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ACL Injury
Jeff Wang, MD, MPH
J. Herbert Stevenson, MD
BASICS
DESCRIPTION
The anterior cruciate ligament (ACL) is a primary knee stabilizer that serves to prevent
excessive anterior translation and internal rotation of the tibia on the femur.
During dynamic movement, the ACL and posterior cruciate ligament (PCL) work together to
stabilize the knee.
ACL injuries are common and can occur through multiple mechanisms. >70% of ACL injuries
are caused by noncontact forces.
Although partial tears occur, complete ACL tears are more common.
Due to differences in pelvic architecture and lower extremity alignment, female athletes are at
2 to 5 times higher at risk of ACL tear.
EPIDEMIOLOGY
Incidence
250,000 ACL injuries annually in the United States
Greater incidence of noncontact ACL injuries in sports requiring cutting, pivoting, and rapid
deceleration, such as basketball and soccer (1)
Prevalence
Young athletes (15 to 25 years) sustain >50% of all ACL injuries (1)[B].
> 2/3 of patients with complete ACL tear have associated meniscal and/or articular cartilage
injury.
Pediatric Considerations
Rule out physeal injuries in skeletally immature patients.
The incidence of ACL tears in patients with open physes has increased in recent years.
ACL injury rates increase for both boys and girls after age 11 years.
Direct trauma: most often, a valgus blow to the knee with resultant trauma to ACL, medial
collateral ligament, and lateral meniscus (unhappy triad)
Genetics
A genetic predisposition has been identified. An association has been found between the genes
encoding proteoglycans and the risk of ACL tears (7)[B].
RISK FACTORS
Female athletes have increased risk.
Hormonal influence
Increased Q angle, increased genu valgum, narrower femoral notch size, smaller ACL
GENERAL PREVENTION
Neuromuscular training with proprioceptive, plyometric, and strength exercises significantly
reduce noncontact ACL injuries in female athletes if performed several times a week for >6
weeks (2)[C].
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COMMONLY ASSOCIATED CONDITIONS
Meniscal tear
PCL tear
Osteochondral injury
DIAGNOSIS
HISTORY
Describe mechanism
Noncontact
Sudden deceleration
Cutting, sudden change in direction
Landing from a jump with the knee in extension
Contact with player, object
May recall sudden pop or snap
Sudden pain and giving way
Marked effusion/hemarthrosis within 4 to 12 hours
Pop with deceleration or twisting movement associated with early effusion
and inability to continue with participation are highly suggestive of ACL tear.
PHYSICAL EXAM
Inspect for malalignment (fracture, dislocation).
Deficits may be secondary to pain, effusion, mechanical blocks (meniscal tear, loose body,
torn ACL stump).
Joint instability
Special maneuvers (Lachman; anterior drawer; pivot shift) to assess ACL integrity
Lachman test: most sensitive and highly specific diagnostic test for ACL injury in acute setting
(3)[B]
Pivot shift test: less sensitive, but more than Lachman test: specific for ACL tear (3)[B]
Knee is placed in extension. Knee is flexed while valgus and internal rotation stress is
applied. A positive test is anterior subluxation at 20 to 40 degrees of flexion.
Valgus/varus stress test for medial collateral ligament/lateral collateral (MCL/LCL) integrity
DIFFERENTIAL DIAGNOSIS
Fracture
Meniscal injury
Patellar dislocation/subluxation
Tendon disruption
PCL injury
Segond fracture: avulsion fracture of the lateral capsular margin of the tibia
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Fracture of proximal tibia or distal femur
Osteochondral injuries
Secondary signs of ACL injury on MRI include contusion of the anterior femoral condyle and/or
posterior tibial plateau, anterior translation of the tibia, an uncovered or displaced posterior
horn of the lateral meniscus, PCL buckling, or a Segond fracture (an avulsion fracture of the
lateral tibial condyle).
Diagnostic Procedures/Other
Surgical management should be considered in the active population, young or old.
TREATMENT
GENERAL MEASURES
Acute injury: protection, relative rest, ice, compression, elevation, medications, modalities
(PRICEMM) therapy
Locked knee brace may be used initially for comfort. Use with caution and transition to a
hinged knee brace as soon as possible to avoid quadriceps atrophy and stiffness.
