The anterior cruciate ligament (ACL) is one of the most commonly injured ligaments of the knee. The incidence of ACL injuries is currently estimated at approximately 200,000 annually, with 100,000 ACL reconstructions performed each year. Brown CH, Carson EW. Revision anterior cruciate ligament surgery. Clin Sports Med 1999;18:109-171. In general, the incidence of ACL injury is higher in people who participate in high-risk sports, such as basketball, football, skiing, and soccer. Gwinn DE, Wilckens JH, McDevitt ER, et al. The Relative Incidence of Anterior Cruciate Ligament Injury in Men and Women at the United States Naval Academy. Am J Sports Med 2000;28(1):98-102.
The information that follows includes the details of ACL anatomy and the pathophysiology of an ACL tear, treatment options for ACL injuries along with a description of ACL surgical techniques and rehabilitation, potential complications, and outcomes. The information is intended to assist the patient in making the best-informed decision possible regarding the management of ACL injury.
The ACL prevents the shinbone (Tibia) from sliding forward beneath the thighbone (Femur).
The ACL can be injured in several ways:
- Changing direction rapidly
- Stopping suddenly
- Slowing down while running
- Landing from a jump
- Direct contact or collision
If you injure your ACL, you may not feel any pain immediately. However, you might hear a popping noise, and you may feel your knee give out from under you.
- Within 2 to 12 hours, the knee may swell, and you may feel pain when you try to stand.
- Apply ice to control the swelling, and elevate your knee until you can see an orthopedic surgeon.
If you walk or run on an injured ACL, you may damage the cushioning cartilage in your knee. For example, if you plant your foot and then turn your body to pivot, your shinbone may stay in place as your thighbone above it moves with the rest of your body.
Diagnosis of an ACL injury is based on a thorough patient history and physical examination of the knee. The examination may include several tests to see if the knee stays in the proper position when pressure is applied from different directions. Your orthopedist may order an X-ray and a magnetic resonance imaging (MRI) scan of the knee.
A partial tear of the ACL may or may not require surgical treatment. A complete tear is a more serious injury. Complete tears, especially in younger athletes, may require reconstruction. Both nonsurgical and surgical treatment options are available for ACL injury.
Nonsurgical treatment may be used because of a patient’s age (very young or elderly) or overall low activity level. It may be recommended if the overall stability of the knee is intact. Nonsurgical treatment involves a program of muscle strengthening, often with the use of a brace to provide stability. Activities should be modified to limit cutting or pivoting movements.
Arthroscopic surgery or open surgery may be performed. Surgery involves reconstruction of the damaged ligament using a strip of tendon either donated or from the patient’s knee. Examples can include the patellar tendon or hamstring muscle. An exercise and rehabilitation program to strengthen the muscles and restore full joint mobility follows surgery.
Anatomy and Pathophysiology
The bone structure of the knee joint is formed by the femur, the tibia, and the patella. The ACL is one of the four main ligaments within the knee that connect the femur to the tibia.
The knee is essentially a hinged joint that is held together by the medial collateral (MCL), lateral collateral (LCL), anterior cruciate (ACL) and posterior cruciate (PCL) ligaments. The ACL runs diagonally in the middle of the knee, preventing the tibia from sliding out in front of the femur as well as providing rotational stability to the knee.
Arthroscopic picture of the normal ACL. Christina Allen, MD
The weight-bearing surface of the knee is covered by a layer of articular cartilage. On either side of the joint, between the cartilage surfaces of the femur and tibia, are the medial meniscus and lateral meniscus. The menisci act as shock absorbers and work with the cartilage to reduce the stresses between the tibia and the femur.
It is estimated that 70 percent of ACL injuries occur through non-contact mechanisms while 30 percent result from direct contact with another player or object. Griffin LY. Noncontact Anterior Cruciate Ligament Injuries: Risk Factors and Prevention Strategies. J Am Acad Orthop Surg 2000;8:141-150. The mechanism of injury is often associated with deceleration coupled with cutting, pivoting or sidestepping maneuvers, awkward landings or “out of control” play. Colby S, Francisco A, Yu B, et al. Electromyographic and Kinematic Analysis of Cutting Maneuvers: Implications for Anterior Cruciate Ligament Injury. Am J Sports Med 2000;28(2):234-240. Several studies have shown that female athletes have a higher incidence of ACL injury than male athletes in certain sportsIreland ML. Anterior Cruciate Ligament Injury in Female Athletes: Epidemiology. Journal of Athletic Training 1999;34(2):150-154. . It has been proposed that this is due to differences in physical conditioning, muscular strength, and neuromuscular control. Other hypothesized causes of this gender-related difference in ACL injury rates include pelvis and lower extremity (leg) alignment, increased ligamentous laxity and the effects of estrogen on ligament properties.Huston LJ, Greenfield ML, Wojtys EM. Anterior Cruciate Ligament Injuries in the Female Athlete: Potential Risk Factors. Clin Orthop 2000;372:50-63.
