Anterior Cruciate Ligament (ACL) Injury


ACL diagram from anterior.png

Injuries to the ACL are relatively common knee injuries among athletes.[1] They occur most frequently in those who play sports involving pivoting (e.g. football, basketball, netball, soccer, European team handball, gymnastics, downhill skiing). They can range from mild (such as small tears/sprain) to severe (when the ligament is completely torn). Both contact and non-contact injuries can occur, although non-contact tears and ruptures are most common. It appears that females tend to have a higher incidence rate of ACL injury than males, that being between 2.4 and 9.7 times higher in female athletes competing in similar activities.[2][3][4][5][6]

Clinically Relevant Anatomy

The ACL is a band of dense connective tissue which courses from the femur to the tibia and considered a key structure in the knee joint, as it resists anterior tibial translation and rotational loads[7].

The ACL arises from the posteromedial corner of the medial aspect of the lateral femoral condyle in the intercondylar notch[8] and inserted anterior to the intercondyloid eminence of the tibia, blending with the anterior horn of the medial meniscus. The ACL courses anteriorly, medially, and distally across the joint as it passes from the femur to the tibia. As it does, it turns on itself in a slight outward (lateral) spiral.

There are two components of the ACL, the smaller anteromedial bundle (AMB) and the larger posterolateral bundle (PLB), named according to where the bundles insert into the tibial plateau. When the knee is extended the PLB is tight, while the AMB is moderately lax. However, as the knee is flexed, the femoral attachment of the ACL assumes a more horizontal orientation, causing the AMB to tighten and the PLB to loosen and thus leave the AMB as the restraint to anterior tibial load[9].

Refer to this page for more information on the ACL Biomechanics:

Anterior Cruciate Ligament (ACL) - Structure and Biomechanical Properties

Mechanisms of Injury

Three major types of ACL injuries are described:[10] 

  • Direct Contact: 30% of the cases [11][12] 
  • Indirect Contact 
  • Non-Contact: 70% of the cases: by doing a wrong movement [11][12] 

Anterior cruciate ligament (ACL) injuries are common in young individuals who participate in sports activities associated with pivoting, decelerating and jumping. [12] 

Most common are the non-contact injuries, caused by forces generated within the athlete’s body while most other sport injuries involve a transfer of energy from an external source.[13] Approximately 75% of ruptures are sustained with minimal or no contact at the time of injury.[14] A cut-and-plant movement is the typical mechanism that causes the ACL to tear, being a sudden change in direction or speed with the foot firmly planted. Rapid deceleration moments, including those that also involve planting the affected leg to cut and change direction, have also been linked to ACL injuries, as well as landing from a jump, pivoting, twisting, and direct impact to the front of the tibia.[14]

Women are three times more prone to have the ACL injured than men and is thought to be due to the following reasons:[15]

  • Smaller size and different shape of the intercondylar notch. A narrow intercondylar notch and a plateau environment are risk factors of predisposing female non-athletes with knee OA to ACL injury aged 41-65 years. [16] 
  • Wider pelvis and greater Q angle. A wider pelvis requires the femur to have a greater angle towards the knee, lesser muscle strength provides less knee support, and hormonal variations may alter the laxity of ligaments.[17][18]
  • Greater ligament laxity. Young athletes with non-modifiable risk factors like ligament laxity are at a particularly increased risk of recurrent injury following ACL reconstruction (ACLR). [19] 
  • Shoe surface interface. The pooled data from the three studies suggest that the chances of injury are approximately 2.5 times higher when higher levels of rotational traction are present at the shoe-surface interface. [20] 
  • Neuromuscular factors

Risk factors for ACL injuries include environmental factors (e.g. high level of friction between shoes and the playing surface) and anatomical factors (e.g. narrow femoral intercondylar notch). The injury is characterised by joint instability, which is associated with both acute dysfunction and long-term degenerative changes, such as osteoarthritis and meniscal damage. Knee instability leads to decreased activity, which can lead to poor knee-related quality of life. [21] [12] [22] The risk factors for ACL injury have been considered as either internal or external to an individual. External risk factors include type of competition, footwear and surface, and environmental conditions. Internal risk factors include anatomical, hormonal and neuromuscular risk factors. [11] [23][24] 

External Risk Factors [11] [23] 

Competition in games versus practice
Very little is known about the effect of type of competition on the risk of an athlete suffering ACL injury. Myklebust et al[25] reported that athletes are at a higher risk of suffering an ACL injury during a game than during practice. This finding introduces the hypothesis that the level of competition, the way in which an athlete competes, or some combination of the two increases an athlete’s risk of suffering an ACL injury.

Footwear and playing surface
Although increasing the coefficient of friction between the sports shoe and playing surface may improve traction and sports performance, it also has the potential to increase the risk of injury to the ACL. Lambson et al found that the risk of suffering an ACL injury is greater in football athletes who have boots with a higher number of cleats and an associated higher torsional resistance at the foot-turf interface. Olsen et al[25] reported that the risk of suffering an ACL injury is greater in female team handball athletes who compete on artificial floors that have a higher torsional resistance at the foot-floor interface than in those who compete on wood floors. This relationship did not exist for male athletes.

Protective equipment
There is some controversy about the use of functional bracing to protect the ACL-deficient knee. Kocher et al studied professional skiers with ACL-deficient knees and found a greater risk of knee injury in those who did not wear a functional brace than in those who did use a brace. McDevitt et al performed a randomised controlled study of the use of functional braces in cadets attending the US military academies who underwent ACL reconstruction. At the 1-year follow-up the use of functional bracing did not affect the rate of ACL graft re-injury. There were only three injuries among those in the unbraced group and two injuries in the braced group however.

Meteorological conditions
For sports that are played on natural or artificial turf, the mechanical interface between the foot and playing surface is highly dependent on the meteorological conditions. However, very little is known about the effect of these variables on an athlete’s risk of suffering an ACL injury. Orchard et al reported that non-contact ACL injuries sustained during Australian football were more common during periods of low rainfall and high evaporation. This work introduces the hypothesis that meteorological conditions have a direct effect on the mechanical interface (or traction) between the shoe and playing surface, and this, in turn, has a direct effect on the likelihood of an athlete suffering an ACL injury.

