Anterior Cruciate Ligament Injury: To Operate or Not?

Before deciding whether to have surgery for a torn anterior cruciate ligament (ACL), it’s essential to understand what the procedure can achieve and avoid overestimating its potential effects. Let’s examine the key facts to help you make the right decision and guide you on the best course of treatment.

The Anterior Cruciate Ligament Stabilizes the Joint and Communicates Movement to the Brain

he anterior cruciate ligament (ACL) is a crucial structure for the movement and stability of the knee joint for two reasons. First, it ensures the proper positioning of the femur, preventing it from sliding forward and keeping the joint centered during movement. The second function is even more valuable: the ACL contains numerous receptors that inform the brain about the knee’s position at any given moment. This information is vital for the timely activation of muscles, injury prevention, and smooth movement.

How the ACL Is Most Often Injured

ACL injuries typically occur during rotational movements on bent legs. Examples include uncontrolled landings while skiing, overextension of the knee in soccer, or direct impacts to the knee. Symptoms of an ACL injury include pain inside the knee joint, swelling often accompanied by blood accumulation, instability, and a sensation of the knee giving way unexpectedly.

Women Are 8 Times More Likely to Sustain an ACL Injury

This relatively common knee injury occurs more frequently in women, who have up to 8 times the risk compared to men, and also often in athletes. The severity of the injury can range from mild (e.g., small tears or sprains) to severe, where the ligament is completely torn. Quality rehabilitation and adherence to medical guidance are critical for returning to an active lifestyle, partly due to the risk of recurrence. Studies show that the rate of repeated ACL injuries during a return to sports exceeds 20%. Among young athletes under 25, the risk is 30–40 times higher than in uninjured peers, which can significantly impact the length of a professional sports career.

Common Complications of ACL Injuries

• A feeling of instability in the knee (“as if it might give out”).
• Reduced range of motion.
• Loss of muscle support and strength.
• Pain.
• Persistent swelling, especially after physical activity.
• Impaired coordination (the leg feels less responsive than before the injury).
• Frequently associated with injuries to the medial collateral ligament and meniscus.
• Damage to joint cartilage – posing a long-term risk of developing arthritis.

To Operate or Not?

To make the right decision, it is essential to fully understand the problem. Let’s examine some facts and conclusions from extensive studies:

1. After an ACL rupture, conservative treatment is often the initial recommendation before considering surgery.
2. Surgical reconstruction is necessary if the ACL is completely torn and instability persists despite rehabilitation/physiotherapy.
3. In most cases, it is advisable to exhaust conservative treatment options before considering surgery if instability remains. Several factors determine whether surgical treatment is appropriate for an ACL injury:
   • Joint anatomy and overall body constitution,
   • Muscle strength in stabilizing knee muscles, their condition, precision, engagement during complex movements, and endurance,
   • The quality of ligaments and fasciae,
   • Overall movement coordination,
   • Level and type of physical activity or sport.

Clients who undergo surgery benefit from better knee function and fewer meniscus injuries compared to those treated conservatively. However, automatically returning to the knee’s pre-injury level is not guaranteed. In the long term, regarding arthritis prevention, there is no advantage for clients with surgically reconstructed ACLs compared to those treated conservatively.

Given the value of the ACL, it is essential for physiotherapy to be part of the treatment process, whether opting for conservative or surgical approaches. When deciding for or against surgery, consider the client’s age, sports activities, and particularly subjective symptoms of instability during daily activities. If your job is sedentary, you’re not a sports enthusiast, and you don’t feel instability or insecurity in your knee, conservative treatment might be the best choice. Let’s delve deeper into both treatment options.

Conservative Treatment and Physiotherapy After ACL Injury

The conservative (non-surgical) approach initially focuses on reducing acute symptoms, then improving the strength and coordination of knee-stabilizing muscles.

