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Anterior cruciate ligament injury

Author: Ryan P Friedberg, MD

Section Editor: Karl B Fields, MD
Deputy Editor: Jonathan Grayzel, MD, FAAEM

All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jan 2018. | This topic last updated: Aug 04, 2017.

INTRODUCTION — The anterior cruciate ligament (ACL) is an important stabilizing ligament of the knee that is
frequently injured by athletes and trauma victims. There are between 100,000 and 200,000 ACL ruptures per year
in the United States alone [1,2].

This topic review will discuss the presentation, evaluation, and management of ACL injuries. A discussion of the
general approach to the patient with knee pain, including descriptions of examination techniques, and
discussions of other specific knee injuries are found elsewhere. (See "Approach to the adult with knee pain likely
of musculoskeletal origin" and "Medial collateral ligament injury of the knee" and "Meniscal injury of the knee"
and "Patellofemoral pain" and "Posterior cruciate ligament injury" and "Lateral collateral ligament injury and
related posterolateral corner injuries of the knee".)

ANATOMY AND FUNCTION — The primary function of the anterior cruciate ligament (ACL) is to control anterior
translation of the tibia. The ACL also is a secondary restraint to tibial rotation as well as varus or valgus stress
[3]. The ACL originates at the posteromedial aspect of the lateral femoral condyle. It courses distally in an
anterior and medial fashion to the anteromedial aspect of the tibia between the condyles. The position on the
tibia is approximately 15 mm behind the anterior border of the tibial articular surface, and medial to the
attachment of the anterior horn of the lateral meniscus (figure 1 and picture 1 and figure 2) [4]. The ACL is often
said to be comprised of two bundles: an anteromedial bundle that is tight in flexion and a posterolateral bundle
that is tight in extension. The blood supply to the ACL is from branches of the middle geniculate artery and its
innervation comes from the posterior articular nerve, a branch of the tibial nerve [5]. The anatomy and
biomechanics of the knee joint are discussed in detail separately. (See "Physical examination of the knee",
section on 'Anatomy' and "Physical examination of the knee", section on 'Biomechanics'.)

EPIDEMIOLOGY — The anterior cruciate ligament (ACL) is the most commonly injured knee ligament. In the
United States there are between 100,000 and 200,000 ACL ruptures per year, with an annual incidence in the
general population of approximately 1 in 3500, although the actual incidence may be higher [1,2,6-8]. Data are
limited by the absence of any standard surveillance mechanism for the general population. Registries exist for
injuries sustained by United States college and high school athletes, but these account for a small percentage of
the total number of injuries [9-11].
The great majority of ACL tears occur from noncontact athletic injuries. According to the National Collegiate
Athletic Association (NCAA) injury surveillance system, which has tracked all injuries associated with United
States college athletics since 1988, American football players sustain the greatest number of ACL tears, but
these are predominately contact injuries. Female athletes sustain higher rates of ACL injury per athletic exposure
across sports [9-11]. One athlete participating in a single game or practice equals one exposure. Among skiers,
recreational alpine skiers have the highest incidence of ACL rupture, while expert recreational skiers the lowest
[12]. Competitive alpine skiers sustain ACL injuries at a high rate [13]. Participants in women's ice hockey and
men's baseball have a low incidence [14].

With certain sports, female gender confers significantly greater risk of ACL rupture regardless of age [11,15-23].
In addition to gymnasts, female soccer and basketball players sustain significantly more ACL injuries than their
male counterparts (incidence ratios 3.5 and 2.7 for each sport, respectively) [9,10,12]. Although the overall
incidence of ACL injuries is roughly equal for female and male United States college athletes, this stems from the
disproportionate number of contact injuries among male American football players. (See 'Risk factors' below.)

RISK FACTORS

Gender-related — It remains unclear which factors most predispose athletes to anterior cruciate ligament (ACL)
injury. Overall, women engaged in pivoting sports sustain ACL tears at significantly higher rates than men
participating in the same activity. Researchers have proposed several explanations to account for this disparity,
including:

● Quadriceps-dominant deceleration

● Increased valgus knee angulation with pivoting, deceleration, or landing

● Effects of estrogen

● Discrepancies in Q angle and bone length

● Decreased intercondylar notch width

Quadriceps dominance refers to the muscle group used preferentially to control deceleration. Several
biomechanical studies have found that in female athletes the quadriceps group generally contracts first during
deceleration, while in men the hamstring group generally contracts first [24-27]. The quadriceps muscles are less
effective at preventing anterior tibial translation, thereby increasing the stress placed on the ACL. Studies also
suggest that women generally have weaker hamstrings and greater strength imbalances between the two
muscle groups, and such imbalances increase knee instability [28-30]. These findings suggest an important role
for injury prevention training designed to correct relative muscle weakness and imbalance. (See 'Prevention'
below.)

Increased valgus angulation of the knee (ie, knee bent inward, or medially) during sudden changes in direction or
landing substantially increases the stress placed on the ACL [31]. Several biomechanical studies, including some
using video analysis, have found that female athletes are more likely to place their knees in positions of
increased valgus angulation when changing direction during a sporting event [32-36]. Thus, training to correct
faulty biomechanics may limit susceptibility to ACL injury.

The importance of relative muscle weakness and poor biomechanics as risk factors for ACL injury is supported
by studies of dancers, whose training involves holding positions that develop strength in the knee and hip
stabilizers and torso, and perfecting jumping and landing technique. Female dancers sustain ACL injuries at
much lower rates than their field sport counterparts [37]. Laboratory studies of high level dancers and team sport
athletes performing a 30 cm single leg drop-landing have noted that female dancers and male athletes (dancers
and team sport participants) land in a similar fashion, with little or no knee valgus and greater hip and trunk
stability, whereas female team athletes demonstrate significantly greater knee valgus and less hip and trunk
stability [38,39]. (See 'Prevention' below.)

Serum estrogen and relaxin exert effects upon the strength and flexibility of soft tissues, including ligaments, and
may influence neuromuscular function, although this remains controversial [31,40,41]. The direct role of estrogen
in ACL injury, however, remains unclear. One systematic review and several studies differ in their conclusions
about the relationship between ACL injury risk and the different levels of estrogen during the menstrual cycle [42-
47]. Oral contraceptives modulate hormonal effects on soft tissue and several observational studies suggest that
they may reduce the risk of ACL rupture [16,31,46]. However others refute this idea [48]. The use of oral
contraceptives to decrease the risk of ACL injuries remains controversial and requires further study.

