Anterior Cruciate Ligament Reconstruction Practice Patterns by NFL and NCAA Football Team Physicians


      This study aimed to determine practice patterns for National Football League (NFL) and National Collegiate Athletic Association (NCAA) Division I football team orthopaedic surgeons regarding management of anterior cruciate ligament (ACL) tears in elite, young, and middle-aged recreational athletes.


      Two hundred sixty-seven NFL and NCAA Division I team orthopaedic surgeons were surveyed through an online survey. A 9-question survey assessed surgeon experience, graft choice, femoral tunnel drilling access, number of graft bundles, and rehabilitation after ACL reconstruction.


      One hundred thirty-seven team orthopaedic surgeons (51%) responded (mean experience 16.75 ± 8.7 years). Surgeons performed 82 ± 50 ACL reconstructions in 2012. One hundred eighteen surgeons (86%) would use bone–patellar tendon–bone (BPTB) autografts to treat their starting running backs. Ninety (67%) surgeons drill the femoral tunnel through an accessory anteromedial portal (26% through a transtibial portal). Only 1 surgeon prefers a double-bundle to a single-bundle reconstruction. Seventy-seven (55.8%) surgeons recommend waiting at least 6 months before return to sport, whereas 17 (12.3%) wait at least 9 months. No surgeon recommends waiting 12 months or more before return to sport. Eighty-eight (64%) surgeons do not recommend a brace for their starting running backs during sport once they return to play.


      BPTB is the most frequently used graft for ACL reconstruction by NFL and NCAA Division I team physicians in their elite-level running backs. Nearly all surgeons always use a single-bundle technique, and most do not recommend a brace on return to sport in running backs. Return to sport most commonly occurs at least 6 months postoperatively, with some surgeons requiring a normal examination and normal return-to-sport testing (single leg hop).
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        • Daly D.
        Another way to look at the NFL's $9 billion in revenue.
        The Washington Times, Washington, DC2011
      1. Sports Industry Overview. Plunkett Research Ltd., 2013. Available at: Accessed: March 26, 2014.

