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ApproachingtheRupturedAnteriorCruciateLigament
KhaledMSarrafAmirSadriGowreesonThevendranVikasVedi
EmergMedJ.201128(8):644649.

AbstractandIntroduction
Abstract

Anteriorcruciateligament(ACL)disruptionsarecommoninjuriesthatcurrentlyholdafearsomereputationamongathletesofall
abilitiesanddisciplines.Indeed,ifthediagnosisismissedatfirstpresentation,itisdifficulttoattributeongoinginstabilityand
recurrentinjurytoanACLtear.Classically,patientsthenoftenimproveshortlybeforerepeatedlyreinjuringtheirknee.Atsome
point,thekneemaylock,necessitatinganarthroscopicmeniscectomy.Tragically,thisthenhastenstheprogressionofjoint
arthrosisandthedeclineofthejointfunction.Whiletheburdenofresponsibilitydoesnotliesolelywiththejuniordoctororthe
generalpractitioner,itisoftenatthefirstconsultationthatthenaturalhistoryofthisdevastatinginjuryisdecided.Theabilityto
recognise,instituteearlymanagementandreassurepatientswithACLtearsaboutthefutureisaninvaluableassettothenon
specialistjuniordoctor.Oncediagnosed,theresponsibilityofadvisingandfurthercounsellingofpatientswithACLinjuriesisbest
lefttotheorthopaedickneespecialist.Familypractitionersandemergencyroomdoctorsshouldnotfeelpressuredtoofferadvice
onspecialistareassuchasreturntosportswithoutreconstructionorindeedtheneedforreconstruction.Indeed,decisionsto
returntosportswithACLdeficientkneeshavealltoooftenledtodisastrousreinjuryeventstothearticularcartilageand/orthe
menisci.
Introduction

The35mmlengthofconnectivetissuethatistheanteriorcruciateligament(ACL)isperhapsthemostpublicisedpieceof
collageninthehumanbody.Attimes,spellingtheendofacareerforprofessionalfootballersorrugbyplayers,thenaturalhistory
oftheACLdeficientknee,however,remainssomewhatspeculative.Therecanbenodoubtthatsomepatientsfunctionatahigh
levelwithlittleornodifficulty,whileothersaretroubledmarkedlybyfunctionalinstabilityrequiringdrasticchangestotheir
lifestyle.ACLinjuriescanresultinfunctionalinstability,meniscalinjuriesandearlyonsetosteoarthritis. [12]Inaddition,ACL
injuriestendnottooccurinisolation(<10%ofcases), [1]andassociatedinjuriesmustbesought.TheACListhemostcommonly
injuredligamentinathleticpeople[1]forwhichsurgeryisperformed.TheincidenceofACLinjuryisreportedtobehigheramong
femaleathletes, [3]althoughtheprevalenceofsuchinjuriesishigherinmaleathletesbecausetheyaremorelikelytoengagein
highrisksports[4]thatmaydamagetheACL.
Previousstudies[5]havesuggestedanincidenceofkneeligamentinjuriesinthegeneralpopulationof~30per100000
populationperyear.Thus,anemergencydepartmentinanaveragedistrictgeneralhospitalintheUKmayencounteratleasttwo
oftheseinjuriesaweek.
In1983,Noyesetal[6]madeanobservationthatthediagnosisofACLrupturewasmadebytheoriginaltreatingphysicianinonly
6.8%ofcases.Interestingly,some12yearslater,despiteescalatingpublicityandanexplosionofliterature,BollenandScott [7]
reportedthatthediagnosisofACLrupturewasmadebytheoriginaltreatingphysicianinonly9.8%ofcases,ameagre
improvement.Beynnonetal[8]demonstratedthattherewaspooragreementbetweenemergencyroomphysiciansand
orthopaedicsurgeonswhenelicitingsignsinpatientswithACLinjury,thusfewerdiagnosesweremadeasaresult.
Itishelpfulifthenonspecialist,thefirstpointofcontactforanewpatient,bemindfulofapossibleACLinjuryinapatient
presentingwithkneetrauma.Itisthisawarenessthatpromptsasubsequentreferraltoakneeorreviewclinicwhereamore
definitivediagnosiscanbemade.ThisreviewarticleisintendedtoprovideanoverviewofACLinjurieswithregardtoanatomy,
mechanismofinjury,examination,investigationandmodesoftreatment.Itwillhelpemergencyphysiciansandgeneral
practitionerswhoarepresentedwithsuchcomplexinjuriestobeawareofdiagnosticpitfalls,thenaturalhistoryofthis
catastrophicinjury,andtheimportanceofanearlyorthopaedicspecialistconsultation.

