Injuring your ACL for the first time can be a highly emotional experience!  Below, we fill you in on 10 common questions you might have about your ACL injury.

• Tearing you ACL is a sensitive and at times overwhelming experience.  To help take control of your injury management, it is important to understand the key concepts relating to an ACL injury and what are your next steps. 
• This will help you have more informed conversations with your surgeon and physical therapist during your appointments.
• Your knowledge of how to manage your injury with or without an ACL operation will also play a major role in whether or not you can make a full recovery back to normal activity.
• To assist with providing in-depth insights into your ACL injury and possible future operation we have detailed the following topics:

1. What does ACL stand for and why is your Anterior Cruciate Ligament so important?
2. When does the ACL tear and what are you required to do?
3. What are the symptoms of a torn ACL?
4. How is an ACL tear diagnosed?
5. Is surgery always required to fix a torn ACL?
6. What does an ACL operation involve?
7. What are your ACL graft options? Why does it matter?
8. What are the key steps in the ACL operation (surgery) procedure itself?
9. What are the complications, risks and problems associated with an ACL reconstruction?
10. Is post-surgery ACL rehabilitation required?

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1. Why is your Anterior Cruciate Ligament (ACL) so important?

• The knee’s stability is maintained by four ligaments.
• The ACL is one of two cruciate ligaments (Posterior Cruciate Ligament being the other) on the inside of the knee that connects the kneecap (patella), the thigh bone (femur), and shin bone (tibia).
• The ACL is in the middle of the knee where these three bones come together.
• The ACL forms an “X” with the posterior cruciate ligament.
• These two ligaments control the front-to-back motion of the knee and are very important for pivoting actions and when you want to change direction.

• The other two ligaments, known as the collateral ligaments, run along the sides of the knee and control side-to-side motion.
• Without an intact Anterior Cruciate Ligament, you may experience a collapsing sensation when rotating or changing direction.
• ACL reconstruction surgery is a common procedure for people who have torn their ACL and desire to return to playing competitive sport.

2. When does the ACL tear and who is at risk?

• An ACL tear can often happen suddenly and without notice. It can occur when absorbing the impact of colliding with someone such as on the sports field, stopping suddenly, or changing position or direction.
• These actions are often associated with playing sports and there are a number of ACL tear symptoms that are commonly evident with this type of injury.
• An ACL rupture is common at the elite level of sport with superstar athletes as the stress and intensity of forces placed on the knee can be very high.
• However, you don’t have to be a star football player to experience an ACL injury. “Weekend Warriors” are also very prone to ACL tears during everyday activities like gardening,  slipping on ice, recreational activities or working out.
• The ACL tear is one of the most common knee injuries. In the United States, there are over 200,000 cases of torn ACL injuries each year.
• ACL tears are more common among younger people who are more actively involved in competitive sports that place significant demands on their knee joints.
• However, by no means are ACL injuries limited to this group of people and can occur within any age bracket.

3. What are the symptoms of a torn ACL?

• When the tear occurs, you may hear a “popping” sound and experience excruciating pain, or feel the knee give way or collapse.  Swelling in your knee is another ACL tear symptom to be aware of.
• An ACL rupture can either be a complete tear of the ligament or a partial tear which is caused through overstretching.
•  If you incur a knee injury or any of the symptoms noted above you should immediately consult a physician to examine and diagnose the injury.

4. How is an ACL tear diagnosed?

• Initially, physical examination by your therapist will be used to determine if you have an ACL tear. This will include checking for swelling and tenderness as well as specific examination tests such as lachman’s, anterior drawer and pivot-shift.
• Unless you have experienced a critical injury causing significant ongoing pain or problems, the surgeon may wait several weeks before performing the ACL operation.
• This is to allow inflammation in the injured knee to decrease and allow you the opportunity to undertake ACL prehab including exercises before surgery and therefore improve the likelihood of a successful post-surgery recovery.
• If you are diagnosed with having a completely torn ACL and your goal is to return to high-intensity physical activity then you will need an operation (ACL reconstruction) to replace the ligament.
• As suturing the existing ruptured ACL back together will not keep your knee stable under significant load.

