Neurocognitive Factors in ACL Injury: The Missing Piece in Rehabilitation and Prevention? A Scoping Review

Background Increasing evidence suggests that ACL injury should not be classified solely as a musculoskeletal condition, but rather as a neurophysiological injury. Several neurocognitive domains, including dual-task interference, visual attention, reaction time and cognitive fatigue, have been proposed as contributors to ACL injury. However, no studies have looked to explore subsections of these neurocognitive domains and their proposed mechanisms into prevention and injury risk. The purpose of this scoping review was to investigate the role of neurocognitive tasks in ACL injury. Study Design Scoping review. Methods The review was conducted in accordance with the PRISMA extension for Scoping Reviews (PRISMA-ScR Checklist). Literature search was performed in PubMed, Scopus and PEDro databases for studies published between 2006 and 2026. Search terms included combinations of “ACL”, “dual-task”, “neurocognitive”, “reaction time”, “visual attention”, “decision making”, “mental fatigue”, “processing speed”, and “cognitive interference”. Screening was performed by a single reviewer, including publications at all levels of evidence, published in English or Italian. Results Forty-two studies were included in the review. Dual-task interference and visual attention were the most investigated neurocognitive domains, with nine studies combining dual-task interference and visual attention and 10 studies combining dual-task interference, visual attention and reaction time. Six studies examined dual-task interference alone, five studies examined visual attention alone, and three studies examined reaction time alone. Cognitive fatigue was examined either alone or combined with other domains in seven studies. Neurocognitive training interventions demonstrated potential benefits in improving visuomotor efficiency, movement compliance and return to sport readiness after ACL rehabilitation. However, current evidence is predominantly derived from laboratory-based and exploratory studies with limited prospective and clinically translational data. Conclusions Neurocognitive factors appear to represent one of the major missing components in current ACL rehabilitation and prevention frameworks. Integrating neurocognitive challenges into rehabilitation and RTS testing may help clinicians better identify athletes at risk for secondary injury. Future research should prioritize prospective, clinically translational studies, as current evidence is predominantly exploratory and laboratory based. Level of Evidence 3