Eur J Orthop Surg Traumatol (2013) 23:747–752
DOI 10.1007/s00590-012-1079-8
GENERAL REVIEW
The anatomy of the ACL and its importance in ACL
reconstruction
K. Markatos • M. K. Kaseta • S. N. Lallos •
D. S. Korres • N. Efstathopoulos
Received: 22 May 2012 / Accepted: 9 September 2012 / Published online: 22 September 2012
Ó Springer-Verlag 2012
Abstract The anterior cruciate ligament (ACL) anatomy
is very significant if a reconstruction is attempted after its
rupture. An anatomic study should have to address, its
biomechanical properties, its kinematics, its position and
anatomic correlation and its functional properties. In this
review, an attempt is made to summarize the most recent
and authoritative tendencies as far as the anatomy of the
ACL, and its surgical application in its reconstruction are
concerned. Also, it is significant to take into account the
anatomy as far as the rehabilitation protocol is concerned.
Separate placement in the femoral side is known to give
better results from transtibial approach. The medial tibial
eminence and the intermeniscal ligament may be used as
landmarks to guide the correct tunnel placement in ana-
tomic ACL reconstruction. The anatomic centrum of the
ACL femoral footprint is 43 % of the proximal-to-distal
length of lateral, femoral intercondylar notch wall and
femoral socket radius plus 2.5 mm anterior to the posterior
articular margin. Some important factors affecting the
surgical outcome of ACL reconstruction include graft
selection, tunnel placement, initial graft tension, graft fix-
ation, graft tunnel motion and healing. The rehabilitation
protocol should come in phases in order to increase range
of motion, muscle strength and leg balance, it should
protect the graft and weightbearing should come in
stages. The cornerstones of such a protocol remain bracing,
K. Markatos (&)
M. K. Kaseta
S. N. Lallos

D. S. Korres
N. Efstathopoulos
Second Department of Orthopaedic Surgery,
University of Athens, Medical School, Athens, Greece
e-mail: gerkremer@yahoo.gr
K. Markatos
Konstantopouleio Hospital, 3-5 Agias Olgas Str., 142 33 Athens,
Greece
controlling edema, pain and range of motion. This should
be useful and valuable information in achieving full range
of motion and stability of the knee postoperatively. In the
end, all these advancements will contribute to better patient
outcome. Recommendations point toward further experi-
mental work with in vivo and in vitro studies, in order to
assist in the development of new surgical procedures that
could possibly replicate more closely the natural ACL
anatomy and prevent future knee pathology.
Keywords Anterior cruciate ligament
Reconstruction

Anatomy
Rehabilitation
Review
Introduction
The anterior cruciate ligament (ACL) anatomy is very
significant if a reconstruction is attempted after its rupture.
An anatomic study should have to address its biomechan-
ical properties, its kinematics, its position and anatomic
correlation and its functional properties. It is important to
identify and describe reliable landmarks for femoral and
tibial tunnel placement in anatomic ACL reconstruction
[1–4].
A correlation of the ACL anatomy and reconstruction
with rehabilitation protocols and methods should be per-
formed in order to demonstrate the significance of the
anatomic reconstruction in achieving full range of motion
and stability of the knee postoperatively [5, 6].
Anatomy
The anterior cruciate ligament is attached medially to the
anterior intercondylar area of the tibia partly blending with
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the anterior of the lateral meniscus; it ascends posterolat-
erally, twisting on itself and fanning out to attach to the
posteromedial aspect of the lateral femoral condyle. It is
anterolateral to the posterior cruciate ligament [1, 3, 4].
It is suggested that the ACL can be divided into two
functional and anatomic seperate bundles: the anteromedial
(AM) and the posterolateral (PL) bundle. This classifica-
tion is based on their tibial insertion sites, and this division
can be achieved by the varying orientation and tensioning
patterns of the fibers during knee range of motion [5–7].
The cruciate ligaments consist of a highly organized
collagen matrix, which accounts for approximately three-
fourths of their dry weight. The majority of the collagen is
type I (90 %), and the remainder is type III (10 %). In the
ACL, this collagen is organized into multiple fiber bundles
20 lm that are grouped into groups 20–400 lm in diam-
eter. Occasional fibroblasts and other substances, such as
elastin (\5 %) and proteoglycans (1 %), make up the
remainder of the dry weight. Water makes 60 % of the net
weight under physiologic conditions. At the microscopic
level, ligament and tendon insertions into bone have a
distinct structure consisting of collagen fibrils directly
continuous with fibrils within the bone. A calcified facade,
similar to that seen between osteoid and mineralized bone,
can be distinguished [1, 3].