Method
WesearchedMedline(1966toJune2009),EMBASE(1988toMay2009),CINAHL(1995toJune2009),CurrentContents(9
February2008to1April2009),TheCochraneLibraryandreferencelistsofarticlesandconsultedexperts.Searcheswere
performedusingthekeywordsanteriorcruciateligamentcrossedwithsearchtermsas'management','reconstruction',
'presentation'and'pathophysiology'.Studyselection,dataextractionandqualityassessmentwereperformedindependentlyby
KMSandAS.Inclusioncriteriawere:(1)investigationofatleastoneaspectoftheacutelyrupturedACL(2)randomisedand
quasirandomisedcontrolledstudiesofACLruptures.Thissearchstrategyidentified143papers,39ofwhichwereselected.
Anatomy
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TheACLisanintraarticular,extrasynovialligamentfoundwithinthekneejoint.Itcoursesfromtheanteriorintercondylarareaon
thetibiaandrunssuperiorly,posteriorlyandlaterallytoattachtothemedialaspectofthelateralfemoralcondyle.Itiscomposed
oftwobundles,namedanteromedialandposterolateralaccordingtothefemoralattachmentsite[9](figure1).Theanteromedial
fibresattachmoreproximallyonthefemoralsitecomparedwiththeposterolateralfibres.Itsmainbloodsupplyisfromthe
middlegeniculateartery.

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Figure1.

Anteriorviewoftheanteriorcruciateligament.Red,anteromedialblue,posterolateral.
TheACLhastwomainfunctions:tocontrolanteriortranslationofthetibiaonthefemurandrotationalmovementofthefemur
onthefixedtibia. [10]Italsoaidsproprioceptionwithinthekneethroughmechanoreceptors. [10]
Furthermore,thetwoACLbundlesbecomefunctionalaccordingtothepositionoftheknee.Intheextendedposition,the
bundlesareparallel(figure2,top).Theposterolateralfibresaretaut,thuslimitinganteroposteriortranslationandrotational
movementsofthetibiaonthefemur.Intheflexedposition,thetwobundlesarecrossed(figure2,bottom),withthe
anteromedialfibrestaut,thuslimitingtranslationalmovementsofthetibiaonthefemur.

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Figure2.

Changesinpositionandtensionoftheanteriorcruciateligamentbundlewithkneeposition.Intheextendedposition,thebundles
areparallel(top),andintheflexedposition,thetwobundlesarecrossed(bottom).Red,anteromedialblue,posterolateral.
MechanismofInjury

ACLtearsareusuallynotrelatedtodirecttrauma. [11]Thecommoninjurypatternsincludeasuddenchangeofdirectionwhilethe
footweariscaughtintheground,oruncontrolledlanding.ThebiomechanicsofanACLinjuryinvolvecertainmovementswithin
theknee.Theseincludeflexionvalgusexternalrotationmovement,flexionvarusinternalrotation,extremeexternalrotationof
thefemuronthetibiaorhyperextension. [10]
DamagetotheACLcanbelimitedtoasinglebundleorboththiscanaffecttheresidualfunctionaloutcomeafterinjury.
HistoryandExamination

Intheacutesituation,theremaybeahistoryofinjury,andsomepatientsreportanaudible'pop'withintheknee. [12]Reportsof
immediateswellingofthekneearecommon,andthisisduetobleedingfromthehighlyvascularACL. [12]Patientsareusually
unabletocontinuewiththeactivitytheywereperformingandhavedifficultyinfullweightbearing.
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ThediagnosisofatornACLischallengingintheearlypostinjurystagewhenpain,acuteswellingandmuscleguardingmakethe
subtleobservationofwhatisoftenaverysmallincreaseinkneelaxity(anteriortranslation)difficulttoperceive.Rarely,there
remainsasmallwindowofopportunity,oftenlastingseveralhours,betweenthetimeofruptureandsubsequentindurationand
guarding,whenacarefulexaminationmayprovediagnostichowever,thisismorecommoninthecaseofprofessionalathletes.
Intheabsenceofbonytrauma,animmediateeffusionisthoughttohavea72%correlationwithsomedegreeofACLdamage.
[13]

