ACL Tear: Symptoms, Recovery Time and Treatment

Tearing your ACL is as scary as it is painful. Tearing your ACL, like breaking a bone, usually results in a very sudden “uh oh”. Chances are as soon as your tore your ACL, you immediately knew that something was very wrong. Whether the “pop” sound gave it away or the wave of sharp pain that followed, it’s a surprising and unfortunate injury.

If you’ve just injured your ACL and are in research-mode, you’ve come to the right place. Read on as we break down the basics of ACL injury, how it happens, signs you’ve torn it, and what your prognosis and treatments are. Before we get into it, please know that this is a very treatable injury and that by investing some time into your health, you will get back to your old self.

Before we get started, let’s explain…

Where is the ACL (Anterior Cruciate Ligament)?

The anterior cruciate ligament (ACL) is one of four main ligaments that makes up the knee. The ACL and the posterior cruciate ligament (PCL) form an “X” pattern that support and stabilizes the knee, allowing for side-to-side and back-to-front motion. The ACL (making up part of the “X’ pattern) runs diagonally across the middle of the knee. The ACL connects to the thighbone (femur) and shinbone (tibia).

Why Me? Who Tears Their ACL?

If you’ve torn your ACL, chances are you’re younger. Are you a millennial? Maybe. Generation Z? Possibly. Most people that tear their ACL are between the ages of 14-35. In this demographic, women are more likely to tear their ACL. Your odds are most likely if you’re a young, female, athlete. Sorry, sporty girls!

ACL injuries are seen among “athletes in football, basketball, soccer, rugby, wrestling, gymnastics and skiing”. Sound like you?

Female athletes have a greater imbalance of muscle strength in their thighs and hamstrings. The front of the thigh is often stronger than the hamstring. The hamstring is a muscle that helps prevent the shinbone from moving too far forward which can overextend the ACL. The disparity in muscle strength between the thigh and hamstring can create the perfect environment for an ACL tear.

Why are athletes more likely to tear their ACL? ACL tears are usually caused by sudden movement changing, pivots, landing from a jump etc. These high-action, sporadic movements are most repeated by athletes. If you’re an athlete engaging in high-intensity sports (like volleyball, soccer, basketball) your odds of tearing your ACL are much higher than a gamer, chess-player, or idle office-worker.

How Does an ACL Tear Happen?

Most ACL injuries happen during team sports or other physical activity. ACLs get torn when there are sudden movement changes, quick pivots of direction, landing a jump, or if hit directly on the knee. Majority of these injuries happen without any contact from an object or another person on the field.

Here’s a cheat-sheet of how most ACL tears happen:

  • Slowing down and changing direction (like in a football play)

  • Pivoting with your foot firmly planted (like in basketball)

  • Landing from a jump wrong (like in volleyball)

  • Stopping quickly (like in baseball)

  • Receiving a direct blow to the knee or collision (like in hockey)

How Do I Know That I’ve Torn My ACL and Not Just Hurt My Knee?

There are some tell-tale signs that a knee injury is specifically an ACL issue. First and foremost, you should ask yourself how the injury happened. If it was a slow onset of knee pain, decreased motion over time, and a “grinding” sort of worsening pain, it may not be an ACL tear. Almost always with an ACL injury, it’s a dramatic moment that you can trace back to.

You can sprain your ACL just like you can sprain other tendons or muscles in your knee. Tearing your ACL takes more force and is usually more severe in nature. Tearing your ACL comes with a unique set of signs and symptoms that indicate you’ve torn it.

Signs and symptoms of an ACL Tear include:

  • None of these signs and symptoms are isolated to just ACL tears (e.g. you could have some of these symptoms with a sprain or another injury).

  • An audible “pop” sound or the feeling of something “popping” in your knee.

  • Sudden onset of the injury.

  • Severe pain.

  • Can’t continue the activity you were engaged in.

  • Cannot weight bear on the affected leg.

  • Instability in the affected leg/ the feeling your knee is “giving out” (feeling like you’d stumble or fall if you tried to walk).

  • Swelling is almost immediate (within a few hours).

  • Poor range of motion and movement in the affected leg (can’t bend knee).

  • Cannot straighten the affected leg (notice when walking down stairs).

  • Knee may feel warm to touch (however, not always the case).

An ACL injury is almost always sudden. It’s not something that gradually gets worse. If you’ve injured your ACL, you can almost always pinpoint when it happened (which is usually during physical activity or team sport).

The Prognosis: How to Treat an ACL Tear

Like most things, the prognosis of your torn ACL depends on a few things. Mostly, it depends whether you’ve partially torn your ACL or have a complete ACL tear. You will often hear ACL injuries graded from 1-3.

The Different Grades of ACL Tears and Prognoses:

  • Grade 1 tear: A slight tear but joint function resumes fairly quickly. Some physical therapy, rest, icing and treatments may be required for healing.

