Anterior cruciate ligament (ACL) injury affects a large number of athletes worldwide, and long-term rate of return to soccer is approximately 50% or less. ACL injury, which is noncontact in approximately 90% of cases, has a complex multifactorial etiology. Younger and higher-level players do better, and 10-year outcomes are superior to baseline. The role of genomics, hormonal status, neuromuscular deficiencies, anatomy, and the environment are all potential contributory risk factors that vary with respect to the individual, especially the female athlete. Furthermore, ACL injury results in a local and regional catabolic cascade and cytokine release, creating an intra-articular environment that is a homeostatic perfect storm and spectrum of scalable articular cartilage and meniscal injury. Once these complexities in the knee organ are defined and understood, the surgeon’s early objectives are stabilization, repair, and restoration with full harmonization of biomechanics, neuromuscular control, and homeostasis. The goal is optimizing long-term outcomes, decreasing the rate of subsequent ACL injury, and preventing osteoarthritis.

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