Early versus standard return to play following ACL reconstruction: impact on volume of play and career longevity in 180 professional European soccer players: a retrospective cohort study

Battaglia et al. Journal of Orthopaedics and Traumatology (2025) 26:29 https://doi.org/10.1186/s10195-025-00837-y ORIGINAL ARTICLE Journal of Orthopaedics and Traumatology Open Access Early versus standard return to play following ACL reconstruction: impact on volume of play and career longevity in 180 professional European soccer players: a retrospective cohort study Michael Battaglia1, Justin W. Arner2, Kaare S. Midtgaard3, Daniel B. Haber4, Liam A. Peebles5, Annalise M. Peebles5, Phob Ganokroj5,6, Ryan J. Whalen5, Matthew T. Provencher5,7, Guglielmo Torre8, Riccardo Ciatti1,9*   and Pier Paolo Mariani8 Abstract Background Patients typically follow a 7–9-month return to play (RTP) protocol following anterior cruciate ligament reconstruction (ACLR); however, much of these data have been based on non-elite athletes. The purpose of this study is to understand whether professional soccer players returning to competition < 6-months following ACLR will have an increased risk of graft failure, play fewer seasons postoperatively, and have lower volume of play compared with those returning > 6 months. Materials and methods A total of 180 male professional European soccer players were enrolled and underwent ACLR with a single surgeon between April 2008 and December 2016 and returned to sport < 6 months (early RTP group, n = 92) or > 6 months (standard RTP group, n = 88). Time from intervention to RTP (days), same season returns, total games and average minutes played in return season, seasons played after surgery, and playing status were recorded. Results The early RTP group returned to soccer sooner (142.8 ± 21.4 days) than the standard RTP group (276.2 ± 118.9) (p < 0.01), and more players returned the same season as the injury in the early RTP group (n = 55/92, 62.5%) than the standard RTP group (n = 18/88, 20.5%) (p < 0.01). The difference in average minutes per game in the first season back was not statistically significant (early RTP, 56.7 ± 22.3 min; standard RTP 49.9 ± 29.8 min, p = 0.094). The early RTP group had significantly longer careers following ACLR (5.7 ± 2.2 seasons) than the standard RTP group (4.7 ± 2.4 seasons) (p = 0.005). The early RTP group sustained more reruptures (n = 4, 4.4%) than the standard RTP group (n = 1, 1.1%). Conclusions Professional European soccer players returning to competition < 6 months following ACLR did not have poorer outcomes than those who returned > 6 months despite the fact that there were three more failures. However, the early RTP group players were more likely to return during the same season, had longer careers after ACLR, and played a similar number of games and minutes per game, but had more graft failures. Level of evidence Retrospective cohort study level IV. *Correspondence: Riccardo Ciatti Full list of author information is available at the end of the article © The Author(s) 2025. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. Battaglia et al. Journal of Orthopaedics and Traumatology (2025) 26:29 Page 2 of 7 Trial registration: Retrospectively registered according to prot. Professionisti_OSS_22. Keywords Knee, Ligaments, ACLR, Football (soccer), Physical therapy/rehabilitation, Return-to-play Graphical Abstract Introduction There is a paucity of scientific literature regarding the ideal return to professional sports following anterior cruciate ligament reconstruction (ACLR). It is known that a higher activity level leads to a greater risk of ACL graft failure, but many other factors are also at play [13]. Basic science studies suggest that ACL graft maturation and re-ligamentization are critical; however, these processes continue to occur after athletes actually return to play, with some studies reporting changes up to 24 months [19, 23]. The time for the optimal return to play is, therefore, controversial, with most advocating for between 6 and 12 months. Recently published data have suggested that lower failure rates may be obtained 9 months after ACLR [10]. Despite this, several factors must be considered regarding return to play (RTP) in addition to timing. These include range of motion, proprioception, strength, and isokinetic and functional testing, as well as psychological readiness [20, 22]. Although an inadequate RTP protocol carries an increased risk of reinjury, many professional athletes desire to push the envelope to avoid loss of position, decline in conditioning and skill level, and loss of income. However, professional athletes likely have greater neuromuscular control, proprioception, and strength compared with non-elite athletes. Further, these athletes typically have greater access to high-level and more frequent physical therapy, recovery resources, technology, and nutrition, leaving little applicability to many of the currently published studies [18]. Further, elite athletes are typically more likely to continue important injury prevention exercises throughout their play [5, 22]. Conversely, professional sports, including soccer, are likely riskier due to high levels of jumping, pivoting, and hard cutting [10]. This begs the question of whether professional athletes should be restricted from returning to play for 9 months, as many surgeons currently recommend, which is based on data from nonelite athletes. Materials and methods Aim of the study, design, and setting The aim of this study was to retrospectively evaluate the impact of early (< 6 months) versus standard (> 6 months) return to play (RTP) protocols on the rate of failure, volume of play, and career longevity following ACLR in a cohort of professional European soccer players. It was hypothesized that athletes returning to professional competition earlier than 6 months after ACLR would have an increased risk of failure, lower volume of play, and would play for fewer seasons following surgical intervention compared with those returning after 6 months. Professional soccer players treated with primary anterior cruciate ligament reconstruction by a single surgeon (P.P.M.) between April 2008 and December 2016 were included in this retrospective study. The study was approved by the institutional review board (prot. Professionisti_OSS_22), a (...truncated)