Return to sport after ACL reconstruction in female athletes: a meta-analysis of return rates and time to return.

BACKGROUND

Female athletes face an elevated risk of ACL injuries and unique challenges in returning to sport, while sex-specific RTS outcomes remain insufficiently described. This study systematically evaluated RTS rates and time to RTS among female athletes following anterior cruciate ligament reconstruction.

METHODS

A systematic search of five databases was conducted through October 2025 to identify studies reporting RTS outcomes in female athletes post-ACLR. Pooled RTS proportions were calculated using a random-effects model with logit transformation. Subgroup and meta-regression analyses were performed to assess heterogeneity. Study quality was evaluated using the MINORS tool. Sensitivity and publication bias analyses were also undertaken.

RESULTS

Sixteen studies comprising 1,147 female athletes were included. The pooled RTS rate post-ACLR was 69% (95% CI 63-75%). RTS rates were higher among those returning to professional-level competition (78%) compared to general sports participation (63%) (p = 0.020). Meta-regression indicated an inverse association between RTS time and RTS rates (β = - 0.147, p = 0.046). The average time to RTS was 10.5 months.

CONCLUSION

This meta-analysis suggests that approximately 69% of female athletes return to sport after ACL reconstruction, with an average return time of 10.5 months, indicating that approximately one-third of female athletes may not return to sport, which is broadly consistent with prior literature. However, these pooled estimates should be interpreted with caution given substantial heterogeneity and potential publication bias. Higher RTS rates were observed among professional-level athletes, although this may reflect contextual rather than modifiable clinical factors. Meta-regression also suggested a negative association between RTS time and RTS rates, which should be interpreted cautiously as it may be influenced by residual confounding.