flexed to 90°. Both thumbs are placed on the joint
line, and the tibia is drawn gently forward. The degree
of laxity and the quality of the endpoint are evaluated.- Other evaluations of the acute ACL injured knee
include the flexion-rotation-drawer test, the pivot shift
test, the MacIntosh test, and the Losee test (Silbey and
Fu, 2001). - Instrumented testing devices strive to minimize
interexaminer variability determining the degree of
knee laxity. The devices work by tracking motion of
the tibial tubercle in relation to the patella, thereby
measuring an objective measurement of anterior tibial
translation (D’Amato and Bach, 2003). The most
commonly cited model is the KT-1000 arthrometer
(Medmetric, San Diego, CA) (D’Amato and Bach,
2003). - The history and physical remains the cornerstone of
ACL injury diagnosis. Radiographs can provide
important adjunct information in the setting of a torn
ACL, especially to include associated injuries.
Findings that should be closely evaluated for include
avulsion of the tibial spine, Segond fractures, and
tibial plateau fractures. - MRI imaging is now often used to assess the integrity
of the ligament and look for associated injury to other
structures (menisci, PCL, collateral ligaments). MRI
also shows bone contusions in up to 80% of patients
(Johnson et al, 1998). It should be stressed that diag-
nosis of an ACL tear relies most heavily on the history
and physical and in the majority of cases the addi-
tional cost of the MRI is not warranted.
NATURALHISTORY
- The menisci are often concomitantly injured with the
ACL (Bellabarba, Bush-Joseph, and Bach, Jr, 1997;
Fithian, Paxton, and Goltz, 2002). In a review of the
literature, Bellabarba et al. reported a 41 to 81% inci-
dence of meniscal tears in acute ACL injuries, and a
58 to 100% incidence in chronic ACL tears 11). With
our current knowledge of the fate of the postmenis-
cectomized knee, it is imperative to identify and repair
torn menisci associated with ACL tears when at all
possible. - Chondral injuries are also commonly found in the
evaluation of the ACL disrupted knee. Studies show
an approximately 20% incidence of chondral injuries
in acute ACL tears and 50% or more in chronic ACL
patients (Indelicato and Bittar, 1985).
•Development of late degenerative arthritis in the
ACL injured knee is controversial. Long-term follow
of ACL deficient knees often reveals associated
degenerative arthritic changes. These “fairbanks
changes” have been correlated with meniscal pathol-
ogy in some studies (Satku, Kumar, and Ngoi, 1986;
Fowler and Regan, 1987), while others show similar
rates of degeneration in ACL deficient knees with or
without meniscectomy (Giove et al, 1983; Noyes
et al, 1983).- In addition to the associated injuries listed above,
nonoperative treatment also frequently leads to insta-
bility with activity. Noyes et al. reported a 65% inci-
dence of giving way during strenuous activity
following conservative treatment of ACL tears (Noyes
et al, 1983). They also reported that only 19% of non-
operative patients could perform turning or twisting
activities. Obviously, many young and athletically
active patients will not tolerate such an outcome.
MANAGEMENT- Decision making concerning the optimal treatment of
ACL tears must take into account patient preference,
age, activity level, knee instability, and associated
injuries. Some older patients who do not engage in
strenuous activities may be satisfied with conservative
treatments. Other patients will require reconstruction
in order to function at an acceptable level. - Fu et al outlined several indications for ACL recon-
struction (Fu and Schulte, 1996): ( 1 ) Athletically
active patients who desire to continue to participate at
a high level. ( 2 ) Patients who present with reparable
meniscus tears in addition to the ACL tear. ( 3 ) Patients
with associated grade III tears of other major knee lig-
aments (PCL, MCL, LCL). ( 4 ) Patients experiencing
instability that is interfering with activities of daily
living.
•Several studies have stressed the importance of the
timing of ACL surgery. ACL reconstruction surgery
too soon after the initial injury is associated with
increased incidence of arthofibrosis and decreased
range of motion following surgery (Harner et al,
1992). As such, Harner et al recommend waiting 3 to
4 weeks after the acute injury before reconstruction is
undertaken (Harner et al, 1992). - Successful ACL reconstruction relies on grafts that
mimic the complex anatomy and biomechanical
properties of the native ACL (Miller and Gladstone,
1002). The most commonly used choices today for
intra-articular ACL reconstruction are bone-patellar
tendon-bone (BTB) grafts, quadrupled semitendi-
nosus/gracilis tendon grafts, and quadriceps tendon
grafts. - BTB grafts are generally 8- to 11-mm wide and com-
prise the central third of the patellar tendon adjacent
tibial and patellar bone blocks (Miller and Gladstone,
1002; Fu et al, 1999). This method is popular due to a
high initial tensile load and stiffness, and the ability to
achieve rigid fixation with the bony ends.
Disadvantages are largely due to donor site morbidity.
352 SECTION 4 • MUSCULOSKELETAL PROBLEMS IN THE ATHLETE