ACL Surgery: 50 Questions Patients Ask

The anterior cruciate ligament (ACL) is one of the four main ligaments of the knee. It runs through the middle of the joint and keeps the shin bone from sliding forward and rotating under the thigh bone, which is why it matters so much for cutting, pivoting and jumping.

Most ACL tears happen without contact: planting the foot and changing direction, landing awkwardly from a jump, or stopping suddenly. They can also happen with a direct blow to the knee, as in football or skiing falls.^1,2

Many people feel or hear a pop, followed by pain and swelling within a few hours. The knee often feels unstable or gives way, especially when turning or pivoting.

Often, yes. Once the swelling settles, many people can walk in a straight line. The problem is instability with twisting, cutting and sports, which can cause further damage to the meniscus and cartilage, so it is important to have the knee examined before returning to activity.

Dr. Dold can usually diagnose an ACL tear with a careful examination using specific stability tests. X-rays, which can be taken in our office, check for fractures, and an MRI confirms the tear and shows any injury to the meniscus, cartilage or other ligaments. Studies show that a careful exam and MRI are both accurate for diagnosing ACL tears.^3,4

In a partial tear, some of the ligament fibers remain intact. If the knee is stable, many partial tears are treated with physical therapy; if the knee keeps giving way, reconstruction may still be recommended.

About half of ACL injuries come with other damage, most often a torn meniscus, a bone bruise, cartilage injury or another ligament injury such as the MCL. These are checked on MRI and treated at the same time when needed. See meniscus tears.^5,6

Yes. Female athletes in sports like soccer and basketball tear their ACL at a higher rate than male athletes in the same sports. Differences in anatomy, hormones and landing mechanics all play a part, and injury-prevention training can lower the risk.^2,7

A completely torn ACL does not heal back together on its own in most people, because of its location inside the joint. Some people can still do well without surgery if they avoid cutting and pivoting activities and strengthen the muscles around the knee. In a randomized trial of young active adults, structured rehabilitation with the option of later reconstruction gave results similar to early reconstruction at 2 and 5 years, and many patients in the rehabilitation group did not need surgery.^8,9

Not everyone does. Surgery is usually recommended for people who want to return to cutting and pivoting sports, for physically demanding jobs, for knees that keep giving way, and when the meniscus is also torn. Dr. Dold will go over your options and goals with you.^10,8

Less active people, those who don’t play cutting or pivoting sports, and people whose knees feel stable in daily life may do well with physical therapy and activity changes. If the knee keeps giving way later, reconstruction is still an option.^8,9

If the knee keeps giving way, each episode can damage the meniscus and cartilage. Over time, this increases the risk of further tears and knee arthritis.^6,11,12

Some people can play straight-line sports like running or cycling with a well-rehabilitated knee and no ACL. Cutting, pivoting and jumping sports such as soccer, basketball and football are much harder and riskier without one.

Most surgeons prefer to wait until the swelling has gone down and the knee bends and straightens well, usually a few weeks after the injury. Physical therapy before surgery (prehab) helps get the knee ready. Some injuries, such as certain meniscus tears, are best repaired sooner. For patients who choose surgery, the American Academy of Orthopaedic Surgeons (AAOS) guideline recommends reconstruction within 3 months of an isolated ACL tear, and studies show that longer delays raise the risk of additional meniscus and cartilage damage.^10,13,11

Age alone is not the deciding factor. Active adults in their 40s, 50s and beyond can do well after ACL reconstruction. The decision depends on your activity level, the condition of the knee, including any arthritis, and your goals.^14,15

Children and teenagers who are still growing have open growth plates near the knee. Techniques that protect the growth plates are used when needed, and surgery is often recommended because young athletes are at high risk of further knee damage if the knee stays unstable. Studies show that young patients treated without surgery have more instability and meniscus tears, and that delaying surgery increases damage inside the knee.^16,17,18,19

Second opinions are always welcome. Dr. Dold sees many patients for a second opinion on ACL injuries and can review your MRI and records. Request an appointment.

ACL reconstruction replaces the torn ligament with a tendon graft. It is done arthroscopically, through small incisions with a camera: tunnels are made in the bones and the graft is fixed in place, where it heals and acts as a new ACL.

It is a common, well-established procedure, usually done through small incisions as an outpatient. Even so, recovery is long and requires months of dedicated rehabilitation.

A repair stitches the torn ligament back to the bone. It is only possible for certain tears right off the thigh bone with good-quality tissue. Reconstruction replaces the ligament with a graft and is the standard treatment for most ACL tears. Dr. Dold offers repair for selected patients with these proximal tears. Age matters: in one published series, repairs failed in 37% of patients aged 21 or younger, compared with about 4% of older patients, so reconstruction is usually recommended for teens and young athletes.^31,32,10

The surgery itself usually takes about one to two hours, longer if the meniscus or other ligaments are also repaired. You will spend additional time in pre-op and recovery.

