Safer and Cheaper

An Enhanced Milestone-Based Return to Play

Program After Anterior Cruciate Ligament Reconstruction
in Young Athletes Is Cost-Effective Compared
With Standard Time-Based Return to Play Criteria
Christopher J. DeFrancesco,* MD, Drake G. Lebrun,* MD, MPH,
Joseph T. Molony Jr,y PT, MS, SCS, CSCS, Madison R. Heath,* BS,
and Peter D. Fabricant,*z MD, MPH
Investigation performed at the Hospital for Special Surgery, New York, New York, USA

Background: Safe return to play (RTP) after anterior cruciate ligament (ACL) reconstruction is critical to patient satisfaction. Enhanced
rehabilitation after ACL reconstruction with appropriate objective criteria for RTP may reduce the risk of subsequent injury. The cost-
effectiveness of an enhanced RTP (eRTP) strategy relative to standard post-ACL reconstruction rehabilitation has not been investigated.
Purpose: To determine if an eRTP strategy after ACL reconstruction is cost-effective compared with standard rehabilitation.
Study Design: Economic and decision analysis.
Methods: A decision-analysis model was utilized to compare standard rehabilitation with an eRTP strategy, which includes addi-
tional neuromuscular retraining, advanced testing, and follow-up physician visits. Cost-effectiveness was evaluated from a payer
perspective. Costs of surgical procedures and rehabilitation protocols, risks of graft rupture and contralateral ACL injury, risk
reductions as a result of the eRTP strategy, and relevant health utilities were derived from the literature. An incremental cost-
effectiveness ratio of \$100,000/quality-adjusted life-year was used to determine cost-effectiveness. Sensitivity analyses were
performed on pertinent model parameters to assess their effect on base case conclusions. In the base case analysis, the
eRTP strategy cost was conservatively estimated to be $969 more than the standard rehabilitation protocol. Completion of the
eRTP strategy was considered to confer a 25% risk reduction for graft rupture in comparison with standard rehabilitation.
Results: The eRTP strategy was more cost-effective than standard rehabilitation alone. Based on 1-way threshold analyses, the
eRTP strategy was cost-effective as long as its additional cost over standard rehabilitation was \$2092 or the eRTP strategy
decreased the incidence of contralateral ACL rupture by .13.8%.
Conclusion: The eRTP strategy in this study adds additional neuromuscular retraining and additional physician follow-up—as
well as advanced testing goals upon which RTP is contingent—to traditional physical therapy. Our data suggest that these addi-
tions are cost-effective, even assuming only modest associated decreases in ACL graft failure. This study also determined that
the only variable that had the potential to change the cost-effectiveness conclusion based on predetermined ranges was the addi-
tional cost of rehabilitation based on 1-way sensitivity analysis.
Clinical Relevance: This study provides evidence of cost-effectiveness for payers, supporting the use of enhanced RTP pro-
grams. The sensitivity analyses herein may be used to determine if any given RTP program going forward is cost-effective,
regardless of the exact components of the program.
Keywords: economic and decision analysis; ACL; knee; sports; utility

The number of anterior cruciate ligament (ACL) recon-
structions (ACLRs) has increased over recent decades,
with .100,000 cases performed annually in the United
States.13,15,18 ACL injury has been increasingly recognized
The American Journal of Sports Medicine
1–8
DOI: 10.1177/0363546520907914
Ó 2020 The Author(s)
in children and adolescents, with recent investigations
indicating that the number of ACLRs in that population
increased at almost 3 times the rate of orthopaedic surger-
ies in general over the time period 2004-2014.30
In addition to the physical morbidity of ACL injury and
the associated meniscal and chondral damage, ACL rup-
ture in this population is associated with high financial
morbidity. When managed with physical therapy (PT)
alone, the societal cost of 1 ACL rupture is estimated at
$88,538.19 Intervention with ACLR is associated with an

