Risco de Lesão do Ligamento Cruzado Anterior em Jogadores de Futebol

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High Risk of Further ACL Injury in a 10-Year
Follow-up Study of ACL-Reconstructed Soccer
Players in the Swedish National Knee Ligament
Registry
Alexander Sandon, M.D., Björn Engström, M.D., and Magnus Forssblad, M.D.
Purpose: To follow up on soccer players 10 years after a primary anterior cruciate ligament (ACL) reconstruction to find
out how many players returned to play soccer, what influenced their decision, and if there are any differences in addi-
tional ACL injuries (graft failure and/or contralateral ACL injury) between those who returned to play and those who did
not. Methods: The study cohort consists of 1661 soccer players from the Swedish National Knee Ligament Registry. A
questionnaire was sent to each player regarding their return to play and additional knee injuries that may have occurred
10 years after their primary ACL. The results are based on the 684 responders. Data such as age, sex, surgical procedural
data, associated injuries, patient-reported outcome measures, and additional knee surgeries were collected from the
registry. Results: In this study, 51% returned to play soccer. For those who did not return to play, the primary reason was
knee related (65.4% of the cases). The most common knee-related reasons for not returning were pain and/or instability
(50%; n ¼ 109), followed by fear of reinjury (32%; n ¼ 69). Players who return to soccer have a significantly higher risk of
additional ACL injury. Of the players who returned to play soccer, 28.7% (odds ratio [OR] 2.3, P < .001) had additional
ACL injury, 9.7% (OR 2.9, P < .001) had a graft failure and 20.6% (OR 2.1, P < .001) had a contralateral ACL injury.
Conclusions: Players that return to soccer have a significantly higher risk of sustaining further ACL injury. Only half of
the soccer players return to play after ACL reconstruction, and in two-thirds of those who did not return, the reason was
knee related. The high risk of sustaining additional knee injury is of serious concern to the player’s future knee health and
should be considered when deciding on a return to play. Level of Evidence: Level III retrospective case-control study.
Introduction
he primary indication for an anterior cruciate lig-
Tament (ACL) reconstruction (ACLR) is functional
instability. Due to the high physical demands on knee
stability in such a pivoting sport like soccer, ACLR is
often performed for those with the desire to return to
play.1
Since 2005, ACLRs performed in Sweden are regis-
tered in the Swedish National Knee Ligament Registry
Department of Molecular Medicine and Surgery, Stockholm
ma Research Center, Karolinska Institutet, Stockholm, Sweden
M.F.); and the Department of Orthopaedics, Västmanland
spital, Västerås, Sweden (A.S.).
rs report that they have no conflicts of interest in the authorship
tion of this article. Full ICJME author disclosure forms are
this article online, as supplementary material.
anuary 17, 2019; accepted May 23, 2019.
rrespondence to Alexander Sandon, M.D., Hornsbergs Strand 21,
holm, Sweden. E-mail: alexander.sandon@ki.se
y the Arthroscopy Association of North America
/1948/$36.00
.org/10.1016/j.arthro.2019.05.052
Arthroscopy: The Journal of Arthroscopic and Related
(SNKLR). Soccer is by far the most common etiology of
ACLR in the SNKLR; in both 2005 and 2006, 42% of
the recorded ACLRs were performed on soccer players.