Although some researchers claim an association exists between a larger Q angle and increased risk of ACL tear,
no convincing evidence exists to substantiate this claim [31,49]. The Q angle is made by drawing a line from the
anterior superior iliac spine to the patella and a second line from the patella to the tibial tubercle (figure 3). The
relatively wide pelvis and short femur of women creates a larger Q angle.

Some researchers claim that decreased width of the intercondylar notch of the distal femur is associated with
ACL tear [50-52]. Others refute this [53]. The role of notch width remains debatable and unmodifiable.

Additional factors — A wide range of factors ranging from playing surface to genetics may predispose particular
athletes to ACL injury. Our understanding of which factors play a major role is limited by the dearth of controlled
studies. Potential risk factors under investigation include external factors (eg, shoe-surface interface) and
intrinsic factors (eg, joint laxity, hamstring weakness).

Among extrinsic factors, footwear and field surface are the subject of a number of studies, many of which have
concluded that the risk of ACL injury increases when traction, whether due to shoe type or playing surface (eg,
synthetic gym floors), is greater [31,34,54-58]. As an example, a systematic review of three prospective studies
involving 4972 male American football players found a strong relationship between higher rotational traction and
increased risk of lower extremity injury, including ACL tears [56]. A survey of noncontact injuries among
professional American football players found that fewer than 5 percent occurred on a wet playing surface [59].

Improper biomechanics likely contribute to ACL tears. One study using video analysis found that athletes were
more likely to be in an unstable or unbalanced position just prior to sustaining an ACL injury [34]. (See
'Mechanism and presentation' below.)
Intrinsic factors that may predispose to ACL tear include increased knee joint laxity, hamstring weakness or
laxity, smaller ACL, increased body mass index (BMI), core muscle weakness, impaired proprioception, muscle
fatigue, and genetic factors [31,50,60-65]. Further research is needed to clarify the role of such factors.

MECHANISM AND PRESENTATION — Anterior cruciate ligament (ACL) injuries can occur by a variety of
mechanisms, including both high-energy (eg, motor vehicle collision) and low-energy (ie, noncontact field sports).
Low-energy injuries may involve contact (eg, blow to the lateral knee), but noncontact injuries are more common,
accounting for approximately 70 percent of ACL tears [22,61]. The most common mechanism involves a low-
energy, noncontact injury sustained during an athletic activity.

Noncontact mechanism — The typical mechanism for a noncontact ACL injury involves a running or jumping
athlete who suddenly decelerates and changes direction (eg, cutting) or pivots or lands in a way that involves
rotation or lateral bending (ie, valgus stress) of the knee. According to several studies using video to assess the
biomechanics of ACL tears, the majority of injuries are associated with a valgus position with the knee, minimal
knee flexion, and internal rotation of the tibia [34,35,66,67]. Dynamic valgus collapse of the knee appears to be
more common in female athletes, and may contribute to their higher injury rates. Sports associated with ACL
injuries often involve pivoting and sudden changes in direction, and include alpine skiing, soccer (football),
basketball, and tennis (table 1). (See 'Epidemiology' above and 'Risk factors' above.)

Contact mechanism — Contact-related ACL injuries usually occur from a direct blow causing hyperextension or
valgus deformation of the knee. This is often seen in American football when a player's foot is planted and an
opponent strikes him on the lateral aspect of the planted leg [68].

ACL injuries also occur during high speed motor vehicle collisions. Such injuries are often missed in the multiple
trauma patient because clinicians concentrate appropriately on managing life-threatening injuries, and the
tertiary trauma examination may be delayed.

Signs and symptoms — Patients who sustain a noncontact ACL injury often complain of feeling a "pop" in their
knee at the time of injury, acute swelling thereafter, and a feeling that the knee is unstable or "giving out." Nearly
all patients with an acute ACL injury manifest a knee effusion from hemarthrosis. Conversely, approximately 67
to 77 percent of patients presenting with acute traumatic knee hemarthrosis have an ACL injury [69,70].

Often after the initial swelling has improved, patients are able to bear weight but complain of instability.
Movements such as squatting, pivoting, and stepping laterally, and activities such as walking down stairs, in
which the entire body weight is placed on the affected leg, most often elicit such instability.

Associated injuries — Other structures are often damaged during an acute ACL injury [71]. Associated structures
that are commonly injured include the meniscus, joint capsule, articular cartilage, subchondral bone (bone
bruise), and other ligaments [72,73]. Such injuries may be more frequent if the mechanism involves significant
force (eg, contact injury). One small study suggests that weightbearing motion in the uninjured knee does not
appear to be adversely affected [74].
PHYSICAL EXAMINATION — Evaluation of the knee includes an appropriate history and physical examination. In
patients with a possible anterior cruciate ligament (ACL) injury, the clinician should inquire about the timing of
the injury, the mechanism, joint swelling, functional ability (eg, can the patient walk, climb stairs), joint instability
(eg, is the knee giving out), and associated injuries. (See 'Mechanism and presentation' above.)

An appropriate examination includes inspection, palpation, testing of mobility, strength, and stability, and
performance of special tests of ACL integrity. Depending upon the patient and the time elapsed since the acute
injury, the knee examination may be limited by pain or hemarthrosis. Although an ACL tear can generally be
diagnosed clinically, MRI is often used to assist diagnosis. Performance of the knee examination is discussed in
detail elsewhere. (See "Physical examination of the knee".)

One key to an accurate knee examination is to evaluate the unaffected knee for comparison. Many patients have
increased laxity that is not pathologic. When evaluating for an ACL injury, it is often best to examine the patient
immediately after the injury is sustained. This avoids the difficulty of trying to evaluate a knee with a significant
hemarthrosis, which can develop within a few hours.

Many tests to delineate ACL injury are described. Three such tests, the Lachman, the Pivot Shift, and the Anterior
drawer, are the most sensitive and specific [75,76]. We suggest the clinician perform these tests whenever
possible to assess patients at risk for ACL injury.

The Lachman test is performed by placing the knee in 30 degrees of flexion and then stabilizing the distal femur
with one hand while pulling the proximal tibia anteriorly with the other hand, thereby attempting to produce
anterior translation of the tibia (picture 2). An intact ACL limits anterior translation and provides a distinct
endpoint. Increased translation compared with the uninjured knee and a vague endpoint suggests ACL injury.

