Knee Surg Sports Traumatol Arthrosc. 2026 Jun 4. doi: 10.1002/ksa.70470. Online ahead of print.
ABSTRACT
PURPOSE: We aimed to evaluate the direct and indirect costs of anterior cruciate ligament (ACL) injuries and assess their effects on career trajectories, market value, and potential associations with the age of the head coach at the time of injury in European professional football.
METHODS: A retrospective Transfermarkt.com cohort study was conducted on 211 professional male footballers who underwent ACL reconstruction. Primary outcomes related to demographics, career outcomes, market value, and coaching profiles were analysed. Data were analysed using SPSS 30, employing analysis of variance, Mann-Whitney U tests, Wilcoxon signed-rank tests, and independent-samples t-tests. Post-hoc power analysis (G Power) confirmed statistical power > 0.99 for the primary outcome.
RESULTS: The mean recovery period was 256.6 days (standard deviation [SD]: 91.9; median: 241; interquartile range [IQR]: 102; range: 109-674). ACL injuries were associated with a mean market value depreciation of approximately 2.5% (Value Drop Ratio [VDR]: 1.0; SD: 0.1; 95% confidence interval [CI]: 1.0159-1.033). Age was significantly associated with financial loss (F = 6.2, p < 0.001; Cohen’s f = 0.332); players ≥ 30 years showed a 5.5% decline compared to 0.9% for those aged ≤ 22 years. Post-injury, 16.0% transitioned to a lower-tier league and 7.3% to a higher-tier league. Players who transitioned to lower tiers had shorter mean recovery durations (221.6 vs. 264.1 days; p = 0.011). In an exploratory analysis (n = 38 coaches), teams coached by managers < 40 years had lower ACL injury rates among newly transferred players (p = 0.004). After Bonferroni correction (p < 0.007), only Scottish and Dutch subgroup findings remained significant.
CONCLUSION: ACL injuries in professional male footballers impose a substantial economic burden on clubs through market value depreciation, prolonged recovery and continued salary obligations. Older player age is the strongest determinant of financial impact, while a meaningful proportion of injured players transition to lower-tier leagues, with shorter recovery paradoxically associated with downward career mobility. These findings suggest that ACL injury constitutes a multidimensional risk encompassing medical, financial and career consequences.
LEVEL OF EVIDENCE: Level III, retrospective cohort study.
PMID:42241013 | DOI:10.1002/ksa.70470
