PARTIAL
TEARS
OF
THE
PROGRESSION
FRANK
R. NOYES,
From
TO
LISA
ANTERIOR COMPLETE
A. MOOAR,
Cincinnati
In a prospective seven-year study, ligament (ACL) verified by arthroscopy.
we treated 32 patients Twelve knees (38%)
positive
anteroposterior
pivot
shift
tests
and increased
III,
GEORGE
the Deaconess
Hospital,
with partial progressed
translation
H. McGINNISS
Ohio
ruptures of the anterior cruciate to complete ACL deficiency with
on tests
with
the KT-1000
Patients with partial ACL tears frequently had limitation for strenuous sports, deficiency had additional functional limitations involving recreational activities. Three factors were statistically significant in predicting which partial tears deficiency: the amount of ligament tearing one-fourth tears infrequently
would develop progressed,
progressed
in 50%
anterior
occurrence
of a subsequent
and partial rupture of (ACL) and the frequently
and
three-fourth
tears
re-injury
the anterior associated
articular cartilage, and to other (Noyes et al 1980). Patients with given a rehabilitation programme These and subsequent patients
with
in 86%;
a subtle
Partial ACL years (Liljedahl, 1972; 1983).
McDaniel Small
We
cruciate injuries
limitations discover deficiency
ligament to menisci,
ligamentous structures partial ACL tears were and then followed-up. form the basis of this
(McDaniel Bachman
Lucie, Wiedel long-term study been
and Messner (Odensten,
reported
to date.
that about halfofthe injured and repaired. ligament functional
injuries outcome
1984) Lysholm That
or
operations ofa partial
should
be sent
71-B.
No.
5. NOVEMBER
I989
aimed
franslation;
to determine
of patients the frequency and
the
the
ACL tears and
factors
the
AND
and to ACL
METHODS
In all cases, was observed
movement
functional
ACL tear to complete
involved.
Criteria. During a 7.3 year period made the arthroscopic diagnosis
attempted
long-term
after a partial of progression
PATIENTS
differs
DeHaven reported
from
other 1985) ours
in
ligaments with other affect
the
Of evaluation
and
Department, 45219, USA.
Deaconess
Joint
Surgery
Hospital,
the
38 (84%),
to resist
from 1976 to 1983, we of acute partial ACL the remaining to become anterior
injury
and
all were
patients, 32 returned the others being unable
lost to follow-up. At 38 years (average 21 The injury was to the left in 17. Typically, were involved in fully days three
and
complete one-half
intact tense on
tibial
trans-
prior history of knee surgeon (FRN).
which could ACL tear.
1989 British Editorial Society of Bone 0301-620X/89/5 1 68 $2.00 J Bone Joint Surg [Br] 1989 :7 1-B :825-33.
ACL
but only one and Gillquist
to Dr F. R. Noyes.
©
arthrometer. developing
Monaco, Noble and and Osborne 1983;
1983; been
knees also had other knee We have excluded knees
F. R. Noyes, MD L. A. Mooar, BA C. T. Moorman III, MD G. H. McGinniss, MD Cincinnati Sportsmedicine Research 31 1 Straight Street, Cincinnati, Ohio Correspondence
study
those
lation. We excluded tears involving more than 75% of the ligament, in which only a few major fibre bundles were intact. All our cases had a negative pivot shift and were evaluated within six weeks of injury. None had a
1980, have
1976; Noyes et a! 1980; 1982 ; Farquharson-Roberts
in initial
tears in 38 patients. portion of the ACL
tears have been recognised for many Lindvall and Wetterfors 1965; Bassett
and Dameron series of patients
increase
while
giving-way.
report.