The pivot shift test can be difficult to perform in the awake patient due to guarding, and is sensitive only in a fully
relaxed and cooperative patient. A positive test is highly specific, albeit insensitive, for ACL rupture [75,77]. The
test is performed with the knee starting in extension. The clinician holds the lower leg with one hand and
internally rotates the tibia, while placing a valgus stress on the knee using the other hand (figure 4). This causes
subluxation in the ACL-deficient knee. While maintaining the forces described, the clinician flexes the knee. In the
ACL-deficient knee this causes a reduction of the subluxed tibia, which the clinician senses as a "clunk," and
which constitutes a positive test.

The anterior drawer test is performed with the patient lying supine and the knee flexed at 90 degrees. The
proximal tibia is gripped with both hands and pulled anteriorly, checking for anterior translation. Often the
clinician sits on the foot while performing the test to provide stability (picture 3). The test is positive if there is
anterior translation. Comparing the degree of translation to the uninjured knee is helpful.

It is important to evaluate for posterior translation of the tibia prior to performing the drawer test. A false positive
anterior drawer test can occur if a posterior cruciate ligament (PCL) injury exists. Posterior sag from the PCL
injury will give the clinician the sensation of anterior tibial translation, when in fact the knee is returning to a
neutral position. Sag exists if one tibia lies below the other when observing the legs from the side with the knees
flexed to 90 degrees.
A meta-analysis of the efficacy of these tests shows the Lachman is the most useful, with a sensitivity of 85
percent and a specificity of 94 percent for ACL rupture [75]. The pivot shift has a sensitivity of 24 percent and
specificity of 98 percent. The anterior drawer has a sensitivity of 92 percent and specificity of 91 percent in
chronic conditions but is not accurate in acute injury [68,75]. Other reviews have reported similar results [78].

The KT-1000 knee ligament arthrometer is a device that provides an objective measurement of anterior-posterior
translation and is often used in studies evaluating ACL tears. This machine is seldom used in clinical practice
because physical examination is generally reliable. Due to the high sensitivity of the Lachman and the high
specificity of the pivot shift, we suggest performing both tests to confirm an ACL rupture. The combination of a
positive Lachman and a negative pivot shift can mean the ACL is partially torn [68].

It is important to evaluate the other knee structures that can sustain injury in conjunction with the ACL. Test the
stability of the medial and lateral collateral ligaments by applying gradual varus and valgus stress. Test the
posterior collateral ligament by performing a posterior drawer test. Assess for meniscal injury by palpating the
medial and lateral joint lines, and performing the appropriate examination maneuvers. Examination techniques
for meniscal injury are described separately. (See "Meniscal injury of the knee", section on 'Physical
examination'.)

DIAGNOSTIC IMAGING — Plain radiographs are often performed following traumatic knee injuries to rule out
fractures but cannot be used to diagnose anterior cruciate ligament (ACL) tears. In some cases, an avulsion
fracture of the anterolateral tibial plateau at the site of attachment of the lateral capsular ligament (the so-called
Segond fracture) is identified on plain film (image 1). Such an injury suggests the presence of an associated ACL
rupture [79-81].

In the United States, magnetic resonance imaging (MRI) is the primary modality used to diagnose ACL rupture. In
parts of Europe, ultrasound is often used to assist in the diagnosis. Knee arthrograms are only performed in
patients in whom MRI is contraindicated and physical examination is inconclusive.

MRI is both highly sensitive and specific in the diagnosis of complete ACL rupture (image 2). A systematic review
using arthroscopy as a gold standard found MRI to have a sensitivity of 86 percent and a specificity of 95 percent
for ACL tear [71]. Diagnostic studies, again using arthroscopy as the gold standard, describe sensitivities as high
as 92 to 100 percent and specificities as high as 95 to 100 percent [82-84]. MRI is less accurate in differentiating
complete tears from partial tears, and in detecting chronic tears.

In some parts of Europe, ultrasound is widely used to aid in the diagnosis of ACL tear. Like MRI, ultrasound is
best at detecting complete ACL rupture. Ultrasound is inexpensive, rapid, and painless, and several studies
purport high specificity and positive predictive value [83,85-89]. Sensitivity is likely more limited than MRI. The
accuracy of ultrasound is highly user-dependent.

Multidetector computed tomography (MDCT) is not used to evaluate ACL injury. Data suggest MDCT is accurate
at detecting an intact ACL, but is unreliable for determining ACL tear [90].
DIAGNOSIS — A definitive diagnosis of anterior cruciate ligament (ACL) tear is made by diagnostic imaging study
(MRI is most accurate) or knee arthroscopy. However, in many instances, the clinical presentation can establish
the diagnosis without the need for imaging. ACL tears sustained through a non-contact injury are most common
and are suspected on the basis of a suggestive history (sudden change of direction or landing during sport
causing the knee to "pop" or give out) and clinical findings (acute knee effusion; positive Lachman, pivot shift,
and anterior drawer tests). Contact injuries typically stem from a direct blow causing hyperextension or valgus
deformation of the knee, and are often associated with injuries to other structures.

TREATMENT

Acute management — Acute management consists of rest, ice, compression of the injured knee, and elevation of
the affected lower extremity. Crutches may be needed acutely to avoid weight-bearing, particularly if the knee is
unstable. Over the counter analgesics are generally sufficient to control pain. While nonsteroidal
antiinflammatory drugs (NSAIDs) provide effective short-term pain relief, their effect on ligament and bone
healing remains unclear. This issue is discussed separately. (See "Nonselective NSAIDs: Overview of adverse
effects", section on 'Possible effect on tendon injury'.)

Operative or nonoperative treatment? — Appropriate treatment for an anterior cruciate ligament (ACL) injury
depends upon the extent of injury, patient characteristics and activities, and available resources. These issues
are reviewed below. It is important that the patient feel comfortable discussing the available treatment options
with their surgeon and that issues such as patient expectations, rehabilitation, and potential complications are
addressed in such discussions.

Determining the need for surgery — ACL injuries can be managed operatively or nonoperatively. Most active,
younger patients and high-level athletes opt for surgical reconstruction. In general, patients with an ACL injury
should be referred to an orthopedist to discuss treatment options. Patients who decide not to pursue surgical
management should be referred to a knowledgeable physical therapist or athletic trainer for rehabilitation. (See
'Rehabilitation' below.)

