ACL Tear, ABOS Oral Boards Preparation

This is a 24-year-old female Division I collegiate soccer player who sustained a non-contact pivoting injury to her right knee during a game five days ago. She felt a pop, had immediate swelling, and could not return to play. No prior knee injuries, no medical comorbidities, and she wants to return to competitive soccer.

On exam, she had a moderate effusion. Lachman was 2+ with a soft endpoint, that is the most sensitive test for ACL disruption. Anterior drawer was positive. Pivot shift was positive. McMurray was negative. She had full passive extension and flexion to 120 degrees. No varus or valgus instability at 0 or 30 degrees, so the collaterals were intact. I also examined the contralateral knee to assess her baseline ligamentous laxity, she was not hypermobile.

MRI confirmed a complete ACL tear at the femoral attachment. Both menisci were intact. There was the classic bone bruise pattern on the lateral femoral condyle and posterolateral tibial plateau from the pivot mechanism. Articular cartilage was normal throughout.

For a 24-year-old Division I athlete who wants to return to a cutting and pivoting sport, non-operative management carries a high risk of recurrent instability, subsequent meniscal injury, and accelerated cartilage damage. We discussed both options. She understood the surgery, the rehabilitation timeline, and the re-tear risk. After shared decision-making, she elected for reconstruction.

I did not rush to surgery. We spent six weeks in pre-habilitation focused on restoring full range of motion, reducing the effusion, and regaining quadriceps activation. Once her knee was quiet, I performed an anatomic ACL reconstruction using a bone-patellar tendon-bone autograft.

Post-operatively, she was placed in a hinged knee brace with immediate weight-bearing and range of motion. At two weeks, wounds were healing well. At six weeks, she had 0 to 130 degrees of motion and was progressing with quad strengthening. At three months, she was jogging in a straight line. At six months, she began sport-specific agility drills. At nine months, she met her return-to-sport criteria, quad strength index greater than 90%, symmetric hop testing, and she completed a psychological readiness assessment. She returned to full competition at ten months.

She was back on the field and performing well. Looking back, I would have started the psychological readiness component of her rehabilitation earlier, we incorporated it at six months, but I think introducing it at three or four months would have better prepared her mentally for the sport-specific phase. The re-tear rate in young female athletes is significant, and I counseled her on long-term ACL health. I followed her for two full seasons and she remained stable with no instability or effusions.