Anterior Cruciate Ligament (ACL) Tear

An anterior cruciate ligament (ACL) tear is one of the most common knee injuries. This type of injury occurs most frequently during sports such as football (soccer), basketball, and skiing, which involve sudden movements or changes in direction, awkward landings, and jumping. Early treatment is essential for the patient to safely return to daily activities without persistent postoperative pain.

The method of treatment depends both on the severity of the injury and the patient’s activity level. Patients who regularly participate in sports and intense physical activity should address the injury promptly to prevent further deterioration. In most cases, surgical intervention is considered the necessary solution to restore full knee function, as conservative treatment often proves insufficient. In cases where an ACL tear is accompanied by another injury—such as a meniscal tear—simultaneous surgical repair of both injuries can be performed. The decision not to proceed with arthroscopic reconstruction of an ACL tear should only be made after thorough evaluation of the increased risk of developing knee osteoarthritis, which rises significantly if the injury is left untreated. Following a detailed medical history and clinical assessment, the orthopedic surgeon will design the most appropriate treatment plan.

There are four main ligaments in the knee that function as stabilizing bands. Their purpose is to connect the lower end of the femur to the upper end of the tibia and act as a stabilizing mechanism for the knee joint. The anterior cruciate ligament is one of these. It is located in the center of the knee and controls rotational stability, as well as forward movement of the tibia.

When the anterior cruciate ligament is injured or completely torn, the knee joint may become unstable.

Although an ACL tear occurs mainly during sports activities, it can also be caused by a simple fall or a sudden impact. An anterior cruciate ligament tear typically happens when the knee twists abruptly during a change of direction, or when there are intense and sudden accelerations and decelerations, as well as awkward landings after a jump.

It is worth noting that women—particularly female athletes—are more likely to experience an ACL tear compared to men. This is mainly due to increased ligamentous laxity influenced by estrogen, anatomical differences, and variations in muscle strength and neuromuscular control.

The diagnosis of an anterior cruciate ligament tear usually involves a combination of clinical examination, imaging studies, and, in some cases, diagnostic arthroscopy. During the physical examination, signs of instability are assessed, and specific clinical tests are performed to evaluate the integrity of the ligament. X-rays and magnetic resonance imaging (MRI) also contribute to the diagnostic process, helping to confirm the injury and identify any associated damage, such as meniscal or cartilage lesions. Prompt and accurate diagnosis is essential for developing an appropriate treatment plan and achieving optimal outcomes for patients.

An anterior cruciate ligament tear is accompanied by intense pain. According to most patients, the moment of injury is extremely vivid, as they feel as though something has snapped inside the knee. The rupture creates the sensation that something is tearing within the joint, and significant swelling develops in the knee. An ACL tear is a very serious injury that has a greater impact on knee stability than most other knee injuries, which makes proper and timely treatment essential.

The symptoms of an ACL tear vary depending on the mechanism of injury, the extent of the damage, and the patient’s physical condition.

More specifically, common symptoms include:

• A “tearing” sensation in the knee
• Severe pain
• A popping or snapping sound at the time of injury
• Swelling and redness
• Tenderness on palpation
• Loss of full range of motion
• Knee instability
• Muscle atrophy around the knee
• Difficulty walking

If a patient experiences any of the above symptoms, they should immediately consult a specialized orthopedic surgeon. The knee joint is a complex structure composed of bones, ligaments, tendons, and other tissues that work together to enable movement. Therefore, obtaining a timely and accurate diagnosis is essential to determine the severity of the injury—whether it is a partial or complete ACL tear—and to propose the most appropriate and fully personalized treatment plan.

Many patients wonder about the differences between a partial and a complete anterior cruciate ligament tear. The main distinguishing factor between the two lies in the method of treatment. When the tear is partial, there may be room for conservative management and avoidance of surgery. However, in cases of a complete tear, surgical reconstruction is considered the ideal solution for achieving optimal and long-lasting results. Early surgical intervention significantly improves the patient’s quality of life by allowing for a faster and more effective recovery.

