GENERAL REVIEW
Anterior Cruciate Ligament Injuries: Anatomy, Physiology,
Biomechanics, and Management
Leon Siegel, BA,* Carol Vandenakker-Albanese, MD, and David Siegel, MD, MPH
Objective: Anterior cruciate ligament (ACL) injuries are the most
common ligament injury in the United States. These injuries can be
career ending for athletes and severely disabling for all individuals.
Our objectives are to review the epidemiology of these injuries, as
well as ACL biomechanics, anatomy, and nonsurgical and surgical
management so that generalists as well as sports medicine physi-
cians, orthopedists, and others will have a better understanding of
this serious injury as well as choices in its management.
Data Sources: PubMed was used to identify relevant articles.
These articles were then used to identify other sources.
Main Results: Anterior cruciate ligament injuries occur more
commonly in women than in men due to a variety of anatomical
factors. The ACL consists of 2 major bundles, the posterolateral and
the anteromedial bundles. Forces transmitted through these bundles
vary with knee-joint position. Some patients with ACL injuries may
not be candidates for surgery because of serious comorbid medical
conditions. However, without surgical repair, the knee generally
remains unstable and prone to further injury. There are a variety of
surgical decisions that can inuence outcomes. Single-bundle versus
double-bundle repair, whether to leave the ruptured ACL remnant in
the knee, the selection of the graft tissue, graft placement, and
whether to use the transtibial, far anteromedial portal, or tibial
tunnelindependent technique are choices that must be made.
Conclusions: With a sound knowledge of the anatomy and kinetics
of the knee, newer improved surgical techniques have been devel-
oped that can restore proper knee function and have allowed many
athletes to resume their careers. These new techniques have also
limited the disability in nonathletes.
Key Words: anterior cruciate ligament, anterior cruciate ligament
reconstruction, posterolateral bundle, anteromedial bundle, hamstring
tendon graft, patellar tendon graft, quadriceps tendon graft
(Clin J Sport Med 2012;22:349355)
Submitted for publication April 6, 2011; accepted March 29, 2012.
From the *Department of Kinesiology, Occidental College, Los Angeles,
California; Department of Physical Medicine and Rehabilitation,
School of Medicine, University of California, Davis, California; Med-
ical Service, Department of Veterans Affairs, Northern California
Health Care System, Mather, California; and Department of Medicine,
School of Medicine, University of California, Davis, California.
The views expressed in the article do not necessarily represent the views of
the Department of Veterans Affairs or of the US Government.
The authors report no conicts of interest.
Corresponding Author: David Siegel, MD, MPH, Medical Service (111),
Department of Veterans Affairs, NCHCS, 10535 Hospital Way, Mather,
CA 95655 (david.siegel@va.gov).
Copyright 2012 by Lippincott Williams & Wilkins
Clin J Sport Med  Volume 22, Number 4, July 2012
INTRODUCTION
In the United States, anterior cruciate ligament (ACL)
injuries total between 100000 and 200000 yearly, making
this the most common ligament injury.14 This number con-
tinues to increase in both the general population and in indi-
viduals who play sports. Football players sustain the greatest
number of ACL injuries (53% of the total) with skiers and
gymnasts also at high risk.5,6 This is a focused review based
on a search of PubMed using the topic headings below that
will be of interest to clinicians who take care of patients with
ACL injuries. Articles identied through PubMed articles
were then used to identify additional sources. A comprehen-
sive review of each area is beyond the scope of this article,
and the reader is referred to discussions of specic areas in the
references.
Factors That Contribute to Anterior Cruciate
Ligament Injuries
Anterior cruciate ligament injury rates tend to be higher
for women than for men.79 At the United States Naval acad-
emy, in intercollegiate soccer, basketball, and rugby, women
had a relative risk of 3.96 of ACL injury compared with men.
The National Collegiate Athletic Association Injury Surveil-
lance System (1990-2002) found that the rate of ACL injury,
regardless of the mechanism, was signicantly higher for
female collegiate athletes than for male collegiate athletes in
both soccer and basketball.10 The stronger the quadriceps
muscles, the larger and hence stronger the ACL, although it
is unclear that in any one individual that an increase in quad-
riceps size and strength results in an increase in ACL size.7
Quadriceps muscles, even after adjustments for differences in
weight and lean body mass, are larger in male athletes than in
female athletes.