The cruciate ligaments are named for their attachments
on tibia and are important to function of the knee joint. The
cruciate ligaments act to stabilize the knee joint and pre-
vent anteroposterior displacement of the tibia on the femur.
The existence of many sensory endings also implies a
proprioceptive function. These ligaments are intra-articular
but, because they are covered by synovium, are considered
extrasynovial. They receive their blood supply from bran-
ches of the middle genicular and both inferior genicular
arteries [1, 3, 8].
The ACL originates from the medial surface of the
lateral femoral condyle posteriorly in the intercondylar
notch in the form of the segment of a circle. The anterior
side of the attachment is nearly straight and the posterior
side convex. The ligament courses anteriorly, distally and
medially toward the tibia. Over the length of its course, the
fibers of the ligament undergo slight external rotation. The
average length of the ligament is 38 mm and the average
width 11 mm. About 10 mm beneath the femoral attach-
ment, the ligament stands out, as it proceeds distally to the
tibial attachment, which is a wide, depressed area anterior
and lateral to the medial tibial tubercle in the intercondylar
fossa. The tibial attachment is oriented in an oblique
direction and is wider than the femoral attachment. There is
a well-marked slip to the anterior horn of the lateral
meniscus [8, 9]. In summary, proximal to distal, the ana-
tomic centrum of the ACL femoral footprint, as a whole, is
43 % of the distance from the proximal articular cartilage
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Eur J Orthop Surg Traumatol (2013) 23:747–752
margin to the distal articular margin. Such a line can be
identified and quantitated arthroscopically [10].
On MRI, the ACL is best visualized on sagittal images.
Because of its oblique course the ACL should routinely be
imaged on two or three sagittal sections. A normal ACL
has a relatively low signal, but toward the distal insertion
the ACL may appear linear. The specificity of the exami-
nation is higher in the sagittal level compared to that in the
coronal level and it is better imaged in the T2 sequence. A
rupture in the fibers or a soft tissue mass in the notch with
high-signal characteristics resulting from edema and hem-
orrhage indicates an ACL tear. Partial ACL tears may be
imaged by increased signal, thickening or redundancy in
the ligament. However, accurate diagnosis of partial inju-
ries remains challenging. Arthroscopic evaluation of the
ACL remains the gold standard for assessing suspected
partial and complete tears [7, 8, 11].
Biomechanics
The ACL is the main static stabilizer against anterior
translation of the tibia on the femur and accounts for up to
86 % of the total force resisting anterior draw. At different
stages of knee motion, distinct portions of ACL appear to
act to stabilize the knee joint. Clinical examination has
failed to reveal distinct bundles; therefore, the bundles
seem to represent functional, rather than anatomic, struc-
tures. An anteromedial bundle becomes taut at 90° degrees
of flection, and a posterolateral bundle becomes tight as
full extension is approached. The ACL also plays a lesser
role in resisting internal and external rotation. The maxi-
mum tensile strength of the ACL is approximately
1,725 ± 270 N, which is less than the maximum force that
occurs in vigorous athletic activities. Stability is enhanced
by dynamic stabilizers, such as the muscles that apply a
force across the knee joint. For the muscles to aid in pro-
tective stabilization of the knee, effective proprioceptive
feedback regarding joint position is crucial. It appears that
the ACL plays an important proprioceptive function
because a variety of mechanoreceptors and free nerve
endings have been identified. In humans with ACL-defi-
cient knees, a significantly higher threshold for detecting
passive motion of the involved knee has been suggested.
The afferent and efferent signals concerning the ACL are
carried by branches of the posterior tibial nerve [3, 8, 11,
12].
These complex anatomies make the ACL particularly
efficient for limiting excessive anterior tibial translation as
well as axial tibial and valgus knee rotations. Laboratory
studies have determined load-elongation curve of a bone-
ligament-bone complex by a uniaxial tensile test. The
stiffness and ultimate loads are appropriate to represent its
Eur J Orthop Surg Traumatol (2013) 23:747–752
structural properties. In the same test, a stress–strain rela-
tionship can also be obtained, from which the modulus,
tensile strength, ultimate strain and strain energy density
can be measured to represent the mechanical properties
[7, 8, 13].
