From the Guidelines
Management of a confirmed Anterior Cruciate Ligament (ACL) tear typically involves surgical reconstruction, particularly for young and active patients.
Treatment Options
- Surgical reconstruction is often recommended for patients who wish to return to high-level sports or activities, as it can provide a stable knee and reduce the risk of further injury to the menisci and articular cartilage 1.
- Autograft is preferred over allograft for ACL reconstruction, especially in young and active patients, due to its potential benefits in reducing graft failure and improving functional scores 1.
- Bone-tendon-bone (BTB) or hamstring autograft may be favored for ACL reconstruction in skeletally mature patients, depending on the individual patient's needs and preferences 1.
Non-Surgical Management
- Non-surgical treatment with physical therapy and activity modification may be suitable for older patients with lower activity levels, as they may not experience functional instability and the risk of subsequent meniscus tear is reduced 1.
Timing of Reconstruction
- ACL reconstruction should be performed as soon as possible when indicated, as the risk of additional cartilage and meniscal injury increases within 3 months of the injury 1.
Return to Sport
- Functional evaluation, such as the hop test, may be considered to determine return to sport after ACL reconstruction, although more research is needed in this area 1.
From the Research
Management Options for Anterior Cruciate Ligament (ACL) Tear
The management of a confirmed ACL tear can be categorized into several options, including:
- Rehabilitation as first-line treatment, followed by ACL reconstruction (ACLR) in patients who develop functional instability 2
- ACLR and post-operative rehabilitation as the first-line treatment 2
- Pre-operative rehabilitation followed by ACLR and post-operative rehabilitation 2
- Non-operative treatment, which can be considered for less active patients or those with certain patient characteristics and expectations 3, 4
Factors Influencing Management Decisions
Several factors should be considered when deciding on the best treatment method for an ACL tear, including:
- Patient characteristics and expectations 3
- Concomitant injuries 3, 5
- Clinical evaluation, including laxity or instability 3, 5
- Patient's level of activity and desired return to sport 5, 4
Treatment Outcomes
Studies have shown that both operative and non-operative treatments can have favorable outcomes, but the choice of treatment depends on various factors, including patient characteristics and expectations 3, 6. A systematic review found low-quality evidence that there was no difference between surgical management (ACL reconstruction followed by structured rehabilitation) and conservative treatment (structured rehabilitation only) in patient-reported outcomes of knee function at two and five years after injury 6. However, many participants with an ACL rupture remained symptomatic following rehabilitation and later opted for ACL reconstruction surgery 6.
Rehabilitation and Return to Sport
Rehabilitation plays a crucial role in the management of ACL tears, regardless of whether surgical or non-operative treatment is chosen 2, 4. The goal of rehabilitation is to restore knee function, address psychological barriers to activity participation, prevent further injury and osteoarthritis, and optimize long-term quality of life 2. Criteria for return to sport decisions should be based on evidence-based rehabilitation protocols 2.