In professional soccer players, Waldén et al.2 reported
a return to soccer rate at 94%. For a more general
soccer population, the return to soccer rate was 54% at
a mean follow-up of 3 years, and males returned to a
higher extent than females.3
The revision rate, at 2 years, has been reported at
3.3% in the MARS cohort.4 At the 5-year follow-up of
the SNKLR, 9.1% (contralateral 5.0%, revision 4.1%)
of the patients underwent a contralateral ACLR or ACL
revision surgery of the index knee. The corresponding
number for the group of 15- to 18-year-old female
soccer players was 22.0% (contralateral 10.2%, revi-
sion 11.8%). For the group of 15- to 18-year-old male
soccer players, the number was 9.8% (contralateral
4.4%, revision 5.4%).5
The present study aims to follow up on soccer players
10 years after primary ACLR to find out how many
returned to soccer, what influenced their decision, and
if there are any differences in further ACL injuries (graft
Surgery, Vol -, No - (Month), 2019: pp 1-7 1
mailto:alexander.sandon@ki.se
https://doi.org/10.1016/j.arthro.2019.05.052
Table 1. Characteristics of the Soccer Players Who
Participated in the Follow-up (Included) and the Players Who
Did Not Participate (Dropouts)
Variable Included Dropouts P value
Sex, %/n .01
Male 63/432 69/801
Female 37/252 31/360
Graft, %/n NS
Boneepatellar tendonebone 18/118 18/209
Hamstring 82/556 82/931
Age at surgery, mean � SD yr 25.9 � 8.6 24.4 � 7.9 .007
Cartilage injury, %/n .014
Yes 30/208 25/292
No 70/476 75/869
Medial meniscus injury, %/n NS
Yes 22/148 23/272
No 78/536 77/889
Lateral meniscus injury, %/n NS
Yes 21/145 23/261
No 79/539 77/900
NS, nonsignificant.
Table 2. Descriptive Data From the SNKLR Regarding Sex,
Graft, Associated Injuries, Further ACL Surgeries, and Age
Variable % n Mean SD
Sex
Male 63.2 432
Female 36.8 252
Graft
BPTB 17.5 118
Hamstring 82.5 556
ACL revisions 5 34
Contralateral ACL surgery 7.9 54
Meniscal injury 37.3 255
Medial 21.6 148
Lateral 21.2 145
Meniscal surgery 79.6 203
Medial 81.1 120
Lateral 75.2 109
Cartilage injury 30.4 208
Cartilage surgery 14.6 30
Meniscal and/or cartilage injury 53.7 367
Age at injury, yr 632 23.5 7.6
Age at surgery, yr 684 25.9 8.6
Time until surgery, mo 632 23.7 41.7
ACL, anterior cruciate ligament; SD, standard deviation; SNKLR,
Swedish National Knee Ligament Registry.
2 A. SANDON ET AL.
failure and/or contralateral ACL injury) between those
who returned to soccer and those who did not.
The hypothesis is that for the players who return to
soccer, there is a significantly higher risk of further ACL
injuries.
Method
Patient Selection
The present study is a 10-year follow-up on soccer
players selected from the SNKLR who underwent pri-
mary ACLR between January 1, 2005, and December
31, 2006, and had soccer as the etiology for their ACL
injury. The patients were followed up in 2016 and 2017
with written information about the present study and
asked to fill out a web-based study-specific question-
naire. Data such as age, sex, surgical procedural data,
associated injuries, patient-reported outcome measures
(PROMs), and further knee operations were collected.
Patient also reported outcome measures from presur-
gery with follow-ups after years 1, 2, 5, and 10. In the
SNKLR, 1845 patients matched the study criteria. Of
those 1845 patients, 1661 were still living in Sweden
and accessible for the study follow-up. The question-
naire was sent to the 1661 patient, and the results are
based on the 684 patients who chose to participate.
The SNKLR
The SNKLR was established in 2005 as a nationwide
database for prospective data collection of ACL surgeries.
The surgeon enters all surgical procedures on the knee,
graft type and diameter, fixation method, surgical tech-
nique, associated injuries, and any surgical treatments of
meniscal or cartilage injuries. Etiology and date of injury
are also registered. Patients are asked to fill out 2 PROMs:
the Knee injury and Osteoarthritis Outcome Score
(KOOS)6 and EuroQoL-5 Dimensions questionnaire
(EQ-5D).7 The SNKLR covers >90% of all ACLRs per-
formed in Sweden and has a 50% to 70% response rate
for the PROMs.8Although the response rate is not as high
as expected, a nonresponse analysis has been performed
showing that the registry is valid.9 The registry complies
with Swedish data security legislation. Participation in
the SNKLR is voluntary for patients and surgeons, andno
written consent is necessary for the use of national reg-
istries in Sweden.
