THE function of the anterior cruciate ligament (ACL) is to provide stability to the knee and minimize stress across the knee joint. It restrains excessive forward movement of the tibia in relation to the femur. It also limits rotational movements of the knee. A hard twist or excessive pressure on the ACL can tear or rupture the ligament, resulting in high levels of short-term disability and extensive rehabilitation. The cost of treatment & rehabilitation of an ACL injured person is also phenomenal.

1. Risk of Anterior Cruciate Ligament Rupture With Generalized
Joint Laxity Following Trauma

2. Original Article
RISK OF ANTERIOR CRUCIATE LIGAMENT RUPTURE WITH GENERALIZED
JOINT LAXITY FOLLOWING TRAUMA
Raju Vaishya* and Rohit Hasija**
*Senior Consultant, **Registrar, Department of Orthopaedics & Joint Replacement Surgery, Indraprastha Apollo
Hospitals, Sarita Vihar, New Delhi 110 076, India.
Correspondence to: Dr Raju Vaishya, *Senior Consultant, Department of Orthopaedics & Joint Replacement
Surgery, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi 110 076, India.
Anterior Cruciate Ligament (ACL) tears are very common sport injuries. Increased joint laxity has been found
to be one of the most important contributory factors in causation of ACL tears.
Key words: Anterior cruciate ligament, Joint laxity, ACL injury.
A detailed clinical history was obtained, with especial
emphasis on the mode of injury, prior to clinical
examination. All patients presented to us with history of
trauma. The mode of injury was mostly due to sports
(66.6%), followed by injuries sustained in a Road Traffic
Accident (21.8%), domestic falls (11.6%) (Fig.1). The
diagnosis was confirmed by MRI and all ACL tears
confirmed by arthroscopy prior to reconstruction. We had
prospectively assessed the degree of joint laxity in all the
patients with a symptomatic ACL injury before they
underwent reconstruction.
INTRODUCTION
THE function of the anterior cruciate ligament (ACL) is to
provide stability to the knee and minimize stress across the
knee joint. It restrains excessive forward movement of the
tibia in relation to the femur. It also limits rotational
movements of the knee. A hard twist or excessive pressure
on the ACL can tear or rupture the ligament, resulting in high
levels of short-term disability and extensive rehabilitation.
The cost of treatment & rehabilitation of an ACL injured
person is also phenomenal.
Chronic ACL insufficiency can cause damage to the articular cartilage & hence these patients are prone to developing
early degenerative arthritis, menisci tears [1] and stretching
of secondary stabilizers like collateral ligaments etc.
All had their laxity scored by Beighton’s criteria. In this
method, the following ranges of motion are assessed: (i)
passive hyperextension of fifth metacarpophalangeal joint,
1 point for each joint beyond 90º; (ii) thumb apposition to
the volar aspect of the forearm, 1 point for each thumb
touching the arm, active hyperextension of the elbow, 1
point for each joint beyond 10º; (iii) active hyperextension
of the knee, 1 point for each joint beyond 10º; (iv) trunk
Many intrinsic & extrinsic causes have been associated
as risk factors for ACL tears [2] like excessive athletic
demands placed on unconditioned knee, knee flexion angle
whilst landing, limb alignment, notch size, hormonal
fluctuations, muscle strength & generalized joint laxity.
Sports 66%
Recently, joint laxity have been implicated as an
important contributory factor in the causation of ACL
injuries, especially in females [3], those with generalized
joint laxity and hyperextension of the knee [4].
MATERIALS AND METHODS
We performed 110 ACL reconstructions between 2000
and 2006 in our hospital, using Patella Bone Tendon Bone
(PBTB) autografts. There were 65 men and 45 women,
whose ages ranged between 20 and 36 years (mean 24.6
years). They presented to us for ACL reconstruction after a
mean duration of 11 months (range: 3 to 18 months) after the
primary injury.
Domestic falls 12%
Road traffic accidents
Fig.1 Mechanisms of injury.
13
Apollo Medicine, Vol. 6, No. 1, March 2009

