The Physician and Sportsmedicine

ISSN: 0091-3847 (Print) 2326-3660 (Online) Journal homepage: http://www.tandfonline.com/loi/ipsm20

State-of-the-art anterior cruciate ligament tears: A

primer for primary care physicians

Matt Salzler, Benedict U. Nwachukwu, Samuel Rosas, Chau Nguyen, Tsun

Yee Law, Thomas Eberle & Frank McCormick

To cite this article: Matt Salzler, Benedict U. Nwachukwu, Samuel Rosas, Chau Nguyen, Tsun
Yee Law, Thomas Eberle & Frank McCormick (2015) State-of-the-art anterior cruciate ligament
tears: A primer for primary care physicians, The Physician and Sportsmedicine, 43:2, 169-177,
DOI: 10.1080/00913847.2015.1016865

To link to this article: http://dx.doi.org/10.1080/00913847.2015.1016865

Published online: 23 Feb 2015.

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ISSN: 0091-3847 (print)

Phys Sportsmed, 2015; 43(2): 169–177

DOI: 10.1080/00913847.2015.1016865

CLINICAL FEATURE
REVIEW

State-of-the-art anterior cruciate ligament tears: A primer

for primary care physicians
Matt Salzler1, Benedict U. Nwachukwu2, Samuel Rosas3, Chau Nguyen3, Tsun Yee Law3, Thomas Eberle4 and
Frank McCormick4
1
Tufts Medical Center, Department of Orthopedic Surgery, Boston, MA, USA, 2Hospital For Special Surgery, Department of Orthopedic Surgery,
New York, NY, USA, 3Holy Cross Orthopedic Research Institute, Fort Lauderdale, FL, USA, and 4Holy Cross Hospital, Department of Orthopedic Surgery,
Fort Lauderdale, FL, USA

Abstract Keywords
The purpose of this article is to provide primary care physicians and other members of the Anterior cruciate ligaments, articular ligament,
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medical community with an updated, general review on the subject of anterior cruciate ligament physical therapy modality, physical therapy
(ACL) tears. We aim to enhance awareness of these injuries and to prepare those practicing in the techniques
primary care setting to address these injuries. Because ACL injuries are quite common, it is very
likely that a primary care physician will encounter these injuries and need to address them History
acutely. The current literature is replete with new concepts and controversies regarding ACL
Received 24 October 2014
injuries, and this article provides a concise review for our target audience in regard to the care of
Accepted 7 January 2015
a patient with an ACL injury. This article is composed of an overview with current epidemiologic
Published online 23 February 2015
data, basic anatomy and physiology, clinical presentation, physical examination findings,
imaging modalities, and treatment options. After reading this short article, a medical care
provider should understand ACL injuries and their appropriate management.

Introduction The ACL is one of four main ligaments that stabilize the
knee joint and provides nearly 90% of the stability to anterior
Anterior cruciate ligament (ACL) tears are among the most com-
translation [7,8]. The femoral insertion site of the ACL is
mon knee injuries. An estimated 200,000 ACL tears occur each
located on the lateral intercondylar wall 43% of the distance
year in the United States [1], which amounts to 1 in 3500 people
from the proximal to distal femoral articular margin and, in
[1,3]. This type of injury occurs commonly during sporting
the anterior to posterior dimension, 2.5 mm plus the radius of
activities such as soccer, football, and other sports involving cut-
the ACL footprint anterior to the posterior articular margin
ting movements [5,6]. After the initial injury, many patients
[9]. Previous literature described the position as 1 O’clock on
experience hemarthrosis, crepitus, instability, and pain. As the
the left knee and 11 O’clock position on the right knee in
first medical professional to encounter these patients, a primary
reference to a clock placed in the intercondylar notch. This
care physician must be able to provide a diagnostic impression
two-dimensional reference to a three-dimensional structure
and deliver proper care prior to referral to a specialist.
led to nonanatomic ACL reconstructions, and recent literature
In this article we provide the readers with the information
has discarded the clock position for this more precise descrip-
on the anatomy and physiology of the knee, clinical presenta-
tion of the location of the femoral origin of the ACL. The
tion of ACL injuries, methods of examining the knee, imaging
ACL’s insertion on the tibial plateau is 15 mm anterior to the
modalities, surgical techniques, treatment options, and current
posterior cruciate ligament (PCL) insertion and two-fifths of
debates on the topic.
the width from the medial to lateral tibial spine [9].
Our expectation after reading this article is that primary
The ACL is composed of two bundles: the anteromedial
care physicians will have the most recent information and
bundle, which tightens in knee flexion, and the larger post-
reinforce their knowledge regarding a common knee injury
erolateral bundle, which tightens in knee extension [10].
such that patients can benefit from proper and timely care.
These biomechanical differences allow the ACL to remain
taut throughout a wide range of knee motion and enable the
Anatomy and function
ACL to rotate as the knee moves from extension to flexion
Proper evaluation of ACL tears and associated injury patterns [7]. An intact ACL stabilizes the femur on the tibia and
is guided by a general understanding of basic knee anatomy. prevents anterior tibial translation and rotation during agility

