Sports performance following ACL reconstruction

By Mick Hughes 

I’ve written about ACL injury in the past: at-risk age groups, risk factors, when it is safe to return to sport following ACL surgery and ACL prevention programs – to name a few (read past posts on my blog). For my guest spot in this BJSM blog, I turn my attention to sport performances upon return to sport.

Reports suggest that within 1-2 years following ACL reconstruction 80% of people will return to some form of sport, 65% will return to the same sporting level, and 55% will return to competitive sports (1). That’s all well and good, but the question I am interested in is: Are the return to sport statistics the same at the elite level, and importantly for the fans, will the athlete ever be the same again when he or she gets back on the sporting field?

How do elite athletes perform after ACL reconstruction?

basketball player

One study found that 86% of NBA players successfully made a comeback in the next playing season. However, total games started, total games played and player efficiency ratings were all significantly lower in their first season back compared to age-matched controls. Their careers were almost 2 years shorter as well (2).

Conversely, I also wrote about the rise and rise of Australian Cricket test batsman Usman Khawja, after he recently returned to sport following ACL reconstruction. Prior to his ACL injury in late 2014, he was in-and-out of the Australian test team, and had a test batting average of 24 runs per innings. However, only 10 months after sustaining his injury, he was picked for the Australian test team, scored 170+ runs in his first match back, and has been averaging over 100 runs per innings ever since.

The obvious difference between these 2 case studies is that the physical requirements and tightly packed playing schedules in the NBA requires the knee to function significantly greater than what is required for test-match cricket. Nevertheless, I was Intrigued as to how one cohort of players can experience declines in performance after ACL recons, and one cohort of players can seemingly thrive, so I dug deeper and found these interesting results:

 MLS Soccer players: (3)

  • 77% players RTS around 10 months post-op
  • 10% ACL re-rupture rate (data unclear as to whether ipsilateral or contralateral)
  • Average career length after ACLR was 4 years
  • ACL surgery had no significant effect on player performance in post-op follow-up period


NFL players #1: (4)

  • 82% of 559 athletes returned to sport after ACL at average of 378 days (>12 months).
  • Career length following ACLR was only 1.6 years
  • ACLR led to significantly worse performances in the first 3 seasons upon RTS (if able to continue to play that long)

NFL players #2: (5)

  • 63% RTS around 10 months post-op.
  • Those who returned to sport played significantly more games prior to injury (av. 50) vs those that didn’t (av. 28).
  • Players who were drafted in the first 4 rounds were 12x more likely to RTS, rather those drafted in rounds 5-7.
  • Interesting conclusion that highly skilled and experienced athletes more likely to return to NFL than those that aren’t as skilled or have as much playing experience

NHL players: (6)

  • 97% players RTS at 7.8 months post-op.
  • ACL Re-rupture rate was only 2.5% (data unclear as to whether ipsilateral or contralateral).
  • Players who RTS, played another 4.5 years post-op.
  • Performance measures actually increased in ACL patients than age-matched player controls (mean goals and points per season, mean power play and strength goals per season, and mean shots and shooting percentage per season)

Take home messages

So there you have it, a bit of a mixed bag of successful and less successful return to sport performances across a number of different sporting codes.

Being an eternal optimist, I guess the moral of my story today is that: Despite what the research shows for NBA players and NFL players, ACL injury doesn’t have to mark the start of a slow and steady decay in player performance and an early retirement from the game. In fact, in some sports, an ACL injury to an athlete can be the catalyst to spark or revive a career. The time spent on the sidelines and working in rehab allows the player to work on weaknesses and improve strength, power, agility, balance and speed. This means the player can come back, fitter, stronger and faster than ever before.

And that’s simply a joy to watch!


Mick Hughes is a Physiotherapist with 7 years experience working in private practice sports physiotherapy clinics

Facebook Page: Mick Hughes Physiotherapy and Exercise Physiology
Twitter: @mickwhughes
Instagram: @mickhughesphysio
Linkedin: @mickhughesphysio


1.            Kester BS, Behery OA, Minhas SV, Hsu WK. Athletic performance and career longevity following anterior cruciate ligament reconstruction in the National Basketball Association. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA. 2016 Mar 12. PubMed PMID: 26971105. Epub 2016/03/14. Eng.

2.            Erickson BJ, Harris JD, Cvetanovich GL, Bach BR, Bush-Joseph CA, Abrams GD, et al. Performance and Return to Sport After Anterior Cruciate Ligament Reconstruction in Male Major League Soccer Players. Orthopaedic journal of sports medicine. 2013 Jul;1(2):2325967113497189. PubMed PMID: 26535238. Pubmed Central PMCID: PMC4555483. Epub 2013/07/01. eng.

3.            Mai HT, Alvarez AP, Freshman RD, Chun DS, Minhas SV, Patel AA, et al. The NFL Orthopaedic Surgery Outcomes Database (NO-SOD): The Effect of Common Orthopaedic Procedures on Football Careers. The American journal of sports medicine. 2016 Jun 16. PubMed PMID: 27311414. Epub 2016/06/18. Eng.

4.            Shah VM, Andrews JR, Fleisig GS, McMichael CS, Lemak LJ. Return to play after anterior cruciate ligament reconstruction in National Football League athletes. The American journal of sports medicine. 2010 Nov;38(11):2233-9. PubMed PMID: 20610771. Epub 2010/07/09. eng.

5.            Erickson BJ, Harris JD, Cole BJ, Frank RM, Fillingham YA, Ellman MB, et al. Performance and Return to Sport After Anterior Cruciate Ligament Reconstruction in National Hockey League Players. Orthopaedic journal of sports medicine. 2014 Sep;2(9):2325967114548831. PubMed PMID: 26535359. Pubmed Central PMCID: PMC4555634. Epub 2014/09/01. eng.

6.            Mehran N, Williams PN, Keller RA, Khalil LS, Lombardo SJ, Kharrazi FD. Athletic Performance at the National Basketball Association Combine After Anterior Cruciate Ligament Reconstruction. Orthopaedic journal of sports medicine. 2016 May;4(5):2325967116648083. PubMed PMID: 27294169. Pubmed Central PMCID: PMC4887878. Epub 2016/06/14. eng.

7.            Keller RA, Mehran N, Austin W, Marshall NE, Bastin K, Moutzouros V. Athletic Performance at the NFL Scouting Combine After Anterior Cruciate Ligament Reconstruction. The American journal of sports medicine. 2015 Dec;43(12):3022-6. PubMed PMID: 26493338. Epub 2015/10/24. eng.

8.            Ardern CL, Taylor NF, Feller JA, Webster KE. Fifty-five per cent return to competitive sport following anterior cruciate ligament reconstruction surgery: an updated systematic review and meta-analysis including aspects of physical functioning and contextual factors. British journal of sports medicine. 2014 Nov;48(21):1543-52. PubMed PMID: 25157180. Epub 2014/08/27. eng.

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