J Orthop Sci (2010) 15:251–256
DOI 10.1007/s00776-009-1432-x
Case report
Mucoid degeneration of the anterior cruciate ligament associated with
subclinical instability in young patients
YASUO NIKI1, HIDEO MATSUMOTO2, HIROYUKI ENOMOTO1, YOSHIAKI TOYAMA1, and YASUNORI SUDA1
1
Department of Orthopaedic Surgery, Keio University, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
2
Institute for Integrated Sports Medicine, Keio University, Tokyo, Japan
Introduction
Mucoid degeneration of the anterior cruciate ligament
(ACL) is an unusual entity that has been described only
since 1999.1 With increasing use of magnetic resonance
imaging (MRI) to evaluate the knee, a number of cases
with this entity have been accumulated to date,2–7 and
characteristic features of MRI have been accepted as
important diagnostic information. Past experience can
be summarized as showing that the patients are middle-
aged and they present with knee pain and limited
motion but without clinical ligament instability.2
We report herein two cases of mucoid degeneration
of the ACL in which the patients were in their twenties.
These cases differed substantially from previously
reported cases, not only in the much younger age but
also in that the patients exhibited substantial subclinical
ACL insufficiency manifesting only in an anesthetized
condition. Despite their young age, both patients also
presented with intercondylar osteophyte, which was
removed at the time of operation to avoid impingement
of the ACL. The causal relation between minor ACL
insufficiency and such osteophyte formation warrants
further consideration. Although partial débridement of
degenerative ACL has been reported to alleviate knee
pain and is the common therapeutic strategy for this
entity, patients should be carefully followed particularly
for knee instability postoperatively owing to the inher-
ent loss of ACL integrity associated with mucoid
degeneration.
Offprint requests to: Y. Niki
Received: January 7, 2009 / Accepted: June 29, 2009
Case reports
Case 1
A 23-year-old man presented with a 3-year history of
left knee pain that was exacerbated in terminal knee
extension and after long walks. There was no history of
major knee trauma. The patient had visited his local
physician several times who had failed to reach a defini-
tive diagnosis. The patient was subsequently referred to
our hospital for specialist treatment.
On examination, no diagnostic instability was appar-
ent from the Lachman, pivot shift, and anterior/poste-
rior drawer tests. Range of motion was 0°–130°, with
pain on both terminal extension and flexion. MRI indi-
cated a bulky ACL with increased intraligamentous
signal, particularly on T2-weighted and fat-suppressed
sequences (Fig. 1). Based on these characteristic MRI
findings, mucoid degeneration of the ACL was sus-
pected, and arthroscopic treatment was applied as
reported previously.
Under anesthesia, arthrometric examination using
KT-2000 (MEDmetric, San Diego, CA, USA) revealed
3 mm of anterior displacement and 32 N/mm of ante-
rior terminal stiffness; but manual pivot shift testing
revealed no rotatory instability. On arthroscopic exami-
nation, the posterolateral bundle (PLB) of the ACL was
hypertrophic and bulbous, easily bulging into the lateral
wall of the notch in terminal extension (Fig. 2A). The
PLB was arthroscopically removed; and the notch, nar-
rowed by osteophyte formation, was widened using a
motorized burr. Tendon fibers of the PLB were found
to be interspersed with a yellowish homogeneous mass.
Although the anteromedial bundle (AMB) of the
ACL remained completely intact, arthrometric analysis
revealed that anteroposterior (AP) instability had
increased by 1.5 mm postoperatively. Histological
examination revealed loose fibrocollagenous tendinous
tissue containing fibrin deposits and myxedematous
252
Fig. 2. Case 1. Arthroscopic view of the ACL shows a hyper-
trophic, bulbous posterolateral bundle (PLB) and the inter-
condylar notch narrowed by osteophyte growing at the roof
and lateral wall of the notch (A). Histological evaluation of a
changes indicative of mucoid degeneration of the liga-
ment (Fig. 2B).
As of 1 year postoperatively, the patient had gained
complete pain relief and full range of knee motion, with
the Lysholm score improved from 69 to 95. MRI at this
time revealed complete recovery of intensity in the
ACL on T2-weighted and fat-suppressed imaging, but
substantial attenuation of ACL fibers was apparent
(Fig. 3). AP instability measured using a KT-2000
arthrometer revealed 4.5-mm side-to-side differences at
14 months postoperatively.
Case 2
A 28-year-old woman presented with an 11-month
history of left posterior knee pain during terminal knee
Y. Niki et al.: Mucoid degeneration of the ACL
Fig. 1. Case 1. Coronal (A)
and sagittal (B) T2-weighted
and fat-suppressed imaging
shows increased intraliga-
mentous signal intensity of
the bulky anterior cruciate
ligament (ACL) with intact
ACL fibers
biopsy specimen from the ACL shows mucoid degeneration
of the ligament with loose fibrocollagenous tendinous tissue
containing fibrin deposits and myxedematous changes (B)
flexion, squatting, and long walking. The patient played
basketball at a recreational level. There was no history
of trauma or previous knee problems. The patient had
visited a local hospital, and an unusual intraligamentous
signal with intermediate intensity was identified on pro-
ton-weighted imaging along with high-intensity signals
on T2-weighted and fat-suppressed imaging (Fig. 4).
The patient was thus referred to our hospital for special-
ist treatment.
On examination, no ligament instability was identi-
fied by the Lachman, pivot shift, and anterior/posterior
drawer tests. Range of motion was 0°–120°, with pain at
maximum flexion and extension. Based on the char-
acteristic MRI findings, mucoid degeneration of the
ACL was suspected, and arthroscopic treatment was
performed.
Y. Niki et al.: Mucoid degeneration of the ACL 253

