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Three major types of ACL injuries are distinguished:[7]

Direct contact

Indirect contact

Non contact

Most common are the non contact injuries, caused by forces generated within the
athletes body while most other sport injuries involve a transfer of energy from a source
external to the athletes body.[8] A cut-and-plant movement is the typical mechanism that
causes the ACL to tear: sudden change of direction or speed with the foot firmly planted.
A direct impact to the front of the tibia or stiff-legged landing are other frequently
reported causes.
Women are three times more prone to have the ACL injured then men. It is due to
following reasons [9]

Smaller size and different shape fo the intercondylar notch

Wider pelvis and greater Q angle

Greater ligament laxity

Shoe surface interface

Neuromuscular factors

A wider pelvis requires the femur to angle toward the knee, lesser muscle strength gives
less support to the knee and hormonal variations may alter the laxity of ligaments.[10][11]

Biomechanics of injury
As 60-80% of ACL injuries occur in non-contact situations, it seems likely that
appropriate prevention efforts are warranted. Cutting or sidestep maneuvers are
associated with dramatic increases in the varus-valgus and internal rotation moments.
The ACL is placed at greater risk with both varus and internal rotation moments. The
typical ACL injury occurs with the knee externally rotated and in 10-30 of flexion when
the knee is placed in a valgus position as the athlete takes off from the planted foot and
internally rotates with the aim of suddenly changing direction.(fig shown below). [12][13]The
ground reaction force falls medial to the knee joint during a cutting maneuver and this
added force may tax an already tensioned ACL and lead to failure. Similarly, in landing
injuries, the knee is close to full extension. High-speed activities such as cutting or
landing maneuvers require eccentric muscle action of the quadriceps to resist further
flexion. It may be hypothesized that vigorous eccentric quadriceps muscle action may
play a role in disruption of the ACL. Although this normally would be insufficient to tear
the ACL, it may be that the addition of valgus knee position and/or rotation could trigger
an ACL rupture.[14]


Non-Contact ACL Mechanism

The athlete could be off balance, be held by an opponent, be trying to avoid collision with
an opponent, or have adopted an unusually wide foot position. These perturbations
contribute to the injury by causing the athlete to plant the foot so as to promote
unfavorable lower extremity alignment; this may be compounded by inadequate muscle
protection and poor neuromuscular control.[16] Fatigue and loss of concentration may also
be a factor. What has become recognized is that unfavourable body movements in
landing and pivoting can occur, leading to what has become known as the 'functional
valgus' or 'dynamic valgus' knee, a pattern of knee collapse where the knee falls medial
to the hip and foot. This has been called by Ireland the 'position of no return', or
perhaps it should be termed the 'injury prone position' since there is no proof that one
cannot recover from this position[17]. Intervention programs aimed to reduce the risk of
ACL injury are based on training safer neuromuscular patterns in simple maneuvers such
as cutting and jump landing activities.[18]

Position of No Return

Grades of injury
An ACL injury is classified as a grade I, II, or III sprain.[19]
Grade I sprain o The fibres of the ligament are stretched but there is no tear. o There is
a little tenderness and swelling. o The knee does not feel unstable or give out during
activity. o No increased laxity and there is a firm end feel.
Grade II sprain o The fibres of the ligament are partially torn or incomplete tear with
haemorrhage. o There is a little tenderness and moderate swelling with some loss of
function. o The joint may feel unstable or give out during activity. o Increased anterior
translation yet there is still a firm end point. o Painful and pain increase with Lachman's
and anterior drawer stress tests.
Grade III sprain o The fibres of the ligament are completely torn (ruptured); the
ligament itself has torn completely into two parts. o There is tenderness but not a lot of
pain, especially when compared to the seriousness of the injury. o There may be a little
swelling or a lot of swelling. o The ligament cannot control knee movements. The knee
feels unstable or gives out at certain times. o There is also rotational instability as
indicated by a positive pivot shift test. o No end point is evident. o Haemarthrosis occurs
within 1-2 hours.
An ACL avulsion occurs when the ACL is torn away from either the upper leg bone or
lower leg bone. This type of injury is more common in children than adults. The
term anterior cruciate deficient knee refers to a grade 3 sprain in which there is a
complete tear of the ACL. It is generally accepted that a torn ACL will not heal.[20]