  • Grade 2 tear: A partial tear. The knee joint has lost functionality. The prognosis for a partially torn ACL is good. Physical therapy will likely be required, but rehabilitation and recovery can happen within 3 months without surgical intervention. In some partial tears, surgery may be recommended.

  • Grade 3 tear: The ACL ligament is completely torn. There will be very little or no function of the knee. Without surgical intervention, a full recovery is not favourable. To recover and regain full range of motion and movements, (like pivoting and team sports) surgery followed by intensive physical therapy and at-home ReHab is likely. Without surgery, instability with pivoting sports will almost always continue.

When you may not need surgery after an ACL tear:

  • The tear is partial (Grade 1 or Grade 2 ACL tear)

  • You are stable on the affected leg (knee doesn’t feel like giving out).

  • Your knee is stable during low-impact movement (walking, stairs etc.)

  • Those who do not live a very active lifestyle

  • And most importantly: You are willing to give up high-intensity sports (e.g. soccer, football, hockey volleyball).

Do you have a full ACL tear or think you need surgery? Join our ACL mailing list and stay in the loop!

ACL Injuries: Partial and Complete Tears of the Anterior Cruciate Ligament

What is the anterior cruciate ligament (ACL)?

The ACL crosses the posterior cruciate ligament in the center of the knee joint and is part of a group of ligaments that connect the thigh bone (femur) to the lower leg (tibia). These ligaments stabilize and support the knee joint. The ACL prevents the tibia from moving too far forward on the femur. It also keeps the knee from twisting inward excessively.
“Tens of thousands of people tear their ACL and approximately 200,000 operations are performed every year in the US” says Scott A. Rodeo, MD, team physician for the New York Giants and co-chief emeritus of the Sports Medicine Institute.

“HSS physicians and researchers are working to identify the most effective current treatments in order to develop new therapies that may be even more successful in helping people return to their active lifestyles after ACL injuries.”

What are the symptoms and causes of a torn ACL?

A person may hear a popping noise at the time of injury. More commonly, though, the injured athlete notices immediate pain and swelling. The knee may also shift or buckle due to instability, and jumping, landing, and pivoting can cause severe pain.

“ACL injuries are fairly common in the NFL with about two occurring each year in every team,” says Russell F. Warren, MD, New York Giants team physician and attending orthopedic surgeon at HSS. “Partial or complete ACL tears are typically non-contact injuries that occur when a person does a sharp twist-pivot with the foot planted, such as when avoiding a tackle during football or changing direction when landing after a jump in basketball,” Dr. Warren explains.

But it’s not only football players who tear this ligament that is crucial for stabilizing and supporting the knee joint. Athletic individuals of any age – particularly those who play sports requiring a pivoting motion such as soccer, lacrosse, basketball, field hockey, golf, and skiing – are at risk.

“Sports medicine physicians can usually diagnose an ACL injury during the physical exam,” Dr. Rodeo says. “A magnetic resonance imaging (MRI) scan also gives the most accurate anatomic information about the injury, and can reveal whether or not the meniscus and other structures in the knee are still intact.”

Dr. Rodeo explains that women experience ACL injuries more often than men, perhaps owing to a variety of factors including differences in neuromuscular function and anatomical differences. Female basketball players, for example, tend to jump and land with their knees straight and in a knock-kneed position, which could lead to injury.

How do you treat ACL injuries?

The first line of treatment for ACL injury involves resting, icing, and elevating the leg. An anti-inflammatory medication can also decrease pain and swelling, Dr. Rodeo says.

In some cases when people do not require a return to pivoting sports, physical therapy can strengthen the joint without surgery, he explains. With physical therapy, many people can continue to be active at the gym and at intermediate levels of jogging, running, and skiing.

In athletes who play sports that demand constant pivoting, ACL reconstruction surgery may be the best option, Dr. Warren says. Fixing the ACL will prevent abnormal movement of the knee that could cause additional knee damage to the menisci and cartilage. When the ACL is injured, the meniscus cartilage between the femur and tibia absorbs a greater impact and can tear, leading to a greater risk of osteoarthritis development, he explains.

“The key element is the time from injury to surgery,” Dr. Warren says. “The longer the time frame, the more injury is possible to the joint. We prefer to do the surgery earlier rather than later.”

Orthopedic surgeons at HSS perform over 1,200 ACL reconstruction procedures on damaged ligaments each year, and have significant experience repairing this injury in young patients. In the past, surgery involved repairing the ligament or using a synthetic material to replace the ligament, but the failure rate was too high, Dr. Warren says.

Though the ligament could heal when the leg was put in a cast for six weeks, the ligament often remained loose and did not stabilize the knee. In addition, when the cast was removed, the knee joint was very weak and stiff. More recently, there has been some renewed interest in repair if the ACL injury occurs directly at the bone attachment rather than in the mid-substance ligament. With improved arthroscopic techniques this may prove to be a viable option.

