2025 ISAKOS Biennial Congress Paper
Outcomes of ACL Reconstruction With and Without MCL Injury in Professional Soccer and Rugby Players Are the Same Even With Concomitant MCL Surgery
Wahid Abdul, BSc(Hons), MBBCh, MRCS, FRCS(Tr&Orth), MSc(SEM), Exeter UNITED KINGDOM
Mary Jones, MSc, Grad. Dip. Phys., Richmond, Surrey UNITED KINGDOM
David Johannes Haslhofer, MD, Linz AUSTRIA
Arman Motesharei, PhD, London UNITED KINGDOM
Simon Ball, MA, FRCS(Tr&Orth), London, Middlesex UNITED KINGDOM
Andy Williams, MBBS, FRCS(Orth), FFSEM(UK), London UNITED KINGDOM
Fortius Clinic, London, UNITED KINGDOM
FDA Status Not Applicable
Summary
Outcomes of ACL Reconstruction With and Without MCL Injury in Professional Soccer and Rugby Players are The Same Even With Concomitant MCL Surgery
Abstract
Introduction
Medial collateral ligament (MCL) injuries are commonly sustained in conjunction with anterior cruciate ligament (ACL) ruptures in elite sport.
Aims:
To compare return to play (RTP) rate, time and career longevity of professional soccer and rugby players following isolated primary anterior cruciate ligament reconstruction (ACLR), ACLR with non-surgically and surgically treated MCL injuries.
Methods
Retrospective review of all professional soccer and rugby players undergoing isolated ACLR, ACLR with non-surgically managed MCL injuries, and combined ACL and MCL reconstructions undertaken by two sports knee surgeons was conducted between 2015 – 2022. Athletes aged over 16 years, with a minimum of two-year follow-up and with accessible Magnetic Resonance Imaging (MRI) scans and/or reports were included. Indications for MCL surgery were medial opening on valgus stress in extension and/or grade II/III valgus laxity at 30 degrees of flexion, positive dial and/or slocum tests for anteromedial rotatory instability, MCL avulsion with ‘Stener-like’ lesion or incarcerated within the knee joint. RTP was defined as first match appearance and all RTP and career longevity information was extracted from publicly available databases.
Results
230 athletes (238 knees) were included: 135 (56.7%) soccer and 103 (43.3%) rugby players with 225 (94.5%) males. 97 (40.8%) had isolated ACLR, 97 (40.8%) had ACLR with non-surgically managed MCL injuries and 44 (18.5%) underwent combined ACL and MCL reconstructions.
Overall RTP rate was 95.4% (96.3% in soccer, 94.2% in rugby); highest in isolated ACLR group compared to those with MCL treated either non-operatively or operatively (99% vs 94.8% vs 88.6% respectively) (p=0.06). Ten players failed to RTP (1 isolated ACLR, 4 ACLR + non-operative MCL and 5 ACLR + MCL reconstruction).
Overall mean RTP time was 12.0 (+/- 4.4) months post-surgery; 11.8 months (isolated ACLR), 12.2 months (ACLR + non-operative MCL) and 11.9 months (ACLR + MCL reconstruction) (p=0.88). Difference in RTP times between the ACL-MCL groups were approximately 12 days. Approximately 25-30 athletes had RTP times affected by Covid-19 sporting restrictions.
At 2 years post-surgery, 79.8% (n=190) were still playing; 88.8% (n=81) isolated ACLR, 78.4% (n=76) ACLR + non-operative MCL and 75% (n=33) ACLR + MCL reconstruction (p=0.55). Overall, 5-year still playing rate was 69% (n=98); 71% (n=44) isolated ACLR, 68.3% (n=43) ACLR + non-operative MCL and 55% (n=11) ACLR + MCL reconstruction (p=0.53). Mean follow up was 5.8 (+/-2.4) years with 102 players (42.9%) still playing at the time of the study.
Seven (2.9%) players sustained ACL re-rupture: 2 (2.1%) isolated ACLR, 4 (4.1%) ACLR + non-operative MCL and 1 (2.3%) ACLR + MCL reconstruction (p=0.67).
Conclusion
There were no significant differences in RTP rate, time, career longevity or re-rupture rates between isolated ACLR or ACLR and MCL treated with or without surgery. Patients with combined ACL and MCL injuries require careful clinical examination to ascertain whether the MCL injury requires surgical intervention. However, good RTP outcomes in professional soccer and rugby players that require MCL surgery can be obtained.
Level of evidence: IV
Keywords: Return To Play, Career Longevity, Soccer, Rugby, Anterior Cruciate Ligament, Medial Collateral Ligament