AJSM - 2026-06-07 - Journal Article
Are There Sex Disparities in Return to Sport After Anterior Cruciate Ligament Reconstruction? A Systematic Review and Exploratory Meta-analysis.
Elliott DA, Gill SS, Gupte CM
Topics
Key Takeaway
Female athletes have 24-28% lower odds of returning to sport at 12 months (OR 0.76) and up to 24 months (OR 0.72) after ACLR compared to males, despite no significant difference in return to competition or preinjury activity level.
Summary Depth
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Summary
This PRISMA-compliant systematic review and exploratory random-effects meta-analysis compared RTS outcomes between sexes across 25 studies of primary ACLR. Female athletes had significantly lower odds of RTS at 12 months (OR 0.76, 95% CI 0.62–0.92) and at up to 24 months (OR 0.72, 95% CI 0.61–0.85). No significant sex-based differences were detected for RTS to competition or return to preinjury sport level, suggesting the disparity is time-dependent rather than absolute.
Key Limitation
Heterogeneity in RTS definitions across included studies—ranging from any sport participation to return to preinjury competition level—prevents definitive conclusions about which specific RTS milestone is most affected by sex.
Original Abstract
BACKGROUND
Sex disparities in return-to-sport (RTS) outcomes after anterior cruciate ligament reconstruction (ACLR) remain poorly reported. Female athletes may demonstrate higher rates of anterior cruciate ligament (ACL) injuries than male athletes yet exhibit lower RTS rates.
PURPOSE
To compare postoperative RTS outcomes between male and female patients after primary ACLR.
STUDY DESIGN
Systematic review; Level of evidence, 4.
METHODS
A systematic search of the PubMed, MEDLINE, Embase, Scopus, and Web of Science databases was conducted from database inception through September 2025, following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Studies directly comparing RTS outcomes between males and females after primary ACLR with ≥12 months of follow-up were included. Data were synthesized using an exploratory random-effects meta-analysis. Odds ratios with 95% confidence intervals were calculated for dichotomous outcomes, and mean differences for continuous variables.
RESULTS
In total, 25 studies including 7183 athletes (2892 females, 4291 males) met the inclusion criteria. Female athletes demonstrated significantly lower odds of RTS at 12 months (OR, 0.76; 95% CI, 0.62-0.92; P = .005) and up to and including 24 months (OR, 0.72; 95% CI, 0.61-0.85; P < .001). No significant sex-based differences were observed for RTS to competition or return to preinjury levels.
CONCLUSION
Female athletes are significantly less likely to RTS after ACLR during the critical midterm recovery period. These findings highlight the need for sex-specific rehabilitation and psychological support strategies to optimize RTS outcomes in female athletes.