Fig. 3. Case 1. T2-weighted

imaging at 1 year postopera-
tively shows reduced signal
intensity of the ACL and
decreased fibers of low signal
with an intact ACL

Fig. 4. Case 2. Sagittal pro-

ton-weighted imaging shows
an enlarged ACL with inter-
mediate signal intensity (A).
T2-weighted and fat-sup-
pressed imaging shows an
enlarged ACL with entirely
increased signal intensity (B)

In the anesthetized condition, arthrometric examina-
tion revealed 2.5 mm of anterior displacement and
37 N/mm of anterior terminal stiffness, but rotatory
instability was insignificant on pivot shift testing. On
arthroscopy, hypertrophic AMB of the ACL contacted
the lateral wall of the intercondylar notch, which was
narrowed by osteophyte formation (Fig. 5A). Only
AMB was arthroscopically removed and reconstructed
using semitendinosus tendon (Fig. 5B,C). In addition,
the notch osteophyte was removed to prevent impinge-
ment of the reconstructed ACL. Histological examina-
tion revealed fibrin deposits and myxedematous
changes, indicating mucoid degeneration of the
ligament.
By 6 months postoperatively, the patient had com-
pletely recovered without any knee symptoms, with the
254
Fig. 5. Case 2. Arthroscopic view of the ACL shows the
anteromedial bundle (AMB) impinging on the lateral wall of
the intercondylar notch (A). Only the AMB was reconstructed
using double-looped semitendinosus tendon with the postero-
lateral bundle (PLB) preserved (B). Postoperative radiogra-
Lysholm score improved from 74 to 100. AP instability
measured by arthrometry showed a 0.5-mm side-to-side
difference at 8 months postoperatively, at which time
she had returned to playing basketball.
Discussion
To the best of our knowledge, 13 cases of mucoid
degeneration of the ACL have been reported previ-
ously.1–7 A review of these 13 cases indicates that mucoid
degeneration of the ACL generally affects middle-aged
patients with ages ranging from 35 to 60 years — in
contrast to the present two patients, who were in their
twenties. As in the previous 13 cases in the literature,
our two patients presented with knee pain during ter-
Y. Niki et al.: Mucoid degeneration of the ACL
phy shows the AMB fixed with an Endobutton (Smith &
Nephew, Memphis, TN, USA) and double spike plate (DSP)
(Smith & Nephew) (C). Histology of the ACL shows myxede-
matous changes throughout the ligament (D)
minal extension and flexion, with pain in extension
dominant in patient 1 and pain in flexion dominant in
patient 2.
To date, the mechanisms evoking knee pain associ-
ated with mucoid degeneration of the ACL remain a
matter of debate. According to previous studies,
increased volume of the ACL and resultant increases
in internal pressure within the notch have been con-
sidered a cause of knee pain during terminal flexion,3,8
whereas impingement of the ACL against the osteo-
phyte of the notch plays a role in knee pain during
terminal extension.9 At present, we think it more likely
that increased tension on the degenerated ACL in ter-
minal flexion and extension result in knee pain as a
previous biomechanical study using cadaveric knees
revealed that the length of both the AMB and PLB
Y. Niki et al.: Mucoid degeneration of the ACL
was maximum with the knee in >0° of extension and
in >140° of flexion,10 suggesting that in situ tension
within the ACL is maximized with the knee in these
positions. Increased tension in the degenerative ACL
appears to be the only mechanism that would explain
knee pain in both terminal flexion and extension
simultaneously.
Although the previous 13 cases in the literature were
reportedly not associated with clinical instability of the
ACL and exhibited negative results on Lachman testing,
the present two patients showed minor ACL insuffi-
ciency and decreased terminal stiffness when measured
in the anesthetized condition using a KT-2000 arthrom-
eter. An anesthetized condition might allow precise
detection of the integrity of the ACL, not only as ante-
rior displacement but also as anterior terminal stiffness.
Anterior terminal stiffness reportedly reflects mechani-
cal properties of the ACL11 and has been considered a
useful indicator of ACL insufficiency.12,13
Several studies have suggested that minor instability
of the knee in extension potentiates osteophyte forma-
tion around the notch as a natural homeostatic mecha-
nism to prevent instability during knee extension,
independent of the presence of osteoarthritis (OA).14,15
