Sports Medicine (2021) 51:653–660

https://doi.org/10.1007/s40279-020-01404-7

REVIEW ARTICLE

Return to Sport and Reinjury Rates in Elite Female Athletes After

Anterior Cruciate Ligament Rupture
Kate E. Webster1 

Accepted: 28 November 2020 / Published online: 7 January 2021

© The Author(s), under exclusive licence to Springer Nature Switzerland AG part of Springer Nature 2021

Abstract
While there has been significant interest in the documentation of return to sport outcomes following anterior cruciate ligament
(ACL) injury, the elite level female athlete has not been a focus of this research. This is despite women being at increased
risk for ACL injury and considerable global growth in women participating in sport. Therefore, the focus of this review was
to examine the available literature regarding return to sport outcomes in elite level women with an ACL injury. The topics
of discussion focus on return to sport rates, timing and determinants of return to sport, longevity of play, return to sport
performance, and further ACL injury. Knee health in the longer term is also briefly discussed along with the limitations of
the existent literature.

Key Points  injury occurs in 1 out of every 29 female athletes compared

Most elite female athletes return to the same preinjury
sport participation after anterior cruciate ligament (ACL)
injury.
Data regarding performance on return to play after ACL
injury are severely lacking in elite female athletes.
The occurrence of a further ACL injury appears to be
relatively common and is estimated to occur in one in
four elite female athletes.
1 Introduction
It is well established that female athletes are at greater risk
of sustaining an anterior cruciate ligament (ACL) injury than
male athletes. Across all sports it has been shown that this
Electronic supplementary material  The online version of this
article (https​://doi.org/10.1007/s4027​9-020-01404​-7) contains
supplementary material, which is available to authorized users.
* Kate E. Webster
k.webster@latrobe.edu.au
1 ticipation or participation at the highest competitive level
School of Allied Health, Human Services and Sport, La
Trobe University, Kingsbury Drive, Bundoora, VIC 3086,
Australia
to 1 out of every 50 male athletes [1]. When level of sport is
considered, ACL injuries occur at approximately twice the
rate in both amateur and elite females compared to males
[1]. Therefore, female athletes are particularly susceptible
to this devastating injury at all levels of sport participation.
A goal for most athletes, especially elite level athletes,
who sustain an ACL injury is to be able to make a timely
return to their preinjury level of sport participation [2]. As
such, there has been much interest in documenting sport
related outcomes such as return to sport rates, the ability to
achieve preinjury levels of performance as well as reinjury
occurrence. However, the datasets that have been used to
determine return to sport outcomes at the elite level pre-
dominately consist of male athletes. This was highlighted
by Mohtadi and Chan [3] in a review of return to sport per-
formance, where it was noted that most of the available data
were only for elite male athletes. Therefore, data for elite
female athletes tend to be diluted or overlooked within the
literature on return to sport outcomes following ACL injury.
This is despite women being at increased risk for this dev-
astating injury along with  a considerable global growth in
women’s sport at all levels of participation. Therefore, the
purpose of this review was to evaluate return to sport out-
comes in elite level female athletes who have sustained an
ACL injury. Elite will be defined as professional sport par-
for the sport, including Division I of the National Collegiate
Athletic Association (NCAA). Return to sport rates, timing

