Prevalence, risk factors, and outcomes of anterior cruciate ligament injuries in athletes. A comprehensive review

Nº de DOI: 10.34896/RSI.2025.36.24.002

AUTHORS

1. Juan Carlos Serrano Alvarez. General Practitioner. Attached to Private Clinics in Ecuador. Graduate of the University of Guayaquil. (Guayaquil-Ecuador). https://orcid.org/0009-0008-5584-0142
2. Esteban Andrés Mena Rueda. General Practitioner. Attached to Armed Forces Hospital No. 1. Graduate of the Pontifical Catholic University of Ecuador. (Quito-Ecuador). https://orcid.org/0009-0009-8000-9593
3. Erick Lauriel Romero Anchundia. General Practitioner. Attached to the Luis Moscoso Basic Hospital. Graduate of the University of Guayaquil. (Guayaquil-Ecuador). https://orcid.org/0009-0004-1081-4080
4. Luis Adrián Crespo Vélez. General Practitioner and Master’s Degree in Health Institution Management. Attached to the Quito No. 1 Specialty Hospital of the National Police. Graduate of the Catholic University of Cuenca. (Quito-Ecuador). https://orcid.org/0000-0002-5571-5914
5. Alan Leonel Quiñónez Plaza. General Practitioner. Attached to Private Clinics in Ecuador. Graduate of the State University of Guayaquil. (Guayaquil-Ecuador). https://orcid.org/0009-0001-2028-7438

ABSTRACT

This review aims to synthesize current evidence on these aspects, providing a detailed overview of the epidemiology, risk determinants, and prognostic factors associated with ACL injuries in athletes, thereby informing prevention strategies, clinical management, and future research directions in this critical area of sports health.

KEY WORDS

Anterior cruciate ligament (ACL) injuries, sports medicine, epidemiology, risk factors, biomechanics, neuromuscular control.

RESUMEN

Esta revisión tiene como objetivo sintetizar la evidencia actual sobre estos aspectos, proporcionando una visión detallada de la epidemiología, los determinantes de riesgo y los factores pronósticos asociados con las lesiones del ligamento cruzado anterior (LCA) en deportistas, con el fin de orientar las estrategias de prevención, el manejo clínico y las futuras líneas de investigación en esta área crítica de la salud deportiva.

PALABRAS CLAVE

Lesiones del ligamento cruzado anterior (LCA), medicina deportiva, epidemiología, factores de riesgo, biomecánica, control neuromuscular.

INTRODUCTION

Anterior cruciate ligament (ACL) injuries constitute a significant concern within the realm of sports medicine, owing to their high incidence among athletes across various competitive levels and disciplines. These injuries are notably prevalent in sports that demand rapid pivoting, cutting, jumping, and sudden deceleration, such as soccer, basketball, football, and skiing, with reported incidence rates varying considerably depending on sport type, athlete age, gender, and competition intensity. Epidemiological data indicate that ACL injuries are not only common but also show troubling trends of increasing prevalence in recent years, highlighting the growing impact of these injuries on athletic populations worldwide. Multiple intrinsic factors, including anatomical variations such as a narrow intercondylar notch or ligamentous laxity, physiological aspects like hormonal influences, and biomechanical and neuromuscular deficiencies, have been identified as contributors to heightened susceptibility. External factors such as training surfaces, footwear, and specific sport demands further modulate injury risk, underscoring the multifactorial nature of ACL injury etiology. The consequences of these injuries extend beyond immediate physical impairment, affecting an athlete’s short-term functional capacity, long-term joint stability, and overall quality of life. Management strategies, ranging from surgical reconstruction to conservative rehabilitation, significantly influence recovery trajectories and return-to-sport outcomes, while psychological impacts and career disruptions often accompany the physical toll. Given the substantial burden of ACL injuries on individual athletes and sports organizations alike, a comprehensive understanding of their prevalence, risk factors, and subsequent outcomes is essential.

OBJECTIVE

Synthesize current evidence on these aspects, providing a detailed overview of the epidemiology, risk determinants, and prognostic factors associated with ACL injuries in athletes, in order to inform prevention strategies, clinical treatment, and future lines of research in this critical area of sports health.

METHODOLOGY

This study was designed as a narrative review aimed at synthesizing current evidence on the epidemiology, risk factors, and outcomes associated with anterior cruciate ligament (ACL) injuries in athletes. A comprehensive literature search was conducted in PubMed, Scopus, Web of Science, and Google Scholar, covering publications from 2000 to 2024 in order to capture both classical and contemporary research relevant to sports populations.