Correspondence: Samuel Rosas, MS, Holy Cross Orthopedic Research Institute, 5597 N. Dixie Highway, Fort Lauderdale, FL 33334, USA.
E-mail: Sam.rosas@icloud.com

2015 Informa UK Ltd.
 170 M Salzler et al. Phys Sportsmed, 2015; 43(2):169–177

exercises, jumping, deceleration, and pivoting with sudden

changes of direction [3,5,6,11]. Thus, the ACL is an impor-
tant structure in maintaining full knee function.
Recently, the anterolateral ligament (ALL) has gained
wide attention. Segond initially described it in the nineteenth
century as a “resistant band” that is now recognized as a
secondary stabilizer of tibial rotation in addition to the ACL
[12]. This ligament is located on the lateral knee; it arises
from the lateral femoral epicondyle anterior to the lateral
collateral ligament (LCL) and attaches on the lateral tibia.
Because of its location, it is in close proximity to the lateral
meniscus, genicular vein, and artery [12]. In a study of
206 diagnostic knee magnetic resonance imaging (MRI) Figure 1. Illustration showing the Lachman’s test. The patient is
confirming ACL tears, 78.8% of the knees demonstrated a instructed to lay supine on the table. The examiner flexes the patients’
concomitant injury to the ALL [13]. This suggests a relation- knee to 30 flexion and must verify that the patient’s muscles are not
ship between the two ligaments, but further biomechanical contracted. Then the clinician places his or her hands with two fingers
just below the patellar tendon insertion. Then, a gentle force is applied
studies are needed to determine their clinical relationship and intended to translate the tibia anteriorly. The test is positive when the
role of the ALL, if any, in the treatment of ACL injuries. tibia translates anteriorly > 5 mm or when no firm end point is felt.

Clinical presentation flexion, and slightly externally rotated to relax the pull of the
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ACL injuries occur commonly in sports such as basketball,
soccer, football, and wrestling, and the mechanism of injury
is more commonly a noncontact injury than one caused by
contact [15]. Typically, ACL tears result from landing with
the knee in nearly full extension, or from pivoting while
changing direction after a sudden deceleration [5,6]. Certain
athletic training programs have been shown to alter athlete’s
lower extremity biomechanics in order to reduce the risk of
ACL injury [16,17]. A recent systematic review found that
these programs provide a risk reduction of 52% in female
athletes and 85% in male athletes [18].
In addition to knee pain, swelling, and difficulty in bearing
weight following an ACL injury, patients typically report
hearing a “pop” or feeling a tearing sensation and their knee
“giving way” [19]. Approximately 80% of patients notice a
rapid onset of swelling within 3 hours of injury. However, a
gradual swelling over 24 hours does not rule out an ACL tear
[7,19]. The swelling results from a hemarthrosis, which
follows an ACL rupture. In high-impact sports, hemarthrosis
may be a result of an intraarticular fracture, which must be
considered during the evaluation.
Patients with chronic tears often complain of instability with
side-to-side movements, which may cause a fall, inability to
return to recreational activities, and discomfort when walking
or running. Chronic tears may also lead to further development
of injuries such as meniscal tears [20], and therefore, patients
may complain of meniscal pain, pain with weight bearing,
kneeling, and a potential locking sensation in the knee.
quadriceps and iliotibial band (Figure 1) [7]. This positioning
minimizes any secondary support given to the injured knee
and allows for a better direct evaluation of ACL competency.
The test is positive when a no firm end point is felt and/or
when the tibia translates anteriorly > 5 mm. Comparison with
the contralateral knee is useful as some patients may have
genetic laxity. The anterior drawer test has a reported sensi-
tivity from 80% to 99% [23] and may be used in combination
with the Lachman’s test to obtain more evidence that points
in the direction of an ACL tear. With the patient in the supine
position and the affected knee flexed to 90 , the examiner
pulls the tibia anteriorly to test for anterior translation
(Figure 2). The pivot shift test is the most specific test for a
complete ACL tear with a specificity of 98%, but it has a low
sensitivity of 24%–48% (Figure 3) [21,22]. The pivot shift
test is performed with the patient supine, the hip flexed up to
30 , and with the knee flexed at 20 , and a force is applied to
further flex the knee while at the same time additional valgus
force is directed toward the midline. A feeling of a shift or a
“popping feeling” describes a positive test.

