177/0363546512459476 (published online ahead of print September 21, 2012).

2. http://www.nfhs.org/Participation/HistoricalSearch.aspx.

3. National Collegiate Athletic Association: 1981-82-2008-09 NCAA Sports Sponsorship and Participation Rates Report. Indianapolis: National Collegiate Athletic Association, 2010 (http://www.ncaapublications.com/productdownloads/PR2010pdf)(Accessed August 23, 2012). 

Posted October 5, 2012