Comparative return to play and performance outcomes following lower extremity injuries in European professional soccer: a systematic review and meta-analysis.

Abstract

Lower extremity injuries are common in professional soccer and can significantly impact return to play (RTP) and player performance. While individual injuries have been studied, comparative data across injury types remain limited. To systematically evaluate return to play rate (RTPR), return to play time (RTPT), and post-injury performance outcomes following lower extremity injuries in professional European soccer players. Systematic review and meta-analysis; Level of evidence, 4. A systematic search of PubMed and Embase was performed in accordance with PRISMA guidelines, covering database inception through May 2026 (initial search conducted January 2024; updated May 2026). Studies evaluating professional European soccer players with lower extremity injuries and reporting RTP outcomes were included. Primary outcomes were RTPR and RTPT. Secondary outcomes included post-injury performance metrics. A random-effects meta-analysis of proportions was performed for anterior cruciate ligament (ACL) injuries and Achilles tendon ruptures. Twenty-nine studies met inclusion criteria. ACL injuries demonstrated RTPR ranging from 80% to 95%, with RTPT of 215-267 days, and were associated with persistent declines in performance metrics, including minutes played and offensive production. Achilles tendon ruptures had RTPR of 70% to 78% and RTPT of 119-161 days, with significant short-term reductions in performance. Meniscus and medial collateral ligament (MCL) injuries demonstrated lower RTPR (approximately 70%) but shorter recovery timelines. Adductor and hamstring injuries were associated with the shortest RTPT (approximately 15-24 days) and minimal long-term performance decline. Meta-analysis demonstrated a pooled RTPR of 90.3% (95% CI, 81.2%-95.2%; I²=70.6%) for ACL injuries and 76.6% (95% CI, 69.2%-82.7%; I²=0%) for Achilles tendon ruptures. Among lower extremity injuries in professional European soccer, ACL injuries and Achilles tendon ruptures are associated with the greatest impact on RTP and player performance, whereas muscle injuries are associated with faster recovery and less sustained performance decline. As all included studies were observational, these findings represent associations rather than causal relationships and should be interpreted accordingly. These findings may assist clinicians and teams in prognostication and return-to-play decision-making.