Physical examination findings

A focused physical examination test includes the Lachman’s
test, the anterior drawer, and the pivot-shift test. Assessment
of ACL tear in an acute setting is best performed with the
Lachman’s test, with the highest sensitivity of 85% and a
specificity of 94%–99%, which combine to capture a large
number of tears without including many false negatives
[21,22]. The Lachman’s test evaluates the injured knee for
ACL laxity by placing the knee in a position of 20 –30
Figure 2. Illustration showing the anterior drawer test. With the patients
lying supine, the physician flexes the patients knee to 90 flexion and
proceeds to place his or her thumbs medial and lateral to the patellar
tendon. Later, a force is applied directed anteriorly looking for tibia
translation. Movement > 5 mm is indicative of an anterior cruciate liga-
ment tear, as well as a no firm end point.
 DOI: 10.1080/00913847.2015.1016865 State-of-the-art anterior cruciate ligament tears: A primer for primary care physicians
Figure 3. Illustration showing the pivot shift test. This examination is
done in the same position as in Figures 1 and 2. The patient’s knee is
flexed up to 80 and a valgus force is applied while also pushing the
knee toward the chest. When a pivot or a “step-wise” sensation is felt,
the test is said to be positive.
Evaluating for associated injuries
An isolated acute ACL rupture occurs in < 10% of the cases
[24-26]. Concomitant injuries include meniscus, articular and
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subchondral bone injuries, as well as collateral ligament tears.
ACL tears are mostly associated with meniscal injuries, with
a high prevalence of 60%–75% [27,24-26]. O’Donoghue first
described the “unhappy triad” in 1950, in which he described
an ACL tear, a medial collateral ligament (MCL) tear, and
medial meniscal injury [28]. Despite this initial description;
when an ACL tear is present with a combined MCL ligament
tear, the lateral meniscus is more likely to be injured than the
medial meniscus [28]. These findings are currently the
accepted concept of the unhappy triad, which occurs com-
monly after an athlete sustains a blow to the knee. In a recent
multicenter study of over 1000 ACL injuries, 36% of the
patients had a concomitant medial meniscus tear and 44%
had a lateral meniscus tear [29]. At the time of injury, the lat-
eral meniscus is most commonly damaged. However, after
the injury, persistent episodes of instability that displace the
tibia lead to medial meniscus tears as the medial meniscus is
a secondary restraint to anterior translation of the tibia. In
addition to meniscal injuries, chondral injuries also often
occur at the time of injury when there is an abnormal contact
between the articular surfaces.
Care must be taken to evaluate for collateral ligament inju-
ries including the MCL and LCL as these injuries often occur
in conjunction with ACL tears. To test for MCL and LCL
stability, with the patient supine on the table, the examiner
holds the femur in place at 0 and then at 30 of knee flexion
with one hand while applying a valgus (for MCL) and then a
varus force (for LCL) to the knee. A positive test for a collat-
eral ligament tear will be > 5 of opening or asymmetry as
compared with the uninjured knee.
The PCL should also be examined when an injury to the
knee has occurred. The incidence of PCL injuries varies
according to the patient population and the inciting event, that
is, traumatic injury or non-traumatic. The overall incidence
reported by Wind et al. is 3% in the general population,
whereas in the traumatic setting the overall incidence is 37%.
In high-velocity injuries, the same authors found PCL injuries
in 95% of combined ligaments knee injuries. The most
171
commonly performed test to clinically evaluate the compe-
tency of the PCL is the posterior drawer test, which is
performed in the same manner as the anterior drawer test,
although with a posteriorly directed force applied to the tibia.
A positive test constitutes an ill-defined end point of tibial
translation and/or if the tibia translates > 10–15 mm [30]. This
test has been reported to have 90% sensitivity and 99% specif-
icity [31]. The quad activation test is also used in the examina-
tion of the PCL. It is performed by placing the patient in a
supine position and flexing the patients’ knee to 90 . The
examiner sits on the patients’ foot and asks the patient to
“kick” or apply force directing the foot to the ceiling. This