Study-SpecificQuestionnaire
A web-based questionnaire was created for the pre-
sent study. All subjects received written information
about the study and how to fill out the questionnaire.
The Swedish personal identity number was used to
identify each subject and match subjects with data from
the SNKLR. The study-specific questionnaire contains
questions regarding whether the player returned to
soccer after the ACLR, reasons for not returning to
soccer, preinjury and postinjury levels of soccer, dura-
tion of return, and, last, reasons for retiring from the
sport. A section with questions focusing on new injuries
to and operations on the index knee and the contra-
lateral knee were also presented in the questionnaire.
All information obtained from the questionnaire are
presented here later.
Statistics
A statistician assigned to the SNKLR performed the
statistical analyses. All variables were summarized with
standard descriptive statistics such as mean,
Table 3. Preoperative and 1-, 2-, 5-, and 10-Year Follow-up KOOS and EQ-5D Scores of Soccer Players in the SNKLR Who
Underwent ACLR
Total PROMs
Preoperative 1 yr 2 yr 5 yr 10 yr
n (%)
KOOS 407 (59.5) 411 (60.1) 401 (58.6) 389 (56.9) 333 (48.7)
EQ
5D 353 (51.6) 408 (59.6) 398 (58.2) 373 (54.5) 326 (47,7)
VAS 351 (51.3) 353 (51.6) 383 (56) 374 (54.7) 326 (47.7)
Mean � SD
KOOS
Pain 79 � 16 87 � 14 87 � 14 88 � 14 89 � 13
Symptoms 71 � 17 81 � 16 81 � 17 83 � 16 83 � 16
ADL 88 � 15 94 � 10 93 � 11 94 � 11 94 � 11
Sports 48 � 26 68 � 25 69 � 26 72 � 25 73 � 25
QoL 36 � 17 63 � 23 66 � 24 68 � 23 69 � 23
EQ
5D 0.74 � 0.21 0.84 � 0.17 0.84 � 0.16 0.85 � 0.17 0.89 � 0.14
VAS 67 � 21 79 � 19 82 � 19 81 � 19 80 � 19
Preoperative vs 10-yr Scores* n (%)
Score, mean � SD
PPreoperative 10 yr Change
KOOS
Pain 209 (30) 79 � 15 90 � 12 11 � 16 <.001
Symptoms 209 (30) 70 � 16 84 � 15 14 � 20 <.001
ADL 209 (30) 88 � 15 95 � 9 7 � 15 <.001
Sports 209 (30) 47 � 25 73 � 24 26 � 29 <.001
QoL 209 (30) 36 � 15 70 � 21 34 � 22 <.001
EQ
5D 125 (18) 0.73 � 0.20 0.87 � 0.15 0.14 � 0.23 <.001
VAS 173 (25) 67 � 20 79 � 19 12 � 25 <.001
ACL, anterior cruciate ligament; ACLR, anterior cruciate ligament reconstruction; 5D, 5 Dimensions; EQ, EuroQoL; KOOS, Knee Injury and
Osteoarthritis Outcome Score; PROM, patient-reported outcome measure; QoL, quality of life; SD, standard deviation; SNKLR, Swedish National
Knee Ligament Registry; VAS, visual analog scale.
*Comparison of the preoperative and final scores for players who completed the PROMs at both time points (N ¼ 684).
SWEDISH SOCCER PLAYERS AFTER ACLR 3
frequencies, and standard deviation. Differences be-
tween return to soccer rates and rerupture rates were
tested with use of the c2 test. In this analysis, the re-
lationships between the variables were expressed as
odds ratios with a 95% confidence interval. Statistical
significance was determined at an a level of .05.
Ethics
The Regional Ethical Review Board in Stockholm,
Sweden, approved this study (DNR 2016/1194-31). All
subjects received written information about the study and
participation was voluntary. The data are presented at the
group level and are anonymized before statistical analysis
to secure the personal integrity of all participants.