The decision to have surgery is based upon multiple factors, including the patient's level of activity, functional
demands placed on the knee, and the presence of associated injuries to the meniscus or other knee ligaments.
Other factors such as age and occupation also play a role. Patients with injuries to multiple knee structures (eg,
ACL plus meniscus or medial collateral ligament) generally need surgical reconstruction due to the increased
instability of the knee, which typically causes substantial activity limitations, mechanical symptoms (eg, locking,
giving out), and because such injuries probably increase the risk for developing osteoarthritis. (See 'Risk of
osteoarthritis or subsequent injury' below.)

In addition, surgical reconstruction of the ACL is appropriate for patients who:

● Participate in high-demand sports or occupations (ie, those involving cutting, jumping, pivoting, and quick
deceleration)

OR
 ● Experience significant knee instability (eg, knee gives out while climbing stairs).

Traditionally, anterior translation of more than 5 mm with testing on a KT1000 or comparable device has been
used as a criterion for surgery. However, some studies question the use of static translation as an accurate
predictive tool for knee function and the need for surgical reconstruction [91]. Some experts believe a positive
pivot shift test three months following injury best predicts the future need for surgical repair [92].

There are no long term studies that directly compare the rates of return to sport between athletes treated
operatively and nonoperatively. Nevertheless, in our experience, athletes who participate in sports involving rapid
deceleration, pivoting, and change in direction have a better chance of returning to play if they undergo ACL
reconstruction [93].

According to a systematic review of 69 studies involving 7556 participants, 81 percent of patients treated with
ACL reconstruction returned to some type of athletic activity, 65 percent attained their preinjury level of
competition, and 55 percent of high-level athletes successfully returned to competition [94]. These rates are
relatively low given that approximately 90 percent of patients achieve normal or near normal knee function
following surgery, suggesting that other factors, such as fear of reinjury, play an important role in athletes'
decision-making about return to play. According to the review, factors associated with successful return to
preinjury levels of activity include symmetric performance of unilateral hopping exercises, younger age, male
gender, playing sport at an elite level, and a positive psychological outlook. Among elite athletes, financial
incentives may also play a role. Motivation is an important factor that likely influences whether an athlete returns
to high level sport. Elite athletes are almost twice as likely to return. While they may have some advantages from
their access to high quality medical and rehabilitation services, their investment in sport probably explains much
of this result.  

Less active patients who do not participate in sports that involve squatting, pivoting, and lateral movement have
less risk of developing further injury. Patients who fare worst with nonoperative treatment are high level athletes
and young athletes [72]. The patients best suited for nonoperative management are described below. (See
'Patients amenable to nonoperative treatment' below.)

Theoretically there is no age cut-off for surgery. Although patients older than 55 years rarely undergo ACL
reconstruction, the decision whether to perform surgery depends upon the patient's condition including
symptomatic knee instability, activity level, and the surgeon's judgment. Observational studies suggest that ACL
reconstruction is generally successful in patients older than 40 years [95-97].

Risk of osteoarthritis or subsequent injury — When deciding to treat a complete ACL rupture nonoperatively,
it is important to understand the possible sequelae. Although rigorous prospective studies are scant, the ACL-
deficient knee is associated with an increased risk for meniscal tear, articular cartilage injury, chronic knee pain,
and decreased activity [98-104]. Whether the absence of the ACL itself increases the long-term risk for
osteoarthritis (OA) is a subject of debate. Some observational studies suggest that a major factor determining
the risk for OA is the degree of joint trauma sustained during the initial injury that caused the ACL to rupture. We
believe the risk for OA is likely multifactorial and that the severity of the initial trauma, extent of meniscal injury,
knee biomechanics, and subsequent patient activity all play a role [99,100,105-108].

Multiple systematic reviews have been performed to try to determine the risk of developing OA following ACL
injury. One such review, which included patients who underwent surgical repair and those treated conservatively,
noted the following [99]:

● Higher quality studies found the prevalence of knee OA in patients with isolated ACL injury to range from 0
to 13 percent, lower than previously thought. Radiographic follow-up was performed a minimum of 10 years
following injury.

● The prevalence of knee OA was higher (between 21 and 48 percent) in patients with associated injuries,
particularly meniscal tear. The association between meniscal injury or meniscectomy and the development
of OA is supported by numerous studies [101,104,107,109].

● Most studies of OA risk were retrospective and of limited quality. Moreover, the seven radiologic
classification schemes used to determine the presence of OA are inconsistent, making comparisons
among studies difficult.

Other systematic reviews have noted that degenerative OA may occur regardless of the treatment approach
[100,103]. According to one review, the risk of OA in a knee with a surgically repaired ACL is approximately four
times that of the uninjured knee in the same patient [103]. However, an important limitation of nearly all studies
included in the systematic reviews is the inability to account for patients' activity levels following injury. Activity is
typically higher in patients who undergo surgical repair, which increases the risk for developing osteoarthritis. In
addition, surgical repair may be more common in patients whose initial knee injury was more extensive, another
likely risk factor for OA. It seems unlikely that surgical repair itself increases the risk for OA, but it may be a
marker for these other factors.

Another limitation of many surveillance studies is their limited time frame; a longer period (eg, over 20 years from
the time of injury) may be needed to reveal signs of OA in patients managed conservatively. To address concerns
about the limited time frame of many surveillance studies, researchers performed a systematic review of 29
studies with a minimum of 10 years of follow-up that included 1585 patients treated with surgical reconstruction
and 685 patients treated nonoperatively [110]. Notable findings included the following:

● Patients managed surgically initially had less need for subsequent knee surgery, including meniscal
surgery.

● Patients managed nonoperatively had a greater decline in their level of activity (as determined by the
Tegner score), although the absolute level of activity at final follow-up did not differ significantly between
the two cohorts.

● The rate of radiographically evident OA did not differ between the operative and nonoperative cohorts (35.3
and 32.8 percent, respectively).
 Patients amenable to nonoperative treatment — A minority of patients with ACL injury are capable of
returning to sustained, high-level athletic activity without surgical repair [111]. Assessment to identify these
patients soon after their injury is likely to be more accurate when several tests of dynamic neuromuscular
function are used [91,112,113]. While a significant number of these athletes may later choose to undergo
surgical repair, identification of those capable of performing without surgery gives them the option of continuing
to compete, once symptoms have subsided, while surgery would preclude early participation in competitive
sports.

