INTRODUCTION

The knee joint is a common site for injury, mainly due to trauma and sports related injuries.¹

Disruption in the anterior crucial ligament (ACL), a major stabilizer of the knee, leads to loss of stability, dysfunction and pain in the knee joint.

The ACL is the most common torn ligament of knee; the ACL tear has remained clinically elusive. History regarding mechanism of knee injury and clinical examination gives a vital clue to the internal derangements of knee joint.

Magnetic resonance imaging (MRI) is needed for early diagnosis in evaluation and treatment planning in acute injuries to knee joint.²

Use of arthrography and arthroscopy improves the accuracy of the diagnosis; but they are invasive and may cause complications. Advanced modality is arthroscopy, which can be used as dual mode, as diagnostic and/or as therapeutic modality. 

1.      Kaplan PA, Walker CW, Kilcoyne RF, Brown DE, Tusek D, Dussault RG. Occult fractures patterns of the knee associated with ACL tears. Assessment with MR imag- ing. Radiology. 1992; 183: 835-838.

2.      Otani T, Matsumoto H, Suda Y, Niki Y, Jinnouchi M. Proper use of MR imaging in internal derangement of the knee (orthopedic surgeon’s view). Semin Musculoskelet Radiol 2001;5:143-5. 


3.      Polly DW Jr, Callaghan JJ, Sikes RA, McCabe JM, McMahon K, Savory CG. The accuracy of selective magnetic resonance imaging compared with the findings of arthroscopy of the knee. J Bone Joint Surg Am 1988;70:192-8. 


4.      Bui-manseld LT, Youngberg RA, Warme W, Pitcher JD, 
Nguyen PLL. Potential cost savings of MR imaging obtained before arthroscopy of the knee: evaluation of 50 consecutive patients. AJR. 1997; 168: 913-918. 


5.      Crawford R, Walley G, Bridgman S, Maffulli N. Mag- netic resonance imaging versus arthroscopy in the di- agnosis of knee pathology, concentrating on menis- cal lesions and ACL tears: a systematic review. Br Med Bull. 2007; 84: 5-23. 


6.      Yasuda K, van Eck CF, Hoshino Y, Fu FH, Tashman S. Ana- tomic single- and double-bundle anterior cruciate ligament 
reconstruction, part 1: basic science. Am J Sports Med 2011; 39: 1789-1799

7.      Norwood LA, Cross MJ. Anterior cruciate ligament: func- tional anatomy of its bundles in rotatory instabilities. Am J Sports Med 1979; 7: 23-26 


8.      Amis AA, Dawkins GP. Functional anatomy of the anterior cruciate ligament. Fibre bundle actions related to ligament replacements and injuries. J Bone Joint Surg Br 1991; 73: 260-267 


9.      Girgis FG, Marshall JL, Monajem A. The cruciate ligaments of the knee joint. Anatomical, functional and experimental analysis. ClinOrthopRelat Res 1975; 216-231 


10.  Cohen SB, VanBeek C, Starman JS, Arm eld D, Irrgang JJ, Fu FH. MRI measurement of the 2 bundles of the normal an- terior cruciate ligament. Orthopedics 2009; 32: 687

11.  Takai S, Woo SL, Livesay GA, Adams DJ, Fu FH. Determi- nation of the in situ loads on the human anterior cruciate ligament. J Orthop Res 1993; 11: 686-695

12.  Sakane M, Fox RJ, Woo SL, Livesay GA, Li G, Fu FH. In situ forces in the anterior cruciate ligament and its bundles in re- sponse to anterior tibial loads. J Orthop Res 1997; 15: 285- 293

13.  Gabriel MT, Wong EK, Woo SL, Yagi M, Debski RE. Distri- bution of in situ forces in the anterior cruciate ligament in response to rotatory loads. J Orthop Res 2004; 22: 85-89

14.  Niitsu M, Ikeda K, Fukubayashi T, Anno I, Itai Y. Knee extension and flexion: MR delineation of normal and torn anterior cruciate ligaments. J Comput Assist Tomogr1996; 20: 322-327

15.  Gene Saragnese. 3D imaging of the knee takes a step for- ward. Field strength. 2010; 42: 16-19

16.  Lee JK, Yao L, Phelps CT, Wirth CR, Czajka J, Lozman J. An- terior cruciate ligament tears: MR imaging compared with arthroscopy and clinical tests. Radiology 1988; 166: 861-864

