The ACL: Anatomy, Biomechanics, Mechanisms of Injury, and the Gender Disparity

  • Frank R. Noyes
  • Sue D. Barber-Westin


This chapter summarizes the current knowledge regarding ACL anatomy, biomechanics, common injury mechanisms, and the differences in ACL injury rates between male and female athletes. The anatomy of the ACL has been well described; however, disagreement exists regarding its division into two distinct fiber bundles. At least two-thirds of ACL tears occur during noncontact situations such as cutting, pivoting, accelerating, decelerating, and landing from a jump. Reduced knee flexion angles, increased hip flexion angles, valgus collapse at the knee, increased hip internal rotation, and increased internal or external tibial rotation are frequently reported at the time of or just prior to ACL injury. Female athletes are at greater risk for sustaining an ACL injury compared to male athletes participating in soccer, basketball, rugby, and handball. Research has shown that comprehensive training programs can effectively “reprogram” the neuromuscular system to avoid potentially dangerous body mechanics and positions.


Anterior Cruciate Ligament Anterior Cruciate Ligament Reconstruction Knee Flexion Anterior Cruciate Ligament Injury Anterior Cruciate Ligament Rupture 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Agel J, Arendt EA, Bershadsky B (2005) Anterior cruciate ligament injury in national collegiate athletic association basketball and soccer: a 13-year review. Am J Sports Med 33(4):524–530PubMedCrossRefGoogle Scholar
  2. 2.
    Ait Si Selmi T, Fithian D, Neyret P (2006) The evolution of osteoarthritis in 103 patients with ACL reconstruction at 17 years follow-up. Knee 13(5):353–358PubMedCrossRefGoogle Scholar
  3. 3.
    Amis A, Dawkins G (1991) Functional anatomy of the anterior cruciate ligament. Fibre bundle actions related to ligament replacements and injuries. J Bone Joint Surg 73B(2):260–267Google Scholar
  4. 4.
    Arendt E, Dick R (1995) Knee injury patterns among men and women in collegiate basketball and soccer. NCAA data and review of literature. Am J Sports Med 23(6):694–701PubMedCrossRefGoogle Scholar
  5. 5.
    Arms SW, Pope MH, Johnson RJ et al (1984) The biomechanics of anterior cruciate ligament rehabilitation and reconstruction. Am J Sports Med 12(1):8–18PubMedCrossRefGoogle Scholar
  6. 6.
    Baer GS, Harner CD (2007) Clinical outcomes of allograft versus autograft in anterior cruciate ligament reconstruction. Clin Sports Med 26(4):661–681PubMedCrossRefGoogle Scholar
  7. 7.
    Barber-Westin SD, Noyes FR (2009) Risk factors for anterior cruciate ligament injuries in the female athlete. In: Noyes FR (ed) Noyes’ knee disorders: surgery, rehabilitation, clinical outcomes. Saunders, Philadelphia, pp 359–378Google Scholar
  8. 8.
    Barber-Westin SD, Noyes FR (2009) Lower limb neuromuscular control and strength in prepubescent and adolescent male and female athletes. In: Noyes FR (ed) Noyes’ knee disorders: surgery, rehabilitation, clinical outcomes. Saunders, Philadelphia, pp 379–403Google Scholar
  9. 9.
    Barber-Westin SD, Noyes FR, Smith ST et al (2009) Reducing the risk of noncontact anterior cruciate ligament injuries in the female athlete. Phys Sportsmed 37(3):49–61PubMedCrossRefGoogle Scholar
  10. 10.
    Barber-Westin SD, Noyes FR (2011) Objective criteria for return to athletics after anterior cruciate ligament reconstruction and subsequent reinjury rates: a systematic review. Phys Sportsmed 39(3):100–110PubMedCrossRefGoogle Scholar
  11. 11.
    Berns GS, Hull ML, Patterson HA (1992) Strain in the anteromedial bundle of the anterior cruciate ligament under combination loading. J Orthop Res 10(2):167–176PubMedCrossRefGoogle Scholar
  12. 12.
