Anterior cruciate ligament (ACL) rupture is one of the most common and consequential musculoskeletal injuries worldwide and represents a major precursor to post-traumatic osteoarthritis (PTOA) of the knee [1-4]. In the United States alone, approximately 120,000–200,000 ACL ruptures occur annually, generating substantial healthcare utilization related to diagnostic imaging, orthopedic consultation, surgical reconstruction, rehabilitation, and long-term management of degenerative joint disease [5-8].

Direct medical expenditures combined with productivity losses produce an estimated annual economic burden exceeding $7–10 billion in the United States [8-11]. Based on authors' projections incorporating current trends in sports participation (estimated annual growth of 2%–3%), surgical rates (approximately 50% of injuries), and healthcare cost inflation (approximately 3%–5% annually), the annual economic burden may approach $12–15 billion by 2040 in the United States. This trajectory aligns with independent analyses of musculoskeletal disease burden and underscores the urgency of preventive strategies. However, precise projections require formal health economic modeling incorporating incidence, treatment patterns, and long-term outcomes.

Outcomes after ACL reconstruction remain variable, with approximately 55%–70% of patients returning to competitive sport and fewer returning to their preinjury level of performance [12-14]. Furthermore, 30%–50% of patients develop radiographic posttraumatic osteoarthritis within 10–15 years after injury, even following technically successful reconstruction [15-17].

This review synthesizes current evidence regarding ACL injury epidemiology, mechanisms, whole-joint pathophysiology, socioeconomic impact, return-to-sport outcomes, healthcare disparities, prevention strategies, and advanced imaging biomarkers. Emphasis is placed on the evolving role of radiology in early detection, risk stratification, and longitudinal monitoring of PTOA.