Where to refer a patient with an anterior cruciate ligament (ACL) tear for appropriate management?

Referral Destination for ACL Tear

Patients with ACL tears should be referred to an orthopaedic surgeon, preferably one with sports medicine expertise, for evaluation and treatment planning. 1

Primary Referral Pathway

• Refer all patients with confirmed or suspected ACL tears to an orthopaedic surgeon who can comprehensively assess the injury, discuss both surgical and non-surgical options, and coordinate appropriate management based on patient-specific factors. 1

• The American Academy of Orthopaedic Surgeons guidelines emphasize that treatment decisions depend on multiple factors including associated injuries (meniscal or cartilage damage), skeletal maturity, activity level, and future functional demands. 1

When Urgent Orthopaedic Referral is Critical

Refer urgently (within days to weeks) for:

• Younger, active patients (<30 years) with vigorous physical activity demands who are at highest risk for secondary meniscal and cartilage injury without timely intervention. 2

• Patients with tense, painful knee effusions may benefit from aspiration by the orthopaedic surgeon for symptom relief during initial evaluation. 1, 2

• Any patient with suspected concomitant injuries (meniscal tears, MCL injury, cartilage damage) requires surgical assessment even if ACL reconstruction itself may be delayed. 1

Role of Physical Therapy Referral

• Consider concurrent referral to physical therapy for preoperative rehabilitation ("prehabilitation") while awaiting orthopaedic evaluation, particularly if there is: 1

  • Extension deficit (lack of full extension) - a major risk factor for postoperative complications including arthrofibrosis 1
  • Quadriceps strength deficit >20% - predicts significant strength deficits up to 2 years post-reconstruction 1
  • Hamstring weakness 1

• Prehabilitation ensures better self-reported knee function up to 2 years after ACL reconstruction and may prevent complicated or prolonged rehabilitation. 1

Key Clinical Pitfalls to Avoid

Do not delay orthopaedic referral based on age alone. While older patients (>55 years) may be candidates for non-surgical management, this decision should be made by the orthopaedic surgeon after comprehensive evaluation, not by the referring provider. 3

Do not assume all ACL tears require surgery. The orthopaedic surgeon will determine candidacy based on:

• Activity level and occupational demands 2, 4
• Associated injuries (meniscal tears significantly influence surgical timing) 2
• Patient willingness to modify activities 4
• Presence of symptomatic instability 1, 4

Timing matters for surgical candidates. Early reconstruction within 3 months is strongly recommended for acute isolated ACL tears to minimize risk of additional cartilage and meniscal injury. 2, 3 Delayed referral increases morbidity risk.

Patient Counseling Prior to Referral

• Inform patients that both surgical and non-surgical options exist, and the orthopaedic surgeon will help determine the optimal approach. 1, 4

• Set realistic expectations: even with successful treatment, patients with ACL tears have increased long-term risk of knee osteoarthritis. 2

• Explain that return to preinjury sport level occurs in approximately 65% of patients after reconstruction, with only 38% maintaining that level beyond 2 years. 1

• Discuss that rehabilitation typically takes 9 months regardless of surgical versus non-surgical management, requiring commitment to physical therapy. 5