Return To Sport Following ACL Reconstruction

Abstract

Purpose of Review

Outcomes after anterior cruciate ligament reconstruction (ACLR) are generally favorable, yet the timing and extent of return to sport vary widely and are influenced by numerous factors. This review examines the principal pre-operative, intra-operative, and post-operative considerations that influence return to sport following ACLR.

Recent Findings

Successful return to sport depends on many crucial elements during the pre-operative, intra-operative, and post-operative periods. Recent developments for adjunctive rehabilitation modalities—such as blood flow restriction, hyperbaric oxygen therapy, cryotherapy, and photo-biomodulation—may further enhance recovery for some patients. Additionally, psychological readiness has emerged and continues to grow as a key predictor of both the timing and success of return to sport.

Summary

A criteria-based strategy that integrates physical performance, sport-specific skills, and psychological preparedness offers the most reliable framework for tailoring rehabilitation and maximizing retorn-to-sport outcomes following ACL reconstruction.

Introduction

Anterior cruciate ligament (ACL) tears are common orthopaedic injuries with approximately 200,000 ACL tears occurring annually in the United States [1]. Although non-operative treatment is an option for some patients, athletes and active individuals typically choose ACL reconstruction (ACLR) to facilitate a return to sport or pre-injury activity [2]. ACLR may be performed as an isolated procedure; however, concomitant repairs for meniscal, chondral, or other ligamentous injuries are common. For example, nearly half of ACLR procedures include a meniscal repair or partial meniscectomy [3].

The mechanism of ACL tears is commonly a non-contact injury that occurs due to a sudden, rapid change in velocity or direction, poor landing biomechanics, or twisting and pivoting motions [4]. Sports that require rapid directional changes—such as soccer, rugby, football, and skiing—pose an increased risk for both primary ACL injuries and re-injuries [5]. Female athletes experience ACL injuries at higher rates than their male counterparts [6]. Despite these risks, clinical outcomes following ACLR are generally good, with patients typically achieving functional knee stability and low graft failure rates [7, 8].

Returning to sport is a critical milestone for many patients, determined through collaboration among surgeons, physical therapists, athletic trainers, and coaches. Traditionally, time-based rehabilitation protocols guide recovery; however, the focus has shifted over the past decade to incorporate milestone-based approaches that emphasize progression as opposed to strict timelines [9, 10]. These newer protocols emphasize improvements in strength, pain, swelling, range of motion, and sports-specific functions [9]. Return to sport decisions are multifactorial and highly individualized, incorporating clinical expertise, patient-specific goals, demographics (such as age and sex), and psychosocial factors like psychological readiness, athletic identity, and kinesiophobia [11]. Despite the use of these factors by surgeons to guide return to play, there is a lack of widely accepted, evidence-based guidelines incorporating these factors.

Although 81 to 92% of patients return to some form of sport after ACLR recovery, only 55 to 79% of patients return to their pre-injury level of sport, and only 55% of patients return to competition in their respective sports at full capacity [7, 12]. The purpose of this review is to summarize recent literature on ACLR and examine the pre-operative, intra-operative, and post-operative factors that influence return to sport. An improved understanding of these factors can aid clinicians in tailoring treatment, setting realistic rehabilitation goals, and optimizing patient outcomes.

Pre-Operative Factors

Sex

ACL injuries are more common in female athletes, and research shows that following ACLR, female patients experience worse functional and strength recovery, lower psychological readiness to return to sport, and overall lower return to sport rates compared to male patients [6, 13–16]. Moreover, although male patients tend to return to sport more frequently, they are at a higher risk for revision ACLR than female patients [17]. These findings underscore the importance of addressing psychosocial factors and tailoring rehabilitation to ensure equitable outcomes for all athletes [18–20].

