The Knee 14 (2007) 339 – 347

Review
MR imaging of acute anterior cruciate ligament injuries
Darren Klass a,⁎, Andoni P. Toms a , Richard Greenwood a , Philip Hopgood b
a
Department of Radiology, Norfolk and Norwich University Hospital, Colney Lane, Norwich, NR4 7UY, United Kingdom
b
Department of Trauma and Orthopaedics, Norfolk and Norwich University Hospital, Colney Lane, Norwich, NR4 7UY, United Kingdom

Received 7 February 2007; received in revised form 21 April 2007; accepted 23 April 2007

Abstract

MRI of the knee has become an indispensable clinical tool in the management of chronic knee conditions. MRI for acute knee injuries is
less well established but is becoming increasingly prevalent. MRI in acute ACL injuries is particularly useful for identifying associated
injuries that will influence the early management of the patient. The aim of this paper is to describe the MRI findings of acute ACL tears,
their commonly associated, and less common but serious associated injuries. Where available, the evidence for the sensitivity and specificity
of these MRI features is presented. The contribution of these MRI findings to the management of the patient is discussed.
© 2007 Elsevier B.V. All rights reserved.

Keywords: ACL; Anatomy; Associated injury; Direct signs; Indirect signs; MRI; Open MRI; Postero-lateral corner

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 340
339
2. MRI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 340
2.1. MRI hardware . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 340
2.2. MRI protocol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 340
2.3. MR sequences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 340
2.4. T1 weighted (T1W) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 340
2.5. T2 weighted (T2W) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 341
2.6. Proton density (PD) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 341
2.7. T2⁎ gradient echo sequence (T2⁎GRE) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 341
3. The normal ACL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 341
4. Injured ACL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 342
4.1. Direct MRI signs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 342
4.2. Indirect MRI signs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 343
4.3. Indirect signs include . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 343
4.4. Partial tears . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 344
4.5. Associated injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 345
5. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 346
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 346

⁎ Corresponding author. Radiology Academy, Cotman Centre, Norfolk and Norwich University Hospital, Colney Lane, Norwich, NR4 7UB, United Kingdom.
Tel.: +44 1603286140; fax: +44 1603286146.
E-mail address: [email protected] (D. Klass).

0968-0160/$ - see front matter © 2007 Elsevier B.V. All rights reserved.
doi:10.1016/j.knee.2007.04.008
340 D. Klass et al. / The Knee 14 (2007) 339–347

