THE DILEMMA IS IN THE DETAIL
Glossary:
AMIC – Autologous Matrix Induced Chondrogenesis,
BMS – Bone Marrow Stimulation,
BMAC – Bone Marrow Concentrate,
(M)ACI – (Matrix) Autologous Chondrocyte Implantation,
MSCs – Mesenchymal Stromal Cells,
OCA – Osteochondral Allograft,
OATS – Osteochondral Autologous Transfer,
PRP – Platelet Rich Plasma
2026 EDITION
One of the significant challenges clinicians encounter in the field of soccer/football when dealing with cartilage injuries is the decision-making process for the players. This article aims to elucidate a straightforward yet evidence-based approach to determining the parameters to be considered and ultimately deciding, taking into account the patient’s willingness to undergo the necessary treatment.
The article serves as a guideline to assist in making optimal decisions for the athlete, as we often encounter multiple options due to misconceptions regarding surgical treatment, particularly concerning the duration of rehabilitation required for a return to sports. Additionally, traditional methods are often perceived as providing faster recovery, without considering several other well-established facts that compromise the long-term results and potentially the athlete’s career.
Introduction
One of the most challenging practices in sports orthopaedics and sports medicine is to treat musculoskeletal conditions that require a prolonged rehabilitation and a delayed return to play. A key example is the professional athlete suffering from a cartilage injury or pathology.
As sports medicine physicians, we are frequently confronted with debilitating cartilage injuries in our athletic population. The predominant reasons are:
- Increased participation in popular sports.
- Availability of imaging techniques like MRI.
- Increased incidence of surgery in athletes (such as ACL reconstruction and meniscal repair).
- High index of suspicion towards the pathophysiology of cartilage injury in the athlete.
Clinical decision making
The athlete suffering from a cartilage lesion presents typically with pain, swelling, locking, catching or in a combination. Very often, this condition presents as a pseudo-instability and/or inability to move the articulation.
The etiology of the above symptoms is not always straightforward, but synovial inflammation caused by cartilage debris and inflammatory proteins are known to be key. Considering that cartilage is avascular and aneural, the presence of pain is a strong indicator of synovial inflammation and/or subchondral bone involvement. Additionally, mechanical symptoms (such as locking, catching, or pseudo-instability) are known to be linked with the intra-articular presentation of loose free bodies, cartilage flaps or exposed bone. The key to understanding why many athletes with MRI documented cartilage lesions are still able to engage in their sport, can be explained by the unique anatomical features of cartilage1-3. Current evidence shows that up to 14 % of athletes with cartilage lesions can present asymptomatic, even with full thickness lesions1-5.
Especially in identified sports such as ice-hockey, volleyball, football and basketball6-9, cartilage pathology can present as asymptomatic regardless of any loss of function or future surgical indication10.
THE IDEAL PATIENT AND TREATMENT TIMING
In a systematic review, published in 2016, younger patients (with shorter preoperative duration of symptoms and without previous surgical interventions) were shown to have a better prognosis and earlier return to play after surgical treatment. Compliance to rehabilitation protocols and smaller size cartilage defects are also known to be positive prognostic factors11.
Additionally, a systematic review in 2017 revealed that lesion size, athlete’s age and concomitant surgical procedures are important predictors to consider as well12. On top of that, previous surgery was shown to be the single most predictive factor for return to the same sports level, together with younger age, traumatic lesions and absence of previous surgery13.
A defect that is left untreated, or delayed (+1 year), or initially treated by means of bone marrow stimulation techniques, has shown the poorest of outcomes14-17.
Predictors of a successful outcome are:
- Young patients with traumatic injuries (<25 yr in athletes, <30 yr in recreational athletes)
- Absence of delay in diagnosis and treatment (Within a year after the symptoms)
- Absence of previous surgeries or injuries
- Smaller mall defects (<2 cm²).
INDICATIONS FOR SURGERY
One of the challenges that the physician faces when dealing with an athlete suffering from a cartilage defect, is to determine whether the symptoms are correlated to the lesion. Many different parameters can play a role in the symptomatic condition of the athlete. Although cartilage defects are aneural, it is the pathophysiological lesion pathway that leads to pain and/or swelling. Therefore, conservative treatment, including physical therapy, medications, supplements, and intraarticular injections (Corticosteroids, HA, orthobiologics) are the first line approach and can assist the physician in the differential diagnosis.
This does not account however for defects with mechanical symptoms such as locking or catching. They often require a direct referral towards surgery.
Indications for surgery can be summarized by loss of function and/or disability, concomitant pathology, failure of nonsurgical treatment including intra-articular injections and clinical and/or radiological deterioration.
