ACL Tear Treatment Options

Treatment for ACL tears typically falls into two categories: conservative nonsurgical management and surgical reconstruction. The choice of treatment depends on the severity of the tear, the patient’s activity level, and their long-term goals.

The main goals of ACL tear management are to:

• Reduce pain and swelling
• Restore knee stability and strength
• Improve function and confidence in the knee
• Allow a safe return to daily activities or sports
• Prevent further injury to the knee, such as meniscus or cartilage damage

Not all ACL tears require surgery, and some patients do well with non-surgical care.

Nonsurgical management is generally reserved for patients with partial ACL tears, lower activity levels, or those who are not candidates for surgery due to medical or personal reasons. Non-surgical approaches focus on:

Physical Therapy

Physical therapy is the cornerstone of conservative management. A structured rehabilitation program aims to restore knee strength, stability, and range of motion. Therapists work with patients to build the surrounding muscles, particularly the quadriceps and hamstrings, to compensate for the compromised ligament.

Bracing

Functional knee braces can provide additional support during daily activities and low-impact sports. Braces are often used in conjunction with therapy to enhance stability and prevent further injury.

Activity Modification

For patients with sedentary or less physically demanding lifestyles, avoiding high-impact activities can reduce the risk of instability episodes or additional damage to the knee.

While nonsurgical management can be effective in some cases, it is not ideal for individuals with high activity levels or those whose knees exhibit persistent instability.

For patients who wish to return to sports or whose knee feels unstable despite nonsurgical interventions, ACL reconstruction is the gold-standard treatment.

ACL Reconstruction

The ACL does not typically heal on its own, so surgery often involves reconstructing the ligament using a graft rather than repairing it. Most ACL reconstructions are performed arthroscopically using small incisions.

The graft may come from:

The patient’s own tissue (autograft), commonly from the patellar tendon or quadriceps tendon

• Autograft is typically recommended for young, high-demand, active patients
• Graft choice is based on patient age, sport played, activity level, occupation, and other personalized factors. The most common autografts used are bone-patella tendon-bone (BTB) and all-soft tissue quadriceps tendon (QT) autograft. Additional autograft options include quadrupled hamstring (HS) and bone-quadriceps tendon (BQT) among others.
• Each autograft has its own set of pros and cons for use and Dr. Boden will discuss this extensively on an individualized basis with her patients. There is no one-size fits all strategy when it comes to ACL reconstruction and Dr. Boden takes an individualized patient-specific approach to these surgeries accounting for numerous factors that can impact outcomes and patient satisfaction.

Donor tissue (allograft) in select cases

• Allograft is often used in older patients with lower demands placed on the knee.
• In addition to decreased morbidity, easier recovery, and shorter operative times, numerous studies have demonstrated outcomes and revision rates after allograft use in patients who are > 40 years of age are consistently similar to those after autograft ACL reconstructions.

If you would like to read more on graft choices for ACL reconstruction, click the following link to an article published by Dr. Boden on graft choice in modern ACL reconstruction.

ACL Reconstruction Augmentation

In certain cases including high risk athletes, patients with hypermobility, and revision cases, augmentation of the ACL reconstruction may also be discussed. Augmentation options include internal bracing, graft augmentation, and extra-articular procedures including a lateral extra-articular tenodesis (LET). These procedures can reinforce knee stability and may reduce the risk of ACL graft failure and re-tear.

ACL Repair

In select cases, ACL repair may be considered instead of reconstruction. The ability to repair the ACL depends on several factors, including the tear extent, location, tissue quality, and timing of surgery. Dr. Boden specializes in minimally invasive arthroscopic techniques that allow for repair of the ACL without graft harvest, allowing for smaller incisions, preservation of native tissue, and improved proprioception after repair.

Bridge Enhanced ACL Repair

Bridge Enhanced ACL Repair (BEAR) is a minimally invasive strategy to repair torn ACLs in select patients who meet specific criteria. This technique uses a protein-based scaffold that is soaked in the patient’s blood to form a biologic bridge allowing the ACL to heal back together. In contrast to traditional ACL reconstruction techniques, this repair technique avoids using graft tissue from other parts of the body and helps to preserve native anatomy which may improve proprioception and strength following recovery. Common risks, similar to standard ACL reconstruction surgery, include re-tear, knee stiffness, and pain.

Advanced Open Reconstruction

In complex cases, such as high-risk patients, multi-ligament injuries, or revisions of prior ACL surgeries, Dr. Boden may employ advanced open reconstruction techniques to ensure optimal outcomes. This may include a lateral extra-articular tenodesis (LET) to help stabilize the knee joint and reduce the risk of ACL re-tear.

Timing of Surgery

Surgery may be performed after swelling decreases and knee motion improves. In some cases, delaying surgery to complete physical therapy first (prehab) can improve outcomes.

Recovering from an ACL injury, whether treated nonsurgically or surgically, requires a well-structured rehabilitation plan. Dr. Boden emphasizes the importance of individualized care to ensure patients regain full function and achieve their personal goals.

Post-Surgical Recovery Timeline

• Immediate Post-Operative Period (Weeks 1-2) – Following ACL reconstruction, the focus is on reducing pain and swelling while regaining knee extension. Cryotherapy and compression are commonly used, along with gentle range-of-motion exercises. Physical therapy is started right away to allow for optimal knee range of motion and quadriceps re-activation.
• Early Rehabilitation (Weeks 3-6) – During this phase, physical therapy emphasizes restoring range of motion and improving quadriceps strength. Patients may progress weight-bearing activities with the guidance of their surgeon and therapist.
• Intermediate Rehabilitation (Weeks 7-12) – As strength improves, patients progress to more challenging exercises that target balance, proprioception (position, movement and balance), and functional strength. Exercises include squats, lunges, and step-ups to mimic daily activities and sports-specific movements.
• Advanced Rehabilitation (Months 3-6) – Patients gradually return to higher-impact activities, including light jogging and sport-specific drills. Emphasis is placed on neuromuscular control to reduce the risk of re-injury.
• Return to Sport (6-12 Months) – Return to sport functional testing can be performed at 6 months to allow for a patient-specific rehabilitation plan. Full return to sport is typically permitted around the 9 to 12 months, depending on the patient’s progress. Dr. Boden collaborates closely with therapists and trainers to ensure a safe and successful return to play.

The key to a successful recovery is:

1. Consistent participation in physical therapy
2. Focusing on hip, core, and lower extremity strength to reduce strain on the knee joint.
3. Avoiding premature return to high-impact activities helps prevent complications.