This approach is supported by a prospective observational study of 345 consecutive patients, all active in sports
that place significant demands on the knee, who sustained an isolated ACL rupture, and were tested within seven
months of injury [91]. Dynamic functional testing (a series of specific hopping tests) better predicted those
patients capable of returning to preinjury levels of athletic performance without ACL repair than did traditional
isolated testing of joint laxity or strength.

In this study, 88 of 146 athletes who attained a minimum level of strength and knee mobility with preliminary
rehabilitation and passed dynamic functional testing chose rehabilitation as the primary treatment for their ACL
injury. Ten-year follow-up data were available in 61 of 63 athletes who returned to full sporting activity: 25
continued without surgical repair, while 36 ultimately underwent ACL reconstruction. Long-term follow-up studies
are needed to confirm these results. The results of this study and a randomized trial described elsewhere in this
review suggest that there is a subset of active patients, albeit not yet clearly defined, for whom nonoperative
treatment is a viable approach [91,114]. Further research is needed to delineate this group of patients.

Patients with low functional demands and athletes who participate in sports that do not place high demands on
the knee, such as those involving linear, non-deceleration activities, may be treated nonoperatively [5]. With some
activity modification and proper rehabilitation, such patients can achieve good results [115,116]. We believe such
patients should work with a qualified physical therapist following their injury to improve the strength and
proprioception needed to support the injured knee, and thereby reduce the risk of degenerative disease and
further injury. (See 'Rehabilitation' below.)

Graft selection — ACL reconstruction is generally performed with arthroscopy using a graft to replace the
ruptured ACL. Graft selection remains a source of debate among orthopedic surgeons. Native grafts may be
taken from the patellar tendon, hamstring tendon (semitendinosus and gracilis), or quadriceps tendon, or an
allograft may be used. Allografts are usually taken from an Achilles or patellar tendon, but the quadriceps,
hamstring, and tibialis tendons may also be used. No particular graft has clearly demonstrated superior
functional outcome [117-120].  

The three most common grafts are the patellar tendon graft, the hamstring tendon graft, and the allograft. The
theoretical advantages of the patellar graft include increased initial strength and stiffness compared with the
normal ACL and potential bone-to-bone healing in the femoral and tibial tunnels made during surgery, which
promotes earlier graft fixation [121]. Systematic reviews confirm that reconstruction using the patellar tendon
graft results in greater anterior knee pain compared with other grafts [117,122,123]. Such pain usually resolves
after the first year. Patellar tendon grafts provide greater stability than traditional hamstring grafts, but this may
no longer be the case with four stranded hamstring grafts [123]. Patellar tendon grafts may increase the long-
term risk for osteoarthritis of the knee [124,125].

The hamstring graft has several advantages. Use of the hamstring tendon eliminates patellar tendon morbidity,
primarily anterior knee pain. A systematic review found that hamstring donor site pain usually resolved by three
months, while hamstring strength returned to normal by 12 months [122,126]. The hamstring graft is stronger
and stiffer when quadruple strands are used [127]. Studies are underway using eight-stranded tendon grafts
[128], and double-bundle reconstructions, which appear to yield greater strength and stability [129-131]. Studies
of these techniques are ongoing.

Patellar tendon grafts include a portion of bone at either end, while hamstring grafts are comprised entirely of
tendon. A potential disadvantage of hamstring grafts is the need for healing between a tendon and an osseous
tunnel. As a result, initial fixation may be slower and ultimately weaker than the bone-to-bone healing of a patellar
tendon graft [121,132], although techniques (eg, endo-button) are being developed to address this [122].

Allografts are commonly used for ACL reconstruction. The advantages of allograft include reduced surgical time,
reduced harvest site morbidity, and the availability of a range of sizes. Possible disadvantages include potential
disease transmission, immunologic reactions, slower remodeling and integration, and cost [133].

The risk of infection from an allograft is extremely low. Although reports exist of HIV and hepatitis transmission,
no transmissions have been reported since 2002 [121,134]. Clinically significant bacterial infections occur in less
than 1 percent of cases [135,136]. Animal models and radiologic studies suggest allografts may require three
years or longer for complete cellular remodeling [137,138]. Theoretically, native tissue heals more rapidly
enabling the patient to begin rehabilitation and activities sooner, but this is unproven and the clinical significance
of the prolonged period required for the integration of allografts remains unclear.

The quadriceps tendon graft is a less common approach to ACL reconstruction. Its primary advantages lie in
avoiding injury to the infrapatellar branch of the saphenous nerve, which can occur with patellar tendon grafts,
and sparing the area around the tibial tubercle. The quadriceps tendon can be made into a double bundle, thereby
improving graft strength, and allows for bone-to-bone healing at one end of the graft. Several studies show no
difference in outcome between patellar and quadriceps tendon repairs [139-141].

No specific graft has proven superior [117-119]. In our practice, most young patients active in high-demand
sports receive patellar tendon autograft reconstructions because of their strength and relatively rapid healing.
However, improvements in surgical technique have reduced concerns over the fixation of hamstring grafts and
these are now more common, in part because they reduce graft site morbidity (ie, anterior knee pain). Allografts
are usually reserved for middle-aged athletes who engage in low-impact sports, but they have not been found to
be inferior to autografts [119].

Timing — The best time to undergo ACL reconstruction remains unclear. We believe the condition of the injured
knee is the most important factor when determining the timing of surgery. The knee should exhibit full range of
motion with no significant effusion and adequate strength at the time of reconstruction. Observational studies
suggest that surgery performed prematurely increases the risk of arthrofibrosis [142,143]. One such study found
that 70 percent of patients with signs of knee swelling and inflammation at the time of ACL reconstruction went
on to develop arthrofibrosis. Early repair may result in better long-term knee motion [144]. Often, our patients
undergo two to four weeks of "prehabilitation" to maximize strength and motion prior to surgery.

In one randomized trial involving young healthy adults with acute uncomplicated ACL injuries, no difference in
symptoms or patient perceptions of knee function were noted at two year follow-up between patients treated
with structured rehabilitation and early reconstruction and those treated with structured rehabilitation and
optional delayed reconstruction [114]. The authors claim that the latter approach could substantially reduce the
number of ACL surgeries without adversely affecting outcomes. However, the accompanying editorial notes that
functional assessment at two years, even using a well-validated score, does not accurately reflect long-term knee
function or injury risk and that many ACL reconstructions are performed more than two years following the initial
injury [145]. Delayed reconstruction may increase the risk of further knee injury (eg, medial meniscal tear) and
prolong the time before an athlete can return to full activity [146-148]. (See 'Risk of osteoarthritis or subsequent
injury' above.)

