Women's Football Hub

By: Hannah Antony, M.Phty, B.Kin

When can I play again?” This is one of the most common questions I hear as a physiotherapist from patients when they’ve torn their ACL or just had ACL reconstruction (ACLR) surgery.

The ACL, anterior cruciate ligament, is in your knee as one of the four main ligaments, and is a commonly injured ligament for female football players. Being a female footballer myself, I have gone through this ligament rupture and subsequent surgical reconstruction just three years ago. Over the past seven years as a musculoskeletal physiotherapist, I’ve diagnosed and treated this injury in many athletes.

Returning to sport after an ACL tear or reconstruction takes hard work and commitment. To get to that point, you should be reaching criteria-based milestones in your rehab. This means being able to complete certain tasks, with a certain level of competency and confidence to move forwards in the rehab plan.

Return to Sport after an ACL-reconstruction

For returning to sport – over 84% of athletes are sure that they will get back to their sport after their ACL injury (1). I had this exact mindset and was determined to return to highly competitive women’s football after having torn my ACL and undergone a reconstruction surgery.

Unfortunately, the number of athletes who do return to sport, especially at a competitive level, is much lower than we think.

What are the return to sport rates after an ACLR?

Generally, studies found that of those who underwent an ACL-reconstruction:

• 81% of participants returned to a general level of sport (meaning NOT their pre-injury level or competitive level) (2)
• 59-65% of recreational athletes returned to their pre-injury sport level (2, 3)
• 55% returned to competitive sport (2)
  
  

To increase your chance of returning to competitive, pre-injury level sport, you can follow a criterion-based rehabilitation program, supervised by a physiotherapist and strength and conditioning coaches who are versed in ACL rehab (4, 5).

These numbers vary for different groups of people:

• Elite athletes – around 83% return to competitive and pre-injury level sports (6) and a 6x more likely than non-elite athletes to reach that goal (4)
• Males are 1.5x more likely than females to return to competitive sport (1)
• Youth athletes (younger than 19 years old) – around 30% more likely to return to sport than older athletes (1)

How long does it really take?

The research discusses the importance of not returning to pivoting, competitive sports before 9 months, anytime before that exponentially increases the risk of re-injury (7). The more realistic timeframe that I outline for my patients as a physiotherapist is at least 12 months before returning to a high-risk sport like soccer or skiing.

When I was going through my own ACLR rehab, I had made it back to a recreational level of football around 1 year post-op, and only made it back to a competitive, pre-injury level at just over 2 years post-op.

This timeline actually follows the RTS reality closer than the societal expectations that we place on athletes:

• For non-elite younger athletes, it has taken up to 2 years to state they felt they were back at their pre-injury level (1)
• Actual average time of return to play is closer to 17 months (5)

The ACL Reconstruction Journey

As someone who has gone through the rehab process for ACL-reconstruction, and as a physiotherapist, I can understand both sides – being taken from your sport is devastating, and you want to get back as soon as you can.

However, rushing the rehab or ‘accelerating’ the process isn’t possible. Having an experienced team guiding you through a criterion-based rehabilitation process puts you at the best chance of returning to pre-injury sport, and maintaining long-term knee health.

The goal isn’t ONLY return to sport, it is also reducing risk of re-injury (to the same knee or the other knee), and setting you up for success as you age.

References

1. Webster KE, Feller JA. A research update on the state of play for return to sport after anterior cruciate ligament reconstruction. Journal of Orthopaedics and Traumatology. 2019 Dec;20(1):1-7.
2. Ardern CL, Taylor NF, Feller JA, Webster KE. Fifty-five per cent return to competitive sport following anterior cruciate ligament reconstruction surgery: an updated systematic review and meta-analysis including aspects of physical functioning and contextual factors. British journal of sports medicine. 2014 Nov 1;48(21):1543-52.
3. Brzeszczyński F, Turnbull K, McLelland C, MacDonald D, Lawson G, Hamilton D. Functional outcomes and return to sport following anterior cruciate ligament reconstruction in recreational athletes: A systematic review. The Knee. 2022 Jun 1;36:103-13.
4. Joreitz R, Lynch A, Popchak A, Irrgang J. Criterion-based rehabilitation program with return to sport testing following ACL reconstruction: a case series. International Journal of Sports Physical Therapy. 2020 Dec;15(6):1151.
5. Drole K, Paravlic AH. Interventions for increasing return to sport rates after an anterior cruciate ligament reconstruction surgery: A systematic review. Frontiers in psychology. 2022 Aug 22;13:939209.
6. Lai CC, Ardern CL, Feller JA, Webster KE. 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. British journal of sports medicine. 2018 Jan 1;52(2):128-38.
7. Grindem H, Snyder-Mackler L, Moksnes H, Engebretsen L, Risberg MA. Simple decision rules can reduce reinjury risk by 84% after ACL reconstruction: the Delaware-Oslo ACL cohort study. British journal of sports medicine. 2016 Jul 1;50(13):804-8.