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Anterior cruciate ligament injury Author Ryan P Friedberg, MD Disclosures All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Mar 2013. | This topic last updated: abr 1, 2013. 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 (US) 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 "Evaluation of the active adult patient with knee pain" and "Medial collateral ligament injury of the knee" and "Meniscal injury of the knee" and "Patella fractures" and "Patellofemoral pain syndrome".) 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) [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]. EPIDEMIOLOGY The anterior cruciate ligament (ACL) is the most commonly injured knee ligament. In the United States (US) 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 US college and high school athletes, but these account for a small percentage of the total number of injuries [9,10]. 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 US college athletics since 1988, American football players sustain the greatest number of ACL tears (53 percent of total), but female gymnasts sustain the highest rate of injury (0.33 ACL injuries/1000 athletic exposures). 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 [11]. Competitive alpine skiers sustain ACL injuries at a high rate [12]. Participants in women's ice hockey and men's baseball have a low incidence [13]. With certain sports, female gender confers significantly greater risk of ACL rupture [14-21]. 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) [9-11]. Although the overall incidence of ACL injuries is roughly equal for female and male US college athletes, this stems from the disproportionate number of injuries among male American football players. (See 'Risk factors' below.) Section Editor Karl B Fields, MD Deputy Editor Jonathan Grayzel, MD, FAAEM

RISK FACTORS Gender-related It remains unclear which factors most predispose athletes to 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 or deceleration 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 [22-25]. 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 [26-28]. 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) during sudden changes in direction substantially increases the stress placed on the ACL [29]. 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 [30-34]. Thus, training to correct faulty biomechanics may limit susceptibility to ACL injury. (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 [29,35,36]. 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 [37-42]. Oral contraceptives modulate hormonal effects on soft tissue and several observational studies suggest that they may reduce the risk of ACL rupture [15,29,41]. However others refute this idea [43]. 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 [29,44]. 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 2). 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 [45-47]. Others refute this [48]. 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 several studies. One review found no clear association between footwear or playing surface and ACL injury [49], while other studies suggest increased risk for athletes playing on surfaces with increased traction (eg, synthetic gym floors) [29,32,50,51]. A survey of noncontact injuries among professional American football players found that fewer than 5 percent occurred on a wet playing surface [52]. 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 [32]. (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, and genetic factors [29,45,53-57]. 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 [21,54]. The most common mechanism involves a lowenergy, 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 in a way that involves rotation or lateral bending (ie, valgus stress) of the knee. Researchers using video to assess the biomechanics of ACL tears have found that the majority of injuries occur when an athlete moves her leg forcefully into a valgus position with the knee extended and the tibia rotated internally [32,33,58]. Sports associated with ACL injuries often involve pivoting and sudden changes in direction, and include alpine skiing, soccer (football), basketball, and tennis (table 1). Women are more prone to ACL tears than men. (See 'Epidemiology' above and 'Risk factors' above.) Contact mechanism Contact-related ACL injuries usually occur from a direct blow causing hyperextension or valgus stress to 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 [59]. 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 exam 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 [60,61]. 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 [62]. Associated structures that are commonly injured include the meniscus, joint capsule, articular cartilage, subchondral bone (bone bruise), and other ligaments [63,64]. 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 [65]. 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 "Evaluation of the active adult patient with knee pain".) 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 [66,67]. 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 1). 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 [66,68]. 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 3). This causes subluxation in the ACL-deficient knee. While maintaining the forces described, the clinician flexes the knee. In the ACLdeficient 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 2). 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 metaanalysis 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 [66]. 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 [59,66]. Other reviews have reported similar results [69]. 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 [59]. 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 "Evaluation of the active adult patient with knee pain".) DIAGNOSTIC IMAGING Plain radiographs are often performed following traumatic knee injuries to rule out fractures, but cannot be used to diagnose 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 [70-72]. 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. 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 [62]. 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 [73-75]. 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 [74,76-80]. 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 [81]. 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 NSAIDs provide effective shortterm 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 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 patients 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, in part due to their increased 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 [82]. Some experts believe a positive pivot shift test three months following injury best predicts the future need for surgical repair [83]. 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 [84]. According to a systematic review of 48 studies involving 5770 participants, 82 percent of patients treated with ACL reconstruction returned to some type of athletic activity, while 63 percent attained their preinjury level of competition [85]. These rates are relatively low given that 90 percent of patients achieved normal or near normal knee function following surgery, suggesting that other factors, such as fear of reinjury, play an important role in athletes decisionmaking about return to play. 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 [63]. 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 [86,87]. 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 lacking, the ACLdeficient knee may place patients at increased risk for osteoarthritis (OA), meniscal tear, articular cartilage injury, chronic knee pain, and decreased level of activity [63,88-91]. Partial or complete meniscectomy at the time of surgical repair of the ACL is associated with a substantial increase in the risk of knee OA [92]. A systematic review performed to determine the risk of developing OA following ACL injury, which included patients who underwent surgical repair and those treated conservatively, noted the following [93]: 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 is higher (between 21 and 48 percent) in patients with associated injuries (eg, meniscal tear). The findings of a subsequent prospective cohort study of patients who underwent ACL reconstruction (n = 181) support this conclusion [94]. Most studies to investigate this problem 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. Another systematic review noted that surveillance studies suggest degenerative OA may occur regardless of the treatment approach [95]. Subsequent studies support this notion [96,97]. As examples, a prospective observational study of 40 patients with acute ACL tear noted that all participants sustained longitudinal chondral degradation in compartments unaffected by any initial bone bruise, although nonoperative management was associated with greater risk [96]. A prospective cohort study of 94 patients with ACL tear reported that OA developed infrequently among those managed with activity modification and physical therapy, provided meniscectomy was not performed [98]. One important 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.