Internal Risk Factors [11] [23]

Anatomical risk factors
Abnormal posture and lower extremity alignment (eg, hip, knee and ankle) may predispose an individual to ACL injury by contributing to increased ACL strain values; alignment of the entire lower extremity should therefore be considered when assessing risk factors for ACL injury. Unfortunately, very few studies have studied alignment of the entire lower extremity and determined how it is related to the risk of ACL injury. Most of what is known has come from investigations of specific anatomical measures.

Biomechanics of Injury

As 60-80% of ACL injuries occur in non-contact situations, it seems likely that appropriate prevention efforts are warranted. Cutting or sidestep manoeuvres are associated with dramatic increases in the varus-valgus and internal rotation moments. The ACL is placed at greater risk with both varus and internal rotation moments. The typical ACL injury occurs with the knee externally rotated and in 10-30° of flexion when the knee is placed in a valgus position as the athlete takes off from the planted foot and internally rotates with the aim of suddenly changing direction (as shown in the figure below).[25][26] The ground reaction force falls medial to the knee joint during a cutting manoeuvre and this added force may tax an already tensioned ACL and lead to failure. Similarly, in landing injuries, the knee is close to full extension. High-speed activities such as cutting or landing manoeuvres require eccentric muscle action of the quadriceps to resist further flexion. It may be hypothesised that vigorous eccentric quadriceps muscle action may play a role in disruption of the ACL. Although this normally would be insufficient to tear the ACL, it may be that the addition of valgus knee position and/or rotation could trigger an ACL rupture.[27]

Non-Contact ACL Mechanism

The athlete could be off balance, held by an opponent, avoiding collision with an opponent, or have adopted an unusually wide foot position. These perturbations contribute to this injury by causing the athlete to plant the foot so as to promote unfavourable lower extremity alignment which may be compounded by inadequate muscle protection and poor neuromuscular control.[29] Fatigue and loss of concentration may also be a factor. What has become recognised is that unfavourable body movements in landing and pivoting can occur, leading to what has become known as the 'Functional Valgus' or 'dynamic valgus' knee, a pattern of knee collapse where the knee falls medial to the hip and foot. This has been called by Ireland (1996) as the 'Position of No Return', or perhaps it should be termed the 'injury prone position' since there is no proof that one cannot recover from this position.[30]Intervention programs aimed to reduce the risk of ACL injury are based on training safer neuromuscular patterns in simple manoeuvres such as cutting and jump landing activities.[31] 

A hypothesis of how non-contact ACL injuries occurs is; when valgus loading is applied, the medial collateral ligament becomes taut and lateral compression occurs. This compressive load, as well as the anterior force vector caused by quadriceps contraction, causes a displacement of the femur relative to the tibia where the lateral femoral condyle shifts posteriorly and the tibia translates anteriorly and rotates internally, resulting in ACL rupture. After the ACL is torn, the primary restraint to anterior translation of the tibia is gone. This causes the medial femoral condyle to also be displaced posteriorly, resulting in external rotation of the tibia. Valgus loading is a key factor in the ACL injury mechanism and at the same time, the knee rotates internally. A quadriceps drawer mechanism may also contribute to ACL injury as well as external rotation. [32]

Potential neuromuscular imbalances may be related to components of the injury mechanism. Women have more quadriceps dominant neuromuscular patterns than men. Hamstring recruitment has been shown to be significantly higher in men than in women. The hamstring to quadriceps peak torque ratio tends to be greater in men than in women. Due of the likely injury mechanism, it is recommended that athletes avoid knee valgus and land with more knee flexion. [23] 

Lower extremity valgus (knee abduction) loading and anterior tibial translation are likely to be involved in the mechanism. Future research should combine several research approaches to validate the findings such as video analysis, clinical studies, laboratory motion analysis, cadaver simulation and mathematical simulation. [32][24]
Position of No Return

Grades of Injury

An ACL injury is classified as a grade I, II, or III sprain.[33]

  • Grade I Sprain:
    • The fibres of the ligament are stretched, but there is no tear.
    • There is a little tenderness and swelling.
    • The knee does not feel unstable or give out during activity.
    • No increased laxity and there is a firm end feel.
  • Grade II Sprain:
    • The fibres of the ligament are partially torn or incomplete tear with haemorrhage.
    • There is a little tenderness and moderate swelling with some loss of function.
    • The joint may feel unstable or give out during activity.
    • Increased anterior translation yet there is still a firm end point.
    • Painful and pain increase with Lachman's and anterior drawer stress tests.
  • Grade III Sprain:
    • The fibres of the ligament are completely torn (ruptured); the ligament itself is torn completely into two parts.
    • There is tenderness, but limited pain, especially when compared to the seriousness of the injury.
    • There may be a little swelling or a lot of swelling.
    • The ligament cannot control knee movements. The knee feels unstable or gives out at certain times.
    • There is also rotational instability as indicated by a positive pivot shift test.
    • No end point is evident.
    • Haemarthrosis occurs within 1-2 hours.

An ACL avulsion occurs when the ACL is torn away from either the femur or the tibia. This type of injury is more common in children than adults. The term anterior cruciate deficient knee refers to a grade 3 sprain in which there is a complete tear of the ACL. It is generally accepted that a torn ACL will not heal.[34]

Characteristics/Clinical Presentation[1]

  • ­Occurs after either a cutting manoeuvre or single leg standing, landing or jumping
  • There may be an audible pop or crack at the time of injury
  • ­A feeling of initial instability which may be masked later by extensive swelling
  • Episodes of giving way especially on pivoting or twisting motions. Patient has a trick knee and predictable instability
  • ­A torn ACL is extremely painful, particularly immediately after sustaining the injury
  • ­Swelling of the knee, usually immediate and extensive, but can be minimal or delayed
  • ­Restricted movement, especially an inability to fully extend the knee
  • ­Possible widespread mild tenderness
  • ­Tenderness at the medial side of the joint which may indicate cartilage injury

Associated Injuries

Injuries to the ACL rarely occur in isolation. The presence and extent of other injuries may affect the way in which the ACL injury is managed[27].