    Beynnon BD, Fleming BC, Johnson RJ et al (1995) Anterior cruciate ligament strain behavior during rehabilitation exercises in vivo. Am J Sports Med 23(1):24–34PubMedCrossRefGoogle Scholar
  13. 13.
    Beynnon BD, Johnson RJ, Abate JA et al (2005) Treatment of anterior cruciate ligament injuries, part I. Am J Sports Med 33(10):1579–1602PubMedCrossRefGoogle Scholar
  14. 14.
    Beynnon BD, Uh BS, Johnson RJ (2005) Rehabilitation after anterior cruciate ligament reconstruction. A prospective, randomized, double-blind comparison of programs administered over 2 different time periods. Am J Sports Med 33(3):347–359PubMedCrossRefGoogle Scholar
  15. 15.
    Boden BP, Dean GS, Feagin JA Jr et al (2000) Mechanisms of anterior cruciate ligament injury. Orthopedics 23(6):573–578PubMedGoogle Scholar
  16. 16.
    Boden BP, Torg JS, Knowles SB et al (2009) Video analysis of anterior cruciate ligament injury: abnormalities in hip and ankle kinematics. Am J Sports Med 37(2):252–259PubMedCrossRefGoogle Scholar
  17. 17.
    Brand E, Nyland J (2009) Patient outcomes following anterior cruciate ligament reconstruction: the influence of psychological factors. Orthopedics 32(5):335PubMedCrossRefGoogle Scholar
  18. 18.
    Butler DL, Noyes FR, Grood ES (1980) Ligamentous restraints to anterior-posterior drawer in the human knee. A biomechanical study. J Bone Joint Surg Am 62(2):259–270PubMedGoogle Scholar
  19. 19.
    Chandrashekar N, Mansouri H, Slauterbeck J et al (2006) Sex-based differences in the tensile properties of the human anterior cruciate ligament. J Biomech 39(16):2943–2950PubMedCrossRefGoogle Scholar
  20. 20.
    Clayton RA, Court-Brown CM (2008) The epidemiology of musculoskeletal tendinous and ligamentous injuries. Injury 39(12):1338–1344PubMedCrossRefGoogle Scholar
  21. 21.
    Clemente CD (2007) Anatomy: a regional atlas of the human body, 5th edn. Lippincott, Williams and Wilkins, BaltimoreGoogle Scholar
  22. 22.
    Colby S, Francisco A, Yu B et al (2000) Electro­myographic and kinematic analysis of cutting maneuvers. Implications for anterior cruciate ligament injury. Am J Sports Med 28(2):234–240PubMedGoogle Scholar
  23. 23.
    Colombet P, Robinson J, Christel P et al (2006) Morphology of anterior cruciate ligament attachments for anatomic reconstruction: a cadaveric dissection and radiographic study. Arthroscopy 22(9):984–992PubMedCrossRefGoogle Scholar
  24. 24.
    DeMorat G, Weinhold P, Blackburn T et al (2004) Aggressive quadriceps loading can induce noncontact anterior cruciate ligament injury. Am J Sports Med 32(2):477–483PubMedCrossRefGoogle Scholar
  25. 25.
    Elliot DL, Goldberg L, Kuehl KS (2010) Young women’s anterior cruciate ligament injuries: an expanded model and prevention paradigm. Sports Med 40(5):367–376PubMedCrossRefGoogle Scholar
  26. 26.
    Fithian DC, Paxton LW, Goltz DH (2002) Fate of the anterior cruciate ligament-injured knee. Orthop Clin North Am 33(4):621–636, vPubMedCrossRefGoogle Scholar
  27. 27.
    Fleming BC, Renstrom PA, Beynnon BD et al (2001) The effect of weightbearing and external loading on anterior cruciate ligament strain. J Biomech 34(2):163–170PubMedCrossRefGoogle Scholar
  28. 28.
    Fleming BC, Renstrom PA, Ohlen G et al (2001) The gastrocnemius muscle is an antagonist of the anterior cruciate ligament. J Orthop Res 19(6):1178–1184PubMedCrossRefGoogle Scholar
  29. 29.
    Frobell RB, Lohmander LS, Roos HP (2007) Acute rotational trauma to the knee: poor agreement between clinical assessment and magnetic resonance imaging findings. Scand J Med Sci Sports 17(2):109–114PubMedGoogle Scholar
  30. 30.
