Disparities in ACL Injury and Management: The Impact of Sex, Race, and Social Determinants of Health

Anterior cruciate ligament (ACL) injury is a common condition that significantly affects physical function and long-term knee health across diverse patient populations. Although outcomes after ACL reconstruction have improved, growing evidence demonstrates persistent disparities related to biological sex, gender, race, ethnicity, and socioeconomic factors. This review synthesizes recent literature examining how these factors influence ACL injury risk and outcomes, with the goal of identifying actionable gaps and future directions to improve equity in ACL management. Recent studies confirm that female patients sustain ACL injuries at higher rates and experience inferior patient-reported outcomes and lower return-to-sport rates despite largely equivalent objective surgical outcomes. Recent work highlights neuromuscular and plyometric-based rehabilitation, psychological readiness, and adaptable rehabilitation environments as key modifiable contributors to these disparities. Racial and ethnic minority patients experience delayed surgical care, reduced rehabilitation utilization, and worse functional outcomes, with neighborhood-level socioeconomic deprivation and access-related barriers emerging as key modifiable contributors. Disparities in ACL outcomes arise from the interaction of biological risk, rehabilitation-dependent recovery, and structural barriers affecting access to timely surgery and postoperative care. Rehabilitation offers a critical, modifiable opportunity to reduce these gaps by optimizing neuromuscular recovery and ensuring equitable access to supervised therapy. Future progress will require prospective, sex-, race-, or ethnicity-stratified studies, integration of area-level socioeconomic metrics, and care pathways that address delays in evaluation, surgery, and rehabilitation. Earlier implementation of neuromuscular injury-prevention programs in youth and community-based settings may further reduce downstream disparities.