Today, reconstruction involves replacing the entire ligament with a tendon graft, Dr. Warren says. The graft could come from the injured person’s hamstring tendon, quadriceps tendon or patellar tendon, which stabilizes the kneecap and has bone on each end. Surgeons can also use an allograft, which is human donor tissue.

The source of the tendon graft depends on the situation. “In older patients, we can use an allograft, but the failure rate is higher with an allograft in younger, more active patients,” Dr. Rodeo explains. “For example, recreational skiers in their 40s and 50s seem to heal well when we use an allograft, but in 20-year-old basketball players, an allograft has up to a 25 percent failure rate.”

At HSS, the surgery is commonly performed using regional epidural anesthesia with light sedation. The procedure is done arthroscopically, through small incisions in the knee, with a combination of fiber optics and small instruments.

People who undergo this procedure can move their knee immediately after surgery and return home the same day. Two days later, physical therapy begins.

“In about four months, people are running,” Dr. Warren says. “In about six to eight months, people who have had ACL reconstruction can actively participate in sports.”

What research is conducted on ACL injuries and treatments?

Scientists at HSS have spent decades investigating the function of the ACL and the best methods for repairing injury. Recent efforts have involved understanding ACL injuries and patient experiences through prospective clinical research registries.

“Research registries are a significant area of interest at HSS,” Dr. Rodeo says. “Registries have been and will continue to be a great help for us to learn about what types of ACL procedures perform the best in certain situations—depending on the type of graft, the patient’s age and the patient’s activity level, among other factors.”

The ACL registry at Special Surgery started in 2008. It currently includes data from over 2,700 patients, including samples of synovial fluid within the knee joint that is being used to examine genes, proteins, and inflammatory cells that could be linked to the development of arthritis. The information in the registry allows researchers to prospectively track clinical data and identify successful methods for treating and preventing injury.

Experts are also working in the laboratory to identify advances in ACL repair. “Hospital for Special Surgery uses a team approach to research, with clinicians, surgeons, basic researchers, physical therapists, and others all working together,” Dr. Warren says.

A challenge of developing new materials for ACL repair involves the fact that the tissue must be able to handle weight-bearing immediately, Dr. Rodeo explains. One area of investigation involves cell-based approaches for generating and healing the tissue, such as with stem cells. In another strategy, artificial ligaments could be made through tissue engineering, as living cells begin to grow on a scaffold.

HSS researchers are also going back to basics. Biomechanics experts are investigating the role of ligaments in stabilizing the knee, and biologists are studying how ligament cells respond to mechanical loads and how they heal after damage.

“We as orthopedic researchers are looking forward to advances in other fields, including materials science and molecular biology, which could lead to clinical applications for treating ACL injuries even more effectively in the future,” Dr. Rodeo says.

Updated: 3/26/2019


Russell F. Warren, MD
Attending Orthopedic Surgeon, Hospital for Special Surgery
Professor of Orthopedic Surgery, Weill Cornell Medical CollegeScott A. Rodeo, MD
Attending Orthopedic Surgeon, Hospital for Special Surgery
Professor of Orthopedic Surgery, Weill Cornell Medical College &nbsp

ACL recovery WITHOUT surgery

He had to consider two options for recovering from his injury.

1. have reconstructive surgery and miss lead up training to the winter olympics and possibly not even get selection…or

2. go for conservative treatment by rehabilitating strength & stability to compete without an ACL.

Russ chose option no2.

Russ only had 4 weeks off the slopes. He has not only successfully competed without an ACL but is charging towards Sochi & looking for a medal.

ACL Injury treatment options

The goal of rehabilitation after an ACL injury is to return the individual to their previous level of activity, whether this be elite sport or your work, plus to prevent further injury to the knee.

There are now two options for treatment post ACL injury.

1. conservative management.

This is guided by your physiotherapist. Initial treatment will aim to reduce swelling, regain any loss of movement of the knee, then progress to strength, power and stability training, specific to your goal activity. This rehab program usually takes six months like the post-surgery program, but return to training can happen at about the 3 month mark.

2. reconstructive surgery.

Depending on your level and type of activity, surgery may be indicated to optimise stability of the knee. ACL reconstruction surgery usually involves making 2 or 3 small incisions around the knee, the torn ACL is removed and the replacement graft is anchored in to place.

Depending on the surgeon and the type of graft used, the length of rehabilitation varies. In terms of return to sport, as an average, you are looking at around 6-9 months, but may be back training at the 4 month mark.

Surgery vs No surgery

Russ Henshaw & recent research raises an important question “Do we really need to operate?”

A recent study has compared early ACL reconstruction to conservative rehabilitation. The conservative rehab group had the option to have surgery at a later stage if they still felt unstable.

The rehabilitation programs are relatively similar in the initial stages. The main differences relate to the timing of return to sports specific activities.