Vol.:(0123456789)
 K. E. Webster
654

and determinants of return to sport, longevity of play, return
to sport performance and further injury will specifically be
the focus of discussion.
2 Return to Sport Rates and Timing
of Return
Seven studies have reported return to sport rates in elite level
female athletes and these are detailed in Table 1. Three team
sports (soccer, basketball and handball) have been evaluated
along with alpine skiing and the winter skiing and snow-
boarding X-game events. Most athletes were treated with
surgical reconstruction. Return rates vary between sports
and range from 54% in the earliest study on a subset of team
handball players who underwent surgical treatment [4] to
100% in international level alpine skiers [5]. Combining
return to sport data from Table 1 gives an overall return
rate of 82% (95% confidence interval 63–95%, Fig. 1) for
elite female athletes. This is 1% lower than the 83% return
rate that was previously reported in a systematic review
and meta-analysis which contained 24 studies on return to
sport after ACL reconstruction in elite athletes [6]. There-
fore, despite there being extremely limited data on return to
sport rates in elite level female athletes, from the data that
are available, rates are similar to that reported in elite male
athletes. This is different to the non-elite literature where
return to sport rates have typically been lower, by around
10%, in female compared to male athletes [2]. As the risk for
ACL injury varies between different sports, future work will
need to expand on these data and include a greater scope of
sports so that return rates can be determined for all sports in
which women participate.
The two studies that evaluated soccer at both senior elite
and collegiate levels showed similar return rates of 86% [7]
and 85% [8]. Both also reported data on the time it took to
be cleared for, or to return to, match play following ACL
reconstruction surgery. Women from the Swedish Women’s
First League [7] took an average of 253.6 days (approxi-
mately 8 months) to return to match play and women in the
NCAA Division I South-eastern Conference were cleared
for a return to unrestricted match play after an average of
6.1 months [8]. In basketball, the average time to return
to play in the Women’s National Basketball Association
(WNBA) after ACL reconstruction surgery was 11.8 months
[9]. Therefore, whilst the timing of return to play can be
influenced by other external factors, it would appear that
most elite level female athletes are able to return within the
first year following ACL reconstruction surgery.
3 Determinants of Return to Sport
Two studies have examined some determinants of return
to sport. Namdari et al. [9] reported that a return to play
in the WNBA was not influenced by age, the number of
preoperative seasons played, body mass index or player
position when 14 players who had returned to match play
were compared with 4 who did not. In collegiate soccer,
Howard et al. [8] reported that return to play was also not

Table 1  Details of studies which have reported return to sport rates after ACL rupture in elite female athletes
Study Country or competition Sport No. of ACL treatment RTS definition RTS rate
athletes

Myklebust et al. [4] Norway (upper 3 divi- Handball 50 37 surgical Return to play at same All 31/50 (62%)
sions) 13 non operative level Surgical: 20/37 (54%)
Non-operative: 11/13
(85%)
Namdari et al. [9] USA (WNBA) Basketball 18 ACLR Return to play in 14/18 (78%)
WNBA
Walden et al. [7] Sweden (Women’s First Soccer 15 14 ACLR Match participation ACLR 12/14 (86%)
League) 1 non operative within 12 months
Erickson et al. [10] Winter X-games Skiers and 12 ACLR Return to X-games 9/12 (75%)
snow-
boarders
Haida et al. [5] France (international Alpine ski 81 Not stated Return to international 81/81 (100%)
level) level competition
Howard et al. [8] USA (NCAA Divi- Soccer 78 ACLR Return to collegiate 66/78 (85%)
sion I) competition
Tramer et al. [11] USA (WNBA) Basketball 59 ACLR Return to play in 41/59 (70%)
WNBA

