Anterior Cruciate Ligament (ACL) Reconstruction

Restoring functional stability through personalised surgery and rehabilitation

Anterior Cruciate Ligament (ACL) Reconstruction

What is an ACL reconstruction?

The anterior cruciate ligament (ACL) is one of the key stabilising ligaments of the knee. When it tears or ruptures, the knee may feel unstable or “give way,” particularly during twisting, pivoting, landing, or rapid deceleration movements.

Without appropriate treatment, ongoing instability can increase the risk of further injury to the meniscus or joint cartilage and may contribute to the development of knee arthritis over time.

ACL reconstruction is a surgical procedure designed to restore functional stability; the ability to move, pivot, and return to sport or daily activities with confidence and control, without episodes of giving way.

The procedure involves replacing the torn ligament with a graft, which acts as a scaffold for new ligament tissue to form as it heals and integrates.

View All Knee Conditions

Personalised approach to graft choice

There is no single graft that suits everyone. Each patient’s anatomy, sport, occupation, and long-term goals are different, and these factors guide graft selection.

During consultation, graft options are discussed in detail and selected to best match individual demands. Common graft options include:

  • Hamstring tendon grafts

  • Patellar tendon grafts

  • Quadriceps tendon grafts

Being familiar with all major graft options allows graft choice to be individualised based on anatomy, activity level, sporting demands, and long-term functional goals rather than a one-size-fits-all approach.

How the surgery is performed

ACL reconstruction is performed using keyhole (arthroscopic) surgery.

  • The knee is examined using a camera to confirm the ACL injury and identify any associated injuries, such as meniscal or cartilage damage, which can often be treated during the same procedure.

  • The selected graft is prepared to replicate, or in some cases augment, the strength and function of the native ACL.

  • Precise bone tunnels are created in the femur and tibia at the native ACL attachment sites. Accurate tunnel placement is critical to restoring normal knee biomechanics and is one of the most important factors in long-term success.

  • The graft is passed through the tunnels and secured with contemporary fixation devices, such as screws or suspensory buttons, to hold it stable while healing occurs.

  • In patients at higher risk of re-injury, such as young athletes, those undergoing revision surgery, or those with significant rotational laxity; a lateral extra-articular tenodesis may be added.

    This involves using a small strip of iliotibial band to improve rotational control and reduce the risk of graft re-rupture.

Recovery and follow-up

Recovery after ACL reconstruction is goal-driven rather than purely time-based. Some graft types allow more rapid progression, provided movement quality, strength, and control are restored safely.

Rehabilitation is coordinated closely with your physiotherapist and GP, with progression adjusted based on clinical milestones rather than fixed dates.

Typical follow-up schedule

    • Wound check and early movement assessment

    • Swelling management with rest, ice, compression, and elevation

    • Adjuncts such as crutches, compressive cryotherapy, or muscle-stimulation devices may assist early recovery and quadriceps activation

    • Review of knee movement and strength

    • Most patients can fully straighten the knee and bend beyond 90 degrees

    • Ongoing assessment of strength, control, and function

    • Mild swelling may still be present

    • Completion of structured rehabilitation

    • Objective return-to-sport testing to confirm readiness for unrestricted activity

ACL Reconstruction Rehabilitation Protocol

Key points to remember

  • The goal of ACL reconstruction is to restore functional stability, not just reconstruct a ligament

  • Graft choice is tailored to anatomy, activity level, and goals

  • Rehabilitation is essential and individualised

  • Safe return to sport depends on strength, control, and movement quality, not the calendar

Frequently asked questions

  • All surgery carries some risk. These include:

    Infection
    Uncommon with modern techniques. Superficial infections usually respond to antibiotics; deeper infections may require further treatment.

    Blood clots (DVT/PE)
    Rare, but possible after surgery. Any calf pain or swelling should be reviewed promptly.

    Bleeding or bruising
    Temporary swelling or bruising can occur and usually settles without intervention.

    Nerve or tendon irritation

    • Hamstring grafts: temporary numbness along the inner leg

    • Patellar tendon grafts: discomfort with kneeling (which often settles)

    • Quadriceps grafts: temporary weakness

    Patella fracture
    Rare, most associated with patellar tendon grafts.

    Graft re-rupture
    Risk is highest in the first 12–24 months, particularly in younger athletes. Revision surgery may be considered if this occurs.

    Knee stiffness
    Usually improves with physiotherapy; rarely requires further intervention.

    Long-term osteoarthritis
    Some cartilage injury occurs at the time of the original ACL injury, not because of surgery. As a result, people with ACL injuries have a higher lifetime risk of knee arthritis. Persistent instability can further increase this risk, which is why restoring good knee stability is an important consideration.

  • ACL injuries commonly occur during pivoting, twisting, landing, or deceleration. Fatigue, landing mechanics, and individual anatomy can increase risk.

  • Yes. Although reconstructed ligaments are strong, they are not immune to injury. Completing rehabilitation and passing return-to-sport testing significantly reduces risk.

  • There is a slightly increased risk, likely related to shared biomechanics and movement patterns.

  • Evidence-based injury-prevention programs focus on:

    • Hip and core strength

    • Jump-landing mechanics

    • Balance and agility training

    • Quadriceps and hamstring strength

    These programs are particularly effective in sports such as football, netball, and basketball.

  • Not everyone with an ACL injury requires surgery.

    Non-operative treatment may be suitable if:

    • You do not participate in pivoting or contact sports

    • Your knee feels stable during daily activities

    • You can commit to a structured rehabilitation program

    Surgery is often recommended if:

    • You play sports involving pivoting, jumping, or rapid direction changes

    • Your knee continues to give way despite rehabilitation

    • You have a repairable meniscal tear that would benefit from stabilising the knee

  • Age alone is not a barrier. The decision depends on symptoms, knee function, arthritis level, and activity goals.

  • Yes. Repairable meniscal tears are often treated during ACL reconstruction, as the biological environment supports healing.

  • Most patients walk with crutches on the day of surgery for comfort. A brace may be used if a meniscal repair was performed.

  • Driving is usually possible once you can safely perform an emergency stop and are off strong pain medication.

    As a guide:

    • Right knee: 4–6 weeks

    • Left knee (automatic): 2–3 weeks

    Always confirm with your surgeon and insurer.

    • Showering normally after 2 weeks once wounds are healed

    • Pool-based rehabilitation usually from 4 weeks

    • Open-water swimming later in recovery

  • Return to competitive sport is commonly around 12 months, depending on strength, control, and completion of objective testing. In selected cases, return may occur earlier if criteria are met safely.

Key takeaway

ACL reconstruction is part of a broader process aimed at restoring confidence, control, and long-term knee health. Surgical technique, rehabilitation, and movement quality all play equally important roles.

Have a question or want to book an appointment?

Request a Consultation