ACL Tears

What is an ACL tear?

The ACL is one of four main ligaments in the knee. It sits deep in the joint and keeps the shin bone from sliding forward and rotating on the thigh bone. Most tears happen without contact, when you plant your foot and twist or land awkwardly from a jump in sports like soccer, basketball, football or skiing. Direct hits to the knee also cause them.

Tears are graded from a mild sprain to a complete rupture. Complete tears do not heal on their own because the ligament lies in the joint fluid.

What does an ACL tear feel like?

Many people feel or hear a pop, then the knee swells within hours. The knee may feel loose or buckle when you pivot or step off a curb. Walking in a straight line may feel fine within a few weeks, while cutting and twisting do not. The meniscus is injured at the same time in many cases, which adds locking or catching.

Do I need surgery?

Not everybody does. In a randomized trial of 121 young, active adults with acute ACL tears, those assigned to structured rehabilitation first, with surgery only if needed, had similar knee function at two years to those who had early reconstruction. Roughly four in ten of the rehab group still went on to have reconstruction within two years.¹ The trial excluded people with other major injuries, so it does not tell the whole story for everyone.

Reconstruction is usually advised when the knee keeps giving way during everyday life, when you play cutting or pivoting sports and want to return, when other structures such as the meniscus are also torn and repairable, or when your job demands a stable knee.

How is the decision made?

Dr. Stepanyan considers:

• Your age, activity and the sport or work you want to return to
• Whether the knee feels unstable in real life
• Other injuries found on exam and MRI, especially meniscus and cartilage
• Your willingness to commit to months of rehabilitation
• Your goals, which matter as much as the scan

What happens in ACL reconstruction?

The torn ligament is not sewn back. Instead, it is replaced with a graft, a strip of tendon taken from your own body (often the hamstring, quadriceps or patellar tendon) or from a donor. Dr. Stepanyan performs the surgery arthroscopically, through small incisions with a camera. Tunnels are drilled in the thigh bone and shin bone, the graft is passed through and secured, and any meniscus tears are repaired or trimmed at the same time. The operation is outpatient.

Graft choice affects recovery, strength and re-tear risk, and Dr. Stepanyan will go over the choices that suit your age and sport.

What are the chances of re-injury?

Re-injury is a real concern in younger athletes. Waiting until strength, balance and hop tests are close to normal before returning to sport lowers the risk.

Should I get a second opinion?

It is a good idea if you have been told you need surgery and are not sure, or if the knee has been unstable after a previous ACL surgery. Request a visit and bring your MRI.

Where can I see Dr. Stepanyan?

Dr. Stepanyan sees knee patients in Glendale, East LA and Santa Fe Springs. He completed a fellowship in sports medicine and arthroscopy at Congress Orthopedic Group in Pasadena.

What does recovery look like?

These are the typical stages in Dr. Stepanyan’s physical therapy protocol for ACL reconstruction combined with a meniscus repair. Recovery from an isolated ACL reconstruction is somewhat faster, and your own plan may differ.

1. Weeks 0–2

   Calm it down

   You put about half your weight on the leg with crutches and keep the brace locked straight for walking and sleeping. The goals are full straightening of the knee, bending to 90°, less swelling, and waking up the quadriceps.

2. Weeks 2–6

   Motion and gait

   You work toward bending to 125° and walking normally. Crutches and the brace come off when your quadriceps is strong enough to control the knee. Balance training starts.

3. Weeks 6–14

   Strengthen

   Squats, leg press, step-downs, cycling and elliptical build strength. Running is still off limits.

4. Weeks 14–22

   Start running

   A forward running program begins once you can control an 8-inch step-down and pass strength testing. Agility work and plyometrics follow when strength is adequate.

5. Week 22 and beyond

   Return to sport

   Sport-specific training begins. Dr. Stepanyan clears you for sport after hop testing shows at least 85% symmetry between legs and you are free of apprehension. Many younger athletes wait longer, because re-injury risk is highest early.

Dr. Stepanyan’s therapists follow his written ACL reconstruction protocol. If anything here differs from what you were told, follow your own plan.

Sources

1. Frobell RB, Roos EM, Roos HP, Ranstam J, Lohmander LS. A randomized trial of treatment for acute anterior cruciate ligament tears. N Engl J Med. 2010;363(4):331-342. Journal article