1
2 DeFrancesco et al
incremental cost savings of $50,417 per case.19 This sur-
gery restores joint kinematics12,27 and improves patient
quality of life,4,27 but patient satisfaction after surgery,
especially in younger patients, is strongly linked to the
patient’s ability to return to playing sports.24 The short-
to midterm financial burden after ACLR and subsequent
return to play (RTP) is dominated by 2 major costs: (1)
the cost of revision surgery in the approximately 8% of
patients who suffer graft failure and (2) the cost of ACLR
for contralateral ACL rupture in the approximately 12%
of patients who experience contralateral ACL injury.16,21
Recent research has shown that programs aimed at pri-
mary prevention of ACL rupture can be effective,29 reduc-
ing ACL rupture risk by up to 50%.32 This suggests that
targeted neuromuscular retraining and testing in post-
ACLR rehabilitation programs may be worthwhile in sec-
ondary prevention—that is, reducing the risk of graft rup-
ture and contralateral ACL injury after primary ACLR.
Additional measurement-based and functional testing dur-
ing rehabilitation may provide objective checkpoints for
RTP and thereby reduce the risk of repeat injury. Despite
the availability of these programs, there is no consensus
among surgeons for their use in rehabilitation or for crite-
ria for safe RTP after ACLR in young athletes5 and no
understanding of their cost-effectiveness.
Although an enhanced RTP (eRTP) strategy—including
a traditional PT regimen along with supplemental neuro-
muscular retraining, advanced testing, and additional
follow-up visits with the surgeon—can reduce the risk of
post-ACLR complications, financial limitations regarding its
application must be better understood. For example, it may
not be cost-effective to universally use expensive testing to
assess readiness for return to sports, but functional testing
with a physical therapist may be affordable and effective.
In this study, we used a decision tree model to investigate
the cost-effectiveness of an eRTP strategy. Specifically, we
aimed to define acceptable parameters between program
cost and the relative risk of repeat injury in a pediatric, ado-
lescent, and young adult population. By doing so, stakehold-
ers may better understand what additional training, testing,
and surgeon follow-up would be appropriate for inclusion in
future RTP programs while maintaining cost-effectiveness.
METHODS
Model Design
This was an economic evaluation study using a decision
tree model that was developed using TreeAge Pro 2019
(TreeAge Software, Inc). The 2 strategies being compared
z
Address correspondence to Peter D. Fabricant, MD, MPH, Department of Orthopedic Surgery, Hospital for Special Surgery, 535 East 70th St, New
York, NY 10021, USA.
*Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA.
y
Department of Rehabilitation Medicine, Hospital for Special Surgery, New York, New York, USA.
Submitted September 9, 2019; accepted January 2, 2020.
One or more of the authors has declared the following potential conflict of interest or source of funding: P.D.F. has received travel, education, and hos-
pitality payments from Smith & Nephew and Medical Device Business Services (DePuy). AOSSM checks author disclosures against the Open Payments
Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.
The American Journal of Sports Medicine
were standard post-ACLR rehabilitation and eRTP reha-
bilitation, which includes additional neuromuscular
retraining, advanced testing, and clinical visits; see Table
1 for a detailed example of an eRTP strategy. The decision
tree model was chosen over other economic models (eg,
Markov) to focus on the discrete time period during which
young athletes are engaged in sports. Additionally, a
similar decision tree model was used in previous cost-
effectiveness analyses of ACL injuries in young athletes.29
An initial decision node depicts the decision to use stan-
dard postoperative rehabilitation or the eRTP rehabilita-
tion strategy. Downstream from this decision node are
multiple chance nodes, which reflect the idea that each
patient can fall into 1 of 3 groups: (1) ipsilateral ACL
(graft) rupture requiring revision ACLR, (2) contralateral
ACL rupture requiring primary ACLR, or (3) no subse-
quent ACL injury. This tree is shown in Figure 1.
Direct medical costs were calculated by analyzing cost-
effectiveness from a payer perspective. Rather than model-
ing costs from a societal perspective, the payer perspective
was selected as a more relevant strategy for this study
because cost and reimbursement decisions by insurance
companies, Medicare, and other stakeholders are based on
a health care sector (ie, payer) perspective. Additionally,
assessing cost-effectiveness from a payer perspective pro-
vides a more conservative estimate of cost, as the cost of
a revision surgery to society would be higher than for the
payer. Therefore, the true cost-benefit of implementing
eRTP programs is, if anything, even greater than our con-
servative model concludes. Outcomes were defined in
quality-adjusted life-years (QALYs), which account for the
quality of life differences among unique health states.
According to guidance published by the Panel on Cost-
Effectiveness in Health and Medicine,22 the analysis was
carried out using an incremental cost-effectiveness ratio
(ICER) of \$100,000/QALY as the threshold for cost-
effectiveness. One-way threshold analyses and 2-way sensi-
tivity analyses were performed on pertinent model parame-
ters to measure their effect on base case conclusions.
Relevant assumptions in the model are that all patients
(1) are young (14-22 years old), otherwise healthy, cutting
and pivoting sport (eg, football, soccer, lacrosse, handball,
volleyball, basketball) athletes, who underwent an uncom-
plicated primary ACLR; (2) are appropriate candidates for
postoperative rehabilitation; and (3) desire to return to cut-
ting and pivoting sports.
Base case values, cost ranges for sensitivity analyses,
transition probabilities, and utility values were derived
from the literature. In circumstances in which costs and tran-
sition probabilities were not defined by the current literature,
these values were estimated with input from multiple
AJSM Vol. XX, No. X, XXXX ACLR eRTP Cost-Effectiveness 3

