eMedicine Specialties > Sports Medicine > Knee

Anterior Cruciate Ligament Injury: Differential Diagnoses & Workup

Author: John D Hubbell, MD, Consulting Surgeon, Department of Orthopedic Surgery, Southampton Hospital
Coauthor(s): Evan Schwartz, MD, Director of Orthopedic Surgery, St John's Queens Hospital, New York Medical College; Assistant Professor, Department of Surgery, Albert Einstein School of Medicine
Contributor Information and Disclosures

Updated: Mar 7, 2006

Differential Diagnoses

Medial Collateral Knee Ligament Injury
Posterior Cruciate Ligament Injury

Other Problems to Be Considered

Tibial spine fracture
Tibial plateau fractures
Osteochondral fracture
Knee dislocation
Patella dislocation
Meniscal tear

Workup

Laboratory Studies

  • Arthrocentesis
    • Blood with fat globules are indicative of an osteochondral or tibial fracture.
    • Tapping of the knee is rarely performed with the advent of other less invasive and more specific diagnostic tests (MRI).

Imaging Studies

  • Plain radiographs
    • Radiographic findings are usually negative.
    • Anteroposterior, lateral, merchant, sunrise, and notch views may be used by the physician to diagnose certain radiographic findings that are associated with ACL ruptures.
    • Oblique radiographs may be helpful to exclude tibial plateau fractures.
    • The Segond fracture (lateral capsular avulsion fracture) may be visualized on an anteroposterior view.

      • This is an avulsion fracture of the lateral tibial plateau, located near the joint line and posteriorly to the Gerdy tubercle.
      • The Segond fracture represents a disruption of the meniscotibial portion of the lateral capsule.
      • Segond fracture is direct evidence of a lateral capsule injury and indirect evidence of an ACL injury.
         
    • The lateral notch fracture (lateral view) is located in the lateral femoral condyle.

      • This type of fracture is more commonly seen in chronic ACL-deficient knees, resulting from anterior subluxation of the lateral tibial plateau.
      • The physician must differentiate lateral notch fractures from osteochondral defects or fractures.
         
  • Arthrograms
    • These studies generally been replaced by MRI.
    • Arthrograms are mostly of historical interest, having occasionally been used by physicians to diagnose ACL ruptures; they must be performed by a radiologist who is highly skilled in double-contrast arthrography.
       
  • MRI
    • MRI has a sensitivity of 90-98% for ACL tears. MRI also may identify bone bruising, which is present in approximately 90% of ACL injuries.
    • An MRI allows the physician to confirm an ACL tear, but it should not be used as a substitute for a good history and physical examination.

Other Tests

  • Instrumented ligament testing
    • KT-1000 compares the difference in tibial excursion between the injured and the unaffected knee of a patient.
    • An excursion greater than 3 mm as measured by the KT-1000 is classified as pathologic.

More on Anterior Cruciate Ligament Injury

Overview: Anterior Cruciate Ligament Injury
Differential Diagnoses & Workup: Anterior Cruciate Ligament Injury
Treatment & Medication: Anterior Cruciate Ligament Injury
Follow-up: Anterior Cruciate Ligament Injury
Multimedia: Anterior Cruciate Ligament Injury
References
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References

  1. Belanger MJ, Moore DC, Crisco JJ 3rd, Fadale PD, Hulstyn MJ, Ehrlich MG. Knee laxity does not vary with the menstrual cycle, before or after exercise. Am J Sports Med. Jul-Aug 2004;32(5):1150-7. [Medline].

  2. Beynnon BD, Johnson RJ, Abate JA, Fleming BC, Nichols CE. Treatment of anterior cruciate ligament injuries, part I. Am J Sports Med. Oct 2005;33(10):1579-602. [Medline].

  3. Cosgarea AJ, Sebastianelli WJ, DeHaven KE. Prevention of arthrofibrosis after anterior cruciate ligament reconstruction using the central third patellar tendon autograft. Am J Sports Med. Jan-Feb 1995;23(1):87-92. [Medline].

  4. Daniel DM, Malcom LL, Losse G, Stone ML, Sachs R, Burks R. Instrumented measurement of anterior laxity of the knee. J Bone Joint Surg Am. Jun 1985;67(5):720-6. [Medline].

  5. Gardner E, O'Rahilly R. The early development of the knee joint in staged human embryos. J Anat. Jan 1968;102(2):289-99. [Medline].

  6. Getelman MH, Friedman MJ. Revision anterior cruciate ligament reconstruction surgery. J Am Acad Orthop Surg. May-Jun 1999;7(3):189-98. [Medline].