There are neuromuscular and biomechanical risk factors
associated with ACL injury.11 Compared with running, there
is a signicant increase in ACL load during sidestepping and
crossover cutting maneuvers.12 This is the result of a large
increase in varus/valgus and internal/external rotation move-
ments. These increased stresses during cutting put the ACL at
risk, especially when the knee is at exion angles between
0 and 40 degrees. Appropriate muscle activation strategies
may counter these movements. A project aimed at implement-
ing neuromuscular training for soccer and handball players
resulted in increased electromyography activity for the medial
hamstring muscles, thereby decreasing the risk of dynamic
valgus.13
Notch stenosis may contribute to an increase in rates of
ACL injury.1417 The notch width index (NWI) has been used as
www.cjsportmed.com | 349
Siegel et al Clin J Sport Med  Volume 22, Number 4, July 2012

a measure of notch stenosis.14 The NWI is the ratio of the width

of the intercondylar notch to the width of the distal femur at the
level of the popliteal groove. In a study, the mean NWI for
normal knees was 0.2338; for acute ACL injured knees, it
was 0.2248; and for those with bilateral ACL injuries, it was
0.1961.14 Notch stenosis is not felt to be a factor in gender
differences in ACL injury.7 In a study of 895 US Military
Academy cadets who were followed up for more than 4 years,
small femoral notch width was found to be a signicant risk
factor for ACL injuries in men and women and body mass index
was a risk factor in women.15 The NWI did not differ signi-
cantly between male and female athletes. Notch width has also
been found to correlate with ACL and posterior cruciate liga-
ment (PCL) width, and it has been argued that it is the ACL size
rather than notch size that is the important risk factor for ACL
injury.17

ANTERIOR CRUCIATE LIGAMENT ANATOMY

The ACL controls anterior movement of the tibia and
inhibits extreme ranges of tibial rotation. The majority of
authorities believe that the ACL consists of 2 major bundles,
the posterolateral bundle (PL) and the anteromedial bundle
(AM). The component ACL bundles are named based on their
tibial insertion.18
Both bundles originate on the posteromedial side of the
lateral femoral condyle and insert on a region just anterior to
the intercondylar tibial eminence (Figure 1).19 The broad
ACL tibial insertion point occurs so that there is no physio-
logical impingement on the intercondylar notch in full exten-
sion.1820 Placement of the ACL graft insertion into the tibia
during reconstructive surgery must adhere to this principle.
Mean length of the AM bundle is 33 mm and is 18 mm for the
PL bundle.1,18,21 The overall width of the ACL in cadavers
ranged from 7 to 17 mm, with the average being 11 mm.18
Average ACL cross-sectional area is 36 and 47 mm2 for
women and men, respectively.7,18
The ACL is composed of type I collagen bers.18 Dis-
section by Giuliani et al18 found that the primary blood supply
to the ligament comes from the middle genicular artery, with
additional supply coming from the inferomedial and infero-
lateral genicular arteries. There are also several types of
mechanoreceptors found within the ACL: Rufni corpuscles,
pacinian corpuscles, Golgi-like organs, and free nerve ends.22
ANTERIOR CRUCIATE
LIGAMENT BIOMECHANICS
Forces transmitted through ACL bundles vary with
knee-joint position. To replicate the in situ strain associated
with the ACL, Gabriel et al23 tested an anterior tibial load and
a combined rotatory load applied to the medial side of the
knee stressing the valgus angle and an internal tibial torque to
test the allocation of forces between the PL and AM bundles
using a robotic testing system in 10 cadaveric knees. The
greatest forces transmitted through the AM bundle were at
60 and 90 degrees of exion. The force was greatest for the
PL bundle at full extension. At 15 degrees of exion, there
was no statistical difference in stress between the 2 bundles.
FIGURE 1. A, MRI of the knee. B, A knee model with ACL
and PCL bundle insertion sites for a typical subject. Taken
from Li et al19 with permission.
At greater exion angles, the AM bundles had a signicantly
higher in situ force than the PL bundle.23 Another study using
cadaveric knees found that the PL bundle handled more force
overall than the AM bundle in response to anterior tibial
loads, whereas the in situ forces in the AM bundle remained
relatively constant and unaffected by the changes in exion
angle and anterior tibial load force.24
In situ forces in the PL bundle correlate to that of the
entire ACL at different angles of exion.24 This suggests that
reconstruction during surgery of the PL bundle as closely as
possible to that of the intact knee might be of more impor-
tance than that of the AM bundle. Because most injuries to
the ACL occur when the knee is at full extension, the PL
bundle is considered more important for the overall biome-
chanical stability of the knee because the in situ force is
greatest in the PL bundle at full extension.2325
Based on the above, it seems that the AM and PL
bundles have unique contributions to load transfer across the
knee joint. Surgical ACL reconstruction tends to restore the
limit of anterior tibial translation closer to that of an intact knee.
However, more complex rotatory motions, such as internal
tibial and valgus rotation, are less successfully addressed by
standard ACL reconstructions. It would thus seem that

350 | www.cjsportmed.com 2012 Lippincott Williams & Wilkins

Clin J Sport Med  Volume 22, Number 4, July 2012
reconstructions that predominately replicate the AM bundle
and its function may not restore full knee function and stability.
Because the PL bundle carries the majority of load when the
knee is at full extension or at 15% of exion, especially in
response to rotatory loads, and the AM bundle carries the
majority of load with the knee exed past 30%, surgical
techniques should address the function of both bundles.
DIAGNOSING ANTERIOR CRUCIATE
LIGAMENT INJURIES
The most common history of an ACL injury may be of
a noncontact deceleration, jumping, or cutting action, fre-
quently involving changing direction. This frequently
involves rotational maneuvers or lateral bending of the knee
into a valgus position with the knee extended and the tibia
rotated.26,27 If the ACL injury results from direct contact,
present in about one-third of patients, there is often a history
of hyperextension or valgus stress on the knee.28 A pop is
frequently heard and/or felt. Postinjury swelling of the knee
frequently occurs at about 4 hours and aspiration usually
reveals hemarthrosis.
