Nonsurgical management for anterior cruciate ligament (ACL) tear
Initial management (including first aid) for an acute ACL tear involves the POLICE regimen1 and analgesia; see Subacute management for soft-tissue limb conditions.
The initial severe pain usually settles rapidly. If analgesia is required, paracetamol or nonsteroidal anti-inflammatory drugs (NSAIDs) may be considered; see Analgesia for soft-tissue limb conditions.
Acute management should include a short period of immobilisation (eg 48 hours) for comfort. Optimal loading in the subacute stage should include nonweightbearing on the affected limb; see Features of nonpharmacological management techniques for acute soft-tissue limb conditions for details on optimal loading. Often people are reluctant to weight bear and they should use crutches. A knee immobilisation brace may help to prevent further injury and is a reasonable recommendation in the early phase, especially if multiple structures are damaged; however, this is not usually required.
Consider nonsurgical management for people who are willing to moderate their activity. This may include avoiding activities that involve pivoting and twisting (ie they can continue doing ‘straight-line’ activities). These people should consider physiotherapy-guided training in neuromuscular control to strengthen the knee and learn how to avoid offending movements. If there are delays to accessing physiotherapy, start a gentle progressive hamstring-strengthening program.
Encourage their return to walking (including weight bearing), depending on comfort and additional ligament (eg medial collateral ligament) or meniscal injuries.
The utility of a functional knee brace for people who choose nonsurgical management is unclear. Use of a functional knee brace (eg a ‘derotation’ brace that allows flexion and extension but not rotation) may allow the person to remain active, and there is some evidence to support its use. Recommend functional knee bracing based on the person’s:
- desired activities
- degree of knee laxity and instability
- frequency of episodes of the knee giving way.
If the person complains of ongoing knee laxity and instability during their desired activities, despite following a suitable rehabilitation program, they should be referred to an orthopaedic surgeon for consideration of surgical reconstruction.