    Graham GP, Fairclough JA (1988) Early osteoarthritis in young sportsmen with severe anterolateral instability of the knee. Injury 19(4):247–248PubMedCrossRefGoogle Scholar
  31. 31.
    Granan LP, Bahr R, Steindal K et al (2008) Development of a national cruciate ligament surgery registry: the Norwegian National Knee Ligament Registry. Am J Sports Med 36(2):308–315PubMedCrossRefGoogle Scholar
  32. 32.
    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
  33. 33.
    Gwinn DE, Wilckens JH, McDevitt ER et al (2000) The relative incidence of anterior cruciate ligament injury in men and women at the United States Naval Academy. Am J Sports Med 28(1):98–102PubMedGoogle Scholar
  34. 34.
    Hanypsiak BT, Spindler KP, Rothrock CR et al (2008) Twelve-year follow-up on anterior cruciate ligament reconstruction: long-term outcomes of prospectively studied osseous and articular injuries. Am J Sports Med 36(4):671–677PubMedCrossRefGoogle Scholar
  35. 35.
    Hashemi J, Breighner R, Chandrashekar N et al (2010) Letter to the editor: a framework for assessing the viability of proposed anterior cruciate ligament injury mechanisms. Am J Sports Med 38(7):NP3–NP7PubMedCrossRefGoogle Scholar
  36. 36.
    Hashemi J, Breighner R, Chandrashekar N et al (2011) Hip extension, knee flexion paradox: a new mechanism for non-contact ACL injury. J Biomech 44(4):577–585PubMedCrossRefGoogle Scholar
  37. 37.
    Hefzy MS, Grood ES, Noyes FR (1989) Factors affecting the region of most isometric femoral attachments. Part II: the anterior cruciate ligament. Am J Sports Med 17(2):208–216PubMedCrossRefGoogle Scholar
  38. 38.
    Hewett TE, Lindenfeld TN, Riccobene JV et al (1999) The effect of neuromuscular training on the incidence of knee injury in female athletes. A prospective study. Am J Sports Med 27(6):699–706PubMedGoogle Scholar
  39. 39.
    Hootman JM, Dick R, Agel J (2007) Epidemiology of collegiate injuries for 15 sports: summary and recommendations for injury prevention initiatives. J Athl Train 42(2):311–319PubMedGoogle Scholar
  40. 40.
    Hutchinson MR, Ash SA (2003) Resident’s ridge: assessing the cortical thickness of the lateral wall and roof of the intercondylar notch. Arthroscopy 19(9):931–935PubMedCrossRefGoogle Scholar
  41. 41.
    Kim S, Bosque J, Meehan JP et al (2011) Increase in outpatient knee arthroscopy in the United States: a comparison of National Surveys of Ambulatory Surgery, 1996 and 2006. J Bone Joint Surg Am 93(11):994–1000PubMedCrossRefGoogle Scholar
  42. 42.
    Koga H, Nakamae A, Shima Y et al (2010) Mechanisms for noncontact anterior cruciate ligament injuries: knee joint kinematics in 10 injury situations from female team handball and basketball. Am J Sports Med 38(11):2218–2225PubMedCrossRefGoogle Scholar
  43. 43.
    Kostogiannis I, Ageberg E, Neuman P et al (2007) Activity level and subjective knee function 15 years after anterior cruciate ligament injury: a prospective, longitudinal study of nonreconstructed patients. Am J Sports Med 35(7):1135–1143PubMedCrossRefGoogle Scholar
  44. 44.
    Krosshaug T, Nakamae A, Boden B et al (2007) Estimating 3D joint kinematics from video sequences of running and cutting maneuvers – assessing the accuracy of simple visual inspection. Gait Posture 26(3):378–385PubMedCrossRefGoogle Scholar
  45. 45.
    Krosshaug T, Nakamae A, Boden BP et al (2007) Mechanisms of anterior cruciate ligament injury in basketball: video analysis of 39 cases. Am J Sports Med 35(3):359–367PubMedCrossRefGoogle Scholar
  46. 46.
