Bone Bruises Associated with Anterior Cruciate Ligament Injury as Indicators of Injury Mechanism: A Systematic Review

  • Liwen Zhang
  • Jonathon D. Hacke
  • William E. Garrett
  • Hui LiuEmail author
  • Bing YuEmail author
Systematic Review



Anterior cruciate ligament (ACL) injury is one of the most common injuries in sports, and the injury mechanisms are not completely clear. Bone bruises seen on magnetic resonance imaging (MRI) following ACL injuries may provide significant information for determining ACL injury mechanisms.


The aim was to determine ACL injury mechanisms through an evaluation of locations of bone bruises associated with ACL injury.


A search for related articles in PubMed and the EBSCO Sport Database was performed using selected search strings from inception to August 6, 2018. Original studies with specified bone bruise locations identified using MRI technology were reviewed.


A total of 12 studies with 589 patients were selected for review. A total of 471 bone bruises in the lateral tibial plateau were reported. Of these bone bruises, 409 (87%) occurred in the posterior section. A total of 242 bone bruises in the medial tibial plateau were reported. Of these bone bruises, 208 (86%) occurred in the posterior section. A total of 266 bone bruises in the lateral femoral condyle were reported. Of these bone bruises, 65 (25%) and 184 (69%) occurred in the anterior and central sections, respectively. A total of 105 bone bruises in the medial femoral condyle were reported. Of these bone bruises, 49 (47%) and 41 (39%) occurred in the anterior and central sections, respectively.


Bone bruise location patterns indicate that tibial anterior translation relative to the femur was a primary injury mechanism in the majority of ACL injuries selected in this review, and that the maximal knee valgus apparently occurred after tibial anterior translation sufficient to injure the ACL. Bone bruise location patterns also indicate knee hyper-extension as another mechanism of non-contact ACL injury.


Author Contributions

LZ selected the original studies, extracted data from the finally included studies, participated in data analysis, and wrote the first draft of the manuscript. JH and WG participated in data analysis and revised the manuscript. HL and BY designed the study, filtered selected studies, participated in data analysis, and revised the manuscript. All authors read and approved the final submitted manuscript.

Compliance with Ethical Standards


This review was partially supported by two grants from the China National Natural Science Foundation (grant nos. 81572212 and 30870600). The funding source had no influence on the direction, planning or results of the research, nor on the interpretation of its findings.

Conflict of interest

Liwen Zhang, Jonathon Hacke, William Garrett, Hui Liu and Bing Yu declare that they have no conflicts of interest relevant to the content of this review.


