Anterior Cruciate Ligament (ACL) Lesions

  • Pier Paolo MarianiEmail author
  • Guglielmo Cerullo
  • Germano Iannella
  • Marco Giacobbe


Soccer is currently the most popular sports with over 240 million participants worldwide, and unfortunately, soccer-related knee injuries are very common. The anterior cruciate ligament (ACL) is the most common ligament knee injury during soccer activity and usually causes long layoff from soccer [1]. The annual prevalence of ACL injury is reported to be between 0.5 % and 6.0 % of all female players and between 0.6 % and 8.5 % of all male players, respectively [2]. The frequency of ACL ruptures, whether expressed as an incidence or as an absolute value, is probably higher because the gathering of data on a large number of athletes with different age, gender, or level is actually impossible. Moreover, many other extrinsic factors such as differences of training, climate zones, exposure time to match play, and team level may reduce the statistical power of epidemiological analyses. Despite our little knowledge regarding incidence of ACL injury, soccer has a high rate of injury especially when compared to other types of sports. The etiology of ACL injuries includes a variety of intrinsic and extrinsic factors. The intrinsic factors, race and gender specific, are not modifiable and include hormonal issues, lower limb alignment, intercondylar notch size, ACL size, and joint laxity. In addition to these, there exist a variety of extrinsic factors such as environmental conditions, equipment, and athlete strength and conditioning.