17.  McCauley TR, Moses M, Kier R, L ynch JK, Barton JW , Jokl P. MR diagnosis of tears of anterior cruciate ligament of the knee: importance of ancillary ndings. AJR Am J Roentgenol1994; 162: 115-119

18.  Mink JH, Levy T, Crues JV. Tears of the anterior cruciate ligament and menisci of the knee: MR imaging evaluation. Radiology 1988; 167: 769-774 Robertson PL, Schweitzer ME, Bartolozzi AR, Ugoni A. An- terior cruciate ligament tears: evaluation of multiple signs with MR imaging. Radiology 1994; 193: 829-834

19.  Tung GA, Davis LM, Wiggins ME, Fadale PD. Tears of the anterior cruciate ligam-ent: primary and secondary signs at MR imaging. Radiology 1993; 188: 661-667

20.  Lo IK, de Maat GH, Valk JW, Frank CB. The gross morphol- ogy of torn human anterior cruciate ligaments in unstable knees. Arthroscopy 1999; 15: 301-306

21.  Duc SR, Zanetti M, Kramer J, Käch KP, Zollikofer CL, Wentz KU. Magnetic resonance imaging of anterior cruciate liga- ment tears: evaluation of standard orthogonal and tailored paracoronal images. ActaRadiol2005; 46: 729-733

22.  Hong SH, Choi JY, Lee GK, Choi JA, Chung HW, Kang HS. Grading of anterior cruciate ligament injury. Diagnostic ef- cacy of oblique coronal magnetic resonance imaging of the knee. J Comput Assist Tomogr2003; 27: 814-819

23.  Ng AW, Grifth JF, Law KY, Ting JW, Tipoe GL, Ahuja AT, Chan KM. Oblique axial MR imaging of the normal anterior cruciate ligament bundles. Skeletal Radiol2011; Epub ahead of print

24.  McCauley TR, Moses M, Kier R, L ynch JK, Barton JW , Jokl P. MR diagnosis of tears of anterior cruciate ligament of the knee: importance of ancillary ndings. AJR Am J Roentgenol1994; 162: 115-119

25.  Schweitzer ME, Cervilla V, Kursunoglu-Brahme S, Resnick D. The PCL line: an indirect sign of anterior cruciate liga- ment injury. Clin Imaging 1992; 16: 43-48

26.  Vahey TN, Hunt JE, Shelbourne KD. Anterior translocation of the tibia at MR imaging: a secondary sign of anterior cru- ciate ligament tear. Radiology 1993; 187: 817-819

27.  Chiu SS. The anterior tibial translocation sign. Radiology 2006; 239: 914-915

28.  Chan WP, Peterfy C, Fritz RC, Genant HK. MR diagnosis of complete tears of the anterior cruciate ligament of the knee: importance of anterior subluxation of the tibia. AJR Am J Roentgenol1994; 162: 355-360

29.  Boeree NR, Ackroyd CE. Magnetic resonance imaging of anterior cruciate ligament rupture. A new diagnostic sign. J Bone Joint Surg Br 1992; 74: 614-616

30.  Moran CJ, Poynton AR, Moran R, Brien MO. Analysis of meniscofemoral ligament tension during knee motion. Arthroscopy 2006;22(4):362–366.

31.  Park LS, Jacobson JA, Jamadar DA, Caoili E, Kalume- Brigido M, Wojtys E. Posterior horn lateral meniscal tears simul-ating meniscofemoral ligament attachment in the setting of ACL tear: MRI ndings. Skeletal Ra- diol 2007;36(5):399– 403.

32.  Simonian PT, Sussmann PS, Wickiewicz TL, et al. Popliteomeniscal fasciculi and the unstable lateral meniscus: clinical correlation and magnetic resonance diagnosis. Arthroscopy 1997;13(5):590–596.

33.  Sakai H, Sasho T, Wada Y, et al. MRI of the popliteo- meniscal fasciculi. AJR Am J Roentgenol 2006;186(2): 460– 466.

34.  Kramer DE, Micheli LJ. Meniscal tears and discoid meniscus in children: diagnosis and treatment. J Am Acad Orthop Surg 2009;17(11):698–707.

35.  KimYG, Ihn JC, Park SK, Kyung HS. An arthroscopic analysis of lateral meniscal variants and a comparison with MRI ndings. Knee Surg Sports TraumatolAr- throsc 2006;14(1):20–26.