    Langford JL, Webster KE, Feller JA (2009) A prospective longitudinal study to assess psychological changes following anterior cruciate ligament reconstruction surgery. Br J Sports Med 43(5):377–378PubMedCrossRefGoogle Scholar
  47. 47.
    Li G, Rudy TW, Allen C et al (1998) Effect of combined axial compressive and anterior tibial loads on in situ forces in the anterior cruciate ligament: a porcine study. J Orthop Res 16(1):122–127PubMedCrossRefGoogle Scholar
  48. 48.
    Li G, Rudy TW, Sakane M et al (1999) The importance of quadriceps and hamstring muscle loading on knee kinematics and in-situ forces in the ACL. J Biomech 32(4):395–400PubMedCrossRefGoogle Scholar
  49. 49.
    Li G, DeFrate LE, Park SE et al (2005) In vivo articular cartilage contact kinematics of the knee: an investigation using dual-orthogonal fluoroscopy and magnetic resonance image-based computer models. Am J Sports Med 33(1):102–107PubMedCrossRefGoogle Scholar
  50. 50.
    Lindenfeld TN, Schmitt DJ, Hendy MP et al (1994) Incidence of injury in indoor soccer. Am J Sports Med 22(3):364–371PubMedCrossRefGoogle Scholar
  51. 51.
    Logan M, Dunstan E, Robinson J et al (2004) Tibiofemoral kinematics of the anterior cruciate ligament (ACL)-deficient weightbearing, living knee employing vertical access open “interventional” multiple resonance imaging. Am J Sports Med 32(3):720–726PubMedCrossRefGoogle Scholar
  52. 52.
    Logan MC, Williams A, Lavelle J et al (2004) What really happens during the Lachman test? A dynamic MRI analysis of tibiofemoral motion. Am J Sports Med 32(2):369–375PubMedCrossRefGoogle Scholar
  53. 53.
    Lohmander LS, Englund PM, Dahl LL et al (2007) The long-term consequence of anterior cruciate ligament and meniscus injuries: osteoarthritis. Am J Sports Med 35(10):1756–1769PubMedCrossRefGoogle Scholar
  54. 54.
    MacWilliams BA, Wilson DR, DesJardins JD et al (1999) Hamstrings cocontraction reduces internal rotation, anterior translation, and anterior cruciate ligament load in weight-bearing flexion. J Orthop Res 17(6):817–822PubMedCrossRefGoogle Scholar
  55. 55.
    Mandelbaum BR, Silvers HJ, Watanabe DS et al (2005) Effectiveness of a neuromuscular and proprioceptive training program in preventing anterior cruciate ligament injuries in female athletes: 2-year follow-up. Am J Sports Med 33(7):1003–1010PubMedCrossRefGoogle Scholar
  56. 56.
    Markolf KL, Gorek JF, Kabo JM et al (1990) Direct measurement of resultant forces in the anterior cruciate ligament. An in vitro study performed with a new experimental technique. J Bone Joint Surg Am 72(4):557–567PubMedGoogle Scholar
  57. 57.
    Markolf KL, Burchfield DM, Shapiro MM et al (1995) Combined knee loading states that generate high anterior cruciate ligament forces. J Orthop Res 13(6):930–935PubMedCrossRefGoogle Scholar
  58. 58.
    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):1144–1149PubMedCrossRefGoogle Scholar
  59. 59.
    McLean SG, Huang X, van den Bogert AJ (2005) Association between lower extremity posture at contact and peak knee valgus moment during sidestepping: implications for ACL injury. Clin Biomech (Bristol, Avon) 20(8):863–870CrossRefGoogle Scholar
  60. 60.
    Messina DF, Farney WC, DeLee JC (1999) The incidence of injury in Texas high school basketball. A prospective study among male and female athletes. Am J Sports Med 27(3):294–299PubMedGoogle Scholar
  61. 61.
    Meyer EG, Haut RC (2005) Excessive compression of the human tibio-femoral joint causes ACL rupture. J Biomech 38(11):2311–2316PubMedCrossRefGoogle Scholar
  62. 62.
