An Evidence-Based and Mechanistic Approach to Reducing the Risk of Anterior Cruciate Ligament Injury: An Exercise and...

Anterior cruciate ligament (ACL) rupture is a serious sporting injury associated with impaired performance, high recurrence rates, early-onset knee osteoarthritis and substantial health and economic burden. In Australia, ACL injury incidence has increased over the past two decades, with particularly high rates observed among female and adolescent athletes participating in cutting and landing sports. Neuromuscular and structured warm-up programs can reduce ACL injury risk; however, implementation and adherence remain inconsistent, and evidence for effectiveness in males, elite athletes and several high-risk sports is unclear. Practitioners, therefore, require clear, evidence-based guidance to prescribe effective prevention strategies across diverse populations. This position statement provides contemporary, evidence-informed recommendations to guide exercise prescription for ACL injury prevention by (1) critically evaluating the effect of existing exercise interventions on ACL injury incidence, and (2) synthesising evidence on intrinsic risk factors and mechanistic pathways for non-contact ACL injury to inform targeted training strategies. Two systematic literature searches were conducted in Scopus, Embase and PubMed. The first identified randomised and non-randomised controlled trials and cohort studies evaluating the effect of exercise-based interventions on ACL injury incidence. The second identified prospective studies examining intrinsic risk factors for non-contact ACL injury. Evidence on ACL injury aetiology was synthesised by integrating injury risk factors, video analyses of injury events, in vivo and in vitro laboratory studies and in silico biomechanical modelling. We propose a tiered framework for exercise prescription. Tier 1 strategies emphasise population-level neuromuscular and structured warm-up programs, which meta-analyses indicate can reduce ACL injury risk by approximately 60% in adolescent female soccer, basketball and handball players. Effective programs typically combine plyometric, strength, balance/proprioception, mobility and agility exercises performed for 10-30 min, 2-3 times per week. Tier 2 strategies target specific neuromuscular deficits or high-risk movement patterns, including low knee flexion, dynamic knee valgus, lateral trunk flexion and excessive step width. Interventions may include plyometric and resistance exercises, motor control drills and neurocognitive challenges to increase transfer to game scenarios; however, direct evidence linking Tier 2 strategies to reduced injury incidence remains limited. This position statement provides an evidence-based framework to support the design and practical implementation of effective ACL injury prevention strategies in sport.