ACL injury Soccer ACL reconstruction Return to play Rehabilitation 


  1. 1.
    Linko E, Harilainen A, Malmivaara A et al (2005) Surgical versus conservative interventions for anterior cruciate ligament ruptures in adults. Cochrane Database Syst Rev 18(2):CD001356Google Scholar
  2. 2.
    Waldèn M, Hagglund M, Werner J et al (2011) The epidemiology of anterior cruciate ligament injury in football (soccer): a review of the literature from a gender-related perspective. Knee Surg Sports Traumatol Arthrosc 19:3–10CrossRefPubMedGoogle Scholar
  3. 3.
    Shea KG, Pfeiffer R, Wang JH et al (2004) Anterior cruciate ligament injury in pediatric and adolescent soccer players: an analysis of insurance data. J Pediatr Orthop 24:623–628CrossRefPubMedGoogle Scholar
  4. 4.
    Carling C, Orhant E, Le Gall F (2010) Match injuries in professional soccer: inter-seasonal variation and effects of competition type, match congestion and positional role. Int J Sports Med 31:271–276CrossRefPubMedGoogle Scholar
  5. 5.
    Ekstrand J, Gillquist J, Moller M (1983) Incidence of soccer injuries and their relation to training and team success. Am J Sports Med 11:63–67CrossRefPubMedGoogle Scholar
  6. 6.
    Faude O, Junge A, Kindermann W et al (2006) Risk factors for injuries in elite female soccer players. Br J Sports Med 40:785–790CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Roos H, Ornell M, Gardsell P et al (1995) Soccer after anterior cruciate ligament injury: an incompatible combination? Acta Orthop Scand 66:107–112CrossRefPubMedGoogle Scholar
  8. 8.
    Bell RD, Shultz SJ, Wideman L et al (2012) Collagen gene variants previously associated with anterior cruciate ligament injury risk are also associated with joint laxity. Sports Health 4:312–318CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Kobayashi H, Kanamura T, Koshida S et al (2010) Mechanisms of the anterior cruciate ligament injury in sports activities: a twenty-year clinical research of 1,700 athletes. J Sports Sci Med 9:669–675PubMedPubMedCentralGoogle Scholar
  10. 10.
    Bjordal JM, Arnöy F, Hannestad B et al (1997) Epidemiology of anterior cruciate ligament injuries in soccer. Am J Sports Med 25:341–345CrossRefPubMedGoogle Scholar
  11. 11.
    Azubuike SO, Okojie OH (2009) An epidemiological study of football (soccer) injuries in Benin City, Nigeria. Br J Sports Med 43(5):382–386CrossRefPubMedGoogle Scholar
  12. 12.
    Rochcongar P, Laboute E, Carling C (2009) Ruptures of the anterior cruciate ligament in soccer. Int J Sports Med 30:372–378CrossRefPubMedGoogle Scholar
  13. 13.
    Hagglund M, Walden M, Ekstrand J (2009) UEFA injury study-an injury audit of European Championships 2006 to 2008. Br J Sports Med 43(7):483–489CrossRefPubMedGoogle Scholar
  14. 14.
    FIFA (2011) Fédération internationale de football association e quality concept for football turf. consult. 10 Jun 2011. disponível em.
  15. 15.
    Andersson H, Ekblom B, Krustrup P (2008) Elite football on artificial turf versus natural grass: movement patterns, technical standards, and player impressions. J Sports Sci 26(2):113–122CrossRefPubMedGoogle Scholar
  16. 16.
    Aoki H, Kohno T, Fujiya H et al (2010) Incidence of injury among adolescent soccer players: a comparative study of artificial and natural grass turfs. Clin J Sport Med 20(1):1–7CrossRefPubMedGoogle Scholar
  17. 17.
    Bjorneboe J, Bahr R, Andersen T (2010) Risk of injury on third-generation artificial turf in Norwegian professional football. Br J Sports Med 44(11):794–798CrossRefPubMedGoogle Scholar
  18. 18.
    Ekstrand J, Hagglund M, Fuller C (2011) Comparison of injuries sustained on artificial turf and grass by male and female elite football players. Scand J Med Sci Sports 21(6):824–832CrossRefPubMedGoogle Scholar
  19. 19.
    Arnason A, Tenga A, Engebretsen L et al (2004) A prospective video-based analysis of injury situations in elite male football: football incident analysis. Am J Sports Med 32(6):1459–1465CrossRefPubMedGoogle Scholar
  20. 20.
    Faunø P, Wulff Jakobsen B (2006) Mechanism of anterior cruciate ligament injuries in soccer. Int J Sports Med 27:75–79CrossRefPubMedGoogle Scholar
  21. 21.
    Arendt E, Dick R (1995) Knee injury patterns among men and women in collegiate basketball and soccer. Am J Sports Med 23:694–701CrossRefPubMedGoogle Scholar