Inadditiontothestandardkneeexaminationandassessmentofneurovascularstatus,teststhatcanaiddiagnosis,iftolerated,
aretheanteriordrawer,Lachmanandpivotshift.
LachmantestThekneeisplacedin2030degreesofflexion.Thefemurisstabilisedwiththenondominanthand.Ananteriorly
placedforceisappliedtotheproximaltibiawiththedominanthand.Theamountoftranslationofthetibiaonthefemur,andthe
firmnessofthe'endpoint'shouldbecomparedwiththatofthecontralateralknee(figure3)

Figure3.

Lachmankneeexamination.
AnteriordrawertestThistestcanbeunreliableandthusimpracticalbecauseoftheinabilitytoflexthekneeafteranacute
injury.Anegativetestthereforeisnotvaliduntilitisperformedonthefullyrelaxedknee.Thetestisperformedwiththeknee
flexedto90degreesinasupinepatient.Theexaminersitsonthepatient'sfootandgraspsthekneewithbothhands,thumbs
placedoverthetibialtuberosity.Ananteriorforceisapplied.Theamountoftibialtranslationanteriorlyiscomparedwiththaton
thecontralateralside(figure4).

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Figure4.

Anteriorposteriorkneeexamination.
PivotshifttestInthefullyextendedACLdeficientknee,thetibiaisreducedrelativetothefemur(figure5A).Astheknee
beginstoflex,gravityresultsintranslationofthetibia(figure5B).At~40degreesofflexion,thetranslationreduces,resultingin
'shiftingorpivoting'ofthetibiaintoitscorrectalignmentwiththefemur.This'jumping'isduetotheiliotibialbandfallingbehind
theaxisofrotationofthefemur.Thepivotshifttestisbestperformedwiththepatientfullyrelaxed.Thelegisextended,thefoot
ininternalrotation,andavalgusstressisappliedtothetibia.

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Figure5.

Pivotshiftkneeexamination.
Ostrowski[14]showedthatapositiveresultforthepivotshifttesthasadiagnosticsensitivityandspecificityof48%and98%,
respectively,forACLrupture.However,anegativeLachmantest(sensitivityof93%andspecificityof99%)isthebestforruling
outanACLrupture.Healsoconcludedthat,solelyusingsensitivityandspecificityvalues,theLachmantestisabetteroverall
testforbothrulinginandrulingoutACLruptures. [14]Theanteriordrawertestisinconclusiveforinferringstrongconclusions
eitherway. [14]Asystematicreview[15]identified35studiesthatusedtheresultofarthroscopicsurgeryasthereferencestandard
andcommentedontherelativeaccuracyofthemostwidelyusedmanoeuvres.ApositiveLachmantestorpivotshiftisstrong
evidenceofanACLtear,andanegativeLachmantestisfairlygoodevidencetorefutethisinjury.
Inpractice,giventhedelayinpresentation,thevastmajorityofthegeneralpublicwithanacutelyinjuredswollenkneemaynot
beamenabletotheaboveprovocativetests.Therefore,theutilisationofthesediagnostictestsbecomesmorepracticalinthe
settingofareviewcliniconcetheacuteswellinghassettled,usuallyatleast10dayslater.
AssociatedInjuries

DamagetotheACLcanoccurinassociationwithotherkneeinjuries.Thiscomplicatesthemanagementandeventualoutcome
ofACLtears.Thetypesofinjurythatcanoccurinclude:
1. Ligamentousinjurythiscanrangefromamildsprainofoneotherligamenttocompletetearsofallkneeligaments. [16]
2. Meniscaldamageoccursin1540%ofacuteACLtearsandbecomesmuchmorecommonwithchronicACLdeficiency.
[17]

3. Osteochondrallesions(bonebruising)80%ofACLtearsareassociatedwithbonebruising. [18]Thisessentiallyincludes
damagetothearticularcartilagefromthecrusheffectofthetibialplateauandthefemoralcondyles.Suchlesionscan
developintoosteoarthritis.
O'Donaghue[19]describedaclassictriadinvolvingacombinationofmedialmeniscal,medialcollateralandACLdisruption,
commonlyreferredtoasthe'unhappytriad'.
Investigations