force causes the quadriceps muscle to activate, and if a PCL
injury exists, the tibia is translated anteriorly. A systematic
review reported sensitivity ranging from 53% to 98% and spe-
cificity ranging from 96% to 100%, and recommended that the
quadriceps activation test be used for detecting a PCL injury.
In addition to evaluating for other ligamentous injuries,
meniscal injuries should be examined with the McMurray’s
test and by assessing joint line tenderness.
McMurray’s test is performed by having the patient lay
supine on the table. The clinician flexes the knee to 90 and
applies a rotational force to the tibia. The lateral meniscus is
examined with external rotation, and the medial meniscus
is examined with internal rotation. Pain and/or clicking at
90 indicate a positive McMurray’s test. The sensitivity for
this exam ranges from 16% to 86% with a 29%–96%
specificity [32].
In a study that evaluated 109 patients with a history of
possible meniscal injuries, the diagnostic accuracy of joint
line tenderness for meniscal injuries was reported to be 81%
for medial meniscal injuries and 90% for lateral meniscus
(Figure 4) [33]. This test is performed by applying pressure
with a finger at the joint line of the knee, and the patient
acknowledges whether they have pain.
Imaging
Isolated acute ACL tear injuries typically appear normal on
plain X-ray films. However, the presence of a Segond frac-
ture, a small avulsion fracture of the lateral tibial eminence,
is highly suggestive of ACL rupture [3].
Figure 4. Illustration showing the palpation for joint line tenderness test.
This is done by pressing over the bones of the joint. In order to better
define the joint line, the clinician can flex and extend the knee to
observe where the joint contact points are located.
 172 M Salzler et al.
MRI is the most accurate noninvasive diagnostic modality
in identifying a torn ACL, with sensitivity of 86%–95.9%,
and specificity of 91%–95% [1]. MRI findings include direct
and indirect signs of injury, with indirect signs representing
findings seen not directly on the ACL fibers. A normal ACL
appears as dark signal with a normal trajectory, and the lack
of dark signal with disorganized or disrupted fibers implies
an ACL injury. Indirect signs are equally as important.
A pathognomonic sign for an ACL rupture is the presence of
bone bruising which can be seen as a distortion of the normal
appearance of the bone on either the femur or tibia. Other
indirect signs include anterior tibial translation seen in a sag-
ittal view, which is measured by tracing a vertical line from
the posterior femur toward the ground; the posterior aspect of
the tibia must not be further than 7 mm anterior to this line.
This has a sensitivity of 86% and sensitivity of 99% for ACL
tears. When anterior tibial translation occurs, a second indi-
rect sign may appear as the uncovering of the posterior aspect
of the lateral meniscus, which is seen when a portion of the
lateral meniscus is more posterior than the tibia. Another use-
ful sign is to determine whether the ACL fibers are parallel
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to Blumensaat’s line, a line is traced on a sagittal view from
the posterior aspect of the femur to the most anterior portion
of the tibia. Another indirect sign of an ACL tear is viewing
of the entirety of the LCL fibers in one coronal MRI slice
[35]. Much of the reliance on indirect signs is due to the fact
that the ACL does not lie directly in the sagittal or coronal
plane, making direct visualization suboptimal. Recently, the
use of a sagittal oblique MRI in the plane of the ACL has
been described to better evaluate the ACL directly [36,37].
Every lesion occurring at the knee has its own direct and
indirect signs; for that reason we suggest discussing the MRI
with a radiologist or orthopedic surgeon when in doubt of the
findings. Further, with the knowledge that only 10% of ACL
tears are isolated ACL injuries, the majority of patients
require an MRI not only to confirm the ACL injury but also
as an important preoperative test in order manage patients
according to the entirety of their pathology.
Surgical versus conservative treatment
The management of ACL injuries includes both conservative
and surgical interventions. The ideal goal of either treatment
plan is to provide the knee with the stability needed to meet
the demands of the patient and to decrease the risk of associ-
ated future knee pathology such as meniscal tears and osteoar-
