Multi-modal return-to-play criteria after ACL reconstruction: systematic review
DOI:
https://doi.org/10.12775/QS.2026.54.70312Keywords
ACL reconstruction, return to play, criterion-based protocols, re-injuryAbstract
Background: Traditional 9-month return-to-play (RTP) clearance after anterior cruciate ligament reconstruction (ACLR) lacks objective functional testing. This systematic review evaluates multi-modal criterion-based RTP protocols versus chronological clearance in team sport athletes.
Methods: The study selection process followed PRISMA 2020 guidelines. Databases searched included PubMed, Scopus, and Web of Science (January 2015–March 2026). Eligible studies included systematic reviews, prospective cohorts, and randomized controlled trials involving ≥15 adult team-sport athletes after primary ACL reconstruction with ≥12 months follow-up. Risk of bias was assessed using AMSTAR-2 and ROBINS-I tools. Meta-analysis was performed using RevMan 5.4.1.
Results: 22 studies (n=3,247 athletes; 64% soccer). RTP to pre-injury level: 72% (95% CI 68-76%). Re-injury incidence: 18.3% (24 months). Multi-modal protocols (H/Q ratio ≥85%, hop LSI ≥85%, ACL-RSI ≥75) reduced re-injury 47% versus time-based clearance (RR=0.53, 95% CI 0.38-0.74, p<0.001).
Conclusions: Current evidence suggests that criterion-based RTP protocols may represent a more reliable clinical standard. Polish hospital implementation requires affordable alternatives: handheld dynamometry (2,500 PLN), smartphone applications, standardized clearance checklists. Three-phase framework proposed for resource-limited settings.
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Copyright (c) 2026 Weronika Ziółkowska, Wiktor Wisoky, Natalia Czapla, Ewelina Strużyńska, Joanna Łopińska, Marta Majchrzycka, Martyna Graczyk, Piotr Ignyś, Natalia Graczyk, Mateusz Majchrzak
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