  22. 22.
    Griffin LY, Agel J, Albohm MJ et al (2000) Noncontact anterior cruciate ligament injuries: risk factors and prevention strategies. J Am Acad Orthop Surg 8(3):141–150CrossRefPubMedGoogle Scholar
  23. 23.
    McNair PJ, Marshall RN, Matheson JA (1990) Important features associated with acute anterior cruciate ligament injury. N Z Med J 103(901):537–539PubMedGoogle Scholar
  24. 24.
    Livesay GA, Rudy TW, Woo SL et al (1997) Evaluation of the effect of joint constraints on the in situ force distribution in the anterior cruciate ligament. J Orthop Res 15(2):278–284CrossRefPubMedGoogle Scholar
  25. 25.
    Sakane M, Livesay GA, Fox RJ et al (1999) Relative contribution of the ACL, MCL, and bony contact to the anterior stability of the knee. Knee Surg Sports Traumatol Arthrosc 7(2):93–97CrossRefPubMedGoogle Scholar
  26. 26.
    Draganich LF, Vahey JW (1990) An in vitro study of anterior cruciate ligament strain induced by quadriceps and hamstring forces. J Orthop Res 8(1):57–63CrossRefPubMedGoogle Scholar
  27. 27.
    Markolf KL, O’Neill G, Jackson SR et al (2004) Effects of applied quadriceps and hamstrings muscle loads on forces in the anterior and posterior cruciate ligaments. Am J Sports Med 32(5):1144–1149CrossRefPubMedGoogle Scholar
  28. 28.
    Fung DT, Zhang LQ (2003) Modeling of ACL impingement against the intercondylar notch. Clin Biomech (Bristol, Avon) 18(10):933–941CrossRefGoogle Scholar
  29. 29.
    Shimokochi Y, Shultz SJ (2008) Mechanisms of noncontact anterior cruciate ligament injury. J Athl Train 43(4):396–408CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Burkhart B, Ford KR, Myer GD et al (2008) Anterior cruciate ligament tear in an athlete: does increased heel loading contribute to ACL rupture? J Sports Phys Ther 3(3):141–144Google Scholar
  31. 31.
    Boden BP, Griffin LY, Garrett WE (2000) Etiology and prevention of noncontact ACL injury. Phys Sportsmed 28:53–60CrossRefPubMedGoogle Scholar
  32. 32.
    Torg JS, Conrad W, Kalen V (1976) Clinical diagnosis of anterior cruciate ligament instability in the athlete. Am J Sports Med 4(2):84–93CrossRefPubMedGoogle Scholar
  33. 33.
    Feagin JA, Cooke TD (1989) Prone examination for anterior cruciate ligament insufficiency. J Bone Joint Surg Br 71(5):863PubMedGoogle Scholar
  34. 34.
    Benjaminse A, Gokeler A, van der Schans CP (2006) Clinical diagnosis of an anterior cruciate ligament rupture: a meta-analysis. J Orthop Sports Phys Ther 36(5):267–288CrossRefPubMedGoogle Scholar
  35. 35.
    van Eck CF, van den Bekerom MP, Fu FH et al (2013) Methods to diagnose acute anterior cruciate ligament rupture: a meta-analysis of physical examinations with and without anaesthesia. Knee Surg Sports Traumatol Arthrosc 21(8):1895–1903CrossRefPubMedGoogle Scholar
  36. 36.
    Robert H, Nouveau S, Gageot S et al (2009) A new knee arthrometer, the GNRB: experience in ACL complete and partial tears. Orthop Traumatol Surg Res 95(3):171–176CrossRefPubMedGoogle Scholar
  37. 37.
    Collette M, Courville J, Forton M et al (2012) Objective evaluation of anterior knee laxity; comparison of the KT-1000 and GNRB arthrometers. Knee Surg Sports Traumatol Arthrosc 20(11):2233–2238CrossRefPubMedGoogle Scholar
  38. 38.
    Spindler KP, Wright RW (2008) Clinical practice. Anterior cruciate ligament tear. N Engl J Med 359(20):2135–2142CrossRefPubMedPubMedCentralGoogle Scholar
  39. 39.
    Kosaka M, Nakase J, Toratani T et al (2014) Oblique coronal and oblique sagittal MRI for diagnosis of anterior cruciate ligament tears and evaluation of anterior cruciate ligament remnant tissue. Knee 21(1):54–57CrossRefPubMedGoogle Scholar
  40. 40.
    Dimond PM, Fadale PD, Hulstyn MJ et al (1998) A comparison of MRI findings in patients with acute and chronic ACL tears. Am J Knee Surg 11(3):153–159PubMedGoogle Scholar
  41. 41.
    Irvine GB, Dias JJ, Finlay DB (1987) Segond fractures of the lateral tibial condyle: brief report. J Bone Joint Surg Br 69(4):613–614PubMedGoogle Scholar
  42. 42.
    Vincent JP, Magnussen RA, Gezmez F et al (2012) The anterolateral ligament of the human knee: an anatomic and histologic study. Knee Surg Sports Traumatol Arthrosc 20(1):147–152CrossRefPubMedGoogle Scholar
  43. 43.
