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ACL Reconstruction



When this ligament tears, unfortunately it doesn't heal and often leads to the feeling of instability in the knee.




Often other structures such as the meniscus, the articular cartilage (lining the joint) or other ligaments can also be damaged at the same time as a cruciate injury and these may need to be addressed at the time of surgery.

History of Injury

  • It can occur with a sudden change of direction, a direct blow e.g., a tackle, landing awkwardly
  • Often there is a popping sound when the ligament ruptures
  • Swelling usually occurs within hours



The diagnosis can often be made on the history alone.



At times the final diagnosis can only be made under anesthetic or with arthroscopic surgery.



  • Rest
  • Ice
  • Elevation
  • Bandage

Long term




Indications for Surgery

Young patients wishing to maintain an active lifestyle
Sports involving twisting activities e.g., soccer, basketball, football

Giving way with activities of daily living
People with dangerous occupations e.g., policemen, firemen, roofers, scaffolders

It is advisable to have physical therapy prior to surgery to regain motion and strengthen the muscles as much as possible.



The surgery is performed arthroscopically. The ruptured ligament is removed and then tunnels (holes) in the bone are drilled to accept the new graft. This graft that replaces your old ACL is taken either from the hamstring tendon or the patella tendon. There are advantages and disadvantages of each with the final decision based on your surgeons preference.



The rest of the knee can be clearly visualized at the same time and any other damage is dealt with such as meniscal tears.

The wounds are then closed, often with a drain in place, and a dressing applied.


Surgery is performed as a day surgery or overnight.

You will have pain medication by tablet or in a IV.

Any drains will be removed from the knee.

A splint is sometimes used for comfort.

You will be seen by a physical therapist who will teach you to use crutches and show you some simple exercises to do at home.


You can put all your weight on your leg.

Avoid anti-inflammatory medications or aspirin for 10 days.


Post-op review will usually be at 7-10 days

Physical therapy can begin after a few days or can be arranged at your first post-op visit.

If you have any redness around the wound, increasing pain in the knee, have an elevated temperature or feelgenerally unwell, you should contact your surgeon as soon as possible.


Physical therapy is an integral part of the treatment and is recommended to start as early as possible. Preoperative physical therapy is helpful to better prepare the knee for surgery. The early goal is to regain range of motion, reduce swelling and achieve full weight bearing.





Acute (0 - 2 WEEKS)


  1. Wound healing
  2. Reduce swelling
  3. Regain full extension
  4. Full weight bearing
  5. Wean off crutches
  6. Promote muscle control

Treatment guidelines

  2. Patella mobilization
  3. Active range of motion knee exercises, calf and hamstring stretching, contraction (non weight bearing progressing to standing), muscle control and full weight bearing. Aim for full extension by 2 weeks. Full flexion will take longer and generally will come with gradual stretching. Care needs to be taken with hamstring contraction as this may result in hamstring strains if too vigorous. Light hamstring loading continues into the next stage with progression of general rehabilitation. Resisted hamstring loading should be avoided for approximately 6 weeks

Gait retraining encouraging extension at heel strike

Stage 2 - Quadriceps control (2-6 weeks)


  1. Full active range of motion
  2. Normal gait with reasonable weight tolerance
  3. Minimal pain and effusion
  4. Develop muscular control for controlled pain free single leg lunge
  5. Avoid hamstring strain
  6. Develop early proprioceptive awareness

Treatment guidelines

  4. Water-based exercises can begin once the wound has healed, including treading water, and gentle swimming, avoiding breaststroke
  5. Begin proprioceptive exercises including single standing leg balance on the ground and mini-tramp. This can progress by introducing body movement while standing on one leg
  6. Bilateral and single calf raises and stretching

Stage 3 - Hamstring/Quadriceps Strengthening (6-12 weeks)


  1. Begin specific hamstring loading
  2. Increase total leg strength
  3. Promote good quadricep control in lunge and hopping activity in preparation for running

Treatment guidelines

  2. a) Active prone knee flexion which can be quickly progressed to include a light weight and gradually increasing weights.


    c) Single straight leg dead lift initially active with increasing difficulty by adding dumbbells.


  3. Gym based activity including leg presses, light squats and stationary bike that can be progressively increased in intensity as pain and control allow. It is important to monitor any effusions following exercise and if it is increasing then exercise should be toned down
  4. Once single leg lunge control is comparable to the other side hopping can be introduced. Hops can be made more difficult by including variations such as forward/back, side to side, off a step and in a quadrant
  5. Running may begin towards the latter part of this stage

Prior to running certain criteria must be met

  • No anterior knee pain
  • The knee must have no effusion
  1. Increased proprioceptive maneuvers with standing leg balance and progressive hopping based activity
  2. Expand calf routine to include eccentric loading

Stage 4 - Sport specific (3-6 months)


  1. Improve leg strength
  2. Develop running endurance speed, change of direction
  3. Advanced proprioception
  4. Prepare for return to sport and recreational lifestyle

Treatment guidelines

  3. Monitor potential problems associated with increasing loads
  4. No open chain resisted leg extension exercises unless authorized by your surgeon

Stage 5 - Return to sport (6 months plus)


A safe return to sporting activities

Treatment guidelines

  2. Preparation for body contact sports: Begin with low intensity one on one contests and progress by increasing intensity and complexity in preparation for drills that one might be expected to do at training

Risks & Complications

Complications are not common, but can occur. Prior to making the decision of having this operation, it is important you understand these so you can make an informed decision on the advantages and disadvantages of surgery.

Risks and complications can be Medical (Anesthesia) complications and surgical complications.

Medical (Anesthesia) Complications


Allergic Reactions to Medications

Blood loss requiring transfusion with its low risk of disease transmission.

Heart attacks, strokes, kidney failure, pneumonia, and bladder infections.

Complications from nerve blocks such as infection or nerve damage.

Serious medical problems can lead to ongoing health concerns and prolonged hospitalization. The following is a list of surgical complications. These are all rare but can occur. Most are treatable and do not lead to long term problems.


Occurs approximately 1 in 200 cases. Treatment involves either oral or IV antibiotics, or rarely further surgery to wash the infection out.

Deep Vein Thrombosis

These are clots in the veins of the leg. If they occur you may need blood thinning medication in the form of injections or tablets. Very rarely they can travel to the lung (Pulmonary Embolus), which can cause breathing difficulties or even death.

Excessive Swelling & Bruising


Joint stiffness


Graft Failure


Damage to Nerves or Vessels

There are small nerves under the skin that cannot be avoided and cutting them can lead to areas of numbness in the leg. This normally reduces in size over time and does not cause any functional problems with the knee. Very rarely there can be damage to more important nerves or vessels causing weakness in the leg.

Hardware Problems


Donor Site Problems

Donor site is the location from where the graft is obtained. In general, either the hamstrings or patella tendon are used. There can be pain or swelling in these areas, which usually resolves over time.

Residual Pain


Reflex Sympathetic Dystrophy

This is an extremely rare condition that is not entirely understood, which can cause unexplained and excessive pain.




Injury Information at Orthoillustrated