ACL Reconstruction
Background
ACL reconstruction replaces a torn anterior cruciate ligament with a tendon graft to restore knee stability. It is commonly considered for patients who want to return to sports involving cutting or pivoting, experience repeated episodes of the knee giving way, or have associated injuries that affect the treatment plan.
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The procedure is usually performed arthroscopically through small incisions. The graft is positioned where the original ACL was located and secured to the thighbone and shinbone. Any meniscus or cartilage injuries are assessed at the same time.
The Surgical Procedure
ACL reconstruction is typically performed under general anesthesia, often with a nerve block to help manage pain after surgery. The exact procedure depends on the graft selected and whether other knee injuries need treatment.
Graft Choice
The new ACL can be made from the patient’s own tendon, called an autograft, or from donor tissue, called an allograft. Autograft options include the quadriceps tendon, bone-patellar tendon-bone, and hamstring tendons. Each has advantages and tradeoffs, including differences in graft harvest discomfort and the type of activity a patient hopes to resume.
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For young and active patients, an autograft is generally preferred because it is associated with a lower risk of graft failure. Graft selection is discussed individually based on age, sport, activity goals, anatomy, and prior surgery.
Surgical Technique
A camera is placed inside the knee to evaluate the ACL, menisci, and cartilage. The torn ACL tissue is cleared as needed, and small tunnels are created in the thighbone and shinbone. The tendon graft is passed through these tunnels and secured in position.
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In selected patients at higher risk of repeat injury, an additional procedure called a lateral extra-articular tenodesis, or LET, may be performed to provide added rotational stability. This is considered based on factors such as age, sport, knee laxity, and whether the surgery is a revision.
Additional Procedures
Meniscus tears are common alongside ACL injuries. A repairable tear may be sutured during the same surgery. Cartilage injuries and other ligament damage are also evaluated and addressed when appropriate. These additional procedures may change the early weight bearing and rehabilitation plan.
Recovery Timeline
ACL recovery is a gradual process that depends on both graft healing and the return of strength and knee control. Physical therapy is an essential part of recovery. Your plan may be adjusted if a meniscus repair or another procedure is performed.
Early Recovery (Weeks 1 - 6)
The priorities are reducing swelling, regaining full knee extension, restoring walking, and beginning to reactivate the quadriceps muscle.
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Crutches and a brace may be used initially
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Ice, elevation, and medication help manage pain and swelling
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Physical therapy begins early
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Weight bearing instructions depend on any additional procedures
Intermediate Recovery (Weeks 6 - 12)
Therapy focuses on restoring motion, normalizing walking, and building strength and balance. Progress is guided by knee swelling, muscle control, and movement quality.
Late Recovery (Months 3 - 6)
Patients continue strengthening and may begin a supervised running progression when they meet the appropriate goals. Jumping, landing, and more challenging movements are introduced gradually.
Return to Sport (Months 6 - 12 and Beyond)
Rehabilitation progresses to cutting, pivoting, and sport specific practice. Return to unrestricted pivoting sports is generally considered no earlier than nine months after surgery, and some athletes need longer. Before clearance, patients complete testing of strength, single leg hopping, movement quality, and confidence in the knee.
What to Expect
Pain Management
We utilize a multimodal approach including a nerve block when appropriate, oral medications, and ice therapy to minimize the postoperative pain and to limit narcotic use. Swelling and discomfort are expected early on, but most patients find their pain very manageable with this comprehensive approach.
Graft Healing
The tendon graft gradually attaches to the bone and remodels after surgery. This process continues for more than a year, even after the knee begins to feel strong. Following each rehabilitation phase helps protect the graft while strength and coordination return.
Return to Sport Testing and Brace
The calendar is only one part of the return decision. Testing evaluates quadriceps and hamstring strength, hopping, landing and cutting mechanics, and psychological readiness. Strength and hop performance are commonly compared with the uninjured leg, with at least 90% symmetry used as a benchmark. The goal is a knee that performs reliably during the specific demands of your sport.
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A functional ACL brace may be discussed for selected athletes returning to sport. Some patients feel more confident wearing one, but a brace has not been shown to reliably prevent another ACL injury. It does not replace rehabilitation or return to sport testing.