Management of Total ACL Rupture
For patients with a total ACL rupture, treatment should be based on age, activity level, and functional demands, with ACL reconstruction recommended for young and active patients, while non-surgical management is appropriate for older, less active individuals.
Initial Assessment and Diagnosis
- Complete ACL rupture is confirmed by MRI, which has 96% sensitivity and 97% specificity at 3T 1
- Clinical examination using the anterior drawer test has 84% sensitivity and 96% specificity when performed 4-5 days after injury 2
- Associated injuries should be identified, including meniscal tears, bone bruises, and other ligament injuries 2
Treatment Decision Algorithm
Non-surgical Management (Appropriate for):
- Older patients (typically >40 years) with lower activity demands 2
- Patients with mild/moderate osteoarthritic changes 2
- Patients who can modify activities to avoid pivoting sports 2
- Patients with medical comorbidities that increase surgical risk 3
Non-surgical treatment includes:
- Supervised rehabilitation program focusing on strengthening and neuromuscular training 2, 4
- Activity modification to avoid pivoting and high-demand activities 2
- Self-directed exercise program after initial supervised therapy 2
- Functional knee bracing may be considered but has limited evidence of benefit 2
Surgical Management (Appropriate for):
- Young patients (typically <30 years) 2
- Athletes or individuals with high activity demands 2
- Patients experiencing functional instability despite rehabilitation 3
- Patients wishing to return to pivoting sports 2
Surgical recommendations:
- ACL reconstruction should be performed as soon as possible when indicated, as risk of additional cartilage and meniscal injury increases within 3 months 2
- Autograft is preferred over allograft, particularly in young and active patients, to decrease graft failure rates 2
- For autograft selection, bone-tendon-bone (BTB) reduces risk of graft failure but may cause anterior/kneeling pain, while hamstring grafts reduce kneeling pain but may have higher failure rates 2
- ACL repair (as opposed to reconstruction) is not recommended due to higher revision rates 2
Post-Treatment Rehabilitation
- Comprehensive rehabilitation is essential regardless of treatment choice 4, 5
- Rehabilitation should address the entire kinetic chain, including hip musculature 4
- Early range of motion and progressive weight bearing should begin within the first week after surgery 5
- Return to running typically occurs at 2-3 months post-surgery 5
- Return to contact sports, including cutting and jumping activities, typically at 6 months post-surgery 5
- Functional evaluation (e.g., hop tests) should be used to determine readiness for return to sport 2
Important Considerations and Pitfalls
- Delayed ACL reconstruction is associated with increased risk of meniscal and cartilage damage 2
- Functional knee braces are not recommended for routine use after primary ACL reconstruction as they confer no clinical benefit 2
- Prophylactic knee bracing is not recommended to prevent ACL injury 2
- In combined ACL/MCL injuries, non-surgical treatment of the MCL component typically results in good outcomes 2
- Patients should be counseled that ACL injury increases the risk of future osteoarthritis regardless of treatment choice 6
- Patients who undergo non-surgical treatment should be monitored for development of functional instability, which may indicate need for delayed reconstruction 3