In the present two cases, a narrow notch associated with
an osteophyte impinging against the ACL was a common
pathological feature. Narvekar and Gajjar reported five
similar cases of mucoid degeneration of the ACL, in
which notchplasty contributed to postoperative relief
from pain.3 We thus speculate that minor instability
resulting from mucoid degeneration of the ACL may
promote osteophyte formation in the roof and lateral
wall of the notch, which in turn starts to impinge against
the ACL and represents a potential cause of knee pain
in terminal extension.
In addition to the controversy of the mechanism
underlying knee pain in mucoid degeneration of the
ACL, the etiology of this entity remains contentious.
Several possible etiologies have been proposed to date,
including structural variations of the intercondylar
notch (e.g., notch wide index and notch area),16 micro-
trauma with cellular response leading to the release of
a mucin substance and hyaluronic acid,17 herniation of
synovial tissue,18 and displacement of synovial tissue
during embryogenesis.6 An alternative theory has been
postulated that mucoid degeneration and ganglion cyst
formation coexist on MRI and commonly represent
mucinous degenerative changes of connective tissue,
suggesting that similar mechanisms may contribute to
the pathogenesis of both entities.19
Regarding surgical treatment, partial resection of
the ACL, as either the AMB or PLB, has been shown
to relieve pain without causing clinical instability
postoperatively.3,4 However, two case reports have rec-
ommended ACL augmentation or reconstruction, as
255
some patients sustain ACL rupture subsequent to
débridement of mucoid tissues.17,20 Actually, in patient
1, arthrometric AP instability was increased by 1.5 mm
just after operation compared with preoperatively and
showed 4.5 mm of AP instability at 14 months postop-
eratively; whereas in patient 2, instability was 0.5 mm at
8 months postoperatively following successful ACL
augmentation.
In agreement with the past two reports, single bundle
augmentation of either AMB or PLB should be consid-
ered as a therapeutic option following débridement of
the ACL, particularly when the patient is young and
participates in sport activities.2 Indeed, we performed
ACL augmentation in patient 2 for three reasons. First,
as mucoid degenerative changes normally extend to
both the AMB and PLB, as confirmed on MRI, the rest
of the bundle after débridement of either AMB or PLB
is inevitably degenerative, and mechanical properties
are possibly deteriorated. If the patient participates in
sport activities, the remaining degenerative bundle may
be easily loosened or ruptured, as seen in case 1. Second,
most patients with mucoid degeneration of the ACL
show decreased activity and do not participate in any
sport activities due to knee pain, even though the
patients are young and previously participated in sport
activities. This may explain why most patients with
mucoid degeneration do not complain of knee instabil-
ity. Young patients with higher levels of participation in
sport activities may experience ACL insufficiency after
knee pain is relieved by débridement of the degenera-
tive ACL. Third, single bundle débridement followed
by single bundle augmentation may offer substantial
advantages from the perspective of reduced surgical
damage and rapid return to function compared with
total ACL reconstruction. Current advances in single
bundle augmentation techniques may further encour-
age consideration of this procedure for young, active
patients.21
Although the pathogenesis and pain mechanisms in
mucoid degeneration of the ACL remain unclear, the
present two cases show that knee pain during terminal
extension and flexion was relieved after débridement of
either the AMB or PLB, as reported previously. Post-
operative arthrometric analysis revealed increased AP
instability in patient 1 and normal AP laxity in patient
2. Whether single bundle augmentation is effective after
partial débridement of the ACL remains unknown,
however this procedure may offer a reasonable thera-
peutic option, particularly in young, active patients.
However, as we described only two cases with a rela-
tively short follow-up period, larger numbers and longer
follow-up intervals are necessary to investigate pre-
cisely the clinical outcomes of ACL débridement with
or without augmentation of the ACL in patients with
mucoid degeneration of the ACL.
256
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