Abstract
Background:
Return-to-sport (RTS) decisions following anterior cruciate ligament reconstruction (ACLR) are critical to optimize long-term health-related outcomes. Beginning in 2015-2016, clinical practice guidelines, consensus statements, and high-impact publications advocated for longer timelines for RTS clearance. This shift was largely driven by evidence demonstrating that delaying RTS clearance to ≥9 months postoperatively significantly reduced the risk of second ACL injury. However, it remains unclear whether these evolving recommendations have led to measurable changes in clinical practice over time. Therefore, the purpose of this study was to evaluate whether the time from surgery to RTS clearance following ACLR has increased in the past decade.
Hypothesis:
We hypothesized that time to clearance progressively increased between 2015 and 2023, with an accelerated shift beginning in 2017 in response to newly published guidelines and research advocating for delayed RTS to reduce reinjury risk.
Methods:
We conducted a retrospective analysis of 1,662 patients aged 13–30 years who underwent primary ACLR between January 1, 2013, and December 31, 2023, at six facilities in the ACL Reconstruction Rehabilitation Outcomes Workgroup. Patients were included if their medical record documented a formal RTS clearance date or end-of-care date. Time to clearance was calculated as the interval between the date of surgery and date of documented RTS clearance. Temporal trends were examined using a generalized linear model, adjusting for age, sex, graft type, and surgical facility.
Results:
Demographics and surgical characteristics are summarized in Table 1. After adjusting for age (p=.009), sex (p=.004), graft type (p=.005), and surgical facility (p<.001), year of surgery remained a significant predictor of time to clearance (p<.001). Compared to 2015, patients who had surgery in 2020 [covariate adjusted mean difference (md)=.78mos., 95% CI [0.13, 1.43], p=.019], 2021 (md=.96mos., 95% CI [.32, 1.59], p=.003), 2022 (md=.70mos., 95% CI [.08, 1.33], p=.028), and 2023 (md=.80mos., 95% CI [0.09, 1.53], p=.027) experienced significantly longer times to clearance after ACLR (Figure 1).
Conclusion:
Year of surgery was a significant predictor of time to RTS clearance following ACLR even after adjusting for patient age, sex, graft type, and surgical facility. Patients who underwent surgery in 2020 or later experienced significantly longer times to clearance compared to those in 2015, suggesting a shift in clinical practice consistent with evolving evidence and guidelines published starting in 2016. These findings highlight a measurable change in postoperative decision-making and support continued efforts to align RTS timing with evidence-based strategies for reducing reinjury risk.
