Abstract
BACKGROUND AND OBJECTIVE: Injuries of the anterior cruciate ligament (ACL) are common among high-level athletes. Treatment is not always successful and elite athletes often have difficulties returning to a preinjury level of performance. Treatment of athletes is very demanding due to the high loads and strong forces on the ACL during competitive sports. Multiple risk factors associated with ACL reconstruction failure have been identified over the past decades. To provide the best possible treatment, knowledge about the diagnostic tools at the physician's disposal and their interpretation are of utmost importance. The objective of this review is to provide a structured summary of the literature on the evaluation of ACL-injured high-level athletes. METHODS: A manual PubMed review about evaluation of ACL injured high-level athletes has been conducted on January 30(th), 2025. KEY CONTENT AND FINDINGS: The Lachman test yields high sensitivity, and the pivot-shift test high specificity. Knee hyperextension and general joint laxity (GJL) are risk factors for ACL reconstruction failure. Radiographs are necessary to rule out fractures or dislocations and are needed for alignment analysis, especially of the posterior tibial slope (PTS). Magnetic resonance imaging (MRI) is recommended to confirm diagnosis, rule out concomitant injuries and plan anatomic reconstruction. Instrumented laxity measurement tools aim to measure anterior or rotational laxity. A variety of arthrometers can be used to quantitatively measure anterior laxity. Preoperative and postoperative pivot-shift correlates with clinical outcome of ACL reconstruction. Many attempts have been made to establish simple and reliable quantification methods. It remains a challenging task especially due to the dynamic nature of the pivot-shift test. Randomised controlled trials with large cohorts and multi-centre studies might provide more information about the reliability, accuracy and validity of these tools in the future and help determine a gold standard. CONCLUSIONS: This narrative review provides a structured summary of the literature and evidence-based recommendations regarding the assessment of ACL injured high-level athletes.