Age and Body Mass Index

Age and BMI also affect return to sport rates, with younger patients and those with lower BMI more likely to return to their pre-injury level of sport [21]. One study reported that patients under 30 years of age had a 62% return rate, compared to only 4% for those aged 50 and above [21]. Similarly, patients with a BMI of 20–25 kg/m² returned to sport at a rate of approximately 48%, while those with a BMI higher than 35 kg/m² experienced markedly lower return rates at 4% [22, 23] Factors such as reduced general activity, impaired range of motion, and worse subjective knee function likely contribute to these trends [24].

Sport Specific Factors

Additionally, the type of sport influences both the risk of ACL injury and reinjury. High-contact sports like rugby, football, and basketball exhibit higher incidences of ACL injuries emphasizing the need for sport-specific return criteria [5]. The sport risk can vary depending on sex where, among males, high-contact, collision sports such as rugby, wrestling, and football pose the most risk while, among females, gymnastics, soccer, and basketball demonstrate the highest rates of ACL injury [25]. Regarding sports-specific return to sport, timing and rates of return vary.

Among elite basketball players, approximately 84% return to play within 1 year following surgery with younger and less experienced players returning to play at higher rates [28]. The rates for return to play among American football players was lower at 67.2%, but higher among ice hockey players in the National Hockey League at 97% [32, 33]. For timing of return to play among professional athletes, those who play basketball, soccer, American football and rugby generally all return to play within the standard, recommended window of 9–12 months [26, 27, 29–32]. Additionally, collegiate and amateur players of these sports return to play within a similar timeframe [30, 31]. In contrast, professional ice hockey players typically return to sport earlier at 7.8 months on average, though guidelines maintain that all-comer, nonprofessional hockey players should meet critical rehabilitation milestones before returning to the ice, which normally falls within 9–12 months as well [33, 34].

Notably, alpine skiing has a high incidence of ACL injuries. In fact, it is estimated that ACL tears account for 17.2% of all skiing injuries [25]. Similar to other sports, return to recreational skiing is typically recommended within the 9–12 month range, depending on individual patient goals and rehabilitation milestones met [26] (Fig. 1).

Fig. 1.

Road to Return to Sport. Preoperative, Intraoperative, and postoperative factors affect return to sport after ACLR

Intra-Operative Factors

Several intra-operative factors have been shown to impact return to play including graft choice, technical factors, and concomitant procedures. Surgical options for ACL tears include reconstruction with autograft, reconstruction with allograft, and repair or restoration.

Graft Choice

Common graft options for ACLR include hamstring, quadriceps tendon, and bone-tendon-bone (BTB) autografts. Proponents of the BTB autograft argue that bone-to-bone healing permits more aggressive rehabilitation, which may translate into faster return to play. In a retrospective study of 73 athletes, patients receiving BTB autografts returned to sport sooner (9.7 months) and at higher rates (74%) compared to those with hamstring grafts (10.7 months and 53% return) [27]. A large registry study further supported these findings, with BTB autografts showing higher odds of returning to preinjury levels at both 1- and 2-years post-surgery [28]. In contrast, allografts are generally avoided in younger athletes due to higher retear rates, and a systematic review found that autograft ACLR yielded a significantly higher return to sport rate (66.2%) compared to allograft (45.3%) [28, 29].

ACL Repair/Restoration

Bridge enhanced ACL restoration (BEAR) has emerged as a management option for ACL injuries that avoids donor site morbidity. In 100 patients with at least 50% remaining tibia stump randomized to BEAR vs. ACLR with autograft, Sanbourn et al. found significantly higher ACL-RSI scores in patients undergoing BEAR when compared to ACLR (71.1 vs. 58.2, p = 0.008) [30]. The same group also found higher International Knee Documentation Committee Subjective Score scores at 6 months and higher Knee injury and Osteoarthritis Outcome Score-Symptoms scores at 12 months postoperatively in patients who had undergone BEAR, although there was no difference in rates of surgeon clearance for return to play [30]. There were also no statistically significant differences in patient reported outcomes at longer term follow up [30].

