Female athletes were less likely than male athletes to return to any high-risk sport after anterior cruciate ligament reconstruction, or ACL surgery, according to an analysis of athletes aged 14 to 25. The difference was largest for this broad high-risk-sport measure: 72.0% of female athletes returned, compared with 81.5% of male athletes. The comparison was statistically significant, while smaller differences appeared for returning to the same sport and level or to any sport.
Across the full group, 45.5% returned to the same high-risk sport at their preinjury level within up to two years. The proportion rose to 76.5% for returning to any high-risk sport at any level and to 86.5% for returning to any sport, including lower-risk activities. The figures show how the definition of return changes the picture: returning to the exact previous level was the least common outcome.
What the analysis measured
The analysis used data from 500 patients aged 14 to 25 who were skeletally mature, had ACL-deficient knees and had taken part in jumping, pivoting or cutting sports before injury. The patients came from a pragmatic, multicenter randomized trial that compared hamstring-tendon autograft reconstruction alone with the same reconstruction plus lateral extra-articular tenodesis. This was a retrospective secondary analysis, so the investigators examined existing trial data rather than assigning patients to the sex groups being compared.
The investigators separated three outcomes. Return to performance meant getting back to the preoperative-level high-risk sport. Return to high-risk sport meant taking part in any high-risk sport at any level. Return to any sport included low-risk sports as well. The primary analysis included 53.2% female athletes, after four early graft ruptures and cases without the required predictor data were excluded.
The gap remained after adjustment
When the analysis accounted for confidence in the knee and postoperative knee stability, female athletes had 53% lower odds of returning to high-risk sport than male athletes. The odds ratio was 0.47, with a 95% confidence interval from 0.29 to 0.76 and P < 0.01. An odds ratio compares the odds of an outcome between groups; it does not mean that exactly 53% fewer athletes returned.
The sex difference was not statistically significant for returning to the same preinjury high-risk sport and level, where the rates were 44.5% for female athletes and 46.8% for male athletes. It was also not statistically significant for returning to any sport, where the rates were 84.5% and 88.8%, respectively. The reported P values were 0.61 for the first comparison and 0.15 for the second, compared with 0.01 for return to any high-risk sport.
Factors linked with returning
In the overall high-risk-sport model, surgery within three months of injury, greater confidence in the knee and a stable knee were associated with higher odds of returning. Their odds ratios were 2.39, 1.01 and 1.75, respectively. The reported 95% confidence intervals were 1.45 to 3.94 for surgery timing, 1.00 to 1.02 for knee confidence and 1.07 to 2.85 for knee stability.
Among female athletes, the same three factors were identified in a sensitivity model. Surgery within three months had an odds ratio of 2.96, a stable knee had an odds ratio of 2.58, and knee confidence had an odds ratio of 1.01. These results describe associations within the dataset. They do not show that operating earlier, changing confidence or producing a stable knee would by itself cause a return to high-risk sport.
For returning to the same preinjury sport and level, sex was not a significant predictor. Surgery within three months and knee confidence were significant predictors, with odds ratios of 1.89 and 1.02. For returning to any sport, female sex was also no longer significant after confidence and knee stability were included in the model; the adjusted odds ratio was 0.67, with a 95% confidence interval from 0.33 to 1.36 and P = 0.27. Earlier surgery, meniscal repair and knee confidence remained significant predictors for that outcome.
What the findings cannot answer
The findings apply to a narrow group: young, skeletally mature athletes who had participated in high-risk sports before ACL injury and underwent hamstring-tendon autograft reconstruction, with or without lateral extra-articular tenodesis. The authors say the results cannot be applied to everyone with an ACL injury. They also note that psychological readiness was not measured directly with a dedicated validated instrument, and that information about athletes’ intentions and goals was limited.
The prediction models also had poor fit. The authors considered fit acceptable only when the pseudo R-squared measure reached at least 0.20, but none of the models reached that threshold. That leaves substantial uncertainty about how well the measured factors could predict who returned to sport.
The study also left important context unresolved because return-to-sport information was limited and patients’ return intentions were uncertain. Since this was a retrospective secondary analysis, the findings support associations rather than causal claims.
Paper data and sources
Original title: Female Athletes Are Half as Likely to Return to High-Risk Sports Compared With Male Athletes After Anterior Cruciate Ligament Reconstruction: An Exploration of Return-to-Sport Outcomes Between Sexes
Authors: Marmura H, Firth A, Getgood A et al.
Journal/Repository: Sports health
Status: Peer-reviewed
First online: 2026-10-12
DOI: Not available
Original paper · Full text