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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.

ACL injury is associated with early onset of knee osteoarthritis.

EPIDEMIOLOGY
Incidence
250,000 ACL injuries annually in the United States

Female incidence 2- to 5-fold > male (1)

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.

ETIOLOGY AND PATHOPHYSIOLOGY


Noncontact mechanisms: torsional or hyperextension forces creates anterior translation of the
tibia relative to the femur. This creates excessive stress across the ACL with resultant rupture.

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

Alterations in hormonal balance hypothesized to increase risk, but no conclusive evidence


linking menstrual phase to ACL injury risk.

Anatomic gender differences

Increased Q angle, increased genu valgum, narrower femoral notch size, smaller ACL

Neuromuscular imbalances (increased quadriceps activation, decreased hamstring activity


during landings)

Movement patterns (sudden deceleration, change-of-direction cutting movements, landing


from a jump in hyperextension)

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].

Prophylactic knee bracing does not prevent ACL injury.

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COMMONLY ASSOCIATED CONDITIONS
Meniscal tear

Collateral ligament tear

PCL tear

Tibia or femur fractures

Osteochondral injury

Early-onset degenerative joint disease

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).

Palpate for effusion.

Decreased range of motion (ROM)

Deficits may be secondary to pain, effusion, mechanical blocks (meniscal tear, loose body,
torn ACL stump).

Joint instability

Difficulty bearing weight


Evaluate integrity of extensor mechanism

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]

Knee is placed in 20 to 30 degrees of flexion. Tibia is translated anteriorly with femur


stabilized by the opposite hand. Increased anterior translation compared with uninjured
knee indicates injury. Lack of a solid end point indicates rupture.

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.

Anterior drawer test (3)[B]

Low sensitivity for ACL integrity, especially in acute setting

Posterior drawer test assesses PCL integrity.

McMurray test assesses for meniscal tears.

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

Collateral ligament injury

DIAGNOSTIC TESTS & INTERPRETATION


Initial Tests (lab, imaging)
Radiographs to rule out associated bony injury

Anterior-posterior (AP), lateral, and tunnel views

Segond fracture: avulsion fracture of the lateral capsular margin of the tibia

Tibial eminence avulsion fracture

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Fracture of proximal tibia or distal femur

Osteochondral injuries

Follow-Up Tests & Special Considerations


MRI is the gold standard for imaging ligamentous and intra-articular structures. The sensitivity
of MRI is 87-94%, specificity 88-93% (4).

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).

Ultrasound is an emerging technique that is fast and noninvasive (5)[B].

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

Crutches may be useful until patient is able to ambulate without pain.

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.

Aspiration of large effusion may alleviate pain and increase ROM.

P.11

MEDICATION
First Line
Nonsteroidal anti-inflammatory drugs (NSAIDs)

Acute ligament sprains

Ibuprofen: 200 to 800 mg TID

Naproxen: 250 to 500 mg BID


Acetaminophen: 3 g/day divided TID

Opioids for severe pain (e.g., acetaminophen-hydrocodone)

ISSUES FOR REFERRAL


The decision to manage ACL tears surgically or non-surgically (conservatively) can be difficult.
Consider surgical management in active patients or if the injury interferes with activities of daily
living.

Physical therapy is essential whether an athlete chooses nonsurgical or surgical treatment.


Proper rehabilitation is time-consuming (6 to 12 months) and hard work. Physical therapy
restores ROM, strength, and proprioception.

Preoperative phase

Increase ROM and quadriceps strength, minimize inflammation.

Early postoperative phase: weeks 2 to 4

ROM: Full extension is the primary goal. Rehabilitation begins immediately.

Progress to full weight bearing

Intermediate postoperative phase: weeks 4 to 12

ROM: full flexion, hyperextension

Quadriceps and hamstring strengthening proprioceptive training, normalize gait

Late postop phase: >3 months postop

Straight-line running

Increase speed, duration over 6 to 8 weeks

Progress to cutting and sport-specific drills

Strength and proprioceptive training

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.

No significant difference in patient-reported knee function or muscle strength between surgical


and nonsurgical management (6)[B].

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

Bone-patella tendon-bone autograft

Hamstring autograft

Allograft tendon (from cadaver)

No consistent significant differences in outcome between patellar tendon and hamstring


tendon autografts

In the hamstring autograft approach, double bundle is superior to the single bundle (7)[B].

Concomitant meniscal tears are repaired at the time of ACL reconstruction.

INPATIENT CONSIDERATIONS
Admission Criteria/Initial Stabilization
Outpatient

ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
ROM exercises to regain full flexion and extension

Advance activity as tolerated

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.

2. Acevedo RJ, Rivera-Vega A, Miranda G, et al. Anterior cruciate ligament injury:


identification of risk factors and prevention strategies. Curr Sports Med Rep. 2014:13(3):186-
191.

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.

5. Grindem H, Eitzen I, Engbretsen L, et al. Nonsurgical or surgical treatment of ACL injuries:


knee function, sports participation, and knee reinjury: the Delaware-Oslo ACL cohort study. J
Bone and Joint Surg. 2014;96(15):1233-1241.

6. Koga H, Muneta T, Yagishita K, et al. Mid- to longterm results of single-bundle versus


double-bundle anterior cruciate ligament reconstruction: randomized controlled trial.
Arthroscopy. 2015;31(1):69-76.

7. Mannion S, Mtintsilana A, Posthumus M, et al. Genes encoding proteoglycans are


associated with the risk of anterior cruciate ligament rupture. Br J Sports Med.

UnitedVRG
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

Algorithm: Knee pain

Codes

ICD10
S83.519A Sprain of anterior cruciate ligament of unsp knee, init

M23.619 Oth spon disrupt of anterior cruciate ligament of unsp knee

S83.511A Sprain of anterior cruciate ligament of right 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.

2/3 of complete ACL tears have associated meniscal or articular injuries.

The decision for surgical repair is based on patient age, activity level, and associated
symptoms.

UnitedVRG

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