Technical Factors

Certain technical factors, including graft positioning and tensioning, during ACLR have been explored as factors impacting recovery. Fernandes at al. assessed femoral tunnel position for 86 athletes undergoing ACLR in the coronal and sagittal planes by assessing the position between epicondyles and the position along Blumensaat’s line, respectively [31]. The authors observed that patients who did return to sport had a more anterior tunnel in the sagittal plane (73% anterior to posterior along Blumensaat’s line) compared to those who did not (79% anterior to posterior posterior) return to sports. There was no difference in coronal plane position [31].

Unlike tunnel position, initial graft tensioning does not seem to have a long-term impact on return to play. In a randomized trial of 90 patients undergoing ACLR, Fleming et al. compared normal tensioning to “over tensioning” (defined as 2 mm less translation than contralateral knee) and found no differences in patient reported or biomechanical endpoints [32]. In a systematic review of randomized trials investigating graft tension, there were no differences in any patient functional outcomes with different levels of graft tensioning [33].

Concomitant Procedures

The presence and treatment of meniscal injuries during ACLR can affect return to play timelines. When meniscus injuries are present, they are generally repaired when amenable or debrided. Because of a longer period of restricted weight bearing following meniscus repair, patients may be at risk for slower return to play. A retrospective review of 215 professional soccer players observed a significantly longer time to RTP in athletes who underwent any type of meniscus surgery, but specifically with medial meniscus repair when compared to debridement (12.5 vs. 9.6 months, p = 0.022) [34].

Lateral Stabilizing Procedures

In patients at high risk for re-tear, additional procedures such as lateral extra-articular tenodesis (LET) or anterolateral ligament (ALL) repair may be considered. LET has been associated with 2.4 times higher odds of returning to the same level of soccer compared to ACLR without LET [35]. However, results from STABILITY suggest patients experience increased pain and decreased quadriceps strength within the first 6 months [36]. Ferretti et al. demonstrated that ACLR with concomitant ALL repair was associated with a faster time to return to the preinjury level of sport when compared to ACLR with LET. (6.4 vs. 9.5 months; P < 0.01) [37].

Post-Operative Factors

Numerous post-operative factors influence return to sport. These include the design and timing of rehabilitation protocols, adjunctive therapies such as bracing, cryotherapy, and hyperbaric oxygen therapy, and psychological readiness.

Rehabilitation Timelines

A standard timeline for returning to sport among guidelines is often cited as 9 to 12 months following ACLR, while a commonly noted threshold for an accelerated timeline for return is 6 months [38]. The more conservative timeline for rehabilitation accounts for the biological considerations such as graft revascularization and healing as well as adequate time for restoration of neuromuscular control, psychological readiness for returning to sport, and the improvement of biomechanics, strength and range of motion [39–41]. Grindem et al. found that for pivoting sports, each additional month of rehabilitation up to 9 months reduced the reinjury risk by 51%, with no further reduction beyond that point [42].

While accelerated and standard rehabilitation protocols aim to safely restore function, strength, neuromuscular control, proprioception, joint stability, range of motion, and confidence in returning to sport—as well as ensuring healing and cohesion of the graft— there are important differences in the protocols and early rehabilitation emphases [38]. For example, knee proprioception and strength are still impaired at 6 months following surgery, but exercises and functional milestones such as immediate full range of motion, early weightbearing as tolerated, quadriceps strength assessments with the knee near or at full extension, as well as closed kinetic chain exercises (i.e. step ups, partial squats) and sport specific drills (plyometrics, jumping rope) are introduced earlier, such that earlier recovery of strength and range of motion can be observed [5, 43]. Along these objective clinical endpoints, patients on an accelerated rehabilitation program return to sport sooner.

