ACL TEARS: OPERATIVE AND NON-OPERATIVE TREATMENTS
The anterior cruciate ligament (ACL) is one of the four primary stabilizing ligament complexes of the knee and plays an important role in activities that involve cutting and pivoting movements. There is a spectrum of injury patterns that can affect the ACL ranging from partial to complete tears. Furthermore, concomitant injuries occur in nearly 50% of cases and may include the cartilage surfaces, other knee ligaments, or the shock absorbing cushions (i.e. menisci) of the knee. Occasionally, early treatment decisions are made based on the presence and nature of these concomitant injuries. For example, if, in addition to sustaining an injury to the ACL, an individual has a torn meniscus that is either likely to be repairable or is blocking the knee from moving normally, early surgery may be encouraged within several weeks of the injury. Similarly, if multiple knee ligaments have been injured, then surgery may be encouraged over non-operative treatment.
In the absence of additional injuries and PRIOR to deciding on the need for surgery, the mainstay initial treatment for ACL injuries is early rehabilitation, typically lasting several weeks. The goals of this early rehab are to reduce the swelling within the knee and to restore knee range-of-motion and strength, since these factors have been shown to directly impact how well patients feel and function after surgery. The secondary goal of the early rehab is to return the knee to a functional state whereby testing can be done to determine if the patient is likely to do well with non-operative treatment.
After several weeks of rehab, the decision to proceed with surgery or non-operative treatment is made. After an ACL injury, the resultant functional implications are largely dependent upon an individual’s activity level. In other words, someone who places high demands on their knee, especially with activities that involve high-velocity cutting or pivoting movements, may have an activity-limiting degree of instability, even with just a partial ACL tear. On the contrary, an individual with a relatively sedentary lifestyle who is either not regularly involved in high-demand sports or who wishes to avoid those activities in the future, may do reasonably well with conservative treatment, even in the setting of a complete ACL tear.
For the majority of young, active individuals, however, surgery is typically recommended, since non-operative treatment in this population has been associated with a high risk of recurrent instability, secondary meniscal tears, arthritis, and the need for total knee replacement in the future.1 In a few select cases, the torn ACL can occasionally be repaired without the need for any new tissue. This is determined based on the patient age, activity level, the pattern of the ACL tear, and the presence of associated injuries. In most patients, however, the ACL is unable to be repaired and requires the use of a new tendon graft. When the ACL is replaced with a tendon graft, we call it an ACL reconstruction. Over time, the body grows new blood vessels into the graft and remodels the tendon into a new ligament. This revascularization takes approximately 12 months, at which time the graft has the same cellular appearance and strength properties as a normal ACL. Depending on the type of tendon graft used and the method of fixation, most individuals are able to return to high-demand activities at 9 months after surgery.
1. Sanders TL, Pareek A, Kremers HM, Bryan AJ, Levy BA, Stuart MJ, Dahm DL, Krych AJ. Long-term follow-up of isolated ACL tears treated without ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2017;25(2):493–500..
If you are experiencing any ACL issues or would like to learn more please contact us.
Nels Sampatacos, MD
Orthopedic Surgeon and Sports Medicine Specialist
