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Student Education

Twist and turn

BMJ 2004; 329 doi: (Published 01 July 2004) Cite this as: BMJ 2004;329:0407280
  1. M G H van de Sande, sixth year medical student1,
  2. M J H Ariës, sixth year medical student2,
  3. C P van der Hart, orthopedic surgeon3
  1. 1Academic Medical Centre, Amsterdam, Netherlands
  2. 2University Medical Centre, Nijmegen, Netherlands
  3. 3OLVG Hospital, Amsterdam

A 25 year old professional football player presented to an orthopaedic clinic reporting knee instability, especially on turning. He said that five weeks ago he had been playing when he suddenly heard a snap after changing direction. His knee was slightly flexed when it happened, and it immediately got swollen. Afterwards, he was not able to continue playing. The examination showed some effusion, along with positive Lachman and pivot shift tests. Other tests proved negative.

Fig 1


  1. What is your differential diagnosis?

  2. What additional diagnostic investigations would be important in this case?

  3. What does the picture show?

  4. What is the treatment of choice for this patient?


  1. Doctors should suspect a partial or complete tear of the anterior cruciate ligament when a patient describes a combination of non-contact twisting, a “snap” sound, and immediate swelling with knee instability. Positive results in both the Lachman and pivot shift tests make the diagnosis likely. This is also often associated with injuries to the medial collateral ligament, meniscal cartilage, or articular cartilage. In this patient, however, direct signs are lacking.

  2. Medical resonance imaging is the first choice for confirmation of a tear of the anterior cruciate ligament. It detects complete and meniscal tears with an average accuracy of 90% and 80-90%, respectively. Since the diagnosis of a torn anterior cruciate ligament …

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