PlainradiographsofthekneeintheanteroposteriorandlateralprojectionsshouldbeobtainedinthesuspectACLdeficientknee.
Althoughnotcommon,certainradiologicalstigmatamaysometimesprovidecluestoapossibleACLpathology.Thefirstisa
Segondfracture(figure6).Thisisalateralcapsularavulsionfractureseenonananteroposteriorview,whichindirectlyimpliesan
ACLinjury.Thesecondisavulsionofthetibialeminence,whichissometimesseeninjuvenileswithopenphysesand
occasionallyinadults.

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Figure6.

ASegondfractureseenoccasionallyonplainanteroposteriorradiographsofthekneeinanteriorcruciateligamenttearslateral
capsularavulsion.
MRIiscurrentlythemostaccuratenoninvasivemethodofidentifyingtheACL(sensitivity,86%sensitivity,95%)[20](figure7A).
Itisalsousefulinidentifyingassociatedinjuriessuchascollateralligamentdamage,bonebruising,andmeniscalandarticular
cartilagedamage[1](figure7B).However,theMRIscanremainsanadjuncttothediagnosticprocessandoftenafirmclinical
diagnosisnegatestheneedforthiscostlyimagingmodality. [21]

Figure7.

SagittalviewofakneeMRIscanshowinganintact(A,arrow)andaruptured(B,arrow)anteriorcruciateligament(ACL).
Furthermore,ACLtearscanalsobediagnosedduringarthroscopicevaluationofthepainfulorunstableknee.
Treatment

Intheemergencydepartment,itisimportanttoattemptrestorationoffullextensionwithanalgesia,elevationandcoldpacks.
Theimportanceofearlymobilisationcannotbeoveremphasised. [22]Whilethereisascientificbasistosupporttheuseofbraces
inthechronicallyACLdeficientkneeandkneesafterACLreconstruction,theroleoffunctionalkneebracingintheacutely
rupturedACLissomewhatlessclear.Swirtunetal[23]showedapositiveeffectwiththebracewithregardtofeelingsofinstability
andrehabilitation,butnosignificantdifferencewithrespecttokneeosteoarthritisscores,painscoresormusclepeaktorque.
Rigorousphysiotherapyisneededbeforethekneecanbemobilisedenoughtoalloweitherconservativetreatmentorindeeda
delayedACLreconstruction. [24]Inthesmallcohortofhighlymotivatedathletes,earlyjointmotionisparticularlycrucialsoasnot
tojeopardisetheoptionofanearlyACLreconstruction. [25]AspirationofahaemarthrosisisrarelyindicatedinpatientswithACL
disruption.Equally,anurgentarthroscopyisonlyindicatedifthereisafixedflexiondeformityofthekneesuggestiveofa
mechanicalimpingement.Significantvalguslaxityapparentoninitialexaminationshouldbedealtwithbyusingahingedknee
braceallowingearlymovementinthesagittalplane.
CounsellingapatientwithacuteACLdisruptionoftenbeginswiththeemergencyphysicianintheemergencydepartment.
ReconstructivesurgeryoftheACLisnotrequiredinallpatientswithsuchinjuries. [26]ManypatientswithACLtearscanwalk,
run,climbstairsandrideabikenormally.ThisisnotduetohealingofthedamagedACL,butthroughcompensatoryinvolvement
ofotherstaticanddynamicstabilisersoftheknee. [27]
Ingeneral,healingandregenerationoccurpoorlyinatornACL. [28]Thetwoendsofarupturedligamentarebathedinsynovial
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fluidandareoftencompletelydisassociated,impedinganyhealingresponseacrossawidegap. [28]Inaddition,theACLhasonly
athinvascularisedsynoviallining.Althoughspeculative,itisbelievedtearingoftheACLresultsindisruptionofthisthinsynovial
liningandthereforetheabsenceofalocalisedhaematomasurroundingthetornsegments.Hence,thereisafailureofthe
expectedinflammatoryresponsewithitsassociatedfibroblastmigrationandremodellingwithsubsequentregenerationasseenin
bonefractures. [29]
Reconstructionisgenerallywarrantedforpatientswithsymptomsofinstabilityduringnormalactivitiesofdailyliving,often
describedastheknee'givingway'orthepatientclaimingthatthey'don'ttrusttheirknee'.Itisalsoindicatedinpatientswith
occupationalrequirementsandthosewantingtoresumesportsthatrequirepivotingmovementssuchasfootballandrugby.
Assessingtheinjuredchildmayprovemorechallenging,astheymaynotbecompletelyforthrightabouttruesymptomsof
instability.Adescriptionthat'mykneejustdoesn'tfeelright'maybeallthatiselicitedduringhistorytaking.
ConservativeManagement