Regarding conservative treatment for an ACL tear, this may include rest and a structured physiotherapy program aimed primarily at strengthening the muscles and enhancing knee stability.

More specifically, conservative management includes:

• Anti-inflammatory medication in the form of pharmaceutical preparations
• Strengthening exercises
• Ice therapy
• Immobilization and offloading of the knee with the use of crutches
• Rest and avoidance of sports activities
• Use of a knee brace in certain cases

The clinical examination is what ultimately determines whether surgery is necessary to restore an anterior cruciate ligament tear. The diagnosis is confirmed with X-rays and a magnetic resonance imaging (MRI) scan of the knee, which provides a clearer assessment of the extent of the damage.

If surgery is deemed necessary, the patient should not delay the procedure under any circumstances, as postponement may have serious consequences for mobility. Potential risks of delaying surgery include the development of severe associated injuries or fractures.

Furthermore, over time, additional damage may occur to the menisci and the articular cartilage, potentially leading to post-traumatic knee osteoarthritis. The goal of surgical treatment is to restore knee stability so that the joint bears weight properly and is better supported by the surrounding muscles. Today, ACL reconstruction can be performed with greater precision and safety thanks to robotic-assisted surgical techniques.

Strengthening the muscles surrounding the knee through physiotherapy and targeted exercise significantly facilitates postoperative recovery, both in terms of quality and duration. Naturally, the exercise program should be mild and carefully supervised in order to avoid a new potential injury that could delay or complicate the surgical procedure.

Additionally, if the patient is overweight, it would be beneficial to reduce body weight so that the joints are not subjected to excessive stress during the rehabilitation period. On the day of the operation, the patient should be as well-rested as possible.

Adherence to the treating physician’s instructions is a fundamental and integral part of achieving full and prompt recovery. Initially, the patient will need to use crutches to avoid placing excessive weight on the operated leg during the day. Their use will gradually decrease until they are no longer necessary.

This phase usually lasts approximately 10 days after surgery, although the exact duration depends on each individual’s healing capacity. The goal is for the patient to be able to walk without assistance about 10 days after arthroscopic reconstruction. Walking ability will continue to improve progressively over the following days and weeks, eventually returning to pre-injury levels.

Additionally, all patients—regardless of age—should follow a personalized physiotherapy program starting from the third day after surgery. In this way, they can return promptly to their daily and athletic activities, achieving full restoration of mobility. It is extremely important for the patient to strictly follow the doctor’s instructions and to report anything unusual observed during the recovery period. The combination of exercise, ice therapy, and analgesic medication forms the cornerstone of a successful rehabilitation.

The safest and most effective surgical method for treating an anterior cruciate ligament tear is ACL reconstruction (ligamentoplasty). This is a safe and minimally invasive procedure that is now performed arthroscopically. Its purpose is to restore the damaged ligament using a graft taken from another part of the knee, which is then placed in the anatomical position of the torn ligament.

An important advantage of this procedure is that it does not require a large incision. Instead, the arthroscope and specialized instruments are inserted through two small openings, approximately 0.5 cm in size, on the anterior surface of the knee. This minimally invasive technique allows for optimal restoration of the injured joint and faster patient recovery, while minimizing postoperative pain and ensuring long-lasting results.

Thanks to advances in surgical techniques, we now achieve:

• Significantly less postoperative pain
• Faster return to daily activities
• No need for hospitalization

The cost of the surgery is generally affordable. However, it depends on the surgical technique applied, the specific characteristics of each case, and the type of implants used during the procedure. For patients with private insurance, the cost is covered partially or fully, depending on the terms of their insurance policy.

Dr Kosta Dretakis and his team are highly specialized in arthroscopic surgery and have treated many world class athletes from Greece and other countries.