The impact of on‐field rehabilitation on return to play and ACL re‐injury risk after ACL reconstruction in football (soccer) players: A study on 401 consecutive cases

PURPOSE: Examine the association between preoperative, intraoperative and postoperative variables, including on-field rehabilitation (OFR) participation and return to play (RTP) rates and re-injury risk in a large cohort of 11-a-side football (soccer) players after anterior cruciate ligament reconstruction (ACLR). METHODS: Data from 401 male football players who underwent primary ACLR were retrospectively analysed. All players completed a standardised rehabilitation protocol, involving a period of OFR. Participants were stratified by competitive level (professionals and amateurs), and between-group differences in RTP and re-injury outcomes were documented. The association between preoperative, intraoperative and postoperative variables for each outcome was assessed using logistic regressions, controlling for competitive level. RESULTS: Median follow-up time was 40.6 months post-ACLR. Eighty-four percent of players RTP at their pre-injury competitive level, with professionals (88%) and amateurs (83%) returning in 5.9 ± 2.1 and 6.9 ± 3.2 months, respectively. Greater OFR volume (odds ratio [OR], 1.06; 95% confidence interval [CI], 1.00-1.12; p = 0.034) and weekly frequency (OR, 1.53; 95% CI, 1.00-1.07; p = 0.014) were associated with increased RTP likelihood. High OFR compliance was associated with higher odds of RTP (OR = 2.62, p = 0.003), in which 91% of compliant players RTP at their pre-injury competitive level. Forty-two players (10%) sustained a second ACL injury (20 ipsilateral and 22 contralateral). OFR variables were not significantly associated with overall second ACL re-injury risk. In an exploratory subgroup analysis of young (<20 years old) players, OFR compliance was associated with lower odds of ipsilateral re-injury (OR = 0.23, p = 0.041). CONCLUSION: ACLR football players in our cohort had high RTP (88%) and low ACL re-injury risk (10%). Greater exposure to OFR, particularly higher volume and weekly frequency, was associated with an increased likelihood of RTP. No association was observed between OFR compliance and overall second ACL injury risk, although in young players, greater OFR compliance was associated with a reduction in ipsilateral ACL re-injury. LEVEL OF EVIDENCE: Level IV.