Slower but Not Safer: A Systematic Review and Meta-Analysis of Return to Play and Graft Re-Rupture After ACL Reconstruction in Professional Soccer Players

Background: Anterior cruciate ligament (ACL) rupture is one of the most severe injuries in professional soccer players, often leading to long absences from competition and career-threatening consequences. Understanding how return to play (RTP) outcomes have evolved over time is essential for optimizing recovery and minimizing re-injury risk. The aim of this systematic review and meta-analysis was to compare RTP rate, level of RTP, time to RTP, and ACL graft re-rupture rate in professional soccer players across three distinct time periods after ACL reconstruction (ACLR). Methods: Following PRISMA guidelines, MEDLINE (PubMed), Embase (Elsevier), and the Cochrane Library were systematically searched on March 8, 2025, and updated on March 22, 2025. Studies reporting RTP outcomes after ACLR in professional soccer players were included. Methodological quality was assessed using the Methodological Index for Non-Randomized Studies (MINORS). Four primary outcomes-RTP rate, level of RTP, time to RTP, and ACL graft re-rupture rate-were extracted and meta-analyzed across three publication periods (2011-2016, 2017-2021, 2022-2025). Results: Twenty studies met the inclusion criteria, comprising 1,988 professional soccer players (5 published before 2017, 5 between 2017 and 2021, and 10 after 2021). The mean player age at surgery did not differ across time periods (p > 0.05). Overall, 92.3% of players returned to play, 80.1% regained their pre-injury performance level. The mean time to RTP was 263.2 days, with a significantly slower return observed in 2022-2025 (295.1 days) compared with 2011-2016 (203.5 days; p = 0.006), and the pooled graft re-rupture rate was 8.2%. No significant differences were found among periods for overall RTP, level of RTP, or re-rupture rate (p > 0.05). Conclusion: More than 92% of professional soccer players successfully RTP after ACLR, and approximately 80% recover their pre-injury level. However, in recent years, RTP has become significantly slower-by over 40%-without a corresponding reduction in graft re-rupture rates. These findings suggest a shift toward more conservative, criteria-based RTP decision-making in professional soccer, reflecting greater emphasis on graft protection and long-term knee health. Level of Evidence Systematic review and meta-analysis of level IV. Trial Registration PROSPERO - CRD420251012143.