        • Bradley J.P.
        • Klimkiewicz J.J.
        • Rytel M.J.
        • Powell J.W.
        Anterior cruciate ligament injuries in the National Football League: epidemiology and current treatment trends among team physicians.
        Arthroscopy. 2002; 18: 502-509
        • Dick R.
        • Ferrara M.S.
        • Agel J.
        • et al.
        Descriptive epidemiology of collegiate men's football injuries: National Collegiate Athletic Association Injury Surveillance System, 1988-1989 through 2003-2004.
        J Athl Train. 2007; 42: 221-233
        • Dragoo J.L.
        • Braun H.J.
        • Durham J.L.
        • Chen M.R.
        • Harris A.H.
        Incidence and risk factors for injuries to the anterior cruciate ligament in National Collegiate Athletic Association football: Data from the 2004-2005 through 2008-2009 National Collegiate Athletic Association Injury Surveillance System.
        The Am J Sports Med. 2012; 40: 990-995
        • Crisco J.J.
        • Wilcox B.J.
        • Machan J.T.
        • et al.
        Magnitude of head impact exposures in individual collegiate football players.
        J Appl Biomech. 2012; 28: 174-183
        • Shah V.M.
        • Andrews J.R.
        • Fleisig G.S.
        • McMichael C.S.
        • Lemak L.J.
        Return to play after anterior cruciate ligament reconstruction in National Football League athletes.
        Am J Sports Med. 2010; 38: 2233-2239
        • Erickson B.J.
        • Harris J.D.
        • Cvetanovich G.L.
        • et al.
        Performance and return-to-sport after anterior cruciate ligament reconstruction in male major league soccer players.
        OJSM. 2013; : 1
        • Erickson B.J.
        • Harris J.D.
        • Fillingham Y.A.
        • et al.
        Performance and return to sport after anterior cruciate ligament reconstruction in X-Games skiers and snowboarders.
        OJSM. 2013; 1 (2325967113511196)
        • Harris J.D.
        • Erickson B.J.
        • Bach B.R.
        • et al.
        Return-to-sport and performance after anterior cruciate ligament reconstruction in National Basketball Association players.
        Sports Health. 2013; 5: 562-568
        • Prodromos C.C.
        • Han Y.
        • Rogowski J.
        • Joyce B.
        • Shi K.
        A meta-analysis of the incidence of anterior cruciate ligament tears as a function of gender, sport, and a knee injury-reduction regimen.
        Arthroscopy. 2007; 23 (e6): 1320-1325
        • Suomalainen P.
        • Jarvela T.
        • Paakkala A.
        • Kannus P.
        • Jarvinen M.
        Double-bundle versus single-bundle anterior cruciate ligament reconstruction: A prospective randomized study with 5-year results.
        Am J Sports Med. 2012; 40: 1511-1518
        • Hussein M.
        • van Eck C.F.
        • Cretnik A.
        • Dinevski D.
        • Fu F.H.
        Individualized anterior cruciate ligament surgery: A prospective study comparing anatomic single- and double-bundle reconstruction.
        Am J Sports Med. 2012; 40: 1781-1788
        • Beyaz S.
        • Ozkoc G.
        • Akpinar S.
        • Demir S.
        • Adam M.
        • Tuncay I.C.
        Comparison of tunnel expansion and isometric muscle strength after ACL reconstruction with single- or dual-bundle hamstring allograft: A prospective, randomized study.
        Acta Orthop Traumatol Turc. 2012; 46: 353-360
        • Spindler K.P.
        • Huston L.J.
        • Wright R.W.
        • et al.
        The prognosis and predictors of sports function and activity at minimum 6 years after anterior cruciate ligament reconstruction: a population cohort study.
        Am J Sports Med. 2011; 39: 348-359
        • Kraeutler M.J.
        • Bravman J.T.
        • McCarty E.C.
        Bone-patellar tendon-bone autograft versus allograft in outcomes of anterior cruciate ligament reconstruction: A meta-analysis of 5182 patients.
        Am J Sports Med. 2013; 41: 2439-2448
        • Lui P.
        • Zhang P.
        • Chan K.
        • Qin L.
        Biology and augmentation of tendon-bone insertion repair.
        J Orthop Surg Res. 2010; 5: 59
        • Maletis G.B.
        • Inacio M.C.
        • Reynolds S.
        • Desmond J.L.
        • Maletis M.M.
        • Funahashi T.T.
        Incidence of postoperative anterior cruciate ligament reconstruction infections: Graft choice makes a difference.
        Am J Sports Med. 2013; 41: 1780-1785
        • Chalmers P.N.
        • Mall N.A.
        • Cole B.J.
        • Verma N.N.
        • Bush-Joseph C.A.
        • Bach Jr., B.R.
        Anteromedial versus transtibial tunnel drilling in anterior cruciate ligament reconstructions: A systematic review.
        Arthroscopy. 2013; 29: 1235-1242
        • Franceschi F.
        • Papalia R.
        • Rizzello G.
        • Del Buono A.
        • Maffulli N.
        • Denaro V.
        Anteromedial portal versus transtibial drilling techniques in anterior cruciate ligament reconstruction: Any clinical relevance? A retrospective comparative study.
        Arthroscopy. 2013; 29: 1330-1337
        • Wang H.
        • Fleischli J.E.
        • Zheng N.N.
        Transtibial versus anteromedial portal technique in single-bundle anterior cruciate ligament reconstruction: Outcomes of knee joint kinematics during walking.
        Am J Sports Med. 2013; 41: 1847-1856
        • Barker J.U.
        • Drakos M.C.
        • Maak T.G.
        • Warren R.F.
        • Williams III, R.J.
        • Allen A.A.
        Effect of graft selection on the incidence of postoperative infection in anterior cruciate ligament reconstruction.
        Am J Sports Med. 2010; 38: 281-286
        • Boszotta H.
        Arthroscopic anterior cruciate ligament reconstruction using a patellar tendon graft in press-fit technique: Surgical technique and follow-up.
        Arthroscopy. 1997; 13: 332-339
        • Hospodar S.J.
        • Miller M.D.
        Controversies in ACL reconstruction: Bone-patellar tendon-bone anterior cruciate ligament reconstruction remains the gold standard.
        Sports Med Arthros Rev. 2009; 17: 242-246
        • Mayr H.O.
        • Stueken P.
        • Munch E.O.
        • et al.
        Brace or no-brace after ACL graft? Four-year results of a prospective clinical trial.
        Knee Surg Sports Traumatol. June 27, 2013; ([Epub ahead of print])
        • Chechik O.
        • Amar E.
        • Khashan M.
        • Lador R.
        • Eyal G.
        • Gold A.
        An international survey on anterior cruciate ligament reconstruction practices.
        Int Orthop. 2013; 37: 201-206
        • Curtin R.
        • Presser S.
        • Singer E.
        The effects of response rate changes on the index of consumer sentiment.
        Public Opin Q. 2000; 64: 413-428
        • Keeter S.
        • Miller C.
        • Kohut A.
        • Groves R.M.
        • Presser S.
        Consequences of reducing nonresponse in a national telephone survey.
        Public Opin Q. 2000; 64: 125-148
        • Carey J.L.
        • Dunn W.R.
        • Dahm D.L.
        • Zeger S.L.
        • Spindler K.P.
        A systematic review of anterior cruciate ligament reconstruction with autograft compared with allograft.
        J Bone Joint Surg Am. 2009; 91: 2242-2250
        • Lewis P.B.
        • Parameswaran A.D.
        • Rue J.P.
        • Bach Jr., B.R.
        Systematic review of single-bundle anterior cruciate ligament reconstruction outcomes: A baseline assessment for consideration of double-bundle techniques.
        Am J Sports Med. 2008; 36: 2028-2036
        • Samuelsson K.
        • Andersson D.
        • Karlsson J.
        Treatment of anterior cruciate ligament injuries with special reference to graft type and surgical technique: An assessment of randomized controlled trials.
        Arthroscopy. 2009; 25: 1139-1174
        • Poolman R.W.
        • Abouali J.A.
        • Conter H.J.
        • Bhandari M.
        Overlapping systematic reviews of anterior cruciate ligament reconstruction comparing hamstring autograft with bone-patellar tendon-bone autograft: Why are they different?.
        J Bone Joint Surg Am. 2007; 89: 1542-1552
        • Spindler K.P.
        • Kuhn J.E.
        • Freedman K.B.
        • Matthews C.E.
        • Dittus R.S.
        • Harrell Jr., F.E.
        Anterior cruciate ligament reconstruction autograft choice: Bone-tendon-bone versus hamstring: Does it really matter? A systematic review.
        Am J Sports Med. 2004; 32: 1986-1995
        • Krych A.J.
        • Jackson J.D.
        • Hoskin T.L.
        • Dahm D.L.
        A meta-analysis of patellar tendon autograft versus patellar tendon allograft in anterior cruciate ligament reconstruction.
        Arthroscopy. 2008; 24: 292-298