Physical examination frequently establishes a diagnosis
of ACL injury, especially if the examination is done soon
after the injury before swelling, pain, and muscle guarding
occurs. Anterior stability of the knee is usually assessed with
the Lachman test.2932 The Lachman test is usually performed
at 20-degree to 30-degree angle of knee exion while stabi-
lizing the distal femur with one hand. A manual force is then
applied to the proximal tibia with the opposite hand, and
anterior laxity is assessed in the degree of anterior translation
of the tibia relative to the femur. This should be compared
with the noninjured knee. The Lachman test has been found
to have a sensitivity of 85% and a specicity of 94% for ACL
rupture. The KT 1000 arthrometer (a presurgical and post-
surgical tool used to measure anterior-posterior slippage and
side-to-side laxity of the knee33) has also been used to mea-
sure ACL laxity. However, use of these devices is limited in
the acute setting when pain and muscle guarding are present.
They may be more valuable to document surgical results both
intraoperatively and in the postoperative period.
Plain radiographs will rule out fractures, loose bodies,
degenerative disease, osteophyte formation, and other asso-
ciated injuries. They may also result in a diagnosis of Segond
fracture or avulsion fracture of the lateral capsule, which is
pathognomonic of an ACL tear.34 Using arthroscopy as the
gold standard, magnetic resonance imaging (MRI) has a spec-
icity of 95% and a sensitivity of 86% for diagnosing ACL
injuries.35 Magnetic resonance imaging is able to visualize
both bundles of the native ACL, an important information
for surgical reconstruction when the double-bundle technique
is used (see below).3638
TREATMENT OF ANTERIOR CRUCIATE
LIGAMENT INJURIES
Regardless of whether surgical or nonsurgical treatment
is ultimately pursued, patients should be advised to ice, com-
press, elevate, and limit the use of the injured knee immediately
2012 Lippincott Williams & Wilkins
Anterior Cruciate Ligament Injuries
after the injury. If the injury to the ACL also affects the
associated structures within the knee, including the menisci,
PCL, medial collateral ligament, or lateral collateral ligament,
surgical reconstruction is needed.
Nonsurgical (Conservative) Management of
Anterior Cruciate Ligament Injuries
Some patients with ACL injuries may not be candidates
for surgery because of serious comorbid medical conditions
including serious cardiac, renal, or hepatic disease or because
they no longer wish to participate in strenuous physical activ-
ities. For individuals who opt for conservative treatment,
physical therapy with an experienced physical therapist or
athletic trainer aimed at strengthening the muscles around the
knee, especially the quadriceps femoris and hamstring
muscles, is pursued. However, without surgical repair, the
knee generally remains unstable and prone to further injury.4
Long-term studies have shown that there is a signicant
increase in rates of damage to menisci and articular cartilage
associated with delayed reconstruction.4,39 The rate of healing
for meniscal tears is faster when done at the same time as
ACL reconstruction as opposed to being performed alone.4
Generally, about one-third of patients who are selected as
suitable for conservative treatment are able to complete the
therapy regimen without the need for surgical interven-
tion.40,41 However, patients with high level of sports activity
show poor results after conservative treatment of ACL
ruptures.4,40,42,43
Surgical Management of Anterior Cruciate
Ligament Injuries
Because of the frequent failure of nonsurgical
approaches to ACL injuries, surgery remains the treatment
of choice in almost all athletes who want to remain active.
Unfortunately, surgery is not universally successful. Some
problems that have resulted in failed ACL reconstruction are
graft impingement on the intercondylar roof, graft tension,
nonanatomic femoral and tibial tunnel placement (not repro-
ducing the histological and biomechanical characteristics of
the native ligament), and incomplete replication of an intact
ACL, in particular omitting reconstruction of the PL bun-
dle.19,2325 Despite these efforts, 15% to 25% of patients
who undergo ACL reconstruction continue to suffer pain
and instability in their injured knee.23
Often, when reconstruction is performed, there is a piece
of the ruptured ACL remaining that can be either removed or
left in the knee. If the ligament piece is left in place, it can
impact visualization during surgery and possibly impact the
quality of the reconstruction.22 In 1% to 9.8% of reconstruc-
tions, impingement or a Cyclop lesion (focal nodule[s] of
brous tissue sitting in the intercondylar notch anterior to
the reconstructed ACL) may occur when parts of the ACL
are left.19,22,33,44
When the ruptured ACL is left in place, mechanor-
eceptors may help with reinnervation. Sensory neurons
involved in kinesthesia may also be preserved in the ruptured
ACL.22 It has been suggested that the ACL functions as a sen-
sory organ, not only providing proprioceptive feedback but
www.cjsportmed.com | 351
Siegel et al
also initiating protective and stabilizing muscular reexes. In
a study, patients who had undergone surgery 3 months to
3.5 years after the ACL injury had the remainder of the rup-
tured ACL adapted to the posterior cruciate ligament . and
sometimes with scar tissue connected to the femur, whereas
the second group had [free oating] . ACL remnants.22
In the rst group, mechanoreceptors of Rufni, paccinian,
and, in 1 patients specimen, Golgi-like organs were present
(Figure 2).22 In the second group, no signicant numbers of
mechanoreceptors were found. If reinnervation of the ACL
causes restoration of kinesthesia and if ACL remnants can be
left without risking impingement in the postreconstruction
knee biomechanics, it seems to be of benet.22
Graft Selection
The 2 most commonly used grafts in ACL reconstruc-
tion are the patellar tendon (PT) and the 4-strand hamstring
(HS) tendon made of gracilis and semitendonosus tendons.