Characteristics/Clinical Presentation[1]

Occurs after either a cutting maneuver or one leg standing, landing or jumping

There may be an audible pop or crack at the time of injury

A feeling of initial instability which may be masked later by extensive swelling

Episodes of "giving way" especially on pivoting or twisting motions. Patient has a

"trick knee" and a predictable instability
A torn ACL is extremely painful, particularly immediately after sustaining the
Swelling of the knee, usually immediate and extensive, but can be minimal or
Restricted movement, especially an inability to fully extend

Possible widespread mild tenderness

Tenderness at the medial side of the joint which may indicate cartilage injury

Associated Injuries
Injuries to ACL rarely occur in isolation. The presence and extent of other injuries may
affect the way in which the ACL injury is managed.[21]

Meniscal Lesions
Over 50% of all ACL ruptures have associated meniscal injuries. If seen in combination
with a medial meniscus tear and MCL injury, it is calledODonohues triad.[1] which has 3

Anterior cruciate ligament (ACL) tear

Medial collateral ligament (MCL) tear / strain

Meniscal tear

Medial Collateral Ligament Injuries

Associated injury to MCL (grade I-III) poses a particular problem due to tendency to
develop stiffness after this injury. Most orthopaedic surgeons will first treat MCL injury in
a limited-motion knee brace for a period of six weeks, during which time the athlete
would undertake a comprehensive rehabilitation program. Only then would ACL
reconstruction be performed or be treated.[22]

Bone Contusions and Microfractures

Subcortical trabecular bone injury (bone bruise) may occur due to the pressures exerted
on the knee in traumatic injury and are especially associated with ACL rupture.
Associated injuries of the menisci and the MCL tended to increase the progression of
bone contusion[23]. The focal signal abnormalities in subchondral bone marrow seen on
MRI (undetectable on rdiographs) are thought to represent microtrabecular fractures,
haemorrhage and edema without disruption of adjacent cortices or articular cartilage.
Bone contusions may occur in isolation to ligamentous or meniscal injury.[25]
Occult bony lesions have been reported in 84-98% of the patients with ACL rupture. [23][26]
The majority of these have lesions of the lateral compartment[28], involving either the
lateral femoral condyle, the lateral tibial plateau, or both. The boney bruising itself is
unlikely to cause pain or reduced function.[29] Although the majority of bony lesions
resolve, permanent alterations may remain. There is confusion in the literature as to how

long these bony lesions remain. However, it has been reported that they can persist on
MRI for years[30]. Rehabilitation and the long-term prognosis may be affected in those
patients with extensive bony and associated articular cartilage injuries. In the case of
severe bone bruising it has been recommended to delay return to full weightbearing
status to prevent further collapse of subchondral bone and further aggravation of
articular cartilage injury.[30]

Chondral Injury
Hollis et al suggested that all patients following traumatic ACL disruption sustained a
chondral injury at the time of initial impact with subsequent longitudinal chondral
degradation in compartments unaffected by the initial bone contusion a process that is
accelerated at 5 to 7 years follow-up[31].

Tibial Plateau Fractures

A tibial plateau fracture is a bone fracture or break in the continuity of the bone occurring
in the proximal part of the tibia or shinbone called the tibial plateau; affecting the knee
joint, stability and motion. The tibial plateau is a critical weight-bearing area located on
the upper extremity of the tibia and is composed of two slightly concave condyles (medial
condyle and lateral condyle) separated by an intercondylar eminence and the sloping
areas in front and behind it. It can be divided into three areas: the medial tibial plateau
(the part of the tibial plateau that is nearer to the center of the body and contains medial
condyle), the lateral plateau (the part of the tibial plateau that is farthest away from the
center of the body and contains the lateral condyle) and the central tibial plateau (located
between the medial and lateral pleateaus and contains intercondylar eminence).
These fractures are also cause by a varus (inwardly angulating) or valgus(outwardly
angulating) force combined with axial loading or weight bearing on knee and are occur
rarely alone, mostly occur with ACL injuries. The fracture of lateral tibial plateau is also
called as Segond fracture which is most common to occur with ACL injury.