Arthroscopic picture of torn ACL [yellow star]. Christina Allen, MD
Approximately 50 percent of ACL injuries occur in combination with damage to the meniscus, articular cartilage, or other ligaments. Additionally, patients may have bone bruises of the bone beneath the cartilage surface. These may be seen on an MRI and may indicate injury to the overlying articular cartilage. Johnson DL, Urban WP, Jr, Caborn DNM, et al. Articular Cartilage Changes Seen With Magnetic Resonance Imaging-Detected Bone Bruises Associated With Acute Anterior Cruciate Ligament Rupture. Am J Sports Med 1998;26(3):409-414.
Immediately after the injury, patients usually experience pain and swelling and the knee feels unstable. Within a few hours after a new ACL injury, patients often have a large amount of knee swelling, a loss of full range of motion, pain or tenderness along the joint line and discomfort while walking.
In addition to performing special tests for identifying meniscus tears and injury to other ligaments of the knee, the physician will often perform test s to see if the ACL is intact.
Arthroscopic picture of torn medial meniscus in chronically ACL-deficient knee. In this case, the torn meniscus is pushed forward [yellow star] and locked in front of the knee [called a "bucket handle" meniscus tear], so the patient could not straighten out the leg. Christina Allen, MD
The natural history of an ACL injury without surgical intervention varies from patient to patient and depends on the patient’s activity level, degree of injury and instability symptoms.
The prognosis for a partially torn ACL is often favorable, with the recovery and rehabilitation period usually at least 3 months. However, some patients with partial ACL tears may still have instability symptoms. Close clinical follow-up and a complete course of physical therapy helps identify those patients with unstable knees due to partial ACL tears.
Complete ACL ruptures have a much less favorable outcome. After a complete ACL tear, some patients are unable to participate in cutting or pivoting-type sports, while others have instability during even normal activities such as walking. There are some rare individuals who can participate in sports without any symptoms of instability. This variability is related to the severity of the original knee injury as well as the physical demands of the patient.
Arthroscopic picture of damaged articular cartilage in chronically ACL-deficient knee. Christina Allen, MD
Some ACL injuries occur in combination with damage to the meniscus, articular cartilage or other ligaments. Secondary damage may occur in patients who have repeated episodes of instability due to ACL injury. With chronic instability, up to 90 percent of patients will have meniscus damage when reassessed 10 or more years after the initial injury. Similarly, the prevalence of articular cartilage lesions increases up to 70 percent in patients who have a 10-year-old ACL deficiency.
Surgical and Non-Surgical Options
MRI of complete ACL tear. The ACL fibers have been disrupted and the ACL appears wavy in appearance [yellow arrow]. Christina Allen, MD
When a patient with an ACL injury is initially seen for evaluation in the clinic, the doctor may also order X-rays to look for any possible fractures. He or she may also order an MRI (Magnetic Resonance Imaging) scan to evaluate the ACL and to check for evidence of injury to other knee ligaments, meniscus cartilage or articular cartilage.
Treatment options for ACL injuries include both surgical and nonsurgical treatments.
ACL tears are not usually repaired using suture to sew it back together, because repaired ACL’s have generally been shown to fail over time. Kaplan N, Wickiewicz T, Warren R. Primary surgical treatment of anterior cruciate ligament ruptures. A long-term follow-up study. Am J Sports Med 1990;18(4):354-358. Therefore, the torn ACL is generally replaced by a substitute graft made of tendon. The grafts commonly used to replace the ACL include:
- Patellar tendon autograft (autograft comes from the patient)
- Hamstring tendon autograft
- Allograft (taken from a cadaver) patellar tendon, Achilles tendon, semitendinosus, gracilis, or posterior tibialis tendon
In nonsurgical treatment, progressive physical therapy and rehabilitation can restore the knee to a condition close to its pre-injury state and educate the patient on how to prevent instability. Noyes FR, McGinniss GH, Grood ES. The variable functional disability of the anterior cruciate ligament-deficient knee. Orthop Clin North America 1985;16:47-67. This may be supplemented with the use of a hinged knee brace. However, many people who choose not to have surgery may experience secondary injury to the knee due to repetitive instability episodes.
