ACL tears: Symptoms, surgery, and recovery

Neal Goldenberg, MD, examines a patient for a knee injury

Evidence supports that patients do better when they undergo ACL Prehab. It's like getting a jump start on your recovery.

Neal Goldenberg, MD, chair of Sports Medicine at Cheshire

It happens in the blink of an eye. One minute, you are running down the field, ready to make a cut and weave past the defender. The next, as your foot plants into the grass, something “pops,” and you crumple to the ground, clutching your knee.

An examination on the sideline can aid in the diagnosis: It’s a torn anterior cruciate ligament, more commonly known as the ACL.

ACL tears are one of the most common and devastating knee injuries that affect both young athletes and adult “weekend warriors.” ACL injuries are 2 to 6 times more commonly occur in females than males and most common while playing sports such as soccer, football, basketball, skiing, rugby, and snowboarding. However, they can occur in any sport or athletic activity, even after a slip and fall injury.

If you are active and wish to return to cutting and pivoting type sports, surgery is usually the best form of treatment. Full recovery takes about 9 to 15 months. 

ACL injury symptoms

Most ACL injuries are non-contact, twisting injuries that occur when the athlete goes to make a cut or pivot, changing directions suddenly, and their knee gives way.

“The tibia, or the shin bone, typically moves forward in relation to the femur, causing the ACL to tear,” says Neal Goldenberg, MD, chair of Sports Medicine at Cheshire Medical Center “Often, this happens when the knee is no longer directly above the toes.”

Symptoms of an injury to the ACL include:

  • Hearing or feeling a “pop” in the knee
  • Swelling in the knee
  • Difficulty walking after the injury (often due to pain and swelling)
  • A feeling of instability or giving way in the knee
  • Knee stiffness (due to knee swelling)

ACL surgery preparation

ACL reconstruction is usually the safest and most reliable option when it comes to ACL surgery, Goldenberg says.

“ACLs don’t typically heal on their own,” he says. “So when this injury occurs, it’s important to recognize it because it has implications for your long-term knee health.”

If left untreated, ACL deficiency can lead to injuries to the meniscus or cartilage and an increased likelihood of arthritis down the road.

“We want our patients and student-athletes to get back to sports and the activities they enjoy,” Goldenberg says.

Immediately after diagnosis of an ACL tear by your healthcare provider, your orthopaedist may delay surgery in order to allow the knee to “calm down.” They will then prescribe what Cheshire calls an “ACL Prehab” plan to increase the odds of a full recovery after surgery.

“I have every patient do ACL Prehab before going to surgery,” he says. “The purpose is to decrease swelling and edema in the knee, improve pain, restore a normal range of motion, and then start working on strength.”

The Prehab exercises are similar to those performed in physical therapy after surgery.

“Evidence supports that patients do better when they undergo ACL Prehab. It's like getting a jump start on your recovery,” Goldenberg says. “So, we schedule them with our Sports Medicine department’s athletic trainers. It's a free service we offer—so you can start your recovery now, before surgery, and you'll be better off.”

ACL reconstruction surgery

On the day of surgery, patients first meet their operating room team—a group of trained specialists who aid in patient care before, during, and after the procedure. During surgery, patients are given general anesthesia, meaning they will be asleep during the operation.

First, an orthopaedic surgeon inserts a small camera into the knee. This allows the surgeon to look around the knee and identify any sites of injury. They can then use small tools while viewing through the camera to perform the procedure.

During the procedure, a small hole or tunnel is drilled in the femur and another in the shinbone. Then, a replacement tendon (called a graft) is secured in these tunnels. In an autograft surgery, the graft is taken (harvested) from the patient’s own patellar, hamstring, or quadriceps tendons.

The surgery usually lasts about 90 minutes to 2 hours, and patients are able to go home the same day.

Recovery timeline and return to sport

After surgery, physical therapy (PT) begins within a few days. Patients work with Cheshire’s team of sports medicine outpatient physical therapists to rebuild strength, range of motion, and stability in their knee.

Complete recovery can occur in as little as 7 months—the minimum time needed for the graft to mature—however, time to return to sport is somewhat variable.

There is also no standard battery of return-to-play tests that are 100% predictive of an athlete being ready to return to play. “Typically, an athlete is ready to return to play once the graft is mature, they have regained appropriate strength in their leg, and they are psychologically ready to return to play. They have to trust their knee again”. As Goldenberg states, this process can take time— often 9 months to 1 year, depending on the athlete.

“Imagine a 14-year-old girl, a female soccer player who tears her ACL during her freshman year of high school,” Goldenberg says. “By the time she’s ready to return to play, she’s at least 15. But she’s missed an entire year of growth, maturity, coaching, and strength—at the same time as her teammates are going through puberty, getting stronger and faster. The level of play elevates so quickly at that age. Returning to play can be difficult, and that makes prehab and physical therapy after surgery that much more important.”

Because of all of those factors, Goldenberg says return to sport may not be guaranteed. “We consider these injuries not career-ending but career-threatening,” he says. “With modern techniques and rehab protocols, however, our Sports Medicine trained physical therapists really do a great job at getting these kids ready to return to sports safely.”

That’s why ACL injury prevention is so vital, he says.

For a knee injury assessment with Cheshire Medical Center’s Orthopaedics department, call Orthopeadics at 603-354-5482 or talk to your primary care provider.

If you want Cheshire Medical Center’s Sports Medicine team to help create an injury prevention program for yourself or your team, please call Sports Medicine at 603-354-5454 ext. 3730.