The search strategy included combinations of the following terms and their synonyms: “anterior cruciate ligament injury,” “ACL tear,” “epidemiology,” “incidence,” “prevalence,” “athletes,” “sports,” “risk factors,” “intrinsic,” “extrinsic,” “biomechanics,” “neuromuscular control,” “prevention,” “surgical management,” “non-surgical management,” “return to sport,” “prognosis,” “psychological impact.” Reference lists of key articles and previous reviews were also hand-searched to identify additional relevant publications.

Inclusion criteria comprised:

1. Studies involving athletes or physically active individuals with ACL injuries.
2. Epidemiological studies reporting incidence or prevalence.
3. Research addressing intrinsic (anatomical, physiological, biomechanical) and extrinsic (environmental, equipment, sport-specific) risk factors.
4. Studies evaluating treatment approaches (surgical and non-surgical), functional outcomes, return-to-sport rates, or psychological impact.

Exclusion criteria included:

1. Case reports and small case series with limited generalizability.
2. Non-athlete populations or mixed cohorts without specific subgroup analysis for athletes.
3. Articles lacking sufficient methodological detail or not available in English.

Data were extracted and organized into major thematic domains: (1) prevalence and incidence of ACL injuries across sports, ages, genders, and competition levels, (2) intrinsic risk factors, (3) extrinsic risk factors, (4) biomechanical and neuromuscular determinants, and (5) short- and long-term outcomes, including functional prognosis and psychological consequences. Due to heterogeneity in study designs, outcome measures, and injury definitions, no meta-analysis was performed. Instead, a qualitative, narrative synthesis was undertaken to identify consistent patterns, knowledge gaps, and implications for injury prevention and clinical practice.

RESULTS

Prevalence of Anterior Cruciate Ligament (ACL) Injuries in Athletes

What are the reported incidence rates of ACL injuries across different sports?

Across a substantial dataset encompassing 45 million player-hours and player-exposures, the reported incidence rates of anterior cruciate ligament (ACL) injuries display notable variation across different sports, with soccer standing out as a high-risk activity, reporting an incidence rate of 17.2% for ACL tears among young men^1,2. The reliability and comparability of these findings are reinforced by the methodological rigor observed in the literature, where 91% of the studies had injury data collected and recorded by medical staff, thereby enhancing the validity of the reported injury rates¹. Furthermore, most research adopted a «time-loss» definition for ACL injuries—utilized in 89% of studies—ensuring that cases included in the incidence rates reflect clinically significant injuries that impact athlete participation and rehabilitation needs¹. Given that a substantial proportion of these injuries were non-contact in nature, with a total of 2,748 non-contact ACL injuries documented, understanding interconnections between sport-specific demands, mechanisms of injury, and surveillance practices is critical for accurately comparing incidence rates and developing targeted prevention strategies across athletic domains¹. This synthesis underscores the necessity for standardized reporting and injury definitions, as well as sport-tailored intervention programs, to effectively address and mitigate ACL injury risks in diverse sporting environments.

How does ACL injury prevalence vary by age, gender, and competition level among athletes?

A comprehensive analysis of ACL injury prevalence reveals nuanced variations across age, gender, and competition level among athletes, illustrating the complex interplay of biological and environmental factors. Notably, female athletes are consistently found to have a higher incidence of ACL injuries compared to their male counterparts, with rates estimated to be 2.4-9.5 times greater in females than in males, regardless of the intensity or frequency of vigorous activity³. This disparity is further substantiated by data showing that the peak incidence of ACL injuries in females occurs between the ages of 14 and 18, with a rate of 227.6 per 100,000 person-years, whereas males experience their highest rates between 19 and 25 years of age, reaching 241 per 100,000 person-years³. Such variations are not solely attributed to sport-specific demands, as anatomical and hormonal differences—including narrower intercondylar notch widths, increased Q angles, and hormonal fluctuations—may contribute to the heightened risk in females³. Moreover, these patterns persist across different levels of athletic competition, suggesting that intrinsic factors play a more significant role than training volume or exposure alone^1,3. The observed disparities underscore the need for targeted injury prevention programs, particularly for female athletes in their adolescent years, to address both modifiable risk factors and broader cultural or societal influences that may predispose certain groups to increased injury risk^1,3. Coordinated interventions across age groups and competition levels are essential to mitigate these risks and promote safer athletic participation for all.

What trends in ACL injury rates have been observed over recent years?