    More RC, Karras BT, Neiman F et al (1993) Hamstrings-an anterior cruciate ligament protagonist: an in vitro study. Am J Sports Med 21:231–237PubMedCrossRefGoogle Scholar
  63. 63.
    Morrey MA, Stuart MJ, Smith AM et al (1999) A longitudinal examination of athletes’ emotional and ­cognitive responses to anterior cruciate ligament injury. Clin J Sport Med 9(2):63–69PubMedCrossRefGoogle Scholar
  64. 64.
    Mountcastle SB, Posner M, Kragh JF Jr et al (2007) Gender differences in anterior cruciate ligament injury vary with activity: epidemiology of anterior cruciate ligament injuries in a young, athletic population. Am J Sports Med 35(10):1635–1642PubMedCrossRefGoogle Scholar
  65. 65.
    Noyes FR, Sonstegard DA (1973) Biomechanical function of the pes anserinus at the knee and the effect of its transplantation. J Bone Joint Surg Am 55(6):1225–1241PubMedGoogle Scholar
  66. 66.
    Noyes FR, Grood ES, Butler DL et al (1980) Clinical laxity tests and functional stability of the knee: biomechanical concepts. Clin Orthop 146:84–89PubMedGoogle Scholar
  67. 67.
    Noyes FR, Grood ES (1987) Classification of ligament injuries: why an anterolateral laxity or anteromedial laxity is not a diagnostic entity. Instr Course Lect 36:185–200PubMedGoogle Scholar
  68. 68.
    Noyes FR, Barber-Westin SD, Fleckenstein C et al (2005) The drop-jump screening test: difference in lower limb control by gender and effect of neuromuscular training in female athletes. Am J Sports Med 33(2):197–207PubMedCrossRefGoogle Scholar
  69. 69.
    Noyes FR, Barber-Westin SD (2009) Anterior cruciate ligament primary and revision reconstruction: diagnosis, operative techniques, and clinical outcomes. In: Noyes FR (ed) Noyes’ knee disorders: surgery, rehabilitation, clinical outcomes. Saunders, Philadelphia, pp 140–228Google Scholar
  70. 70.
    Noyes FR, Grood ES (2009) Knee ligament function and failure. In: Noyes FR (ed) Noyes’ knee disorders: surgery, rehabilitation, clinical outcomes. Saunders, Philadelphia, pp 89–113Google Scholar
  71. 71.
    Noyes FR, Grood ES (2009) The scientific basis for examination and classification of knee ligament injuries. In: Noyes FR (ed) Noyes’ knee disorders: surgery, rehabilitation, clinical outcomes. Saunders, Philadelphia, pp 47–88Google Scholar
  72. 72.
    O’Connor JJ (1993) Can muscle co-contraction protect knee ligaments after injury or repair? J Bone Joint Surg Br 75(1):41–48PubMedGoogle Scholar
  73. 73.
    Ochiai S, Hagino T, Tonotsuka H et al (2010) Health-related quality of life in patients with an anterior cruciate ligament injury. Arch Orthop Trauma Surg 130(3):397–399PubMedCrossRefGoogle Scholar
  74. 74.
    Olsen OE, Myklebust G, Engebretsen L et al (2004) Injury mechanisms for anterior cruciate ligament injuries in team handball: a systematic video analysis. Am J Sports Med 32(4):1002–1012PubMedCrossRefGoogle Scholar
  75. 75.
    Pandy MG, Shelburne KB (1997) Dependence of cruciate-ligament loading on muscle forces and external load. J Biomech 30(10):1015–1024PubMedCrossRefGoogle Scholar
  76. 76.
    Petersen W, Braun C, Bock W et al (2005) A controlled prospective case control study of a prevention training program in female team handball players: the German experience. Arch Orthop Trauma Surg 125(9):614–621PubMedCrossRefGoogle Scholar
  77. 77.
    Petersen W, Zantop T (2007) Anatomy of the anterior cruciate ligament with regard to its two bundles. Clin Orthop Relat Res 454:35–47PubMedCrossRefGoogle Scholar
  78. 78.
    Pfeiffer RP, Shea KG, Roberts D et al (2006) Lack of effect of a knee ligament injury prevention program on the incidence of noncontact anterior cruciate ligament injury. J Bone Joint Surg Am 88(8):1769–1774PubMedCrossRefGoogle Scholar
  79. 79.
