Ramp lesions are common in ACL deficient knees. Their diagnosis is difficult and, therefore, they may be underestimated. So far, no study analyzed their prevalence in a pediatric population. The diagnosis of these Ramp lesions is of major clinical relevance because of a frequent misestimating and technic difficulties. Ramp lesions might be associated with residual knee pain and instability after ACL reconstruction. The aim of this study was to evaluate the prevalence of ramp lesions explored through a systematic intercondylar and posteromedial arthroscopic approach during an ACL reconstruction in a pediatric and adolescent population.Children and adolescents who underwent an ACL reconstruction were screened prospectively between October 2014 and 2016. The presence or absence of a ramp lesion was evaluated after each of three arthroscopic steps: (1) an anterior approach, (2) an intercondylar inspection, and (3) a posteromedial approach. Ramp lesions were screened at each step and their prevalence was evaluated. Furthermore, their presence was correlated to age, weight, size, sex, and state of the physis (open or closed). Finally, the meniscal status on MRI and arthroscopic findings were compared.Fifty-six patients were analyzed. The median age was 14.0 ± 1.3 years (12-17). The median interval between injury and surgery was 11.5 months (1-108). During step 1 (anterior approach), only 1 ramp lesion (2%) was diagnosed. 13 (23%) ramp lesions were found after inspection through the intercondylar notch. No additional lesions were found with a direct view through the posteromedial approach. No correlation between ramp lesions and side, sex, weight, size, or state of physis was found. 10 ramp lesions out of 13 could not be diagnosed on MRI.The prevalence of ACL-associated ramp lesions in children and adolescents is similar to adult populations. A systematic inspection through the intercondylar notch is recommended during ACL reconstruction to make a precise diagnosis. The posteromedial approach is essentially useful for meniscal repair LEVEL OF EVIDENCE: Testing, previously developed diagnostic criteria in a consecutive series of patients and a universally applied "gold" standard, Level I.