PURPOSE: To compare the risk of a secondary bucket handle tear (BHT) of the medial and lateral menisci after an anterior cruciate ligament reconstruction (ACLR) with an unrecognized ramp lesion. The hypothesis was that an unrecognized ramp lesion would be associated with a secondary medial meniscus BHT more often than a lateral meniscus BHT. METHODS: A retrospective review of adults aged 18 or older who experienced a meniscal BHT after ACLR was conducted. An analysis of the clinical and radiological data from initial injury to revision surgery was completed. Two experts retrospectively documented the prevalence of ramp lesions present on preoperative magnetic resonance imaging (MRI) at the time of the index ACLR. The predictive value of a ramp lesion for BHT laterality was evaluated using logistic regression. RESULTS: Seventy-six patients, 46 in the medial BHT group and 30 in the lateral BHT group, were included. A ramp lesion was present on the preoperative MRI in 33 patients in the medial BHT group compared to 13 in the lateral BHT group ( CONCLUSION: After a primary ACLR, an untreated ramp lesion was associated with a post-operative medial BHT more often than a lateral BHT. Unrepaired ramp lesions may be a risk factor for subsequent medial meniscus BHT after primary ACLR. LEVEL OF EVIDENCE: Level IV.