Results
Dropout Analysis
The results are based on the 684 participants who
filled out the study-specific questionnaire. The dropout
analysis shows that females, patients with a cartilage
injury, and older patients were more likely to answer
the questionnaire. No other significant differences
could be found (Table 1).
The SNKLR
The soccer players in the SNKLR were predominantly
male. Hamstring grafts were used more frequently than
the boneepatellar tendonebone (BPTB) graft. In 10
cases, the graft type was not registered in the SNKLR. In
all cases, an autograft was used. Associated injuries in
the form of a meniscus rupture and/or cartilage damage
were present in just over half of the cases. Injuries to
the meniscus was surgically addressed during ACLR to a
higher extent than cartilage lesions. Most of the
meniscal surgeries were resections (73%), followed by
sutures (24%); in a few cases, a synthetic meniscal
repair was used (3%). ACLR on the contralateral knee
was more common than ACL revision to the index
knee. Descriptive data from the SNKLR are given in
Table 2.
Preoperatively, 79% of those who responded to the
PROMs completed both the KOOS and the EQ-5D, 17%
only responded to the KOOS, and 4% responded only
Table 4. Player-Reported Return to Soccer, Main Reason for
Not Returning or Quitting, Level Returned to, and Time
Played After Return to Soccer (N ¼ 684)
Questions % n
Did you return to soccer following your ACLR?
Yes 51 349
No 49 335
If No, was that primarily for reasons related
to the operated knee?
Yes 65.4 219
No 34.6 116
Return to soccer rates at different age intervals.
13 to 15 63.4 26
16 to 20 60.3 114
21 to 25 65.8 102
26 to 30 49.1 56
31 to 35 35.8 29
36 to 40 31.5 17
>40 10 5
To what level of soccer did you return to
compared to before the injury?
Same or higher 68.3 235
Lower 31.7 109
Do you still play soccer?
Yes 20.5 71
If No, main reason for quitting
Knee 37.9 131
Other 41.6 144
How many years did you play soccer after
you returned from the ACLR?
Mean 4.9 SD 3.3
ACLR, anterior cruciate ligament reconstruction.
4 A. SANDON ET AL.
to the EQ-5D. For the postoperative follow-ups, most
participants responded to both PROMs (91% to 98%),
and there was no meaningful difference in how many
responded to only 1 of the PROMs. There was an
improvement for all KOOS subscales from presurgery to
the 1-year follow-up (Table 3). The improvement was
maintained over time, and all KOOS subscales were
slightly higher at the 10-year follow-up compared with
the 1-year scores. The same was observed in the EQ-5D
and the EQ-VAS: the scores improved between pre-
surgery and the 1-year follow-up, and they remain
elevated and were higher at the 10-year follow-up than
at the 1-year follow-up. A comparison of the preoper-
ative and 10-year scores for the players who completed
the PROM at both time points show a significant
improvement at the final follow-up for all KOOS sub-
scales, EQ-5D, and EQ-VAS (Table 3). The loss to
follow-up was considerable for this analysis. However,
a dropout analysis did not show any significant differ-
ence in any of the PROMs between those who
completed both the presurgery and 10-year PROMs and
those who completed the PROM at one time point but
not the other.
Ten-Year Follow-up Questionnaire for Soccer
Players Who Underwent ACLR
When asked whether they returned to soccer after the
ACLR, 51% answered that they returned to soccer. For
49% who did not return to soccer, the primary reason
was knee related (65.4% of cases). The most common
knee-related reason for not returning was that the knee
did not allow it due to pain and/or instability (50%,
n ¼ 109) followed by fear of reinjury (32%, n ¼ 69).
Eleven players were told not to return to soccer by their
physician, and the remaining 30 who did not return
because of the ACL reconstructed knee left no
comment or had various other reasons. For the
remaining 34.6% who did not return to soccer pri-
marily due to reasons unrelated to the operated knee,
their reasons can be broadly summarized as changes in
career paths, family obligations, and other life priorities.
There was no significant difference in the return to
soccer rate between males and females or between
whether the patient received a BPTB or a hamstring
graft. Players in the younger age groups had a higher
return to play rate (P < .001). Further data from the
study-specific questionnaire are presented in Table 4.