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 [99]. Assessment to identify these patients soon after their injury is likely to be more accurate when several tests of dynamic neuromuscular function are used [82,100,101]. 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 [82]. 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 [82,102]. 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, nondeceleration activities, may be treated nonoperatively [5]. With some activity modification and proper rehabilitation, such patients can achieve good results [103,104]. 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 [105-107]. 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 [108]. Systematic reviews confirm that reconstruction using the patellar tendon graft results in greater anterior knee pain compared with other grafts [105,109,110]. 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 [110]. Patellar tendon grafts may increase the long-term risk for osteoarthritis of the knee [111,112]. 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 [109,113]. The hamstring graft is stronger and stiffer when quadruple strands are used [114]. Studies are underway using eight-stranded tendon grafts [115], and double-bundle reconstructions, which appear to yield greater strength and stability [116-118]. 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 [108,119], although techniques (eg, endo-button) are being developed to address this [109].

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 [120]. 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 [108,121]. Clinically significant bacterial infections occur in less than 1 percent of cases [122,123]. Animal models and radiologic studies suggest allografts may require three years or longer for complete cellular remodeling [124,125]. 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 [126-128]. No specific graft has proven superior [105-107]. 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 [107]. 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 [129,130]. 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 [131]. 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 [102]. 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 [132]. 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 [133-135]. (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 [136]. 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 [137]. (See 'Rehabilitation' below.)

REHABILITATION Principles Novel approaches to ACL rehabilitation develop continually. Nevertheless, several principles of rehabilitation have been shown consistently to be important for complete recovery [138]. 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 [139]. Closed kinetic chain exercises to strengthen the hamstring and quadriceps muscles are effective for initial rehabilitation [1,140]. 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 [140,141]. Exercises to enhance balance, proprioception, and core strength should be incorporated into postoperative rehabilitation, as should training to improve sport-specific biomechanics [138,142]. 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 [143]. 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 [144]. 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 [145]. 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 [146]. Return to activity Little high quality research is available to help determine when patients can safely return to full activity and sport. 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. A systematic review of over 264 studies addressing return to play after ACL reconstruction identified only 35 studies with objective criteria for return [147]. 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 followed [140]. However, studies supporting early participation involve small numbers of patients and athletes should be aware that this approach entails some risk of reinjury [148]. 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. PREVENTION The overall toll of 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 [149]. Although the benefit of such programs is likely to be greatest among young female athletes [150], we believe well-designed programs are likely to help all athletes, male and female, that participate in high-risk sports (table 1) [151,152]. A meta-analysis of prospective studies (n = 6) found that the overall risk of ACL injury was reduced in female athletes that participated in neuromuscular training programs [151]. A total of 29 ACL injuries occurred among program participants compared with 100 injuries among nonparticipant athletes (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. A subsequent 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) [153]. 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 board training (15 minutes three times weekly), when performed alone, reduce the risk of ACL injury. 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 (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) [150]. 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 womens 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 [154]. Athletes participating in the program (n = 583) sustained only two noncontact ACL injuries over the course of one season while those following their teams 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 [155]. 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 similar findings [156]. 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 [38,154,155,157-161]. 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 [162]. The Caraffa program focuses on proprioceptive training for soccer players [157]. FIFA (Fdration Internationale de Football Association), the governing body of international soccer, includes a program for ACL injury prevention on its website. 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 [160]. A program developed by the Vermont Safety Research group, based in part on video analysis, teaches downhill skiers to avoid certain highrisk positions and movements [158]. 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 [163]. 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 [146,164166]. 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 [167]. FUTURE TREATMENTS Future developments in ACL reconstruction may include repair of the injured ACL, synthetic replacements, and bioengineered ACL reconstruction [168]. 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 information: Anterior cruciate ligament tear (The Basics)" and "Patient information: Knee pain (The Basics)") Beyond the Basics topics (see "Patient information: Anterior cruciate ligament injury (Beyond the Basics)" and "Patient information: 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. MRI is both highly sensitive and specific. (See 'Diagnostic imaging' above.) ACL injuries can be managed operatively or nonoperatively. Although rigorous studies are lacking, the ACLdeficient knee may place patients at 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.)

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GRAPHICS
Anterior anatomy of the knee

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

Q angle

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

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.

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.

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.

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.

Segond fracture

Plain radiographs cannot be used to diagnose ACL 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.

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