ACLR anterior cruciate ligament reconstruction, RTS return to sport, WNBA Women’s National Basketball Association, NCAA​ National Colle-
giate Athletic Association
Elite Female Athlete Outcomes After ACL Injury
Fig. 1  Proportional meta-analysis (random effects model) showed an
overall return to sport rate of 82% (95% CI 63–95%) in elite female
athletes following ACL injury. Raw values from Table  1 were ana-
lysed with StatsDirect software (V3.2; Altrincham, UK) to create this
forest plot. For Myklebust et al. [4] all female athletes were included.
As Namdari et al. [9] and Tramer et al. [11] both studied WNBA ath-
influenced by a variety of factors including player position,
the use of a knee injury prevention program or a variety
of ACL reconstruction surgical factors (i.e. graft source,
type, or fixation device or concomitant procedures). Play-
ers who were in their earlier years of college, and therefore
had more available seasons in which to make a return,
had significantly higher return rates. Being on a sporting
scholarship was also strongly associated with a return to
play in the female collegiate soccer players [8]. This may
be a surrogate measure which is indicative of greater ath-
letic skill, or motivation to perform well to maintain schol-
arship funding, and similar findings in respect to higher
return rates for athletes who are on scholarship have previ-
ously been reported in male American Football collegiate
athletes [12].
Successful rehabilitation is also a key factor in the
return to sport pathway. To better understand what psy-
chosocial features may be characteristic of resilience dur-
ing rehabilitation, 13 athletes from the Swedish Women’s
Elite Football League were interviewed after undergoing
ACL reconstruction for a first time ACL injury [13]. Three
core themes that helped players cope with the rehabilita-
tion were identified and included communication, self-
efficacy and goal getting. Communication entailed the
ability to have constructive interaction with significant
others both within the sporting context, such as coaches
and teammates, but also with family and friends outside of
sport. Self-efficacy was having a belief in the importance
655
letes, to avoid double counting of athletes, only data from Tramer
et  al. were included because their study time period (ACL injuries
sustained between 1997–2018) was greater and fully included the
time period of Namdari et  al. (1998–2008). NCAA​ National Colle-
giate Athletic Association, Div Division
and usefulness of your own actions. Finally, goal setting
involved the ability to set clear and reasonable goals for
both physical and psychological wellbeing and recovery.
Although no causal relationship has been established
between exhibiting such behaviours and actual return to
play, it is reasonable to consider such behaviours as having
an important modifying influence on return to play after
ACL injury.
4 Performance on Return to Sport
and Career Longevity
Data on performance after returning to sport following ACL
injury in elite female athletes are severely lacking and has only
been reported in three studies [5, 9, 11]. In the first of these,
13 different performance measures were analysed for two full
seasons in 14 women who had returned to WNBA match play
after ACL reconstruction surgery [9]. Only two of the perfor-
mance measures, shooting percentage and steals per 40 min of
game time, were significantly decreased when pre to post sur-
gery performance was compared. In addition, no performance
measure was significantly different between the players who
had an ACL injury and those who did not. However, in a more
recent study [11], in a larger group of 41 WNBA players who
had ACL reconstruction surgery, 10 out of 12 performance
measures were significantly decreased compared with the
year before injury. When compared to control athletes, those
 K. E. Webster
656
with ACL reconstruction had significantly decreased perfor-
mance regarding games played, games started, minutes played,
rebounds, assists and blocks per game in the first return to play
season; however, these differences resolved by the third year
of play. In the NBA, athletes have also been shown to have a
decrease in performance for the season after returning from
injury but recover to preinjury levels in seasons 2 and 3 [14,
15] and performance overall is not significantly different from
controls [16, 17].
In a study of 81 women alpine skiers, there were signifi-
cantly more podium finishes after ACL injury compared to
prior to injury (90 vs. 18 finishes respectively) [5]. Interna-
tional rankings also improved after surgery; however, it took
approximately 3.1 years after surgery for these best perfor-
mances to be achieved. Elite male skiers had similar findings.
Interestingly, all athletes (male and female) who sustained an
ACL injury had higher preinjury performance rankings com-
pared to those who had never had an ACL injury, which may
indicate that more aggressive skiers are at greater risk for ACL
injury. ACL injured skiers also had longer career lengths.
In studies of elite male athletes, it is usually acknowl-
edged that ACL injury is associated with a shorter career
length. This has been reported across several different sports
including soccer [18–20], basketball [21] and American
Football [22]. However, in the WNBA Gordon et al. [23]
reported that professional career length averaged 6.11 sea-
sons for players with an ACL reconstruction compared to 5.7
seasons for those without. However, it should be noted that
ACL injured players whose career ended were not included
in this study. For women entering the WNBA Combine
there was also no difference in career longevity for those
who entered with a prior history of ACL surgery (mean
3.8 years) compared to those with no ACL surgery (mean
3.4 years) [24]. In fact, those with a previous ACL injury
were 21% more likely to have an extended playing career
length. Career length was also not affected by having ACL
surgery combined with meniscal surgery. Rugg et al. [25]
also showed that NCAA Division I career length in athletes
with a prior ACL injury was not different from those with-
out across a variety of sports in both male and female ath-
letes. Roos et al. [26] noted that none of the 19 elite national
female soccer players they surveyed at 7 years after ACL
injury were still playing at the same level as before the
injury. This is perhaps not surprising, and unfortunately they
did not detail how many years the athletes had already been
playing at the elite level prior to injury or for how long they
were able to return to play after injury to fully determine
whether the ACL injury had an impact on career longevity.
There are no other individual or team sports which have
documented performance following ACL injury or career
longevity in a cohort of elite female athletes from a defined
sporting association or league. Future studies are clearly
needed in this area.
5 Further ACL Injury
A subsequent  ACL injury, whether it be a reinjury to the same
knee or a new injury to the contralateral ACL, is a devastat-
ing occurrence for an athlete who has resumed sport. There
are some data from six studies on the rates of further ACL
injury in elite female athletes (Table 2). At the professional
level, subsequent ACL injuries have been documented in both
basketball and soccer [9, 23, 27]. In the WNBA, graft rup-
tures were found to occur in 7%-10% of women within the
first two–three playing seasons after reconstruction surgery
[9, 11]. This rate increased to 16% when the entire career was
considered, and the rate of all further ACL injuries was 21%
[23]. This is similar to the 26% further ACL injury rate that
was seen in females participating in soccer as part of the Ger-
man National League [27].
In a recent study, professional athletes from a variety of
sports who were part of the Scientific Anterior Cruciate Liga-
ment Network International (SANTI) database and had under-
gone combined ACL and anterolateral ligament reconstruction
for a primary ACL injury were followed for a minimum of
two years [28]. Most patients (86%) returned to their sport but
rates of further ACL injury in the female athletes were high
at 36.4% (13.6% graft rupture and 22.7% contralateral ACL
injury) and significantly greater than the 13% rate reported in
elite male athletes from the same database.
Further ACL injury rates have also been shown to be
high in female collegiate athletes. One in every 5 Division
I NCAA basketball players who reported a prior history
of an ACL tear suffered from a further ACL injury (to the
same or a contralateral knee) during their college years [23].
Kamath et al. [29] stratified athletes who had sustained an
ACL injury before entering college (precollegiate group;
PC) or during college years (intracollegiate group; IC) and
found similarly high rates of repeat ACL reinjuries to the
graft or opposite knee in both the female (23%) and male
(21%) athletes participating in a variety of sports. In addi-
tion, of the 47 female athletes in the cohort, 16 (34%) had a
further knee operation of any type.
By combining available data from Table  2, the esti-
mated overall rate of further ACL injury is 26% for elite
female athletes (Fig. 2). This is substantial and higher than
the rates reported in men’s professional American Football
(18%) [30] and soccer (16%) [31]. Similar rates have been
reported in men’s Australian Rules Football (30% second
ACL injury rate) [32]. Caution must however be exercised
when interpreting injury rates in professional cohorts as the
total number of athletes is often small. However, from the
data that are available further ACL injury does appear to be
a significant issue that warrants reporting in all sports that
women participate in so that injury reduction strategies can
be advocated.
Elite Female Athlete Outcomes After ACL Injury 657

