The majority of elite and professional athletes return to the preinjury level of activity after ACL reconstruction: A systematic review and meta-analysis

Purpose: To compare return to play (RTP), time to RTP, level of RTP, and anterior cruciate ligament (ACL) graft failure among elite and professional athletes from different sports after anterior cruciate ligament reconstruction (ACLR). Methods: The PubMed, Embase and Cochrane Library databases were searched to identify potentially relevant research articles that analysed RTP, time to RTP, level of RTP, and graft failure rate in elite and professional athletes after ACLR. An elite or professional athlete was defined as one who participates in national- or international-level competitions in professional or amateur sports-including academy players aged 15 years or over. Results: A total of 49 studies met the inclusion criteria. Eleven different sports and 4463 knees were included in the final analysis. The pooled data revealed an RTP rate of 85.8% (95% confidence interval [CI] 82.8-88.5]. A lower RTP was observed in Australian football (67.8% [95% CI 54.1-80.1]; p < 0.001) and football (73.0% [95% CI 65.9-79.5]; p < 0.001) than in soccer (92.8% [95% CI 89.3-95.7]). Almost 90% of the athletes returned to their preinjury level. The meta-analysis revealed no difference (p > 0.05) in the level of RTP rate among the different studies, ranging from 79.0% (soccer) to 97.3% (basketball). The pooled mean time to RTP was 292 days (95% CI 268-316 days). The pooled ACL graft failure rate was estimated to be 7.0% for athletes. Conclusions: Following ACLR, more than 85% of elite and professional athletes returned to play and almost 90% returned to their preinjury level, with a graft failure rate of 7.0% and a mean return to play at 292 days. Athletes and their treating physicians can utilise these findings to set reasonable expectations for their return to competition after ACLR. Study registration: CRD42025632248. Level of evidence: Systematic review and meta-analysis of level IV.