Sex differences and gender factors in anterior cruciate ligament injury prevention: A call for purpose-driven strategies.

Abstract

Female athletes face a disproportionately high risk of anterior cruciate ligament (ACL) injuries, with patterns that vary by age and developmental stages, influenced by interactions among biological sex factors, anatomy, hormones, neuromuscular control and gendered sports environments shaped by social norms, organisational structures and unequal access to resources. Despite significant progress, most ACL injury prevention strategies still rely on male-derived evidence and are implemented in systems that neither recognise sex-linked physiology nor address gendered barriers to training, communication and support. Building on the substantial work of Female, woman and/or girl Athlete Injury pRevention (FAIR) consensus, a sex- and gender-responsive framework for ACL injury prevention that integrates biological mechanisms, neuromuscular priorities, contextual factors and communication considerations is proposed in this editorial. Ongoing gaps in surveillance, intervention design and reporting are highlighted; essential components for a purpose-driven ACL prevention framework are suggested; and equitable, context-sensitive implementation is advocated to reduce the ACL injury gap among female athletes worldwide.