1. Introduction Open MRI was developed in an attempt to eliminate some

of the claustrophobia and anxiety associated with traditional
MRI of the knee has been a clinical tool for twenty years “closed” bore MRI [53]. One of the drawbacks with open
and has been widely available in developed countries for MRI has been many of them have low magnetic field
fifteen years [2,23]. The sensitivity and specificity of knee strengths (0.2 T), and therefore the problems with ultra-low-
MRI for anterior cruciate ligament (ACL) injury is high, with field MRI remain, despite increased patient tolerance.
sensitivities and specificities of 90–95% and 95–100% Manufacturers today have largely overcome this problem,
respectively quoted in the literature [2,5,9,14]. The role that by designing “large bore” scanners (Magnetom Espree®,
MRI plays in the diagnostic algorithm varies from clinician Siemens Medical, Munich, Germany). While maintaining
to clinician, often owing to the accuracy of clinical exam- the high field strength (1.5 T), more room is now available
ination [16,41,43,56,57]. In the UK it is not common around the patient's head. The “open” bore MRI scanner
practice to perform MRI in suspected acute ACL tears but combines an increased inner bore diameter (70 cm), and a
anecdotally this practice is increasing in prevalence. In shorter bore length (125 cm), thus allowing the patient's
patients with major knee trauma, in whom the knee is very head to remain out of the bore during many examinations.
swollen and the plain radiographs are normal, MRI may This development, combined with an ultra-high field magnet
significantly contribute to the management of the patient overcomes common imaging problems associated with MRI,
[9,26]. Although, for most patients, an ACL tear does not such as patient anxiety and claustrophobia.
need to be reconstructed in the acute setting [9], associated
injuries such as trabecular fractures, peripheral meniscal or 2.2. MRI protocol
collateral ligament tears, or capsular ruptures may alter the
immediate management [2,5,24,29,34,50]. Most authorities consider that at least one sequence in
The aim of this paper is to describe the MRI findings of each principle orthogonal plane is mandatory [2,5,22,31].
acute ACL tears. Some associated injuries which have not Two sequences are typically prescribed in the sagittal plane
been previously illustrated, that may be useful in the early and extra sequences are commonly employed if there is a
management of acute ACL tears are also presented. Al- history of previous surgery. Each plane is optimal for
though the role of MRI in managing acute ACL tears is still evaluation of separate structures, and so the planes should be
the subject of debate, this paper presents the potential use orientated to the joint rather than the patient.
and limitations of MRI in this role. Images of the knee are typically obtained in the axial,
oblique sagittal and oblique coronal planes [13,26,42]. Axial
2. MRI images extend from the quadriceps tendon, proximal to the
epicondyles to the patella tendon tibial insertion [26]. Oblique
2.1. MRI hardware coronals are prescribed from the axial images, extending from
the patella anteriorly to the posterior musculature. They are re-
Most authorities consider that optimal knee MRI requires a orientated parallel to a line drawn through the epicondyles. The
superconducting magnet of 1 to 1.5 T field strength and a oblique sagittals are prescribed from the axial images and
dedicated knee coil [53], but things are changing fast on two orientated at 90° to the coronal images, and extend from the
fronts. The standard MR platform for many new installations medial to lateral subcutaneous tissues, just beyond the col-
has a 3 T field strength which has superior signal to noise ratios lateral ligaments [26].
when compared with 1 or 1.5 T. This allows either reduced
examination times or improvements in spatial resolution [54]. 2.3. MR sequences
There are however, safety concerns for patients, higher field
strengths cause increased energy deposition in tissue. This Sequences employed to image the knee vary from insti-
may be four fold higher at 3 T than at 1.5 T, which is being tution to institution depending on the hardware, strength of the
evaluated. particular imaging system and experience of the radiologist.
Despite these caveats there is emerging evidence that 3 T In general, fast spin-echo (FSE)[6,17], proton density and
MRI may produce superior soft tissue contrast in the muscu- FSE fat suppressed T2-weighted images are used to diagnose
loskeletal system [54]. internal derangements of the knee. Images without fat sup-
Conversely there is a drive to develop cheaper MRI ma- pression are used to delineate anatomy [26]. Most centres
chines with smaller footprints that do not require expensive acquire thin 3–4 mm slices in each plane [2,22,24,28,29].
builds to accommodate them. Extremity magnets at 0.5 to 1 T The following is an outline of the principle's uses of each of
field strengths are now widely available and are particularly the commonly used sequences.
suited to imaging peripheral joints such as the knee [2,21]. A
recent study comparing a 0.2 T to a 1.5 T MR scanner showed 2.4. T1 weighted (T1W)
no significant difference in diagnostic performance, the only
drawback was an increased scan time for the 0.2 T machine by Fat is high signal and fluid is low signal on this sequence
15 min [4]. which is often considered to be the optimal sequence for soft
 D. Klass et al. / The Knee 14 (2007) 339–347 341

contusions and fractures can also be seen using a fat sup-

pression sequence [2,5,22].

2.6. Proton density (PD)

The signal generated by PD sequences depends princi-

pally on the number of protons within tissue. They are
sensitive for tears and degenerative changes in the menisci
[26] and therefore are commonly used in conjunction with
T2W fast spin-echo and fat suppressed sequences for the
assessment of the menisci [22,26].

2.7. T2⁎ gradient echo sequence (T2⁎GRE)

This sequence is also considered to be very sensitive for

Fig. 1. Sagittal fat saturated proton density MR image through the lateral aspect meniscocapsular disease and therefore is usually employed
of the intercondylar notch demonstrating a normal low signal (black) antero-
to examine the meniscus at the periphery [22]. The use of
lateral ACL bundle which parallels Blumensaat's line (arrowhead). At the end
the bundles split and fan out in to the tibial insertion (arrow). T2⁎ GRE with 3D acquisition has been evaluated for
diagnosing ACL tears [5]. This was found to be slightly less
accurate than routine spin echo sequences [5].
tissue anatomy [26]. Fat provides a contrasting high signal
background to the low signal ligaments and tendons and 3. The normal ACL
intermediate signal muscles. It is essential in acute major
knee trauma as it is the most sensitive sequence for Starting with the sagittal sequences, the normal ACL
demonstrating trabecular fractures [5], which appear as low appears as a band comprising low signal lines which parallel
signal linear structures against the high signal of marrow fat. the anterior wall of the intercondylar notch (Blumensaat's
line); inclined to about 55° from the tibial plateau [2,5], usually
2.5. T2 weighted (T2W) over two consecutive slices in the mid-sagittal plane [2]. When
these appearances are seen an intact ACL can be inferred. As
T2W sequences are sensitive to fluid which is high signal. the ACL fans out to its tibial attachment, individual fibre
Fat is also high signal on T2W and therefore some form of fat bundles of the ligament can be seen, with alternating increased
signal suppression (spectral fat saturation or STIR) is and decreased signal intensities [2,5] (Fig. 1).
required to demonstrate bone marrow oedema and oedema When the appearances are abnormal this can be for two
in subcutaneous fat [22]. T2W images, including fat reasons; the plane of the sagittal slice is not parallel with the
suppressed sequences highlight ligamentous oedema and ACL or the ACL is abnormal. The coronal (Fig. 2) and axial
haemorrhage in collateral ligaments in the coronal plane, and
cruciate ligaments in the sagittal plane. Trabecular bone