TABLE 1
Example of an Enhanced Return to Play Rehabilitation Strategy

Protocol Element Description and Examples

Neuromuscular retraining
Advanced testing
Quantitative tests
Qualitative tests
Clinical visits
Squats, single-leg squats, step downs, jumping and running/agility with feedback regarding
alignment and control
Occurs approximately 6 months after surgery
Patient-reported outcome measures, KT-1000, handheld dynamometer strength testing, isokinetic testing
(a variety of speeds are utilized), hop testing, agility tests
Single-leg squat, 8-inch forward step-down, lateral step-down, drop jump, Landing Error Scoring
System, video analysis
Visits approximately 2 weeks, 6 weeks, 3 months, 6 months, 9 months, and 1 year after surgery

experienced physical therapists from across the United
States with particular expertise in clinical care and costs
associated with ACLR rehabilitation.
Model Inputs
Costs. The base case cost of primary ACLR was set at
$8000 based on a previous cost-effectiveness study using
data from the Pediatric Health Information System data-
base.29 The cost of a revision ACLR was estimated to be
110% of that for a primary ACLR based on previous
research showing that costs in the 9 months starting
with ACLR were approximately 10% higher for patients
who had a previous ACLR.10
A full course of basic PT after ACLR was estimated to
cost $2200 based on previous work by Zhang et al34 and
De Carlo and Sell.3 Another previous study estimated the
cost of a follow-up visit with the surgeon at $381.2 Costs
of surgery and postoperative visits were modeled discretely
instead of as a global fee plus extra care, consistent with
previous studies.20,28 Furthermore, differences in postopera-
tive visit frequency between the 2 study groups would occur
outside a 90-day global period, and therefore modeling extra
visit charges as discrete costs rather than under a global fee
does not affect the marginal cost differences between treat-
ment strategy groups. Using these values, we estimated the
total cost of enhanced rehabilitation (including 6 follow-up
physician visits) to be $4486 in the base case.
Although the eRTP strategy was expected to include addi-
tional neuromuscular retraining, we expected the incremental
cost of the eRTP strategy over standard rehabilitation to stem
only from (1) advanced testing and (2) additional physician fol-
low-up. Advanced testing includes functional tests (hop test-
ing, agility testing, drop jump, etc) and measurement-based
tests, such as KT-1000 arthrometry and isokinetic testing.
This testing would be performed after at least 6 months of
rehabilitation, when the physical therapist and/or surgeon
thought the patient was ready. This advanced testing battery
would cost an additional $588 in the base case (Joseph T. Mol-
ony Jr, PT, MS, SCS, CSCS, personal communication and
internal billing data, 2019). Clinical follow-up in the eRTP
strategy was estimated to require 1 additional clinic visit
with the surgeon, making the eRTP strategy $969 more
expensive than standard rehabilitation in the base case. Table
2 further details all input values for the model.
Transition Probabilities. The baseline risks of ACL graft
rupture and contralateral ACL injury after ACLR in young
patients were set to 0.10 and 0.15, respectively, based on
previous literature.16,21 Completion of the eRTP strategy
was assumed to reduce the risk of contralateral ACL rup-
ture by a magnitude similar to that seen in primary preven-
tion of ACL injuries (50% risk reduction).32 The eRTP
strategy was also assumed to reduce the risk of ACL graft
rupture in the base case. A previous study found that the
risk of graft rupture after ACLR was 67% less likely in par-
ticipants who passed an eRTP functional testing battery.14
While this work suggests that an eRTP strategy may reduce
the risk of graft rupture after ACLR by 50% or more, few
studies have replicated these results, and their eRTP pro-
grams differ slightly from the strategy described in this
study. Therefore, this study opted to use a conservative
25% risk reduction to ensure results were not exaggerated.
Utilities. Utility, a measure of relative quality of life, was
determined for each of the 3 possible postsurgical outcomes
considered. Previous studies have indicated that common
pediatric orthopaedic knee injuries can be associated with
exceedingly low utility values, showing just how debilitating
such problems might be. Adjei et al1 described utility scores
as low as 0.15 in pediatric patients with osteochondritis dis-
secans lesions of the knee. In another study, adolescent
patients with recurrent patellofemoral dislocations after
treatment reported median utility scores of 0.20.23 In this
study, for patients with no subsequent injury, the expected
International Knee Documentation Committee (IKDC)
grade distribution was set according to a previous study
that provided utility values for each associated IKDC
grade,29 with utility values as low as 0.233 for IKDC grade
D knees. For patients who had graft rupture and underwent
revision ACLR, the subsequent distribution of IKDC grades
was defined according to work by Grassi et al.9 For the sub-
group of patients who had contralateral ACL rupture and
underwent bilateral ACLRs, 1 study has described the
Knee Injury and Osteoarthritis Outcome Score in similar
patients.6 Data from this paper were extrapolated to esti-
mate the weighted mean health state utility for these
patients using a published regression model.25 These values
are shown in Table 3.
Sensitivity Analyses
One- and 2-way sensitivity analyses, including tornado
diagrams, were utilized to determine thresholds at which
the eRTP strategy became more or less cost-effective.
4 DeFrancesco et al The American Journal of Sports Medicine