Both PT and HS autografts result in a functionally stable knee
in more than 95% of surgeries with a 3% absolute difference
in graft failure: 1.9% with PT and 4.9% with HS tendon
grafts.2 Benets of PT grafts include that they are readily
accessible, have good structural xation properties, and have
the potential for tendon-to-bone healing.45 Detriments include
anterior knee pain, loss of sensation, patellar fracture, and
inferior patellar contracture, although patellar knee pain has
been associated with less aggressive rehabilitation methods
and use of open kinetic chain extension exercises.2 The use of
PT grafts has also been associated with postreconstruction
extensor quadriceps weakness.2
The HS tendon graft with all 4 strands equally tensioned
can withstand much greater tension strains than a 10-mm PT
graft.46 Some researchers have found that harvesting HS
grafts can severely reduce HS strength and endurance up to
9 months after the surgery.45,46 Hamstring grafts can also be
difcult to harvest because graft diameter and lengths are
variable. A review of patients determined that HS graft diam-
eter was related to height but not to body mass index.46 When
FIGURE 2. Mechanoreceptors, Ruffini (black arrow) and
pacinian (white arrow), in a torn anterior cruciate ligament
(ACL) specimen adapted to the PCL. Taken from Georgoulis
et al22 with permission.
352 | www.cjsportmed.com
Clin J Sport Med  Volume 22, Number 4, July 2012
height decreases below 147 cm and graft diameter decreases
below 7 mm, there is an association between graft strength
and its cross-sectional diameter.46
In a meta-analysis, PT autografts were compared with
HS tendon autografts.2 Using KT-1000 arthrometer testing,
statistically signicant differences between these graft types
were found: the PT group had a 79% side-to-side difference
of ,3 mm compared with 73.8% for the HS group, leading
the authors to conclude that PT autografts led to more stable
reconstructed knees than HS tendon grafts. No signicant
differences between PT and HS grafts were found between
the proportion of patients requiring postoperative meniscal
surgery, and no statistically signicant differences were seen
between PT autografts and HS autografts infection rates.
Quadriceps tendon grafts used for ACL reconstruction
have been associated with signicantly less anterior knee pain
and graft-site morbidity compared with PT grafts.47,48 These
grafts are taken from the central third of the quadriceps tendon
and are composed of the vastus medialus, vastus intermedius,
and rectus femoris, yielding a bilaminar graft.47 The mean
cross-sectional area for a 10-mm-wide quadriceps tendon graft
is 64 mm2, larger than 37 mm2 for the PT; hence, quadriceps
tendon grafts produce a broader anatomic insertion of the
reconstructed ACL to the tibia. 48 This can decrease physio-
logic impingement on the intercondylar notch in full extension
of the knee. Quadriceps muscle power is not compromised,
despite sacricing a part of the tendon.48 Overall, quadriceps
tendon grafts have the advantage of ease of excision and are
comparable with respect to graft size and strength with both
PT and HS grafts.47,48
The main advantage of allografts versus autografts is
avoidance of donor-site morbidity.49 Other advantages include
savings in operative time of graft harvest, availability of larger
grafts, superior cosmesis, and the possibility for multiple lig-
ament reconstructions.49 Potential disadvantages include
delayed graft incorporation, disease transmission, potential
immune reactions, altered mechanical properties caused by
sterilization, and cost of the allograft.50 Of primary concern is
whether allografts are less stable than autografts.4951 A recent
meta-analysis found that allografts failed 3 times more fre-
quently than autografts.49 However, a recent study found that
autografts and nonirradiated (vs radiated or chemically pro-
cessed) allografts had similar side-to-side differences of
,3 mm according to the KT-2000 arthrometer.51
Single-Bundle Versus
Double-Bundle Reconstruction
Between 10% and 30% of patients reported persistent
instability in their reconstructed knee after single-bundle sur-
gery.25 This resulted in a return-to-sport rate of only 60% to 70%
for single-bundle restorations. Single-bundle reconstruction can
restore anterior-posterior knee stability but produces knees that
are unable to resist combined rotatory loads and do not have
normal rotational kinematics.25,52,53 Double-bundle restored knees
are better at resisting extrinsic forces placed on the knee.2,5460
Although the double-bundle technique is better at restoring nor-
mal knee kinematics, there are some disadvantages. It is more
difcult to perform surgically and could be the cause of recon-
struction failures due to the improper positioning of bone tunnels.
2012 Lippincott Williams & Wilkins
Clin J Sport Med  Volume 22, Number 4, July 2012
Graft Placement
Placement of grafts can have a major impact on the
clinical outcome of ACL reconstruction. Failure to regain full
exion postoperatively can be caused by high graft tension
during extension of the knee, which in turn may cause the graft
to stretch.25 This may occur when the ACL graft is placed
vertically at the apex of the notch, with the tibial tunnel being
in a vertical orientation at an angle .70 degrees from the
medial joint line of the tibia and the femoral tunnel and then
drilled through that tibial tunnel. Prevention of PCL impinge-
ment can be achieved by 3 different techniques: widen the
notch so that the space between the PCL and lateral femoral
condyle exceeds the diameter of the graft by 1 mm, construct
the tibial tunnel at an angle of 60 to 65 degrees with respect to
the medial joint line of the tibia, which moves the femoral
tunnel farther down the sidewall and decreases the risk of
PCL impingement, and making certain that the lateral edge
of the tibial tunnel is placed through the tip of the lateral tibial
spine.25 There is no consensus on the amount of ligament
tensioning or the optimal knee exion angle. Some surgeons
prefer to set the tension of the AM bundle in moderate exion
and the PL bundle near full extension.25 The preference for
tensioning angles mirrors the position of the bundles to provide
the greatest strength when at the most tension in intact knees.
