ACL Injury Management

Diagnostic Approach

The American Academy of Orthopaedic Surgeons recommends the Lachman test as the most reliable clinical examination for detecting ACL rupture, and it should be the primary physical examination maneuver when evaluating suspected ACL injury 1
The Lachman test is more sensitive than the anterior drawer test for ACL rupture, and proper technique involves positioning the patient supine with the knee flexed to 20-30 degrees, stabilizing the distal femur, and applying anteriorly directed force to the proximal tibia 1
The American College of Radiology recommends obtaining plain radiographs first if Ottawa knee rules are positive, to rule out fractures and assess for joint effusion, which should prompt MRI in patients under 40 years old 2
MRI is superior for soft tissue evaluation and should be obtained when radiographs are negative but ACL injury is suspected, with a 93.5% detection rate for soft-tissue injuries in acute knee trauma 2

The American Academy of Orthopaedic Surgeons recommends ACL reconstruction with autograft as the most appropriate treatment for patients participating in cutting and pivoting sports with complete ACL tears, to prevent instability, protect menisci, and reduce risk of subsequent cartilage damage 3
ACL reconstruction with autograft is the preferred option, with a rating of 8, while ACL reconstruction with allograft has a rating of 7, and activity modification without reconstruction has a rating of 7, but only if the patient accepts the risk 3
The American Academy of Orthopaedic Surgeons recommends patellar tendon autograft to reduce the risk of graft failure or infection, and hamstring tendon autograft to reduce the risk of anterior knee pain or kneeling pain 4
Early reconstruction is preferable in young, active patients to provide knee stability and protect menisci, and delayed reconstruction is acceptable if the patient initially chooses conservative management but develops instability 4

Meniscal repair should be the first option whenever technically possible, as it results in similar clinical outcomes to isolated ACL injuries, and partial meniscectomy increases osteoarthritis risk, with an odds ratio of 1.87 4
The presence of minor osteoarthritic changes does not influence treatment decision-making, according to the American Academy of Orthopaedic Surgeons and Praxis Medical Insights 3, 4
Adequate rehabilitation with open and closed kinetic chain exercises for quadriceps recovery is fundamental, and functional knee orthoses are not recommended for routine use after primary isolated ACL reconstruction, as they provide no clinical benefit 4