5. Is surgery always required to fix a torn ACL?

• There are instances where your surgeon will recommend not having a knee reconstruction.
• For example, for older and non-active people, surgeons may choose to not repair the ACL at all but rather just recommend a rehabilitation program that includes strengthening and mobility exercises.
• Some people choose to try and return to normal activity without levels without surgery.  Whether or not they will be successful depends on a number of factors.
• There are a number of important decisions for a person to work through when confronted with an ACL injury and considering an ACL operation to repair a torn Anterior Cruciate Ligament. These decisions include:
  • The decision of whether or not an ACL operation procedure should be determined on a case by case basis.  Some of the important factors can include your physical activity levels, age, sporting goals, the extent of damage to your torn ACL, damage to your knee structure and cartilages, stability, and the recommendations provided by a good surgeon and your physical therapist,
  • Understanding your ACL graft options,
  • Choosing an ACL graft type that is appropriate for your individual circumstances.  There is a range of factors to consider including your surgeon’s preference, the nature of your physical and sporting activities, existing damage to the knee structure, your age, and whether or not this is your first ACL operation.
• Whether or not your knee really requires ACL reconstruction surgery is a decision you should consider carefully and usually, there is no rush to make a decision.

6. What is involved with an ACL Operation?

• An ACL operation involves replacing the torn ligament normally with a tissue graft from your own body that is designed to provide scaffolding for the new ligament to grow around.
• It is not uncommon for an ACL tear to be accompanied by a meniscus tear, cartilage damage, or broken bones.
• These damaged areas are corrected by your surgeon during the ACL surgery.  For example, removing torn cartilage which has been permanently damaged by the injury.
• The ACL surgery procedure is performed by an orthopedic surgeon and takes one to two hours to complete.
• The procedure is typically performed arthroscopically.
• The benefits of arthroscopic procedures include ease of viewing and manipulating the knee, smaller incisions, ability to complete the surgery with one operation, and fewer risks compared to open procedures.
• Arthroscopic procedures can be done under regional or general anesthetic.

7. What are your ACL graft options? Why does it matter?

• The most popular ACL graft options preferenced by surgeons are grafts which are harvested from your own body tissue – otherwise known as autografts.
• This includes the patella, hamstring and quadriceps tendons which have historically demonstrated low retear rates.
• Each of these 3 ACL graft options has there own pros and cons but if performed by a good surgeon will all work.
• Another option which a number of surgeons may preference because they save surgeons time is donor grafts or otherwise know as allografts.
• However, the retear rates with allografts are high and therefore a lot of surgeons will recommend against its use to replace a torn ACL.

8. What are the key steps in the ACL operation procedure itself?

An example of how an ACL operation procedure may be undertaken is summarised as follows:

• For the patellar and hamstring graft procedure, the orthopedic surgeon starts by making two to three small incisions in the knee and inserting an arthroscope.
• The images that are captured are displayed on the operating room monitor and give the surgeon a clearer picture of the injury.
• Next, the surgeon fills the knee with saline to expand the surgical field. Small drills are inserted into the incisions and holes are made in the tibia and femur.
• For the next step, the surgeon enters the knee through another incision and removes the graft.
• If using the patellar graft procedure, the surgeon also removes two pieces of bone, referred to as “bone blocks”, from the ends of the tibia and femur.
• For this reason, the patellar graft is often preferred because the tendon is still attached to its original bone. This promotes healing and growth and ultimately a stronger new ACL in your injured knee.
• The hamstring graft follows the same steps as above. However, at the graft removal stage, the surgeon does not take bone blocks from the tibia and femur.
• Surgeons who prefer the hamstring graft believe that the procedures give patients a more “normal” looking knee compared to the patellar graft.
• This is because surgeons do not manipulate the front of the knee.
• After removing the graft from the hamstring or patella, the surgeon shapes it and inserts it through the tunnel created by the holes drilled into the tibia and femur.
• After shaping, the surgeon uses screws or staples to secure the graft. The surgeon concludes the ACL operation procedure by suturing or taping the incisions.
• Patients go to the recovery room for several hours where they are provided medication to ease the pain.

9. What complications, risks and problems are associated with an ACL reconstruction?

• Complications of graft procedures include screws loosening, grafts stretching, your knee becoming unstable and scar tissue forming.
• Surgery-related adverse events can include numbness, pain, infection, damage to surrounding tissue, blood clots, and anesthesia-associated complications.
• Another post-procedure problem is the kneecap grating against the femur. This can cause pain and limit movement.