The players were asked to input the division level in
the Swedish soccer league system in which they played
at the time of the injury. The results show that the
study population consists of players from the youth
leagues all the way up to the national team, with the
majority playing in the middle and lower divisions.
There is a significant difference in the return ratesfor
players at different levels (P < .001), with players at
higher levels being more likely to return to soccer
(Table 5). All the players in the national team and in the
Swedish top division returned to soccer.
When asked whether they had sustained any new
injuries to the index knee, 231 players (33.8%)
claimed that they had. Rerupture of the ACL graft in
the index knee were reported by 46 players (6.7%),
and 34 (5%) had ACL revision surgery. Any type of
new injuries to the contralateral knee were reported
by 208 players (29.8%), and 109 (15.9%) sustained
ACL injuries to the contralateral knee. Of those, 89
(13%) reported that they had ACLR surgery. In this
10-year follow-up, 21.8% (n ¼ 149) of the players had
either an ACL rerupture and/or contralateral ACL
injury.
Risk of Further ACL Injury, Graft Failure, and
Contralateral ACL Injury
There is a significantly higher risk of rerupture of the
ACL graft for players who return to soccer (P < .001;
Table 6). A significantly higher risk of ACL injuries to
the contralateral knee for the players who returned to
soccer after ACLR was also observed (P < .001). Of the
349 players who returned to soccer after the primary
ACLR, 100 (28.7%) had a further ACL injury (graft
failure and/or contralateral ACL injury). That is
Table 5. Level Played in the Swedish Soccer League System
at Time of Injury and Return to Soccer Rates (N ¼ 684)
Preinjury level n Returned to Soccer (%)
National team 1 100
Top division 7 100
Higher divisions 26 65.4
Middle divisions 179 61.5
Lower divisions 317 51.7
Recreational 67 25.4
Youth 87 37.9
SWEDISH SOCCER PLAYERS AFTER ACLR 5
significantly more than the new ACL injuries found in
the players who did not return to soccer (P < .001).
When looking at sex variances, we found that 62 of the
females (24.6%) and 87 of the males (20.1%) had
further ACL injuries; this difference was not statistically
significant. There was also no significant difference in
the risk of rerupture dependent on the type of graft:
BPTB (n ¼ 7, 5.9%) and hamstring (n ¼ 39, 7%).
Discussion
The principal finding in this study is that players who
return to soccer after an ACLR have a significantly
higher risk of further ACL ruptures compared with
players who do not return to soccer. Returning to a
pivoting sport like soccer is a known risk factor for
further ACL injuries in the literature.10-13 There is sig-
nificant evidence that younger patients return to sports
at a higher rate, which was observed in this
study.11,13,14 Several studies identified young age as a
risk factor for second ACL injuries, with injury rates in
the range of 20% to 35%.15-18 Webster et al19 ques-
tioned whether young age in indeed a risk factor or a
proxy for higher exposure to risk activity like returning
to soccer or other pivoting sports. The very high rate of
further ACL injuries in soccer players who return to
play in our study is a further indication in support of
that reasoning.