Meniscal Lesions

Over 50% of all ACL Ruptures have associated Meniscal injuries. If seen in combination with a medial meniscus tear and an MCL Injury, it is termed O’Donohue’s Triad which has 3 components:[1]

Medial Collateral Ligament Injuries

Associated injury to the MCL (Grade I-III) poses a particular problem due to tendency to develop stiffness after this injury. Most orthopaedic surgeons will first treat an MCL injury in a limited motion knee brace for a period of six weeks, during which time the athlete would undertake a comprehensive rehabilitation program. Only then would ACL reconstruction be performed or be treated[27].

Bone Contusions and Microfractures

Subcortical trabecular bone injury (bone bruise) may occur due to the pressures exerted on the knee in traumatic injury and are especially associated with ACL rupture. Associated injuries of the menisci and the MCL tend to increase the progression of bone contusion.[35] The focal signal abnormalities in subchondral bone marrow seen on MRI (undetectable on rdiographs) are thought to represent microtrabecular fractures, haemorrhage and edema without disruption of adjacent cortices or articular cartilage.[36] Bone contusions may occur in isolation to ligamentous or meniscal injury.[37]

Occult bony lesions have been reported in 84-98% of the patients with ACL rupture.[35][38][39] The majority of these have lesions of the lateral compartment,[40] involving either the lateral femoral condyle, the lateral tibial plateau, or both. The boney bruising itself is unlikely to cause pain or reduced function.[41] Although the majority of bony lesions resolve, permanent alterations may remain. There is confusion in the literature as to how long these bony lesions remain, but it has been reported that they can persist on MRI for years.[42] Rehabilitation and the long-term prognosis may be affected in those patients with extensive bony and associated articular cartilage injuries. In the case of severe bone bruising it has been recommended to delay return to full weight-bearing status to prevent further collapse of subchondral bone and further aggravation of articular cartilage injury.[42]

Chondral Injury

Hollis et al suggested that all patients following traumatic ACL disruption sustained a chondral injury at the time of initial impact with subsequent longitudinal chondral degradation in compartments unaffected by the initial bone contusion, a process that is accelerated at 5 to 7 years’ follow-up.[43]

Tibial Plateau Fractures

A Tibial Plateau Fracture is a bone fracture or break in the continuity of the bone occurring in the proximal tibia affecting the knee joint, stability, and motion. The tibial plateau is a critical weight-bearing area located on the upper tibia and is composed of two slightly concave condyles (medial and lateral condyles) separated by an intercondylar eminence and the sloping areas in front and behind it. It can be divided into three regions: the medial tibial plateau (the part of the tibial plateau nearest the centre of the body and contains the medial condyle), the lateral plateau (the part of the tibial plateau that is farthest away from the centre of the body and contains the lateral condyle) and the central tibial plateau (located between the medial and lateral plateaus and contains intercondylar eminence).

These fractures are also caused by varus or valgus forces combined with axial loading on knee and mostly occur with ACL injuries, rarely alone. The fracture of lateral tibial plateau is also called a Segond fracture which most commonly occurs with an ACL injury.

Posterolateral Corner Injury

The stability of the posterolateral corner of the knee is provided by capsular and non--capsular structures that function as static and dynamic stabilisers[44] including the lateral collateral ligament (LCL), the popliteus muscle and tendon including its fibular insertion (popliteofibular ligament), and the lateral and posterolateral capsule. Injuries to this region that result in posterolateral rotatory instability are usually associated with concurrent ligamentous injuries elsewhere in the knee.[45][46][47][48] High-grade posterolateral corner injuries are usually associated with rupture of one or both cruciate ligaments. Importantly, failure to address instability of the posterolateral corner structures increases the forces at the ACL and PCL graft sites, and may ultimately predispose to failure of the cruciate reconstruction.[49][50][51] (See also: Knee Rotary Instability)

Popliteal Cyst

Popliteal cysts, originally called Baker’s cyst, form when a bursa swells with synovial fluid, with or without a clear inciting aetiology. Presentation ranges from asymptomatic to painful, limited knee motion. Management varies based on symptoms and aetiology.
Popliteal cysts have been described as an interconnection between the knee joint and the bursa resulting from local fluid mechanics. Wolfe and Colloff stated that ‘there are two requirements for a cyst to form: the anatomical communication and a chronic effusion which opens this potential communication’. The pathophysiology of cyst formation has been attributed to trauma, arthritis and infection. Sansone et al. found that 44 of 47 popliteal cysts studied were associated with intra-articular lesions. The lesions include medial meniscal and anterior cruciate ligament tears, synovitis, chondral lesions, and total knee replacement. Intra-articular trauma, arthritis and infection result in knee effusions that lead to popliteal cyst formation. [52] 

Popliteal cysts have been found in the posterolateral and posteromedial thigh, between the gastrocnemius muscle and the deep fascia, and between the soleus and gastrocnemius muscles. Most occur within the posteromedial popliteal fossa between the gastrocnemius and deep fascia, as in the present study. Synovial fluid is produced by the synovial capsule through a rich meshwork of fenestrated micro vessels. The driving force for the continuous production of synovial fluid is the physiological osmotic gradient between the microvasculature of the synovium and the intra-articular space. The osmotic pressure of the intra-articular space draws fluid from the microvasculature according to the Starling forces. In the normal knee, intra-articular volume and pressure are minimised by the osmotic suction exerted by the synovial matrix. The synovial fluid is then drawn back into the veins and lymphatics of the synovium, from where it is pumped out by the articular motion of the knee. The pathological knee, associated with trauma, arthritis or infection, involves an increase in synovial fluid volume and pressure. An effusion occurs when the clearance of synovial fluid lags behind microvascular leakage. [53] 

