Excessive tibial rotation has been documented in anterior cruciate ligament (ACL) deficiency during walking. ACL reconstruction has been unable to correct this abnormality in activities that are more demanding than walking and involve both anterior and rotational loading of the knee. These findings persist regardless of graft selection for the ACL reconstruction (bone-patellar tendon-bone or semitendinosus gracilis). Based on this research work, we propose a theoretical perspective for the development of osteoarthritis in both the ACL-deficient and the ACL-reconstructed knee. We propose that excessive tibial rotation will lead to abnormal loading of the cartilage areas that are not commonly loaded in the healthy knee. Over time, this abnormal loading will lead to osteoarthritis. We hypothesise that the development of new surgical procedures and grafts, such as a more horizontally oriented femoral tunnel or a double-bundle ACL reconstruction, could possibly restore tibial rotation to normal levels and prevent future knee pathology. However, in vivo gait analysis studies are needed to examine the effects of these surgical procedures on tibial rotation. Prospective in vivo and in vitro studies are also necessary to verify or refute our theoretical proposition for the development of osteoarthritis.