If problems persist for an extended period of time you may require revisionary surgery.

10. Is post-surgery ACL rehabilitation required?

• Firstly, remember that recovery and exercises before surgery are important to enable improved post-surgery outcomes.
• Following on from the reconstruction it is very important that your ACL tear recovery process and rehabilitation commences immediately.
• A structured and progressive rehabilitation program as prescribed by your physician can help you keep on track with your recovery timeline goals.
• Rehabilitation treatment plans must be tailored to each patient’s needs and the ACL recovery timelines can also be different for each individual.
• Your ACL surgery recovery timeline can be split into 5 key phases each of which needs to be completed in order for a full recovery to be achieved.
• Overall, it normally takes 9 to 12 months before a return to full activity and competitive sport is possible.
• Ligaments can take six months to regrow (however can take up to 3 years to complete 100% growth) and during that time the patient will be on restricted activity and undergo physical therapy.
• ACL replacement procedures have an 82-95% long-term success rate according to a 2013 study published in the Journal of Bone and Joint Surgery.
• Your ACL injury rehabilitation should focus on regaining motion and strength to the knee.
• A knee brace may be required in the early stages of ACL rehabilitation depending on what your surgeon recommends.
• Walking after surgery will be limited in the first week or two (and a little longer to return to a normal walking gait).
• To assist with walking after ACL surgery the use of crutches is recommended for as long as you feel you need them.  But overall try to walk normally and reduce your reliance on crutches within the first 1 to 2 weeks.

Summary

• In summary, tearing your ACL can be a traumatic experience and it is important to speak with your doctor or surgeon immediately following injury to help with your injury management.  
• If this is your first time injurying your ACL, then your are likely to a have a number of questions including:

Why is the Anterior Cruciate Ligament (ACL) so important?

• Your ACL and PCL control the front-to-back motion of the knee and are very important for pivoting actions and when you want to change direction. The ACL prevents your knee from ‘giving way’ during physical activity.

When does your ACL tear and who is at risk?

• ACL tears can happen to any person during everyday activities like gardening, slipping on ice, recreational or sporting activities. An ACL tear can often happen suddenly without notice and may or may not involve a collision.

What are the symptoms of a torn ACL?

• When the ACL tear occurs, you may hear a “popping” sound and experience excruciating pain, knee swelling, loss of full range of motion, or you may feel your knee give way or collapse.

How is an ACL tear diagnosed?

• Initially, physical examination by your therapist and surgeon will be used to diagnose an ACL tear. This will include checking for swelling and tenderness as well as specific examination tests. MRI scans are used to determine the extent of damage to the ACL injury and other structures within the knee as well.

Is surgery always required to fix a torn ACL?

• The decision of whether or not to have ACL reconstruction surgery should be determined on a case by case basis. Some of the important factors include your stability, physical activity levels, age, sporting goals, and the extent of damage to your torn ACL as well as damage to other areas of your knee. Normally there is no rush to make a decision.

What is the purpose of an ACL operation?

• In summary, an ACL operation involves replacing the torn ligament normally with a tissue graft from your own body that is designed to provide scaffolding for the new ligament to grow around.

What are your ACL graft options?

• Most surgeons prefer to use a graft from your patella, hamstring and quadriceps tendons which have historically demonstrated low re-tear rates. Other options include donor grafts (allografts) which have higher failure rates. Each option has there pros and cons.

How long does an ACL operation take?

• The ACL surgery procedure should be performed by a good surgeon who does many ACL reconstructions every month. The surgery takes one to two hours to complete. You can be in and out of hospital on the same day although normally you will go home the next day after surgery.

Are there any risks associated with ACL surgery?

• Yes there are some risks associated with ACL surgery that you should be aware of and discuss with your surgeon prior to the operation. These risks include but not limited to the possibility of infection, blood clots, and failure of the new graft.

Is rehabilitation required to recovery from ACL surgery?

• Yes adherence to your rehabilitation program is very important. The most important factors with your ACL recovery include achieving full knee extension and good quadriceps activation which needs to be a key focus area early in your recovery.

Good Luck With Your ACL Injury Rehabilitation!

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