Posterolateral Corner Injury

The stability of the posterolateral corner of the knee is provided by capsular and
noncapsular structures that function as static and dynamic stabilizers[32] including the
fibular collateral ligament, the popliteus muscle and tendon including its fibular insertion
(popliteofibular ligament), and the lateral and posterolateral capsule. Injuries to this
region that result in posterolateral rotatory instability can be but are uncommonly
isolated; usually these injuries are associated with concurrent ligamentous injuries
elsewhere in the knee.[33][34][35][36]High-grade posterolateral corner injuries are usually
associated with rupture of one or both cruciate ligaments. Importantly, failure to address
instability of the posterolateral corner structures increases forces at anterior cruciate
ligament (ACL) and PCL graft sites and may ultimately predispose to failure of the
cruciate reconstruction.[37][38][39] (See also: Knee Rotary Instability)

Popliteal Cyst
Diagnostic Procedures
An exact diagnosis can be made by the following procedures:

1. PHYSICAL EXAMINATION which includes the following important tests;

Lachman test

Anterior drawer test of the knee

Pivot shift

Radiographs of the knee should be performed when an ACL tear is suspected, including
AP view, lateral view and patellofemoral projection. The standing AP weight-bearing view
provides a way of evaluating the joint space between the femur and tibia.[40] It also allows
for measurement of notch width index which provides important predictive values for ACL
tears.[41]. The patellar tendon and height are measured on lateral radiograph. A tunnel
view may also be helpful. The Merchant's radiograph view [42] not only shows the joint
space between the femur and patella but also helps to determine whether the patient has
patellofemoral malalignment. The presence of the following factors should be noted
clearly during review of an x-ray.

Notch width index

Osteochondral fracture

Segond fracture

Bone bruise

Notch width index is the ratio of the width of the intercondylar notch to the width of
the distal femur at the level of the popliteal groove measured on a tunnel view
roentgenogram of the knee. The normal intercondylar notch ratio was 0.231 0.044.
The intercondylar notch width index for men is larger than that for women. It was found
that athletes with noncontact anterior cruciate ligament injuries had a notch width index
that was at least 1 standard deviation below the average, meaning that a person with an
ACL injury is more likely to have a small notch width index compared to normal. It is
measured with the help of a ruler placed parallel to joint line. The narrowest portion of
the notch at the level of ruler is measured.[43] In more chronic ACL injuries, there may be
intercondylar eminence spurring or hypertrophy, or patellar facet osteophyte formation.

Notch Width Index

Notch Width Index


This is also one of the reasons why women are more prone to ACL injuries compared to
men. It has also been seen that the value of inner angle of lateral condyle of femur was
significantly higher in women athletes with ACL tear compared to those without. Value of
width of intercondylar notch was statistically smaller in athletes with ACL tear, compared
to those without. Also it was seen that the inner angle of lateral femoral condyle is a
better predictive factor for ACL tears in young female handball players compared to
intercondylar notch width.[44]
In more chronic ACL injuries, there may be interchondral eminence spurring or
hypertrophy, patellar facet osteophyte formation, or joint space narrowing with marginal
osteophytes. It is particularly important in skeletally immature patients to have plain
radiographic assessment. This is because there is frequently a ligamentous avulsion in
this age group.
Bone bruise is usually present in conjunction with an ACL injury in more than in 80% of
cases.[45] The most common site is over the lateral femoral condyle. The bone bruise is
most likely caused by impaction between the posterior aspect of the lateral tibial plateau
and the lateral femoral condyle during displacement of the joint at the time of the injury.
The presence of bone bruise indicates impaction trauma to the articular cartilage.