VOL.
and
LIGAMENT
DEFICIENCY
T. MOORMAN
Center
In 1976 we established guidelines for the arthroscopic evaluation of patients with acute traumatic haemarthrosis and in 1980, we reported the incidence of complete
has
LIGAMENT
CLAUDE
Sportsmedicine
CRUCIATE
treated
by one
for follow-up to attend or
injury, their ages ranged from 14 to .4); 28 were male and four female. right knee in 1 5 patients and to the the patients were very active; 24 competitive sports on four to seven
per week ; five in major times per week ; and
recreational sports one three in light recreational
to
sports. Mechanism ofinjury. Injury had occurred most frequently during American football (31%), basketball (16%), and baseball or softball (13%). In 26 patients, a non-contact event
involving
twisting,
turning,
orjumping
caused
the
825
F. R. NOYES,
826
injury, and 20 patients (62%) had the time. An acute haemarthrosis,
L. A. MOOAR,
felt or heard with swelling
C. T. MOORMAN
a pop at within
III,
G. H. McGINNISS
opposite normal had physiologically
knee (grade I). lax ligaments,
If the unaffected knee a one grade increase is
24 hours, had occurred in 30 knees (94%). Twenty-six patients were unable to continue their sports or activity, four had continued with mild difficulty, and two had continued without problems. Initial examination. All patients were examined under anaesthesia and graded using the system we have
shown (from a grade II normal knee). All knees that progressed to ACL deficiency are noted by a hash mark in Table I. Anterior cruciate disruption. Arthroscopic evaluation was performed at an average of 14 days after injury (Table I). An anteromedial portal was used to visualise the femoral
previously
attachment
Crood
the
described
(Noyes
1987). For the classical phenomenon
this
is shown
Table
I. Details
by
pivot
an
et al
increase
of 32 patients
l983a,b;
Noyes
shift test, grade and, in the scoring
with
in
two
partial
tears
grades
over
Follow-up (months)
Mechankm
Case 1
14M
99
Football contact
2
l4M
56
Basketball
3
17M
80
4
24M
101
5
15M
61
6
20F
84
Gymclass
of
Injury
of the
nerve hook, we removed overlying
the
was
recorded
anterior
cruciate
carefully synovium.
ligament.
Using
by : the region
ofthe
tear
(proximal,
middle-
lnstabiIIty
Injury to
Estimated
TIbio femoral
arthroscopy (days)
ACL disruption’
Menisdt
articular surfaces
Patellar surfaces
25
25 Pros
L-incomplete
N
N
(Initial
follow-up)
Lachman
PIvot shift
Lateral
I/O
1/0
0/0
in KT-1000 displacement (mm)
Post-op cast
Significant re-injuries
Additional iurglcal procedurea
-
Yes
0
None
3.75
5
25A,M. PS
N
N
N
I/I
I/I
0/0
Yes
0
None
Body surfing contact
9
IFIA.D
N
N
Softening
0/0
0/0
0/0
-0.50
No
0
None
Softball
varus
4
25A.D
N
N
Fracture
0/0
0/0
0/0
-0.25
Yes
0
None
Baseball
salgus
5
IH A. D
L-incomplete
N
N
0/1
0/I
0/0
.