Table 2  Details and results of studies that have reported further ACL injuries in elite female athletes
Study Country or compe- Sport Follow-up period Rate graft rupture Rate contralateral Rate all sub-
tition and RTS ACL injury sequent  ACL
injuries

Faude et al. [27] German National Soccer All RTS, unknown 5/19 (26.3%)
League time since ACL
injury
Namdari et al. [9] USA (WNBA) Basketball 78% returned RTS only: 1/14
for min 2 full (7.1%)
seasons Full cohort: 1/18
(5.6%)
Gordon et al. [23] USA (WNBA and Basketball All RTS, unknown WNBA 3/19 WNBA 1/19 WNBA 4/19
NCAA Divi- time since ACL (15.8%) (5.3%) (21.1%)
sion 1) injury NCAA: 4/34 NCAA: 3/34 NCAA: 7/34
(11.8%) (8.8%) (20.6%)
Kamath et al. [29] USA (NCAA Divi- Mixed All RTS, stratified PC: 3/20 (15.0%) PC: 3/20 (15.0%) PC: 6/20 (30.0%)
sion 1) ACL injuries that IC: 0/27 (0%) IC: 5/27 (18.5%) IC: 5/27 (18.5%)
occurred precol-
lege (PC) and
intracollege (IC)
Rosenstiel et al. France (SANTI Mixed (basketball, 85.7% returned to 3/22 (13.6%) 5/22 (22.7%) 8/22 (36.4%)
[28] database) handball, skiing, preinjury level,
soccer) min 2 years
follow-up
Tramer et al. [11] USA (WNBA) Basketball 70% returned for RTS only: 4/41
min 3 seasons (9.8%)
Full cohort: 4/59
(6.8%)

RTS return to sport, ACL anterior cruciate ligament, WNBA Women’s National Basketball Association, NCAA​ National Collegiate Athletics
Association, PC pre-collegiate, IC intra-collegiate, SANTI Scientific Anterior Cruciate Ligament Network International

