Around 20,200 ACL injuries occur each year in the UK, according to The Systematic Review: Annual Incidence of ACL Injury and Surgery in Various Populations study. Recovery can take many months, particularly when other structures in the knee are injured. Timely clinical assessment helps identify these injuries and guide treatment and rehabilitation.

Why Associated Injuries Matter

An ACL tear can occur alongside a meniscal tear, cartilage injury or damage to another ligament. These findings can affect treatment decisions and the rehabilitation plan.

Associated meniscal injury also matters for long-term knee health. It is estimated that the lifetime risk of symptomatic knee osteoarthritis was 34% after a combined ACL and meniscal injury, compared with 16–17% after an isolated ACL injury, according to The Projecting Lifetime Risk of Symptomatic Knee Osteoarthritis and Total Knee Replacement in Individuals Sustaining a Complete Anterior Cruciate Ligament Tear in Early Adulthood modelling study. These figures are estimates for the populations studied, not predictions for an individual patient.

The Whole Injury Guides Treatment

Some people with an isolated ACL injury and a stable knee can manage well with structured rehabilitation. Others have ongoing instability, demanding sporting or work goals, or associated injuries that make surgical assessment more appropriate. The decision depends on the patient and the full pattern of injury.

Clinical examination, supported by MRI when indicated, helps establish the extent of injury. When an ACL injury occurs alongside an injury to the medial collateral ligament (MCL), for example, the MCL may be managed initially before the timing of ACL reconstruction is decided. The approach depends on the severity of both injuries and the patient’s progress.

Timing of Treatment

When reconstruction is appropriate, the timing is another decision. One option is very early surgery, while the knee is still in the acute phase following injury. This can mean undertaking reconstruction before the initial haemarthrosis and inflammatory response have settled, potentially allowing the patient to pass through one period of acute swelling rather than two.

The other approach is to let the knee settle, begin rehabilitation and return to surgery later. Before a delayed reconstruction, the aim is to regain a good range of motion, particularly full extension, and have a reasonably quiet knee with reduced swelling and irritation. These preoperative conditions matter because stiffness after reconstruction can be difficult to resolve. The timing is tailored to the knee, any associated injuries and the patient’s circumstances.

Understanding the Risk of Re-injury

Planning treatment also means considering the risk of another ACL injury, whether to the reconstructed knee or the other knee. Younger age, a return to sports involving cutting and pivoting, and generalised joint hypermobility (Zsidai et al, 2023) can increase this risk. Marked rotational instability and previous ligament injuries may also influence the assessment.

These factors are considered alongside the patient’s goals and progress through rehabilitation. Identifying them early helps the patient and clinical team make informed decisions about surgery and return to sport.

Advances in ACL Surgery

Surgeons now have several graft choices for ACL reconstruction. Hamstring and patellar tendon grafts are established options, while quadriceps tendon grafts are increasingly used. The rectus femoris tendon is a newer, emerging option under study. Graft selection can be tailored to the patient’s anatomy, activity and reinjury risk.

Fixation techniques have also developed. Suspensory fixation uses a device such as a cortical button to secure the graft against the bone. It can give the surgeon more flexibility in graft preparation and help achieve a more consistent planned graft size. The choice of fixation still depends on the graft and surgical plan. Comparative studies, such as by Fu et al (2020), have not shown that suspensory fixation reduces repeat rupture for every patient.

For selected patients at higher risk of graft failure, a surgeon may also add a lateral extra-articular tenodesis (LET). A LET helps control rotational movement of the knee. In the STABILITY randomised trial, adding a LET reduced graft rupture among young, higher risk patients undergoing hamstring graft ACL reconstruction.

Supporting Your ACL and Sports Injury Referrals

Vista Health provides access to musculoskeletal imaging to help referring clinicians investigate suspected knee injuries. Through its partnership with Cabot Clinic, patients who need specialist assessment can explore treatment options, including rehabilitation, bracing and surgery where appropriate.

Together, Vista Health and Cabot Clinic help patients move from investigation to a treatment plan suited to their injury.

Refer your patient today.