Usually, in an adult patient, an underlying intra-articular disorder is present. In children, the cyst can be isolated and the knee joint normal.[54] A Baker's cyst is less prevalent in a paediatric orthopaedic population than in an adult population. In children, it seems that a Baker's cyst is seldom associated with joint fluid, meniscal tear, or anterior cruciate ligament tear. [55] Sansone et al. affirmed that popliteal cysts are associated with one, or more, disorders detected by MRI. The commonest lesions were meniscal (83%), frequently involving the posterior horn of the medial meniscus, chondral (43%), and anterior cruciate ligament tears (32%). [56] 

Diagnostic Procedures

An exact diagnosis can be made by the following procedures:

Physical assessment which includes the following tests:


Radiographs of the knee should be performed when an ACL tear is suspected, including AP (anterior to posterior) view, lateral view, and patellofemoral projection. The standing AP weight-bearing view provides a way of evaluating the joint space between the femur and tibia.[57] It also allows for measurement of the notch width index which provides important predictive values for ACL tears.[58] The patellar tendon and height are measured on lateral radiograph. A tunnel view may also be helpful. The Merchant's radiograph view not only shows the joint space between the femur and patella but also helps to determine whether the patient has patellofemoral malalignment.[59] The presence of the following factors should be noted from x-ray:

  • Notch width index
  • Osteochondral fracture
  • Segond fracture
  • Bone bruise

The Notch width index is the ratio of the width of the intercondylar notch to the width of the distal femur at the level of the popliteal groove measured on a tunnel view roentgenogram of the knee. The normal intercondylar notch ratio is 0.231 ± 0.044. The intercondylar notch width index for men is larger than that for women. It was found that athletes with non-contact ACL injuries had a notch width index that was at least 1 standard deviation below the average, meaning that a person with an ACL injury is more likely to have a small notch width index compared to normal. It is measured with the help of a ruler placed parallel to joint line. The narrowest portion of the notch at the level of ruler is measured.[60]  In more chronic ACL injuries, there may be intercondylar eminence spurring or hypertrophy, or patellar facet osteophyte formation.

Notch Width Index
Notch Width Index Measurement

This is also one of the reasons why women are more prone to ACL injuries compared to men. It has also been seen that the value of inner angle of the lateral condyle of femur was significantly higher in women athletes with ACL tear compared to those without. Value of width of intercondylar notch was statistically smaller in athletes with ACL tear, compared to those without. Also it was seen that the inner angle of lateral femoral condyle is a better predictive factor for ACL tears in young female handball players compared to intercondylar notch width.[61]

In more chronic ACL injuries, there may be interchondral eminence spurring or hypertrophy, patellar facet osteophyte formation, or joint space narrowing with marginal osteophytes. It is particularly important in skeletally immature patients to have plain radiographic assessment. This is because there is frequently a ligamentous avulsion in this age group.

A Bone bruise is usually present in conjunction with an ACL injury in more than 80% of cases.[62] The most common site is over the lateral femoral condyle. The bone bruise is most likely caused by impaction between the posterior aspect of the lateral tibial plateau and the lateral femoral condyle during displacement of the joint at the time of the injury. The presence of bone bruise indicates impaction trauma to the articular cartilage.[63] Patients with bone bruises are more prone to develop osteoarthritis later.[64] Bone bruise can be seen most prominently in MRIs.

Bone bruise diagrame.jpg
Bone bruise.jpg
Bone bruise MRI.PNG


MRI has the advantage of providing a clearly defined image of all the anatomic structures of the knee. A normal ACL is seen as a well-defined band of low signal intensity on sagittal image through the intercondylar notch. With an acute injury to the ACL, the continuity of the ligament fibers appears disrupted and the ligament substance is ill defined, with a mixed signal intensity representing local oedema and haemorrhage.[65]

MRI can diagnose ACL injuries with an accuracy of 95% or better.[66] MRI will also reveal any associated meniscal tears, chondral injuries, or bone bruises.

Instrumented laxity testing/arthrometric evaluation of the knee

An adjunct to the clinical special tests in assessing anterior translation is the use of instrumented laxity testing. The most commonly cited arthrometer is the KT1000 (Medmetric, San Diego, California). The arthrometer provides an objective measurement of the anterior translation of the tibia that supplements the Lachman test in ACL injury. It can be particularly useful in the examination of acutely injured patients in whom pain and guarding may preclude evaluation. In such patients the Lachman and other tests can be difficult to perform accurately. The arthrometeric results can be used as a diagnostic tool to assess ACL integrity or as part of the follow up examination after ACL reconstruction.[67] The results of the KT1000 and its sibling. the KT2000 have been noted to be both reliable and accurate.[68]

KT 1000.jpg

Differential Diagnosis


The same characteristics for an ACL injury can be found with;

  • Knee dislocations
  • Meniscal injuries
  • Collateral ligaments injury
  • Posterolateral corner injuries to the knee.

Other problems that have to be considered are:

  • Patellar dislocation or fracture
  • Femoral, tibial or fibular fracture.

The differential diagnosis of an acute hemarthrosis of the knee due to ACL in addition to a major ligamentous tear would include meniscal tear or patellar dislocation or osteochondral fracture.

Differentiation can mostly be made based on a thorough examination with particular attention for the mechanism at the time of injury. An additional MRI scan can visualise the injury.


The examination of ACL injury can be done in two ways:

  • Physical/Clinical examination
  • Examination under anesthesia and arthroscopy

Physical/Clinical Examination:

An organised, systematic physical examination is imperative when examining any joint. Immediately after the acute injury, the physical examination may be very limited due to apprehension and guarding by the patient. While inspecting, the examiner should look for the following:[70]

  • Overall alignment of the knee.
  • Severe distortion of the normal alignment may represent a fracture of the distal femur or proximal tibia or indicate knee dislocation.
  • Any gross effusion, which most commonly be present within a few hours after an ACL injury. Absence of an effusion does not mean that an ACL injury has not occurred; in fact, with more severe injuries that include the surrounding capsule and soft tissues, the hemarthrosis may be able to escape from the knee, and the degree of swelling may paradoxically be diminished. In addition, the presence of swelling and effusion does not guarantee that an ACL injury has occurred. According to Noyes et al, in the absence of bony trauma, an immediate effusion is believed to have a 72% correlation with an ACL injury of some degree.
  • Bony abnormality may suggest an associated fracture of the tibial plateau.
  • Palpation follows inspection and should begin with the uninvolved extremity. Palpation confirms the presence and degree of effusion and bony injury. Subtle effusions missed during inspection should be picked up by the careful manual examination. Palpation of joint lines and collateral ligaments can rule out a possible associated meniscus tear or sprained ligaments.
  • Periarticular tenderness should also be examined.
  • Assessing the patient’s range of motion (ROM) should be carried out to look for lack of complete extension, secondary to a possible bucket-handle meniscus tear or associated loose fragment.
  • Laxity testing should be done either with the special test or with the help of arthrometer.