P.11
MEDICATION
First Line
Nonsteroidal anti-inflammatory drugs (NSAIDs)
Preoperative phase
Straight-line running
Geriatric Considerations
Management is based on anticipated activity level, associated injuries, coexisting medical
conditions, and acute versus long-standing ACL deficiency.
SURGERY/OTHER PROCEDURES
The decision for surgery depends on patient's activity level, age, associated injuries, and
presence of osteoarthritis.
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There is an insufficient evidence to recommend surgery over conservative management in
skeletally immature patients.
In young, active adults with acute ACL tears, rehabilitation plus early ACL repair was not
superior to a strategy of initial rehabilitation with delayed repair if rehabilitation alone failed.
Rehabilitation alone results in an overall reduction of ACL reconstructions (6)[B].
Reconstruction techniques
Hamstring autograft
In the hamstring autograft approach, double bundle is superior to the single bundle (7)[B].
INPATIENT CONSIDERATIONS
Admission Criteria/Initial Stabilization
Outpatient
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
ROM exercises to regain full flexion and extension
Patient Monitoring
Assess functional status, rehabilitative exercise compliance, and pain control at follow-up visit.
PROGNOSIS
Athletes typically are out of competitive play for 6 to 9 months after injury for reconstructive
surgery and rehabilitation.
High prevalence of OA, even in those with early ACL reconstruction
Delaying surgical repair of torn ACL increases risk of secondary meniscal injury.
COMPLICATIONS
Instability
Secondary meniscal and articular cartilage injury
Early-onset degenerative arthritis
Surgical risks
Infection, pulmonary embolism (PE), subsequent ACL graft rupture, laxity
due to failure of graft remodeling
REFERENCES
1. Beynnon B, Vacek PM, Newell MK, et al. The effects of level of competition, sport, and sex
on the incidence of first-time noncontact anterior cruciate ligament injury. Am J Sports Med.
2014;42(8):1806-1812.
3. Jain DK, Amaravati R, Sharma G. Evaluation of the clinical signs of anterior cruciate
ligament and meniscal injuries. Indian J Orthop. 2009;43(4):375-378.
4. Grzelak P, Podgrski MT, Stefa czyk L, et al. Ultrasonographic test for complete anterior
cruciate ligament injury. Indian J Orthop. 2015;49(2): 143-149.
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2014;48(22):1640-1646.
Additional Reading
Christiansen BA, Anderson MJ, Lee CA, et al. Musculoskeletal changes following non-invasive
knee injury using a novel mouse model of post-traumatic osteoarthritis. Osteoarthr Cartil.
2012;20(7):773-782.
Frobell RB, Roos EM, Roos HP, et al. A randomized trial of treatment for acute anterior cruciate
ligament tears. N Engl J Med. 2010;363(4):331-342.
Hewett TE, Di Stasi SL, Myer GD. Current concepts for injury prevention in athletes after
anterior cruciate ligament reconstruction. Am J Sports Med. 2013;41(1):216-224.
Mohtadi NG, Chan DS, Dainty KN, et al. Patellar tendon versus hamstring tendon autograft for
anterior cruciate ligament ruptures in adults. Cochrane Database Syst Rev. 2011;
(9):CD005960.
Silvers HJ, Mandelbaum BR. Prevention of anterior cruciate ligament injury in the female
athlete. Br J Sports Med. 2007;(41 Suppl 1):i52-i59.
White K, Di Stasi SL, Smith AH, et al. Anterior cruciate ligament- specialized post-operative
return-to-sports (ACL-SPORTS) training: a randomized control trial. BMC Musculoskelet Disord.
2013;14:108.
See Also
Codes
ICD10
S83.519A Sprain of anterior cruciate ligament of unsp knee, init
Clinical Pearls
Lachman test is the most sensitive and specific physical examination maneuver for diagnosing
acute ACL injury.
Bone contusion of the anterior femoral condyle and/or posterior tibial plateau on MRI is highly
suggestive of ACL tear.
The decision for surgical repair is based on patient age, activity level, and associated
symptoms.
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