The rates of ACL revisions (5%) and contralateral
ACLR (7.9%) from the SNKLR in this study are higher
than those in the MARS cohort and in previous data
from the SNKLR.4,5 When including the player-
reported secondary ACL injuries, the difference from
previous data from the SNKLR is even greater, but this
study has a longer follow-up and involves a subgroup
with a known high risk of further ACL injuries. Our
Table 6. Differences in Number of Players Contracting Further A
Play After ACLR (N ¼ 684)
Returned to Soccer
Yes
n % n
Rerupture index knee 34 9.7 12
Contralateral ACL injury 72 20.6 37
New ACL injury total 100 28.7 49
ACL, anterior cruciate ligament; ACLR, anterior cruciate ligament recon
finding of twice as many contralateral ACL injuries as
graft reruptures is consistent with the literature.11,20
We found no significant sex difference in the risk of
further ACL injuries, which is consistent with a previ-
ous systematic review and a meta-analysis.21,22
For soccer players, an ACL rupture is a potential
career-ending injury even with surgery. For 109 of the
players (16%) in this study, knee function after ACLR
was not good enough for them to return to play. Just
over half of the soccer players (51%) who underwent
ACLR returned to soccer, considerably lower than the
return rate that was found in elite players, where
almost all players returned to soccer, but consistent
with other studies of more general soccer or sporting
populations, like ours.2,3,23-25 The decision to return to
play is multifactorial and does not depend only on knee
function26; 1 in 3 of those who did not return stated
that the main reason was not related to the knee. One
would expect some players to quit soccer regardless of
injuries because participation in organized sports de-
creases with time when life priorities and interests
change. The average time played after return to play
was 5 years; 1 in 5 still played 10 years after the primary
ACL, and a similar decline in soccer participation has
been reported in other long-term follow-up
studies.27-29 Previous studies have shown that fear of
reinjury is common and can prevent an athlete from
returning to preinjury sports participation; this finding
was substantiated in our study.30-32 Patients being
afraid to use their knee in strenuous situations is, of
course, undesirable. However, in the light of the high
risk of further ACL injuries on returning to soccer found
in this study and previous data indicating worse
outcome after ACL revisions,33,34 not returning to a
pivoting sport like soccer might be sensible for players
who want to avoid risking further knee injuries.
About 2 of 3 players in this study were males.
Although studies show that the relative risk of ACL
injury is higher in female soccer players, the actual
number of ACL injuries is higher in males. This
discrepancy is most likely due to differences in how
many participate and exposure time.35-38
We found that PROMs improved at the 1-year follow-
up after ACLR and were maintained at the 2-, 5-, and
10-year follow-ups. This is consistent with the 10-year
follow-up of ACLR patients recently published by the
CL Injuries Depending on Whether They Returned to Soccer
No
OR 95% CI P Value%
3.6 2.90 1.48 to 5.71 <.001
11 2.09 1.36 to 3.22 <.001
14.6 2.34 1.60 to 3.43 <.001
struction; CI, confidence interval; OR, odds ratio.
6 A. SANDON ET AL.
Multicenter Orthopaedic Outcomes Network (MOON)
knee group.39 Although there was a slight difference,
they did not include a 1-year follow-up and had a
midterm follow-up at 6 years instead of at 5 years as
used in the SNKLR.
Limitations
Although the study consists of a large cohort of soccer
players, not all patients completed the study-specific
questionnaire and this substantial loss to follow-up is a
serious limitation. This fatigue in filling out surveys is
also seen in the response rates to PROMs in the SNKLR.
Furthermore, the reliability of the patient-reported ACL
injuries is not known. There is a match in the number of
patient-reported ACL revisions and the revisions regis-
tered in the SNKLR. We could also match the contra-
lateral ACLR in the SNKLR with a corresponding answer
in the questionnaire. The accuracy of the diagnosis in
those conservatively treated and those with ACLR not
registered in the SNKLR is uncertain. This is, however, a
patient group with prior experience and knowledge of
the diagnosis and treatment of ACL injuries, and the
answers that could be checked were correct.
Conclusions
Players who return to soccer have a significantly
higher risk of sustaining further ACL injury. Only half
of the soccer players return to play after ACLR, and in
two-thirds of those who did not return, the reason was
knee related. The high risk of sustaining additional knee
injury is of serious concern to the player’s future knee
health and should be considered when deciding on a
return to play.
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	High Risk of Further ACL Injury in a 10-Year Follow-up Study of ACL-Reconstructed Soccer Players in the Swedish National Kn ...
	Introduction
	Method
	Patient Selection
	The SNKLR
	Study-Specific Questionnaire
	Statistics
	Ethics
	Results
	Dropout Analysis
	The SNKLR
	Ten-Year Follow-up Questionnaire for Soccer Players Who Underwent ACLR
	Risk of Further ACL Injury, Graft Failure, and Contralateral ACL Injury
	Discussion
	Limitations
	Conclusions
	References