Occupational ACL Injuries Are Associated with Inferior Clinical Outcomes and Lower Return to Sport Rates: A Comparative Analysis of 301 Patients

André Guimarãe; Guilherme Paiva Marques; Guilherme Madeira; Manuel Oliveira; Gonçalo Martinho; Levi Reina Fernandes

DOI: 10.70885/hmsj.2026.02.004

Abstract

Background: Anterior cruciate ligament (ACL) injuries present a substantial socioeconomic burden. Although outcomes after ACL reconstruction are well-documented, the prognostic role of the injury context, particularly occupational injuries (OI), remains unclear. Emerging data suggest OI may lead to delayed intervention and poorer recovery trajectories.Purpose: This study compares outcomes and return to activity rates between patients sustaining ACL ruptures in occupational versus non-occupational settings (Non-OI).Methods: This retrospective longitudinal study analyzed 301 patients undergoing primary ACL reconstruction (2019–2024). Patients were classified into Occupational Injury (OI, n=110) or Non-Occupational Injury (Non-OI, n=191) based on Workers' Compensation status. Primary outcomes were Subjective Knee Value (SKV) and Return to Sport (RTS) rates at a minimum 1 year follow-up. Secondary outcomes were associated meniscal injuries, reoperation rate and graft rupture rate. Multivariable regression was performed to control for emerging confounders.Results: At mean follow‐up of 33.1 ± 14.8 months the OI group was older (mean 38.2 vs. 23.4 years; p<0.001) and had a longer surgical delay (3.7 vs. 1.5 months; p=0.007). The OI group demonstrated lower SKV (71.0 ± 1.8 vs. 81.8 ± 1.2; p<0.001) and lower RTS rates (48.8% vs. 78.6%; p<0.001). In multivariable analysis, occupational status was the only independent predictor of lower SKV ($\beta$:-9.7 (95% CI: -14.4 – -4.9; p < 0.001) as well as RTS (OR: 0.44 (95% CI: 0.21 – 0.92; p =0.029)).Conclusion: Occupational ACL injuries are associated with older age, delayed intervention, and demonstrate inferior subjective clinical outcomes and RTS rates. These findings underscore the negative prognostic impact of OI, highlighting the need to continue studying this specific population, with the aim of improving their clinical outcomes and bringing them closer to those observed in patients with non-occupational injuries.What this study adds: Occupational ACL injuries are associated with worse subjective clinical outcomes (SKV) and lower return to sport rates, regardless of re-rupture rates or surgical complications.How this study might affect research, practice or policy: It is essential to implement targeted management strategies, including early referral and personalized rehabilitation that addresses psychological barriers and work demands, aiming to optimize outcomes.Study Design: Retrospective longitudinal studyLevel of evidence: Level IIKeywords: Anterior cruciate ligament; Occupational injuries; Anterolateral ligament; Subjective knee function; Return to sporthttps://doi.org/10.70885/hmsj.2026.02.004

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