Fig. 3. Axial fat saturated T2 weighted MRI demonstrating the antero-

medial (grey arrow) and postero-lateral (arrowhead) low signal bundles of
Fig. 2. Coronal PD/T2 weighted image demonstrating the two bundles of the the ACL just distal to their attachment to the lateral femoral condyle. The
ACL which can be identified as separate medial and lateral low signal lines femoral insertion of the PCL is seen in the medial aspect of the intercondylar
(arrow). notch (white arrow).
342 D. Klass et al. / The Knee 14 (2007) 339–347

(Fig. 3) images are then examined. In each of these planes

the antero-medial (AMB) and postero-lateral bundles (PLB)
can be identified separately as low signal linear structures
which progress from postero-superior to antero-inferior in
equally spaced increments from femoral to tibial insertion.
Slightly inhomogeneous signal intensity may be seen in the
normal ligament [2], this may be due to the altering tensions
of the cruciate ligaments through the arc of motion [49]. The
change in water content is thought to be responsible for this
[49]. MR examinations of the knee have traditionally been
performed with the knee in extension [11,22,26,27], but
recent studies looking at the knee MRI in slight flexion have
shown this to be superior in delineating the entire length of
ACL [11,27]. If the knee is flexed the signal intensity of the
ACL decreases [2,22,49]. The normal PLB may be of
intermediate signal intensity on T1W images [22] (This is
thought to be due to the differing tensions placed on the
bundle fibres of the ligament.). At the femoral insertion the
two bundles are closely approximated and at the tibial
insertion they flare out [2,5,22].

4. Injured ACL

4.1. Direct MRI signs

The appearances of the acutely torn ACL are variable but

there are a number of recognised patterns.
Common findings include:

1. A well-defined mass filling the intercondylar notch

replacing the well-defined band-like structure of the
ACL [2,5,15,22,25,26,28]. The mass comprises high Fig. 5. A. Sagittal T2W Fat Saturated Image (FSI) showing an anterior
signal, indicating fluid and haemorrhage which may be translocation of the femur on the tibia. The “Anterior Draw Sign” is present
confined to an intact synovial sheath [18,19,29]. when the posterior tibial border is more than 5 mm anterior to a
However all fibrillar structures are absent [29]. The perpendicular dropped from the posterior aspect of the femoral condyle.
B. A line drawn at an angle of 45° to the posterior superior end of Blumensaat's
margins of the lesion are typically convex and ill- line does not intersect with the flat portion of the tibial plateau indicating
defined (Fig. 4). anterior tibial translation.

2. The ACL may be poorly demonstrated or not demon-

strated at all on sagittal images [22,29] (Fig. 5B).
3. The ACL may be discontinuous [22]. Damage to the
ligament seen on one slice may indicate a possible complete
tear, partial tear or intrasubstance tear. This seen alone is not
sufficient to diagnose an ACL tear. Review of the images in
other planes is required to confirm the diagnosis.
4. The linear low signal of the AMB and PLB may still be
present, apparently in continuity from the tibial to femoral
insertion. ACL disruption on axial and sagittal images, and
failure of the ACL fascicles to parallel Blumensaat's line
are a primary and accurate sign of a ligament tear. Increased
signal intensity on T2, or T2⁎ GRE sequences may also be
seen at the femoral attachment of the ACL [22,28–30].
Fig. 4. Sagittal gradient echo MRI demonstrating high signal replacement of
the ACL (arrow) in a complete tear. The proximal ACL remnant can be seen There are less common patterns of ACL tears. The ACL
falling away from Blumensaat's line (arrowhead). may avulse cleanly from bone with relatively little disruption
 D. Klass et al. / The Knee 14 (2007) 339–347 343

are normal synovial recesses around the ACL and PCL in

which the synovial fluid must be distinguished from free
fluid of recent trauma.

