The Journal of Bone and Joint Surgery (American). 2009;91:2381-2389.
doi:10.2106/JBJS.H.01721
© 2009 The Journal of Bone and Joint Surgery, Inc.
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Tibiofemoral Alignment: Contributing Factors to Noncontact Anterior Cruciate Ligament Injury

Barry P. Boden, MD1, Ilan Breit, BS1 and Frances T. Sheehan, PhD2

1 The Orthopaedic Center, 9711 Medical Center Drive, Suite 201, Rockville, MD 20850. E-mail address for B.P. Boden: bboden{at}starpower.net
2 Functional and Applied Biomechanics, National Institutes of Health, Bethesda, MD 20895

Investigation performed at The Orthopaedic Center, Rockville, Maryland, and the Uniformed Services University of the Health Sciences and the Functional and Applied Biomechanics Laboratory, The National Institutes of Health, Bethesda, Maryland

Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

A commentary is available with the electronic versions of this article, on our web site (www.jbjs.org) and on our quarterly CD-ROM/DVD (call our subscription department, at 781-449-9780, to order the CD-ROM or DVD).

Background: The mechanisms of noncontact anterior cruciate ligament injury remain undefined. The purpose of this study was to identify the tibiofemoral alignment in the lateral compartment of the knee for three variations of a one-limb landing in noncontact sports activities: the safe, provocative, and exaggerated provocative positions. These positions were chosen on the basis of a previous study that measured the average joint angles of the limb at the point of ground contact for athletes who landed without injury (safe) and those who sustained an anterior cruciate ligament injury (provocative). It was hypothesized that, in the provocative positions, altered tibiofemoral alignment predisposes the knee to possible subluxation, potentially leading to an anterior cruciate ligament injury.

Methods: Magnetic resonance images were acquired for a single knee in twenty-five noninjured athletes for the three landing positions. The angle between the posterior tibial slope and the femur along with three distances (from the tibiofemoral point of contact to [1] the femoral sulcus point, [2] the posterior tibial point, and [3] the most anterior point of the circular posterior aspect of the condyle) were measured for each acquisition.

Results: The tibial slope relative to the femur was directed significantly more inferior to superior in the provocative and exaggerated positions than in the safe landing position. Similarly, as the limb transitioned from the safe to the provocative positions, the tibiofemoral joint contact point was significantly closer to the femoral sulcus point and to the most anterior point of the circular posterior portion of the lateral femoral condyle.

Conclusions: As the limb moves toward the provocative landing position, the anatomical alignment based on slope and contact characteristics places the knee at possible risk for noncontact anterior cruciate ligament injury. An enhanced understanding of the mechanism of anterior cruciate ligament injury may lead to improved preventative strategies.


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