Partial tear — In most cases, incomplete tears of the ACL can be managed nonoperatively with an emphasis
upon physical therapy and proper sport-specific biomechanics [149]. Clinical findings suggestive of a partial ACL
tear include an asymmetric Lachman test, a negative pivot shift test, and KT-1000 arthrometer testing that
demonstrates no more than 3 mm of anterior-posterior translation.

A hinged knee brace may be worn during the early stages of rehabilitation. There is no evidence that wearing a
brace upon returning to full activity reduces the risk of progression to a complete tear, but some clinicians
suggest bracing. Once the strength and motion of the injured leg equals that of the opposite leg, the patient may
return to sports. Symptom progression depends upon the extent of the tear and the patient's activities. Patients
should be referred to an orthopedic surgeon if symptomatic instability develops. Preliminary studies of primary
repair of partial ACL tears are ongoing [150]. (See 'Rehabilitation' below.)

PEDIATRIC CONSIDERATIONS — The overriding clinical question with children and adolescents who have
sustained a complete tear of the anterior cruciate ligament (ACL) is whether to perform surgical repair. We
recommend surgical management for the large majority of these patients. The risk of growth disturbance or
other complications from surgery is low [151]. One notable exception is the adolescent whose growth plates are
expected to close within six to nine months. In such cases, we prefer to delay surgery until the growth plates
close, and to restrict the patient's activity in the interim.

Our preference for surgical repair is supported by a meta-analysis that included results from six studies involving
217 children and adolescents comparing operative and nonoperative treatment, and five studies involving 353
children and adolescents comparing early to delayed reconstruction [152]. The meta-analysis reported that
multiple, clinically important complications occurred significantly more frequently among patients treated
nonoperatively. The following findings were emphasized:

● According to three studies, clinically significant knee instability developed in 13.6 percent of patients
managed surgically compared to 75 percent of those managed nonoperatively.
 ● According to two studies, the incidence of meniscal tear was substantially greater among patients treated
nonoperatively (35.4 percent versus 3.9 percent among patients treated surgically)

● According to two studies, no patient treated nonoperatively was able to return to their previous level of
activity, compared to 85.7 percent of those treated surgically.

REHABILITATION

Principles — Novel approaches to anterior cruciate ligament (ACL) rehabilitation develop continually.

Nevertheless, several principles of rehabilitation have been shown consistently to be important for complete
recovery [153]. Full range of motion, especially in knee extension, should be promoted immediately following ACL
reconstruction. The inability to regain normal knee motion is associated with an increased risk of osteoarthritis
[154].

Closed kinetic chain exercises to strengthen the hamstring and quadriceps muscles are effective for initial
rehabilitation [1,155]. Closed chain exercises require that both feet be planted and remain in a fixed position
throughout the exercise (eg, squat). Closed chain exercises may place less stress on a new ACL graft than open
kinetic chain exercises, in which the feet change position during the activity.

Controversy continues about the role of open chain exercises in ACL rehabilitation. Based upon limited evidence,
we believe that open chain exercises may be added to the rehabilitation program no sooner than six weeks
following surgery [155,156].

Exercises to enhance balance, proprioception, and core strength should be incorporated into postoperative
rehabilitation, as should training to improve sport-specific biomechanics [153,157]. Patients who opt for
nonoperative management also benefit from such exercises and should participate in a comprehensive
rehabilitation program following injury.

Motivated patients can perform postoperative rehabilitation effectively on their own with no difference in long-
term outcomes [158]. Patients wishing to perform rehabilitation independently must be given clear instructions
explaining how to perform the exercises correctly and should demonstrate proper technique to a knowledgeable
clinician before beginning. Different muscle groups manifest relatively greater weakness postoperatively
depending upon the site of the autograft. Specific rehabilitation protocols based on the autograft site have been
developed [159].

A number of devices have been used as part of rehabilitation, but often there is little evidence of effectiveness. A
systematic review found no benefit from the use of passive-motion machines following surgery [160]. Use of a
brace after surgery is based upon surgeon and patient preference. A systematic review of bracing following ACL
reconstruction, which included 12 randomized controlled trials, found no evidence of improved outcome or
reduced risk of subsequent injury among patients using a brace [161].

Return to activity — Little high quality research is available to help determine when patients can safely return to
full activity and sport [162]. A premature return increases the risk for reinjury and graft failure. We believe that
athletes may safely return to sport once their repaired knee demonstrates strength, proprioception, and function
roughly equal to the unaffected knee. We tell patients to expect a return to full activity and sports between 6 and
12 months following surgery, depending upon the sport and their compliance with a sound rehabilitation
program. However, 18 months or longer may be required for a graft to be fully incorporated, and complete
rehabilitation of the affected extremity to be achieved.

A systematic review of over 264 studies addressing return to play after ACL reconstruction identified only 35
studies with objective criteria for return [163]. In many studies, time from surgery was the sole factor. Additional
research is needed to identify the most useful criteria for determining when an athlete is ready to return to sport
with minimal risk of reinjury or graft failure. Such criteria are likely to involve a combination of factors involving
knee motion, strength of supporting muscles, and neuromuscular function.

Some patients are now returning to full activity at six months (and some high-level athletes sooner) following
reconstructive surgery. For selected athletes eager to return to competition, early participation may not be
disadvantageous, provided an appropriate and rigorous rehabilitation program is completed and appropriate
functional milestones are achieved [155]. However, studies supporting early participation involve small numbers
of patients and athletes should be aware that this approach entails some risk of reinjury [164]. Expedited returns
occur before reconstructed ACL grafts are completely incorporated into the knee. Athletes who participate in
accelerated rehabilitation programs may continue to demonstrate some abnormal joint motion and relative
weakness for up to 22 months following surgery. Although studies are limited, early return to full sport following
ACL reconstruction may increase the risk for knee osteoarthritis [165]

PREVENTION — The overall toll of anterior cruciate ligament (ACL) reconstruction is high and this has stimulated
research into the prevention of noncontact ACL injuries. Studies have focused on various aspects of physical
training, particularly neuromuscular training, and on extrinsic supports (ie, braces).