4.2. Indirect MRI signs

Indirect signs of an ACL tear are those appearances which

result as a consequence of the ACL tear alone and not
features of associated injuries. These findings can be helpful
in diagnosing an ACL tear but cannot be used in isolation.
They cannot be used to diagnose a tear in the absence of any
of the direct signs described above [28].

4.3. Indirect signs include

Fig. 6. Sagittal T2 MRI through the patella ligament. Anterior translation of 1. Anterior subluxation of the tibia relative to the femur,
the tibia has caused buckling of the patella tendon (arrowheads). The high
“The Draw Sign”.
signal foci within the tendon occur because the collagen fibres are aligned at
55° to the axis of the magnetic field. This is called the “magic angle” effect This can be demonstrated on mid-condylar sagittal
and should not be confused with a tendon tear. images. The femoral condyles translate posteriorly
relative to the posterior margin of the tibia, by more
to the main body of ACL fibres. These injuries are difficult to than 7 mm [2,22,29,30]. In a normal knee the line is
appreciate on the sagittal sequences [31]. Occasionally the drawn from the posterior cortex of the medial or lateral
proximally torn ACL may adhere to the PCL thereby femoral condyle to pass within 5–7 mm of the posterior
maintaining its gross alignment on the sagittal sequences. In cortex of the tibia [29,30,32] (Fig. 5A). An “uncovered
both these scenarios the diagnosis may be made in the axial lateral meniscus” sign has also been described as a sign of
or coronal planes [31]. increased anterior tibial shift. Relative posterior displace-
A disrupted ACL with a small oedematous focus is also a ment of the lateral meniscus, compared to the tibia,
common presentation of an acute ACL tear. The axial plane regarded as positive if the line intersects the meniscus but
is used to identify sites of tears corresponding to the AMB not the tibia [28].
and PLB. Fluid signal in the proximal ACL, at the insertion 2. Buckled PCL
into the lateral femoral condyle is a common finding in ACL A buckled PCL is defined as when any segment of the
ruptures in skiers [22]. PCL is concave posteriorly [2,28–30].
The axial and coronal planes are especially useful for Both the femoral and tibial insertions of the PCL are often
differentiating femoral avulsion of the ACL and lesser degrees visualised on a single sagittal image. The curve of the
of sprain injury from the more typical midsubstance rupture. PCL can be quantified by constructing a line from the
The torn ligament is often obviously interrupted and anteriormost insertions of the ligament on the tibia and
associated with fluid and haemorrhage [2,8,22,29,30]. There

Fig. 8. Sagittal fat saturated PD weighted MRI demonstrating high signal

Fig. 7. Axial fat saturated T2W MRI demonstrating the presence of only a within the posterior horn of the lateral meniscus (arrow). The high signal
single ACL bundle (arrow) in a partial thickness ACL tear. Compare this extends to the superior and inferior articular surfaces indicating a vertical
image with Fig. 3. tear at the junction of the middle and outer thirds.
344 D. Klass et al. / The Knee 14 (2007) 339–347

one paper in the literature, however this sign has a low

sensitivity of 54% as quoted by the authors [29].
5. The posterior femoral line
When positive a line drawn at 45° from the postero-
superior corner of Blumensaat's line fails to intersect the
flat portion of the proximal tibial surface. Or failure of the
line to intersect a point within 5 mm of its posterior
margin [22,29] (Fig. 5A and B). This sign was found to be
accurate and reliable for the detection of instability
secondary to an ACL tear [29].
6. Buckling of the patella tendon [29,40] (Fig. 6)
Tears of the ACL and subsequent anterior translation of
the tibia decrease the angle of insertion of the patellar
tendon on the tibial tubercle, causing shortening of the
patella–tibial tubercle distance [40]. A relatively fixed
patella with anterior tibial translation may cause buckling
of the patella tendon [40].