The most important parameter for the athlete is shown to be return to play. Any surgical shared decision making, or treatment algorithm will focus on this determinant factor12. Consequently, the timing and surgical treatment type are key factors to consider. Athletes with minor symptoms can sometimes try to delay treatment due to contractual or seasonal combined factors. However, once their performance is affected, the symptoms become more apparent or mechanical symptoms arise, surgery is indicated.
EVIDENCE-BASED TREATMENT ALGORITHM
The challenge remains to follow a common treatment algorithm for cartilage lesions in the athlete. The specific athletic needs and the multifactorial parameters require an individually tailored approach.
Predictive factors such as lesion characteristics, age and bony involvement are shown to be directly linked with early return to play and delayed rehabilitation timing18,19,20.
CURRENT EVIDENCE
Small defects do well with BMS or OATS (if one plug)12,19 while AMIC and BMAC or One-Stage Chondrons and MSCs techniques are shown to improve outcome21-25.
Medium and large defects, (M)ACI and OATS or OCA provide longer durability and return to sport rates compared to BMS26-37.
When bone is involved OAT, OCA and (M)ACI (with Sandwich technique) yield better results .
Return to sport rate ranges:(different indications as per the defect size)11-12:
- OATS 89 – 93%,
- OCA 88%,
- ACI 82 – 84%,
- BMS 58 – 75%.
The above presented research evidence justifies the treatment algorithm on surgical techniques according to the size of cartilage lesion, bone involvement and age of the athlete, as illustrated in Figure 1.
LESSONS LEARNED FROM SPORTS ENVIRONMENT REALITY
Debridement
Arthroscopic debridement is known to be a symptom-relieving technique with low morbidity, relative fast rehabilitation and return to play, low-cost with the disadvantage of providing only a short-term solution.
Especially in grade 2 lesions, good results can be obtained by debridement of the unstable cartilage fragments while creating smooth and stable defect edges38. Cartilage lesion debridement in the knee is shown to present with improved KOOS scores along the German Cartilage Registry, except for bigger lesions and combined partial meniscectomy39.
The evidence on debridement indications are40:
- Partial thickness injury,
- Smaller lesions (2 to 3 cm²) in low demand individuals,
- Temporary solution during season competition
- Smaller lesions (2- 3 cm²) in late career athletes.
In a case series41 on professional NFL players, the majority were able to return to play after chondroplasty - debridement for articular cartilage defects.
In a systematic review on RTP in football players who were treated by different surgical techniques, the authors reported a 100% return to play, approximately two and a half months postoperatively with evidence of fibrocartilage defect fill-up. However, 26% of the athletes developed additional cartilage lesions at a mean time of 1.6 years postoperatively, although in three out of four cases, the defect was found in another location42,43.
Patients that were treated by a cartilage debridement, prior to a secondary ACI or Mosaicplasty procedure did not require the additional intervention in 27 % of cases44.
Arthroscopic cartilage debridement (chondroplasty) is still a widely popular procedure45-46 in sports surgery today ranging between 9 - 43%, with patellofemoral defects (49%) leading the indication as first line treatment47,48.
Orthobiologics
The role of Orthobiologics in the treatment of athletic cartilage injuries can be summarized as follows:
1. Proof of safety in the use for cartilage injury and osteoarthritis
Current evidence provides the confirmation of safety with PRP and BMAC treatment options. Both look to cause minimal adverse effects (comparable or less) to similar injection therapies. Minor local inflammatory reaction with pain swelling or local skin reaction and low percentage of infection, bleeding or needle breakage are presented49-53.
2. Clinical efficacy
Recent literature on intra-articular orthobiological injections presents with a reduction of symptoms without however any proof of tissue regeneration. These injections are considered symptom but not structure-modifying approaches. However, there is emerging evidence on the benefits of combining orthobiological treatments as adjunct to surgical cartilage repair54-57.
3. Efforts to provide evidence
Although, Orthobiological injections are still considered unproven therapies for symptom modification in focal cartilage injuries of the knee, they can provide symptomatic relief in diagnosed Knee OA although its regenerative potential remains doubtful58.
4. Non-Clinically driven decisions
In a survey among sports medicine physicians in the USA, orthobiological injections are used by a significant number of athlete doctors, with PRP being the most popular and OA being the predominant pathology to be treated. Additionally, reasons other than clinical efficacy (especially competitor utilization) were also identified as part of the decision making59.