TheimmediatetreatmentofACLtearsisthesameasformostmusculoskeletalinjuries.Conservativemeasuresincluderest,ice,
compressionandelevation(RICE).Nonsteroidalantiinflammatorydrugscanalsobegivenasanalgesiaandthesehelpto
reduceswelling.
NonoperativetreatmentoftheACLdeficientkneedependsonenhancementofneuromuscularcontrolofthekneewithstrength
training(hamstrings),controlandagility. [30]
KneebracinghasbeenshowntosignificantlyimproveinstabilitysymptomsinpatientswithACLtears.Ithasalsobeenshownto
beapositiveaidinrehabilitation. [23]However,bracinghasnoeffectonpeakquadricepsmusclestrengthgainorthe
developmentofposttraumaticosteoarthritis. [23]
Ultimately,thepatientwhochoosestohavenonoperativetreatmentmustberemindedthattheyremainvulnerableandthat
regularandconsistentphysiotherapyinvolvingstrengtheningexercisesisrequiredtoachieveagoodfunctionaloutcome.Studies
haveshownthatisolatedACLrupturesaffectthemedialjointmotionandhencestressthemedialmeniscus,therebyleadingto
prematuremedialcompartmentosteoarthritisandworseninginstabilitysymptoms. [31]
SurgicalManagement

Thelast5yearshasseennosignificantchangesinACLsurgery,butratherasteadyconsolidationofexistingtechniques. [32]The
majorimpetusforclinicalresearchhasdwelledoncomparingdifferenttypesofautograftreconstructions,variousmethodsof
graftfixation,andthepositionofgrafttunnels. [33]
Inprinciple,surgeryisperformedeitheropenorarthroscopically.Achosengraft,eitherautograftorallograft,isusedtoreplace
therupturednativeligament. [34]Thegraftisfixedwithinabonytunnelthatiscreatedwithinboththefemurandtibiausinga
choiceofdifferentmechanicaldevices.ThecommoncomplicationsspecifictoACLsurgeryincludegraftharvestdonorsite
morbidityandgraftfailure.Theincidenceofthishasbeenreportedas820%at2years. [35]
PostoperativeRehabilitation

Rehabilitationcanvaryfromsurgeontosurgeonandisverydependentonthepatientandthephysiotherapist. [36]'Accelerated'
rehabilitationtodayconsistsofagraduatedfunctionalprogrammethatisonlysupervisedbyaphysiotherapistonanintermittent
basis.Muchoftheemphasisliesonpatienteducationwhichenablesthemtolookaftertheirreconstructedknee.Thetotallength
ofrehabilitationandreturntonormalactivitiestakes~68months. [37]
Summary

