Ask the Expert: Do all ACL tears need surgery?

A male lies on his back with his leg bent as the other person sits beside him with both hands below the bent knee.
A male therapist or doctor, starting to perform the anterior drawer test. A test in 90° of knee flexion for the objectivation of stability of anterior cruciate ligament.

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Q: I have played soccer since high school and never had a major injury. Three months ago, I was tackled from behind and badly twisted my right knee. My unit medical officer felt my anterior cruciate ligament (ACL) was torn and an MRI confirmed this diagnosis. My knee currently feels quite stable and I can run and cycle without pain. I have an appointment with an orthopedic surgeon and want to know if all ACL tears require surgery.

—Sidelined

A: Dear Sidelined:
Sorry to hear about your knee injury. While the ACL is a major stabilizer of the knee, not everyone who tears this ligament needs a surgical repair. The decision on whether or not to operate is based on a number of considerations which include:

  1. If there is damage to other structures in the knee such as the menisci, articular cartilage or other knee ligaments, then surgery is often recommended.
  2. Is the person experiencing knee instability? We don’t understand why, but some people with partial or complete ACL tears have little or no instability, while other people’s knees are so loose they don’t feel safe walking down stairs. People with instability usually require surgery.
  3. What are the person’s performance expectations in terms of work and sports? An office worker who cycles for fitness is more likely to tolerate an unrepaired ACL than an infantry soldier who plays on the unit basketball team.
  4. Does the person feel stable wearing a custom-made knee brace? Some people find they only experience instability when they do activities requiring cutting, pivoting, twisting or rapidly moving from side to side. Many of these people are able to do these activities without instability if they wear a custom-made knee brace.
  5. Has the person had physiotherapy focused on increasing their quadriceps’ strength, improving their balance and enhancing their control over their knee movements? Many people find they experience little or no instability after going through a program like this.

The bottom line: Every ACL tear is unique and some people can function at high levels without surgical repair or the support of a custom-made knee brace. It sounds like you are coping very well, but the only way to know if you require surgery will be to carefully test your knee to see how stable it is when you return to soccer and your full military duties. Exercise is medicine!

 

Dr. Darrell Menard, M.D., Diploma in Sport Medicine

Darrell.menard@forces.gc.ca

For more info visit Strengthening the Forces.

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