Grading and examining the anterior tibial subluxation post ACL injury:

Severity Amount of Abnormal Tibial Rotation Positive test 'Comment
Mild (Grade 1) 1+ (< 5 mm)  Lachman and FRD May be present with generalised joint laxity (physiological)
Moderate (Grade II) 2+ (5-10 mm) Lachman,FRD,Losee,ALRI,pivot 'slide" but not "jerk' no obvious jump with jerk and PS
Severe (Grade III) 3+ (11-15 mm) Lachman,FRD, Losee,ALRI,jerk and PS Obvious jump with jerk and PS and gross subluxation-reduction with test
Gross (Grade IV) 4+ (> 15mm) Lachman,FRD,Losee,ALRI,jerk and PS Impingement of lateral tibial plateau in subluxation position, which requires examiner to back off during pivot shift test to effect reduction
(FRD- flexion rotation drawer, ALRI- anterolateral rotatory instability, PS- pivot shift)

Examination under anaesthesia and arthroscopy:

Arthroscopy combined with examination under anaesthesia is an accurate way to diagnose a torn ACL. It may be indicated in the case whereby the diagnosis is suspected from the patient's history, but is not evident on clinical examination. The main value of using arthroscopy on the basis of examination is to diagnose associate joint pathologic conditions such as meniscal tears or chondral fractures.[72][73]

See this page for additional information on assessment of the knee: Knee Examination

Medical Management

Please see Anterior Cruciate Ligament (ACL) Reconstruction

Please see Anterior Cruciate Ligament (ACL) Rehabilitation

Physiotherapy Management

Please see Anterior Cruciate Ligament (ACL) Rehabilitation



Rates of non-contact ACL injury are higher among females than males. Several factors have been identified to explain this sex disparity. Gender differences have been found in motion patterns, positions, and muscular forces generated with various lower extremity coordinated activities. Anatomic and hormonal factors, such as a decrease in ACL circumference, a small and narrow intercondylar notch width, a decrease joint laxity and a pre-ovulatory phase of menstrual cycle in females, have been discussed as increased risk factors for non-contact ACL injuries. Level of evidence: [75][24]

However, modifying these particular risk factors is difficult if not impossible. In contrast, evidence indicates that neuromuscular risk factors are modifiable. Neuromuscular risk factors such as knee valgus position, muscular control (quadriceps and hamstrings muscular activation) and hip and trunk controls have been increasingly implicated in this injury aetiology. .[75][76] 

Given the importance of neuromuscular factors and the aetiology of ACL injuries, numerous programs have aimed to improve neuromuscular control during standing, cutting, jumping, and landing. [77] The components of neuromuscular training are:

  • Balance training: balance exercises
  • Jump training – plyometrics: landing with increased flexion at the knee and hip
  • Strengthening that emphasises proximal hip control mediated through gluteus and proximal hamstring activation in a close kinetic chain
  • Stretching
  • Skill training: Controlling body motions, especially in deceleration and pivoting manoeuvres
  • Movement education and some form of feedback to the athlete during training of these activities
  • Agility training: agility exercises

Examples of more recent neuromuscular training programs include: Sportsmetrics and Prevent Injury and Enhance Performance program. Both programs have a positive influence on injury reduction and improve athletic performance tests. [75] [78] [79][80] The PEP plan includes: Warm Up, stretching, strengthening, plyometric and agility exercises. [78] 

Some studies suggest that plyometric and strengthening components were more important than balance training, but other studies suggest that both plyometric and balance training are effective at increasing measures of neuromuscular power and control. A combination of plyometric and balance training may further maximise the effectiveness.[78] [81]

It is not only about what exercises are used, but also about how the exercises are done. The mode, length, frequency, and duration of neuromuscular interventions may vary and is very dependent on the individual, [75] but for maximal effect of neuromuscular training interventions, training should be completed at least two times in a week for minimum 30 min and, also, the higher the compliance, the better the effect.

Some studies revealed an age-related association between neuromuscular training implementation and reduction of ACL incidence. To optimise the reduction of ACL injury risk, neuromuscular training must be initiated before the onset of neuromuscular deficits and peak knee injury incidence. Neuro muscular training may be most beneficial if initiated during early adolescence, before the period of altered mechanics that can increase injury risk. [76] [80] [82] Prevention programmes can reduce ACL injury risk by around 50%. [83] [84] [85] [76] [80] [86] [87] [88] [89]

Clinical Bottom Line

In order to provide the injured athlete with the best care, physiotherapists should have in-depth knowledge of the anatomy and functioning of the ACL. The keystone to proper care of an ACL injury is obtaining the correct diagnosis within the first hour of injury before the development of significant hemarthrosis. This should also include the detection of and diagnosis of associated injuries.[90] Injury treatment and the return to activities for an individual is entirely dependent upon the ACL injury grade and any associated injuries.