Femoral Tunnel Drilling Techniques
There are different techniques for creating the femoral
tunnel.58 The transtibial technique (drilling through the tibial
tunnel) and the far anteromedial portal technique (drilling
through the far anteromedial tunnel) are frequently used in
ACL surgeries to create a femoral bone tunnel for the AM and
PL graft in double-bundle reconstructions (Figure 3).
Although both are commonly used, the far anteromedial
portal approach makes it easier to access the femoral footprint
of the AM and PL bundles. This is because unlike in the
transtibial technique, the placement of the femoral tunnel is
not limited by the site or angulation of the tibial tunnel. For the
far anteromedial portal procedure, the PL bundle tunnel should
be drilled at a knee position of 110 degrees of extension to
avoid damage to the subchondral bone, cartilage of the lateral
femoral condyle, and peroneal nerve.58 For the transtibial tech-
nique, the knee should be exed at 90 degrees for drilling of
the femoral bone tunnel.56 For the transtibial technique, the
graft bending angle of the AM and PL bundles are consider-
ably larger than that of the far anteromedial portal technique
at low exion angles when the graft is fully stretched.58
Nishimoto et al58 believe that the far anteromedial portal tech-
nique can produce a more obtuse bending angle at the femoral
tunnel in comparison to the transtibial technique and that the
former approach might reduce the abrasive stress at this posi-
tion in anatomic double-bundle ACL reconstructions.
Recently, investigators from Duke have emphasized the
importance of placing the ACL graft within the ACL footprint
on the femur to restore normal joint kinematics.61,62 In the
tibial tunnelindependent technique, the graft is placed closer
to the center of the native ACL attachment compared with the
transtibial technique. Using MRI of 8 patients in each group,
the transtibial technique placed the tunnel center an average
2012 Lippincott Williams & Wilkins
Anterior Cruciate Ligament Injuries
FIGURE 3. A, Extended lines of the virtual AM and PL graft to
the femoral side at 90 degrees of knee flexion are acquired as
a virtual femoral tunnel in the transtibial technique. B, The
acquired position of the femoral attachment site of each bun-
dle and that of the far anteromedial portal are connected and
the virtual femoral tunnel are created along the connecting line
to the femoral side at 110 degrees of knee flexion in the far
anteromedial portal technique. Taken from Nishimoto et al58
with permission.
of 9 mm from the center of the ACL attachment, compared
with 3 mm for the tibial tunnelindependent technique.61 In
another study, the same group used MRI and biplanar uo-
roscopy to compare 12 patients where the graft was placed
near the anteroproximal border of the ACL and 10 patients
where the graft was placed near the center of the ACL.62
Grafts placed anteroproximally on the femur were longer
and more vertical than the native ACL, whereas anatomically
placed grafts more closely mimicked ACL motion and length
in the contralateral knee.
POSTOPERATIVE REHABILITATION
Goals of postoperative rehabilitation are to restore
normal joint motion and strength to the reconstructed knee
while protecting the graft.63 As a consequence of improve-
ments in surgical techniques, graft selection, and xation
methods, rehabilitation programs have changed in recent
years to permit immediate weight bearing, early range of
motion (within 1-2 weeks after the surgery), and earlier return
to sports (usually not before 6 months or until there is return
of at least 80% of thigh strength and the ability to do sport-
specic agility drills). However, too early return to sports
activities may result in graft failure and decisions regarding
when to return to sports activities should be based on the
functional assessment rather than on time from ACL recon-
struction.63 Generally, early in the rehabilitation program,
closed kinematic chain exercises to strengthen the hamstring
and quadriceps are started.64 Closed kinematic chain exercises
are those in which the foot is in contact with a solid surface
such as with squats and leg presses. Open kinematic chain
exercises, in which the foot is not in contact with a solid
surface, such as those using leg extension, are considered less
safe in the postoperative period and should be added no
www.cjsportmed.com | 353
Siegel et al
sooner than 6 weeks after the surgery. Postoperative rehabil-
itation should also include exercises to enhance core strength,
balance, and proprioception.65
FUTURE DIRECTIONS
Future directions in ACL injury research will seek to
improve all aspects of care of the patient with an ACL injury.
Research in interface tissue engineering aims to improve the
regeneration of tissue interfaces to improve the xation of soft
tissue grafts by devising a new generation of integrative
xation devices for soft tissue repair.66 Freeze-dried allografts
offer potential advantages including limited immunogenicity,
ease of graft storage, and the potential for improved biologic
function.67 Platelet-rich plasma has the potential to speed
recovery after ACL reconstruction by improving autograft
maturation, donor-site morbidity, pain control, and allograft
incorporation.68 Other future developments in ACL recon-
struction may include repair of the injured ACL and newer
synthetic replacement grafts.69 Whether the potential benets
currently ascribed to each of the above areas will be borne out
remains to be determined.
