Anterior Cruciate Ligament (ACL) Injury. Do I need surgery?

Anterior Cruciate Ligament or ACL is an important stabilizer of the knee and is one of the most common ligament in the knee that is injured. Most injuries are either through motor vehicle accidents or sporting injuries. The most common sports related to ACL injury in Malaysia are due to football, futsal and basketball.

Anterior cruciate ligament injury is when the anterior cruciate ligament (ACL) is either stretched, partially torn, or completely torn. Symptoms include pain, a popping sound during injury, and joint swelling. Later this injury may include locking and instability of the knee. Diagnosis is typically by physical examination and is sometimes supported by magnetic resonance imaging (MRI).

Initial treatment

In the case of an injury to the knee, it is always best to consult an Orthopaedic surgeon initially to assess the degree of injury (whether it is stretched, partially or completely torn) and also to assess if other structures such as the meniscus or cartilage or other ligaments are injured. An MRI may be required.

Initial treatment will be to control the pain and swelling. RICE therapy is started immediately. RICE being the acronym for Rest, Ice, Compression and Elevation. This is followed by pain killers and physiotherapy to prevent stiffness of the knee and later to strengthen the surrounding muscles.

Conservative treatment

In nonsurgical treatment, progressive physical therapy and rehabilitation can restore the knee to a condition close to its pre-injury state and educate the patient on how to prevent instability. This may be supplemented with the use of a hinged knee brace. However, many people who choose not to have surgery may experience secondary injury to the knee due to repetitive instability episodes.

Surgical Treatment

ACL tears are not usually repaired using suture to sew it back together, because repaired ACLs have generally been shown to fail over time. Therefore, the torn ACL is generally replaced by a substitute graft made of tendon.

  • Patellar tendon autograft (autograft comes from the patient)
  • Hamstring tendon autograft
  • Quadriceps tendon autograft
  • Allograft (taken from a cadaver) patellar tendon, Achilles tendon, semitendinosus, gracilis, or posterior tibialis tendon

ACL reconstructions are now done via arthroscope (key hole surgery) the advantages of which includes shorter hospital stay and less pain.


Rehabilitation is essential after any surgery, more so in ACL reconstruction. The outcome of surgery greatly depends on the initial surgery as well as the subsequent rehabilitation, both having equal importance in the success of the surgery. The goals for rehabilitation of ACL reconstruction include reducing knee swelling, maintaining mobility of the kneecap to prevent anterior knee pain problems, regaining full range of motion of the knee, as well as strengthening the quadriceps and hamstring muscles and with the final aim of returning the patient to his previous activity level.

Do I need surgery?

After a period of rest and rehabilitation, if there are any symptoms of instability, one should consider surgical option. Active adult patients involved in sports or jobs that require pivoting, turning or hard-cutting as well as heavy manual work are encouraged to consider surgical treatment. This includes older patients who have previously been excluded from consideration for ACL surgery. Activity, not age, should determine if surgical intervention should be considered. Surgical treatment is also usually advised in dealing with combined injuries (ACL tears in combination with other injuries in the knee).

This article is by Dr Leong Wan Hee, Orthopaedic Surgeon (with a sub-specialty in Sports Injuries) at Timberland Medical Centre.

*The information ​in this ​article is ​not​ intended to replace a one-on-one relationship with a qualified health care professional and is not intended as medical advice​ to diagnose or treat a health problem or disease. You should consult your health care provider if you have or suspect you may have a health problem.