Introduction and background

Sports participation has increased globally due to growing awareness of physical fitness, recreational engagement, and competitive performance. Although sports provide substantial physical and psychological benefits, they are also associated with a high risk of musculoskeletal injuries. Among these, knee injuries are one of the most common and clinically significant conditions affecting athletes because they frequently result in pain, functional limitations, prolonged rehabilitation, delayed return to sport, and increased healthcare costs. The knee joint is exposed to considerable mechanical stress during sprinting, jumping, cutting, pivoting, landing, and rapid deceleration, making athletes particularly susceptible to both acute traumatic injuries and chronic overuse conditions. Consequently, sports-related knee injuries remain a major concern in sports medicine due to their multifactorial nature and impact on athletic performance and long-term joint health [1,2].

Sports-related knee injuries can be broadly categorized into acute traumatic injuries, such as anterior cruciate ligament (ACL), posterior cruciate ligament, collateral ligament, and meniscal tears; and chronic or overuse injuries, including patellofemoral pain syndrome, patellar tendinopathy, cartilage lesions, and osteochondral injuries. ACL injuries are considered one of the most serious and clinically significant sports-related knee injuries. Their long-term consequences include persistent functional impairments, early knee osteoarthritis, and an increased risk of recurrent injury [3].

The occurrence of sports-related knee injuries is multifactorial, resulting from the interaction of intrinsic and extrinsic risk factors. Intrinsic factors include anatomical characteristics, neuromuscular deficits, muscle weakness, proprioceptive impairment, joint laxity, and previous injury, whereas extrinsic factors include playing surface, footwear, training load, and sport-specific demands. Biomechanical studies indicate that many ACL injuries occur during non-contact movements involving sudden deceleration, cutting, pivoting, and poor landing mechanics. Dynamic knee valgus, inadequate knee flexion, altered trunk alignment, and impaired neuromuscular control further increase ACL loading and injury risk [4,5].

Research on injury mechanisms indicates that many major knee injuries occur in non-contact situations. Ligamentous injuries, especially ACL ruptures, have been found to be frequently caused by sudden deceleration, cutting maneuvers, pivoting motions, and poor landing mechanics. Excessive dynamic knee valgus, decreased knee flexion angles, changed trunk alignment, and insufficient neuromuscular control all enhance joint stress and injury risk, according to biomechanical assessments. The knowledge of modifiable factors linked to sports-related knee injuries has greatly improved as a result of these findings [5,6], as shown in Figure 1.

Figure 1: Injuries and causes of sports-related knee injuriesACL: Anterior Cruciate LigamentImage created by Durga A. Jagdale, using Microsoft PowerPoint (Microsoft Corporation, Redmond, WA, USA).

Specific injury prevention programs have been developed as a result of the identification of modifiable biomechanical and neuromuscular risk factors. Enhancing strength, balance, proprioception, movement quality, agility, and neuromuscular control are the main goals of modern preventative techniques. These therapies are intended to improve dynamic joint stability, rectify abnormal movement patterns, and lessen excessive knee structural loading during sports involvement. Programs for preventive exercise are becoming a crucial part of global efforts to enhance athlete safety and reduce the risk of injury. One of the most effective methods for lowering the risk of knee injuries is neuromuscular training. Plyometric exercises, balance training, strength training, agility drills, and movement retraining methods are frequently included in these programs. Reductions in injury-related risk variables have been linked to improvements in lower-extremity alignment, landing mechanics, postural control, and muscular coordination. As a result, systematic neuromuscular training regimens have been widely accepted in situations related to athletic performance and sports medicine [6,7].

Effective rehabilitation requires an individualized approach that addresses physical, functional, and psychological recovery. Modern rehabilitation extends beyond pain relief and muscle strengthening to include neuromuscular control, movement quality, sport-specific performance, and psychological readiness. Return-to-sport decisions are increasingly guided by objective functional testing, strength assessment, movement analysis, and psychological evaluation rather than time-based criteria alone, thereby reducing the risk of reinjury [7-9].

Recent advances in technology have created new opportunities for improving the assessment, prevention, and rehabilitation of sports-related knee injuries. Emerging technologies are increasingly being incorporated into sports medicine practice and can be broadly categorized into: assessment tools, including wearable sensors, inertial measurement units, motion capture systems, force platforms, and surface electromyography; intervention tools, such as virtual reality, augmented reality, blood flow restriction training, and tele-rehabilitation platforms; and decision-support systems, including artificial intelligence and machine learning algorithms. These innovations provide objective, real-time, and data-driven information that can enhance clinical decision-making and optimize rehabilitation outcomes [10-13], as shown in Figure 2.

Figure 2: Emerging technologies in sports-related knee injuriesImage created by Durga A. Jagdale, using Microsoft PowerPoint (Microsoft Corporation, Redmond, WA, USA).

Therefore, the primary aim of this systematic review is to evaluate the current evidence regarding exercise-based rehabilitation and emerging technology-assisted interventions for sports-related knee injuries. Specifically, this review focuses on the effects of these interventions on pain, muscle strength, dynamic stability, proprioception, functional performance, athletic readiness, and return-to-sport outcomes. Furthermore, the review aims to investigate the contribution of the entire kinetic chain, including the trunk, hip, knee, and lower extremity musculature, in influencing knee biomechanics and injury recovery. By synthesizing evidence from randomized controlled trials (RCTs), this systematic review seeks to identify the most effective rehabilitation strategies and emerging technologies for improving clinical outcomes, enhancing athletic performance, preventing recurrent injuries, and supporting evidence-based sports rehabilitation practice.