The implementation gap in anterior cruciate ligament prevention programs—From evidence to everyday practice

Anterior cruciate ligament (ACL) injury remains one of the most impactful injuries in pivoting sports, with non-contact mechanisms accounting for the majority of cases and offering a clear target for prevention. Robust evidence-including multiple Level 1 meta-analyses-demonstrates that structured neuromuscular training (NMT) programs can reduce ACL injury rates by approximately 50%, particularly among youth and female athletes. Effective programs are multicomponent, integrate strength, plyometrics, agility, balance and movement-quality feedback, and require adequate training dose and in-season continuity. Despite this well-established evidence base, real-world implementation remains limited. Coaches and sports organisations frequently report barriers such as time constraints, competing performance priorities and low confidence in delivering prevention exercises. This disconnect reflects a broader implementation gap: while we know what works, we are not consistently doing it. Insights from implementation science, including JBI's phased models, facilitation strategies and context-driven frameworks, provide a roadmap for translating evidence into sustained practice. Reframing prevention as performance-enhancing movement training and embedding programs such as the ESSKA 'Prevention for All' initiative into coaching pathways and club standards are essential system-level strategies. The priority is no longer proving efficacy, but achieving widespread, high-fidelity implementation so that ACL prevention becomes a routine component of athlete preparation.