Nonsurgical Treatment Benefits and Limits
Surgical treatment is usually advised in dealing with combined injuries (ACL tears in combination with other injuries in the knee). However, deciding against surgery is reasonable for select patients. Nonsurgical management of isolated ACL tears is likely to be successful or may be indicated in patients:
- With partial tears and no instability symptomsMessner K, Maletius W. Eighteen- to Twenty-Five-Year Follow-up After Acute Partial Anterior Cruciate Ligament Rupture. Am J Sports Med 1999;27(4):455-459.
- With complete tears and no symptoms of knee instability during low-demand sports who are willing to give up high-demand sports
- Who do light manual work or live sedentary lifestyles
- Whose growth plates are still open (children)
Surgical Intervention and Considerations
Patients treated with surgical reconstruction of the ACL have long-term success rates of 82 percent to 95 percent. Recurrent instability and graft failure are seen in approximately 8 percent of patients. The goal of the ACL reconstruction surgery is to prevent instability and restore the function of the torn ligament, creating a stable knee. This allows the patient to return to sports. There are certain factors that the patient must consider when deciding for or against ACL surgery.
Active adult patients involved in sports or jobs that require pivoting, turning or hard-cutting as well as heavy manual work are encouraged to consider surgical treatment. Noyes FR, Mooar LA, Moorman CT, et al. Partial tears of the anterior cruciate ligament. Progression to complete ligament deficiency. J Bone Joint Surg Br 1989;71B(5):825-833. This includes older patients who have previously been excluded from consideration for ACL surgery. Activity, not age, should determine if surgical intervention should be considered.
In young children or adolescents with ACL tears, early ACL reconstruction creates a possible risk of growth plate injury, leading to bone growth problems. The surgeon can delay ACL surgery until the child is closer to skeletal maturity or the surgeon may modify the ACL surgery technique to decrease the risk of growth plate injury.Stanitski C. Anterior Cruciate Ligament Injuries in the Young Athlete with Open Physes. Am J Sports Med 1988;16(4):424-.
A patient with a torn ACL and significant functional instability has a high risk of developing secondary knee damage and should therefore consider ACL reconstruction.
It is common to see ACL injuries combined with damage to the menisci (50 percent), articular cartilage (30 percent), collateral ligaments (30 percent), joint capsule, or a combination of the above. The “unhappy triad”, frequently seen in football players and skiers, consists of injuries to the ACL, the MCL and the medial meniscus. Murrell GAC, Maddali S, Horovitz L, et al. The Effects of Time Course after Anterior Cruciate Ligament Injury in Correlation with Meniscal and Cartilage Loss. Am J Sports Med 2001;29:9-14. In cases of combined injuries, surgical treatment may be warranted and generally produces better outcomes. Shelbourne K, Porter D. Anterior cruciate ligament-medial collateral ligament injury: nonoperative management of medial collateral ligament tears with anterior cruciate ligament reconstruction. A preliminary report. Am J Sports Med 1992;20(3):283-286. As many as 50 percent of meniscus tears may be repairable and may heal better if the repair is done in combination with the ACL reconstruction.
Patellar tendon autograft prepared for ACL reconstruction. Christina Allen, MD
The middle third of the patellar tendon of the patient, along with a bone plug from the shin and the kneecap is used in the patellar tendon autograft. Occasionally referred to by some surgeons as the “gold standard” for ACL reconstruction, it is often recommended for high-demand athletes and patients whose jobs do not require a significant amount of kneeling. Spindler KP, Kuhn JE, Freedman KB, et al. Anterior Cruciate Ligament Reconstruction Autograft Choice: Bone-Tendon-Bone Versus Hamstring: Does It Really Matter? A Systematic Review. Am J Sports Med 2004;32(8):1986-1995. In studies comparing outcomes of patellar tendon and hamstring autograft ACL reconstruction, the rate of graft failure was lower in the patellar tendon group (1.9 percent versus 4.9 percent). Freedman KB, D’Amato MJ, Nedeff DD, et al. Arthroscopic Anterior Cruciate Ligament Reconstruction: A Metaanalysis Comparing Patellar Tendon and Hamstring Tendon Autografts. Am J Sports Med 2003;31(1):2-11. In addition, most studies show equal or better outcomes in terms of postoperative tests for knee laxity when this graft is compared to others. However, patellar tendon autografts have a greater incidence of postoperative patellofemoral pain (pain behind the kneecap) complaints and other problems. Sachs R, Daniel D, Stone M, et al. Patellofemoral problems after anterior cruciate ligament reconstruction. Am J Sports Med 1989;17(6):760-765.