thritis. The determination of the optimal treatment remains
controversial [1,3,8,38,39]. While surgical repair is widely
accepted in the treatment of ACL rupture in young persons
and athletes, conservative treatment may have good outcomes
in the general population [40]. In September 2014, the
American Academy of Orthopaedic Surgeons developed
evidence-based treatment guidelines regarding ACL tears [41].
They found that “[m]oderate evidence supports surgical recon-
struction in active young adult [20,26,28,30-33,39,42-51]
patients with an ACL tear” and “limited evidence [sic]
supports non-surgical management for less active patients with
less laxity”. Rather than using a strict age or activity level
cutoff for determination of treatment, orthopedic surgeons
Phys Sportsmed, 2015; 43(2):169–177
often make recommendations based upon the physiological
age of the patient [52].
Even when surgery is recommended, patients are often
instructed to undergo preoperative physical therapy in order
to improve quadriceps and hamstring strength as these have
been shown to enhance recuperation after surgery by decreas-
ing scar tissue and contractures. This has been shown in a
randomized controlled trial to produce better outcomes after
surgery [53].
At an urgent care center in a primary care office, the
physician should initiate treatment with nonsteroidal anti-
inflammatory drugs, ice, and rest and may consider bracing
in order to decrease edema and assist in stabilization [42,43].
Conservative management
There are certain patients or “copers” who may do well with
conservative management, despite an ACL rupture. In a series
of 292 patients, Daniels et al. found that 56 (19%) of the
patients were clinically stable [54] based on anterior translation
measurements. They later developed a treatment algorithm for
patients based on their risk, which accounted for their amount
of anterior instability and their activity level. Despite the
degree of risk, he found that early as opposed to delayed recon-
struction led to a lower risk of late meniscus tears [55]. The
later meniscal tears in the low risk or more stable patients may
be due to rotationally unstable knees, which suggest that we
still cannot accurately predict which patients are going to be
“copers”. Apart from this, a randomized controlled trial of
ACL tears found no difference in outcome between early ACL
reconstruction and structured rehabilitation with the option for
a delayed reconstruction [56].
Patients who elect non-operative treatment are managed
with consistent and structured physiotherapy, which includes
quadriceps and hamstring strengthening and stretching.
Diligence in these routine-strengthening exercises is required
to achieve a better functional outcome. Additionally, some
studies have shown the support in the use of knee bracing in
chronic ACL-deficient knees, and in knees post-ACL recon-
struction [57]. However, the role of functional knee bracing
in an acute ACL tear injury remains unclear [42]. There is
controversy over the effect of bracing on quadriceps muscle
strengthening or on preventing post-traumatic osteoarthritis
[42,43,57].
Surgical management
Reconstructive surgery of an ACL rupture involves the recon-
struction of the torn ligament using a substitute graft of a
tendon or ligament and passing it through drilled tunnels in
the tibia and femur to approximate the normal anatomy [1].
ACL reconstruction is typically performed arthroscopically.
Tendon allografts are chosen in ~ 40% of primary ACL
reconstructions performed in the United States, with the
remaining 60% utilizing autografts, which are tendons from
the patient’s hamstring (semitendinosus and gracilis), patellar
tendon, or quadriceps tendon [1,38,39,58]. Graft selection
depends on different factors such as patients’ age, previous
level of activity, desired activity level after surgery, and
 DOI: 10.1080/00913847.2015.1016865 State-of-the-art anterior cruciate ligament tears: A primer for primary care physicians
lifestyle. Each graft has different biomechanical properties,
different associated recoveries, and different potential compli-
cations; therefore, graft choice is an important part of the
surgical procedure. Surgery may be performed arthroscopi-
cally or, less commonly, in conjunction with open surgery
depending on the concomitant injuries sustained.
There are many different techniques utilized in ACL
reconstruction, but the guiding principle is that a new tendi-