ACLdisruptionsarecommoninjuriesthatcurrentlyholdafearsomereputationamongathletesofallabilitiesanddisciplines.
Indeed,ifthediagnosisismissedatfirstpresentation,itisdifficulttoattributeongoinginstabilityandrecurrentinjurytoanACL
tear.Classically,patientsthenoftenimproveshortlybeforerepeatedlyreinjuringtheirknee.Atsomepoint,thekneemaylock,
necessitatinganarthroscopicmeniscectomy.Tragically,thisthenhastenstheprogressionofjointarthrosisandthedeclineof
jointfunction.
Inthecurrentclimateoftargetdrivenemergencydepartments, [38]itisoftennotfeasibletoelaboratelyevaluateevery
presentationoftheacutelyswollenknee.Indeed,thenatureofthepathology,withitsassociatedpainandswelling,oftendeters
theformulationofadefinitivediagnosis.Therefore,theemphasisshoulddwellontheprobableaetiologyofthepainfulkneeand
theexclusionofabonyinjury.Recognitionofthepatternofinjuryandthepotentialforsevereligamentousderangementisan
invaluableassettotheemergencydepartmentdoctor.Abriefcounselofthepatientfollowedbyadvicetoelevate,icepack,
gentlybeginearlymobilisationandsubsequentreferraltothenextavailablekneeclinicwillsignificantlyinfluencethenatural
historyofthisdevastatinginjury.Formulationofadefinitivediagnosis,choiceofimaging,anddiscussionontreatmentoptions
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shouldbelefttotheforteoftheorthopaedicsurgeon.Familypractitionersandemergencyroomdoctorsshouldnotfeel
pressuredtoofferadviceonspecialistareassuchasreturntosportwithoutreconstructionorindeedtheneedforreconstruction.
Indeed,decisionstoreturntosportwithACLdeficientkneeshavealltoooftenledtodisastrousreinjuryeventstothearticular
cartilageand/orthemenisci.

Box1
Box1Summarypointsforanteriorcruciateligament(ACL)rupture

Oneofthemostcommonathleticinjuriesinvolvingthekneejoint.
ACLisprimarilyastabiliserofthekneeandthusinjuryresultsininstability.
Usuallyapivoting/twistinginjurytothekneedirecttraumacanalsocontribute.
Initialmanagementisrest,ice,elevationandanalgesia.
Historyandexaminationusing(Lachman,anteroposteriororpivotshifttest).
Referraltoorthopaedicsurgeryforfurtherimaging(MRIscan),physiotherapyandnonoperativeoroperative
arthroscopicmanagementdependingonlevelofactivity.

Box2
Box2Ongoingresearchandunansweredquestions

Controversyonthetypeofgraftused:autograft(patellatendonorhamstrings),allograft,syntheticmaterials.
Controversywithregardtotheextentofrehabilitationneededandthefunction(rangeofmotionoftheknee)
expected,aswelltheoptimaltimetoreturntofullsportingactivities.
ControversyintheoptimalnonoperativemanagementofACLtears.
ThereisongoingresearchinthepotentialroleoftissueengineeringtofacilitatesuccessfulrepairofassociatedACL
injuries(includingavascularzonemeniscustearandarticularcartilageinjuries).
TheriskandpotentialofacceleratedkneeosteoarthritisinACLinjuriesremainunclear.
MulticentreobservationalstudiesbeingconductedtodeterminetheoptimaltreatmentofpatientswithanACLinjury
whoareskeletallyimmatureandthosewhohaveafailedACLgraft.

Box3
Box3Additionaleducationalresources

BeynnonBD,JohnsonRJ,AbateJA,etal.Treatmentofanteriorcruciateligamentinjuries.Part1.AmJSportsMed
200533:1579602.Part2.AmJSportsMed200533:175167.
McCullochPC,LattermannC,BolandAL,etal.Anillustratedhistoryofanteriorcruciateligamentsurgery.JKnee
Surg200720:95104.

Box4
Box4Informationresourcesforpatients

ACLfactsheetfromMedlinePlus,aserviceoftheUSNationalLibraryofMedicineandtheNationalInstitutesof
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Health(http://www.nlm.nih.gov/medlineplus/ency/article/001074.htm).
OxfordRadcliffeNHSHospitalscomprehensivephysiotherapyadviceforpatientsundergoingACLreconstruction
(http://www.oxfordradcliffe.nhs.uk/forpatients/patientinfoleaflets_updatedOct07/acl.pdf).
MassachusettsGeneralHospitalanimatedACLreconstructionsurgeryandotherpreandpostoperativeinformation
(http://www2.massgeneral.org/sports/videos.html).

Box5
Box5Symptomsofanteriorcruciateligamentinjury

Earlysymptoms
A'popping'soundatthetimeofinjury
Severepain
Kneeswellingwithinhoursofinjury
Latesymptoms
Kneejointinstability
Arthritis
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Competinginterests
None.
Provenanceandpeerreview
Notcommissionedexternallypeerreviewed.
EmergMedJ.201128(8):644649.2011BMJPublishingGroupLtd&theCollegeofEmergencyMedicine

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