Recent epidemiological data reveal a complex landscape in ACL injury trends across various sports and demographics, underscoring significant interconnections between sex, age, and sport-specific factors. For instance, although the incidence of ACL injuries in female basketball and soccer players has remained stable over the study period, the broader trend indicates an overall increase in ACL injury rates, particularly among adolescents^4,5. This upward trajectory is especially pronounced in females aged 13-17, who have experienced a sharper rise in ACL injuries compared to their male counterparts, suggesting that adolescent females may be particularly vulnerable due to physiological or biomechanical factors⁵. Meanwhile, male athletes in the same age group are seeing increased rates of ACL reconstruction surgeries, which may reflect both heightened injury rates and greater access to or utilization of surgical interventions⁵. These trends are echoed in specific sports such as lacrosse, where the rate of ACL injuries in women’s lacrosse has increased significantly, contrasting with a recent slight decline or stabilization in men’s lacrosse injury rates⁴. Notably, the disparities between men’s and women’s lacrosse are further illustrated by the near doubling of injuries in women’s leagues, while men’s rates remain comparatively steady, highlighting the necessity for targeted prevention strategies that address the unique risk profiles of female athletes⁴. Collectively, these findings emphasize the urgent need for sex- and age-specific interventions, enhanced injury surveillance, and tailored training programs to mitigate the rising burden of ACL injuries across sports and populations.

Risk Factors Associated with ACL Injuries in Athletes

What intrinsic (anatomical, physiological) risk factors contribute to ACL injuries?

Intrinsic risk factors for ACL injuries encompass a range of anatomical and physiological characteristics inherent to the individual, which may predispose certain populations to elevated injury risk⁶. Among these, modifiable factors such as weak hip abductor muscles play a prominent role, deficiencies in these muscles can cause the knee to collapse inward (valgus movement) during dynamic activities, substantially increasing the strain on the ACL and thereby elevating the likelihood of injury⁶. This interrelationship between hip strength and knee mechanics demonstrates how muscular and biomechanical domains intersect, influencing overall knee stability and injury susceptibility⁶. Moreover, other anatomical features such as the shape of the tibia and femur, particularly the lateral tibial plateau slope, have been identified as significant contributors to ACL injury risk, as a steeper lateral slope can alter joint biomechanics and loading patterns during movement, further exacerbating the risk^6,7. Additionally, morphometric properties of the ACL itself, including reduced length, width, and volume, as well as a narrow intercondylar notch, create structural vulnerabilities that increase the risk of ligamentous failure under stress^6,7. These anatomical predispositions interact with physiological factors like increased knee laxity and poor core stability, compounding the risk across multiple domains⁶. Recognizing these interconnections underscores the importance of targeted interventions, such as strengthening hip abductors and external rotators and improving core stability, as part of comprehensive injury prevention programs that address both anatomical and physiological risk factors to mitigate ACL injury rates⁶.

How do extrinsic factors (training surfaces, footwear, sport type) influence ACL injury risk?

Extrinsic factors such as training surfaces, footwear, and sport type are integral to understanding the complex web of influences that elevate ACL injury risk, especially in high-exposure athletic environments^8,9. The interaction between footwear and playing surface is particularly critical, for example, cleat design and shoe construction can affect the degree of friction between shoe and ground, with higher torsional resistance in cleats, such as edge cleats, being linked to a significantly greater risk of ACL injury^9,10. Conversely, flat cleats, smaller cleats, and shoes with fewer cleats have been found to reduce this risk, suggesting that careful selection of footwear can serve as a preventative strategy⁹. The type of playing surface further compounds injury risk, as certain grasses like Bermuda can entrap cleats, especially during early season games or in northern venues, thus increasing mechanical strain on the knee and predisposing athletes to ACL injuries^9,10. Weather conditions can also modify surface characteristics and shoe-surface friction, with hot weather potentially reducing ligament extensibility and exacerbating the risk, particularly in open stadiums^8,10. These interconnections demonstrate that extrinsic risk factors are not isolated, rather, they dynamically interact, amplifying or mitigating risk based on environmental and equipment choices. Therefore, interdisciplinary interventions—such as optimizing footwear design for specific surfaces, monitoring environmental conditions, and tailoring training protocols—are essential to reduce the overall burden of ACL injuries in athletic populations^8,9.

What role do biomechanical and neuromuscular factors play in increasing susceptibility to ACL injuries?

