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Anterior Cruciate Ligament Tear
Aka: Anterior Cruciate Ligament Tear, ACL Tear, Anterior Cruciate Deficiency, Anterior Cruciate Ligament Rupture, ACL Rupture
- See Also
- Knee Pain
- Knee Injury
- Epidemiology
- Common injury associated with Contact Sports
- Uncommon in children and younger teens
- Growth Plate injuries are more common in this age group due to relative weakness
- Risk Factors
- Female Gender (Relative Risk: 1.4 to 9)
- Play intensity (risk increased >3 fold during games compared with practice)
- High risk sports
- Skiing or snow boarding (esp. ankles locked with fall backwards)
- Soccer (esp. sudden cutting maneuvers)
- Basketball
- Football
- Volleyball
- Mechanism
- Contact Sport related injury (30% of ACL injuries)
- Foot planted or otherwise in fixed position
- Torque from a blow results in tearing of the ACL
- Knee hyperextension injury
- Occurs when sudden deceleration with knee fully extended
- Sudden foot plant with cut to opposite side
- Valgus stress causes tibial anterior displacement
- ACL Ruptures as tibia displaces anteriorly
- Symptoms
- Painful "popping" Sensation at time of injury
- Swelling (hemarthrosis) within 1-2 hours of injury
- "Giving way" or buckling Sensation of knee
- Exam
- See Knee Exam
- Signs
- Hemarthrosis (loss of peri-Patellar groove)
- Typically develops within hours of injury and often limits the remainder of the Knee Exam
- Loss of hyperextension (due to torn ACL fragment catching) in the presence of hemarthrosis is most sensitive for ACL Tear
- Associated with significant pain, guarding and limited range of motion
- Acute Knee Injury and hemarthrosis in athletes is correlated with ACL Tear
- Hardaker (1990) South Med J 83(6):640-44 [PubMed]
- Anterior Cruciate Ligament (ACL) Stability Tests
- Lachman Test (highest Test Sensitivity approaching 84%)
- Knee Anterior Drawer Test (test sesitivity 62%)
- Pivot Shift Test - MacIntosh Test (Test Sensitivity 62%)
- Associated Conditions
- Meniscal tear (>60% of cases)
- Collateral ligament tear (5-24% of cases)
- Radiology
- Knee XRay (3 view)
- Evaluate for Tibial Spine Avulsion Fracture
- Treat with Knee Immobilizer and urgent orthopedic follow-up
- Evaluate for Segond Fracture
- Avulsion of lateral capsular margin of tibia
- Knee MRI
- Efficacy in detecting ACL Tear
- Test Sensitivity: 86%
- Test Specificity: 95%
- Crawford (2007) Br Med Bull 84:5-23 [PubMed]
- Indications
- Preparation for ACL reconstruction
- Assess pediatric patient with suspected ACL Tear
- Management: Conservative
- Quadriceps strengthening Exercises
- Knee Brace
- Activity modification
- Avoid cutting sports
- Avoid jumping sports
- Management: Adults Surgical ACL Reconstruction
- Acute surgical repair is associated with poor results
- Athletic patient
- Participating in "cutting" or jumping sports
- Requires 9-12 weeks of rehabilitation post-operatively
- Bracing after ACL repair is not effective
- Does not prevent reinjury or speed recovery
- McDevitt (2004) Am J Sports Med 32:1887-92 [PubMed]
- Management: Children
- Non-displaced Type I Avulsion Fracture
- Long-leg Cast Immobilization for 4-6 weeks
- Displaced Type II to III Avulsion Fractures
- Open Reduction and Internal Fixation
- Long-leg Cast Immobilization for 4-6 weeks
- Intrasubstance Tears
- Operative Management
- Indicated for older children near skeletal maturity
- Non-operative Management (See above)
- Indicated in Young Children (Open Growth Plates)
- Perform operative reconstruction when mature
- Complications of Un-repaired ACL
- Meniscal Injury
- Knee Osteoarthritis
- Prevention: Athletes
- Enhance Performance Program
- Reduces ACL injuries by >75%
- Focuses on neuromuscular training and proprioception Exercises
- Mandelbaum (2005) Am J Sports Med 33(7): 1003-10 [PubMed]
- References
- Mercier (1995) Practical Orthopedics, Mosby, p. 217-9
- Cimino (2010) Am Fam Physician 82(8):917-22 [PubMed]
- Smith (1995) Am Fam Physician 51(4): 799-806 [PubMed]
- Lastihenos (1996) Phys Sportsmed, 24(4):59-70 [PubMed]