  1. 1.
    Nicolini AP, de Carvalho RT, Matsuda MM, Sayum JF, Cohen M. Common injuries in athletes’ knee: experience of a specialized center. Acta Ortop Bras. 2014;22(3):127–31. Scholar
  2. 2.
    Mather RC, Koenig L, Kocher MS, Dall TM, Gallo P, Scott DJ, et al. Societal and economic impact of anterior cruciate ligament tears. J Bone Joint Surg Am. 2013;95(19):1751–9. Scholar
  3. 3.
    Lohmander LS, Ostenberg A, Englund M, Roos H. High prevalence of knee osteoarthritis, pain, and functional limitations in female soccer players twelve years after anterior cruciate ligament injury. Arthritis Rheum. 2004;50(10):3145–52. Scholar
  4. 4.
    Lohmander LS, Roos EM. Clinical update: treating osteoarthritis. Lancet. 2007;370(9605):2082–4. Scholar
  5. 5.
    Griffin LY, Agel J, Albohm MJ, Arendt EA, Dick RW, Garrett WE, et al. Noncontact anterior cruciate ligament injuries: risk factors and prevention strategies. J Am Acad Orthop Surg. 2000;8(3):141–50.Google Scholar
  6. 6.
    Griffin LY, Albohm MJ, Arendt EA, Bahr R, Beynnon BD, DeMaio M, et al. Understanding and preventing noncontact anterior cruciate ligament injuries: a review of the Hunt Valley II meeting, January 2005. Am J Sports Med. 2006;34(9):1512–32. Scholar
  7. 7.
    Sutton KM, Bullock JM. Anterior cruciate ligament rupture: differences between males and females. J Am Acad Orthop Surg. 2013;21(1):41–50. Scholar
  8. 8.
    Agel J, Arendt EA, Bershadsky B. Anterior cruciate ligament injury in national collegiate athletic association basketball and soccer: a 13-year review. Am J Sports Med. 2005;33(4):524–30. Scholar
  9. 9.
    Hootman JM, Dick R, Agel J. Epidemiology of collegiate injuries for 15 sports: summary and recommendations for injury prevention initiatives. J Athl Train. 2007;42(2):311–9.Google Scholar
  10. 10.
    Dai B, Herman D, Liu H, Garrett WE, Yu B. Prevention of ACL injury, part I: injury characteristics, risk factors, and loading mechanism. Res Sports Med. 2012;20(3–4):180–97. Scholar
  11. 11.
    Mink JH, Deutsch AL. Occult cartilage and bone injuries of the knee: detection, classification, and assessment with MR imaging. Radiology. 1989;170(3):823–9.Google Scholar
  12. 12.
    Speer KP, Spritzer CE, Bassett FH 3rd, Feagin JA Jr, Garrett WE Jr. Osseous injury associated with acute tears of the anterior cruciate ligament. Am J Sports Med. 1992;20(4):382–9. Scholar
  13. 13.
    Vellet AD, Marks PH, Fowler PJ, Munro TG. Occult posttraumatic osteochondral lesions of the knee: prevalence, classification, and short-term sequelae evaluated with MR imaging. Radiology. 1991;178(1):271–6.Google Scholar
  14. 14.
    Lynch TC, Crues JV 3rd, Morgan FW, Sheehan WE, Harter LP, Ryu R. Bone abnormalities of the knee: prevalence and significance at MR imaging. Radiology. 1989;171(3):761–6.Google Scholar
  15. 15.
    Papalia R, Torre G, Vasta S, Zampogna B, Pedersen DR, Denaro V, et al. Bone bruises in anterior cruciate ligament injured knee and long-term outcomes. A review of the evidence. Open Access J Sports Med. 2015;6:37–48. Scholar
  16. 16.
    Sanders TG, Medynski MA, Feller JF, Lawhorn KW. Bone contusion patterns of the knee at MR imaging: footprint of the mechanism of injury. Radiographics. 2000;20(1):S135–51.Google Scholar
  17. 17.
    Bisson LJ, Kluczynski MA, Hagstrom LS, Marzo JM. A prospective study of the association between bone contusion and intra-articular injuries associated with acute anterior cruciate ligament tear. Am J Sports Med. 2013;41(8):1801–7.Google Scholar
  18. 18.
    Chin YC, Wijaya R, Chong LR, Chang HC, Lee YHD. Bone bruise patterns in knee injuries: where are they found? Eur J Orthop Surg Traumatol. 2014;24(8):1481–7. Scholar
  19. 19.
    Westermann RW, Wolf BR, Wahl CJ. Does lateral knee geometry influence bone bruise patterns after anterior cruciate ligament injury? A report of two cases. Iowa Orthop J. 2013;33:217–20.Google Scholar
  20. 20.
    Wittstein J, Vinson E, Garrett W. Comparison between sexes of bone contusions and meniscal tear patterns in noncontact anterior cruciate ligament injuries. Am J Sports Med. 2014;42(6):1401–7.Google Scholar
  21. 21.
    Filardo G, Kon E, Tentoni F, Andriolo L, Di Martino A, Busacca M, et al. Anterior cruciate ligament injury: post-traumatic bone marrow oedema correlates with long-term prognosis. Int Orthop. 2016;40(1):183–90. Scholar
  22. 22.
    Driban JB, Lohmander S, Frobell RB. Posttraumatic bone marrow lesion volume and knee pain within 4 weeks after anterior cruciate ligament injury. J Athl Training. 2017;52(6):575–80.Google Scholar
  23. 23.
    Lattermann C, Jacobs CA, Reinke EK, Scaramuzza EA, Huston LJ, Dunn WR, et al. Are bone bruise characteristics and articular cartilage pathology associated with inferior outcomes 2 and 6 years after anterior cruciate ligament reconstruction? Cartilage. 2017;8(2):139–45. Scholar
  24. 24.
    Temponi EF, de Carvalho Júnior LH, Saithna A, Thaunat M, Sonnery-Cottet B. Incidence and MRI characterization of the spectrum of posterolateral corner injuries occurring in association with ACL rupture. Skeletal Radiol. 2017;46(8):1063–70. Scholar
  25. 25.
    Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JPA, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. PLoS Med. 2009;6(7):e1000100. Scholar
  26. 26.
    Burns PB, Rohrich RJ, Chung KC. The levels of evidence and their role in evidence-based medicine. Plast Reconstr Surg. 2011;128(1):305–10. Scholar