CONCLUSIONS
Anterior cruciate ligament injuries may result in the
premature end of athletic careers and serious disability in
nonathletes. With a sound knowledge of the anatomy and
kinetics of the knee, newer improved surgical techniques have
been developed that can restore proper knee function,
allowing many athletes to resume their careers, and have
also limited disability in nonathletes.
When reconstruction is advised as the correct manage-
ment of an ACL injury, there are a variety of options. Which
type of graft, deciding on a single-bundle versus double-
bundle reconstruction, choosing the placement of grafts, and
whether to use the transtibial, far anteromedial portal, or tibial
tunnelindependent technique are choices that must be made.
Each choice has its advantages and disadvantages, with the
double-bundle strategy, proper placement of grafts, and the
use of autografts found to result in better clinical outcomes
and in greater patient satisfaction. The selection of the best
autograft tissue type remains controversial, with PT, HS ten-
don, and quadriceps tendon each having their proponents.
ACKNOWLEDGMENT
The authors gratefully acknowledge the assistance of
Richard Cacciato, MLIS, Medical Librarian, VA Northern
California Health Care System, for his support in retrieving
articles and of Ms Susan Edwards who provided expert
secretarial assistance.
REFERENCES
1. Buoncristiani AM, Tjoumakaris FP, Starman JS, et al. Anatomic double-
bundle anterior cruciate ligament reconstruction. Arthroscopy. 2006;22:
10001006.
2. Freedman KB, DAmato MJ, Nedeff DD, et al. Arthroscopic anterior
cruciate ligament reconstruction: a metaanalysis comparing patellar ten-
don and hamstring autografts. Am J Sports Med. 2003; 31:211.
354 | www.cjsportmed.com
Clin J Sport Med  Volume 22, Number 4, July 2012
3. Frobell RB, Roos EM, Roos HP, et al. A randomized trial of treatment for
acute anterior cruciate ligament tears. N Engl J Med. 2010;363:331342.
4. Levy BA. Is early reconstruction necessary for all anterior cruciate
ligament tears? N Engl J Med. 2010;363;386388.
5. Hootman JM, Dick R, Agel J. Epidemiology of collegiate injuries for 15
sports: summary and recommendations of injury prevention initiatives.
J Athl Train. 2007;42:311319.
6. Pujol N, Bianchi MP, Chambat P. The incidence of anterior cruciate
ligament injuries among competitive alpine skiers: a 25-year investiga-
tion. Am J Sports Med. 2007;35:10701074.
7. Anderson AF, Dome DC, Gautam S, et al. Correlation of anthropometric
measurements, strength, anterior cruciate ligament size, and intercondylar
notch characteristics to sex differences in anterior cruciate ligament tear
rates. Am J Sports Med. 2001;29:5866.
8. Gwinn DE, Wilckens JH, McDevitt ER, et al. The relative incidence of
anterior cruciate ligament injury in men and women at the United States
Naval Academy. Am J Sports Med. 2000;28:98102.
9. Arendt E, Dick R. Knee injury patterns among men and women in
collegiate basketball and soccer. NCAA data and review of literature.
Am J Sports Med. 1995;23:694701.
10. Agel J, Arendt EA, Bershadsky B. Anterior cruciate ligament injury in
national collegiate athletic association basketball and soccer: a 13-year
review. Am J Sports Med. 2005;33:524530.
11. Hewett TE, Myer GD, Ford KR. Reducing knee and anterior cruciate
ligament injuries among female athletes: a systematic review of neuro-
muscular training interventions. J Knee Surg. 2005;18:8288.
12. Besier TF, Lloyd DG, Cochrane JL, et al. External loading of the knee
joint during running and cutting maneuvers. Med Sci Sports Exerc. 2001;
33:11681175.
13. Zebis MK, Bencke J, Andersen LL, et al. The effects of neuromuscular
training on knee joint motor control during sidecutting in female elite
soccer and handball players. Clin J Sport Med. 2008;18:329337.
14. Souryal TO, Moore HA, Evans JP. Bilaterality in anterior cruciate liga-
ment injuries: associated intercondylar notch stenosis. Am J Sports Med.
1988;16:449454.
15. Uhorchak JM, Scoville CR, Williams GN, 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;3:831842.
16. Davis TJ, Shelbourne KD, Klootwyk TE. Correlation of the intercondylar
notch width of the femur to the width of the anterior and posterior cruciate
ligaments. Knee Surg Sports Traumatol Arthrosc. 1999;7:209214.
17. 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;
26:402408.
18. Giuliani JR, Kilcoyne KG, Rue JPH. Anterior cruciate ligament anatomy:
a review of the anteromedial and posterolateral bundles. J Knee Surg.
2009;22:148154.
19. Li G, DeFrate LE, Sun G, et al. In vivo elongation of the anterior cruciate
ligament and posterior cruciate ligament during knee exion. Am J Sports
Med. 2004;32:14151420.
20. Sidles JA, Larson RV, Garbini JL, et al. Ligament length relationships in
the moving knee. J Orthop Res. 1988;6:593610.
21. Odensten M, Gillquist J. Functional anatomy of the anterior cruciate
ligament and a rationale for reconstruction. J Bone Joint Surg Am.
1985;67:257262.
22. Georgoulis AD, Pappa L, Moebius U, et al. The presence of propriocep-
tive mechanoreceptors in the remnants of the ruptured ACL as a possible
source of re-innervation of the ACL autograft. Knee Surg Sports Trau-
matol Arthrosc. 2001;9:364368.
