Keywords
anterior ligament cruciate reconstruction - return to sports - return to play - soccer
Introduction
Soccer is the most popular sport worldwide, with an estimated 270 million active players.[1] Anterior cruciate ligament (ACL) tears are one of the most common knee ligament
injuries in athletes, especially in contact sports.[2] Studies on the non-surgical treatment of ACL injuries have described acceptable
functional results, but withdrawal from contact sports like soccer is usually required.[3]
[4] The desire of the athletes to return to sports is cited as a major indication for
ACL reconstruction surgery.[5] The surgery is performed with the aim of maximizing the stability and functional
capacity of the ACL-deficient knee, thereby facilitating the return to sports.[6]
[7]
A systematic review and meta-analysis regarding return to sports following ACL reconstruction
with more than 7,000 patients demonstrated that 81% of them resumed playing some form
of sport after surgery, 65% resumed their previous level of sports activities, and
55% returned to competitive sports.[8]
Given the variability in what is demanded of the knee in the different sports, the
outcomes after ACL reconstruction may vary. Patients appear to be more likely to return
to activities such as bicycling and jogging after ACL reconstruction than to sports
that are bruising and require pivoting, such as soccer and football.[9]
Despite ACL tear being a common and potentially serious soccer injury, there are relatively
few studies on the outcomes, especially regarding the return to the same level of
performance after ACL reconstruction in these athletes.[10]
[11]
[12]
[13]
[14] Data on this would give orthopedic surgeons the ability to inform patients about
what they should expect after surgery in terms of performance level, considering the
return to the preinjury levels as the main indicator of success in ACL reconstruction.
The aim of the study is to evaluate the return to play in amateur soccer league players
after ACL reconstruction, and to analyze the reasons why some of them have not returned.
Methods
The present study is a case series in which the surgical protocols of patients with
ACL reconstruction surgeries performed in a sports medicine clinic between July 1st, 2013, to June 30th, 2014, were included. Only the charts of amateur soccer league players who played
once or twice a week (Tegner 9)[15] were selected. The exclusion criteria were: patients younger than 18 and older than
40 years of age; patients of the female gender; those who underwent revision ACL surgery
or multiligament surgery; those who were professional (Tegner 10) or occasional (Tegner
7) soccer players; patients who mainly played a sport other than soccer; and those
not possible to follow up.
The follow-up time was calculated as the number of months between surgery and the
telephone survey.
For each surgical protocol, age, surgical technique, additional meniscal and/or chondral
surgery, and type of graft were recorded.
The telephone survey was conducted by the main author. The current status of return
to team playing (yes/no) was recorded. Those who did not return to play were asked
what kind of sport they were currently playing (occasional soccer, another sport,
or if they now led a sedentary lifestyle), and the main reason for not returning to
play (fear of reinjury, knee symptoms, lack of confidence in their knee, family or
job commitments, not being eligible to participate in competitive sports).
The Fisher exact test and the Mann-Whitney U test were used to calculate the differences
between the group who returned to team playing and the one who did not.
Results
Over a 1-year period, a total of 238 patients underwent ACL reconstruction. From this
group, 61 (25.6%) met the inclusion criteria, and 177 (74,3%) did not, and they were
excluded ([Table 1]). The mean follow-up time was of 22.4 ± 3.4 months. The mean age at the time of
the surgery was of 29.7 years (standard deviation [SD]: 5.5 years; range: 20–40 years).
Table 1
|
Excluded
|
177 (74.3%)
|
|
Age < 18 and > 40 years
|
25
|
|
Female gender
|
10
|
|
Revision anterior cruciate ligament surgery
|
23
|
|
Multiligament surgery
|
10
|
|
Professional soccer players
|
6
|
|
Occasional soccer players
|
23
|
|
Main practice of another sport
|
57
|
|
Not possible to follow up
|
23
|
All of the patients had an arthroscopically-assisted reconstruction of the ACL. In
85% cases, the surgical technique performed was transtibial, and in 15% it was medial
portal. A total of 44 (72.1%) patients were submitted to a concomitant surgery ([Table 2]). Double semitendinosus-gracilis autografts were used in 50 surgeries, and bone-patellar-bone
autografts were used in 11 of them.
Table 2
|
Additional surgery
|
44
|
72.1%
|
|
Medial meniscectomy
|
7
|
11.4%
|
|
Lateral meniscectomy
|
34
|
55.7%
|
|
Medial meniscal repair
|
9
|
14.7%
|
|
Lateral meniscal repair
|
0
|
0%
|
|
Microfracture of the trochlea/patella
|
1
|
1.6%
|
|
Microfracture of the medial femoral condyle
|
0
|
0%
|
|
Microfracture of the lateral femoral condyle
|
1
|
1.6%
|
At the final follow-up, 30 (49.1%) patients were playing in an amateur soccer team.
