Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

sedentary patients

1st line – protected weight bearing/rest/ice/compression/elevation/medicine (PRICEM) + cautious physiotherapy

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ACUTE
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sedentary patients
1st line – 

protected weight bearing/rest/ice/compression/elevation/medicine (PRICEM) + cautious physiotherapy

The main goals of treatment for an isolated ACL tear are to alleviate symptoms, restore function, and minimise complications. The PRICEM acronym defines the initial treatment of all patients. Initial treatment consists of protected weight bearing, rest, ice, compression, elevation, and bracing. Non-steroidal anti-inflammatory drugs or analgesics may help control pain and swelling, but do not alter the course of the injury. Treatment should be tailored to individual preference, along with the exact nature of the injury.

Primary options

diclofenac potassium: 50 mg orally (immediate-release) three times daily when required, maximum 150 mg/day

OR

ibuprofen: 400-800 mg orally every 6-8 hours when required, maximum 2400 mg/day

OR

naproxen: 500 mg orally initially, followed by 250 mg every 6-8 hours when required, maximum 1250 mg/day

moderate intensity demands

1st line – PRICEM + cautious physiotherapy

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ACUTE
|
moderate intensity demands
1st line – 

PRICEM + cautious physiotherapy

The main goals of treatment for an isolated ACL tear are to alleviate symptoms, restore function, and minimise complications. The PRICEM acronym defines the initial treatment of all patients. Initial treatment consists of protected weight bearing, rest, ice, compression, elevation, and bracing. Non-steroidal anti-inflammatory drugs or analgesics may help control pain and swelling, but do not alter the course of the injury. Treatment should be tailored to individual preference, along with the exact nature of the injury.

Primary options

diclofenac potassium: 50 mg orally (immediate-release) three times daily when required, maximum 150 mg/day

OR

ibuprofen: 400-800 mg orally every 6-8 hours when required, maximum 2400 mg/day

OR

naproxen: 500 mg orally initially, followed by 250 mg every 6-8 hours when required, maximum 1250 mg/day

Plus – formal physiotherapy + customised bracing

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ACUTE
|
moderate intensity demands
Plus – 

formal physiotherapy + customised bracing

Treatment recommended for ALL patients in selected patient group

Activities such as recreational golf, swimming, cycling, jogging, tennis, and similar activities have low demands for dynamic knee stability. Moderate knee instability may not cause significant trouble in patients who enjoy these activities. Depending upon the severity of the injury and the specific lifestyle demands, formal physiotherapy and customised ACL bracing may work best for this group. Activity modification may also be necessary if these patients continue to have instability episodes despite this approach.[70][71]

intense dynamic demands

1st line – PRICEM + cautious physiotherapy

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ACUTE
|
intense dynamic demands
1st line – 

PRICEM + cautious physiotherapy

The main goals of treatment for an isolated ACL tear are to alleviate symptoms, restore function, and minimise complications. The PRICEM acronym defines the initial treatment of all patients. Initial treatment consists of protected weight bearing, rest, ice, compression, elevation, and bracing. Non-steroidal anti-inflammatory drugs or analgesics may help control pain and swelling, but do not alter the course of the injury. Treatment should be tailored to individual preference, along with the exact nature of the injury.

Primary options

diclofenac potassium: 50 mg orally (immediate-release) three times daily when required, maximum 150 mg/day

OR

ibuprofen: 400-800 mg orally every 6-8 hours when required, maximum 2400 mg/day

OR

naproxen: 500 mg orally initially, followed by 250 mg every 6-8 hours when required, maximum 1250 mg/day

Plus – surgical reconstruction

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ACUTE
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intense dynamic demands
Plus – 

surgical reconstruction

Treatment recommended for ALL patients in selected patient group

Tears of the ACL should be treated with reconstruction in preference to repair due to the lower risk of revision surgery with reconstruction.[42]

ACL reconstruction is performed primarily to restore the functional stability of the knee, but may also be considered to lower the risk of future meniscus pathology or procedures, particularly for younger and/or more active patients.[42]​ The surgery can be performed soon after the injury, generally as soon as the swelling has resolved and good range of motion has been restored (usually within the first 1 to 2 weeks after injury in motivated patients who receive proper initial treatment as above). Early reconstruction is recommended as the risk of cartilage and meniscal injury begins to increase within 3 months.[42]​

Although ACL injuries are most common in people between the ages of 15 and 45 years, older age alone does not necessarily preclude an aggressive surgical approach.[75]​ Even preexisting arthrosis does not rule out ACL reconstruction.

Surgeries are usually performed as outpatient procedures under general or spinal anaesthesia, with or without an intra-articular anaesthetic. The surgical time ranges from 1 to 3 hours. Risks of the surgery include infection, deep vein thrombosis/venous thromboembolism, neurovascular injury, loss of motion, patellofemoral pain, harvest site pain, patellar fracture, tendon rupture, and pain from hardware.

In general, there is no definitive superiority of one specific ACL reconstruction procedure over another.[76][77][78][79]​ The choice of graft type should be individualised. Available data and expert opinion suggest that the proficiency and experience of the patient's surgeon should determine which procedure should be done. The American Academy of Orthopaedic Surgeons recommends an autograft, in preference to an allograft, based on improved patient outcomes and decreased ACL graft failure, especially in young and/or active patients.[42]​ In cases where an increased risk of patellofemoral pain would be unacceptable, a hamstring graft to reduce the risk of anterior or kneeling pain, or a bone-patellar tendon-bone graft to reduce the risk of graft failure or infection, may be considered.[42]

Primary ACL repair is rarely performed any more due to generally poor outcomes. ACL bony avulsion injuries may be treated with closed, open, or arthroscopic reduction.[80]​ Revision of ruptured grafts and bilateral ACL injury requires more complex decision making and often involves the use of allografts. Detailed discussion of these issues is outside the scope of this topic.

The initial post-operative course depends upon procedure, patient characteristics, and surgeon's preference.

The patient can expect to be up on crutches and wearing a brace that day. Cold, elevation, and other modalities are commonly employed. Physiotherapy begins within the first few days post-operatively. Immobiliser use, bracing, and specific physiotherapy regimens vary.[81][82][83]​ Ongoing care using braces, rest, non-weight-bearing exercise, and non-steroidal anti-inflammatory drugs can be considered after surgical intervention. Reconstruction frequently allows return to high-demand activities, but does not definitively decrease the risk for post-traumatic arthrosis.[84][85]

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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