Fig. 2  Proportional meta-
analysis (random effects
model) showing an overall
subsequent (graft rupture or
contralateral ACL injury) ACL
injury rate of 26% (95% CI
19–33%) in elite female ath-
letes. Raw values from Table 2
were analysed with StatsDirect
software to create this forest
plot. For Kamath et al. [29] the
precollegiate and intracollegiate
groups were combined. WNBA
Women’s National Basketball
Association, NCAA​National
Collegiate Athletic Association,
ACL anterior cruciate ligament

6 Long Term Knee Health
A recent study by Prien et al. [33] highlighted the potential
for poor longer-term knee health in elite women athletes.
In a cross-sectional study, former German elite female
soccer players (n = 49) who had been retired for a mini-
mum of 2 years and were aged between 30 and 50 under-
went magnetic resonance imaging (MRI) and self-reported
symptoms of knee osteoarthritis. Results of the MRI anal-
ysis indicated that 51% of the former players fulfilled the
 K. E. Webster
658
criterion for knee osteoarthritis. Of the cohort, 17 athletes
had previously sustained combined ACL and meniscal
injuries which had been surgically treated. This subgroup
had the highest likelihood for both chondral and menis-
cal loss (odds ratios of 14.8 and 9.5 respectively when
compared to players without injury). These findings are
consistent with an earlier study in Sweden which showed
that 51% of female soccer players fulfilled the criterion for
radiographic knee osteoarthritis 12 years after sustaining
an ACL injury [34]. Thirty-two percent of the cohort had
played top level soccer (first or second league in Sweden).
The combined data from both these studies are therefore
consistent with the notion that an ACL injury, particularly
when combined with meniscal injury, may greatly increase
the risk for the development of knee osteoarthritis [35].
In young (20–26 years) elite male collegiate American
Football players participating in the NFL Combine, 24% of
those with a prior ACL injury were shown to already have
MRI evidence of osteoarthritic changes in the knee [36].
This demonstrates that degenerative change can occur in
the early years after injury. Unfortunately, there are no
comparable female data, but as female athletes tend to
sustain ACL injuries at an earlier age than their male coun-
terparts it would be reasonable to hypothesise that they
too may be susceptible to early osteoarthritic changes in
the knee. The impact of any such osteoarthritic changes
over time as well as the role of continued participation
in high impact activity after an ACL injury are currently
unknown.
7 Limitations and Future Work
The scope of the current review was to explore a range of
return to sport outcomes, including further injury, in elite
female athletes who had sustained an ACL injury. Ulti-
mately, this review has highlighted that there are limited
data on this topic for this group of athletes. It is acknowl-
edged that it is a challenge to audit and include elite level
athletes in research studies. However, sex specific informa-
tion is required to form a knowledge base so that outcomes
for women who have been injured through sport participa-
tion can be enhanced. Therefore, the assessment of such
outcomes in elite female athletes requires greater attention.
The current review is limited by the relatively modest
number of studies that include elite female athletes, and
the restricted number of sports that have been evaluated.
Despite these limitations, the current information can be
used as a platform to hopefully stimulate further discus-
sion and research investment in the outcomes of these
elite female athletes. As the intent was to take a broad
overview approach to the topic, it was felt that a review
format was most appropriate as this allowed for numerous
areas of discussion. To ensure that all key studies were
included, an electronic search of several databases (Med-
line, SPORTDiscus, Embase and Cochrane) was under-
taken from which 2527 individual studies were screened
for relevance (see Supplementary Table S1 for details of
terms used in the search).
8 Conclusion
This review has examined return to sport and further ACL
injury outcomes in elite female athletes who sustained an
ACL injury. An overview of return to sport rates showed
that most elite female athletes (82%) can return to their
same preinjury sport participation. Data regarding perfor-
mance on return to play are lacking, but the limited infor-
mation which is available indicates that performance is not
markedly impaired and career longevity is largely unaf-
fected after an ACL injury. However, the occurrence of a
further ACL injury appears to be relatively common after
returning to sport and is likely to occur in one in four elite
female athletes who have had reconstruction surgery. It is
hoped that this review will promote further investigation
of outcomes in elite female athletes who have sustained an
ACL injury so that return to sport expectations can be met,
performance goals achieved, and reinjury risk reduced.
Declarations 
Funding  No sources of funding were used to assist in the preparation
of this article.
Conflicts of interest  Kate Webster declares she has no conflicts of in-
terest relevant to the content of this review.
Availability of data and materials  All data are available within the
manuscript.
Ethics approval  Not applicable as a review paper.
Consent  Not applicable as a review paper.
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