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Anterior Cruciate Ligament Pathology Workup

  • Author: John Maguire, MBBS, MSc, FRACS; Chief Editor: Thomas M DeBerardino, MD  more...
Updated: Jun 10, 2016

Laboratory Studies

Routine laboratory studies are not required. However, infection, crystal arthropathy, and inflammatory arthropathy must be excluded in routine fashion when suspected.


Imaging Studies


Radiologic examination should be undertaken in all cases. Radiographs are needed to exclude fracture, tumor, chondrocalcinosis, crystalline arthropathy, and osteoarthrosis. Routine series should include an anteroposterior (AP) view, a lateral view at 30°, notch view, a patellofemoral view, and a weightbearing posteroanterior (PA) view in extension and 45° in chronic cases or in older individuals who may be at risk of osteoarthritis.

Computed tomography

In cases associated with fracture or avulsions of the cruciates, computed tomography (CT) can add valuable information. The location and origin of bony loose bodies can be identified well with this modality.


Magnetic resonance imaging (MRI; see the image below) is a useful tool when the diagnosis is unclear or when nonoperative management of the anterior cruciate ligament (ACL) tear is being considered.[7] Cruciate integrity is well visualized in T1- and T2-weighted images. In the acute phase, when pain and apprehension can cloud clinical signs, an accurate diagnosis can be made in 98% of cases.

MRI is used as an aid to diagnose anterior cruciat MRI is used as an aid to diagnose anterior cruciate ligament injury. MRI has a sensitivity of 95%.

Meniscal pathology also can be identified. With more than 50% of cases having a meniscal tear, some surgeons find this information of use in choosing a management plan. Bone bruising commonly is seen, particularly of the lateral femoral condyle. The long-term influence this may have on the outcome is not yet known.

Radionuclide scanning

Radionuclide scanning is not used routinely. Its major uses in the setting of ACL injury are to identify and quantify degeneration in chronic cases. Radionuclide scanning also is used to help make the diagnosis in cases of suspected postoperative infection.


Other Tests

A number of mechanical devices (eg, KT1000) are available on the market that are used in some centers to assist in diagnosis. Most centers do not use these devices on a routine basis in acute assessment. They are widely used in research to help quantify the degree of tibial translation.

Strength assessment using specific muscle testing units is a tool commonly involved in research. Muscle testing also can be used in the rehabilitation phase to compare strength in opposite legs. This can aid some practitioners in deciding when return to play is possible.


Diagnostic Procedures

In the postinjury workup, few procedures are used.

Aspiration and drainage of a large hemarthrosis can aid diagnosis and assist in providing pain relief. If crystal arthropathy is suspected, assessment can be made to exclude this. Fracture creates fatty deposits in the hemarthrosis. Therefore, aspiration can aid in making a diagnosis in these cases. The authors do not recommend this as a routine measure.

Some practitioners use arthroscopy to assist in making a diagnosis. If the diagnosis is unclear after other testing, accurate assessment can be made by means of arthroscopy. Meniscal pathology and cruciate stump impingement also can be dealt with at the time of arthroscopy. This may be the only requirement for patients who are not planning to undergo early reconstruction. Results of meniscal repair are improved if the procedure is combined with cruciate reconstruction. Therefore, the authors recommend a single procedure if reconstruction is planned.

Contributor Information and Disclosures

John Maguire, MBBS, MSc, FRACS Partner, Townsville Orthopaedics and Sports Surgery, Australia

Disclosure: Nothing to disclose.


Mervyn J Cross, MBBS, FRACS, MD Director of the Australian Institute of Musculoskeletal Research, Department of Orthopedic Surgery, North Sydney Orthopedic/Sports Medicine Center, Crows Nest, Australia

Mervyn J Cross, MBBS, FRACS, MD is a member of the following medical societies: American Orthopaedic Society for Sports Medicine, Australasian College of Sports Physicians, Australian Association of Surgeons, Australian Medical Association, Australian Orthopaedic Association, Hughston Society, Royal Australasian College of Surgeons

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Thomas M DeBerardino, MD Orthopedic Surgeon, The San Antonio Orthopaedic Group; Research Director, BRIO of the San Antonio Orthopaedic Group; Consulting Surgeon, Sports Medicine, Arthroscopy and Reconstruction of the Knee, Hip and Shoulder, Team Physician; Adjunct Associate Professor, Uniformed Services University of the Health Sciences, F Edward Hebert School of Medicine

Thomas M DeBerardino, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Orthopaedic Society for Sports Medicine, Arthroscopy Association of North America, Herodicus Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Arthrex, Inc.; Ivy Sports Medicine; MTF; Aesculap; The Foundry, Cotera; ABMT<br/>Received research grant from: Histogenics; Cotera; Arthrex.

Additional Contributors

Robert D Bronstein, MD Associate Professor, Department of Orthopedics, Division of Athletic Medicine, University of Rochester School of Medicine

Robert D Bronstein, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, Arthroscopy Association of North America, Medical Society of the State of New York

Disclosure: Nothing to disclose.

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Hemarthrosis of the knee occurs early following injury to the anterior cruciate ligament.
The Lachman test is a sensitive test for examining the cruciate-deficient knee.
Dynamic extension test produces anterior tibial translation in the cruciate-deficient knee.
This image demonstrates the anterior tibial translation compared to that seen in the image above.
The anterior draw test commonly is performed to diagnose anterior cruciate ligament injury.
The pivot-jerk test is a sensitive test for examining anterior cruciate ligament integrity.
MRI is used as an aid to diagnose anterior cruciate ligament injury. MRI has a sensitivity of 95%.
Anterior cruciate ligament reconstruction aims to reduce instability episodes in an attempt to preserve the meniscus. When meniscal injury has occurred, the knee becomes degenerate with time.
Surgical reconstruction most commonly uses the patella tendon or the hamstrings as donor grafts. This image shows the patella tendon being harvested.
Hamstring tendons also may be used as a donor graft for anterior cruciate ligament reconstruction. This image shows a 4-strand hamstring graft being prepared.
Image demonstrating the use of the patella tendon as a donor graft for anterior cruciate ligament reconstruction
Anterior femoral tunnel placement is a common error in ACL reconstruction. This image shows a femoral tunnel placed far too anterior, resulting in a nonfunctional graft.
Poor tunnel position and improper placement of hardware are common causes of anterior cruciate ligament graft failure.
Interference screws are the most commonly used form of anterior cruciate ligament graft fixation.
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