What to Do Immediately After an Injury

The key to acute injury treatment is a combination of rest, ice, compression, and elevation. Early therapy aims to manage initial inflammation and promote healing. Rest immediately after the injury—stop activity and rest as much as possible for the first two days. Swelling, redness, and warmth in the knee joint cause pain. Cooling therapy can help reduce this pain. During the first 24–48 hours post-injury, apply an ice pack (wrapped in a light absorbent cloth) for 15–20 minutes every 2–3 hours. To limit swelling, use a soft bandage to wrap the knee. The bandage should fit snugly but not too tightly to avoid cutting off blood flow. If the skin under the bandage turns blue or feels cold, loosen the bandage. Finally, elevation—raising the injured area is critical during the first 48–72 hours after the injury to reduce swelling caused by gravity. Raise the injured limb above heart level to reduce pain, throbbing, and swelling.

Reducing Swelling and Pain

In the early phase, swelling, pain, and partial knee flexion are dominant symptoms. This position protects the joint and prevents further injury. It is maintained by the calf and hamstring muscles, which take over the stabilizing function of the ACL in the anterior-posterior direction, resulting in increased tension. Lymphatic drainage techniques—manual or with kinesiology taping—can help reduce swelling. High-power lasers are also effective in reducing swelling, alleviating pain, and speeding up healing by draining stagnant lymph fluid.

Achieving New Stability Through Muscles

Another crucial aspect of conservative therapy is improving the stability and confidence of the knee joint. This involves strengthening the muscle corset around the knee, including the thigh, calf, and hamstrings. The strength of the inner head of the quadriceps, often reduced after an ACL injury, plays a specific role in joint stability. Early-stage rehabilitation focuses on strengthening this muscle and incorporating it into movement patterns. Exercises on unstable surfaces and eccentric trainers are used to enhance muscle strength and precision. Later stages focus on improving movement patterns disrupted by the injury, such as posture, walking, or running.

How Long Does Treatment take?

Recovery time and loss of sports activity vary depending on the severity of the ACL injury:

• Minor injuries: 14 days to 3 weeks.
• Tears: 3–5 weeks.
• Complete ruptures: 5–8 weeks, after which the necessity of surgery is reassessed.

Even if surgery is eventually performed, the body benefits from completed physiotherapy treatment, leading to faster healing and full recovery post-surgery. Rehabilitating under the guidance of an experienced physiotherapist is strongly recommended.

Simple Exercises to Start at Home After an ACL Injury

1. Sliding the Heel

Begin by sitting on the floor with your legs extended and wearing socks. Slowly slide your heel along the floor towards yourself and then back. Ensure the movement is aligned, and the knee does not deviate sideways. This exercise is entirely weightless; respect your pain threshold and do not push for a full range of motion immediately. Repeat 10 times.

2. Thigh Muscle Contraction

Sit on the floor again, keeping the injured leg extended and the other leg bent. Try to contract the thigh muscle of the extended leg without moving it. If the knee joint is slightly bent and cannot yet be straightened, place a lightly inflated overball or a small cushion under the knee. Attempt to contract the front thigh muscle while applying gentle pressure from the back of the knee onto the ball/cushion. Hold for 10 seconds, then relax. Repeat 10 times.

3. Passive Knee Joint Straightening

This exercise requires two chairs of equal height. Place the chairs facing each other at a distance slightly shorter than the length of your leg. Sit on one chair and rest your heel on the seat of the other chair. Relax the leg and let gravity gradually straighten the knee. Rest in this position for 15–30 seconds initially, then for 1–2 minutes several times a day.

Surgical Treatment and Physiotherapy After ACL Surgery

Even the best-performed surgery is not effective without subsequent rehabilitative care. Do not underestimate the importance of time invested in physiotherapy and a strategic return to everyday or sports activities after injuries or surgeries. It accelerates recovery and joint stability, helping to prevent further injuries and excessive wear on the knee joint.

