How Are ACL Tears Treated? What Is the Recovery Time?
When surgery is considered, the ligament is not repaired but instead is reconstructed usually with minimally invasive surgery using an arthroscope. A variety of techniques may be used, and the orthopedic surgeon and patient usually discuss the options available before a decision as to what type of surgery is performed. The "new" ligament may be taken from part of the patellar tendon (the tendon that attached the quadriceps muscle to the tibia), from part of the hamstring tendon in the back of the knee, or it may be a donor or cadaver graft. Each option has its advantages and disadvantages.
Other structures in the knee may also be damaged in association with an ACL tear, including other ligaments and menisci (cartilage), and will often be repaired at the same time.
In children, instead of the ligament being torn, the ligament can pull a piece of bone off the tibial spine where it inserts. Surgery make be required to reattach the bony fragment instead of reconstructing the ligament.
Surgery is often the recommended option for patients with ACL injuries. The purpose of surgery is to return patients to their original level of activity. For patients who are sedentary and do not perform sports, or for those who perform light manual work and are involved in non-cutting sports like running and bicycling, nonoperative treatments of ACL injuries may be reasonable alternatives.
The international Knee Documentation Committee has four categories of activity:
- Level 1 includes jumping, pivoting, and hard cutting.
- Level 2 is heavy manual work or side-to-side sports.
- Level 3 encompasses light manual work and non-cutting sports (such as running and cycling).
- Level 4 is sedentary activity without sports.
Treatment without surgery may be an option for those in categories 3 and 4.
Surgery usually does not occur immediately after the injury but may be delayed three to four weeks or more. This time is used to allow for the initial swelling and bleeding from the injury to decrease and to plan for the operation.
Physical therapists are an important part of the treatment team and are usually involved in the planning phase before surgery and after surgery. Recovery is measured in months, and often rehabilitation and physical therapy are required after the ACL reconstruction. This commitment to rehabilitation is an essential part of a successful operation. In the time prior to surgery, many patients are encouraged to "pre-hab" their injured leg. When the knee is injured, the quadriceps muscle tends to weaken almost immediately, and it is important to minimize any loss in strength and range of motion in the knee.
Rehabilitation may take six to nine months to return to full activity:
- In the first two to three weeks, the goal for physical therapy is to increase range of motion of the knee in a controlled fashion. Since the cruciate ligament graft needs time to heal in place, excessive flexing or bending is discouraged so that the graft doesn't rip. The goal in the first couple of weeks is full extension (straightening) of the knee and 90 degrees flexion (bending).
- In weeks three to six, the goal is to return full range of motion to the knee. Strengthening exercises may be considered and bicycles or stair-climbers are often used.
- For the next many months, the goal is to increase strength and agility while maintaining range of motion. The progress is closely monitored by the surgeon and physical therapist, again to protect the reconstructed knee and to push the patient to the goal of full recovery.
The patient is often kept in a protective knee brace through much of the rehabilitation process to protect the grafted ACL from any undue stress. The brace use may be continued even after the ACL has healed, especially during sporting activities to decrease the risk of reinjury.