The ultimate aim of an ACL reconstruction is to restore
the function of the intact ACL. Laboratory study on human
cadaveric knee designed to test the effectiveness of ACL
reconstruction under clinical maneuvers, that is, anterior
drawer and Lachman test, reveal that most of the current
reconstruction procedures are satisfactory during anterior
tibial loads. However, they fail to restore both the kine-
matics and the in situ forces in the ACL under rotatory
loads and muscle loads [7–9, 14, 15].
ACL reconstruction
Although many patient follow-up studies report good out-
comes in the short term after anterior cruciate ligament
(ACL) reconstruction, some questions remain. Long-term
studies have reported a high incidence of joint degeneration
(as much as 52–56 % 12–13 years after surgery) and an
estimated 8–10 % of ACL reconstructions result in recur-
rent instability and graft failure. Furthermore, studies have
suggested that the ability of current reconstruction tech-
niques to prevent degenerative changes compared with
nonoperative treatment is limited. These biological factors
contribute in knee deterioration, and they are almost
uncontrollable therapeutically [14–16].
Although many mechanisms likely contribute to this
degeneration (for example, traumatic injury to other soft
tissues at the time of ACL rupture), numerous authors
suggest the inability of the reconstruction to restore normal
joint kinematics is an important factor [16, 17]. The
reconstruction of the ACL is a factor of the outcome that
can be controlled by sound anatomic technique and proper
tunnel placing. Many authors believe improper femoral
tunnel placement is a common reason for failure of an ACL
reconstruction. Frequently, the grafts are placed too far
anteriorly on the femur, resulting in a vertically oriented
graft. Several in vitro studies suggest a graft placed too far
anteriorly on the femur results in excessive tension in the
graft in flection, which could lead to graft failure. Fur-
thermore, a vertically oriented graft does not reproduce the
oblique orientation of the ACL, which could limit the
ability of the reconstruction to restore the abnormal kine-
matics observed after ACL deficiency. Grafts placed near
the center of the ACL attachment site on the femur more
closely restore normal knee translation and rotation than a
more vertically oriented graft. The transtibial technique, in
which the femoral tunnel is drilled through the tibial tun-
nel, is commonly used in ACL reconstruction. However,
749
several studies have suggested that the transtibial technique
might not be able to center the graft near the anatomic
center of the ACL, owing to constraints imposed by the
tibial tunnel. Techniques where the femoral tunnel is
placed independently of the tibial tunnel might allow for
better placement of the femoral tunnel [16–19].
Inaccurate femoral tunnel placement is a common cause
of failure in ACL reconstruction with the graft often being
placed too far anteriorly. An anteriorly oriented graft does
not restore the oblique orientation of the ACL and has
limited ability to restore normal knee stability. Recent
cadaver studies have suggested a graft placed near the
center of the ACL more closely restores knee kinematics
than an anteriorly placed graft. Therefore, anatomic graft
placement is likely important given the inability of current
reconstruction techniques to restore normal kinematics and
is believed an important factor contributing to the long-
term development of osteoarthritis after ACL reconstruc-
tion [20, 21].
According to Ferretti et al., the medial tibial eminence
demonstrated a constant relationship with the ACL tibial
insertion site center and its bundles, as well as the inter-
meniscal ligament. The anterior root of the lateral meniscus
had a variable relationship with the ACL tibial insertion.
The medial tibial eminence may be used as bony landmark
for tibial tunnel placement in anatomic ACL reconstruc-
tion. The intermeniscal ligament is also a constant land-
mark [9, 17, 21, 22].
Optimal graft placement for restoring normal motion
under physiologic loading conditions is unknown. Cadaver
studies suggest that placing the graft closer to the center of
the attachment site might improve knee kinematics com-
pared with an anterior graft placement. For example, sev-
eral cadaver studies reported placement of the graft in a
more oblique or lateral position improves rotatory knee
stability. One of these studies reported that under rotary
loads, an oblique, anatomically placed single-bundle graft
reproduced intact knee kinematics, whereas a more verti-
cally oriented graft did not. Both grafts reproduced anterior
laxity under anterior tibial loads. In another study under
combined rotary loads, no differences in tibial rotation and
anterior translation were detected between a double-bundle
reconstruction and a laterally placed single-bundle recon-
struction [23–25].