Proponents of accelerated rehabilitation timelines argue that certain biologic healing parameters such as the vascularity and fiber structure patterns grafts, do not significantly differ at 6 months following surgery compared to 12 months, which may support rationale for a shorter timeline [39]. A randomized controlled trial compared accelerated rehabilitation to standard rehabilitation following ACLR and found no significant differences in terms of patient satisfaction, function, proprioception, and isokinetic strength testing, and clinical assessment at 2 year follow up [5].

Rehabilitation Principles and Protocols

It is important to highlight different principles and protocols during ACLR rehabilitation that can influence recovery and return to sport. Specific factors to consider include open versus closed chain kinetic exercises, quadriceps strengthening, dynamic balance and coordination assessments, and sports specific training.

Regarding exercise paradigms for ACLR post-operative rehabilitation, the decision to involve early open kinetic chain exercises in addition to closed kinetic chain exercises has been an ongoing area of discussion [44]. Open kinetic chain exercises allow free movement of the distal ends of joints without support and allow more targeted muscle isolation strengthening (examples include knee extensions and hamstring curls), whereas for closed kinetic chain exercises, the distal ends of joints are fixed (examples include squats and lunges) such that multiple muscles are engaged to stabilize the joint [45, 46]. In the past, closed chain kinetic exercises have been favored in ACLR rehabilitation with the belief that they pose less risk of placing undue strain on the ACL graft [47]. However, recent evidence suggests that introducing open-kinetic exercises in rehabilitation may provide strength and endurance benefits [48]. In a recent meta-analysis comparing open kinetic and closed kinetic chain exercises following ACLR, open kinetic chain exercises were superior in improving strength of the quadriceps at the 3–4-month follow-up period, with no increase in pain scores or laxity on examination compared to closed kinetic chain exercises [49]. In a prospective cohort study, a significantly higher proportion of athletes returned to their pre-injury level of sport in the group that engaged in both open and closed kinetic chain exercises for strengthening the quadriceps compared to strengthening with closed kinetic chain exercises alone [50].

Restoring quadriceps strength is one of the critical cornerstones of ACL rehabilitation [51]. More symmetrical quadriceps strength, often measured as an index of inter-limb strength with a goal threshold ratio greater than or equal to 0.9 between the affected and unaffected limbs, is significantly associated with reduced rates of knee reinjury and is used as a benchmark for rehabilitation progression and return to sport clearance. Among amateur athletes, quadriceps strength was significantly higher among the group that had returned to competitive sports compared to those who had not [52]. Additionally, patients with decreased quadriceps strength reported worse function and demonstrated worse performance on functional hop tests than those patients with greater quadriceps strength [53].

Additionally, functional exercises that demonstrate neuromuscular control, dynamic stability and balance can be important indicators of progress and predictors of return to sport [50–53]. For example, the Y-balance test is used to assess dynamic postural control (Fig. 2). Garrison et al. found that participants who demonstrate deficits in the Y-balance test at 12 weeks do not meet hop test thresholds for RTP at the time of return [54]. In particular, anterior reach deficits were sensitive for athletes who would not go on to meet hopping test criteria [54]. Additionally, among soccer players already cleared for RTS after ACLR, one study found that these participants were not able to reach as far as uninjured controls, suggesting an under detection of balance deficits with standard RTS protocols [55].

Fig. 2.

Various rehabilitation exercises at different stages and for different domains including early (A) quadriceps and (B) hamstring activation, strength-focused (C) squat and (D) partial lunge, and balance-focused (E) single leg squat and (F/G) Y-balance test

Additionally, the single leg squat (SLS) assessment tests proprioception, balance and the quality of movement (Fig. 2). Among patients 6 months following ACLR, 45% demonstrated poor biomechanics during SLS associated with ipsilateral trunk lean, pelvic tilt, dynamic knee valgus, loss of balance, hip adduction or internal rotation [56]. Those with poor biomechanics during SLS demonstrated worse hopping test performance and lower IKDC scores, which may influence return to sport at later follow-up [56]. Lastly, hop tests are essential assessments of return to sport readiness, testing strength, dynamic balance, and coordination. In a recent meta-analysis examining the prognostic value of hop tests following ACL injury, West et al. found that higher inter-limb symmetry on various hop tests was associated with about twice the odds of returning to sport within 1–3 years following ACLR [57]. Additionally, they found that better performance on hop tests was associated with better patient reported outcomes for knee symptoms and reduced odds for knee osteoarthritis [57].