3. Original Article
have higher rates of ACL injury than men [6]; the reason for
this is unknown. After following up 139 professional
football players, Nicholas [7] concluded that laxity of the
joint predisposes to ligament injuries. Godshall [8]
disagreed, in a series of ‘growing’ athletes, and Moretz,
Walters and Smith [9] concluded, in a series of 155 football
players, that laxity did not predispose to ligament injuries.
However, Boden, et al [10] showed a strong correlation
between hamstring flexibility and ACL rupture after
analyzing data from 100 ruptures. At the Hunt Valley
consensus conference for the prevention of non-contact
ACL injury, it was judged that the relationship between ACL
ruptures and joint laxity remained unresolved [2]. Ramesh
[4] and colleagues found that ACL injury was more frequent
in those patients with greater overall joint laxity, specifically
those with increased knee joint laxity. In our study, the high
number of patients with ACL tears had generalized joint
laxity (92.7%). It is recognized that the Asian and Oriental
population have more lax joints than European and
American population [11-13].This might have been the
factor responsible, as all of our patients were Indians.
flexion with knees straight, 1 point when hand palm flat on
floor. The maximum score is 9 points. It wasaccepted that an
individual is considered “hypermobile” when at least 4
maneuvers exceed the predetermined range.
Our control group comprised 55 individuals matched
for age and gender with no known ACL-related problems or
those attending our OPD but who had no knee symptoms.
The laxity scores were determined in these individuals.
RESULTS
In our prospective cohort study it was found that more
than 92.7 % (102 out of 110) of our patients, with ACL
injuries, have significant joint laxity i.e., score of more than
4/9, compared to only 16.4% in the control group. There
was no significant sex predominance found in this study.
This difference was statistically significant (p<0.05).
Hyper-extension of the affected knee was present in all
patients with significant joint laxity. A non-contact
mechanism of injury was more common in patients of both
groups with ACL injury (Table 1).
DISCUSSION
Nothing can be done to change ligament laxity, but
certain training techniques may help reduce athletes’ risk of
ACL tears – something that might be especially important
for those with greater laxity in the knee joint. There is
enough evidence that neuromuscular training programmes
are effective in increasing performance and preventing
injuries in atheletes [14,15]. For example, learning how to
land from a jump with proper alignment, and not in a
“knock-kneed” position, may help prevent ACL injuries. In
addition, strengthening the hamstring muscles, which help
stabilize the knee joint, appears particularly important.
ACL injury is common amongst young athletic
individuals. Some are more predisposed to have it
compared to others. Various instrinsic & extrinsic factors
have been suggested to contribute to these injuries.
Amongst all the extrinsic factors, joint laxity is now being
recognized as one of the most important risk factors in the
causation of ACL injuries. Ramesh [4] in his study did
highlight hyperextension of knee and physiological joint
laxity as contributing factor to ACL injuries. However no
validated method for the screening and identification of
athletes at greater risk of ACL injury based on joint laxity
has previously been available. We used a simple clinical
method of Beighton [5] to check & quantifiy the joint laxity.
Beighton’s method is quick to perform and has been well
established in the literature. In our study, we have been able
to provide statistically significant evidence to support the
association between generalized joint laxity and ACL
rupture.
We suggest that all the athletes should be screened for
generalized joint laxity based on Beighton’s criteria. If the
score >4/9, they should undergo proper counseling to
prevent these injuries and supportive orthosis, muscle and
joint proprioception training to prevent ACL tear. Further
research into the proposed theory relating to this
musculoskeletal problem is warranted for intervention and
possible prevention of ACL injuries in athletes which can
help in decreasing the number and thus the cost associated
with treatment and rehabilitation of patients with ACL
injuries.
Previously published data indicate that women who
participate in sports or who are otherwise physically active
REFERENCES
Table 1: Clinical profile of patients
1. George AC, Sirish Maddali, Lois Horovitz. The effects of
time course after anterior cruciate ligament injury in
correlation with meniscal and cartilage Loss. Am J Sports
Med. 2001; 29(1):9-14.
Study group Control group
Total number of patients
Male:Female
Patients with Generalised
Ligament Laxity Score >4/9
110
55
65:45
34:21
102
9
Apollo Medicine, Vol. 6, No. 1, March 2009
2. Griffin LY, Agel J, Albohm MJ, et al. Noncontact anterior
cruciate ligament injuries: risk factors and prevention
strategies. J Am Acad Orthop Surg 2000; 8:141-150.
14