36.  Silverman JM, Mink JH, Deutsch AL. Discoid menisci of the knee: MR imaging appearance. Radiology 1989; 173(2):351– 354

37.  Ristow O, Steinbach L, Sabo G, et al. Isotropic 3D fast spin- echo imaging versus standard 2D imaging at 3.0 T of the knee: image quality and diagnostic perfor- mance. EurRadiol 2009;19(5):1263–1272.

38.  Wright RW, Boyer DS. Signicance of the arthroscopic meniscal ounce sign: a prospective study. Am J Sports Med 2007;35(2):242–244.

39.  Schnarkowski P,Tirman PF, Fuchigami KD, Crues JV, Butler MG, Genant HK. Meniscal ossicle: radiographic and MR imaging ndings. Radiology 1995;196(1): 47–50.

40.  Rohilla S,Yadav RK, Singh R, Devgan A, Dhaulakhandi DB. Meniscal ossicle. J OrthopTraumatol 2009;10(3): 143–145.

41.  Kaushik S, Erickson JK, Palmer WE, Winalski CS, Kil- patrick SJ, Weissman BN. Effect of chondrocalcinosis on the MR imaging of knee menisci. AJR Am J Roent- genol 2001;177(4):905–909.

42.  DeSmet AA, Norris MA,Yandow DR, Quintana FA, Graf BK, Keene JS. MR diagnosis of meniscal tears of the knee: importance of high signal in the meniscus that extends to the surface. AJR Am J Roentgenol 1993; 161(1):101–107.

43.  De Smet AA, Graf BK. Meniscal tears missed on MR imaging: relationship to meniscal tear patterns and anterior cruciate ligament tears. AJR Am J Roentgenol 1994;162(4):905–911.

44.  Crues JV 3rd, Mink J, Levy TL, Lotysch M, Stoller DW. Meniscal tears of the knee: accuracy of MR imag- ing. Radiology 1987;164(2):445–448.

45.  De Smet AA, Tuite MJ. Use of the “two-slice-touch” rule for the MRI diagnosis of meniscal tears. AJR Am J Roentgenol 2006;187(4):911–914.

46.  Kaplan PA, Nelson NL, Garvin KL, Brown DE. MR of the knee: the signicance of high signal in the me- niscus that does not clearly extend to the surface. AJR Am J Roentgenol 1991;156(2):333–336.

47.  Crema MD, Hunter DJ, Roemer FW, et al. The rela- tionship between prevalent medial meniscal intrasu- bstance signal changes and incident medial meniscal tears in women over a 1-year period assessed with 3.0 T MRI. Skeletal Radiol 2011;40(8):1017–1023.

48.  Magee T, Williams D. Detection of meniscal tears and marrow lesions using coronal MRI. AJR Am J Roent- genol 2004;183(5):1469–1473.

49.  Tarhan NC, Chung CB, Mohana-Borges AV, Hughes T, Resnick D. Meniscal tears: role of axial MRI alone and in combination with other imaging planes. AJR Am J Roentgenol 2004;183(1):9–15.

50.  Harper KW, Helms CA, Lambert HS 3rd, Higgins LD. Radial meniscal tears: signicance, incidence, and MR appearance. AJR Am J Roentgenol 2005;185(6): 1429–1434.

51.  Fox MG. MR imaging of the meniscus: review, current trends, and clinical implications. RadiolClin North Am 2007;45(6):1033–1053, vii.

52.  Rubin DA. MR imaging of the knee menisci. RadiolClin North Am 1997;35 (1):21–44.

53.  Ferrer-Roca O, Vilalta C. Lesions of the meniscus. II. Horizontal cleavages and lateral cysts. ClinOrthopRelat Res 1980;(146):301–307.

54.  Reagan WD, McConkey JP, Loomer RL, Davidson RG. Cysts of the lateral meniscus: arthroscopy versus arthroscopy plus open cystectomy. Arthroscopy 1989;5 (4):274–281.

55.  Dandy DJ.The arthroscopic anatomy of symptomatic meniscal lesions. J Bone Joint Surg Br 1990;72(4): 628–633.

56.  Tuckman GA, Miller WJ, Remo JW, Fritts HM, Rozan- sky MI. Radial tears of the menisci: MR ndings. AJR Am J Roentgenol 1994;163(2):395–400.

57.  Magee T, Shapiro M, Williams D. MR accuracy and arthroscopic incidence of meniscal radial tears. Skeletal Radiol 2002;31(12):686–689.

58.  Brody JM, Lin HM, Hulstyn MJ, Tung GA. Lateral meniscus root tear and meniscus extrusion with anterior cruciate ligament tear. Radiology 2006;239(3): 805–810.