nous graft replaces the ruptured ACL in an attempt to mimic
the native anatomy. Here we describe a typical ACL recon-
struction surgery. The surgery begins by identifying the land-
marks of the knee, which include the patella, patellar tendon,
tibial tubercle, and tibial plateau. Afterward, a diagnostic
arthroscopy is performed to diagnose and address any other
possible injuries present. Typically, this is done by examining
the entire joint in a systematic fashion, starting with the
medial compartment then lateral compartment and finally the
patella-femoral joint; although this order varies among
surgeons. The menisci are probed to rule out any tears, and
the ACL and PCL are probed to check their integrity. The
cartilage is inspected to detect any signs of osteoarthritis and/
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or possible focal chondral defects. After the diagnostic arthro-
scopy is completed, the remainder of the ACL is excised and
the ACL origin and insertion are prepared for graft implanta-
tion. Next, the tibial and femoral tunnels are created; the
method by which the tunnels are drilled is a current source of
controversy. Regardless of technique, the tunnels must be
placed carefully in order to restore the anatomy as closely as
possible to the patients’ own. After the graft is passed, it is
fixed in the bone tunnels with the surgeon’s choice of fixa-
tion devices, which include suspensory buttons, interference
screws within the tunnels, and screws outside of the tunnels.
Finally, an arthroscopic inspection of the joint is performed
followed by a physical examination to evaluate the graft and
address any possible problems, which could include under- or
over-tensioning the graft, prior to closure. Closure is done in
layers and a cryotherapy device is applied to the knee in
order to minimize swelling. The first postoperative visit is
usually within the first week to evaluate the status of the
patient and the incisions, and for suture removal.
Surgical complications
Unfortunately, every surgical procedure is associated with
complications. Complications may be subdivided into surgi-
cal and nonsurgical complications and may vary depending
upon the type of procedure, patient demographics, surgeon
experience, and type of anesthesia.
Surgical complications may include the following: pain at
the surgical site, surgical site infection, stiffness, deep vein
thrombosis, neural, vascular, or ligamentous injuries, and
others. A recent report which examined 92,565 patients who
underwent arthroscopic knee surgery reported an overall com-
plication rate of 4.7% and a complication rate of 9.0% in
ACL reconstructions [59]. Overall, there were more surgical
(3.68%) than medical or anesthetic complications, and the
most common complication was infection (0.84%). A re-tear
of the ACL graft is a primary concern of patients and is more
common in younger athletes [60]. A recent systematic review
173
found a re-tear rate of 5.8%; however, the rate of tearing the
contralateral ACL is twice as high (11.8%) [61].
Although it is not a direct complication, the current litera-
ture suggests that ACL-deficient knees will develop osteoar-
thritis. Hui et al. [62] found that 51% of patients with isolated
ACL tears had radiographic signs of osteoarthritis at 15 years
of follow up. Current debate exists on whether ACL recon-
structive surgery decreases the development or at least delays
the development of osteoarthritis. A recent Cochrane review
notes the need for well-developed randomized control trials to
improve our understanding of the potential effects of ACL
reconstruction on the development of osteoarthritis.
State-of-the-art physical therapy
Physical therapy is a major component of the recovery proc-
ess of an ACL tear and is essential for obtaining excellent
results. We also advise patients to undergo a strict rehabilita-
tion program prior to reconstruction as this has been shown
by a randomized control trial to help accelerate the recovery
phase [63]. Because of muscle memory, it is easier to regain
muscle strength than to build it de novo. A basic program
with squats, straight leg raises, knee flexion, and core exer-
cises is recommended.
One new development postoperative rehabilitation proto-
cols is the consent of an accelerated protocol, which pro-
gresses more rapidly through the phases of recovery. A recent
large trial that compared an accelerated versus a non-
accelerated rehabilitation protocol determined that at the