4. Original Article
knee injuries in college football players. Phys Sportsmed
1982; 10: 93-97.
3. Gregory D Myer, Kevin R Ford, Mark V Paterno. The effects
of generalized joint laxity on risk of anterior cruciate
ligament injury in young female athletes. The American
Journal of Sports Medicine 2008;36:1073-1080.
10. Boden BP, Dean GS, Feagin JA Jr, Garrett WE Jr.
Mechanisms of anterior cruciate ligament injury.
Orthopaedics 2000; 23: 573-578.
4. Ramesh R, Von Arx O, Azzopardi T, Schranz PJ. The risk of
anterior cruciate ligament rupture with generalized joint
laxity. J Bone Joint Surg Br. 2005; 87:800-803.
11. Everman DB, Robin NH. Hypermobility syndrome. Pediatr
Rev. 1998; 19:111-117.
5. Beighton P, Solomon L, Soskilne C. Articular mobility in an
African population. Ann Rheum Dis 1973; 32:413-418.
12. Finsterbush A, Pogrund H. The hypermobility syndrome.
Clin Orthop Relat Res. May 1982: 124-127.
6. Toth AP, Cordasco FA. Anterior cruciate ligament injuries
in the female athlete. The Journal of Gender-Specific
Medicine 2001; 4(4): 25-34.
13. Larsson LG, Baum J, Mudholkar GS, Kollia GD. Benefits
and disadvantages of joint hypermobility among
musicians. N Engl J Med. 1993; 329:1079-1082.
7. Nicholas JA. Injuries to knee ligaments: relationship to
looseness and tightness in football players. JAMA 1970;
212: 2236-2239.
14. Hall MG, Ferrell WR, Sturrock RD, Hamblen DL,
Baxendale RH. The effect of hypermobility syndrome on
knee joint proprioception. Br J Rheumatol. 1995; 34: 121 125.
8. Godshall RW. The predictability of athletic injuries: an eight
year study. J Sports Med 1975; 3: 50-54.
15. Perlau R, Frank C, Fick G. The effect of elastic bandages
on human knee proprioception in the uninjured population.
Am J Sports Med. 1995; 23: 251-255.
9. Moretz JA, Walters R, Smith L. Flexibility as a predictor of
15
Apollo Medicine, Vol. 6, No. 1, March 2009

5. A o oh s i l ht:w wa o o o p a . m/
p l o p a : t / w .p l h s i lc
l
ts p /
l
ts o
T ie: t s / ie. m/o p a A o o
wt rht :t t r o H s i l p l
t
p /w t c
ts
l
Y uu e ht:w wy uu ec m/p l h s i ln i
o tb : t / w . tb . a o o o p a i a
p/
o
o
l
ts d
F c b o : t :w wfc b o . m/h A o o o p a
a e o k ht / w . e o k o T e p l H s i l
p/
a
c
l
ts
Si s ae ht:w wsd s aen t p l _ o p a
l e h r: t / w .i h r.e/ o o H s i l
d
p/
le
A l
ts
L k d : t :w wl k d . m/ mp n /p l -o p a
i e i ht / w . e i c c a y o oh s i l
n n p/
i
n no o
a l
ts
Bo : t :w wl s l e l . /
l ht / w . t a h a hi
g p/
e tk t n