– sport specific exercise at 3 months

– pre-injury level by 4 months

and for surgery:

– sport specific exercises at 4 months

– pre-injury level by 6 months

50% of subjects who started with conservative rehab, later went for an ACL reconstruction due to ongoing episodes of instability. The other 50% at 5 year follow-up had no significant difference in osteoarthritis, return to pre-injury activity level or a need for further surgery.

If you are an athlete, the decision to go for conservative rehab might be difficult due to the 50/50 possibility of later requiring surgery anyway & a further 6 months rehab again after that.

This might be an easier decision for those who don’t have high demands on their knee for everyday activities & don’t play sport, as ongoing instability at this level is less likely. In this study, 50% of people who would otherwise have had surgery as standard treatment option, did not need to, with no adverse affects 5 years down the track.

Unfortunately the recent research did not involve professional athletes so we are very interested in watching Russ Henshaw in the winter Olympics. Can a conservative rehabilitation program, designed specifically for a particular sport outweigh the presumed importance of an ACL for knee stability?!

Stay tuned for our next blog on surgical options with the different graft choices.

Feel free to post any comments or questions on Facebook.

ocean view physiotherapy
central coast foot & ankle physiotherapy
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“If you have a large meniscus tear and you fix the meniscus and not the ACL, there is a very high likelihood the ACL will fail,” Levy tells WebMD.

On the other hand, a patient who is a relatively low-level recreational athlete — Levy offers the example of a 35-year-old cyclist — may be better off with bracing and rehabilitation. Only if such patients have further ACL problems would surgery be the preferred option. But a collegiate soccer player might not be able to return to play without ACL reconstruction.

“When a patient presents with an ACL tear in the knee, we have a long discussion with the patient and family on the pros and cons of operative and nonoperative treatment,” Levy says. “The decision is based on many factors. First and foremost is the patient’s activity level, and the sport and work demands the knee would undergo.”

Frobell fully agrees with Levy that the study does not give patients or doctors a one-size-fits-all solution to treatment of ACL tears.

“Our study does not answer the question of specifically who needs ACL surgery. It does not look into what factors a patient has to have to need surgery to do well,” he says. “We need a lot of more high-quality science in this area.”

Some of that data may be coming soon. Levy says he’d like to see how Frobell’s patients do in the long term. Frobell says the last patient in the study is just completing five years of follow-up observation. More information is on the way.

The Frobell study, and an editorial by Levy, appear in the July 22 issue of the New England Journal of Medicine.

ACL Tear Treatment Without Surgery & Rehab Exercises

ACL Injury Treatment

The anterior cruciate ligament (ACL) is a tendon located within the knee that attaches the tibia (shin bone) to the femur (thigh bone). As you might imagine, this connective ligament is pretty darn important when it comes to stabilizing the knee and, more specifically, keeping the shin from extending too far relative to the thigh.

Therefore, when this ligament is torn—completely or partially—ACL tear treatment is no small matter. Treatment for ACL injury can stretch out for months and often involves surgery. Unfortunately, more and more athletes, especially of the female sex, must undergo ACL injury rehab each year. Indeed, some have even described it as an ACL tear epidemic.

But before getting worked up about whether your ACL injury treatment will include surgery, you should first get your knee checked out by a medical expert. I recently injured my knee while skiing and spent a very restless night stressed about the surgery I would need and the long recovery period, only to find out the next day I had only severely strained my knee. While a strain is by no means a small matter, it certainly involves less invasive and long-lasting recovery than ACL tear rehab.

If the professional determines you have indeed torn the ACL, he or she may recommend getting the pain, swelling, and inflammation that goes along with the injury to the knee under control, and possibly even engage in some ACL injury exercises before deciding upon a course of treatment. One can do so by following the trusty steps of the acronym RICE:

  • Rest
  • Ice
  • Compression
  • Elevation

Whether or not surgery is needed largely comes down to two things:

  1. Injury severity
  2. Desired post-rehab activity level

Partial ACL tear treatment is far more likely not to involve surgery than a complete ACL tear. Surgery is even more likely to be recommended if the ACL injury coincides with an injury to the other ligaments of the knee and/or cartilage. This is because blood flow to the region the ACL is located is limited. Thus, the body is unable to rehabilitate a torn ligament and surgery is often the likely treatment for ACL tears.

ACL Tear Treatment Without Surgery

Foregoing ACL tear surgery and instead opting to do ACL tear exercises to condition the surrounding muscles of the knee to compensate for the weakened ACL can suffice if you are willing to give up activities that require sudden movements such as cutting, pivoting, jumping, sliding, etc. Such activities greatly increase the risk of another ACL tear or other damage to the knee because the other muscles cannot fully account for the stabilizing effect of the ACL.

ACL partial tear treatment without surgery includes going through a number of ACL injury exercises and stretches to strengthen the associated muscles so that they are able to stabilize the knee without the tendon. ACL tear rehab is also aimed at restoring a normal range of motion to the knee.