No
2ADL
None
2
25A
N
N
N
0/0
0/0
0/0
1.5
No
0
None
valgus
7
IH A. M
Med-incomplete
N
N
0/0
0/0
0/0
1.25
Yes
0
None
valgus
twist
a
probed the ligament and The injury to the ligament
of an ACL
TIme from Age/ Sex
and
III denotes in Table I,
unknown 7
28M
65
Work
8
32M
34
Baseball
jumping
8
25A.Px
N
N
Fracture
0/0
0/0
0/0
4.0
No
0
None
9
20M
110
Football running
8
25A
N
N
Fissuring
0/0
0/0
0/0
I .0
No
0
None
10
28M
42
Football contact
45
25 A. Ps
Med-incomplete L-partial
LFC fracture
N
I/I
0/18
0/I
6.25
No
1 recreational
None
II
l7M
97
Soccerrunning
14
IH
L-incomplete
N
N
0/0
0/0
0/0
2.0
Yes
2 competitive
None
12
16M
24
Football
valgus
9
lH
N
Softening
Softening
0/0
0/0
0/0
-
No etc
0
None
13
19M
93
Football
valgus
5
IH A. M
L-incomplete
N
Softening
0/lb
0/18
0/0
2.25
Yes
0
None
14
16M
60
Football
twist
I I
25 A. D
MM-total
N
N
1/1
1/1
0/0
-2.50
No
0
None
IS
38F
33
Tennisjumping
39
25 A. M
N
N
Softening
I/I
0/0
I/O
-0.25
No
I recreational
None
16
16M
52
Soccer
25A.M
Med-incomplete
N
Softening
I/I
0/0
0/1
Yes
0
None
17
25M
38
Football
16
25 A. M
L-partial
LFC softening
Softening
0/0
0/0
0/0
No
I ADL
None
18
25M
78
Basketball running
37
50A.M
L-partial
N
N
I/l
1/I
0/0
2.25
No
2 recreational
None
N
N
N
I/O
0/0
0/0
0.75
Yes
S competitive
Partial medial meniscectomy
N
N
l/2#
l/2#
0/0
Yes
I ADL
valgus varus
0
A. M
19
17M
84
Football jumping
0
SOPs,Px
20
23M
37
Workjumping
2
50 A. Ps
Med-incomplete N
0.75 -0.50
-
-
ACL
reconstruction
21
22M
83
Basketball jumping
IS
SOA.M
N
Softening
1/28
l/2/
0/0
Yes
5 recreational
None
22
17M
46
Basketball falling
9
SOA.Px
N
N
N
l/2#
l/2#
0/0
5.0
Yes
Scompetitive
ACL reconstruction
23
26 M
36
50
Med-repaired through arthroscope
N
N
1/1
1/1
0/0
-
No
0
None
6
50A.M
N
N
N
O/l#
0/18
0/1
Yes
I competitive
None
3
SOAM. PS
N
N
N
0/0
0/0
0/0
No
0
None
8
75 Ant
Med-incomplete
N
N
1/28
1/28
1/0
6.0
Yes
I competitive
Arthroscopyabsent ACL. Partial medial and lateral meniscectomy
75 A. Ps
Med-repaired through arthroscope
LFC
Exposed
I/I
I/l
0/0
2.0
No
4ADL
None
fracture
bone I/I
7.25
No
6 recreational
None
Non-athletic
I2
varus 24
24 M 100
Soccercontact
25
22 M
93
Football
26
22 M
31
Basketball hyperexiension
27
34 M
32
volleyball valgus
IS
valgus
19M
87
volleyball hyperextension
56
75
Med-total
N
N
I/I
I/I
29
23M
64
Wrestling contact
It)
75 A. M
L-partial
LFC fissures
N
I/I
l/2#
I/I
5.75
Yes
3 light recreational
None
30
26F
96
Softball
8
75 A. M
Med-incomplete
MTP fissures
N
1j2#
1/I
0/0
7.0
Yes
I recreational
Partial medial meniscectomy
25
75 A. M. Ps
N
N
N
l/2#
l/2#
0/0
5.25
No
1 major recreational
None
2
75 A. M. D
N
N
N
I/I
l/2#
0/0
-
Yes
I competitive
Arthroscopy absent ACL
and
equal
28
valgus
31
SM
80
Football contact
32
l5M
56
Footballtwist
S
A anterior
fibre;
Ps posterior
estimated 25’,oftheligament; S N normal; L lateral tear;
:§
fibre.
Ps proximal
SOtearofeslimated Med medial tear
LFC lateral femoral condyle MTP Initial assessment under anaesthesia.
medial tibial Ligamentous
one-third S0’,ofthe plateau stability
.
