Knee

ACL Tear

A torn ACL is one of the most common, and most successfully treated, sports injuries in orthopedic surgery. With the right surgeon and a structured rehabilitation plan, the vast majority of patients return to full activity, including competitive sport. Our fellowship-trained sports medicine team has returned thousands of patients back to their competitive sports.

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What is acl tear?

The anterior cruciate ligament (ACL) is one of the four primary stabilizing ligaments of the knee. It connects the femur (thighbone) to the tibia (shinbone) and resists rotational movement and forward translation of the tibia relative to the femur. It is one of the most common sports injuries.

The anterior cruciate ligament (ACL) is one of the four primary stabilizing ligaments of the knee. It connects the femur (thighbone) to the tibia (shinbone) and controls rotational movement and forward translation of the shin relative to the thigh. When the ligament is stretched beyond its structural limits (most commonly during sudden deceleration, pivoting, or an awkward landing), it tears partially or completely.

ACL tears affect approximately 200,000 Americans each year and are among the most frequent injuries in cutting and pivoting sports such as soccer, basketball, football, and skiing. Female athletes are at significantly higher risk. Studies consistently report injury rates 2 to 9 times higher than in male athletes participating in the same sports, a difference attributed to neuromuscular, anatomic, and hormonal factors.

Unlike some ligaments, the ACL has poor intrinsic healing capacity due to its intra-articular environment. Complete tears rarely heal on their own, and untreated ACL deficiency significantly increases the risk of secondary meniscal tears and early-onset knee osteoarthritis over time.

Symptoms — do you recognize these?

ACL tears typically present with a recognizable cluster of symptoms. If you experienced any of the following, especially in combination, you should be evaluated promptly:

A sudden, audible or felt "pop" in the knee at the moment of injury
Rapid swelling developing within the first 2–4 hours (hemarthrosis)
A sensation that the knee "gave out" or buckled beneath you
Inability to continue playing or bear full weight immediately after the injury
Loss of full range of motion — difficulty fully bending or straightening the knee
Joint-line tenderness and a feeling of generalized knee instability
Persistent instability with pivoting or cutting movements, even after initial swelling resolves

If you suspect an ACL injury, avoid returning to activity and call us at (301) 515-0900. We offer same-day appointments for acute sports injuries at our Bethesda and Germantown locations.

How we diagnose it

Diagnosis begins with a thorough history and physical examination. Your physician will perform several well-validated clinical tests to assess ligament integrity:

Lachman test: the most sensitive physical examination test for ACL tears, with sensitivity exceeding 85% and specificity of approximately 94% in acute injuries
Anterior drawer test: assesses anterior tibial translation with the knee at 90 degrees of flexion
Pivot shift test: the most specific test for ACL-deficient rotatory instability; particularly useful in assessing functional impact in athletes

In-office X-rays are obtained at your first visit to rule out associated bony injury, including tibial spine avulsion fractures and the Segond fracture. The Segond fracture is a lateral capsular avulsion that is highly specific for ACL rupture. MRI is the definitive imaging study and provides confirmation of the ACL tear grade, assessment of the posterior horn menisci (frequently injured concurrently), and evaluation of bone bruise patterns characteristic of the injury mechanism.

Most patients leave their first appointment with a clear diagnosis and a specific treatment plan in hand.

Treatment options

Treatment is individualized based on your age, activity level, degree of instability, and the presence of any associated injuries. We will walk you through every option. There is no one-size-fits-all approach.

Non-Operative Management

Non-surgical treatment is appropriate for a defined subset of patients: those with low physical demands, older and less active individuals, patients with partial ACL tears with preserved stability, and those willing to permanently modify their activity away from pivoting sports. A structured physical therapy program focused on quadriceps and hamstring strengthening, neuromuscular retraining, and functional stability can allow many low-demand patients to return to straight-line activities and work without surgery. However, current evidence clearly demonstrates that operative reconstruction results in significantly superior outcomes compared to non-operative management for active patients, with lower rates of recurrent instability, fewer secondary meniscal tears, and better patient-reported outcomes over a 3-year follow-up period.

