Outpatient Management of ACL Tear While Awaiting Specialist Referral
Initiate immediate referral to an orthopaedic surgeon for all patients with confirmed or suspected ACL tears, while concurrently starting structured physical therapy to optimize pre-referral function and prevent complications. 1
Immediate Actions
Pain and Effusion Management
- Aspirate painful, tense knee effusions for symptom relief if the patient presents with significant swelling causing discomfort 2, 1
- Prescribe NSAIDs (topical or systemic) for pain control during the waiting period 3
- Apply cryotherapy as an adjunct for pain and swelling management 3
Concurrent Physical Therapy Referral
- Refer immediately to physical therapy for prehabilitation, particularly if the patient has extension deficit, quadriceps strength deficit, or hamstring weakness 1
- Prehabilitation ensures better self-reported knee function up to 2 years after ACL reconstruction and prevents complicated or prolonged rehabilitation 1
- Exercise interventions should be the mainstay of management during this waiting period 2
Structured Rehabilitation Protocol While Awaiting Surgery
Early Phase Focus (First 2-4 Weeks)
- Address range of motion limitations, pain, and swelling as priority targets 2
- Physical therapy modalities can be helpful as adjuncts in this early phase when pain, swelling, and ROM limitations are present 2
- These modalities allow earlier pain-free commencement of exercise rehabilitation 2
Strength Training Components
- Implement both open and closed kinetic chain exercises for quadriceps strength recovery 1
- Include hamstring strengthening as part of structured physical therapy 3
- Combine strength training with motor control exercises in the rehabilitation protocol 1
Patient Education and Counseling
Treatment Options Discussion
- Inform patients that both surgical and non-surgical options exist, and the orthopaedic surgeon will determine the optimal approach based on individual factors 1
- Explain that treatment decisions depend on associated injuries, skeletal maturity, activity level, and future functional demands 1
Realistic Expectations
- Counsel that approximately 65% of patients return to preinjury sport level after reconstruction, with only 38% maintaining that level beyond 2 years 1
- Discuss that even with successful surgical treatment, patients have an increased risk of developing knee osteoarthritis long-term 1
Activity Modification
- Advise immediate cessation of jumping, cutting, and pivoting activities until orthopaedic evaluation is complete 4
- Patients should avoid activities that provoke instability or giving-way episodes 5
Timing Considerations
Urgency of Referral
- The American Academy of Orthopaedic Surgeons strongly recommends early reconstruction within 3 months for acute isolated ACL tears, as the risk of additional cartilage and meniscal injury increases after this timeframe 2, 1
- Younger patients (<30 years) with vigorous physical activity should undergo early ACL reconstruction to provide knee stability and protect menisci from subsequent injuries 1
Pre-Referral Optimization
- Use the waiting period productively to address modifiable factors: improve quadriceps strength, restore full ROM, and reduce effusion 1
- This prehabilitation phase improves surgical outcomes and prevents prolonged post-operative rehabilitation 1
Common Pitfalls to Avoid
- Do not delay orthopaedic referral even if the patient initially appears to function well, as the 3-month window for optimal surgical timing is critical 2, 1
- Do not prescribe prophylactic knee bracing as it is not a preferred option to prevent further ACL injury 2
- Do not allow patients to return to high-risk sports (jumping, cutting, pivoting) before specialist evaluation, as this increases risk of meniscal and cartilage damage 1
- Do not assume all patients require surgery—the orthopaedic surgeon will determine if the patient is a candidate for conservative management based on activity level and functional demands 1, 4