After strength, mobility, and balance improve to baseline, the focus of rehabilitation often transitions to sport specific training [58]. It has been shown that patients who participate in sport-specific activities such as running, cutting, and pivoting activities had higher odds of returning to pre-injury level of play than those who did not [12]. While the standard criteria that focus on quadriceps strength, range of motion, and neuromuscular control are crucial for recovery and injury prevention, incorporating sport-specific movements, conditioning and strength are critical variables to consider for optimizing return to sport among athletes following ACLR [58].

Return to Play Timing and Criteria

Return-to-play timelines after ACL reconstruction vary considerably based on patient age, rehabilitation goals, and clinical factors. Pediatric protocols recommend RTP at as early as 7.5 months, while consensus for adult patients often suggest 9 to 12 months, depending on functional and symptomatic milestones [59]. Although the specific criteria used for clearance across practices varies, recent efforts have begun to establish more uniform definitions and pathways for returning to sport [40, 51].

For example, the Panther Symposium ACL Injury Return to Sport Consensus Group introduced the concept of a continuum of recovery, highlighting the importance of criteria-based progression, multidisciplinary collaboration, and validated assessments of both functional and psychological readiness [40]. They also recommended moving away from exclusively time-based RTP criteria but acknowledged ongoing debates over optimal testing batteries and how to incorporate psychological readiness [40].

Despite these advances, RTP remains inconsistently defined and reported in the literature. In a systematic review, only 52% of studies used more than one criterion when evaluating unrestricted activity following ACLR [59]. Time-based protocols continue to dominate many clinical settings [60]. Typically, RTP testing batteries include measurements of quadriceps, hamstring, and gluteal strength, as well as hop or balance tests [61]. Patient-reported outcome measures (e.g., KOOS and IKDC) and psychological readiness scales (e.g., ACL-RSI) have also gained prominence in aiding evaluation of readiness to RTP [7, 12, 51].

However, the validity and generalizability of these RTP tests remain uncertain [62]. Some studies indicate that a notable proportion of athletes already engage in high-intensity sports before meeting standard RTP criteria [63]. Conversely, other findings suggest that passing RTP testing correlates with a higher likelihood of resuming pre-injury activity, whereas others show no clear relationship [64, 65]. Additionally, limb symmetry indices commonly used in testing can overestimate true knee function by comparing post-operative strength to the contralateral limb, rather than a pre-injury baseline [58].

Overall, a more nuanced understanding of the interplay among pre-operative, intra-operative, and post-operative factors is crucial for refining RTP criteria and decision-making. Adopting a comprehensive, individualized approach can enhance accuracy and better align clinical goals with patient outcomes.

Bracing

After ACL reconstruction (ACLR), many patients receive knee braces during later rehabilitation stages or as they resume sporting activities, despite inconclusive evidence on their overall benefits for key clinical outcomes [8, 66]. A systematic review of three studies encompassing 1,196 patients found no definitive protective effect of bracing against re-injury or graft failure, although one study suggested a potential protective benefit for younger athletes (< 17 years) [67].

Regarding return to play, the evidence remains limited. One study reported that 63% of braced patients returned to strenuous pivoting activities, compared with 88% among unbraced patients [68]. Some data also indicates that bracing may enhance subjective confidence during rehabilitation [69, 70]. For instance, a randomized controlled trial evaluating functional braces versus neoprene sleeves found no significant differences in objective performance tests or quality-of-life scores. However, subjective knee confidence was higher among those wearing functional braces [69].

