Purpose To evaluate the prevalence of and factors associated with meniscal ramp lesions on magnetic resonance imaging (MRI) in patients with anterior cruciate ligament (ACL) injuries. Methods Data from the Natural Corollaries and Recovery after ACL injury multicentre longitudinal cohort study (NACOX) were analysed. Only patients who underwent MRI were included in this study. All MRI scans were reviewed by an orthopaedic knee surgeon and a musculoskeletal radiologist. The patients were divided into two groups, those with and without ramp lesions according to MRI findings. Univariable and stepwise forward multiple logistic regression analyses were used to evaluate patient characteristics (age, gender, body mass index, pre-injury Tegner activity level, activity at injury) and concomitant injuries on MRI (lateral meniscus, medial collateral ligament MCL, isolated deep MCL, lateral collateral ligament, pivot-shift-type bone bruising, posteromedial tibial PMT bone bruising, medial femoral condyle bone bruising, lateral femoral condyle LFC impaction and a Segond fracture) associated with the presence of meniscal ramp lesions. Results A total of 253 patients (52.2% males) with a mean age of 25.4 ± 7.1 years were included. The overall prevalence of meniscal ramp lesions was 39.5% (100/253). Univariate analyses showed that contact sports at ACL injury, pivot-shift-type bone bruising, PMT bone bruising, LFC impaction and the presence of a Segond fracture increased the odds of having a meniscal ramp lesion. Stepwise forward multiple logistic regression analysis revealed that the presence of a meniscal ramp lesion was associated with contact sports at ACL injury odds ratio (OR) 2.50; 95% confidence intervals (CI) 1.32–4.72; P  = 0.005, pivot-shift-type bone bruising (OR 1.29; 95% CI 1.01–1.67; P  = 0.04), PMT bone bruising (OR 4.62; 95% CI 2.61–8.19; P  < 0.001) and the presence of a Segond fracture (OR 4.38; 95% CI 1.40–13.68; P  = 0.001). Conclusion The overall prevalence of meniscal ramp lesions in patients with ACL injuries was high (39.5%). Contact sports at ACL injury, pivot-shift-type bone bruising, PMT bone bruising and the presence of a Segond fracture on MRI were associated with meniscal ramp lesions. Given their high prevalence, meniscal ramp lesions should be systematically searched for on MRI in patients with ACL injuries. Knowledge of the factors associated with meniscal ramp lesions may facilitate their diagnosis, raising surgeons’ and radiologists’ suspicion of these tears. Level of evidence III.