2-year follow-up point, there was no statistically significant
difference between the groups regarding knee laxity, proprio-
ception, function, and patient satisfaction [13]. We recom-
mend that each patient undergoes a physical therapy program
that matches their specific goals.
Other rehabilitation therapies include water training or
decreased gravity treadmills. The latter uses a modified
electronic prosthesis that reduces body weight and allows for
earlier activity levels with decreased force across the recon-
structed ACL. This warrants further investigation, but it
appears to be a safe and effective technology [64].
Following surgery, the initial goal is to regain range of
motion (ROM); once completed, rehabilitation shifts toward
recovering neuromuscular function.
Week 1:
Focuses on mobility following surgery. We strongly advise
not to force ROM.
Initiation of physical therapy
. Manual therapy:
Stimulation to quadriceps/hamstrings/gastrocnemius;
patellofemoral and tibiofemoral non-thrust manipulation.
. Therapeutic exercises:
Non-weight bearing: straight leg raises, quadriceps and
gluteal sets, seated or prone heel slides;
Full weight-bearing (FWB) in brace: weight shifts for-
ward/side, heel raises, standing abduction/flexion;
 174 M Salzler et al.
Home Exercise Program: ROM therapeutic exercises per-
formed 6 times/day for swelling/pain.
. Begin increasing weight bearing and wean from crutches
as able to demonstrate good mechanics.
. Brace is to be used until 1–2 weeks postoperation depend-
ing on ability to control the leg with ambulation.
. Goals:
ROM goal should be at least 0 –75 ;
Independent straight leg raise; and
Full extension with active vastus medialis and oblique
(VMO) recruitment.
Weeks 2–3:
. Manual therapy:
Stimulation to quadriceps, hamstrings, gastrocnemius, scar
tissue;
Patellofemoral and tibiofemoral non-thrust manipulation;
Progress ROM, can use end range. Leg holds, if edema is
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minimal.
. Therapeutic exercises:
Bike riding when patient has > 100 flexion/can perform
full revolutions;FWB (in brace): progress with light resistive
therapeutic exercises in weight-bearing through available
range up to 90 flexion: leg press, mini squats, assisted
lunges, all planes of hip motions, hamstring curls, balance/
proprioception, and core stability;ROM therapeutic exercises
performed 6 times/day for swelling/pain (if necessary);Pool
exercises when incision closed;Avoid varus/valgus knee
motion with therapeutic exercises;
. Begin increasing weight-bearing and wean from crutches
as able to demonstrate good mechanics.
. Brace is to be used until 1–2 weeks postoperation depend-
ing on ability to control the leg with ambulation.
. Goals:
ROM goal should be at least 0 –110 ;independent straight
leg raise; andfull extension with active VMO recruitment.
Weeks 4–5:
. Manual therapy:
Continue with stimulation and non-thrust manipulation for
ROM as necessary;
Kinesiology taping of the quadriceps/hamstring, as
necessary.
. Therapeutic exercises:
Continue to progress weight-bearing exercises, progressing
ROM past 90 .
Add single leg loading with leg press;Advance core
stabilization program and balance/proprioception;
Phys Sportsmed, 2015; 43(2):169–177
Add Stairmaster, VersaClimber, Elliptical Trainer, if
available.
Weeks 6–7: MD follow up at 6 weeks.
. Manual therapy:
Kinesiology taping (if needed).
. Therapeutic exercises:
Continue restive progressions for lower extremity and
core;
Progress balance with single leg exercises;
Add Lateral training; andcontinue to monitor exercises for
signs of diminished eccentric, varus, and valgus.
Weeks 8–12: will reduce number of visits to 1 time/week.
Continued with supervised care 1 time/ week;
Begin jogging when hip and knee strength allow normal
mechanics and no pain;
Add complex lateral movements (carioca);
Add plyometrics; and
Add sport-specific training.
Current debates
As old debates on the optimal graft choice and fixation meth-
ods continue, a new and major debate in ACL reconstructions
is determining the optimal method of drilling the femoral
tunnel. This debate arises from discussions on the benefits of
a single-bundle (one tendon) versus double-bundle (two
tendons) ACL reconstruction. Double-bundle reconstructions
have shown improved laxity measurements, but no difference
in patient reported outcomes when compared with single-
bundle reconstructions [65]. Despite not changing patient
reported outcomes, awareness of the double-bundle technique