23. Gabriel MT, Wong EK, Woo SLY, et al. Distribution of in situ forces in
the anterior cruciate ligament in response to rotatory loads. J Orthop Res.
2004;22:8589.
24. Sakane M, Fox RJ, Woo SL-Y, et al. In situ forces in the anterior cruciate
ligament and its bundles in response to anterior tibial loads. J Orthop
Res. 1997;15:285293.
25. Prodromos CC, Fu FH, Howell SM, et al. Controversies in soft-tissue
anterior cruciate ligament reconstruction: grafts, bundles, tunnels, xa-
tion, and harvest. J Am Acad Orthop Surg. 2008;16:376384.
26. Krosshaug T, Nakamae A, Boden BP, et al. Mechanisms of anterior
cruciate ligament injury in basketball video analysis of 39 cases. Am J
Sports Med. 2007;35:359367.
2012 Lippincott Williams & Wilkins
Clin J Sport Med  Volume 22, Number 4, July 2012
27. Boden BP, Torg JS, Knowles DB, et al. Video analysis of anterior
cruciate ligament injury: abnormalities in hip and ankle kinematics. Am
J Sports Med. 2009;37:252259.
28. Beynnon BD, Fleming BC. Anterior cruciate ligament strain in-vivo:
a review of previous work. J Biomech. 1998;31:519525.
29. Benjaminse A, Gokeler A, vand der Schans CP. Clinical diagnosis of an
anterior cruciate ligament rupture: a meta-analysis. J Orthop Sports Phys
Ther. 2006;36:267288.
30. Solomon DH, Simel DK, Bates DW, et al. The rational clinical exami-
nation. Does this patient have a torn meniscus or ligament of the knee?
Value of the physical examination. JAMA. 2001;286:16101620.
31. Galway HR, MacIntosh DL. The lateral pivot shift: a symptom and sign
of anterior cruciate ligament insufciency. Clin Orthop. 1980;147:4550.
32. Ostrowski JA. Accuracy of 3 diagnostic test for anterior cruciate ligament
tears. J Athl Train. 2006;41:120121.
33. Noyes FR, Mooar PA, Matthew DS, et al. The symptomatic anterior
cruciate-decient knee, part I. J Bone Joint Surg Am. 1983;65:154162.
34. Sherman MF, Warren RF, Marshall JL, et al. A clinical and radiograph-
ical analysis of 127 anterior cruciate insufcient knees. Clin Orthop.
1988;227:229237.
35. Spindler KP, Wright RW. Clinical practice. Anterior cruciate ligament
tear. N Engl J Med. 2008;359:21352142.
36. Chhabra A, Starman JS, Ferretti M, et al. Anatomic, radiographic, bio-
mechanical, and kinematic evaluation of the anterior cruciate ligament and
its two functional bundles. J Bone Joint Surg Am. 2006;88(suppl 4):210.
37. Steckel H, Vadala G, Davis D, et al. 2D and 3D 3-Tesla magnetic
resonance imaging of the double bundle structure in anterior cruciate
ligament anatomy. Knee Surg Sports Traumatol Arthrosc. 2006;14:
11511158.
38. Starman JS, Vanbeek C, Armeld DR, et al. Assessment of normal ACL
double bundle anatomy in standard viewing planes by magnetic resonance
imaging. Knee Surg Sports Traumatol Arthrosc. 2007;15:493499.
39. Fithian DC, Paxton EW, Stone ML, et al. Prospective trial of a treatment
algorithm for the management of the anterior cruciate ligament-injured
knee. Am J Sports Med. 2005;33:335346.
40. Barrack RL, Bruckner JD, Kneisl J, et al. The outcome of nonoperatively
treated complete tears of the anterior cruciate ligament in active young
adults. Clin Orthop Relat Res. 1990;259:192199.
41. Noyes FR, Barber SD, Mooar LA. A rationale for assessing sports activ-
ity levels and limitations in knee disorders. Clin Orthop Relat Res. 1989;
246:238249.
42. Scavenius M, Bak K, Hansen S, et al. Isolated total ruptures of the
anterior cruciate ligament: a clinical study with long-term follow-up of
7 year. Scand J Med Sci Sports. 1999;9:114119.
43. Wittenberg RH, Oxfort HU, Plafki C. A comparison of conservative and
delayed surgical treatment of anterior cruciate ligament ruptures:
a matched pair analysis. Int Orthop. 1998;22:145148.
44. Recht MP, Piraino DW, Cohen MA, et al. Localized anterior arthrob-
rosis (cyclops lesion) after reconstruction of the anterior cruciate liga-
ment: MR imaging ndings. Am J Roentgenol. 1995;165:383385.
45. Aune AK, Holm I, Risberg MA, et al. Four-strand hamstring tendon
autograft compared with patellar tendon-bone autograft for anterior cru-
ciate ligament reconstruction: a randomized study with two-year follow-
up. Am J Sports Med. 2001;29:722728.
46. Tuman JM, Diduch DR, Rubino LJ, et al. Predictors for hamstring graft
diameter in anterior cruciate ligament reconstruction. Am J Sports Med.
2007;35:19451949.
47. DeAngelis JP, Fulkerson JP. Quadriceps tendona reliable alternative
for reconstruction of the anterior cruciate ligament. Clin Sports Med.
