Second ACL injury risk

Second ACL injury risk

Colin Wong

Aim: To determine if objective criteria-based return to sport decisions are associated with less risk of a second ACL injury (either graft failure or contralateral ACL injury). Methods:

PRISMA guidelines were followed for the systematic review.

Three level 2b cohort studies and one 3b case-control study was used in this review.



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The primary finding was that there were non-significant associations between passing objective RTS criteria and risk of a second ACL injury. However, despite non-significant associations 12% of those who failed RTS testing suffered a graft injury compared to 5.9% of patients who passed.


Limitations/Things to consider:

1️⃣Limited studies used in this systematic review.

2️⃣Time from surgery to RTS varied in the studies. (ie. is there a role in biological tissue healing?

3️⃣Validity of the RTS criterias used (no gold standard and consensus in terms of RTS criterias!).

4️⃣Not enough psychological readiness criterias?


Clinical Implications:

As listed above, there were many limitations of this study and there is a definite need for more studies looking at RTS criterias. However, I like to always have a takeaway from every studies I read.


Despite no significant differences were found from this study, we can see from the raw data that there may be some associations between passing RTS criterias and re-injuries. What we do know is that the tests we currently are using may not be enough! In saying that, we need to do more.


I challenge you guys to think more broadly:

1️⃣Do we need more tests looking at the ability for the muscle to generate power?

2️⃣Do we need to look at psychological readiness more or kinesiophobia tests?

3️⃣Is there a biological tissue healing component?


I would say based on this study, we need to do more in terms of objective measures before we can return our patient back to sport.


Do you agree/disagree? What tests do you normally use that isn’t listed on the studies in this systematic review?


📚 The Association between Passing Return-to-Sport Criteria and Second Anterior Cruciate Ligament Injury Risk, a Systematic Review with Meta-Analysis    Losciale, et al. (2018)


If there are any reviews of our you have seen and would like to share them, please let me know and I’ll email them across.


About the authors:

Adrian and Colin are Physiotherapist from Sydney (Australia) and Vancouver (Canada) respectively. Educating and sharing research was a passion of their even since studying Physiotherapy at University together. They continued to develop and challenge their thoughts and judgments whilst working in Private practice sector in Sydney. 

Following Colin’s return his homeland of Canada. Adrian and Colin decided to kick-start an initiative to help new graduate Physiotherapists.
The Freshman Physio page HERE aims to Empower new graduate clinicians with an evolving way of reasoning and bridge the gap from University to practice. With the primary goal of “Creating Better Clinicians."


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