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In 2018, the International Olympic Committee (IOC) issued a consensus statement on the prevention, diagnosis and management of paediatric anterior cruciate ligament (ACL) injuries. It articulated fundamental principles to guide children, parents and clinicians in making informed decisions, safeguarding long-term knee health and supporting lifelong activity.1 Subsequent research has identified previously unaddressed aspects of paediatric ACL injuries and underscored their emergence as a significant public health concern requiring a coordinated and sustainable response. This editorial examines recent advances, current evidence and persistent challenges in paediatric ACL injury prevention, individualised management decisions, evolving surgical strategies and long-term holistic care (table 1).