Figure 1. Decision tree model used to compare the cost-effectiveness of (1) standard post–anterior cruciate ligament reconstruc-
tion (ACLR) rehabilitation versus (2) enhanced return to play (eRTP) rehabilitation strategy. IKDC, International Knee Documenta-
tion Committee; RR, relative risk; RTP, return to play; s/p, status post.

RESULTS
Base Case Analysis
In the base case analysis, the eRTP strategy was more effec-
tive (0.764 QALYs vs 0.756 QALYs) than standard postoper-
ative rehabilitation and was less costly ($7388 vs $7687).
The eRTP strategy was therefore the dominant strategy in
our analysis given that it was both more effective and less
costly than standard postoperative rehabilitation.
Sensitivity Analysis
The eRTP strategy remained cost-effective when cost, util-
ity, and transition probabilities varied across predefined
AJSM Vol. XX, No. X, XXXX ACLR eRTP Cost-Effectiveness 5

TABLE 2
Input Values for the Cost-Effectiveness Modela

Values

Description Base Case Low High Supporting Studies

Costs
Surgical cost—primary ACLR $8000 $5000 $17,000 Swart et al29
Surgical cost—revision ACLR $8800 $5500 $18,700 Swart et al29
Herzog et al10
Cost of standard rehabilitation $4486 $2143 $9810
Cost of basic PT $2200 $1000 $6000 Zhang et al34
De Carlo and Sell3
Cost of clinical follow-up $381 3 6 = $2286 $1143 $3810 Armstrong et al2
(3-10 visits)
Additional eRTP program cost $969 $100 $2583
Additional clinical follow-up $381 3 1 = $381 $0 $1143 Armstrong et al2
(0-3 extra visits)
Functional testing $588 $100 $1440 Joseph T. Molony Jr, PT, MS, SCS, CSCS
(personal communication and internal
billing data)
Probabilities
Risk of ACL graft failure 0.10 0.05 0.20 Wiggins et al33
Risk of contralateral ACL rupture 0.15 0.10 0.25 Morgan et al21
Magnussen et al17
Webster et al31
Hettrich et al11
Faunø et al7
RR of injury with eRTP program
ACL graft failure 0.75 0.50 0.95 Webster and Hewett32
Contralateral ACL rupture 0.50 0.40 0.80 Sadigursky et al26

a
ACL, anterior cruciate ligament; ACLR, ACL reconstruction; eRTP; enhanced return to play; PT, physical therapy; RR, relative risk.