  1. 1.0 1.1 1.2 Nagano Y, Ida H, Akai M, Fukubayashi T. Biomechanical characteristics of the knee joint in female athletes during tasks associated with anterior cruciate ligament injury. The Knee. 2009 Mar 1;16(2):153-8.
  2. Arendt E,Dick R. Knee injuries patterns among men and women in collegiate basketball and soccer. NCAA data and review of literature. Am J Sports Med 995;23:694-701
  3. Arendt EA, Agel J,Dick R.Anterior cruciate ligament injury patterns among collegiate men and women. J Athl Train 1999;34:86-92.
  4. Garrick JG, Requa RK. Anterior cruciate ligament injuries in men and women: how common are they? In: Griffin LY, ed. Prevention of noncontact ACL injuries. Rosemont,IL:American Academy Orthopaedic Surgeons,2001:1-10.
  5. Agel J, Arendt E, Bershadsky B.Anterior cruciate ligament injury in national collegiate athletic association basketball and soccer: a 13 year review.Am J Sports Med 2005;33(4):524-30.
  6. Beynnon BD,Johnson RJ,Abate JA,et al. Treatment of anterior cruciate ligament injuries, Part 1. Am J Sports Med 2005;33(10):1579-602.
  7. Matsumoto, H., Suda, Y., Otani, T., Niki, Y., Seedhom, B. B., Fujikawa, K. (2001). Roles of the anterior cruciate ligament and the medial collateral ligament in preventing valgus instability. J Orthop Sci, 6(1), 28-32.
  8. Mark L. Purnell, Andrew I. Larson, and William Clancy. Anterior Cruciate Ligament Insertions on the Tibia and Femur and Their Relationships to Critical Bony Landmarks Using High-Resolution Volume-Rendering Computed Tomography. Am J Sports Med November 2008 vol. 36 no. 11 2083-2090
  9. Girgis, F. G., Marshall, J. L., Monajem, A. (1975). The cruciate ligaments of the knee joint. Anatomical, functional and experimental analysis. Clin Orthop Relat Res(106), 216-231.
  10. American Orthopaedic Society for Sports Medicine. Understanding and preventing noncontact ACL injuries. Hewett TE, Shultz SJ, Griffin LY, editors. Champaign, IL: Human Kinetics; 2007.
  11. 11.0 11.1 11.2 11.3 11.4 Hewett TE. et al. Anterior Cruciate Ligament Injuries in Female Athletes: Part 1, Mechanisms and Risk Factors. Am J Sports Med. 2006; 34:299-311.
  12. 12.0 12.1 12.2 12.3 Haim A. et al. Anterior cruciate ligament injuries. Harefuah 2006;145(3): 208-14, 244-5.
  13. M. Darrow. The knee Sourcebook. The McGraw-Hill Companies. USA. 2007
  14. 14.0 14.1 Wetters N, Weber AE, Wuerz TH, Schub DL, Mandelbaum BR. Mechanism of Injury and Risk Factors for Anterior Cruciate Ligament Injury. Operative Techniques in Sports Medicine. 2015 Oct 17.
  15. Brukner, Khan. Clinical Sports Medicine. 3rd edition.Ch 27.Tata McGraw- Hill Publishing. New Delhi.
  16. Geng, Bin, et al. Narrow Intercondylar Notch and Anterior Cruciate Ligament Injury in Female Nonathletes with Knee Osteoarthritis Aged 41–65 Years in Plateau Region. Chinese Medical Journal 129.21 (2016): 2540.
  17. McLean SG, Huang X, van den Bogert AJ (2005). "Association between lower extremity posture at contact and peak knee valgus moment during sidestepping: implications for ACL injury". Clin Biomech (Bristol, Avon) 20 (8): 863–70
  18. Mountcastle, Sally; et al. "Gender Differences in Anterior Cruciate Ligament Injury Vary With Activity. The American Journal of Sports Medicine. 35.10 (2007)
  19. Price, Meghan J., et al. Nonmodifiable risk factors for anterior cruciate ligament injury. Current Opinion in Pediatrics 2016.
  20. Thomson et al. Higher shoe-surface interaction is associated with doubling of lower extremity injury risk in football codes: a systematic review and meta-analysis. British journal of sports medicine 2015.
  21. Uhorchak JM. et al. Risk Factors Associated with Noncontact Injury of the Anterior Cruciate Ligament. A Prospective Four-Year Evaluation of 859 West Point Cadets. Am J Sports Med. 2003; 3: 831-842.
  22. Mandelbaum BR. et al. Effectiveness of a neuromuscular and proprioceptive training program in preventing anterior cruciate ligament injuries in female athletes: 2-year follow-up. Am J Sports Med. 2005; 33(7):1003-10.
  23. 23.0 23.1 23.2 23.3 Renstrom P, Ljungqvist A, Arendt E, Beynnon B, Fukubayashi T, Garrett W, Georgoulis T, Hewett TE, Johnson R, Krosshaug T, Mandelbaum B. Non-contact ACL injuries in female athletes: an International Olympic Committee current concepts statement. British journal of sports medicine. 2008 Jun 1;42(6):394-412.
  24. 24.0 24.1 24.2 Alentorn-Geli E. et al. Prevention of non-contact anterior cruciate ligament injuries in soccer players. Part 1: Mechanisms of injury and underlying risk factors. Knee Surg Sports Traumatol Arthrosc. 2009; 17(7):705-29.
  25. 25.0 25.1 25.2 Olsen OE,Myklebust G,Engebretsen L, et al.Injury mechanisms for anterior cruciate ligament injuries in team handball: a systematic video analysis.Am J Sport Med 2004;32(4):1002-12.
  26. Teitz analysis of ACL injuries. In:Griffin LY, ed. Prevention of Non contact ACL injuries. Rosemont,IL: American Academy Orthopaedic Surgeons,2001
  27. 27.0 27.1 27.2 Brukner, Khan. Clinical Sports Medicine. 3rd edition.Ch 27.Tata McGraw- Hill Publishing. New Delhi.
  28. City Clinic on YouTube. ACL Tear (Sports Injury). Available from: [last accessed 04/10/14]
  29. Teitz analysis of ACL injuries. In:Griffin LY, ed. Prevention of Non contact ACL injuries.Rosemont,IL: American Academy Orthopaedic Surgeons,2001