M middle ligament;
: 0 equal
one-third
D distal
75tearofestimated
to normal
side,
one-third 75%
I one grade
lH grossly
observable
haemorrhage
25 haemorrhage
tear of fibre
-
to or less than
of the ligament
increase,
2 two
grade
increase.
conversion
THE
to ACL
JOURNAL
deficient
OF BONE
AND
JOINT
SURGERY
PARTIAL
third,
or distal);
the
fibre
bundles
TEARS
OF THE
in relationship
ANTERIOR
CRUCIATE
recognised
to the
that
tibia (anterior or posterior); and the estimated amount of gross tearing that could be observed one-fourth or less, one-half, or three-fourths. This latter estimate was not
amount of tearing the gross disruption In 17 knees
intended ligament
one-fourth within and plus partial
-
to define the exact amount may sustain microscopic
disruption
(Noyes,
DeLucas
of damage since the injury without gross
and
Torvik
1974).
We
II.
Sports
activities
scale
of the Points
Level I (participates 4 to 7 days per week) Jumping, hard pivoting, cutting (basketball, volleyball, football, gymnastics, soccer) Running, twisting, turning (tennis, racquetball, handball, baseball, ice hockey, field hockey, skiing, wrestling) No running, twisting, jumping (cycling, swimming)
100
Level II (participates 1 to 3 days per week) Jumping, hard pivoting, cutting (basketball, volleyball, football, gymnastics, soccer) Running, twisting, turning (tennis, racquetball, handball, baseball, ice hockey, field hockey, skiing, wrestling) No running, twisting, jumping (cycling, swimming)
Level IV (no Activities Activities Activities crutches,
Table
III.
sports) ofdaily living ofdaily living ofdaily living full disability
Grading
scales
without problems with moderate problems with severe problems
for limitations
Activities
of daily
Sports
living
I Straight
Normal, unlimited Some limitations Smooth surface OK up to I mile Only 3 to 4 blocks possible Less than one block, cane, crutch
2
50 40 30 20 0
65 60
55
g 0
of function
).
Stairs
Normal. Some Only Only Only
2 Short
unlimited limitations 20 to 30 steps possible 10 to 19 steps possible I to 9 steps possible
50 40 30 20 0
3 Squatting/kneeling
sprints,
stops
3 Jumping/landingon
Normal. unlimited limitations Only 6 to 10 possible Only 0 to 5 possible Notable
50 40 30 20 0
Some
Fully competitive Some limitations, Definite limitations, Affects all sports, Notable 4 Hard Fully Some
limitations,
Affects all sports, Not able
71-B. No.
5,
NOVEMBER
1989
and
80 70 60 50
starts
affected
100 80 70 60 0
leg
100 guarding halfspeed constantly
twists/cuts/pivotson competitive limitations,
Definite
VOL.
100
Fully competitive Some limitations, guarding Run half-speed, definite limitations Only able to do a few per game Not able
80 70 60 0
guards
affected
leg
100 guarding avoids constantly
at times guards
of approximately one-half (cases 26 to 32) had tearing
ligament,
but
the
remaining
of the ligament. of three-fourths
portion
still
resisted
anterior tibial translation at arthroscopy. Meniscal tears. There was a tear of one or both menisci in 17 of the 32 knees (53%) (Table I), involving the
with grade the patella.
80 70 60 0
in nine, in one.
the lateral meniscus in seven, Surgery for the meniscal tear
IV. Two patients had Four knees showed
chondral lesions
of
fractures of the lateral
femoral condyle : one with grade I changes, one with grade II and two with chondral fractures. Initial treatment and rehabilitation. All patients had a standard rehabilitation programme designed to protect the partial tear. We used a ‘4-4-4-4’ programme, which allows a graduated return to activities over 16 weeks. During the first four weeks the patient is allowed partial weight-bearing with crutches. A cast was used in 16 cases and a soft compression dressing and/or splint in the others. The weight-bearing,
second four-week weaning from
of walking.
