Soccer, better known as football outside of the United States, is one of the most popular sports in the world for spectators and participants alike. Soccer players are at relatively high risk for anterior cruciate ligament (ACL) tears, often when tackling. In elite European soccer, a high-level professional men’s team can expect one ACL injury every 2.5 seasons, and this increases to 1 every 1.4 seasons for a similar women’s team. In the United States, the most common knee injury for high school soccer athletes in both girls (1.17 per 10,000 athlete exposures [AEs]) and boys (0.50 per 10,000 AEs) was an ACL tear. There is a delayed return to play after ACL injury in these athletes, and the injury may be career ending.

Athletes trying to get back to soccer are usually treated with surgical reconstruction of the ACL, most often with bone–patellar tendon–bone autograft or hamstring autograft. A number of studies have looked at return to soccer after treatment for ACL injury. Among soccer players who underwent ACL reconstruction with iliotibial band autograft, 68% were still participating in soccer at a median follow-up of 4 years. Return to play occurred at a median of 7 months (range 5–24 months). In another study out of Sweden, only 28% of male and female soccer athletes were playing soccer 3 years out from ACL injury, although half of these athletes were treated nonoperatively (28). At 4-year follow-up, 25% of men and 7% of women were still playing soccer. However, 26% of males and 12% of females treated with ACL reconstruction were still playing soccer at 7-year follow-up. In high-level soccer athletes from Europe, 94% of athletes returned to play within 10 months, although there was no long-term follow-up in this study. While there was no difference in time of return to play between bone–patellar tendon–bone autograft and hamstring autograft, the rates of return to play were not reported by graft type.

In a study of soccer players undergoing ACL reconstruction in the United States, 72% returned to play at a mean of 12 months after surgery. Among those who returned to play, 85% got back to the same or higher level of competition as prior to injury. This declined over time to 36% of athletes still participating in soccer at average 7-year follow-up. Older athletes and females were less likely to return to play. There was a higher risk of future ACL injury on the contralateral lower extremity (9%) than the injured leg (3%). The risk of a future contralateral ACL tear was greater if the initial injury occurred on the nondominant leg (16%) than on the dominant leg (3.5%). Females were more likely to have future ACL injury on either limb (20%) than males (5.5%). When asked to assess why they were no longer playing soccer, the injury itself was more relevant for men (55%) than women (26%). Most of the patients in this series were treated with bone–patellar tendon–bone autograft (69%) or hamstring autograft (28%). Graft choice was not associated with return to play or risk of future injury in this cohort.

One of the factors affecting return to play may be the morbidity of ACL reconstruction. In a randomized, prospective trial, soccer athletes who had undergone ACL reconstruction with either a bone–patellar tendon–bone or hamstring autograft had less quadriceps and hamstrings strength and inferior hop performance and jump-landing strategy than controls. At the time of return to play (average 8 months after reconstruction), athletes reconstructed with hamstring autograft had greater quadriceps strength and better performance on the triple-hop, crossover-hop, and jump-landing tests than athletes reconstructed with bone–patellar tendon–bone autograft. This study did not include any information on whether these differences influenced performance, durability, or risk of future injury upon return to play.

Considering the high rate of future ACL injury in these athletes, soccer players who have undergone ACL reconstruction are excellent candidates for secondary ACL prevention programs. Fortunately, there is a growing body of evidence that ACL injury-prevention programs may be effective in soccer athletes. Females and athletes who injure the ACL in their nondominant lower extremity may be particularly likely to benefit from such an approach. Additional research is needed to better understand the role of secondary prevention in these athletes after ACL injury and reconstruction.

In summary, athletes can get back to soccer after ACL injury and reconstruction, although return to play declines over time. Return to play is lower in females and older athletes. More studies are needed to better understand outcomes from ACL reconstruction in athletes playing soccer. While reconstruction is usually performed using bone–patellar tendon–bone or hamstring autograft, the optimal graft has yet to be elucidated. The impact of other variables such as concomitant meniscus and cartilage injury and alignment on return to play as well as the implications of injury and return to soccer on knee joint health also have yet to be determined.