Overall, consensus on bracing after ACLR remains elusive. While it may confer a psychological improvement, evidence supporting its routine use for reducing re-injury risk or expediting return to play is limited. Additional high-quality studies are needed to clarify which patient populations, if any, may derive the greatest benefit from post-operative bracing.

Cryotherapy

Among adjuvant therapies in the post operative period, cryotherapy or cold therapy is often used to help reduce swelling and pain [61]. In a pilot study that randomized patients to receive standard physical therapy plus ice compress versus standard physical therapy alone, patients who were randomized to the cold therapy had greater improvements in range of motion and self-reported measures of pain within the immediate post-operative period [71]. As it relates to return to sport, a systematic review examining the effect of cryotherapy on return to sport participation did not find a statistically significant association between the use of cryotherapy and return to sport [72].

Although direct evidence for cryotherapy improving return to sport outcomes is not robust, general principles of the analgesic effects and biological healing associated with cold therapy suggest that if pain is more effectively controlled and swelling reduced, patients may be able to more readily participate in rehabilitation to progress strength, range of motion and functional milestones [72–74].

Hyperbaric Oxygen Therapy (HBOT)

Hyperbaric oxygen therapy occurs when a patient sits in a chamber that is pressurized to a level greater than sea level and breathes in 100% oxygen [75]. The concept behind HBOT is that increased oxygen allows for improved healing through angiogenesis, improved fibroblast function, reduction in inflammation, and restoration of oxygen-dependent metabolic processes [76]. Although there is minimal evidence surrounding healing specifically in the knee, there are established benefits to wound healing [76].

After ACL reconstruction, lack of blood flow to the graft hinders the consolidation and healing [76]. HBOT may increase blood flow, which in turn may decrease inflammation, increase cell metabolism, and aid in the healing process [76]. A recent animal study in rabbits who underwent ACLR demonstrated that those who received the HBOT treatment had better graft maturation and integration, higher bone mineral density, greater load to failure of the graft on biomechanical testing, and reduced tunnel widening [77]. Despite these potential benefits of HBOT, there are no high-quality trials demonstrating its effectiveness in post-operative improvements in ACLR.

Photobiomodulation or Red-Light Therapy

Photobiomodulation, low level laser therapy (LLLT), or red light therapy is the process of using low-wavelength (near infra-red) light to help alleviate pain, reduce inflammation, and encourage tissue repair [78]. While the evidence for the effect of LLLT on ACLR recovery and return to sport is limited, adjacent studies for other orthopaedic procedures are promising. For example, in a recent randomized clinical trial comparing LLLT to controls following total knee arthroplasty, range of motion was greater among the patients in the LLLT group at all follow-up time points up to 12 months. Additionally, the LLLT group had lower pain at 3 month and used fewer opiate painkillers during the first month [79]. In another sham-controlled, randomized clinical trial comparing LLLT to sham therapy in patients undergoing rotator cuff arthroscopic surgery, the patients in the LLLT group exhibited greater subjective pain reduction at 3 and 6 months follow up time points [80]. They also exhibited significantly improved function and quality of life at 6 months [80]. Again, while there are no direct clinical trials studying the effect of LLLT after ACLR, the benefits observed in other orthopaedic procedures warrants future study.

Psychological Readiness

Current literature demonstrates a return to sport rate after ACLR to be fairly low, with about 81% of patients returning to any sports, 65% returning to their pre-injury level of sports, and 55% returning to competitive sports [12]. In fact, some of the most common reasons cited by athletes as to why they do not return to sport are psychological factors, including fear of re-injury, lack of confidence in their performance, external life factors, and negative mood states rather than any physical deficit [81, 82]. Some studies have also demonstrated that higher self-efficacy and higher athletic identity are both associated with higher compliance with the post-operative rehabilitation protocol [83]. Higher self-efficacy is also associated with higher levels of return to sport, but data on athletic identity and return to sport is more limited [83].