Surgical Options

Minimally invasive arthroscopic techniques are commonly used today for ACL reconstruction. These aim to remove the damaged ligament and replace it. The procedure allows the surgeon to clear ligament fragments and anchor a new ligament, sourced from a donor or grafted from another part of the body. The most common graft options are from the patellar tendon (the so-called BTB graft) or the hamstrings. Discuss the pros and cons with your surgeon. Minimally invasive surgery often allows patients to return home within a few days, marking only the beginning of a long recovery and rehabilitation process. Recovery speed depends on several factors, including the patient’s age, the extent of ligament damage, muscle condition, fitness level, and response to therapy.

Recovery Time After ACL Surgery

Full weight-bearing is typically achieved 6 to 9 months after surgery. Postoperative rehabilitation is a long process. Light training usually begins at 6 months for most athletes. Recreational athletes may return to light activities at this stage but should allow ample recovery time between them. Professional athletes may require additional training from coaches and physiotherapists to regain peak condition. This phase is delicate; overexertion can delay progress. The new ligament is gradually remodeled and adjusted to sports load. Some experts note that the new ligament is most vulnerable approximately 6 months post-surgery.

Rehabilitation After ACL Reconstruction

Phase 1: Weeks 0–3

Rehabilitation starts the day after surgery. This critical phase lasts about 2–3 weeks. By the end, the patient should achieve full knee extension and a 90-degree bend. Swelling should be minimal, and surgical wounds should heal well.

Phase 2: Weeks 3–5

Focus shifts to further increasing the range of knee flexion. Once a bend of 100–110° is achieved, stationary cycling can be introduced—initially for 15 minutes without resistance, gradually increasing time but not resistance. Rest after activity to prevent swelling. By the end of this phase, the goal is a knee without swelling, walking without limping, and a sense of stability in the knee. Be cautious of overexertion, as the graft is still healing and susceptible to shear and pressure forces.

Phase 3: Weeks 5–8

This phase extends to the 8th week post-surgery. If all progresses well and the patient handles postoperative care without difficulty, training more advanced elements is possible. Coordination and strength training on unstable surfaces are introduced. Exercises such as squats, lunges, or step-ups may be included if there’s no significant pain or swelling and if performed with proper technique under a physiotherapist’s guidance.

Phase 4: Up to 1 Year Post-Surgery

The final stage involves progressive targeted training, aiming to prepare the patient for demanding physical activities or elite sports. The recommended return-to-sports timeline ranges from 4–6 months to a year. The knee approaches full recovery, and therapy intensity gradually increases. However, the risk of ACL injury recurrence remains, especially if the return to sports is rushed. Patience and adherence to medical and physiotherapeutic advice are essential.

Tips to Accelerate Healing After ACL Injuries

1) Optimize Your Diet

• Protein-rich foods like meat and fish help rebuild muscles.
• Vitamin C from citrus fruits and leafy greens supports collagen production and tissue repair.
• Omega-3 fatty acids from salmon, sardines, walnuts, and chia seeds reduce inflammation and aid recovery.
• Calcium-rich foods like dairy, fish with soft bones, almonds, and leafy greens strengthen bones. Ensure adequate vitamin D through sunlight exposure to improve calcium absorption.

 2) Commit to Physiotherapy

Regular and consistent physiotherapy strengthens muscles, restores range of motion, and improves long-term knee health.

3) Focus on Hamstring Training

Hamstring muscles are crucial for knee stability. Strengthen their power, coordination, and endurance with guidance from a physiotherapist.

4) Use Laser Therapy

High-power laser therapy penetrates deep into tissues, reducing inflammation and pain while promoting blood circulation and oxygenation for faster healing.

5) Invest in a Quality Brace

A well-designed brace provides knee protection during recovery, limiting motion range and preventing sudden, damaging movements.

6) Use Kinesiology Tape

Properly applied tape enhances muscle activity, improves circulation, and reduces swelling, aiding recovery.

How will Fyzio svět help?

At Fyzio Svět, we support all stages of ACL injury care, from managing swelling and pain to optimizing muscle activity and creating personalized exercise plans. Our state-of-the-art equipment and experienced physiotherapists ensure the best possible care, whether through conservative treatment or postoperative rehabilitation. Let us help you on your recovery journey.