Platelet Rich Plasma
The use of orthobiologics in athletes has increased substantially over the past decade. Among these modalities, platelet-rich plasma (PRP) has gained particular attention. PRP is an autologous concentration of platelets obtained from whole blood through centrifugation and contains supraphysiologic levels of growth factors and cytokines that have been shown to enhance angiogenesis and cellular proliferation60,61. Additionally, PRP modulates the inflammatory environment of injured knees by downregulating proinflammatory cytokines and inhibiting catabolic signalling pathways62.
Despite growing interest, the current evidence supporting the use of PRP in athletes in general, and in football players specifically, remains limited and methodologically heterogeneous. This heterogeneity is largely attributable to the small number of high-quality studies and the lack of standardized reporting regarding PRP preparation and composition, which significantly limits reproducibility and comparability across studies63,64.
Nevertheless, emerging data suggest that PRP may provide symptomatic and functional benefits in knee-related pathologies. Most available evidence on the knee focuses on osteoarthritis and meniscal disorders, with several studies reporting favourable outcomes following PRP treatment, including improvements in pain and functional scores65–70. In contrast, the evidence supporting the use of PRP for conservative treatment of focal chondral defects remains limited relative to that for osteoarthritis.
In summary, PRP represents a biologically plausible conservative treatment option for both focal and degenerative cartilage lesions, with a favourable safety profile69,71. However, conclusive evidence supporting its efficacy, particularly for cartilage defects, is still lacking. Standardized PRP protocols and well-designed, high-quality trials focusing on focal cartilage lesions are required to better define the role of PRP in preserving and repairing knee cartilage.
ONGOING DILEMMAS
Patient and lesion heterogenicity are commonly involved in the surgical decision-making process12.
Several biases from the surgeon’s perspective based on personal experience, familiarity with techniques and availability of technology need to be considered as well. Additionally, some remaining dilemma’s need to be tackled further:
Size matters
A 2cm² MFC defect in a 1.65 m tall football player requires a different approach compared to a 2 cm² defect in 2.00 m tall Handball player (even in the exact same anatomic location) (Figure 2).
Site matters
A 2cm² lesion in the medial trochlea compared to a 2 cm² defect in the lateral trochlea, can result in a different symptomatology and impact on performance (Figure 3).
Bone involvement matters
A cartilage defect in the lateral femoral condyle of the knee (LFC) for example with: a) no bone edema, b) with bone edema, no tidemark abnormality, c) tidemark with waive appearance, and d) subchondral cyst, needs to be addressed in different ways.
Previous surgery complicates the decision-making process
Such as post-meniscectomy cartilage lesions.
Concomitant pathology needs to be addressed
ACL insufficiency, Trochlear dysplasia with patellar instability, Complex Lateral Meniscal tear, Varus alignment of the knee.
Timing is key
Early career stage athlete, long standing duration of symptoms (more than a year), unrealistic RTP expectations.
Seasonal challenges – Player role in the team
Differences in seasonal timeline, athlete level and individual expectations.
All the above are daily examples of the challenges that a cartilage expert faces on a daily basis while dealing with athletes. Any surgical decision needs to be guided by scientific evidence and combined clinical expertise.
This shared decision-making process needs to remain centered towards the athlete – patient, while involving other stakeholders such as family members, agents, team officials etc. Realistic expectations need to be addressed after thorough expert evaluation together with provision of the scientific evidence as well as clinical experience and expertise.
Ultimately, any medical commitment to the athlete patient’s condition goes all the way back to the ancient Greek Hippocratic oath «Ωφελεέειν ή μη βλ“άπτειν» “First, do not harm”.
On that context, Aspetar Orthopaedic and Sports Medicine Hospital initiated discussions to lead the road for decision making for the treatment of symptomatic cartilage lesions in athletes.
The treatment of the symptomatic athlete with a cartilage defect is presented in the flowchart (Figure 4).
IS CONSENSUS THE FUTURE? THE ROLE OF ASPETAR IN THE INDIVIDUALIZED APPROACH IN FOOTBALL PLAYERS
Since evidence remains limited for the management of knee cartilage injuries in football players, Aspetar has played a critical role in bridging the gap between evidence and practice by partnering with key associations, such as the International Cartilage Regeneration and Joint Preservation Society (ICRS) and the International Federation of Association Football (FIFA), to advance athletes' health and the safe return to sports.
To achieve this task, a systematic review and meta-analysis by Andriolo et al72 was conducted to evaluate the clinical efficacy and return-to-sport outcomes of surgical interventions for knee cartilage injuries, including 409 professional and competitive players across 15 studies (86% men, 14% women). The analysis included a broad spectrum of cartilage procedures, including BMS, OATS, ACI, and matrix-assisted autologous chondrocyte transplantation.