Biomechanical and neuromuscular factors play a pivotal role in increasing susceptibility to ACL injuries, particularly among female athletes, by shaping movement patterns and influencing joint stability during high-risk activities such as cutting, pivoting, and landing¹¹. Key biomechanical mechanisms implicated in ACL injuries include increased knee valgus, limited knee flexion during landing, and multiplanar knee joint loads (KJLs), all of which elevate strain on the ACL and amplify the risk of injury^11,12. These biomechanical tendencies are often exacerbated by neuromuscular deficits, such as poor proprioceptive performance and suboptimal control over core and lower limb musculature, further compounding joint instability and hazardous loading patterns^9,12. The interplay between neuromuscular control and biomechanical execution is particularly significant in female athletes, who may demonstrate distinct neuromuscular activation patterns that increase their vulnerability to ACL injuries during dynamic sports movements¹¹. Moreover, external factors such as the interaction between playing surface and footwear can alter both biomechanical and neuromuscular responses, potentially modulating the magnitude of ACL loading during athletic tasks¹¹. Given the complex and interconnected nature of these risk factors, developing effective injury prevention strategies requires a comprehensive approach that addresses both biomechanical technique and neuromuscular conditioning, as well as context-specific considerations such as surface and footwear selection¹¹. This underscores the urgent need for targeted interventions and ongoing research to clarify the combined effects of these variables, enabling practitioners to reduce ACL injury risk and address persistent sex disparities in injury prevalence.

Outcomes and Prognosis Following ACL Injuries in Athletes

What are the typical short-term and long-term functional outcomes after ACL injury?

The short-term functional outcomes of an anterior cruciate ligament (ACL) injury are marked by a constellation of acute symptoms that significantly impair mobility and daily life. Immediately following the injury, individuals often experience pronounced leg weakness, swelling, and bleeding into the joint (hemarthrosis), which collectively contribute to a rapid decline in joint stability and function¹³. This acute phase is further complicated by loss of motion and reflex inhibition in the quadriceps muscle, making it difficult for patients to straighten their leg or perform even basic activities such as walking or standing¹³. In fact, studies indicate that 44% of patients face moderate to severe impairments in daily activities, and 31% report notable difficulty with autonomous walking shortly after injury¹⁴. These physical deficits are interrelated—weakness and impaired motion increase the risk of unintended knee movements, which can exacerbate the original injury and cause additional damage to other knee structures in both the short and long term¹³. Over time, the persistent instability and inability of the ACL to heal naturally without surgical intervention may result in chronic limitations, as the ligament does not reattach itself and the knee remains vulnerable to further injury¹³. This ongoing instability, coupled with the increased risk of developing knee osteoarthritis, may reduce long-term mobility, compromise independence, and ultimately limit participation in sports, work, and recreational activities^13,14. Given these interconnected functional challenges, timely interventions and regular evaluation by professionals skilled in ACL injuries are essential to monitor recovery and implement rehabilitation strategies that can help mitigate both immediate and lasting impairments¹³.

How do surgical versus non-surgical management approaches affect athlete recovery and return-to-sport rates?

When evaluating the impact of surgical versus non-surgical management on athlete recovery and return-to-sport rates, it becomes clear that each approach uniquely influences both short-term and long-term outcomes for athletes, often interconnecting domains such as performance sustainability, complication risk, and overall recovery trajectory. Surgical interventions, while necessary in certain severe cases, generally entail longer recovery periods and may pose risks such as infection, loss of range of motion, or even long-term detriments to athletic performance, which can delay or diminish an athlete’s ability to return to their previous level of competition¹⁵. On the other hand, non-surgical treatments offer a compelling alternative, as they not only facilitate natural healing and reduce inflammation but also tend to enable athletes to resume sport more rapidly, with recovery timelines often measured in weeks rather than months¹⁵. This expedited recovery is particularly advantageous for elite athletes, whose careers depend on minimizing time away from competition, and also reduces the risk of complications that can arise from surgical procedures¹⁵. Furthermore, non-surgical management is associated with a lower likelihood of compromising range of motion or strength, thereby supporting sustained peak performance and potentially yielding better long-term outcomes for athletes¹⁵. Given these interdependencies, it is crucial for clinicians and sports medicine professionals to carefully assess the specific needs and contexts of each athlete, favoring non-surgical options when clinically appropriate to optimize both recovery and return-to-sport rates, while reserving surgical intervention for cases where it is unequivocally indicated.

What are the psychological and career-related impacts of ACL injuries on athletes?