The pitfalls of the patellar tendon autograft are:
- Postoperative pain behind the kneecap
- Pain with kneeling
- Slightly increased risk of postoperative stiffness
- Low risk of patella fracture
Hamstring tendon allograft prepared for ACL reconstruction. Christina Allen, MD
The semitendinosus hamstring tendon on the inner side of the knee is used in creating the hamstring tendon autograft for ACL Reconstruction. Some surgeons use an additional tendon, the gracilis, which is attached below the knee in the same area. This creates a two- or four-strand tendon graft. Hamstring graft proponents claim there are fewer problems associated with harvesting of the graft compared to the patellar tendon autograft including:
- Fewer problems with anterior knee pain or kneecap pain after surgery
- Less postoperative stiffness problems
- Smaller incision
- Faster recovery Pinczewski LA, Deehan DJ, Salmon LJ, et al. A Five-Year Comparison of Patellar Tendon Versus Four-Strand Hamstring Tendon Autograft for Arthroscopic Reconstruction of the Anterior Cruciate Ligament. Am J Sports Med 2002;30(4):523-536. Shaieb MD, Kan DM, Chang SK, et al. A Prospective Randomized Comparison of Patellar Tendon Versus Semitendinosus and Gracilis Tendon Autografts for Anterior Cruciate Ligament Reconstruction. Am J Sports Med 2002;30(2):214-220.
The graft function may be limited by the strength and type of fixation in the bone tunnels, as the graft does not have bone plugs. Rodeo SA, Arnoczky SP, Torzilli PA, et al. Tendon healing in a bone tunnel. A biomechanical and histological study in the dog. J Bone Joint Surg Am 1993;75A:1795-1803. There have been conflicting results in research studies as to whether hamstring grafts are slightly more susceptible to graft elongation (stretching), which may lead to increased laxity during objective testing. Otsuka H, Ishibashi Y, Tsuda E, et al. Comparison of Three Techniques of Anterior Cruciate Ligament Reconstruction with Bone-Patellar Tendon-Bone Graft: Differences in Anterior Tibial Translation and Tunnel Enlargement with Each Technique. Am J Sports Med 2003;31(2):282-288. Recently, some studies have demonstrated decreased hamstring strength in patients after surgery.Marder RA, Raskind JR, Carroll M. Prospective evaluation of arthroscopically-assisted anterior cruciate ligament reconstruction. Patellar tendon versus semitendinosus and gracilis tendons. Am J Sports Med 1991;19:478-484.
Patellar tendon (top) and Achilles tendon (bottom) allografts prior to being prepared for ACL reconstruction. Christina Allen, MD
Allografts are grafts taken from cadavers and are becoming increasingly popular. Fu FH, Jackson DW, Jamison J, et al. Allograft reconstruction of the anterior cruciate ligament. In: Jackson DW, Arnoczky SP, Woo SL-Y, Frank CB, Simon TM, eds. The Anterior Cruciate Ligament. Current and Future Concepts. New York: Raven Press, 1993;325-338. These grafts are also used for patients who have failed ACL reconstruction before and in surgery to repair or reconstruct more than one knee ligament. Advantages of using allograft tissue include elimination of pain caused by obtaining the graft from the patient, decreased surgery time and smaller incisions. The patellar tendon allograft allows for strong bony fixation in the tibial and femoral bone tunnels with screws.
However, allografts are associated with a risk of infection, including viral transmission (HIV and Hepatitis C), despite careful screening and processing. Conrad EU, Gretch DR, Obermeyer KR. Transmission of the hepatitis-C virus by tissue transplantation. J Bone Joint Surg Am 1995;77A:214-224. Several deaths linked to bacterial infection from allograft tissue (due to improper procurement and sterilization techniques) have led to improvements in allograft tissue testing and processing techniques. There have also been conflicting results in research studies as to whether allografts are slightly more susceptible to graft elongation (stretching), which may lead to increased laxity during testing. Indelicato P, Linton R, Huegel M. The results of fresh-frozen patellar tendon allografts for chronic anterior cruciate ligament deficiency of the knee. Am J Sports Med 1992;20(2):118-121.
