Can a football player return-to-play after surgery to reconstruct a torn anterior cruciate ligament (ACL)? Is it possible to return and advance to the next level of competition? If not, why not? These are the questions Dr. Kirk A. McCullough and his colleagues from Vanderbilt University Medical Center in Nashville, Tennessee addressed in this study.

They conducted a retrospective study of 157 football athletes to find out some answers. A retrospective study means they studied the players after the injury, surgery, and rehab were all over. That makes sense since they wanted to find out what happens much later in terms of return-to-play. All of the patients were either high school or college level athletes. Only athletes with just an ACL injury (no other cartilage, bone, ligamentous or other soft tissue damage) were included in the study.

Each player was interviewed and asked questions about the position they played before the injury, ability to play after surgery, quality of life, and general activity level. Position played is important because some players (e.g., running back, wide receivers) have to be quick on their feet, changing directions, and using pivoting motions that can be compromised by ACL reconstructive surgery. There is the same concern for other players (e.g., lineman) who are more likely to take hits directly to the knees.

In this study, players who did not return to play football were also asked what factors contributed to that decision. The medical record was reviewed for information about the type of injury sustained, type of tissue graft used to reconstruct the ACL, and any problems or complications after surgery.

There was a natural grouping of players into three subsets: 1) those who did not go back to sports at all, 2) those who returned to the game but in a different position or lower level of performance, and 3) those who returned fully (at their preinjury level). Reasons given for not returning at all included fear; knee symptoms such as pain, stiffness, and swelling; perception that strength and/or speed were not enough for competitive play, and advice from others.

About half of the players were able to return to the game. This compares to about an 80 per cent return rate for professional football players with the same injury. For those who did not return to the field, fear of reinjury was a major factor for the college-level players. Performance-related reasons topped the list for the high-school players. And high school football athletes were more likely to leave the team to pursue other interests (including other sports but also other nonsports activities).

The authors conclude that with as many athletes who suffer ACL injuries, the low rate of return to sports should be investigated further. Their discovery that emotional and psychologic factors (fear, perceptions of poor performance) may play a more important role than previously recognized should also be a topic for future studies.

Reference: Kirk A. McCullough, MD, et al. Return to High School- and College-Level Football After Anterior Cruciate Ligament Reconstruction. A Multicenter Orthopaedic Outcomes Network (MOON) Cohort Study. In The American Journal of Sports Medicine. November 2012. Vol. 40. No. 11. Pp. 2523-2529.