Arnold et al. reported the anatomic attachment site of
the ACL could not be reached with a femoral aiming guide
through a standard tibial tunnel. The closest position that
could be reached was at the margin of the anatomic
attachment site, deep and high in the notch. Tunnels placed
too far anteriorly on the femur reportedly have poor clinical
outcomes. Anteriorly placed grafts may lead to notch
impingement or graft stretching. Several biomechanical
studies show tunnels placed at the 11 o’clock position
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restore anterior tibial stability under anterior tibial loads
but fail to control rotational stability. In addition, a graft
placed too far anteriorly could result in a vertically oriented
graft. A vertically oriented graft is unlikely to restore the
oblique orientation of the ACL and might provide inade-
quate restraint to the increased internal rotation and medial
tibial translation observed in patients with ACL deficiency.
Altered kinematics after ACL injury are thought to pre-
dispose the knee to degenerative changes [26].
With an intact ACL footprint, the ACL femoral guide
pin can be placed within 2 mm of the center of the ACL
using the independent technique. The transtibial technique
was less consistent, with the guide pin being placed too far
anteriorly, approximately 7 mm from the center of the
ACL attachment site. If there is no ACL stump, the femoral
guide pin can be placed to within 2 mm of the geometric
center of the ACL using the intersection of a vertical line
through the most posterior edge of the cartilage border and
a horizontal line through the most proximal point of the
cartilage border in the notch. More anatomic placement of
the femoral tunnel might help reduce the incidence of graft
failure and might prevent the long-term degenerative
changes observed after ACL reconstruction, although these
would require clinical confirmation [25, 26].
The results of Piefer et al. in an excellent systematic
review show that the anatomic centrum of the ACL femoral
footprint is 43 % of the proximal-to-distal length of the
lateral, femoral intercondylar notch wall and r ? 2.5 mm
anterior to the posterior articular margin, where r represents
ACL femoral socket radius [10].
Factors affecting the outcome of an ACL reconstruction
Factors that could determine the fate of an ACL recon-
struction include graft selection, tunnel placement, initial
graft tension, graft fixation, graft tunnel motion and rate of
graft healing. It is believed that there is a logical sequence
to examine these factors in order to achieve the ideal
results.
In the future, biomechanical studies must involve more
realistic in vivo loading conditions. An approach that
involves both experimental and computational methods
must be used. Continuous advancements in the develop-
ment of ways to measure in vivo kinematics of the knee
during daily activities are being made [27–29]. Recently, a
dual orthogonal fluoroscopic system has been used to
measure in vivo knee kinematics, with an accuracy of
0.1 mm and 0.1° for objects with known shapes, positions
and orientations [30, 31]. Once collected, the in vivo
kinematic data can be replayed on cadaveric specimens
using the robotics/UFS testing system in order to determine
the in situ forces in the ACL and ACL grafts. In parallel,
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Eur J Orthop Surg Traumatol (2013) 23:747–752
subject-specific computational models of the knee can be
constructed. Based on the same in vivo kinematic data, the
in situ forces in the ACL and ACL grafts can be calculated.
When the calculated in situ forces are matched by those
obtained experimentally, the computational model is then
validated and can be used to compute the stress and strain
distributions in the ACL and ACL grafts, as well as to
predict in situ forces in the ACL and ACL grafts during
more complex in vivo motions that could not be done in
laboratory experiments. In the end, it will be possible to
develop a large database on the functions of ACL and ACL
grafts that are based on subject-specific data (such as age,
gender and geometry), to elucidate specific mechanisms of
ACL injury, to customize patient-specific surgical man-
agement (including surgical preplanning), as well as to
design appropriate rehabilitation protocols. It is widely
believed that such a biomechanics-based approach will
provide clinicians with valuable scientific information to
perform suitable ACL reconstruction and design appro-
priate postoperative rehabilitation protocols. In the end, all
these advancements will contribute to better patient out-
come [30–40].
In addition, a biomechanical study by Abebe et al.
proved that grafts placed anteroproximally on the femur
were longer and more vertical than the native ACL in both
the sagittal and coronal planes, while anatomically placed
grafts more closely mimicked ACL motion. In full exten-
sion, the grafts placed anteroproximally were 12.3° ± 5.2°
(mean and 95 %CI) more vertical than the native ACL in
the sagittal plane, whereas the grafts placed anatomically
were 2.9° ± 3.7° less vertical. Grafts placed anteroproxi-
mally were up to 6 ± 2 mm longer than the native ACL,
while the anatomically placed grafts were a maximum of
2 ± 2 mm longer. Grafts placed anatomically more closely
restored native ACL length and orientation. As a result,
anatomic grafts are more likely to restore intact knee
kinematics [41].
