Trends in Return to Play After ACL Reconstruction in Professional American Football Players: A Systematic Review and...

Anterior cruciate ligament (ACL) injuries are frequent among professional American football players and often require surgical reconstruction followed by prolonged rehabilitation. Return to play (RTP) is a key outcome, yet substantial variability persists in reported RTP rates, timelines, level of return, and re-injury risk. This systematic review and meta-analysis aimed to compare RTP rates, time to RTP, return to preinjury performance, and ACL re-rupture rates in professional American football players across three time periods. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A systematic search of PubMed, Embase, and the Cochrane Library identified studies reporting RTP outcomes following ACL reconstruction (ACLR) in professional American football players, including selected high-level collegiate cohorts. Methodological quality was assessed using the Methodological Index for Nonrandomized Studies. Four outcomes-overall RTP rate, time to RTP, return to preinjury level, and ACL re-rupture rate-were extracted and meta-analyzed across three publication periods (before 2016, 2016-2020, and after 2021) to explore temporal trends. Twelve studies met the inclusion criteria, including 1,166 professional American football players. The pooled RTP rate was 73.1% (95% confidence interval [CI], 62.5-80.5). No significant differences were found across periods (p > 0.05), although RTP rates numerically decreased from 78.9 to 69.8%. Among players returning to sport, 93.6% (95% CI, 77.7-100) regained their preinjury performance level, with no significant temporal differences (p > 0.05). The pooled ACL re-rupture rate was 4.4% (95% CI, 2.0-7.3), with comparable rates across periods. Mean time to RTP was 340.1 days (95% CI, 313.1-367.1), with no temporal differences. More than 70% of professional American football players RTP after ACLR, and most returning athletes regain their preinjury performance level, with low re-rupture rates. Although more recent studies reported numerically lower return-to-play rates, these differences were not statistically significant. This systematic review and meta-analysis included levels III and IV evidence studies and was registered with PROSPERO (registration no. CRD420251022080).