TABLE 3
Utility Values for the 3 Possible Postsurgical Outcomes Analyzed in This Studya

Percentage in Each IKDC Grade (Utility)

ACLR Study A (1.0) B (0.697) C (0.328) D (0.233) Weighted Mean Utility

29
Primary Swart et al 45.3 39.5 13.1 2.1 0.78
Revision Grassi et al9 27 51 18 4 0.69
Bilateral Faltstrom et al6, Odum25 N/A N/A N/A N/A 0.50

a
The 3 possible postsurgical outcomes analyzed are (1) only primary reconstruction needed, (2) revision surgery needed, and (3) contra-
lateral knee injured so bilateral reconstruction needed. ACLR, anterior cruciate ligament reconstruction; IKDC, International Knee Docu-
mentation Committee; N/A, not available.

ranges (tornado diagram) (Figure 2). Based on a 1-way DISCUSSION

threshold analysis, the eRTP strategy was cost-effective at
a willingness-to-pay threshold of $100,000/QALY as long
as the additional cost of further neuromuscular retraining,
advanced testing, and additional physician visits was
\$2092. Similarly, with costs held constant, the eRTP strat-
egy remained cost-effective as long as it decreased the inci-
dence of contralateral ACL injury by .13.8%. The eRTP
strategy also remained cost-effective across all considered
rates of graft rupture during 1-way sensitivity analysis.
This study determined the cost-effectiveness of an eRTP
program after ACLR in young patients. Such an approach
can reduce the risk of repeat injury by improving dynamic
strength and balance, neuromuscular control, functional
kinematics, and protective proprioception. Further,
patients participating in an eRTP strategy would be with-
held from sports until meeting advanced predefined objec-
tive criteria (rather than clearance for sports competition
6 DeFrancesco et al
Figure 2. Tornado diagram illustrating how variations in
costs, transition probabilities, and utility scores affect
whether the enhanced return to play (eRTP) strategy is
cost-effective. ACL, anterior cruciate ligament; ACLR, ACL
reconstruction; ICER, incremental cost-effectiveness ratio;
IKDC, International Knee Documentation Committee; RTP,
return to play.
based on low level factors such as time since surgery, full
pain-free range of motion, normal walking gait etc.) thus
reducing the overall exposure to those at highest risk for
rerupture. To that end, this study showed that subsequent
decreases in the risk of ACL graft rupture and contralat-
eral ACL rupture attributable to an eRTP program likely
would offset any associated extra costs expected with the
eRTP program, making it cost-effective for a young
sports-active patient population. In fact, in the base case,
the eRTP strategy dominated standard rehabilitation.
That is, despite the additional up-front expense associated
with the eRTP strategy, it was both more effective and less
costly because of lower risks of repeat injuries and their
associated costs. According to the model, any RTP program
that decreases the risk of graft failure by 25% could cost an
additional $2092 and still remain cost-effective. Even if
a more conservative willingness-to-pay threshold was
used (defined using an ICER of \$50,000 rather than
\$100,000), this margin would still be $1681.
Using 1-way sensitivity analyses, this study also deter-
mined that the only variable that had the potential to
change the cost-effectiveness conclusion based on predeter-
mined ranges was the additional cost of enhanced rehabili-
tation. This suggests that, even though there is uncertainty
in some variables used in the model, the only one that
makes a critical difference is the price of rehabilitation.
Finally, this study also showed how the acceptable margin
for increased cost increases with the effectiveness of the
eRTP strategy.
One of the greatest strengths of this study is that,
although the base case utilized a strategy with key compo-
nents (Table 2), the study findings can be referenced and
are externally generalizable for a young sports-active
patient population regardless of the specific training exer-
cises or tests used in any current or future RTP program.
Whatever additions to standard rehabilitation are made
to constitute an eRTP program, the cost-effectiveness of
The American Journal of Sports Medicine
Figure 3. Two-way sensitivity analysis of cost-effectiveness
for the enhanced return to play (eRTP) strategy compared
with standard rehabilitation, accounting for surgical costs
and the relative risk of postoperative graft rupture. The
enhanced area depicts scenarios in which the eRTP strategy
is more cost-effective, while the standard area depicts sce-
narios in which it is cost-prohibitive (and a standard time-
based RTP program would be favorable). The horizontal dot-
ted white line indicates the base case relative risk of graft
rupture with the eRTP strategy versus standard rehabilita-
tion alone (0.75). The vertical black dotted line indicates
the base case additional cost of the eRTP strategy relative
to standard rehabilitation alone ($969). An additional cost
of up to $2092 would still produce an eRTP that remained
