Evaluation of the Effectiveness of Current Return-to-Play Criteria After ACL Reconstruction in Preventing Reinjury: A Systematic Review and Meta-Analysis

Anterior cruciate ligament (ACL) rupture represents one of the most prevalent and clinically 
significant injuries affecting physically active populations, particularly adolescents and young 
adults engaged in pivoting and cutting sports. Although advances in surgical techniques, graft 
selection, and postoperative rehabilitation have substantially improved functional outcomes, 
the incidence of secondary ACL injury remains alarmingly high. Both ipsilateral graft failure 
and contralateral ACL rupture contribute to reinjury rates reported between 15% and 30%, with 
even greater vulnerability observed in younger athletes returning to high-demand sports. 
The decision-making process regarding return to sport (RTP) following ACL reconstruction 
(ACLR) constitutes a critical and multifactorial phase of recovery. Historically, RTP clearance 
was predominantly time-dependent, often based on arbitrary postoperative milestones. 
However, contemporary rehabilitation paradigms advocate for a criteria-based progression 
model, emphasizing objective functional recovery rather than elapsed time since surgery. 
Current RTP frameworks commonly incorporate quantitative measures such as limb symmetry 
index (LSI ≥ 90%), isokinetic strength testing, single-leg hop performance, neuromuscular 
control assessments, biomechanical movement analysis, and validated patient-reported 
outcome measures. Increasingly, psychological constructs—most notably assessed via the 
ACL–Return to Sport after Injury (ACL-RSI) scale—are recognized as integral components of 
readiness evaluation.