    Pollard CD, Sigward SM, Powers CM (2010) Limited hip and knee flexion during landing is associated with increased frontal plane knee motion and moments. Clin Biomech (Bristol, Avon) 25(2):142–146CrossRefGoogle Scholar
  80. 80.
    Prodromos CC, Han Y, Rogowski J et al (2007) A meta-analysis of the incidence of anterior cruciate ligament tears as a function of gender, sport, and a knee injury-reduction regimen. Arthroscopy 23(12):1320.e6–1325.e6Google Scholar
  81. 81.
    Renstrom P, Arms SW, Stanwyck TS et al (1986) Strain within the anterior cruciate ligament during hamstring and quadriceps activity. Am J Sports Med 14(1):83–87PubMedCrossRefGoogle Scholar
  82. 82.
    Salmon L, Hui C, Roe J et al (2010) Incidence and risk factors for reinjury 15 years after anterior cruciate ligament reconstruction with patellar tendon autograft. Paper presented at the annual meeting of the American Academy of Orthopaedic Surgeons, New Orleans, LA, 12 March 2010Google Scholar
  83. 83.
    Salmon LJ, Russell VJ, Refshauge K et al (2006) Long-term outcome of endoscopic anterior cruciate ligament reconstruction with patellar tendon autograft: minimum 13-year review. Am J Sports Med 34(5):721–732PubMedCrossRefGoogle Scholar
  84. 84.
    Shimokochi Y, Shultz SJ (2008) Mechanisms of noncontact anterior cruciate ligament injury. J Athl Train 43(4):396–408PubMedCrossRefGoogle Scholar
  85. 85.
    Shin CS, Chaudhari AM, Andriacchi TP (2009) The effect of isolated valgus moments on ACL strain during single-leg landing: a simulation study. J Biomech 42(3):280–285PubMedCrossRefGoogle Scholar
  86. 86.
    Sidles JA, Larson RV, Garbini JL et al (1988) Ligament length relationship in the moving knee. J Orthop Res 6(4):593–610PubMedCrossRefGoogle Scholar
  87. 87.
    Soderman K, Werner S, Pietila T et al (2000) Balance board training: prevention of traumatic injuries of the lower extremities in female soccer players? A prospective randomized intervention study. Knee Surg Sports Traumatol Arthrosc 8(6):356–363PubMedCrossRefGoogle Scholar
  88. 88.
    Standring S (2005) Gray’s anatomy: the anatomical basis of clinical practice. Churchill Livingstone, New YorkGoogle Scholar
  89. 89.
    Strickland JP, Fester EW, Noyes FR (2009) Lateral, posterior, and cruciate knee anatomy. In: Noyes FR (ed) Noyes’ knee disorders: surgery, rehabilitation, clinical outcomes. Saunders, Philadelphia, pp 20–43Google Scholar
  90. 90.
    Trojian TH, Collins S (2006) The anterior cruciate ligament tear rate varies by race in professional Women’s basketball. Am J Sports Med 34(6):895–898PubMedCrossRefGoogle Scholar
  91. 91.
    Udry E, Donald Shelbourne K, Gray T (2003) Psychological readiness for anterior cruciate ligament surgery: describing and comparing the adolescent and adult experiences. J Athl Train 38(2):167–171PubMedGoogle Scholar
  92. 92.
    Woo SL-Y, Hollis JM, Adams DJ et al (1991) Tensile properties of the human femur-anterior cruciate ligament-tibia complex. The effects of specimen age and orientation. Am J Sports Med 19(3):217–225PubMedCrossRefGoogle Scholar
  93. 93.
    Yu B, Kirkendall DT, Taft TN et al (2002) Lower extremity motor control-related and other risk factors for noncontact anterior cruciate ligament injuries. Instr Course Lect 51:315–324PubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2012

Authors and Affiliations

  1. 1.Cincinnati Sportsmedicine and Orthopaedic CenterCincinnatiUSA
  2. 2.Cincinnati Sportsmedicine Research and Education FoundationCincinnatiUSA

Personalised recommendations