Such ACL injury rehab exercises typically must continue regularly for three months. And after this rehab period, you must still avoid the aforementioned sports actions. A knee brace may also be helpful or even recommended for subsequent sports activity both for the peace of mind it affords and for the stability it provides.

Rehab for ACL Tear

ACL tear physical therapy following surgery is similar in that it involves a number of ACL tear rehab exercises aimed at helping you regain the full range of motion of the knee and strengthening and stretching the muscles of your legs.

But it differs in that the knee and likely either the patellar tendon or hamstring from which the new ACL was constructed will be healing. Plus, the surgery itself and the inactivity that is required immediately following surgery result in major weakening of the leg muscles. For this reason, the ACL tear rehabilitation period after surgery must extend over an even longer timeframe, typically ranging from six months to a year.

Physical therapy for ACL tears includes time spent on your own working through ACL tear exercises, as well as time spent with a physical therapist. It is important not to progress too quickly through these exercises for ACL tear. Doing so can result in re-injury, improper healing and ultimately ACL tear rehab setbacks.

Treatment of ACL tear will include a post operation brace immediately following the surgery as you will need to stay off your knee. It is also likely that when your ACL rehab exercises advance to a point where you are once again able to take part in athletic activities you will be recommended to wear a functional ACL brace.

ACL Injury Prevention Exercises

ACL injury prevention exercises focus on developing the same sorts of skills that ACL injury exercises do: Strength, flexibility, agility, stability, etc. Developing these requires focus and self-awareness in regards to using proper form, especially when it comes to jumping, stopping, and moving quickly in the heat of a game.

Concentrating on this during practice will help your body to move more correctly naturally so that you are less injury-prone when your mind is focused elsewhere during competition. The Hospital for Special Surgery (HSS) recommends focusing on the following as you perform drills and repeating them as a mantra:

  • Chest high and over knees
  • Bend from the hips and knees
  • Knees over toes
  • Toes straightforward
  • Land like a feather

It is important to work on building strength in your hips and thighs and especially the hamstrings for women. Warming up and stretching before engaging in strenuous activity is also important for ACL injury prevention.

For more tips on using proper form as well as some illustrated ACL injury prevention exercises, check out the article “ACL Injury Prevention Tips and Exercises: Stay Off the Sidelines!”

How I Recovered After Tearing My ACL Five Times—Without Surgery

“In particular, it prevents forward instability of the tibia (the bottom knee bone) in relation to the femur (the top knee bone). It also helps prevent rotational instability,” he explains. “Typically, a person that tears their ACL may feel a pop, a pain that is deep in the knee and, often, sudden swelling. Bearing weight is difficult at first and the knee feels unstable.” (Check, check, and check.)

And ICYMI, women are more likely to tear their ACL, due to various factors that include the biomechanics of landing due to differences in anatomy, muscle strength, and hormonal influences, says Dr. Popovitz.

My Failed ACL Surgeries

As a young athlete, going under the knife was the answer to continue competing. Dr. Popovitz explains that an ACL tear will never “heal” by itself and for younger, more active, patients surgery is almost always the best option to restore stability—and prevent cartilage damage that can cause severe pain, and potential premature degeneration of the joint and eventual arthritis.

For the first procedure, a piece of my hamstring was used as a graft to repair the torn ACL. It didn’t work. Neither did the next one. Or the Achilles cadaver that followed. Each tear was more disheartening than the last. (Related: My Injury Doesn’t Define How Fit I Am)

Finally, the fourth time I was starting from square one, I decided that since I was done playing basketball competitively (which definitely takes a toll on your body), I wasn’t going to go under the knife and put my body through any more trauma. I decided to rehabilitate my body a more natural way, and—as an added bonus—I’d never have to worry about re-tearing it, ever again.

In September, I experienced my fifth tear (in the opposite leg) and I treated the injury with the same natural, non-invasive process, without going under the knife. The result? I actually feel stronger than ever.

How I Rehabbed My ACL Without Surgery

There are three grades of ACL injuries: Grade I (a sprain that can cause the ligament to stretch, like taffy, but still remain intact), Grade II (a partial tear in which some of the fibers within the ligament are torn) and Grade III (when the fibers are completely torn).

For Grade I and Grade II ACL injuries, after the initial period of rest, ice and elevation, physical therapy might be all that you need to recover. For Grade III, surgery is often the best course of treatment. (For older patients, who don’t put as much strain on their knees, treating with physical therapy, wearing a brace, and modifying certain activities is probably the best way to go, says Dr. Popovitz.)

Luckily, I was able to go the non-surgical route for my fifth tear. The first step was to decrease the inflammation and regain full range of motion; this was essential to reducing my pain.