    Pujol N, Colombet P, Cucurulo T et al (2012) Natural history of partial anterior cruciate ligament tears: a systematic literature review. Orthop Traumatol Surg Res 98(Suppl8):S160–S164CrossRefPubMedGoogle Scholar
  44. 44.
    Andernord D, Karlsson J, Musahl V et al (2013) Timing of surgery of the anterior cruciate ligament. Arthroscopy 29(11):1863–1871CrossRefPubMedGoogle Scholar
  45. 45.
    Krych AJ, Jackson JD, Hoskin TL et al (2008) A meta-analysis of patellar tendon autograft versus patellar tendon allograft in anterior cruciate ligament reconstruction. Arthroscopy 24(3):292–298CrossRefPubMedGoogle Scholar
  46. 46.
    Cain EL Jr, Clancy WG Jr (2002) Anatomic endoscopic anterior cruciate ligament reconstruction with patella tendon autograft. Orthop Clin North Am 33(4):717–725CrossRefPubMedGoogle Scholar
  47. 47.
    Noyes FR (2010) ITB extra-articular tenodesis. In: Noyes FR (ed) Noyes’ knee disorders: surgery, rehabilitation, clinical outcomes. Saunders/Elsevier, Philadelphia, pp 170–172Google Scholar
  48. 48.
    Christel P, Djian P (2002) Plastie extra articulaire antero latérale du genou utilisant une ténodèse courte au fascia-lata. Rev Chir Orthop Rep Appar Mot 88:508–513Google Scholar
  49. 49.
    Amiel D, Kleiner JB, Roux RD, Harwood FL et al (1986) The phenomenon of “ligamentization”: anterior cruciate ligament reconstruction with autogenous patellar tendon. J Orthop Res 4:162–172CrossRefPubMedGoogle Scholar
  50. 50.
    Zech A, Awiswu F, Pfeifer K (2009) Longitudinal changes of neuromuscular quadriceps function after reconstruction of the anterior cruciate ligament. Curr Orthop Pract 20(3):276–280CrossRefGoogle Scholar
  51. 51.
    Tyler TF, McHugh MP, Gleim GW et al (1998) The effect of immediate weightbearing after anterior cruciate ligament reconstruction. Clin Orthop Relat Res 357:141–148CrossRefPubMedGoogle Scholar
  52. 52.
    Grood ES, Suntay WJ, Noyes FR et al (1984) Biomechanics of the knee-extension exercise. Effect of cutting the anterior cruciate ligament. J Bone Joint Surg Am 66(5):725–734PubMedGoogle Scholar
  53. 53.
    Mikkelsen C, Werner S, Eriksson E (2000) Closed kinetic chain alone compared to combined open and closed kinetic chain exercises for quadriceps strengthening after anterior cruciate ligament reconstruction with respect to return to sports: a prospective matched follow-up study. Knee Surg Sports Traumatol Arthrosc 8(6):337–342CrossRefPubMedGoogle Scholar
  54. 54.
    Perry MC, Morrissey MC, King JB et al (2005) Effects of closed versus open kinetic chain knee extensor resistance training on knee laxity and leg function in patients during the 8- to 14-week post-operative period after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 13(5):357–369CrossRefPubMedGoogle Scholar
  55. 55.
    Seto JL, Orofino AS, Morrissey MC et al (1988) Assessment of quadriceps/hamstring strength, knee ligament stability, functional and sports activity levels five years after anterior cruciate ligament reconstruction. Am J Sports Med 16:170–180CrossRefPubMedGoogle Scholar
  56. 56.
    Thomeé R, Kaplan Y, Kvist J et al (2011) Muscle strength and hop performance criteria prior to return to sports after ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 19(11):1798–1805CrossRefPubMedGoogle Scholar
  57. 57.
    Schmitt LC, Paterno MV, Hewett TE (2012) The impact of quadriceps femoris strength asymmetry on functional performance at return to sport following anterior cruciate ligament reconstruction. J Orthop Sports Phys Ther 42(9):750–759CrossRefPubMedPubMedCentralGoogle Scholar
  58. 58.
    Kinzey SJ, Armstrong CW (1998) The reliability of the star-excursion test in assessing dynamic balance. J Orthop Sports Phys Ther 27(5):356–360CrossRefPubMedGoogle Scholar
  59. 59.
    Plisky PJ, Rauh MJ, Kaminski TW et al (2006) Star excursion balance test as a predictor of lower extremity injury in high school basketball players. J Orthop Sports Phys Ther 36(12):911–919CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2015

Authors and Affiliations

  • Pier Paolo Mariani
    • 1
    Email author
  • Guglielmo Cerullo
    • 2
  • Germano Iannella
    • 2
  • Marco Giacobbe
    • 2
  1. 1.Università degli Studi di Roma “Foro Italico”RomeItaly
  2. 2.Villa Stuart Sport ClinicFIFA Medical CenterRomeItaly

Personalised recommendations