Good morning, thank you very much for the invitation. Thank you AOSSM and SLAR directive. We will talk about return to SOCR after ACL reconstruction. So return to SOCR after ACL reconstruction is a challenging goal, considering that the actual rates of return are often lower than expected. There are many factors that influence whether an individual can successfully return to SOCR after surgery, including surgical and rehabilitation factors as well as social, psychological and demographic characteristics. Younger SOCR players in particular face a higher risk of recurrent ACL injuries. So determining when it's safe to return to SOCR and predicting a successful return remain a talent. The definition of return to SOCR is variable, with some considering any SOCR activity as a return and others emphasizing a return to pre-injury level. Studies have shown that while around 82% of patients return to some form of SOCR, only 63% return to their pre-injury level, and even fewer, 44% return to the competitive level. Return rates for younger players are higher, with 79% returning to their pre-injury level and 81% returning to the competitive level. Elite players tend to have the highest rates of return to pre-injury level, with 83%. Several factors influence the likelihood of returning to SOCR after ACL reconstruction, including gender, age, time between injury and surgery, graft type, psychological response, and motivation during rehabilitation. Younger age and being male are associated with higher return rates. The type of graft used in the surgery can also affect the return to sports outcomes. BTB has a higher return for pre-injury level compared with hamstrings. Elite performance level has a higher return than non-elite. A positive psychological response and high motivation during rehabilitation are linked to a successful return. When we compare only the best evidence, Level 1 and 2 studies between return to sport according to graft, BTB has a 7% higher rate than hamstrings, but there is a high heterogeneity between studies. Related with the psychological area, players may choose not to return to soccer due to various reasons. Fear of re-injury is a most cited reason, with 50% of players expressing this concern. Lack of trust in the knee and poor self-reported knee function are additional factors. Work or study commitments can also lead to players giving up soccer after returning. Assessing soccer performance after ACL reconstruction is crucial. Studies show that while most high-performance and professional players return to their pre-injury level, there are measurable decreases in performance statistics. Elite younger players often report being able to play at their pre-injury level after two years. About return to sport criteria, there are different domains. In this figure, the relative size of the footballs represent how frequently different classifications of return to sport criteria are reported in the published studies, being time the most commonly reported return to sport criteria. Return to sport criteria has changed according to development of new tools. 35 years ago, only time was used, but nowadays muscular strength, hop testing, clinical exam, patient reports, and performance-based criteria are used to decide when the player can return. Determining the right time for players to return to soccer is challenging. Animal studies suggest that graft maturation occurs over several months, with increased risk during the remodeling phase. Human studies show that the risk of graft tear is highest in the first two post-operative years, while the risk of contralateral ACL injury increases over time. Younger players are at significant risk of second ACL injuries, and rehabilitation programs and return to soccer criteria aim to address this risk but require further validation. Test batteries used to assess readiness for return have shown limited validity in reducing overall second ACL injury risk. In these cases, when evidence is not clear, consensus can help us to determine which can be the most important variables we should address in the return to sport process for a soccer player. This ISACOS consensus, in which 27 experts participated, showed that returning to soccer after ACL reconstruction should take into account a variety of factors that can influence the outcome. These are mainly preoperative, surgical, and post-operative variables. In preoperative factors, experts agree that addressing the range of motion deficit, the patient's prior high level of sports participation, and their understanding of the injury and willingness to participate in rehabilitation are important considerations when determining the readiness to return to soccer. About surgical considerations, treating associated injuries using autografts and incorporating a lateral extraticular tenodesis in specific cases have received a consensus among experts. These factors may be associated with an increased likelihood of successful return to sports, particular in active young athletes under 25 years old, individuals with hyperlaxity or high rotator laxity, and revision cases. According to post-operative factors, psychological readiness validated through different scales along with adequate physical preparation should be taken into account in the decision-making process. Experts advise against solely relying on the time since surgery when determining the readiness to return to soccer after ACL reconstruction, so an holistic approach considering this factor is essential. In conclusion, rates of return to soccer after ACL reconstruction are often lower than expected, and various factors influence the likelihood of successful return, being fear of re-injury as the most common reason players choose not to return to soccer. There are no validated guidelines for determining whether it's safe to return to soccer, nevertheless, return to sports criteria can provide feedback on rehabilitation progress, but their overall application in clinical practice is uncertain, so more studies are needed to have higher evidence about this topic. Thank you very much.

ACL reconstruction surgery

return to play

recurrent ACL injuries

surgical factors

rehabilitation factors