Neuromuscular training — We concur with the consensus statement issued jointly by numerous organizations,
including the American Academy of Orthopaedic Surgeons and the American College of Sports Medicine, that
supports the use of ACL injury prevention programs for female athletes [166]. Although the benefit of such
programs is likely to be greatest among young female athletes [167], we believe well-designed programs are
likely to help all athletes, male and female, that participate in high-risk sports (table 1) [168-172].

A meta-analysis of prospective studies found that the overall risk of ACL injury was reduced in female athletes
that participated in neuromuscular training programs [168]. A total of 29 ACL injuries occurred among program
participants compared with 100 injuries among nonparticipant athletes (odds ratio [OR] 0.40; 95 percent CI 0.26-
0.61). The reviewers noted the following:

● All four programs that incorporated high-intensity jumping plyometric exercises reduced injury rates.

● All three programs that included biomechanical analysis and provided direct feedback to the athletes about
proper position and movement reduced injury rates.

● Programs that incorporated strength training reduced injury rates, although strength training alone did not.
 ● Balance training alone is unlikely to reduce injury rates, although it may enhance other prevention
techniques.

● Athletes must participate in prevention training at least two times per week for a minimum of six
consecutive weeks to accrue any benefit.

In addition, programs that include strengthening exercises for the core musculature (muscles of the hips, pelvis,
and lower torso) produce statistically significant reductions in ACL injury rates, according to a subsequent meta-
analysis of 14 prospective controlled trials [173]. This meta-analysis also found benefit from lower extremity
strengthening exercises (particularly Nordic hamstring lowers) and prevention programs that incorporated
multiple types of exercises (eg, core strength, extremity strength, plyometrics).

Another meta-analysis of 8 prospective studies did not comment on the best methods for ACL injury prevention
but reported a significant reduction in injury rates for athletes who participate regularly in well-designed
neuromuscular prevention programs (pooled risk ratio [RR] 0.38, 95% CI 0.20-0.72) [170]. The reduction in injury
risk was greatest for male athletes (RR 0.15, 95% CI 0.08-0.28) but remained statistically significant for female
athletes (RR 0.48, 95% CI 0.26-0.89). Of note, the results of negative studies included in the review suggest that
neither plyometric training (20 minutes twice weekly) nor balance training (15 minutes three times weekly), when
performed alone, reduce the risk of ACL injury. The limited effectiveness of balance training alone is supported
by other studies [172,173].

Females in early adolescence, or possibly preadolescence, may benefit the most from neuromuscular training
prevention programs, according to a meta-analysis of 14 randomized trials involving thousands of athletes that
looked specifically at this issue. According to this meta-analysis, females in their mid-teens had greater
reductions in their rate of ACL injury (odds ratio [OR] 0.28; 95% CI 0.18-0.42) than females in their late teens (OR
0.48; 95% CI 0.21-1.07) or early adulthood (OR 1.01; 95% CI 0.62-1.64) [167]. These results suggest that it is
important to implement prevention programs before female athletes develop poor mechanics during movements
associated with an increased risk of ACL injury (eg, suddenly changing direction while running, landing from a
jump). The authors advocate early use of neuromuscular training, and we concur.

Individual trials have focused on particular elements of prevention. In one such trial, high-level intercollegiate
women's soccer (football) teams in the United States were randomly assigned to participate three times per
week before practice in a neuromuscular training program designed to reduce the rate of noncontact ACL injuries
or to engage in their standard team warm-up [174]. Athletes participating in the program (n = 583) sustained only
two noncontact ACL injuries over the course of one season while those following their team's standard warm-up
(n = 852) sustained 10. The program, known as PEP for Prevent injury and Enhance Performance, requires about
10 to 15 minutes to perform and consists of a warm-up followed by several strength, agility, plyometric, and
flexibility exercises [175]. The goal is to increase lower extremity and core muscle fitness and to improve
neuromuscular function such that athletes avoid positions that increase their susceptibility to ACL injury. A
similar trial performed in adolescent female soccer players reported comparable findings [176]. Other smaller
studies involving athletes in a number of high-risk sports (eg, basketball, soccer) have demonstrated decreased
rates of ACL tear among athletes who participate in similar well-designed prevention programs [43,174,175,177-
181].

Different prevention programs incorporate specific drills that more closely approximate the demands of
particular sports, and may hold advantages for athletes engaged primarily in these sports. The Henning program,
based on video analysis of ACL injuries, teaches specific landing, cutting, and stopping maneuvers [182]. The
Caraffa program focuses on proprioceptive training for soccer players [177]. FIFA (Fédération Internationale de
Football Association), the governing body of international soccer, includes a program for ACL injury prevention
(FIFA 11+) on its website that has been shown to be effective for injury prevention [183,184]. The Sportsmetrics
training program includes a large number of volleyball athletes and includes jumping and plyometric training to
increase strength and to inculcate safer landing positions [180]. A program developed by the Vermont Safety
Research group, based in part on video analysis, teaches downhill skiers to avoid certain high-risk positions and
movements [178].

We suggest ACL prevention programs be taught and supervised initially by knowledgeable athletic trainers,
physical therapists, or comparable professionals, until players are able to perform the program with consistent
proficiency. Prevention exercises that address the specific biomechanical faults of individual athletes as
determined by such experts may be useful [185].

Extrinsic supports — Several randomized and observational studies suggest that prophylactic knee bracing does
not prevent ACL tears, and one observational study suggests that such bracing may increase morbidity [161,186-
188]. A small laboratory study suggests medially posted orthotics may reduce the risk of valgus knee angulation,
and thereby ACL injury, but further research is needed before this intervention can be recommended [189].

FUTURE TREATMENTS — Future developments in anterior cruciate ligament (ACL) reconstruction may include
repair of the injured ACL, synthetic replacements, and bioengineered ACL reconstruction [190].

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and
"Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade
reading level, and they answer the four or five key questions a patient might have about a given condition. These
articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond
the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written
at the 10th to 12th grade reading level and are best for patients who want in-depth information and are
comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these
topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on
"patient info" and the keyword(s) of interest.)

● Basics topics (see "Patient education: Anterior cruciate ligament tear (The Basics)" and "Patient education:
Knee pain (The Basics)")
 ● Beyond the Basics topics (see "Patient education: Anterior cruciate ligament injury (Beyond the Basics)"
and "Patient education: Knee pain (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

● The anterior cruciate ligament (ACL) is the most commonly injured knee ligament. Noncontact, low-energy
injuries incurred during athletic activity account for the majority of ACL tears. Female athletes are at
increased risk. (See 'Epidemiology' above and 'Risk factors' above.)