Acupuncture treatments were the key to this. Before trying it, I have to admit, I was a skeptic. Luckily I’ve had the help of Kat MacKenzie—the owner of Acupuncture Nirvana, in Glens Falls, New York—who is a master manipulator of fine needles. (Related: Why You Should Try Acupuncture—Even If You Don’t Need Pain Relief)

“Acupuncture is known to promote blood flow, reduce inflammation, stimulate endorphins (thus decreasing pain) and it inherently moves stuck tissue, allowing the body to heal better naturally,” says MacKenzie. “In essence, it gives the body a little shove to heal faster.”

Even though my knees will never fully heal (the ACL can’t magically reappear, after all), this method of holistic healing has been everything I didn’t know I needed. “It improves circulation in the joint and improves range of motion,” says MacKenzie. “Acupuncture can improve stability in the sense of functioning better .”

Her methods also came to the rescue of my right knee (the one that had all of the surgery) by breaking down scar tissue. “Whenever the body has surgery, scar tissue is created, and from an acupuncture perspective, it is hard on the body,” explains MacKenzie. “Thus we try to help patients avoid it when possible. But we also recognize that if the injury is severe enough, surgery has to occur, and then we try to help the knee joint recover faster. Acupuncture also works preventatively as well by improving the functionality of the joint.” (Related: How I Recovered from Two ACL Tears and Came Back Stronger Than Ever)

The second step was physical therapy. The importance of strengthening the muscles around my knees (quadriceps, hamstrings, calves, and even my glutes) can’t be stressed enough. This was the hardest part because, like a baby, I had to start with a crawl. I began with the fundamentals, which consisted of exercises like tightening my quad (without lifting my leg), relaxing it, and then repeating for 15 repetitions. As time passed, I added the leg lift. Then I would lift up and move the whole leg to the right and left. It doesn’t seem like much, but this was the starting line.

After a few weeks, resistance bands became my besties. Every time I was able to add a new element to my strength training regimen, I felt invigorated. After about three months I started to incorporate body-weight squats, lunges; moves that made me feel I was getting back to my old self. (Related: The Best Resistance Band Exercises for Strong Legs and Glutes)

Finally, after about four to five months, I was able to hop back on a treadmill and go for a run. Best. Feeling. Ever. If you ever experience this, you will feel like recreating Rocky’s run up the stairs so have the “Gonna Fly Now” queued on your playlist. (Warning: Punching the air is a side-effect.)

Even though strength training was integral, gaining my flexibility back was just as necessary. I always made sure to stretch before and after each session. And every night concluded with strapping the heating pad to my knee.

The Mental Component of Recovery

Thinking positive was crucial for me because there have been days when I wanted to give up. “Don’t let an injury discourage you—but you can do this!” MacKenzie encourages. “A lot of patients feel like an ACL tear really prevents them from living well. I’ve had my own medial meniscus tear while in acupuncture school, and I remember climbing up and down the NYC subway steps on crutches to get to my day job on Wall Street, and then climbing up and down the subway steps to get to my acupuncture classes at night. It was exhausting, but I just kept going. I remember that difficulty when I treat patients and I try to encourage them.”

There is no end for my PT, I will never be finished. To stay mobile and agile, I—like anyone who wants to feel good and remain fit—have to continue this forever. But taking care of my body is a commitment I’m more than willing to make. (Related: How to Stay Fit (and Sane) When You’re Injured)

Choosing to live without my ACL’s isn’t a piece of gluten-free cake (and not the protocol for most people), but it has definitely been the best decision for me, personally. I avoided the operating room, the massive, black and incredibly itchy post-surgical immobilizer complete with crutches, hospital fees and—most importantly—I was still able to take care of my soon-to-be two-year-old twin boys.

Sure, it’s been full of challenging ups and downs, but with some hard work, holistic healing methods, heating pads, and a hint of hope, I’m actually ACL-less and happy.

Plus, I can predict precipitation better than most meteorologists. Not too shabby, right?

  • By Molly Congdon

ACL Surgery – No Longer Kneeded?

What evidence is there to inform our decision on whether patients should undergo surgical or non-surgical management after an ACL tear?

The best way for clinician-readers to answer a specific question like this is through systematic reviews and meta-analyses, where the highest standard of empirical evidence of the effects of interventions is assessed (Travers et al 2019). Recent literature reviews have found similar outcomes in both non-surgical and surgical groups with respect to pain, symptoms, function, return to sport levels, quality of life, subsequent meniscal tear and surgery rates, and radiographic knee osteoarthritis (OA) prevalence (Smith et al 2014, Delincé and Ghafil 2012, Monk et al 2016).

We know randomised control trials (RCT’s) are the optimum study design for musculoskeletal pain and injury presentations when examining the effectiveness of exercise therapy to non-necessary-for-life surgical procedures. Ideally, when testing interventions, a placebo surgery arm should also be utilised, with common elective operations for knee, shoulder and elbow now being shown to be no better than placebo (Sihvonen et al 2013, Beard et al. 2018, Kroslak and Murrell 2018). This is yet to be undertaken in ACL injury, therefore clinicians are being challenged to be sceptical, think critically and scrutinise the necessity of any optional surgery yet to be tested in a placebo-controlled trial (Zadro et al 2019).