Although there are obvious associations between psychological factors and returning to sport, there is not yet clear data on what kinds of interventions may be able to address them. There have been several studies that have analyzed the effectiveness of various psychological interventions (including relaxation, imagery, behavioral interventions, and goal setting) on the ACLR rehabilitation process. Although many of these interventions demonstrated improvements in post-operative pain and anxiety, increased self-efficacy, and lower fear of re-injury, none of these studies included data on differences in return to sport rates [84–86].

Despite the clear importance of psychological factors in returning to sport after ACLR, few surgeons report assessing or evaluating it when deciding to release their patients [87]. For those surgeons that did evaluate psychological readiness, most used the Anterior Cruciate Ligament Return to Sport After Injury (ACL-RSI) Scale [87]. Based on that scale, if patients were deemed as not being ready to return to sport, some were referred to a sport psychologist for evaluation and treatment [87]. However, there are no clearly established guidelines as to how to help a patient return to sport based on psychological factors, and more data is needed as to what psychological interventions may be helpful in increasing return to sport rates for athletes [83].

Conclusion

Return to sport after ACL reconstruction is a multifaceted outcome influenced by a complex interplay of pre-operative, intra-operative, and post-operative factors. Individual patient characteristics such as age, sex, and BMI, surgical techniques including graft choice and technical factors, and post-operative rehabilitation strategies all contribute to recovery. Moreover, adjunctive therapies and psychological readiness are emerging as critical components in optimizing RTS outcomes. A comprehensive, criteria-based approach that integrates physical and psychological parameters is essential for tailoring rehabilitation programs and ultimately improving patient outcomes. Future research should aim to standardize RTS testing and develop targeted interventions to address the psychological barriers that many athletes face after ACLR.

Key References

• Kneebone L, Edwards P, Blackah N, Radic R, D’Alessandro P, Ebert JR. Sex-based differences in physical and psychological recovery, and return to sport, following anterior cruciate ligament reconstruction. The Knee. 2025;52:22–31. doi:10.1016/j.knee.2024.10.013.

• • Recent study that examines sex-based difference in successful RTS and the role of psychological readiness.

• Xiao M, van Niekerk M, Trivedi NN, et al. Patients Who Return to Sport After Primary Anterior Cruciate Ligament Reconstruction Have Significantly Higher Psychological Readiness: A Systematic Review and Meta-analysis of 3744 Patients. Am J Sports Med. 2023;51(10):2774–2783. doi:10.1177/03635465221102420.

• • Recent systematic review and meta-analysis that emphasizes the importance of psychological readiness for predicting RTS.

• Pinheiro VH, Borque KA, Laughlin MS, et al. Determinants of Performance in Professional Soccer Players at 2 and 5 Years After ACL Reconstruction. Am J Sports Med. 2023;51(14):3649–3657. doi:10.1177/03635465231207832.

• • Recent paper that examines long term performance outcomes among professional soccer players.

• Ferretti A, Carrozzo A, Saithna A, et al. Comparison of Primary Repair of the Anterior Cruciate Ligament and Anterolateral Structures to Reconstruction and Lateral Extra-articular Tenodesis at 2-Year Follow-up. Am J Sports Med. 2023;51(9):2300–2312. doi:10.1177/03635465231178301.

• • Recent paper that compares surgical techniques in relation to RTS timing and outcomes.

• Waldron K, Brown M, Calderon A, Feldman M. Anterior Cruciate Ligament Rehabilitation and Return to Sport: How Fast Is Too Fast? Arthrosc Sports Med Rehabil. 2022;4(1):e175-e179. doi:10.1016/j.asmr.2021.10.027.

• • Recent paper that discusses the importance of considering rehabilitation timelines, associated risks, and RTS timing.

Author Contributions

All authors contributed significantly to the conception, drafting, analysis and editing of the final manuscript.

Funding

No applicable funding was received.

Data Availability

No datasets were generated or analysed during the current study.

Declarations

Human and Animal Rights Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Competing Interests

The authors declare no competing interests.