  27. 27.
    Graf BK, Cook DA, De Smet AA, Keene JS. “Bone bruises” on magnetic resonance imaging evaluation of anterior cruciate ligament injuries. Am J Sports Med. 1993;21(2):220–3. Scholar
  28. 28.
    Speer KP, Warren RF, Wickiewicz TL, Horowitz L, Henderson L. Observations on the injury mechanism of anterior cruciate ligament tears in skiers. Am J Sports Med. 1995;23(1):77–81. Scholar
  29. 29.
    Viskontas DG, Giuffre BM, Duggal N, Graham D, Parker D, Coolican M. Bone bruises associated with ACL rupture: correlation with injury mechanism. Am J Sports Med. 2008;36(5):927–33. Scholar
  30. 30.
    Yoon KH, Jae Ho Y, Kang-Il K. Bone contusion and associated meniscal and medial collateral ligament injury in patients with anterior cruciate ligament rupture. J Bone Joint Surg Am. 2011;93(16):1510–8. Scholar
  31. 31.
    Berger N, Andreisek G, Karer AT, Bouaicha S, Naraghi A, Manoliu A, et al. Association between traumatic bone marrow abnormalities of the knee, the trauma mechanism and associated soft-tissue knee injuries. Eur Radiol. 2017;27(1):393–403. Scholar
  32. 32.
    Geeslin AG, LaPrade RF. Location of bone bruises and other osseous injuries associated with acute grade III isolated and combined posterolateral knee injuries. Am J Sports Med. 2010;38(12):2502–8. Scholar
  33. 33.
    Ali AM, Pillai JK, Gulati V, Gibbons CER, Roberton BJ. Hyperextension injuries of the knee: do patterns of bone bruising predict soft tissue injury? Skeletal Radiol. 2018;47(2):173–9. Scholar
  34. 34.
    Fayad LM, Parellada JA, Parker L, Schweitzer ME. MR imaging of anterior cruciate ligament tears: is there a gender gap? Skeletal Radiol. 2003;32(11):639–46. Scholar
  35. 35.
    Kaplan PA, Gehl RH, Dussault RG, Anderson MW, Diduch DR. Bone contusions of the posterior lip of the medial tibial plateau (contrecoup injury) and associated internal derangements of the knee at MR imaging. Radiology. 1999;211(3):747–53.Google Scholar
  36. 36.
    Zeiss J, Paley K, Murray K, Saddemi SR. Comparison of bone contusion seen by MRI in partial and complete tears of the anterior cruciate ligament. J Comput Assist Tomogr. 1995;19(5):773–6. Scholar
  37. 37.
    Lee K, Siegel MJ, Lau DM, Hildebolt CF, Matava MJ. Anterior cruciate ligament tears: MR imaging-based diagnosis in a pediatric population. Radiology. 1999;213(3):697–704.Google Scholar
  38. 38.
    Snearly WN, Kaplan PA, Dussault RG. Lateral-compartment bone contusions in adolescents with intact anterior cruciate ligaments. Radiology. 1996;198(1):205–8.Google Scholar
  39. 39.
    Kim SY, Spritzer CE, Utturkar GM, Toth AP, Garrett WE, DeFrate LE. Knee kinematics during noncontact anterior cruciate ligament injury as determined from bone bruise location. Am J Sports Med. 2015;43(10):2515–21. Scholar
  40. 40.
    DeMorat G, Weinhold P, Blackburn T, Chudik S, Garrett W. Aggressive quadriceps loading can induce noncontact anterior cruciate ligament injury. Am J Sports Med. 2004;32(2):477–83. Scholar
  41. 41.
    Patel SA, Hageman J, Quatman CE, Wordeman SC, Hewett TE. Prevalence and location of bone bruises associated with anterior cruciate ligament injury and implications for mechanism of injury: a systematic review. Sports Med. 2014;44(2):281–93. Scholar
  42. 42.
    Meyer EG, Haut RC. Anterior cruciate ligament injury induced by internal tibial torsion or tibiofemoral compression. J Biomech. 2008;41(16):3377–83. Scholar
  43. 43.
    Daia B, Maob M, Garrettc WE, Yub B. Biomechanical characteristics of an anterior cruciate ligament injury in javelin throwing. J Sport Health Sci. 2015;4(4):333–40. Scholar
  44. 44.
    Markolf KL, Burchfield DM, Shapiro MM, Shepard MF, Finerman GA, Slauterbeck JL. Combined knee loading states that generate high anterior cruciate ligament forces. J Orthop Res. 1995;13(6):930–5. Scholar
  45. 45.
    Yu B, Lin CF, Garrett WE. Lower extremity biomechanics during the landing of a stop-jump task. Clin Biomech. 2006;21(3):297–305. Scholar
  46. 46.
    Dai B, Herman D, Liu H, Garrett WE, Yu B. Prevention of ACL injury, part II: effects of ACL injury prevention programs on neuromuscular risk factors and injury rate. Res Sports Med. 2012;20(3–4):198–222. Scholar
  47. 47.
    Liu H, Wu W, Yao W, Spang JT, Creighton RA, Garrett WE, et al. Effects of knee extension constraint training on knee flexion angle and peak impact ground-reaction force. Am J Sports Med. 2014;42(4):979–86. Scholar
  48. 48.
    Szkopek K, Warming T, Neergaard K, Jørgensen HL, Christensen HE, Krogsgaard M. Pain and knee function in relation to degree of bone bruise after acute anterior cruciate ligament rupture. Scand J Med Sci Sports. 2012;22(5):635–42. Scholar
  49. 49.
    Yoon JP, Chang CB, Yoo JH, Kim SJ, Choi JY, Choi J-A, et al. Correlation of magnetic resonance imaging findings with the chronicity of an anterior cruciate ligament tear. J Bone Joint Surg Am. 2010;92(2):353–60. Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Biomechanics Laboratory, College of Human Movement ScienceBeijing Sport UniversityBeijingChina
  2. 2.Division of Physical Therapy, Center for Human Movement Science, School of MedicineThe University of North Carolina at Chapel HillChapel HillUSA
  3. 3.Duke Sports Medicine CenterDuke University Medical CenterDurhamUSA

Personalised recommendations