Purpose:
The purpose of this study was to generate knowledge about the epidemiology and risk factors for anterior cruciate ligament (ACL) injuries in handball. It was hypothesised that the incidence of ACL injuries is high and comparable to other pivoting sports like football.

Methods:
This study is based on the prospective ‘ACL registry in German Sports’ implemented in the 2016–2017 season. Professional (first and second leagues) male handball players were analysed regarding the incidence and risk factors for ACL injuries. Injuries were registered according to the direct reports of the injured players to the study office and double-checked via media analysis. After injury registration, the players received a standardised questionnaire. Data were analysed from the 2016–2017 to the 2022–2023 season.

Results:
A total of 84 ACL injuries were registered. 46.3% of ACL injuries were re-ruptures. This represents a total incidence of 0.044 ACL injuries per 1000 h of exposure in training and matches per player over the study period. An increased incidence rate of 0.064/1000 h in the first league compared to 0.031/1000 h in the second league was reported (p ˂ 0.001). The mean number of injuries in the first division was 8.3, and in the second division, 6.6 ACL ruptures per season. Risk factors for ACL injury include previous knee injury and increased match exposure.

Conclusion:
The incidence of ACL injuries in professional handball is high and comparable to football with an increased risk in the first league compared to the second league in Germany. There was a high incidence of re-injury. Other risk factors for ACL injuries include previous injuries to the affected knee in general as well as increased match exposure.

Level of Evidence:
Level II prospective cohort study.