It is almost unfathomable that a recent review by Kay et al 2017 revealed that only 1 of 412 ACL randomised controlled trials actually compared ACL reconstruction (ACLR) to structured rehabilitation for acute ACL injury, with essentially all other studies comparing various ACL surgeries and graft types to one another (Culvenor and Barton 2018). This single RCT, the famous KANON (Knee Anterior Cruciate Ligament, Nonsurgical versus Surgical Treatment) trial by Frobell and colleagues (2013), recommended that their “results should encourage clinicians and young active adult patients to consider rehabilitation as a primary treatment option after an acute ACL tear.” Given cultural trends in Western society to this point in history – this really is liberating, hopeful and revolutionary thinking!

Why do you think so many physiotherapists and athletes believe surgery is needed after an ACL rupture?

This is a great question that has many facets to cover, and one that could almost be its own PhD research investigation! For me three critical drivers of this ideology are beliefs around the ligament itself, our current healthcare models and the mainstream media.

Our understanding of ACL tears has shifted from one of ‘the ACL’s job anatomically is to do X, Y and Z so let’s try to replicate that surgically’, to one of ‘what do the best-designed studies show that compare the 2 groups of attempting to reconstruct the ligament and receiving rehabilitation, versus undertaking physiotherapy and exercise alone?’ So in our efforts to ‘re-create’ a ligament an entire world-wide, multi-billion dollar per annum industry has burgeoned, and the studies of the best methodological rigour are challenging what we used to believe.

We previously theorised that ACLR prevented OA and further meniscal damage compared to individualised, graded functional strengthening alone; we now realise this is a misconception not supported by high-quality science, with suggestions now ACLR could in fact increase the risk of OA

(Nordenvall et al 2014, Culvenor et al 2019, Filbay 2019). Studies are also now showing, if left, the ACL can heal (Ihara et al 1994, Fujimoto et al 2002, Costa-Paz et al 2012) despite previous belief this was impossible through a lack of blood clot formation.

In Australia at least, where we have the highest rates of reconstruction in the world (Zbrojkiewicz, Vertullo and Grayson 2018), all of our public and private healthcare models are set up to speed-up and fund early MRI, early surgical opinion and early surgery. Physiotherapy and exercise as ‘treatment and management’ of ACL tears is currently not routinely advertised, funded or recommended through government systems or private insurance companies, so both clinicians and patients are simply unaware of the quality of the research for the intervention they may receive.

There is a pervading view in mass media of alarmism and devastation when a player injures their knee on the pitch, with commentators often ‘fearing’ the worst. The emotion follows as the assumption is the athlete has injured their ACL and will require surgery and will need 9 to 12 months off their sport – this is a false narrative which we need to replace with a rational explanation of the most substantive data, and encourage players (and the general population) that many can function at the elite level without the need for invasive surgery.

What does the research suggest is the best management plan after an ACL rupture?

Given the lack of high-quality studies showing additional benefit of reconstruction to physiotherapy and exercises, authors are now highlighting the “emerging realisation that athletes may be overtreated with ACLR surgery, but undertreated when it comes to rehabilitation” (Grindem, Arundale and Ardern 2018) therefore a cultural shift away from early surgery and towards non-surgical management, with surgery “as needed” is required (Zadro and Pappas 2018).

Further analysis by Filbay et al (2017) of the KANON trial showed patients who received early ACLR were prognostically worse across multiple domains compared to the non-surgical and delayed surgical arms, suffering a ‘second trauma’ due to the surgical drilling through intra-articular structures, a period of prolonged joint inflammation and altered weight bearing (Bowes et al 2019, Larsson et al 2017).

We need to take our time educating any patient after an ACL injury about the said evidence through a shared-decision making process, underscoring to them the concept of commitment and adherence to graded, comprehensive, longstanding rehabilitation, with prevention exercises maintained after return to sport. We need to confront any belief that an ACLR is a ‘quick fix’ (Zadro and Pappas 2018), stress the many benefits of undertaking immediate rehabilitation alone ideally for at least 3 to 6 months, which is termed ‘World’s Best Practice’ (Rooney 2018). The bottom line is for many active patients, non-surgical management continues as a permanent, life-long solution.

What should the rehab process look like for someone undergoing non-surgical management? Similar to rehab post ACL reconstruction?

The rehabilitation process really is very similar, however timeframes are expected to be decidedly faster, given there is no need to recover from surgery, or a graft to monitor. Static, non-weight bearing tests for stability like pivot-shift or Lachman’s are less relevant, as it is now well-known that there is a poor correlation between them and functional stability (Snyder-Mackler et al 1997, Hurd et al 2009).

