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Anterior Cruciate

Ligament Tear
Synonyms

ICD-9 Codes
717.83
Chronic disruption of anterior
cruciate ligament
844.2
Acute anterior cruciate ligament
tear

ACL tear
Anterior cruciate insufficiency
Cruciate ligament tear
Internal derangement of knee
Torn cruciate

Definition
Femur
Anterior
cruciate
ligament

Tear

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Tibia

640

Figure 1 Lateral view of the

knee shows a
complete anterior
cruciate ligament tear.

The anterior cruciate ligament (ACL) is a primary stabilizer of


the knee against anterior translation (Figure 1). A tear of the
ACL results from a rotational (twisting) or hyperextension force
applied to the knee joint that overcomes the strength of the
ligament. Although partial tears can occur, injuries involving the
ACL more often result in complete tears. Most ACL tears are
noncontact injuries. An ACL tear is often accompanied by a
significant meniscal tear. An ACL tear also can occur in
association with a tear of the medial collateral ligament or, more
rarely, with tears of the lateral ligaments or the posterior cruciate
ligament. Uncommonly, knee injuries that disrupt multiple
ligaments and result in knee instability also injure the popliteal
artery; this is a limb-threatening emergency.

Clinical Symptoms
Patients with ACL tears usually report sudden pain and giving
way of the knee from a twisting or hyperextension-type injury.
One third of patients report an audible pop as the ligament tears.
A patient who sustains an ACL tear during athletic activity
usually is unable to continue participating because of pain
and/or instability. The pain increases because an effusion caused
by bleeding into the joint (hemarthrosis) develops rapidly.
As the swelling resolves, the patient temporarily may have no
trouble moving the knee; however, if the tear is left untreated,
recurrent instability develops, particularly with attempts to return
to agility sports involving pivoting, running, or jumping.
Chronic knee instability from an untreated ACL tear can lead to
further meniscal and articular cartilage damage, with resulting
degenerative arthritis.

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Figure 2 Lachman test. A, The knee is flexed approximately 30. The examiner gently pulls the tibia forward

with the medial hand while stabilizing the distal femur with the lateral hand. In a relaxed patient,
increased anterior translation of the tibia (in comparison to the uninjured knee) with a soft end point
constitutes a positive test. B, Diagram showing movement of the tibia relative to the femur.

Tests
The most sensitive test for ACL insufficiency is the Lachman
test, in which the knee is flexed to 30 and the tibia is gently
pulled forward while the femur is stabilized (Figure 2). It is
critical that the patients leg, especially the hamstrings, be
relaxed. Otherwise, an accurate examination cannot be
performed. Because of the subcutaneous location of the medial
tibia, it is easier to grasp the tibia on the medial side (right hand
for right knee, left hand for left knee) while stabilizing the
femur from the lateral side with the opposite hand. If the thigh
is large, the examiner may find it difficult to support the thigh in
one hand. In this situation, the examiner may place his or her
knee under the patients thigh. The examiner uses one hand to
stabilize the patients thigh in this position. The examiners other
hand gently elevates the tibia from the supported femur.
Increased motion of the tibia with no solid end point indicates a
tear of the ACL. The anterior drawer test, performed with the
knee flexed to 90, is negative in 50% of acute ACL tears and
thus is less helpful.

Diagnostic Tests
AP, lateral, and tunnel views of the knee should be ordered for
every patient with a suspected ACL tear. Usually these
radiographs are positive only for an effusion and possibly an
avulsion fracture of the lateral capsular margin of the tibia
(lateral capsular sign or Segond fracture); however, radiographs
are helpful in ruling out other pathology.
MRI is sensitive for detecting ACL tears. It also is extremely
useful for evaluating a knee with an acute effusion.

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Physical Examination

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Differential Diagnosis

Fracture (tenderness over the bone, evident on radiographs)


Meniscal tear (continued tenderness along the joint line, pain
or trapping with circumduction) (may occur with ACL tear)
Patellar dislocation/subluxation (positive apprehension sign
when displacing the patella laterally)
Patellar tendon or quadriceps rupture (inability to perform
straight-leg raise)
Posterior cruciate ligament tear (positive posterior drawer test,
firm end point on Lachman test)

Adverse Outcomes of the Disease


If left untreated, the recurring instability resulting from an ACL
tear may cause subsequent meniscal tears and degenerative
disease. The instability also makes successful return to
participation in agility sports such as soccer, football, or
basketball unlikely.

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Treatment

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Initial treatment of an acute ACL injury includes rest, ice, and


the use of crutches until the patient is able to ambulate without
a limp. If the knee effusion (hemarthrosis) is tense, aspiration
may be indicated to relieve symptoms (see page 647). A knee
immobilizer or range-of-motion brace may be used for comfort
when necessary until acute pain subsides.
Early range-of-motion exercises are important. With the
patient sitting, the injured knee should be actively extended and
flexed as comfort allows. Exercises should be performed
repeatedly for several minutes four or five times daily. Full
extension and flexion should be regained as soon as pain and
swelling permit.
Definitive treatment of an ACL injury depends on the
patients age and desired activity level and any associated
injuries. For young, active patients, ACL reconstruction offers
the best chance for a successful return to agility sports. Older or
less active individuals may be treated with physical therapy
aimed at controlling the instability. ACL functional bracing also
may be helpful with older or less active patients, but it usually
does not provide sufficient stability for most younger patients to
return to sports.

Rehabilitation Prescription
The goal of initial treatment of a torn ACL is to control the
inflammation and pain with rest, ice, compression, and elevation
(RICE) of the leg. In addition, maintaining the range of motion
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and regaining muscle strength are important to rehabilitation.


