Returning to Performance After ACL Injury in Competitive Alpine Skiing: A Scoping Review and Evidence- and Expert-Informed Practice Recommendations

Abstract

Anterior cruciate ligament (ACL) injuries are common in competitive alpine skiing and pose significant challenges for return-to-performance (RTP) pathways. The aim of this scoping review was to map the current state of research, identify key factors for recovery, highlight knowledge gaps and synthesize evidence- and expert-informed practice recommendations for RTP after ACL injury. A search was conducted in four electronic databases using a set of pre-defined search terms. Studies that examined relevant aspects of RTP in competitive alpine skiers (not competitive para alpine skiers or recreational alpine skiers) who had suffered an ACL injury were included. Two assessors independently screened titles, abstracts and full-text sources to determine eligibility. Of the 622 double-removed hits from the literature search and the two studies added manually, 35 studies were included in this scoping review based on the eligibility criteria. The entities extracted included study characteristics such as general descriptors, injury patterns, surgical details, rehabilitation/training activities, testing/monitoring metrics, and key outcomes. The extracted data were then narratively/descriptively synthesized across several key domains. Most studies identified focus on epidemiology, secondary risks and early rehabilitation, with limited research on later recovery phases, such as returning to competition and returning to performance. There is also little evidence regarding the psychological and social factors that influence RTP. While further research is needed to fill these knowledge gaps, we propose a sport-specific, criteria-based and multi-domain RTP framework with stepwise progression on snow. Finally, we provide insights into practical implementation and present a comprehensive and jointly created RTP protocol for competitive alpine skiers to serve as a guideline for evidence- and expert-informed practice.

Keywords: athletes; knee injuries; rehabilitation; return to sport; snow sports.

FIGURE 1

Preferred reporting items for systematic reviews and meta‐analyses extension for scoping reviews (PRISMA‐ScR) flow diagram (n = the number of studies). ACL, Anterior cruciate ligament; RTP, Return‐to‐performance; RTS, Return‐to‐sport.