What is the initial management for a partial thickness tear of the Anterior Cruciate Ligament (ACL)?

From the Guidelines

The initial management for a partial thickness tear of the Anterior Cruciate Ligament (ACL) should prioritize conservative treatment, focusing on reducing pain and inflammation while restoring function, as this approach is often sufficient for patients with partial ACL tears who maintain some functional stability. This conservative management is supported by the American Academy of Orthopaedic Surgeons, which suggests that rehabilitation with a gradual return to recreational sports activity is an appropriate initial treatment, with subsequent reconstruction considered if instability develops 1. The RICE protocol is a crucial initial step: Rest to avoid further injury, Ice application for 15-20 minutes every 2-3 hours during the first 48-72 hours, Compression using an elastic bandage to minimize swelling, and Elevation of the affected limb above heart level when possible.

Pain management typically includes NSAIDs such as ibuprofen (400-600mg three times daily with food) or naproxen (500mg twice daily) for 1-2 weeks. Physical therapy is crucial and should start as soon as pain allows, focusing on:

• Quadriceps and hamstring strengthening
• Proprioception exercises
• Range of motion work A hinged knee brace may provide stability during recovery, particularly for activities of daily living. The goal of this conservative approach is to support the healing of the remaining intact ACL fibers, thereby maintaining functional stability. Full recovery typically takes 6-12 weeks, though return to sports should be gradual and based on achieving full range of motion, adequate strength, and functional stability. It's also important to consider the patient's preferences and the risk of future meniscal and articular damage if nonsurgical treatment is chosen 1.

In line with the most recent and highest quality guidelines, rehabilitation after ACL injury, including partial thickness tears, should be criterion-based, progressing through phases that include impairment-based, sport-specific training, and return to play, with a test battery used to guide progression and assess readiness to return to play 1. However, the primary focus for initial management remains conservative, reserving surgery for cases that fail conservative management or for patients with high athletic demands.

From the Research

Initial Management for Partial Thickness Tear of the Anterior Cruciate Ligament (ACL)

The initial management for a partial thickness tear of the ACL can be complex and depends on various factors.

• The decision to proceed with surgery is based on careful history and physical examination findings that suggest either a "functional" or "nonfunctional" ACL 2.
• Conservative treatment is optional for cases without instability, with a focus on motor rehabilitation 3.
• Surgical treatment is a challenge, since it requires correct positioning of the bone tunnels and conservation of the remnants of the torn bundle 3.
• Physiotherapy led interventions such as Pilates, and Tai Chi may improve pain, proprioception and strength in young and middle-aged adults with partial ACL tears 4.

Diagnosis and Treatment Options

• The diagnosis of a partial ACL tear is made with a combination of patient's history, clinical examination, and, if appropriate, magnetic resonance imaging 5.
• The objectives of management are to restore knee function, address psychological barriers to activity participation, prevent further injury and osteoarthritis, and optimize long-term quality of life 5.
• The treatment options for ACL rupture are (1) rehabilitation as first-line treatment, (2) ACL reconstruction (ACLR) and post-operative rehabilitation as the first-line treatment, and (3) pre-operative rehabilitation followed by ACLR and post-operative rehabilitation 5.
• Surgical treatment consists of augmenting the intact bundle with a selective bundle reconstruction versus a traditional ACL reconstruction 2.

Factors Influencing Treatment Decision

• The decision to proceed with surgery is based on careful history and physical examination findings that suggest either a "functional" or "nonfunctional" ACL 2.
• The pivot shift test under anesthesia, the magnetic resonance findings, the previous level and type of sports activity and the arthroscopic appearance and mechanical properties of the remnants will aid the orthopedist in the decision-making process between conservative treatment, surgical treatment with strengthening of the native ACL (selective reconstruction) and classical (anatomical) reconstruction 3.
• Younger, active patients have the risk of progressing to a complete ACL rupture with conservative treatment 2.