59.  Choi CJ, Choi YJ, Lee JJ, Choi CH. Magnetic reso- nance imaging evidence of meniscal extrusion in me- dial meniscus posterior root tear. Arthroscopy 2010;26 (12):1602–1606.

60.  De Smet AA, Blankenbaker DG, Kijowski R, Graf BK, Shinki K. MR diagnosis of posterior root tears of the lateral meniscus using arthroscopy as the reference standard. AJR Am J Roentgenol 2009;192(2):480–486.

61.  Koenig JH, Ranawat AS, Umans HR, Difelice GS. Meniscal root tears: diagnosis and treatment. Arthros- copy 2009;25(9):1025–1032.

62.  Gray JC. Neural and vascular anatomy of the menisci of the human knee. J Orthop Sports PhysTher 1999; 29(1):23–30. 63.Vande Berg BC, Malghem J, Poilvache P, Maldague B,

63.  Lecouvet FE. Meniscal tears with fragments dis- placed in notch and recesses of knee: MR imaging with arthroscopic comparison. Radiology 2005;234(3): 842–850.

64.  McKnight A, Southgate J, Price A, Ostlere S. Menis- cal tears with displaced fragments: common patterns on magnetic resonance imaging. Skeletal Radiol 2010; 39(3):279–283.

65.  Shakespeare DT, Rigby HS. The bucket-handle tear of the meniscus: a clinical and arthrographic study. J Bone Joint Surg Br 1983;65(4):383–387.

66.  Ververidis AN, Verettas DA, Kazakos KJ, Tilkeridis CE, Chatzipapas CN. Meniscal bucket handle tears: a retro- spective study of arthroscopy and the relation to MRI. Knee Surg Sports TraumatolArthrosc 2006;14(4): 343–349.

67.  Dorsay TA, Helms CA. Bucket-handle meniscal tears of the knee: sensitivity and specificity of MRI signs. Skeletal Radiol 2003;32(5):266–272.

68.  Magee TH, Hinson GW. MRI of meniscal bucket- handle tears. Skeletal Radiol 1998;27(9):495–499.

69.  Haramati N, Staron RB, Rubin S, Shreck EH, Feld- man F, Kiernan H.Theipped meniscus sign. Skeletal Radiol 1993;22 (4):273–277.

70.  Bui-Manseld LT, DeWitt RM. Magnetic resonance imaging appearance of a double anterior cruciate liga- ment associated with a displaced tear of the lateral me- niscus. J Comput Assist Tomogr 2006;30(2):327–332.

71.  Venkatanarasimha N, Kamath A, Mukherjee K, Ka- math S. Potential pitfalls of a double PCL sign. Skel- etalRadiol 2009;38(8):735–739.

72.  Subhas N, Sakamoto FA, Mariscalco MW, Polster JM, Obuchowski NA, Jones MH. Accuracy of MRI in the diagnosis of meniscal tears in older patients. AJR Am J Roentgenol 2012;198(6):W575–W580.

73.  Barrie HJ.The pathogenesis and signicance of menis- ceal cysts. J Bone Joint Surg Br 1979;61B(2):184–189.

74.  De Smet AA, Graf BK, del Rio AM. Association of parameniscal cysts with underlying meniscal tears as identied on MRI and arthroscopy. AJR Am J Roent- genol 2011;196(2):W180–W186.

75.  Costa CR, Morrison WB, Carrino JA. Medial menis- cus extrusion on knee MRI: is extent associated with severity of degeneration or type of tear? AJR Am J Roentgenol 2004;183(1):17–23.

76.  Bergin D, Hochberg H, Zoga AC, Qazi N, Parker L, Morrison WB. Indirect soft-tissue and osseous signs on knee MRI of surgically proven meniscal tears. AJR Am J Roentgenol 2008;191(1):86–92.

77.  Kaplan PA, Gehl RH, Dussault RG, Anderson MW, Diduch DR. Bone contusions of the posterior lip of the medial tibial plateau (contrecoup injury) and asso- ciated internal derangements of the knee at MR imag- ing. Radiology 1999;211(3):747–753.

78.  Peterfy CG, Janzen DL,Tirman PF, van Dijke CF, Pol- lack M, Genant HK. “Magic-angle” phenomenon: a cause of increased signal in the normal lateral meniscus on short-TE MR images of the knee. AJR Am J Roent- genol 1994;163(1):149–154.