Strengthening of the quadriceps and particularly the hamstring
muscle group, as in balance training, is critical for knee stability
following an ACL injury. Excessive anterior shearing forces
during knee extension from 60 to 0, especially from 30 to
10, can cause damage, as can varus and valgus stress in full
knee extension. Therefore, exercises that protect the ACL injury
by avoiding these ranges of motion and positions, such as
hamstring curls to strengthen the hamstring muscle group and
isometric quadriceps contraction and straight-leg raises to
strengthen the quadriceps, are used initially.
If instability, pain, and inflammation continue after 2 to
3 weeks, a formal rehabilitation program may be ordered. The
prescription should include an assessment of the strength of the
hip and trunk muscles, especially the hip external rotators and
abductors, as well as the knee, hamstring, and quadriceps
muscles. Outpatient rehabilitation for an ACL-deficient knee
should emphasize strengthening of these muscle groups as well
as neuromuscular training such as plyometrics and perturbation
training. In addition, the rehabilitation specialists evaluation
might include structural deviations that sometimes contribute to
ACL injury, such as a large Q angle, excessive foot pronation,
hip anteversion, and genu recurvatum and valgum, to help
determine the appropriate treatment.

Nonsurgical treatment carries the risk of recurrent instability,


meniscal tears, and degenerative joint disease. Scarring of the
knee joint (arthrofibrosis) with loss of motion can occur after
ACL injury or postoperatively after ACL reconstruction. Surgical
reconstruction carries several risks: the usual risks of surgery
(infection, phlebitis, pulmonary emboli, neurovascular insult,
scarring, etc); the possibility that the ACL can tear again; or
failure of the ACL graft to incorporate or successfully remodel,
resulting in recurrence of laxity. Fracture of the tibial or patellar
graft site also may occur after ACL reconstruction when a
portion of the patellar tendon is used for the ACL graft.

Referral Decisions/Red Flags


Patients with suspected ACL tears and/or posttraumatic knee
effusions require further evaluation and treatment. Even patients
who are not candidates for ACL reconstruction can benefit from
regular monitoring of the ACL tear.

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Adverse Outcomes of Treatment

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Home Exercise Program for ACL Tear

Perform all five exercises in the order listed.


After each exercise session, apply ice (eg, a bag of crushed ice or a bag of frozen peas) to the knee
for 20 minutes or until numb, keep the leg elevated, and apply a compression bandage to the knee.
If pain or swelling increases at any time or if it does not improve after you have adhered to the
program for 3 to 4 weeks, call your doctor.

Exercise Type

Number of
Repetitions/Sets

Muscle Group

Number of Days
per Week

Number of
Weeks

Hamstring curls
(standing)

Hamstrings

20 repetitions/3 sets

4 to 5

3 to 4

Straight-leg raises

Quadriceps

20 repetitions/3 sets

4 to 5

3 to 4

Hip abduction

Gluteus medius

20 repetitions/3 sets

4 to 5

3 to 4

Hip adduction

Adductor group

20 repetitions/3 sets

4 to 5

3 to 4

Straight-leg raises (prone)

Gluteus maximus

20 repetitions/3 sets

4 to 5

3 to 4

Wall slides

Quadriceps, hamstrings

20 repetitions/3 sets

4 to 5

3 to 4

Hamstring Curls

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Stand on a flat surface with your weight evenly


distributed on both feet.
Hold onto the back of a chair or the wall for
balance.
Bend the injured knee, raising the heel of the
affected leg toward the ceiling as far as
possible without pain.
Hold this position for 5 seconds and then relax.
Perform 3 sets of 20 repetitions, 4 to 5 days a
week, continuing for 3 to 4 weeks.

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Straight-Leg Raises

Lie on the floor, supporting your torso with


your elbows as shown.
Keep the injured leg straight and bend the
other leg at the knee so that the foot is flat on
the floor.
Tighten the thigh muscle of the injured leg and
slowly raise it 6 to 10 inches off the floor.
Hold this position for 5 seconds and then relax.
Perform 3 sets of 20 repetitions, 4 to 5 days a
week, continuing for 3 to 4 weeks.

Hip Abduction

Lie on your side with the injured side on top


and with the bottom leg bent to provide
support.
Slowly raise the top leg to 45, keeping the
knee straight.
Hold this position for 5 seconds.
Slowly lower the leg and relax it for
2 seconds.
Perform 3 sets of 20 repetitions, 4 to 5 days a
week, continuing for 3 to 4 weeks.

Lie down on the floor on the side of your


injured leg with both legs straight.
Cross the uninjured leg in front of the injured
leg.
Raise the injured leg 6'' to 8'' off the floor.
Hold this position for 5 seconds.
Lower the leg and rest for 2 seconds.
Perform 3 sets of 20 repetitions, 4 to 5 days a
week, continuing for 3 to 4 weeks.

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Hip Adduction

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Straight-Leg Raises (Prone)

Lie on the floor on your stomach with your


legs straight.
Tighten the hamstrings of the injured leg and
raise the leg toward the ceiling as far as you
can.
Hold this position for 5 seconds.
Lower the leg and rest it for 2 seconds.
Perform 3 sets of 20 repetitions, 4 to 5 days a
week, continuing for 3 to 4 weeks.

Wall Slides

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Lie on your back with the uninjured leg


extending through a doorway and the injured
leg extended against the wall.
Let the foot gently slide down the wall.
Hold this position of maximum flexion for
5 seconds and then slowly straighten the leg.
Perform 3 sets of 20 repetitions, 4 to 5 days a
week, continuing for 3 to 4 weeks.

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