Out of those who did not return to team playing, 19 (61.2%) were playing soccer occasionally,
11 (35.4%) were playing other sports, and 1 (3.2%) developed a sedentary lifestyle.
The main reason for not returning to play were: fear of reinjury in 26%; knee symptoms
in 26%; lack of confidence in the knee in 23%; family or job commitments in 23%; and
not being eligible to participate in competitive sports in 2%.
There were only significant differences regarding age between the group who returned
to team playing and the one who did not ([Table 3]).
Table 3
|
Return to amateur soccer league
|
|
|
(+)
|
(-)
|
p-value
|
|
Age (years)
|
28.1 (20–39)
|
31.1 (23–40)
|
0.04
|
|
Time from surgery (months)
|
22.5 (17–28)
|
22.3 (18–28)
|
0.91
|
|
Surgical technique (n)
|
|
|
|
|
Transtibial/Medial portal
|
25/5
|
27/4
|
0.73
|
|
Type of autograft (n)
|
|
|
|
|
Hamstrings/Bone-patellar-bone
|
24/6
|
26/5
|
0.74
|
|
Additional meniscal and/or chondral surgery (n)
|
|
|
|
|
Yes/No
|
22/8
|
22/9
|
1
|
Discussion
Our study is the first to exclusively describe the return to play in amateur soccer
league players after ACL reconstruction. It has shown that only half of the amateur
soccer league players return to play after an average of two years after surgery.
Our results are similar to those of a large cohort study[16] with diverse competitive athletes that showed that 2 years after ACL reconstruction
surgery only 60% of the participants had returned to their preinjury level of performance.
In another study with athletes who practice physically demanding sports, after an
average time of 43 months from surgery to follow-up, only 42% of them resumed their
previous performance levels or reached higher levels.[17]
Brophy et al[10] analyzed the factors influencing return-to-play in soccer players with different
levels of performance, and they reported that out of all patients who underwent ACL
reconstruction, only 35% were still playing the sport at the 7-year follow-up. Of
those still playing, only 46% were still playing at the same or at a higher level
than before the injury. They concluded that younger and male soccer athletes are more
likely to return to play after ACL reconstruction.
Our results in percentage of return to team playing were higher than those reported
in these previous studies, probably due to the shorter follow-up time, and because
our series consisted exclusively of physically demanding soccer players (Tegner 9),
who are highly motivated to return to competition.
It is relevant to distinguish the performance level when analyzing the return-to-sport,
because most professional and elite players are able to return to play at the same
level as before the injury. This is probably because this group of patients presents
major differences in caretaking compared with amateur players, considering diagnostic
evaluation, time to surgery, and postoperative rehabilitation, as well as high financial
incentives.[18]
One study[14] presented the outcomes of a homogenous group of male professional soccer players
who underwent ACL reconstruction; the authors reported that 95% and 62% of them returned
to professional levels of performance at 1 year and 4 years respectively.
Another study[13] with professional soccer players after ACL reconstruction, revealed that only 2/3
of the players were still playing at the highest level 3 years later.
Some reports on ACL reconstruction in soccer players include patients with different
sports performance levels. One study[10] reported that after an average of 4 years after ACL surgery, 68% of the patients
were still active soccer players. Analyzing this group by sport performance level,
∼ 37% played soccer at international or at the highest national level previous to
injury.
The ability of the patients to return to sports after ACL reconstruction is influenced
by various factors, which include postoperative knee function, social reasons and
psychological state. One study prospectively[19] analyzed the effects of various subjective scoring systems on return-to-sports after
ACL reconstruction, and found no significant differences between athletes who did
and did not return to sports.
Multiple studies have reported that fear of reinjury, rather than clinical findings
of instability or pain, is the single greatest reason for failure to return to sports.[8]
[9]
[20] When analyzing fear of reinjury as a reason not to return to the preinjury performance
level, our results were similar to those reported in a previous study,[21] which describes that it is the main factor for not returning to play in 24% of the
athletes who underwent ACL surgery.
The principal limitation of our study was the small sample size, which limited the
scope of the data analysis. Another limitation was the lack of registration of the
time period between ACL injury and surgery, and the volume and nature of rehabilitation
pre- and postsurgery. Both factors could influence the return to sports to the same
preinjury level.
One strength of our study was that it specifically evaluated, in amateur soccer players,
the rate of return to the same level of performance as before the ACL injury. A return
to the preinjury performance level was thought to represent the most robust assessment
of a successful return-to-sports outcome. Previous studies did not specify whether
the participants who returned to competitive sports returned to their preinjury level
of performance or even to the same sport they used to play before the injury.[14] As a result, these studies possibly overestimated the return-to-sports rate.
Conclusion
After an average of two years of ACL reconstruction, only half of the amateur soccer
league players return to team playing.