Increased understanding of the basic science surround-
ing ACL injury and reconstruction together with advances
in fixation devices has allowed surgeons to successfully
pursue more aggressive rehabilitation schemes. The weak
link in the reconstruction continues to be the fixation
interface, and the surgeon should be familiar with the
biomechanical behavior of the fixation device chosen.
Thus, a series of criteria-based rehabilitation protocols
have been proposed and widely used, which represent a
rational approach that instead of strict adherence to time-
tables, advance the patient through the various phases when
the knee is physiologically ready. These protocols allow
wise utilization of available resources and account for
variations that have to be made for any additional pathol-
ogy that is addressed at the time of ACL reconstruc-
tion. Counseling, activity modification, rehabilitation and
Eur J Orthop Surg Traumatol (2013) 23:747–752
bracing continue to be the mainstays of conservative
management of ACL injuries [42].
In the first phase of rehabilitation bracing, control of
edema and increase range of motion with passive move-
ment and quadriceps movement are in order. In the second
phase, the patient should be encouraged to leave the crut-
ches and start progressive resistive exercises, bicycle with
resistance, leg extension exercises, increase flection and
discontinue bracing. In the third phase, the strength of
hamstrings and quadriceps should increase and open and
closed chain should be implemented. Also in this phase a
stair stepper can be used and plyometric exercising can be
initiated as long as the evaluation is favorable. In the fourth
phase, a full weight lifting program is implemented along
with balance exercises, and a progressive running program
is in order. In this phase, the patient can return to work and
sport progressively. In the fifth phase, running up and down
is recommended along with sport-specific drills. The
muscle strength (quadriceps and hamstrings) should be at
least 90 % of the opposite side, and sport bracing is
optional. Of course, all these should be modified according
to swelling, pain and reassessment of the surgical outcome
[42–44].
The rehabilitation process continues to be an important
link in the chain of events that aim to return the patient
safely and expediently to full activity [42–44].
According to Georgoulis et al., clinical knee joint bio-
mechanics are impaired after ACL injury, in terms of
kinematics and neuromuscular control. Current ACL
reconstruction techniques do not seem to fully restore
normal physiology of the movement. Excessive tibial
rotation is still present in high-demanding activities, and
impairment of neuromuscular control may persist even
though muscle strength is reinstated. These abnormal bio-
mechanical patterns may lead to loading of cartilage areas
which are not commonly loaded in the healthy knee and
longitudinally can lead to osteoarthritis. Muscle imbalance
can also influence patients’ optimal sports performance,
exposing them to increased possibility of knee re-injury.
Recommendations point toward further experimental work
with in vivo and in vitro studies, in order to assist in the
development of new surgical procedures that could possi-
bly replicate more closely the natural ACL anatomy and
prevent future knee pathology [45].
Conclusion
In this review paper, we have summarized how anatomy
and biomechanics of the femoral and tibial stumps have
made many significant contributions to the understanding
of the ACL and ACL replacement grafts and how these
data have helped the surgeons. In the future, biomechanical
751
studies must involve more realistic in vivo loading condi-
tions. Separate placement in the femoral side is known to
give better results from transtibial approach. The medial
tibial eminence and the intermeniscal ligament may be
used as landmarks to guide the correct tunnel placement in
anatomic ACL reconstruction. The anatomic centrum of
the ACL femoral footprint is 43 % of the proximal-
to-distal length of lateral, femoral intercondylar notch
wall and femoral socket radius plus 2.5 mm anterior to
the posterior articular margin. The rehabilitation protocol
should come in phases in order to increase range of motion,
muscle strength and leg balance, it should protect the graft
and weightbearing should come in stages. The cornerstones
of such a protocol remain bracing, controlling edema, pain
and range of motion.
We believe such an anatomic and biomechanics-based
approach will provide clinicians with valuable scientific
information to perform suitable ACL reconstruction and
design appropriate postoperative rehabilitation protocols.
In the end, all these advancements will contribute to better
patient outcome. Recommendations point toward further
experimental work with in vivo and in vitro studies, in
order to assist in the development of new surgical proce-
dures that could possibly replicate more closely the natural
ACL anatomy and prevent future knee pathology.
Conflict of interest The authors have no conflicts of interest to
declare.
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