  30. Ireland ML.Anterior cruciate ligament injuries in young female athletes.Your Patient and Fitness 1996;10(5):26-30.
  31. Brukner, Khan. Clinical Sports Medicine. 3rd edition.Ch 27.Tata McGraw- Hill Publishing. New Delhi.
  32. 32.0 32.1 H. Koga et al. Mechanisms for Noncontact Anterior Cruciate Ligament Injuries. Knee Joint Kinematics in 10 Injury Situations From Female Team Handball and Basketball. Am J Sports Med. 2010.
  33. William E.Prentice, Rehabilitation techniques for sports medicine and athletic training; fourth ed. McGraw Hill publications.
  34. Souryal.T.T.Freeman, and J.Evans.1993. Intercondylar notch size and ACL injuries in athletes: a prospective study. Am. J. of Sports Med.21:535-39.
  35. 35.0 35.1 Yoon KH, Yoo JH, Kim KI.J. fckLRBone contusion and associated meniscal and medial collateral ligament injury in patients with anterior cruciate ligament rupture. Bone Joint Surg Am. 2011 Aug 17;93(16):1510-8.
  36. Dorothy M. Niall and Vladimir Bobic. Bone Bruising and Bone Marrow Edema Syndromes: Incidental Radiological Findings or Harbingers of Future Joint Degeneration? International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine [Accessed online 20th January 2012 at]
  37. Rick W. Wright, Mary Ann Phaneuf, Thomas J. Limbird and Kurt P. Spindler. Clinical Outcome of Isolated Subcortical Trabecular Fractures (Bone Bruise) Detected on Magnetic Resonance Imaging in Knees. Am J Sports Med September 2000 vol. 28 no. 5 663-667
  38. Mark A. Rosen, Douglas W. Jackson, Paul E. Berger. Occult osseous lesions documented by magnetic resonance imaging associated with anterior cruciate ligament ruptures. Arthroscopy: The Journal of Arthroscopic and Related SurgeryfckLRVolume 7, Issue 1 , Pages 45-51, March 1991
  39. R.B. Frobell, H.P. Roos, E.M. Roos, M.-P. Hellio Le Graverand, R. Buck, J. Tamez-Pena, S. Totterman, T. Boegard, L.S. Lohmande. The acutely ACL injured knee assessed by MRI: are large volume traumatic bone marrow lesions a sign of severe compression injury? Osteoarthritis and Cartilage, Volume 16, Issue 7, July 2008, Pages 829-836
  40. Viskontas DG, Giuffre BM, Duggal N, Graham D, Parker D, Coolican M. Bone bruises associated with ACL rupture: correlation with injury mechanism. Am J Sports Med. 2008 May;36(5):927-33. Epub 2008 Mar 19.
  41. Szkopek K, Warming T, Neergaard K, Jørgensen HL, Christensen HE, Krogsgaard M. Pain and knee function in relation to degree of bone bruise after acute anterior cruciate ligament rupture. Scand J Med Sci Sports. 2011 Apr 8. doi: 10.1111/j.1600-0838.2011.01297.x. [Epub ahead of print]
  42. 42.0 42.1 Atsuo Nakamae, Lars Engebretsen, Roald Bahr, Tron Krosshaug and Mitsuo Ochi. Natural history of bone bruises after acute knee injury: clinical outcome and histopathological findings. Knee Surgery, Sports Traumatology, Arthroscopy, Volume 14, Number 12, 1252-1258
  43. Hollis G. Potter, Sapna K. Jain,Yan Ma, Brandon R. Black, Sebastian Fung and Stephen Lyman. Cartilage Injury After Acute, Isolated Anterior Cruciate Ligament Tear Immediate and Longitudinal Effect With Clinical/MRI Follow-up. Am J Sports Med February 2012 vol. 40 no. 2 276-285
  44. Baker CL, Norwood LA, Hughston JC. Acute posterolateral rotatory instability of the knee. J Bone Joint Surg Am1983 ; 65:614 –618
  45. Chen FS, Rokito AS, Pitman MI. Acute and chronic posterolateral rotatory instability of the knee. J Am Acad Orthop Surg 2000; 8:97 –110
  46. Fanelli GC, Edson CJ. Posterior cruciate ligament injuries in trauma patients: part II. Arthroscopy1995 ; 11:526 –529
  47. Davies H, Unwin A, Aichroth P. The posterolateral corner of the knee: anatomy, biomechanics and management of injuries. Injury 2004; 35:68 –75
  48. Fanelli GC. Surgical reconstruction for acute posterolateral injury of the knee. J Knee Surg 2005;28 : 157–162
  49. Moorman CT 3rd, LaPrade RF. Anatomy and biomechanics of the posterolateral corner of the knee. J Knee Surg2005 ; 18:137 –145
  50. Harner CD, Vogrin TM, Hoher J, Ma CB, Woo SL. Biomechanical analysis of a posterior cruciate ligament reconstruction: deficiency of the posterolateral structures as a cause of graft failure. Am J Sports Med 2000; 28:32 –39
  51. LaPrade RF, Resig S, Wentorf F, Lewis JL. The effects of grade III posterolateral knee complex injuries on anterior cruciate ligament graft force: a biomechanical analysis. Am J Sports Med 1999 ; 27:469 –475
  52. Stein et al. Cysts about the knee: evaluation and management. Journal of the American Academy of Orthopaedic Surgeons 2013 21(8), 469-479.
  53. Labropoulos et al. New insights into the development of popliteal cysts. British journal of surgery 2004; 91(10):1313-1318.
  54. Fritschy D. et al. The popliteal cyst. Knee Surgery/Sports Traumatology/Arthroscopy 2006; 14(7): 623–628.
  55. De Maeseneer M. et al. Popliteal cysts in children: prevalence, appearance and associated findings at MR imaging. Pediatric Radiology. 1999; 29(8): 605-609.
  56. Sansone et al. Popliteal cysts and associates disorders of the knee. Critical review with MR imaging.”, International Orthopaedics 1995; 19(5): 275–279.
  57. Rosenberg TD,Paulos LE, Parker RD, et al: The 45-degree posteroanterior flexion weight- bearing radiograph of the knee.J Bone Joint Surg 1988;70A:1479-1483.
  58. Shelbourne KD,Davis TJ, Klootwyk TE. The relationship between intercondylar notch width of the femur and the incidence of anterior cruciate ligament tears. A prospective study.Am J Sports Med 1998;26:402-408