I like to use questionnaires such as the IKDC and KOOS (Collins et al 2011, van Meer 2013) for baseline assessment of patients’ knee function, and the short form of the Örebro Musculoskeletal Pain Screening Questionnaire (Linton et al 2011) to screen for psychological risk or the Tampa Scale of Kinesiophobia (Miller et al 1991) to analyse for the presence of fear-avoidance.

It important to outline to the patient the expected stages of the program and criteria for progression, ideally in a verbal and written Treatment Plan. Management initially involves reducing pain and effusion, while improving ROM, muscle strength, function and movement patterns.

End stage physiotherapy to return to sport includes sports performance (e.g. acceleration, agility, coordination, balance, endurance and sport-specific skills) and assessment of psychological readiness (Filbay and Grindem 2019). Post successful return to play, ‘booster’ follow-up sessions can be scheduled periodically to ensure continued compliance with preventative exercises (Skou et al 2018, Fleig et al 2013, Nessler et al 2017). I also encourage patients to share their success stories with friends, family, colleagues and social media connections, so the general population can benefit from these positive messages!

Can you return to pivoting sports without surgery? Any good case studies in elite athletes?

Absolutely. It’s important for readers to know that it is a fallacy based on biologically-plausible theory that you cannot return to pivoting/cutting sports with an ACL-deficient knee – there are plenty of peer-reviewed papers that show returning to these types of sports is achievable and safe for many patients (Meuffels et al 2009, Grindem et al 2012, Kovalak et al 2018). There is in fact not a single study, at a group level, that shows you can’t return to twisting sports without an ACL. Through intense strengthening, neuromuscular control, balance and sports specific training your musculoskeletal system can be more than adequate to compensate for ligament laxity, making the ligament essentially redundant.

Studies in professional athletes which compare physiotherapy alone to surgery plus physio haven’t actually shown any benefit to the surgery group. A prospective study from Sweden in the 90’s showed no signi?cant difference in return to sports rates and OA in professional soccer players (Roos et al. 1995), as did a group-comparison study by Myklebust in 2003 in professional European handballs players. Van Yperen et al. (2018) compared 50 high-level athletes and found no between-group differences in meniscectomy rates, radiographic OA, and functional outcomes at 20-year follow-up.

The most famous non-operative case study was in an English Premier League player who returned to play without surgery in 8 weeks following a full thickness tear and remained problem-free long-term (Weiler et al 2015, Weiler 2016). There are many others who have been champions at the elite-level in various sports, including in the NBA, NFL and Major league Baseball, although DeJuan Blair is one of my personal favourites: successfully playing in the NBA for the San Antonio Spurs for multiple seasons without an ACL in either of his knees!

What are some key variables that might help us predict whether someone is likely to be a ‘coper’ or ‘non-coper’ from non-surgical management?

The jury is out on how to predict whether someone ‘needs’ an elective reconstruction – we don’t know whether it is cultural tendencies, typical healthcare pathways, beliefs/fear/preferences of the clinician or patient/parents/sporting clubs, lack of commitment to the rehab or true pathophysiological reasons of their knee giving-way with resultant persistent pain and effusion despite high-quality, intense, structured and graded rehabilitation.

Traditional algorithms have been heavily biased towards early ACLR, with elements such as progressive, intense rehabilitation beyond a rigid time frame, movement patterns and psychological fear-avoidance never previously considered ((Fitzgerald, Axe, Snyder-Mackler 2000, Hartigan et al 2013). Many patients that have been classified as ‘copers’ still decide to opt for surgery (Hurd et al 2008), and many ‘non-copers’ if given adequate time ultimately become ‘copers’! (Thoma et al 2019, Moksnes et al 2008).

Based on the KANON trial, psychological factors such as pre-existing preferences, beliefs and lack of motivation towards rehabilitation and exercises were the main reasons patients chose to have a reconstruction (Thorstensson et al 2009), with physical performance of quadriceps strength and hop tests key factors of success (Ericcson et al 2013) in all groups. Choosing to not have an ACLR and opting for exercise therapy alone is also a prognostic factor for less knee symptoms at 5-year follow-up (Filbay et al 2017).

How do you address potential psychological impairments following ACL rupture for those following a non-surgical pathway?

Again, this is such an excellent question with a myriad of potential topics to cover! In our subjective examination we need to at least in a cursory way question around patient beliefs of the injury management options, their expectations, short and long-term goals, social considerations, fears and motivations (Burland et al 2019, Sommerfeldt et al 2018, Scott, Perry and Sole 2017). I have writings elsewhere that speak to specific screening questioning around these elements (Richardson 2018).

In the physical examination, I observe for manifestation of fear-avoidant movement patterns through the affected limb: guarding, bracing, excessive co-contraction of the hamstrings and quadriceps and disproportionate off-loading of the knee (Hartigan et al 2013). I then attempt to correct this with verbal or tactile cues and reassurance to change these aberrant motor-control strategies, which hopefully in turn increases the quality and range of motion (ROM) during functional task assessment and reduces pain.

Acl recovery without surgery

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