Before any surgical treatment, the patient is usually sent to physical therapy. Patients who have a stiff, swollen knee lacking full range of motion at the time of ACL surgery may have significant problems regaining their motion after surgery. Wasilewski S, Covall D, Cohen S. Effect of surgical timing on recovery and associated injuries after anterior cruciate ligament reconstruction. Am J Sports Med 1993;21(3):338-342. It usually takes three or more weeks from the time of injury to achieve full range of motion. It is also recommended that some ligament injuries be braced and allowed to heal prior to ACL surgery. Inoue M, McGurk-Burleson E, Hollis J, et al. Treatment of the medial collateral ligament injury. I: The importance of anterior cruciate ligament on the varus-valgus knee laxity. Am J Sports Med 1987;15(1):15-21.
Post-operative X-ray after ACL patellar tendon reconstruction (with picture of graft superimposed) shows graft position and bone plugs fixation with metal interference screws.
The patient, the surgeon and the anesthesiologist select the anesthesia used for surgery. Patients may benefit from an anesthetic block of the nerves of the leg to decrease postoperative pain. The surgery usually begins with an examination of the patient’s knee while the patient is relaxed due the effects of anesthesia. This final examination is used to verify that the ACL is torn and also to check for looseness of other knee ligaments that may need to be repaired during surgery or addressed postoperatively. If the physical exam strongly suggests the ACL is torn, the selected tendon is harvested (for an autograft) or thawed (for an allograft) and the graft is prepared to the correct size for the patient.
Arthroscopic view of ACL graft [yellow star] in position. Christina Allen, MD
After the graft has been prepared, the surgeon places an arthroscope into the joint. Small (one-centimeter) incisions called portals are made in the front of the knee to insert the arthroscope and instruments and the surgeon examines the condition of the knee.
Meniscus and cartilage injuries are trimmed or repaired and the torn ACL stump is then removed. In the most common ACL reconstruction technique, bone tunnels are drilled into the tibia and the femur to place the ACL graft in almost the same position as the torn ACL. A long needle is then passed through the tunnel of the tibia, up through the femoral tunnel, and then out through the skin of the thigh. The sutures of the graft are placed through the eye of the needle and the graft is pulled into position up through the tibial tunnel and then up into the femoral tunnel. The graft is held under tension as it is fixed in place using a metal button, interference screws, spiked washers, posts or staples. The devices used to hold the graft in place are generally not removed.
Before the surgery is complete, the surgeon will probe the graft to make sure it has good tension, verify that the knee has full range of motion and perform tests to assess graft stability. The skin is closed and dressings and perhaps a postoperative brace and cold therapy device, depending on surgeon preference, are applied. The patient will usually go home on the same day of the surgery.
Potential Surgical Complications
The incidence of infection after arthroscopic ACL reconstruction has a reported range of 0.2 percent to 0.48 percent. Williams R, 3rd, Laurencin C, Warren R, et al. Septic arthritis after arthroscopic anterior cruciate ligament reconstruction. Diagnosis and management. Am J Sports Med 1997;25(2):261-267.
Allografts specifically are associated with risk of viral transmission, including HIV and Hepatitis C, despite careful screening and processing. Conrad EU, Gretch DR, Obermeyer KR. Transmission of the hepatitis-C virus by tissue transplantation. J Bone Joint Surg Am 1995;77A:214-224. The chance of obtaining a bone allograft from an HIV-infected donor is calculated to be less than 1 in a millionBuck BE, Malinin TI, Brown MD. Bone transplantation and human immunodeficiency virus. An estimate of risk of acquired immunodeficiency syndrome (AIDS). Clin Orthop 1989;240:129-136.
Rare risks include bleeding from acute injury an artery or vein (overall incidence is 0.01 percent) and weakness or paralysis of the leg or foot. It is not uncommon to have numbness of the outer part of the upper leg next to the incision, which may be temporary or permanent. Kartus J, Ejerhed L, Sernert N, et al. Comparison of Traditional and Subcutaneous Patellar Tendon Harvest: A Prospective Study of Donor Site-Related Problems After Anterior Cruciate Ligament Reconstruction Using Different Graft Harvesting Techniques. Am J Sports Med 2000;28:328-335. Tifford CD, Spero L, Luke T, et al. The Relationship of the Infrapatellar Branches of the Saphenous Nerve to Arthroscopy Portals and Incisions for Anterior Cruciate Ligament Surgery: An Anatomic Study. Am J Sports Med 2000;28(4):562-567.
