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Published by American Academy of Orthopaedic Surgeons · Level of Evidence (High, Moderate, Low, Very Low, Consensus) and Strength of Recommendation (Strong, Moderate, Limited, Consensus)
This clinical practice guideline evaluates the management of anterior cruciate ligament injuries based on a systematic review of published studies in skeletally mature and immature patients, offering practice recommendations while highlighting gaps in the literature.
A relevant history should be obtained, and a focused musculoskeletal exam of the lower extremities should be performed when assessing for an ACL injury.
When surgical treatment is indicated for an acute isolated ACL tear, early reconstruction is preferred because the risk of additional cartilage and meniscal injury starts to increase within 3 months.
In patients undergoing intraarticular ACL reconstruction single or double bundle techniques can be considered because measured outcomes are similar.
When performing an ACL reconstruction, surgeons should consider autograft over allograft to improve patient outcomes and decrease ACL graft failure rate, particularly in young and/or active patients.
When performing an ACL reconstruction with autograft for skeletally mature patients, surgeons may favor BTB to reduce the risk of graft failure or infection, or hamstring to reduce the risk of anterior or kneeling pain.
Training programs designed to prevent injury can be used to reduce the risk of primary ACL injuries in athletes participating in high-risk sports.
ALL Reconstruction / LET could be considered when performing hamstring autograft reconstruction in select patients to reduce graft failure and improve short-term function, although long-term outcomes are yet unclear.
ACL tears indicated for surgery should be treated with ACL reconstruction rather than repair because of the lower risk of revision surgery.
In the absence of reliable evidence, it is the opinion of the workgroup that physicians may consider aspirating painful, tense effusions after knee injury.
ACL reconstruction can be considered in order to lower the risk of future meniscus pathology or procedures, particularly in younger and/or more active patients. ACL reconstruction may be considered to improve long term pain and function.
In patients with ACL tear and meniscal tear, meniscal preservation should be considered to optimize joint health and function.
In patients with combined ACL and MCL tears, non-operative treatment of the MCL injury results in good patient outcomes, although operative treatment of the MCL may be considered in select cases.
Prophylactic bracing is not a preferred option to prevent ACL injury.
Functional evaluation, such as the hop test, may be considered as one factor to determine return to sport after ACL reconstruction.
Functional knee braces are not recommended for routine use in patients who have received isolated primary ACL reconstruction, as they confer no clinical benefit.
Clinical Topic
Anterior Cruciate Ligament Injuries
Objectives
To help improve treatment based on the current best evidence.
Target Patient Population
Skeletally immature and skeletally mature patients who have been diagnosed with an ACL injury of the knee.
Diagnostic Criteria
History of mechanism/date of injury, popping sensation, ability to bear weight. Physical exam including neurovascular exam, assessment of varus/valgus laxity at 0 and 30 degrees flexion, dial testing, Lachman's, anterior drawer, pivot shift, and active buckling sign tests.
Target Providers
Therapeutic Area
Musculoskeletal CareGuideline Scope
Inclusion Criteria
Exclusion Criteria
Care Settings
Special Populations
System: Level of Evidence (High, Moderate, Low, Very Low, Consensus) and Strength of Recommendation (Strong, Moderate, Limited, Consensus)
Evidence Levels
Recommendation Strength
Contraindications
Difficulty
advanced
Exam Relevance