● The typical mechanism for a noncontact ACL injury involves a running or jumping athlete who suddenly
decelerates and changes direction (eg, cutting) or pivots in a way that involves rotation or lateral bending
(ie, valgus stress) of the knee. (See 'Mechanism and presentation' above.)

● Patients who sustain an ACL injury often complain of feeling a "pop" in their knee at the time of injury, acute
swelling thereafter, and a feeling that the knee is unstable or "giving out." Nearly all patients with an acute
ACL injury manifest a knee effusion from hemarthrosis. (See 'Mechanism and presentation' above.)

● The Lachman, Pivot Shift, and Anterior drawer tests are the most useful examination techniques for
detecting ACL injury. When evaluating a patient for ACL injury it is important to look for associated injuries
(eg, meniscal tear) and to examine the unaffected knee for comparison. Many patients have increased
laxity that is not pathologic. (See 'Physical examination' above.)

● Plain radiographs cannot be used to diagnose ACL rupture. Magnetic resonance imaging (MRI) is both
highly sensitive and specific. (See 'Diagnostic imaging' above.)

● ACL injuries can be managed operatively or nonoperatively. Although rigorous studies are few, the ACL-
deficient knee is associated with an increased risk for further injury (eg, meniscal tear), chronic pain, and
decreased level of activity. Degenerative osteoarthritis may occur regardless of the treatment approach.
(See 'Operative or nonoperative treatment?' above.)

● Patients with injuries to multiple knee structures (eg, ACL plus meniscus or medial collateral ligament) or
who experience significant knee instability (eg, knee gives out while climbing stairs) generally need surgical
reconstruction. Young athletes and athletes who participate and wish to continue in high-demand sports
(ie, those involving cutting, jumping, pivoting, and quick deceleration) generally need surgical
reconstruction.

● Different tissue grafts can be used for ACL reconstruction. Graft selection and the timing of surgery are
discussed in the text. (See 'Graft selection' above and 'Timing' above.)

● Focused neuromuscular training designed to prevent ACL rupture may reduce risk, particularly among
women participating in high-risk sports. We strongly encourage athletes who participate in sports that
place them at high risk for ACL injury to participate in a well-designed, neuromuscular, injury-prevention
program. (See 'Prevention' above.)
 Use of UpToDate is subject to the Subscription and License Agreement.

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Topic 243 Version 41.0

GRAPHICS

Anterior anatomy of the knee joint

This drawing represents an anterior view of the knee with the patella removed and demonstrates the
relationship between the bones, menisci, and major ligaments.

Graphic 69611 Version 9.0

Knee ligaments: Anterior view

Reproduced with permission from: Lower limb. In: Clinically Oriented Anatomy, 7th ed, Moore KL, Dalley AF, Agur AM (Eds),
Lippincott Williams & Wilkins, Philadelphia 2013. Copyright © 2013 Lippincott Williams & Wilkins. www.lww.com.

Graphic 89733 Version 6.0

Knee menisci and related anatomy

(A) Superior view.

(B) Posterior view.

Reproduced with permission from: Lower limb. In: Clinically Oriented Anatomy, 7th ed, Moore KL, Dalley AF, Agur AM (Eds),
Lippincott Williams & Wilkins, Philadelphia 2013. Copyright © 2013 Lippincott Williams & Wilkins. www.lww.com.

Graphic 89730 Version 6.0

Q angle

Although the Q angle is often mentioned, research suggests its role in conditions such as
patellofemoral pain syndrome and patellar instability is of little importance. 

Graphic 55389 Version 4.0

Sports associated with increased risk of ACL injury

Football (ie, Soccer)

American football

Basketball

Volleyball

Gymnastics

Team handball

Downhill skiing

Note: virtually any sport that involves explosive running, jumping, or sudden changing of direction places the athlete at risk for ACL
injury.

ACL: anterior cruciate ligament.

Graphic 70676 Version 1.0

Lachman test

The Lachman test is performed by placing the knee in 30 degrees of flexion and then
stabilizing the distal femur with one hand while pulling the proximal tibia anteriorly with the
other hand, thereby attempting to produce anterior translation of the tibia. An intact ACL
limits anterior translation and provides a distinct endpoint. Lack of a distinct endpoint
suggests ACL injury.

Courtesy of Ryan P Friedberg, MD.

Graphic 65914 Version 2.0

Pivot shift test

The pivot shift test is sensitive only in a fully relaxed patient. The test is performed with the
knee starting in extension. The clinician holds the lower leg with one hand and internally
rotates the tibia, while placing a valgus stress on the knee using the other hand. While
maintaining the forces described, the clinician flexes the knee. In the ACL-deficient knee this
causes a reduction of the subluxed tibia, which the clinician senses as a 'clunk,' and which
constitutes a positive test.

Courtesy of Ryan P Friedberg, MD.

Graphic 52976 Version 1.0

Anterior drawer test

The anterior drawer test is performed with the patient lying supine and the knee flexed at 90
degrees. The proximal tibia is gripped with both hands and pulled anteriorly, checking for
anterior translation. Often the clinician sits on the foot while performing the test to provide
stability. It is helpful to compare the degree of translation with the uninjured knee.

Courtesy of Ryan P Friedberg, MD.

Graphic 73963 Version 3.0

Segond fracture

Plain radiographs cannot be used to diagnose anterior cruciate ligament tears. In some
cases, an avulsion fracture of the anterolateral tibial plateau (ie, Segond fracture) is
identified at the site of attachment of the lateral capsular ligament.

Courtesy of Ryan P Friedberg, MD.

Graphic 59018 Version 3.0

MRI of normal ACL and with avulsion injuries

Image A and B are sagittal projections of the knee using proton density fat saturated sequences. Image A shows a normal ACL
(arrowheads). Image B shows a full thickness tear (arrow) and fraying of the proximal and distal components (arrowheads). Image C is a
sagittal image of the knee using T2 weighted, fast spin echo technique and shows complete avulsion of the ACL at its insertion on to the
tibia (arrow), and normal proximal ligament (arrowhead).

MRI: magnetic resonance imaging; ACL: anterior cruciate ligament.

Graphic 96617 Version 1.0

Contributor Disclosures
Ryan P Friedberg, MD Nothing to disclose Karl B Fields, MD Nothing to disclose Jonathan Grayzel, MD,
FAAEM Nothing to disclose

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must conform to
UpToDate standards of evidence.

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