ACL Tear Treatment Options

The ACL is a strong, rope-like structure that runs diagonally through the center of the knee, connecting the thighbone (femur) to the shinbone (tibia). It prevents the tibia from sliding forward relative to the femur and provides rotational control.

When the ACL tears, the knee may buckle or “give way,” especially during activities like cutting, pivoting, or jumping. Without a functioning ACL, athletes are at higher risk of secondary injuries—particularly meniscus tears and early cartilage degeneration—if they continue to play without stabilization.

Not all ACL tears require surgery. Non-operative treatment may be appropriate for older or less active individuals who do not experience knee instability.

However, surgical reconstruction is typically recommended for:

• Athletes and active individuals who participate in pivoting or cutting sports.
• Patients with persistent knee instability during daily activities.
• Combined injuries involving the meniscus, cartilage, or other ligaments.
• Younger patients at risk of further joint damage if left untreated.

Early evaluation with Dr. José Vega, Cleveland’s trusted sports medicine and knee specialist, helps determine whether surgical or non-surgical treatment is best for each patient’s goals and lifestyle.

During ACL reconstruction, the torn ligament is replaced with a graft that acts as a new ligament. The three main graft options are:

Patellar Tendon Autograft

• Uses the middle third of the patient’s own patellar tendon with small bone plugs from the kneecap and shinbone.
• Provides excellent strength and fixation.
• Common choice for high-level athletes – currently considered the gold standard in the United States
• Anterior knee pain after surgery is not uncommon (affecting up to 20% of patients)

Hamstring Tendon Autograft

• Most commonly used graft for ACL reconstruction outside of the United States (Europe, Asia, South America)
• Uses two tendons from the back of the thigh.
• Carries a slightly higher risk of graft tear in young, active patients
• Results in less anterior knee pain and a smaller incision.
• Often used for older patients or those concerned about kneeling discomfort.
• Tends to stretch out over time so the knee may feel “loose” on exam
• Lifelong hamstring weakness

Quadriceps Tendon Autograft

• Uses a portion of the quadriceps tendon just above the kneecap.
• Has graft re-tear rates that are the same as patellar tendon autograft
• Provides a strong, thick graft with low donor-site pain.
• Early recovery may be slower while the quadriceps muscle function recovers

Allografts (donor tissue) are sometimes used for revision surgeries or lower-demand patients. These are not for use in young patients due to unacceptably high rates of graft tear.

If you decide to proceed with surgery, you and Dr. Vega will select the best graft type based on your anatomy, activity level, and recovery goals.

The procedure is performed arthroscopically, using a small camera and instruments inserted through tiny incisions around the knee.

1. The torn ACL is removed, and tunnels are created in the femur and tibia.
2. The graft (from the patellar, hamstring, or quadriceps tendon) is passed through these tunnels.
3. The graft is secured with small screws, buttons, or anchors to hold it in place while it heals.

Over several months, the body gradually incorporates the graft into the bone, transforming it into a living, functional ligament through a process called ligamentization.

Patients go home the same day, walking with crutches for the first few days (unless additional procedures like meniscus repair are performed), and begin physical therapy shortly after surgery.

Rehabilitation is crucial for a successful outcome. A structured program typically includes:

• Phase 1 (0–6 weeks): Reduce swelling, restore full range of motion, and activate quadriceps.
• Phase 2 (6-12 weeks): Regain balance, and strength.
• Phase 3 (3-6 months): Progress strengthening and dynamic control.
• Phase 4 (6-9 months): Equalize side to side leg strength and return to sport with neuromuscular and agility training.

Return to full activity is usually achieved within 6–9 months, depending on the patient’s progress and sport demands.