Anterior Cruciate Ligament injury (ACL)-Treatment (2020)

Anterior Cruciate Ligament injury
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ACL injury is one of the most commonest injury in the knees (anterior cruciate ligament). Anterior cruciate ligament is one of the group of tissue that holds the bones together within your knee. It is also help to keep your knee stable. When you can stretch or tear your ACL make a sudden movement, sharp turn when you’re running or jumping. It’s often painful, and can make it difficult to walk or put pressure on the injured legs.


 Mechanism: sudden deceleration, cutting, valgus force contact or non contact, hyperextension

Patient may recall pop or tearing sensation–80%

Painful,inability to continue activity

Rapid  hemarthrosis within 3hours–80%

If chronic may have history of recurrent instability

Common sports :skiing, basketball, volleyball, football, soccer

May be isolated or in conjunction with multiple ligament injuries – medial collateral (MCL), posterior cruciate (PCL), postero lateral or knee dislocation

Often associated with meniscal pathology and/or articular cartilage injury

Knee instability complaints: jumping, twisting, deceleration, cutting activities

Physical Exam

Acute: effusion,bloody hemarthrosis if aspirated

Joint line tenderness suggestive of associated meniscal  pathology

Ligament laxity exam–compare to uninjured knee

Abnormal Lachman test most sensitive test

Increased anterior tibial translation @20–30◦ knee fusion

Positive pivot shift test (Losee, Hughston, flexion rotator drawer variants)

Pathognomonic of complete anterior cruciate ligament (ACL)injury

Subluxation – Reduction phenomenon related to axial compression,valgus loading,andflexion/extension occurred at 15–30◦

Associated ligament laxity tests

➣ MCL–Valgus laxityat0◦,30 ◦

➣ Lateral collateral ligament–Valgus laxityat0◦,30 ◦+➣ PCL – Increased posterior translation at 90◦ (posterior drawer), posterior sag test(gravity flexion test)

➣ Posterolateral – Increased posterolateral rotation, increased external tibial rotation,asymmetric dial test

Locked knee–Displaced bucket handle meniscal tear,rule out associated Anterior Cruciate Ligament Injury.



➣ AP, lateral , tunnel, Merchant(fourviews)

➣ Generally normal

➣ Lateral capsular sign (Segond fracture): marginal avulsion fracture from antero lateral tibial plateau pathognomonic

➣ Lateral notch sign (chronic ACL): accentuation of indentation of sulcus terminalis in lateral femoral condyle; rarely seen with PCL/postero lateral corner (PLC) injury

➣ Chronic ACL deficiency: peri articular osteophytes, tibial eminence peaking,inter-condylar notch narrowing


➣ Highly sensitive/specific for Anterior Cruciate Ligament Injury

➣ Generally does not differentiate between partial or complete ACL injury

➣ Associated meniscal pathology common

➣ Bone bruise noted (80%), lateral femoral condyle, lateral tibial condyle most common

➣ Effusion frequently noted

➣ MRI value: detecting associated meniscal pathology and articular cartilage pathology


➣ Instrumented laxity testing device

➣ Measures side-to-side differences (SSD) and absolute translation

➣ Dx: maximum manual SSD >3 mm; 30-pound anterior translation >10mm

Differential Diagnosis


➣ ACL, patellar dislocation, peripheral meniscal tear, intra-articularfracture,PCLinjury,popliteustendonavulsion


➣ Patellar instability

➣ Meniscal tear (e.g.,buckethandle)

➣ Posterolateral

➣ Quad weakness–giving way with level walking/standing

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