The
third
four-week
period involves crutches, and period
increased resumption
includes
gradu-
ated strengthening exercises, but we do not allow terminal quadriceps extension exercises, heavy weights, or the use of high-resistance exercise machines in the OO to 30#{176} knee flexion range in order to diminish forces potentially injurious to the ACL (Paulos et al 1981 ; Grood et al 1984). return
activities running
Fully competitive Some limitations, guarding Run half-speed. definite limitations Only I to 2 blocks possible Not able
of
was performed in eight cases (25%). Articular cartilage. We used the criteria of Outerbridge (1961). Eleven knees (34%) had lesions of the patella; seven with grade I changes, one with grade II, and three
Points
I Walking
the
90
75
Points
to estimate
medial meniscus and both menisci
85
-
difficult
in this way, but direct visualisation remains the only means available. (cases 1 to 1 7, Table I) we estimated
95
80
Level III (participates 1 to 3 times each month) Jumping, hard pivoting, cutting (basketball, volleyball, football, gymnastics, soccer) Running, twisting, turning (tennis, racquetball, handball, baseball, ice hockey, field hockey, skiing, wrestling) No running, twisting, jumping (cycling, swimming)
it is sometimes
or less of tearing (interstitial haemorrhage about the ligament fibres in six, haemorrhage tearing in 1 1 Eight knees (cases 1 8 to 25)
had tearing Seven knees Table
827
LIGAMENT
During the to athletics
final with
four-week running
period there is gradual and sporting activities at
first oflow intensity. Follow-up evaluation. Symptoms of pain, swelling, giving-way were recorded in relation to the activity (Noyes et al 1983a). The objective portion of the
and level rating
system is composed of the physical examination of the knee (Noyes et al 1983), and the classification of ligament defects and joint subluxations (Noyes and Grood 1987). A sports activity rating scale ranging from level I (frequent strenuous sport) to level IV (no sport) was used to analyse the level ofsports participation (Table II), and activities of both daily living and sport were analysed according Compliance
to a five-level gradient to the prescribed
assessed by questionnaire Problems with sport patients moderate,
to estimate or light
(Noyes were
ofdifficulty (Table exercise programme et al l983a). assessed by
their ability to perform intensity sport for one
asking
III). was the
a strenuous, hour without
F. R. NOYES,
828
L. A. MOOAR,
C. T. MOORMAN
III,
G. H. McGINNISS
ACL-Functlonal
_
ACL-Deflciont
61% 0
I (1)118)
10
0
.0
E z
One-fourth Tear or Less
Equd
Three-fourths
One-hoW Tear
Initial ACL Tear Fig. The relationship between between the inital grading deficiency.
Anterior
in different
One Grade
No
Translation Fig.
Yes
I
types
of sport
We (p-
0
C
0.00 1).
RESULTS 2
The
time
from
initial
injury
to final
67 months (range 24 to 1 10). Twelve had progressed to ACL deficiency established. The average follow-up deficient group was 68 months (range the ACL-functional group, 65 months
follow-up
3
5
1
2
3
5
averaged
of 32 knees (38%) by the criteria we time for the ACL31 to 105) and for (range 24 to 110).
Year
From Fig.
Cumulative numbers and percentages way in functional and deficient groups injury.
THE
JOURNAL
Initial
Injury
4 of re-injury episodes with givingrelated to years from the initial
OF BONE
AND
JOINT
SURGERY
PARTIAL
. . . .
Torn
75%
50%
g
Torn
TEARS
OF THE
ANTERIOR
0
.
..
of activity category,
0
0
p
8 25%
or
Less
that
0
#{149}
0
Torn
80
Haemorrhage within Ligament
AOL-Functional
.
AOL-Deficient
these
0 0
0
1
2
Number
tomy,
the
3
4
5
6
of Reinjuries
5
estimated
extent
of
statistically
significant
the
tear
and
the
to
the
scaled in Figure daily living score
injury
to the first
rehabilitation
programme,
work
significant
giving-way
re-injury
for both
and the average number was statistically higher for the ACL-deficient group (2.2 ; range 0 to 6) than for the ACLfunctional group (0.85; Nine patients had one
range 0 to 5) (t-test, re-injury, five had
four, and four patients had could not determine when deficient knee had occurred,
p
