The anterior cruciate: a dilemma in sports medicine

This study presents an extensive review of the literature concerning the natural history, diagnosis and treatment of anterior cruciate (AC) injury. This ligament is the most frequently disrupted ligament in the human knee, yet wide disagreement exists concerning the effects of its rupture and the appropriate means of treatment. Diagnosis of AC sprain is difficult, however the appropriate use of the Lachman and pivot shift tests can improve accuracy markedly. The Lachman test has several advantages over the standard drawer test: 1) the knee is examined in 10--20 degrees of flexion (a comfortable position for the injured knee); 2) it minimizes the blocking effect of the hamstring muscles on the anterior drawer motion; 3) minimized the blocking effect of the posterior horns of the menisci; 4) eliminates confusion with rotary instability. The pivot shift test demonstrates the clinical effects of loss of anterior cruciate function, but does not correspond to anterolateral rotary instability which, unfortunately, it has been named. The wide variety of treatment of acute total disruption suggested numerous authors reveals the lack of a single satisfactory way to successfully obtain excellent results. A survey of 56 North American knee surgeons concerning their treatment of "isolated" tears of the AC ligament in young vigorous athletes revealed that 30.3% would treat nonoperatively, 62.5% would repair the ligament with or without a graft and 7.2% would ignore the ligament but replace it with a graft or do a capsular reconstruction.