A blood clot in the veins of the calf or thigh is a potentially life-threatening complication. A blood clot may break off in the bloodstream and travel to the lungs, causing pulmonary embolism or to the brain, causing stroke. This risk of eep Vein Thrombosis (topic.cfm?topic=A00219) is reported to be approximately 0.12 percent.
Recurrent instability due to rupture or stretching of the reconstructed ligament or poor surgical technique (reported to be as low as 2.5 percent and as high as 10 percent) is possible. Bach BR, Jr, Tradonsky S, Bojchuk J, et al. Arthroscopically Assisted Anterior Cruciate Ligament Reconstruction Using Patellar Tendon Autograft: Five- to Nine-Year Follow-up Evaluation. Am J Sports Med 1998;26(1):20-29.
Knee stiffness or loss of motion has been reported at between 5 percent and 25 percent. Irrgang JJ, Harner CD, Fu FH, et al. Loss of Motion Following ACL Reconstruction: A Second Look. Jour Sports Rehab 1997;6:213-225.
Rupture of the patellar tendon (patellar tendon autograft) or patella fracture (patellar tendon or quadriceps tendon autografts) may occur due to weakening at the site of graft harvest. Stein DA, Hunt SA, Rosen JE, et al. The Incidence and Outcome of Patella Fractures after Anterior Cruciate Ligament Reconstruction. Arthroscopy 2002;18(6):578-583.
In young children or adolescents with ACL tears, early ACL reconstruction creates a possible risk of growth plate injury, leading to bone growth problems. Koman JD, Sanders JO. Valgus Deformity After Reconstruction of the Anterior Cruciate Ligament in a Skeletally Immature Patient. A Case Report. J Bone Joint Surg Am 1999;81(5):711-5. The ACL surgery can be delayed until the child is closer to reaching skeletal maturity. Alternatively, the surgeon may be able to modify the technique of ACL reconstruction to decrease the risk of growth plate injury.
Postoperative anterior knee pain is especially common after patellar tendon autograft ACL reconstruction. The incidence of pain behind the kneecap varies between 4 percent and 56 percent in studies, whereas the incidence of kneeling pain may be as high as 42 percent after patellar tendon autograft ACL reconstruction.Freedman KB, D’Amato MJ, Nedeff DD, et al. Arthroscopic Anterior Cruciate Ligament Reconstruction: A Metaanalysis Comparing Patellar Tendon and Hamstring Tendon Autografts. Am J Sports Med 2003;31(1):2-11.
Physical therapy is a crucial part of successful ACL surgery, with exercises beginning immediately after the surgery. Much of the success of ACL reconstructive surgery depends on the patient’s dedication to rigorous physical therapy. With new surgical techniques and stronger graft fixation, current physical therapy may use an accelerated course of rehabilitation.
Shelbourne K, Wilckens J, Mollabashy A, et al. Arthrofibrosis in acute anterior cruciate ligament reconstruction. The effect of timing of reconstruction and rehabilitation. Am J Sports Med 1991;19(4):332-336.
In the first 10 to 14 days after surgery, the wound is kept clean and dry, and early emphasis is placed on regaining the ability to fully straighten the knee and restore quadriceps control. The knee is iced regularly to reduce swelling and pain. The surgeon may dictate the use of a postoperative brace and the use of a machine to move the knee through its range of motion. Burks R, Daniel D, Losse G. The effect of continuous passive motion on anterior cruciate ligament reconstruction stability. Am J Sports Med 1984;12(4):323-327. Rosen M, Jackson D, Atwell E. The efficacy of continuous passive motion in the rehabilitation of anterior cruciate ligament reconstructions. Am J Sports Med 1992;20(2):122-127. Weight bearing status (use of crutches to keep some or all of the patient’s weight off of the surgical leg) is also determined by physician preference, as well as other injuries addressed at the time of surgery.
The goals for rehabilitation of ACL reconstruction include reducing knee swelling, maintaining mobility of the kneecap to prevent anterior knee pain problems, regaining full range of motion of the knee, as well as strengthening the quadriceps and hamstring muscles. The patient may return to sports when there is no longer pain or swelling, when full knee range of motion has been achieved, and when muscle strength, endurance and functional use of the leg have been fully restored.
The patient’s sense of balance and control of the leg must also be restored through exercises designed to improve neuromuscular control. Griffin LY. Noncontact Anterior Cruciate Ligament Injuries: Risk Factors and Prevention Strategies. J Am Acad Orthop Surg 2000;8:141-150. This usually takes 4 to 6 months. The use of a functional brace when returning to sports is ideally not needed after a successful ACL reconstruction, but some