Treatment Options for Anterior Cruciate Ligament (ACL) Injury
ACL reconstruction is recommended for younger and active patients to reduce the risk of future meniscus pathology, while non-surgical treatment with structured rehabilitation may be appropriate for older, less active individuals. 1
Initial Assessment and Treatment Decision Algorithm
Surgical Treatment
ACL reconstruction is indicated in the following scenarios:
- Young, active patients (especially those participating in cutting/pivoting sports)
- Patients with functional instability during daily activities
- Athletes wanting to return to high-level sports
- Patients with associated meniscal injuries requiring repair
Early surgical reconstruction (within 3 months of injury) is strongly recommended as the risk of additional cartilage and meniscal injury increases beyond this timeframe. 1
Non-Surgical Treatment
Non-surgical management may be appropriate for:
- Older patients with lower activity levels
- Patients without functional instability
- Those willing to modify activities
- Patients with contraindications to surgery
Surgical Options and Considerations
Graft Selection
When performing ACL reconstruction with autograft for skeletally mature patients:
- Bone-patellar tendon-bone (BTB) autograft may be favored to reduce risk of graft failure or infection
- Hamstring autograft may be preferred to reduce risk of anterior knee or kneeling pain 1
Surgical Technique
- Both single-bundle and double-bundle techniques can be considered as outcomes are similar (Strong recommendation) 1
- ACL tears indicated for surgery should be treated with reconstruction rather than repair due to lower risk of revision surgery 1
Special Considerations
- In combined ACL and MCL tears, non-surgical treatment of the MCL injury typically results in good outcomes, though surgical treatment of the MCL may be considered in select cases 1
- Anterior lateral ligament (ALL) reconstruction or lateral extra-articular tenodesis (LET) could be considered when performing hamstring autograft reconstruction in select patients to reduce graft failure 1
Rehabilitation Protocol
Post-Surgical Rehabilitation
Early Phase (0-2 weeks):
- Control pain and swelling
- Begin range of motion exercises
- Weight bearing is encouraged within the first week 2
Intermediate Phase (2-12 weeks):
- Progressive strengthening exercises
- Neuromuscular training
- Light running may begin at 2-3 months post-surgery 2
Advanced Phase (3-6 months):
- Sport-specific exercises
- Functional training
- Return to cutting and jumping activities typically at 6 months 2
Return to Sport Criteria
- Functional evaluation, such as hop tests, should be considered as one factor to determine readiness to return to sport 1
- Adequate muscle strength and performance compared to the uninjured limb
- Functional stability of the knee joint
- Psychological readiness
Prevention Strategies
- Training programs designed to prevent injury can reduce the risk of primary ACL injuries in athletes participating in high-risk sports 1
- Prophylactic knee bracing is not recommended as a preferred option to prevent ACL injury 1
- Functional knee braces are not recommended for routine use after primary ACL reconstruction as they confer no clinical benefit 1
Common Pitfalls and Caveats
Delayed Treatment: Waiting too long (>3 months) for surgical intervention increases risk of additional cartilage and meniscal injury 1
Inadequate Rehabilitation: Rushing return to sport without meeting functional criteria increases risk of re-injury
Overlooking Associated Injuries: Meniscal tears and cartilage damage often accompany ACL injuries and require appropriate management
Inappropriate Patient Selection: Not all patients require surgery; treatment should be based on activity level, age, and functional demands
Aspiration Considerations: Physicians may consider aspirating painful, tense effusions after knee injury, though evidence is limited 1