2007;26:587596.
48. Lee S, Seong SC, Jo H, et al. Anterior cruciate ligament reconstruction using
quadriceps tendon autograft. J Bone Joint Surg Am. 2007;89 (suppl 3):
116126.
49. Prodromos C, Joyce B, Shi K. A meta-analysis of stability of autografts
compared to allografts after anterior cruciate ligament reconstruction.
Knee Surg Sports Traumatol Arthrosc. 2007;15:851856.
2012 Lippincott Williams & Wilkins
Anterior Cruciate Ligament Injuries
50. Krych AJ, Jackson JD, Hoskin TL, et al. A meta-analysis of patellar
tendon autograft versus patellar tendon allograft in anterior cruciate lig-
ament reconstruction. Arthroscopy. 2008;24:292298.
51. Sun K, Tian S, Zhang J, et al. Anterior cruciate ligament reconstruction
with BPTB autograft, irradiated versus non-irradiated allograft: a prospec-
tive randomized clinical study. Knee Surg Sports Traumatol Arthrosc.
2009;17:464474.
52. Ristanis S, Stergiou N, Patras K, et al. Excessive tibial rotation during
high-demand activities is not restored by anterior cruciate ligament
reconstruction. Arthroscopy. 2005;21:13231329.
53. Tashman S, Collon D, Anderson K, et al. Abnormal rotational knee
motion during running after anterior cruciate ligament reconstruction.
Am J Sports Med. 2004;32:975983.
54. Adachi N, Ochi M, Uchio Y, et al. Reconstruction of the anterior cruciate
ligament: single- versus double-bundle multistranded hamstring tendons.
J Bone Joint Surg Br. 2004;86:515520.
55. Hamada M, Shino K, Horibe S, et al. Single- versus bi-socket anterior
cruciate ligament reconstruction using autogenous multiple-stranded
hamstring tendons with endoButton femoral xation: a prospective study.
Arthroscopy. 2001;17:801807.
56. Yasuda K, Kondo E, Ichiyama H, et al. Anatomic reconstruction of the
anteromedial and posterolateral bundles of the anterior cruciate ligament
using hamstring tendon grafts. Arthroscopy. 2004;20:10151025.
57. Mae T, Shino K, Miyama T, et al. Single- versus two-femoral socket
anterior cruciate ligament reconstruction technique: biomechanical anal-
ysis using a robotic simulator. Arthroscopy. 2001;17:708716.
58. Nishimoto K, Kuroda R, Mizuno K, et al. Analysis of the graft bending
angle at the femoral tunnel aperture in anatomic double bundle anterior
cruciate ligament reconstruction: a comparison of the transtibial and the
far anteromedial portal technique. Knee Surg Sports Traumatol Arthrosc.
2009;17:270276.
59. Yagi M, Wong EK, Kanamori A, et al. Biomechanical analysis of an
anatomic anterior cruciate ligament reconstruction. Am J Sports Med.
2002;30:660666.
60. Yamamoto Y, Hsu WH, Woo SL, et al. Knee stability and graft function
after anterior cruciate ligament reconstruction: a comparison of a lateral
and an anatomical femoral tunnel placement. Am J Sports Med. 2004;32:
18251832.
61. Abebe ES, Moorman CT III, Dziedzic TS, et al. Femoral tunnel place-
ment during anterior cruciate ligament reconstruction: an in vivo imaging
analysis comparing transtibial and 2-incision tibial tunnel-independent
techniques. Am J Sports Med. 2009;37:19041911.
62. Abebe ES, Kim JP, Utturkar GM, et al. The effect of femoral tunnel
placement on ACL graft orientation and length during in vivo knee
exion. J Biomechanics. 2011;44:19141920.
63. Shelbourne KD, Klotz C. What I have learned about the ACL: utilizing
a progressive rehabilitation scheme to achieve total knee symmetry after
anterior cruciate ligament reconstruction. J Orthop Sci. 2006;11:318325.
64. Wright RW, Preston E, Fleming BC, et al. A systematic review of anterior
cruciate ligament reconstruction rehabilitation: part II: open versus closed
kinetic chain exercises, neuromuscular electrical stimulation, accelerated
rehabilitation, and miscellaneous topics. J Knee Surg. 2008;21:225234.
65. Risberg MA, Holm I, Myklebust G, et al. Neuromuscular training versus
strength training during rst 6 months after anterior cruciate ligament
reconstruction: a randomized clinical trial. Phys Ther. 2007;87:737750.
66. Moffat KL, Wang IN, Rodeo SA, et al. Orthopedic interface tissue
engineering for the biological xation of soft tissue grafts. Clin Sports
Med. 2009;28:157176.
67. Mahirogullari M, Ferguson CM, Whitlock PW, et al. Freeze-dried allog-
rafts for anterior cruciate ligament reconstruction. Clin Sports Med. 2007;
26:625637.
68. Lopez-Vidriero E, Goulding KA, Simon DA, et al. The use of platelet-
rich plasma in arthroscopy and sports medicine: optimizing the healing
environment. Arthroscopy. 2010;26:269278.
69. Weitzel PP, Richmond JC, Altman GH, et al. Future direction of the
treatment of ACL ruptures. Orthop Clin North Am. 2002;33:653661.
www.cjsportmed.com | 355