The majority of athletes fail to return to play following anterior cruciate ligament reconstruction due to reasons other than the operated knee

Key points

1. 01At 2 years, 1140 of 1362 athletes (83.7%) returned to play and 222 (16.3%) did not.
2. 02Fear of reinjury was the single most common reason for not returning, cited by 27.5%, followed by lack of confidence in performance at 19.4%.
3. 03External life factors such as work and family accounted for a substantial share, exceeding residual knee pain (10%).
4. 04Athletes who did not return had lower psychological readiness (ACL-RSI) scores at both diagnosis and 2 years.
5. 05Athletes who did not return were older on average and more often had medial meniscal tears and chondral damage.

How it was conducted

Design

Retrospective analysis of a prospective single-centre institutional ACL registry (Level III evidence)

Participants

1362 athletes with primary ACL reconstruction performed by two surgeons from 2014 to 2016, screened from 1431 reconstructions

Groups

Returned to play (n=1140) versus did not return to play (n=222)

Outcomes

Return-to-play status and reasons at minimum 2-year follow-up, plus ACL-Return to Sport Index (ACL-RSI) at diagnosis and 24 months

Procedure

Bone-patellar tendon-bone (79.4%) or hamstring autograft with standard rehabilitation; return before 6 months discouraged

What they found

• 1140 athletes (83.7%) returned to play and 222 (16.3%) did not at 2-year follow-up.
• Among non-returners, 62.2% (138/222) cited operated-knee reasons and 37.8% (84/222) cited reasons other than the operated knee.
• Most common reasons for not returning: fear of reinjury 27.5% (61), lack of confidence in performance 19.4% (43), external life factors 16.6%, residual knee pain 10% (22), subsequent injury 5%.
• ACL-RSI was significantly lower in non-returners at diagnosis (40.3 +/- 26 vs 49.3 +/- 26.3; p=0.003) and at 2 years (41.8 +/- 25.6 vs 78.7 +/- 20.2; p<0.0001).
• Non-returners were older (mean 27.2 +/- 7.5 vs 23.6 +/- 7.0 years) and more often had medial meniscal tears (p=0.0053) and chondral pathology (p=0.0026).
• Mean time to return to play was 11.1 +/- 5.1 months; there were 61 second ACL ruptures (23 ipsilateral, 38 contralateral).

Limitations

• Retrospective analysis of prospectively collected data from a single centre, limiting generalisability.
• ACL-RSI was completed by fewer than 50% of athletes at 2 years, raising the risk of incomplete or biased data.
• Reasons for not returning were self-reported and grouped into broad categories.
• Observational design cannot establish that psychological factors cause failure to return.

Why it matters

For patients

If you are recovering from ACL surgery, your confidence and life circumstances, not just your knee, can shape whether you get back to sport, so it is worth raising these concerns with your care team.

For clinicians

Assessing psychosocial readiness, for example with the ACL-RSI before surgery, may help identify athletes who would benefit from psychological support to improve return to play.

For readers

Returning to sport after ACL reconstruction is often limited by fear and life factors rather than the knee itself, reframing recovery as a psychological as well as physical process.