Findings ratified that lesion size is the most significant determinant in surgical selection. Debridement was typically reserved for the small lesions (mean 1.1 cm²). At the same time, BMS, OCA, and matrix-assisted autologous chondrocyte transplantation were applied to small- to mid-sized defects (2.2–3.0 cm²), and ACI was used for the large lesions (mean 5.8 cm²). In terms of return to sports, debridement and scaffold-augmented BMS yielded the shortest return-to-sports times. Microfractures were the most frequently documented and were associated with rapid initial recovery (mean RTS of 4.6 months). However, clinical outcomes deteriorated at mid-term follow-up (beyond 2 years) compared with matrix-assisted autologous chondrocyte transplantation and OCA, which showed superior durability and a higher rate of return to pre-injury levels (93% vs. 52%) compared to microfractures in comparative data.
Current surgical decision-making in football often prioritizes a rapid return to sport, favoring less invasive techniques such as microfracture, which may not yield optimal long-term outcomes for joint health, set the ground for organizing, hosting, and conducting the first ICRS-FIFA-Aspetar consensus73 whose primary objective was to determine which surgical strategies best balance short-term functional recovery with long-term joint preservation in the high-demand environment of professional football.
The first part of the ICRS-FIFA-Aspetar Consensus was established to provide expert-based, patient-specific recommendations on the appropriateness of surgical versus non-surgical treatments for competitive football players. Using the RAND/UCLA Appropriateness Method, a panel of 17 voting experts evaluated 96 distinct clinical scenarios. These scenarios were categorized based on six critical variables: injury onset (traumatic vs. degenerative), lesion location (condyles/trochlea vs. patella), defect size (<2 cm² vs. ≥2 cm²), subchondral bone involvement, symptom severity (ranging from asymptomatic to inability to play), and player preference (prioritizing quick return vs. long-term durability).
The findings revealed that surgical intervention was considered clearly appropriate in only 32% of scenarios, clearly inappropriate in 21%, and uncertain in 47%. The primary reason for recommending surgery was the player’s symptom level, specifically the inability to play, which accounted for 75% of the appropriate surgical scenarios. Other factors increasing the appropriateness of surgery included larger lesion sizes (≥2 cm²), location in the condyles or trochlea, the presence of subchondral bone involvement, and a player’s expressed preference for long-term joint preservation over an immediate return to competition. Conversely, surgery was less frequently recommended for patellar lesions or smaller, asymptomatic defects.
The second part of the ICRS-FIFA-Aspetar Consensus is currently under review and has not yet been published. It aimed to assess the appropriateness of specific cartilage procedures in case-based scenarios and professional athletes' preferences in the decision-making process. Preliminary results indicate that experts favor minimal arthroscopic procedures, such as debridement or debridement with orthobiologics augmentation, in situations requiring a rapid return to sports. In contrast, regenerative techniques or allografts are preferred when aiming for long-term results. Surprisingly, BMS techniques were not favored in any scenario.
Surgical management should not be the default for all cartilage injuries in football. Instead, there is a necessity for a nuanced, individualized approach that weighs the lesion's clinical characteristics against the player’s functional limitations and career goals, emphasizing that conservative management remains a vital component of the treatment algorithm.
TAKE HOME MESSAGE
The treatment of cartilage lesions in the athlete remains a multi-factorial challenge despite a significant amount of new treatment options available.
An evidence-based history taking, clinical and radiological assessment and treatment algorithm allows the physician to indicate the correct and individualized athlete approach. Shared decision-making and realistic return to play protocols, tailored to the specific needs of the athlete are mandatory towards achieving the expected outcome. Taking into account all the aforementioned factors and incorporating the athlete’s perspective and requirements, a novel treatment algorithm should be proposed. Figures 5a and 5b illustrate the comprehensive considerations taken into account, and this is the current proposed pathway that we adhere to at Aspetar, based on the most up-to-date evidence and expert opinions (as per the ICRS – FIFA – Aspetar consensus).
Emmanouil Papakostas MD, FEBSM, FICRS
Orthopaedic Surgeon
Aspetar Orthopaedic and Sports Medicine Hospital
Doha, Qatar
Theodorakys Marín Fermín
Clínica Santa Sofía, El Cafetal
Caracas, Venezuela
Ashraf Hantouly MD, MSc
Division of Orthopaedic Surgery
McMaster University
Hamilton, Ontario, Canada
Contact: emmanouil.papakostas@aspetar.com
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