  7. Hewson GF Jr, Mendini RA, Wang JB. Prophylactic knee bracing in college football. Am J Sports Med. Jul-Aug 1986;14(4):262-6. [Medline].

  8. Johnson DL, Harner CD, Maday MG. Revision anterior cruciate ligament surgery. Knee Surg. 1994;1:877-95.

  9. Kennedy JC, Alexander IJ, Hayes KC. Nerve supply of the human knee and its functional importance. Am J Sports Med. Nov-Dec 1982;10(6):329-35. [Medline].

  10. Larson RL, Tailon M. Anterior Cruciate Ligament Insufficiency: Principles of Treatment. J Am Acad Orthop Surg. Jan 1994;2(1):26-35. [Medline].

  11. Maday MG, Harner CD, Fu FH. Evaluation and Treatment. In: Feagin JA, ed. The Crucial Ligaments: Diagnosis, Treatment of Ligamentous Injuries About the Knee. 2nd. New York, NY: Churchill Livingstone; 1994:711-23.

  12. Miyasaka KC, Daniel DM, Stone ML. The incidence of knee ligament injuries in the general population. Am J of Knee Surg. 1991;4:3-8.

  13. Montgomery KD, Herschman EB, Nicholas S. Anterior cruciate ligament injuries. In: Arendt EA, ed. Orthopaedic Knowledge Update: Sports Medicine 2. Rosemont, Ill: American Academy of Orthopaedic Surgeons; 1999:307-316.

  14. Noyes FR, Bassett RW, Grood ES, Butler DL. Arthroscopy in acute traumatic hemarthrosis of the knee. Incidence of anterior cruciate tears and other injuries. J Bone Joint Surg Am. Jul 1980;62(5):687-95, 757. [Medline].

  15. Noyes FR, Butler DL, Grood ES, Zernicke RF, Hefzy MS. Biomechanical analysis of human ligament grafts used in knee-ligament repairs and reconstructions. J Bone Joint Surg Am. Mar 1984;66(3):344-52. [Medline].

  16. Shelbourne KD, Gray T. Anterior cruciate ligament reconstruction with autogenous patellar tendon graft followed by accelerated rehabilitation. A two- to nine-year followup. Am J Sports Med. Nov-Dec 1997;25(6):786-95. [Medline].

  17. Shelbourne KD, Nitz P. Accelerated rehabilitation after anterior cruciate ligament reconstruction. Am J Sports Med. May-Jun 1990;18(3):292-9. [Medline].

  18. Stanitski CL. Anterior Cruciate Ligament Injury in the Skeletally Immature Patient: Diagnosisand Treatment. J Am Acad Orthop Surg. May 1995;3(3):146-158. [Medline].

  19. Watson JT. Knee and leg: bone trauma. In: Beaty JH, ed. Orthopaedic Knowledge Update 6. Rosemont, Ill: American Academy of Orthopaedic Surgeons; 1999:521-32.

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Further Reading

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Keywords

ACL injury, knee injury, knee ligament injury, sprained knee, twisted knee, ACL injuries, anterior cruciate ligament injuries

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Contributor Information and Disclosures

Author

John D Hubbell, MD, Consulting Surgeon, Department of Orthopedic Surgery, Southampton Hospital
John D Hubbell, 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, and Medical Society of the State of New York
Disclosure: Nothing to disclose.

Coauthor(s)

Evan Schwartz, MD, Director of Orthopedic Surgery, St John's Queens Hospital, New York Medical College; Assistant Professor, Department of Surgery, Albert Einstein School of Medicine
Evan Schwartz, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons and American Orthopaedic Society for Sports Medicine
Disclosure: Nothing to disclose.

Medical Editor

David T Bernhardt, MD, Director of Primary Care Sports Medicine Fellowship, Professor, Department of Pediatrics, University of Wisconsin
David T Bernhardt, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Sports Medicine, and American Medical Society for Sports Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Marlene DeMaio, MD, Consulting Staff, Assistant Professor, Department of Orthopedic Surgery, Bone & Joint/Sports Medicine Institute, Naval Medical Center
Marlene DeMaio, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American College of Sports Medicine, American Orthopaedic Foot and Ankle Society, and American Orthopaedic Society for Sports Medicine
Disclosure: Nothing to disclose.

CME Editor

Jon Whitehurst, MD, Consulting Staff, Rockford Orthopedic Associates
Disclosure: Nothing to disclose.

Chief Editor

Sherwin SW Ho, MD, Associate Professor, Department of Surgery, Section of Orthopedic Surgery and Rehabilitation, University of Chicago
Sherwin SW Ho, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America
Disclosure: Nothing to disclose.

 
 
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