ACL reconstruction is usually done under general anesthesia, often with a nerve block to help control pain after surgery. Your anesthesiologist will go over the plan with you on the day of surgery.

Most patients go home the same day, from an outpatient surgery center or hospital.

Pain is usually worst in the first few days. A nerve block, ice, elevation, anti-inflammatory and other non-opioid medications, and a short course of stronger medication if needed help keep you comfortable.³³

Yes, absolutely. Dr. Dold takes many photos inside your knee during surgery, showing what he found and exactly how your surgery was done. You will receive these photos and review them with Dr. Dold at your first post-operative visit.

Full recovery takes most of a year. Patients generally return to cutting and pivoting sports at about 9 months, once strength, motion and testing show the knee is ready.^34,35

After a standard ACL reconstruction, you can put as much weight on the leg as is comfortable right away, using crutches for support for the first 1 to 2 weeks until you walk without a limp. This can take longer if the meniscus was also repaired.

A brace is often used for the first few weeks after surgery, especially if the meniscus was repaired. Dr. Dold will tell you whether you need one and for how long.

You can drive once you are off narcotic pain medication and can control the car safely. After surgery on the left knee in an automatic car, this is often within the first couple of weeks; after surgery on the right knee, it usually takes longer.

Students and people with desk jobs often return within about one to two weeks. Jobs that involve standing, lifting or climbing usually take longer, sometimes several months.

Physical therapy usually starts within the first week after surgery and continues for several months, progressing from motion and swelling control to strength, running, agility and sport-specific training.

Early on, the priorities are getting the knee fully straight and getting the quadriceps muscle working again with exercises like quad sets and straight-leg raises. Strength, balance and landing drills come later.³⁶

Sleep on your back with the leg supported so the knee rests straight. Avoid a pillow under the knee, which can make it harder to get the knee fully straight.

Most swelling settles over the first several weeks, but mild swelling after activity can come and go for a few months. Ice, compression and elevation help.

Some aching, stiffness and soreness with new activities is common during the first months of rehabilitation. Sudden swelling, giving way, or pain that keeps getting worse should be checked.

Most patients begin a guided return to running at about 3 to 4 months, once strength and motion allow it.

Return to cutting and pivoting sports is generally around 9 months, after you pass strength and functional testing. Returning too early increases the risk of re-injury. In one study, each month that return to sport was delayed, up to 9 months, lowered the re-injury rate by about half.^34,35

Risks are uncommon but include stiffness, infection, blood clots, numbness around the incision, pain at the front of the knee and graft failure. Dr. Dold will review these with you before surgery.

Call for fever, increasing redness or drainage from the incisions, calf pain or swelling, new numbness, pain that is not controlled by your medication, or sudden new swelling. Go to the emergency room for chest pain or shortness of breath.

Yes. In a study of 2,488 ACL reconstructions from the multicenter MOON group, 4.4% of patients re-tore the graft and 3.5% tore the ACL in the other knee. Younger age, higher activity level and a donor (allograft) graft all raised the risk.²⁷ A review of younger athletes found that nearly 1 in 4 athletes under 25 who return to sport have a second ACL injury.³⁷ For young athletes at high risk, Dr. Dold may add a lateral extra-articular tenodesis (LET); see question 20. Completing rehabilitation and an injury-prevention program also matters.

Complete your full rehabilitation, don’t return to sport before you pass testing, and keep doing a neuromuscular injury-prevention program that trains strength, balance and safe landing. Injury-prevention programs have been shown to cut ACL injury rates by about half.^38,7,39,34

An ACL injury does increase the long-term risk of knee arthritis, especially when the meniscus or cartilage is also damaged. Restoring stability and protecting the meniscus helps, but reconstruction does not completely remove the risk.^40,12,41

Most patients return to their usual activities and many to their previous level of sport. Some notice minor differences, such as kneeling discomfort or occasional stiffness. In a large review, 81% of patients returned to some sport and 65% to their pre-injury level.^42,43

Yes. Feeling frustrated, low or fearful of re-injury is common during a long recovery. Talk with Dr. Dold and your therapist; confidence usually grows as strength returns, and extra support is available if you need it.^44,45

Usually not. The devices that hold the graft are designed to stay in place, and many are made of materials that the body gradually absorbs.

Most insurance plans cover ACL reconstruction when it is medically necessary. Dr. Dold accepts most major insurance plans, including Medicare and Tricare; please call 469-850-0680 to confirm your coverage. See insurance.

The cost depends on your insurance plan, deductible and where the surgery is done. Our team can help you understand your expected costs before surgery.

Physical therapy before surgery (prehab) to reduce swelling, restore full motion and strengthen the quadriceps leads to a smoother recovery. Arrange help at home for the first few days, and set up your home so you can move around easily on crutches.^46,47

Request an appointment online or call 469-850-0680. Same-day appointments are available for new injuries, and walk-in visits are welcome Monday, Wednesday and Friday, 8:30 to 10:30 am.