ACL Tear — ABOS Oral Boards Preparation
What examiners expect and how to prepare
Clinical Scenario
A 24-year-old right-hand-dominant female Division I collegiate soccer player presents to your clinic 5 days after a non-contact pivoting injury to her right knee during a game. She felt a pop, had immediate swelling, and was unable to return to play. She has no prior knee injuries and no medical comorbidities. She plans to return to competitive soccer. On exam, there is a moderate effusion. Lachman test is 2+ with a soft endpoint. Anterior drawer is positive. Pivot shift is 1+ under anesthesia. McMurray test is negative. She has full passive extension and flexion to 120 degrees. There is no varus or valgus instability at 0 or 30 degrees. Neurovascular exam is normal.
MRI of the right knee confirms a complete tear of the ACL at its femoral attachment. The medial and lateral menisci are intact. There is a bone bruise pattern on the lateral femoral condyle and posterolateral tibial plateau consistent with the pivot mechanism. Articular cartilage appears intact throughout. There are no associated ligamentous injuries.
After a period of pre-habilitation focused on restoring full range of motion and quadriceps activation, you performed an anatomic ACL reconstruction using a bone-patellar tendon-bone autograft at 6 weeks post-injury. Tunnel positioning was confirmed with intraoperative fluoroscopy. She was placed in a hinged knee brace and began a structured rehabilitation protocol with planned return to sport at 9-12 months.
What Examiners Look For
- Data gathering: Age, sex, activity level, and sport demands are critical — they directly influence graft choice and return-to-play timeline.
- Diagnosis: Describe your physical exam technique — Lachman is the most sensitive test. Can you explain grading and what constitutes a soft endpoint?
- Treatment plan: Why autograft BTB over hamstring or allograft in this patient? What would change your graft choice?
- Technical skill: Describe tunnel placement — where is the femoral tunnel, where is the tibial tunnel, and how do you confirm anatomic positioning?
- Applied knowledge: Discuss the evidence on timing of reconstruction — does acute versus delayed reconstruction affect outcomes?
- Complications: What is the re-tear rate in young female athletes? How does this inform your counseling and rehabilitation protocol?
- Outcomes: What return-to-sport criteria do you use? Discuss strength testing, functional hop tests, and psychological readiness.
Common Pitfalls
- Recommending surgery without discussing non-operative management as an option — even for athletes, the decision is shared.
- Not knowing the pros and cons of each graft type — BTB, hamstring, quad tendon, allograft — and the evidence behind each.
- Naming specific landmark studies by author — describe the findings without the bibliography.
- Forgetting to address the mental component of return to play — psychological readiness is now standard in evidence-based criteria.
- Not examining the contralateral knee — ligamentous laxity assessment is part of a complete evaluation.
Key Classifications
Related Scenarios
Free — takes 3 minutes