4.4. Partial tears

Partial tears of the ACL are notoriously difficult to detect

[20,22,48,51]. Subtle increased signal intensity in the
substance of the ACL is often the only sign [18,20], but
this in isolation may be unreliable [19]. Designation of
specific AMB or PLB tears is often impossible. Although the
bulk of the ligament looks intact, there may be a slight
angulation at the sight of fibre disruption [20,22,47].
The diagnosis of complete or partial tears has an influence
on management [18,19,33,52]. Dowdy et al. [48] concluded
that a positive MRI for an ACL tear combined with a normal
arthroscopy did not necessarily represent a false positive
MRI and that an intrasubstance tear may be present which is
Fig. 9. A. Coronal PD MRI demonstrating a grossly intact but thickened and
ill-defined MCL (arrow) indicating a partial thickness tear. The MCL is
difficult to detect with arthroscopy. Umans et al. [33] con-
surrounded by low signal material (oedema and fibrosis) where high signal cluded that MR alone was inadequate for diagnosis, and re-
fat should be. B. Coronal T1W MRI demonstrating a complete avulsion of commended arthroscopic correlation. The authors did admit
the MCL from the tibial insertion (arrow).

femur, and measuring perpendicularly to the undersurface

of the PCL. These two values are then divided to give a
PCL curvature. [28]. The normal value being less than
0.21 and an abnormal value greater than 0.42 [28].
3. The posterior PCL line
This is the failure of a line drawn along the posterior PCL
on sagittal images to intersect the medullary cavity within
5 mm of the distal femur [28,29,41]. This change in
orientation of the PCL was originally thought to be solely
due to anterior translation, but direct trauma to the ACL is
too, thought to contribute [41]. The ACL and PCL are
functionally related in a complex mechanism; a change in
the PCL orientation may also therefore be due to a change
in the ACL fibre orientation [41].
4. The coronal PCL sign Fig. 10. Coronal PD/T2W MRI demonstrating a complete tear of the fibula
collateral ligament (white arrow) which has been displaced laterally by the
This is present when the whole of the PCL is observed on underlying joint effusion in which lies the popliteus tendon (black arrow). A
a single coronal image [29]. This is a consequence of partial thickness tear of the myotendinous junction of the popliteus tendon
anterior tibial translation, and has only been described in has stretched popliteus allowing for the displacement.
 D. Klass et al. / The Knee 14 (2007) 339–347 345

present with some detectable fibrillar pattern but overall

the ACL is thickened and there is often high signal
throughout the ligament. In these cases it is difficult to
determine how much functional ligament remains intact.

4.5. Associated injuries

Injuries that commonly occur in association with ACL

tears include medial and lateral meniscus tears [1,12,25,
44–46,55] (Fig. 8), tears of the MCL [8] (Fig. 9A and B) and
postero-lateral corner structures [7,10,34–37] (Fig. 10).
The MR imaging of these injuries has already been well
described.
There are two associated injuries which have received less
attention in the medical literature. These are capsular rupture
Fig. 11. Axial T2W MR image demonstrating the high signal of synovial and trabecular fractures. Demonstrating them early with MRI
fluid and blood within the knee joint communicating with the subcutaneous
can influence the early management of the ACL injury.
fat through a breach (arrow) in the medial capsule.
Capsular rupture, although uncommon, usually indicates
major knee trauma due to transient dislocation [5,8,22]. This
that the study was limited by its small size and heterogenous
MR imaging technique.
Partial thickness ACL tears may be diagnosed using the
following intrinsic ACL abnormalities seen on MR.

1. Disruption of the ACL fascicles [22]. Disruption of

fascicles is often the only sign of intrasubstance tear. The
diagnosis can be made by identifying discontinuity in
either the AMB or PLB. The axial images are of the most
helpful for this.
2. Focal oedema or focal thickening in the ACL may indicate
a partial tear [29]. This presents as focal high signal on T2W
and low signal T1W images.
3. Diffuse thickening of the ACL because of fascicle dis-
ruption [29] (Fig. 7). The general form of the ACL may be

Fig. 12. Sagittal fat saturated T2W MRI demonstrating high signal in the
bone marrow of the lateral femoral condyle and the postero-lateral tibial Fig. 13. Coronal MRI of the femoral condyles. The two images demonstrate
plateau where is abuts the articular surface. The high signal has an ill-defined the importance of using T1W images in acute trauma. The PD/T2W image
margin typical of oedema. The epicentre of the oedema indicates the site of (A) demonstrates normal bone marrow but the T1W (B) image in the same
impact; the deepened terminal sulcus of the lateral femoral condyle and the position clearly demonstrates the irregular low signal lines of impacted
posterior margin of the tibial plateau. trabecula fractures (arrow).
346 D. Klass et al. / The Knee 14 (2007) 339–347

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