Context Despite the efficacy of injury prevention programs, anterior cruciate ligament (ACL) injury rates have remained steady, which may be due to limited knowledge of which groups/athletes are greatest at risk of sustaining an ACL injury. Objective The purpose of our study was to characterize ACL injury rate (IR) across sex, sport, and levels of play to identify high-risk groups per season. Data Sources We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and searched electronic databases of PubMed and EBSCOhost. Study Selection Inclusion criteria required that studies noted level of play, number of ACL injuries, and total number of athletes. We excluded studies if the injury was a secondary one, the total population was unclear or noted only cases of reconstruction. Data Extraction We extracted data on sex, sport, level of play, number of ACL injuries, and total number of athletes. Data Synthesis The electronic literature search yielded 9469 studies for initial review, and at the end of the search, a total of 89 studies were included in our meta-analysis. The highest-risk sports were female semipro handball (IR = 0.045/athlete-year), female professional basketball (IR = 0.027/athlete-year), and female professional alpine skiing (IR = 0.025/athlete-year). Across all the comparisons of sex, sports, and levels, there were large gaps in the data and variability in the injury rates. Conclusions There was variability in injury risk rates across sex, sport, and competition level with the highest risk of ACL injury in semiprofessional and professional sports. Whereas female athletes demonstrated greater risk of ACL injury than male athletes, it is unknown if this trend replicates in every sport or level. Improved understanding of the impact of sex and sport differences in ACL injury risk can help guide the best target areas for evidenced-based risk reduction strategies. Key Points Groupings with the most data entries included female (k = 18) and male (k = 15) professional soccer, female high school soccer (k = 12), and female collegiate soccer (k = 8). The highest-risk sports were female semipro handball (IR = 0.045/athlete-year), female professional basketball (IR = 0.027/athlete-year), and female professional alpine skiing (IR = 0.025/athlete-year). Large gaps in available data and high variability in reported injury incidence rates between studies of same sport limit the potential to differentiate need for targeted ACL injury prevention programs within the current available literature. However the evidence strongly indicates a need for continued efforts for ACL injury risk reduction programs for female athletes to reduce the consistent sex discrepancy.
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