ACL tear & reconstruction

What the ACL does, and how it tears

The ACL is the central stabiliser of the knee, preventing the shin bone from sliding forward and controlling rotation. It typically tears during a sudden pivot, awkward landing or collision — often with an audible pop, rapid swelling and an inability to continue playing.

How an ACL tear is confirmed

Clinical examination supported by MRI confirms the tear, grades it, and — critically — maps associated injuries: meniscus tears accompany a large proportion of ACL injuries, and finding them changes the surgical plan. One clinical sign is especially telling — the pivot-shift, in which an unstable shin bone slides and then clunks back as the knee bends.

Does every ACL tear need surgery?

No — and any surgeon who says otherwise is not examining you. Lower-demand patients with stable knees can do well with structured rehabilitation. Reconstruction is advised for active people with instability, athletes in pivoting sports, and knees with repairable meniscus injuries that need protecting. The honest determinant is instability plus demand, not the MRI report alone.

How reconstruction is done

Modern ACL surgery is arthroscopic — keyhole. The torn ligament is replaced with a graft routed through precisely drilled bone tunnels and fixed until it integrates. Anatomic tunnel placement — reproducing your original ligament's attachment points — is the single most important technical determinant of a stable result. Meniscus tears found at surgery are repaired in the same sitting wherever repairable.

Graft options — including peroneus longus

The graft is your new ligament, and the choice matters:

• Hamstring — versatile, small scar, the common workhorse
• Patellar tendon (BPTB) — bone-to-bone healing, favoured in high-demand pivoting athletes
• Quadriceps tendon — robust, useful in revisions and larger patients
• Peroneus longus — a strong graft harvested from the outer leg that spares the knee's own muscles, helping preserve knee strength; increasingly chosen for this reason

Fibre-tape augmentation (internal brace)

In selected knees, the graft is reinforced with a strong suture-tape running alongside it — an 'internal brace' that shares load while the graft heals biologically. Where indicated, it can support more confident early rehabilitation. The same principle allows primary repair with augmentation for certain fresh tears near the ligament's upper attachment, where the ligament can be reattached rather than replaced. Either way, it is an option matched to the case, not a routine add-on.

Rehabilitation is half the operation

The graft matures over months, and physiotherapy is not optional — it is where the result is won or lost. A staged programme respects the biology: early motion and quadriceps activation, progressive strengthening, proprioception and balance retraining, running around the third month, sport-specific drills thereafter, and return to competition only after objective strength and hop testing — usually 8–12 months. The commonest cause of graft re-tear is not surgical failure but rushed or skipped rehabilitation. A committed physiotherapy plan is arranged for every patient.

Hospital stay

ACL reconstruction is a one-night admission for most patients: surgery on the day of admission, first physiotherapy session the same evening or next morning, and discharge the following morning — walking with support and safe on stairs.