  59. Merchant A: Patellofemoral malalignment and instabilities. In: Ewing JW,ed. Articular cartilage and knee joint function: basics science and arthroscopy. New York; Raven press.1990:79-91.
  60. Souryal TO, Moore HA, Evans JP,Intercondylar notch size and anterior cruciate ligament injuries in athletes.A prospective study: Am J Sports Med 16:449,1988.
  61. Miljko M, Grle M, Kozul S, Kolobarić M, Djak I.Intercondylar notch width and inner angle of lateral femoral condyle as the risk factors for anterior cruciate ligament injury in female handball players in Herzegovina;Coll Antropol. 2012 Mar;36(1):195-200.
  62. beynnon BD,Johnson RJ,Abate JA,et al. Treatment of anterior cruciate ligament injuries,part 1.Am J Sports Med 2005;33(10):1579-602.
  63. Johnson DL, Urban WP,Caborn DNM,et al. Articular cartilage changes seen with magnetic resonance imaging detected bone bruise associated with acute anterior cruciate ligament rupture. Am J Sports Med 2005;33(1):131-48.
  64. Brukner, Khan. Clinical Sports Medicine. 3rd edition.Tata McGraw- Hill Publishing. New Delhi.
  65. Turner da,Podromos CC, Petsnick JP, Clark JW: Acute injury of the knee: Magnetic resonance evaluation.Radiology 154:711-722,1985.
  66. Nogalski MP,Bach BR Jr: Acute anterior cruciate ligament injuries.In Fu FH,Harner CD,Vince KG: Knee surgery. Baltimore, Williams and Wilkins,1994,pp 679-730.
  67. DeLee, Drez, Muller. Orthopaedic sports Medicine,Principles and Practice. Vol 2; 2nd edition.Saunder's publication, printed in USA.
  68. Kowalk DL,Wojtys EM,Disher J,Loubert P:Quantitative analysis of the measuring capabilities of the KT1000 knee ligament arthrometer. Am J Sports Med 21:744-747,1993.
  69. Tony Lowe. MRI scan left knee. Available from:[last accessed 04/10/14]
  70. DeLee, Drez, Muller. Orthopaedic sports Medicine,Principles and Practice. Vol 2; 2nd edition. Saunder's publication, printed in USA.
  71. Lower Extremity- Flexion- Rotation Drawer Test (Noyes). Available from:
  72. DeHaven KE: Diagnosis of acute knee injuries with hemarthrosis, Am J Sports Med 8:9,1980.
  73. Noyes FR et al: Arthroscopy in acute traumatic hemarthrosis of the knee, J Bone Joint Surg 62A:687,1980
  74. NCAA. PEP Program. Available from:[last accessed 04/10/14]
  75. 75.0 75.1 75.2 75.3 Sugimoto D. et al. Compliance With Neuromuscular Training and Anterior Cruciate Ligament Injury Risk Reduction in Female Athletes: A Meta-Analysis. J Athl Train 2012; 47(6): 714-723.
  76. 76.0 76.1 76.2 Thompson JA. et al. Biomechanical Effects of an Injury Prevention Program in Preadolescent Female Soccer Athletes. Am J Sports Med. 2016
  77. Hewett TE,Lindenfield TN,Riccobene JV, et al. The effect of neuromuscular training on the incidence of knee injury in female athletes. A prospective study.Am J Sports Med 1999;27:699-706.
  78. 78.0 78.1 78.2 Gilchrist J. et al. A randomized controlled trial to prevent noncontact anterior cruciate ligament injury in female collegiate soccer players. Am J Sports Med. 2008; 36(8): 1476-83.
  79. Noyes F. R. et al. Anterior Cruciate Ligament Injury Prevention Training in Female Athletes. A Systematic Review of Injury Reduction and Results of Athletic Performance Tests. Sports Health. 2012; 4(1): 36–46.
  80. 80.0 80.1 80.2 Noyes F. R. and Barber-Westin SD. Neuromuscular retraining intervention programs: do they reduce noncontact anterior cruciate ligament injury rates in adolescent female athletes?. Artroscophy 2014; 30(2):245-55.
  81. D. Myer G. et al. The effects of plyometric vs. Dynamic stabilization and balance training on power, balance, and landing force in female athletes. Journal of Strength and Conditioning Research 2006; 20(2): 345-353.
  82. D. Myer G. et al. When to initiate integrative neuromuscular training to reduce sports-related injuries in youth?. Curr Sports Med Rep. 2011; 10(3): 155–166.
  83. Noyes F. R. et al. Anterior Cruciate Ligament Injury Prevention Training in Female Athletes. A Systematic Review of Injury Reduction and Results of Athletic Performance Tests. Sports Health. 2012; 4(1): 36–46.
  84. Mandelbaum BR. et al. Effectiveness of a neuromuscular and proprioceptive training program in preventing anterior cruciate ligament injuries in female athletes: 2-year follow-up. Am J Sports Med. 2005; 33(7):1003-10.
  85. Grooms DR. et al. Soccer-specific warm-up and lower extremity injury rates in collegiate male soccer players. J Athl Train. 2013; 48(6):782-9.
  86. D. Myer G. et al. The Influence of Age on the M Effectiveness of Neuromuscular Training to Reduce Anterior Cruciate Ligament Injury in Female Athletes. A Meta-Analysis. Am J Sports Med. 2013; 41(1): 203–215.
  87. D. Myer G. et al. The effects of plyometric vs. Dynamic stabilization and balance training on power, balance, and landing force in female athletes. Journal of Strength and Conditioning Research 2006; 20(2): 345-353.
  88. Holviala et al. Effects of strength training on muscle strength characteristics, functional capabilities, and balance in middle-aged and older women. Journal of Strength and Conditioning Research 2006.
  89. Arendt EA. et al. Anterior cruciate ligament injury patterns among collegiate men and women. J Athl Train. 1999; 34(2): 86–92.
  90. Brukner, Khan. Clinical Sports Medicine. 3rd edition.Ch 27. Tata McGraw-Hill Publishing. New Delhi.