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Infographic

Infographic. High rate of second ACL injury following ACL

reconstruction in male professional footballers: an updated
longitudinal analysis from 118 players in the UEFA Elite Club
Injury Study
Francesco Della Villa ‍ ‍,1 Martin Hägglund ‍ ‍,2,3 Stefano Della Villa,1 Jan Ekstrand ‍ ‍,2,4
Markus Waldén ‍ ‍2,4,5

ACL injury is a serious concern for the
professional football player.1 Studies
about second ACL injury rate and career
length after ACL reconstruction (ACLR)
in male professional football players are
scarce in the current literature.
We studied 118 top-­level professional
football players who sustained an ACL
injury and subsequent ACLR over the
course of 19 seasons as part of a substudy2
of the Elite Club Injury Study. The players
were tracked prospectively for second
ACL injuries as well for the career length
following ACL injury and related treat-
ment. Analysis of potential predictors of
subsequent ACL injury (to either knee)
was carried out using a stepwise Cox
after ACLR. For the index ACL injury, 45
players (38%) had sustained an isolated
ACL injury and 73 (62%) had at least one
associated injury. Regarding injury mech-
anism, 67 (57%) had sustained an index
noncontact ACL injury and 51 (43%) an
indirect or direct contact injury.2
Among the 118 included players,
there were 21 subsequent ACL injuries
after RTT (figure 1). The cumulative
second ACL injury incidence was 17.8%
(21/118), with 9.3% (11/118) ipsilateral
graft ruptures and 8.5% (10/118) contra-
lateral ruptures.2
Having sustained a noncontact or
isolated index ACL injury were indepen-
dent risk factors for a second ACL injury
ACL injury compared with 9 of the other
92 players (42.3% vs 9.8%, p<0.001).
None of the 32 players who sustained
a contact and non isolated ACL injury
sustained a second ACL injury.2
Time to RTT was not an indepen-
dent predictor of second ACL injury
in the multivariable analysis (HR:
0.87; p=0.446). However, none of
the 13 players who had their RTT
after 8 months sustained a second ACL
injury, whereas 10 of 49 players (20%)
with RTT within 6 months sustained a
second ACL injury.2
The median top-­ level career length
was 4.1 (IQR 4.0) years after ACLR

Regression model.
All players returned to training (RTT)
following ACLR and were evaluated at a
median follow-­up of 4.3 (IQR 4.6) years
with a sevenfold and threefold increased
risk, respectively.2 Combined, 11 of the
26 players who sustained a noncontact
isolated index ACL injury had a second
by copyright.
and 3.4 (IQR 3.9) years after RTT.
The proportion of players still playing
at the highest level 5 years after ACLR
was 60%.2

Figure 1 Infographic.

Della Villa F, et al. Br J Sports Med Month 2021 Vol 0 No 0    1


Infographic
Even in top-­level professional foot-
ballers, the second ACL injury rate was
18% after RTT, underlying the impor-
tance of continuous secondary preven-
tion, also after the formal return to play.
Moreover, suffering a pure non-­contact
index ACL injury (44%–66% in profes-
sional footballers3 4 or an isolated index
ACL injury are important risk factors,
with a sevenfold and threefold increase
in second ACL injury risk, respectively.
The athlete sustaining a noncontact
isolated ACL injury (high risk) should
be appropriately counselled and treated
carefully to potentially decrease the
second ACL injury risk. Finally, consid-
ering only players who quit top-­ level
football in the study period, top-­
level football career length was 3.4
years after formal RTT, suggesting an
important effect of ACL injury even at
top-­level European football.
To reduce the impact of ACL inju-
ries on football players’ career and
life, alongside the implementation of
primary reduction programmes, 5 an
optimisation of knowledge translation
on postoperative rehabilitation pathway
and continuous secondary prevention
are warranted.
1
Education and Research Department, Isokinetic
Medical Group, FIFA Medical Centre of Excellence,
Bologna, Italy
2
Football Research Group, Linköping University,
Linkoping, Sweden
2 Della Villa F, et al. Br J Sports Med Month 2021 Vol 0 No 0
3
Unit of Physiotherapy, Department of Health, Medicine
and Caring Sciences, Linköping University, Linkoping,
Sweden
4
Unit of Community Medicine, Department of Health,
Medicine and Caring Sciences, Linköping University,
Linkoping, Sweden
5 doi:10.1136/bjsports-2021-104508
Department of Orthopaedics, Hässleholm-­Kristianstad
Hospitals, Hässleholm, Sweden
Correspondence to Dr Francesco Della Villa,
Education and Research Department, Isokinetic Medical
Group, FIFA Medical Centre of Excellence, Bologna,
Italy; ​f.​dellavilla@​isokinetic.​com
Twitter Francesco Della Villa @fdellavilla, Martin
Hägglund @MHgglund, Jan Ekstrand @JanEkstrand
and Markus Waldén @MarkusWalden
Acknowledgements The authors would like to thank
Adam Virgile for the important work in making the
infographic.
Contributors FDV, MH, SDV, JE and MW were
responsible for the conception of the study. FDV wrote
the first draft of the paper that was critically revised by
MH, SDV, JE and MW. The final manuscript has been
approved by all authors. MW is the study guarantor.
Funding This study was funded by grants from the
Union of European Football Associations.
Competing interests None declared.
Patient consent for publication Not required.
Ethics approval The study protocols were approved
by the UEFA Football Development Division and the
UEFA Medical Committee.
Provenance and peer review Not commissioned;
externally peer reviewed.
© Author(s) (or their employer(s)) 2021. No commercial
re-­use. See rights and permissions. Published by BMJ.
Br J Sports Med: first published as 10.1136/bjsports-2021-104508 on 16 June 2021. Downloaded from http://bjsm.bmj.com/ on August 11, 2021 at Mozambique:BMJ-PG Sponsor. Protected
To cite Della Villa F, Hägglund M, Della Villa S, et al.
Br J Sports Med Epub ahead of print: [please include
Day Month Year]. doi:10.1136/bjsports-2021-104508
Accepted 7 June 2021
Br J Sports Med 2021;0:1–2.
ORCID iDs
Francesco Della Villa http://​orcid.​org/​0000-​0001-​9379-​
6666
Martin Hägglund http://​orcid.​org/​0000-​0002-​6883-​
1471
Jan Ekstrand http://​orcid.​org/​0000-​0002-​6092-​266X
Markus Waldén http://​orcid.​org/​0000-​0002-​6790-​4042
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