Patients with bone bruises are more prone to develop osteoarthritis later.[47] Bone bruise
can be seen most prominently in MRIs.

3. MRI:
MRI has the advantage of providing a clearly defined image of all the anatomic structures
of the knee. A normal ACL is seen as a well-defined band of low signal intensity on
sagittal image through the intercondylar notch. With an acute injury to the ACL , the
continuity of the ligament fibers appears disrupted and the ligament substance is ill
defined, with a mixed signal intensity representing local edema and haemorrhage. [48]
MRI can diagnose the ACL injuries with an accuracy of 95% or better.[49] MRI will also
reveal any associated meniscal tears, chondral injuries or bone bruises.
An adjunct ot the clinical special tests in assessing anterior translation is the use of
instrumented laxity testing. The most commonly cited arthrometer is the KT1000
(Medmetric,San Diego,Calif). The arthrometer provides an objective measurement of the
anterior translation of the tibia that supplements the Lachman test in ACL injury. It can
be particularly useful in the examination of acutely injured patients in whom pain and
guarding may preclude evaluation. In such patients the Lachman and other tests can be
difficult to perform accurately. The arthrometeric results can be used as a diagnostic tool
to assess ACL integrity or as part of the follow up examination after ACL reconstruction.
The results of the KT1000 and its sibling. the KT 2000 have been noted to be both
reliable and accurate.[51]

Differential Diagnosis
The same characteristics for an ACL injury can be found at knee
dislocations andmeniscal injuries and collateral
ligaments injury or posterolateral corner of the
knee. Other problems that have to be considered are patellar dislocation or fracture,
and a femoral, tibial or fibular fracture.
The differential diagnosis of an acute hemarthrosis of the knee due to ACL in addition to
a major ligamentous tear would include meniscal tear or patellar dislocation or
osteochondral fracture.
Differentiation can mostly be made based on a thorough examination with particular
attention for the mechanism at time of injury. An additional MRI scan can visualize the
Can you spot the ACL and associated injuries in the MRI below?

The examination of ACL injury can be done in two ways

Physical/ Clinical examination

Examination under anesthesia and arthroscopy

Physical/ Clinical Examination:

An organized, systematic physical examination is imperative when examining any joint.

Immediately after the acute injury, the physical examination may be very limited due to
apprehension and guarding by the patient.While inspecting, the examiner should look
for [53]

overall alignment of the knee.

severe distortion of the normal alignment may represent a fracture of the distal
femur or proximal tibia or indicate knee dislocation.
Any gross effusion, which most commanly be present within a few hours after an
ACL injury. Absence of an effusion does not mean that an ACL injury has not
occured; in fact, with more severe injuries that include the surrounding capusle
and soft tissues, the hemarthrosis may be able to escape from the knee, and the
degree of swelling may paradoxically be diminished. In addition, the presence of
swelling an effusion does not guaurantee that an ACL injury has occured.
According to Noyes et al, in the absence of bony trauma, an immediate effusion is
believed to have a 72% correlation with an ACL injury of some degree.
Bony abnormality may suggest an associated fracture of the tibial plateau.

Palpation follows inspection and should begin with the uninvolved extremity.
Palpation confirms the presence and degree of effusion and bony injury. Subtle
effusions missed during inspection should be picked up by the careful manual
examination. Palpation of joint lines and collateral ligaments can rule out a
possible associated meniscus tear or sprained ligaments.
Periarticular tenderness should also be examined.
Assessing the patients range of motion (ROM) should be carried out to look for
lack of complete extension, secondary to a possible bucket-handle meniscus tear
or associated loose fragment.
Laxity testing should be done either with the special test or with the help of

Examination under anaesthesia and arthroscopy:

Arthroscopy combined with examination under anesthesia is an accurate way to diagnose
a tore ACL, it may be indicated in the case in which the diagnosis is suspected from the
patient's history but is not evident on clinical examination. the main value of using
arthroscopy on the basis of examination is to diagnose associate joint pathologic
conditions such as meniscal tears or chondral fractures