The psychological and career-related impacts of ACL injuries on athletes are profound and multifaceted, often extending well beyond the initial physical trauma to deeply affect an athlete’s sense of self and personal identity¹⁶. For high school and college athletes, whose identities are frequently intertwined with their athletic roles, sustaining an ACL injury can trigger a crisis of identity, emotional distress, and a feeling of losing a fundamental part of themselves¹⁶. This internal struggle is further exacerbated by the abrupt disruption of daily routines and long-term career aspirations, challenging both their mental resilience and emotional well-being¹⁶. Athletes who strongly identify with their sport may experience depression, anxiety, and a diminished sense of purpose when sidelined, underscoring the need to address the often overlooked psychological component during rehabilitation¹⁶. Moreover, the fear of reinjury and diminished confidence in their physical abilities can inhibit a return to pre-injury performance, potentially altering career trajectories and reducing overall sport participation rates^16,17. These interconnected psychological and career-related factors highlight the importance of comprehensive support systems that integrate mental health care alongside physical rehabilitation, ensuring athletes are equipped to navigate both the emotional and professional challenges posed by ACL injuries¹⁶.

DISCUSSION

The findings of this comprehensive review underscore the multifaceted nature of ACL injuries among athletes, highlighting both intrinsic and extrinsic risk factors that contribute to their prevalence and severity. The markedly higher incidence rates in female athletes, particularly during adolescence, suggest that anatomical, hormonal, and biomechanical differences play a crucial role in predisposing this demographic to injury. The persistent disparities across competition levels indicate that these factors are inherent rather than solely attributable to training volume or intensity. The observed upward trend in injury rates over recent years, especially among adolescent females and in sports such as lacrosse, warrants further investigation into evolving sport-specific demands and environmental factors that may be influencing these patterns. While the review emphasizes modifiable risk factors such as neuromuscular control and strength deficits, it also reveals gaps in standardized prevention protocols, underscoring the need for personalized, sex- and age-specific training programs. The influence of extrinsic factors like footwear and playing surfaces highlights the importance of optimizing equipment and environmental conditions to mitigate injury risk. However, the reliance on observational data and injury surveillance reports introduces potential biases, including underreporting or inconsistent classification of injuries, which may affect the accuracy of prevalence estimates. The long-term consequences of ACL injuries, including osteoarthritis and psychological distress, demonstrate the importance of comprehensive management approaches that integrate physical rehabilitation with mental health support. Although surgical interventions are common, their associated recovery challenges and risk of complications necessitate further research into non-surgical alternatives and minimally invasive techniques. Limitations of the current literature include a lack of prospective, longitudinal studies examining the effectiveness of tailored prevention programs and the psychological impact over time. Future research should focus on developing and validating multifactorial intervention strategies, incorporating biomechanical, hormonal, and psychosocial components, to reduce injury incidence and enhance recovery outcomes. Overall, this review emphasizes that a holistic, individualized approach—considering the complex interplay of intrinsic and extrinsic factors—is essential to effectively prevent ACL injuries and improve long-term health and athletic performance.

CONCLUSIONS

1. ACL injuries in athletes represent a major challenge in sports medicine, characterized by a high and, in some groups, rising prevalence that reflects the complex interplay of intrinsic and extrinsic risk factors. Female athletes, particularly during adolescence, consistently show higher injury rates than their male counterparts, suggesting that anatomical, hormonal, biomechanical, and neuromuscular differences contribute substantially to susceptibility. These disparities persist across competition levels, indicating that inherent factors may outweigh exposure alone.
2. Extrinsic determinants—including playing surfaces, footwear design, and sport-specific movement demands—further modulate risk, reinforcing the notion that ACL injuries are multifactorial in origin. The review also highlights the crucial role of neuromuscular control and biomechanical movement patterns, such as increased knee valgus and inadequate hip and core stability, in predisposing athletes to non-contact ACL injuries.
3. The short-term consequences of ACL injury include pain, swelling, joint instability, and significant functional limitation, while long-term outcomes may involve recurrent instability, reduced sports participation, early-onset osteoarthritis, and persistent psychological distress. Surgical reconstruction remains common, yet is associated with prolonged recovery, potential complications, and variable return-to-sport rates. Non-surgical strategies may offer advantages in selected athletes but are not universally applicable.
4. Overall, the evidence underscores the need for individualized, multifactorial management that integrates targeted prevention programs, optimized equipment and environmental conditions, and comprehensive rehabilitation—incorporating both physical and psychological support. A holistic approach is essential to effectively reduce ACL injury incidence, improve recovery trajectories, and protect long-term joint health and athletic performance.

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