cost-effective over a standard postoperative rehabilitation
program (star).
that program can be determined by the relationship shown
in Figure 3.
This study has several limitations, which are typical of
cost-effectiveness analyses. First, it is not possible to
account for all costs associated with ACLR, such as the
cost of time that a patient and his or her family invest dur-
ing rehabilitation. Such costs might be slightly higher for
the eRTP group, especially if their rehabilitation periods
are longer. Also, we considered health states as endpoints
and did not account for improved quality of life in the
interim between ACLR and any subsequent injury. The
effects of this are expected to be similar regardless of treat-
ment strategy and, therefore, would not be expected to influ-
ence conclusions from our analyses. We also assumed that
including advanced neuromuscular retraining in post-
ACLR PT might require protocol adjustments but would
not incur additional financial costs as it would not require
an increase in the cost of the physical therapy visit (the
activities within the visit would simply change). If addi-
tional neuromuscular retraining resulted in additional
costs, these would likely be small, as previous work has esti-
mated the cost of similar primary prevention programs at
\$25 per patient.29 Such small costs would not affect the
validity of the study conclusions.
Additionally, we did not account for the cost of extra
rounds of advanced testing batteries that would be indicated
AJSM Vol. XX, No. X, XXXX
when a patient had a failed first battery and required later
retesting before returning to sports. The proportion of
patients that would require such additional testing is not
known and may vary based on the tests included, the sur-
geons and therapists involved, and the timing of testing. At
any rate, we expect the proportion requiring extra testing
batteries to be \20% in practice. Moreover, the magnitude
of the cost-effectiveness margin detailed above ($2092) sug-
gests that 4 extra advanced testing batteries could be done
per patient while maintaining cost-effectiveness for the
eRTP strategy. In summary, the costs of additional advanced
testing for patients who failed their first battery is expected
to be small and should not meaningfully change the conclu-
sions drawn from the current study.
Included among the assumptions made to develop the
model used in this study was the concept that neuromuscu-
lar retraining would reduce the risk of subsequent ACL
injury in patients after ACLR to a magnitude comparable
with that seen with neuromuscular retraining programs
focused on primary prevention of ACL rupture. Whereas
some may expect the magnitude of protective effect con-
ferred by specialized therapy to be lower in patients who
have already had an ACL injury, research has actually
shown that patients with previous ACL injury tend to ben-
efit to a greater magnitude with such therapy.8 Understand-
ing this, we believe that our expectation of a 25% reduction
in graft failure with an advanced level of neuromuscular
retraining and testing is, if anything, conservative.
Another shortcoming of the model is that it considered
only 3 potential outcomes after the index ACLR: ipsilateral
graft failure, contralateral ACL injury, or no subsequent
ACL injury. We did not account for the small group of
patients who could perhaps suffer both graft failure and con-
tralateral ACL injury. Of course, there are many unique out-
comes after ACLR, including subsequent meniscal injury,
later development of osteoarthritis requiring arthroplasty,
and multiple recurrent ACL injuries. These more granular
and time-varying outcomes were not considered in order to
achieve a functional and coherent decision tree model that
is applicable to the majority of patients treated with ACLR.
Furthermore, the small proportion of patients who might
experience these rarer outcomes would be unlikely to shift
the model results; this study instead modeled the costs and
outcomes for the large majority of the population to more
appropriately model what would be experienced from the
payer perspective on an epidemiologic scale.
CONCLUSION
In conclusion, the current study shows that an eRTP strategy
after ACLR—including additional neuromuscular retraining,
advanced testing, and additional surgeon follow-up—is finan-
cially justifiable. Moreover, the acceptable marginal
increased cost associated with an eRTP strategy compared
with standard rehabilitation is large and further increases
with the magnitude of associated risk reductions. This study
provides evidence of cost-effectiveness for enhanced RTP pro-
grams, and the sensitivity analyses herein may be used to
determine if any given program going forward is cost-
ACLR eRTP Cost-Effectiveness 7
effective. As future research defines and optimizes RTP pro-
grams, the model in the current study may be used to assess
cost-effectiveness based on program cost and relative risk
reductions for graft failure and contralateral ACL rupture.
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