Determinants of return to performance and recovery time in elite alpine skiers after ACL surgery

Purpose Return to performance (RTPerf) after anterior cruciate ligament (ACL) surgery remains difficult to predict in elite alpine skiers, as general criteria may not fully apply. This study aimed to identify determinants and the time needed to achieve RTPerf at the same competitive level. Methods A prospective cohort of 71 elite alpine skiers (mean age: 23.6 ± 5.2 years; height: 173.0 ± 7.8 cm; weight: 72.0 ± 12.1 kg) who underwent ACL surgery was analysed. Demographic and contextual variables, including sex, age, world ranking and type of injury, were collected. Isokinetic knee muscle strength was assessed six months postsurgery. RTPerf (YES/NO) and time to return were evaluated 2 years postoperatively using the International Ski and Snowboard Federation points system. Associations with categorical and quantitative variables were assessed using χ 2 and t ‐ or Mann–Whitney U tests. Variables with p < 0.2 were included in multivariable logistic regression. Predictors of return time were analysed using Cox regression and receiving operating characteristic (ROC) curves. Statistical significance was set at p < 0.05. Results Seventy‐nine percent of skiers returned to preinjury performance within 2 years. Primary ACL injury (vs. revision) (odds ratio [OR]: 6.6; 95% confidence interval [CI]: 1.85–23.6; p = 0.004) and isolated injury (vs. complex) (OR: 5.35; 95% CI: 1.39–20.48; p = 0.014) were significant predictors. Average return time was 348 ± 51.6 days. Greater relative knee extensor strength was associated with earlier return. Limb symmetry in knee extension at 60°/s predicted return within 1 year, while the hamstring‐to‐quadriceps functional ratio at 90°/s predicted later return (area under the curve [AUC]: 0.78; p < 0.01). Conclusions Primary and isolated ACL injuries were linked to higher RTPerf rates, while greater knee extensor isokinetic strength was associated with shorter time to RTPerf in elite alpine skiers. Level of Evidence Level II.