refocused orthopedic surgeons on the importance of recreat-
ing the anatomy of the native ACL even in single-bundle
ACL reconstructions. This has coincided with a multicenter
study on failed ACL reconstructions that found femoral tun-
nel malposition in 47.5% of the failures [66]. Because of this,
new techniques or alterations of prior techniques for drilling
the femoral tunnel have been developed including drilling
from an anteromedial portal, through the tibial tunnel, or, less
commonly, from outside the femur. The older transtibial
technique has been updated to allow for a more accurate
placement of the femoral tunnel, but it may come at the
expense of the tibial tunnel [67]. The newer anteromedial por-
tal technique had some initial complications including short
tunnels, breaking the posterior femoral cortex, and peroneal
nerve, and biceps tendon injuries – all of which have been
addressed with drilling with more knee flexion. A recent sys-
tematic review of the two techniques found that anteromedial
portal drilling more consistently places both tunnels anatomi-
cally and has better translational and rotational control, but,
to date, no difference in outcome has been found between the
two techniques [68]. An additional meta-analysis of 49 studies
also found that anteromedial portal drilling had improved
 DOI: 10.1080/00913847.2015.1016865 State-of-the-art anterior cruciate ligament tears: A primer for primary care physicians
biomechanics, and it found a small but statistically significant
increase in the Lysholm outcome score [69].
Another continued debate in ACL surgery is whether ACL
reconstruction can decrease the rate or slow the progression
of the development of osteoarthritis. ACL-deficient knees
have been shown to have higher rates of meniscal tears, and
meniscal injuries have been associated with osteoarthritis.
Despite this, one recent trial of patients with ACL injuries
randomized to early reconstruction or the option of delayed
reconstruction found no difference in the amount of radio-
graphic arthritis at 5 years of follow up [70]. A separate
meta-analysis with an average of 14 years of follow up found
that ACL reconstruction was associated with less need for
further knee surgeries and greater improvement in activity
using the Tegner Activity Scale, but it also found no differ-
ence in radiographic arthritis [71].
The above questions as well as questions regarding the
optimal graft choice, graft preparation, postoperative rehabili-
tation protocol, and others require a combination of prospec-
tive randomized studies as well as multicenter studies and
national registries. The first national registry for ACL recon-
Downloaded by [Teldan Inc] at 10:35 26 July 2016
structions has been established in Denmark. The United
States has recently developed the Multicenter Orthopaedic
Outcomes Network and the Multicenter ACL Revision Study
to begin to address these questions with a higher level of
evidence. Hopefully, within the next decade, we will be able
to answer these and other questions with a higher level of
confidence and evidence.
Summary
Physicians in the primary care setting encounter a vast
amount of musculoskeletal complaints and injuries. This
article presents up-to-date information in order to develop a
comprehensive understanding of ACL injuries, which occur
commonly in young patients.
ACL tears often present in a primary setting. The most
sensitive and specific test for diagnosis of an ACL tear is the
Lachman’s test, which should be performed in combination
with the anterior drawer test. A high percentage of ACL tears
have concomitant injuries which must not be overlooked as
they can alter management. MRI is of great value for proper
diagnosis of an ACL tear and for further evaluation of
additional injuries. Early physical therapy is recommended.
Treatment options, including operative and non-operative
management, take into account patients’ age, activity level,
and concomitant injuries. Because of the need for timely
diagnosis and treatment of an ACL tear, primary care physi-
cians should consider early referral to an orthopedic surgeon
or a sports medicine specialist. Further, future research is
needed to focus on the assessment of short- and long-term
effects of surgical and conservative treatments of ACL
injuries.
Declaration of interest
The author reports no conflicts of interest. The authors alone
are responsible for the content and writing of the paper.
175
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