79.  Hristijan Kostov et al Reliability asses-sment of MRI of knee joint in comparison to arthroscopy, cta inform med. 2014 apr 22(2): 111-114 / original paper

80.  F. Rayan et al, clinical examination, MRI scan, and arthroscopy for meniscal and ACL injuries, International Orthopaedics (SICOT) (2009) 33:129–132

81.  De Smet and Graf meniscal tears missed on MR imaging AJR Am J Roentgenol. 1994 Apr;162(4):905-11.

82.  Munshi M, Davidson M, MacDonald PB, Froese W, Sutherland K. The efficacy of magnetic resonance imaging in acute knee injuries. Clin J Sport Med. 2000;10(1):34–39. doi: 10.1097/00042752-200001000-00007.

83.  Jee WH, McCauley TR, Kim JM. Magnetic resonance diagnosis of meniscal tears in patients with acute anterior cruciate ligament tears. J Comput Assist Tomogr. 2004;28(3):402–406. doi: 10.1097/00004728-200405000- 00017.

84.  Lundberg M, Odensten M, Thuomas KA, Messner K. The diagnostic validity of magnetic resonance imaging in acute knee injuries with hemarthrosis. A single-blinded evaluation in 69 patients using high-field MRI before arthroscopy. Int J Sports Med. 1996;17(3):218–222. doi: 10.1055/s-2007-  972835.


85.  Zoltan JD, Bucon KA. Magnetic resonance imaging of the  knee: correlation with arthroscopy. Arthroscopy.  1989;5(3):187–191. doi: 10.1016/0749-8063(89)90169-2.

86.  Mohan BR, Gosal HS. Reliability of clinical diagnosis in meniscal tears. IntOrthop. 2007;31(1):57–60. doi:  10.1007/s00264-006-0131-x..


87.  Rose NE, Gold SM. A comparison of accuracy between  clinical examination and magnetic resonance imaging in the diagnosis of meniscal and anterior cruciate ligament tears. Arthroscopy. 1996;12( 4):398–405. doi: 10.1016/S0749- 8063(96)90032-8.

88.  Abdon P, Lindstrand A, Thorngren KG. Statistical evaluation of the diagnostic criteria for meniscal tears. IntOrthop. 1990;14(4):341–345. doi: 10.1007/BF00182641.

89.  Cheung LP, Li KC, Hollett MD, Bergman AG, Herfkens RJ. Meniscal tears of the knee: accuracy of detection with fast spin-echo MR imaging and arthroscopic corre-lation in 293 patients. Radiology. 1997; 203(2):508–512 Kelly MA, Flock TJ,

90.  Kimmel JA, Kiernan HA, Singson RS, Starron RB, Feldman F. MR imaging of the knee: clarification of its role. Arthroscopy. 1991;7(1):78–85. doi: 10.1016/0749- 8063(91)90083-A

91.  Rangger C, Klestil T, Kathrein A, Inderster A, Hamid L. Influence of magnetic resonance imaging on indications for arthroscopy of the knee. ClinOrthopRelat Res. 1996;330:133– 142. doi: 10.1097/00003086-199609000-00016.

92.  Barronian AD, Zoltan JD, Bucon KA. Magnetic resonance imaging of the knee: correlation with arthroscopy. Arthroscopy. 1989;5(3):187–191. doi: 10.1016/0749- 8063(89)90169-2.

93.  Kreitner KF, Runkel M, Herrig A, Regentrop HJ, Grebe P. MRI of knee ligaments: error analysis with reference to meniscus and anterior cruciate ligaments in an arthroscopic controlled patient cohort. Rofo. 1998;169(2):157–162

94.  Rubin DA, Kettering JM, Towers JD, Britton CA. MR imaging of knees having isolated and combined ligament injuries. Am J Roentgenol. 1998;170:1207–1213. doi:10.2214/ajr.170.5.9574586

95.  M.Schurz et al., the value of clinical examination vs MRI in meniscal injuries of knee, department of trauma radiology, scriptamedicaapril 2008.

96.  96.Ruth Crawford MRI and arthroscopy correlation in knee pathologies british medical bullitanjuly2007 .

97.  Levinsohn EM, Baker BE. Prearthrotomy diagnostic evaluation of the knee: review of 100 cases diagnosed by arthrography and arthroscopy. AJR Am J Roentgenol 1980;134:107-11.

98.  Kamini et al Original Article- Correlation of Clinical, MRI and Arthroscopic findings in diagnosing meniscus and ligament injuries at knee joint- A prospective study. January 2013 DOI: 10.4103/2319-2585.117379 

Dr Prashant Moorthy