Surgical Procedure

ACL Reconstruction — Patellar Tendon Graft

ACL reconstruction using the central third of the patellar tendon with bone plugs at each end (BPTB). Bone-to-bone healing at fixation sites provides exceptional mechanical strength. This graft has long been considered the gold standard for competitive athletes.

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ACL Reconstruction — Quadriceps Tendon Graft

ACL reconstruction using the quadriceps tendon is an increasingly favored choice offering a large-caliber graft, strong mechanical properties, and lower rates of anterior knee pain and kneeling discomfort than the patellar tendon graft.

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ACL Reconstruction — Allograft

ACL reconstruction using donor (cadaver) tendon tissue rather than the patient's own tendon. Appropriate for lower-demand adults or revision cases. Not recommended for young athletes due to meaningfully higher failure rates compared to autograft.

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Lateral Extra-Articular Tenodesis (LET)

Iliotibial band-based augmentation performed alongside ACL reconstruction to directly control anterolateral rotational instability. The STABILITY trial showed ~40% reduction in graft failure in young, high-risk patients with LET addition.

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Recovery & rehabilitation

ACL reconstruction recovery is a structured, phased process, not simply a timeline. Our approach is criterion-based, not calendar-based: athletes advance through rehabilitation milestones based on objective strength, symmetry, and performance testing rather than time alone.

General milestones:

0–2 weeks: Manage swelling, restore full extension, begin quadriceps activation
6–12 weeks: Progressive weight-bearing, range of motion restoration, early strengthening
3–6 months: Running, sport-specific agility, plyometric progression
9–12 months: Return to full competitive sport (criteria-based clearance)

Returning to cutting and pivoting sport before 9 months is associated with a significantly elevated risk of re-injury. Prospective data show up to a sevenfold increase in second ACL injury risk with premature return. In young athletes under 20, reinjury rates of 1 in 5 have been reported with early return to high-risk sport. We use validated return-to-sport criteria including limb symmetry index (LSI) for strength and single-leg hop testing, targeting greater than 90% symmetry prior to sport clearance.

Our in-house physical therapy team at all three locations manages your rehabilitation from the day of surgery through your return to full activity. No referral runaround, no handoff to a stranger.

Frequently Asked Questions

Do I need surgery for an ACL tear?

Not always, but most active patients do. Non-operative management can be appropriate for low-demand patients willing to avoid pivoting sports, or for those with partial tears and preserved stability. For athletes and active individuals who want to return to cutting, pivoting, or jumping activities, reconstruction is the standard of care. We will assess your specific injury, lifestyle, and goals and give you an honest recommendation.

How long until I can return to sport?

Most athletes return to full competitive sport between 9 and 12 months after reconstruction. Current evidence strongly supports delaying return until at least 9 months. In some high-risk patients (under 20 years old, high-demand sport), waiting up to 12 months may further reduce re-injury risk. Return is determined by objective criteria, not the calendar.

Can I walk on my knee after tearing my ACL?

Many patients can bear weight and walk shortly after the injury, particularly once initial swelling subsides. Walking ability does not indicate the severity of the tear. Many complete ACL tears still allow weight-bearing. You should be evaluated promptly even if you can walk without significant pain.

What happens if I don't treat an ACL tear?

Untreated ACL deficiency in an active patient leads to recurrent instability episodes that progressively damage the menisci and articular cartilage. Studies show that ACL-deficient knees are at substantially higher risk for meniscal tears with continued activity, and that persistent instability accelerates the development of knee osteoarthritis. For active patients, early treatment generally leads to better long-term joint health outcomes.

What is a LET, and do I need one?

A lateral extra-articular tenodesis (LET) is a supplemental procedure performed at the time of ACL reconstruction that controls rotational instability in the outer (lateral) compartment of the knee. It is recommended for younger patients, athletes in high-demand cutting sports, and those with high-grade rotatory instability on examination. The STABILITY trial and subsequent data demonstrate meaningful reductions in graft failure rates with LET addition in appropriate candidates.

Will I need physical therapy?

Yes. Physical therapy is a non-negotiable part of ACL recovery regardless of whether you choose operative or non-operative treatment. Pre-operative ("prehab") strengthening significantly improves post-operative outcomes. Post-operative rehabilitation at our in-house PT facilities begins immediately and continues through sport clearance.