Grade 3 ACL tear: what are my options?

Last week I went skiing for the first (and probably last!) time.

It seems that I’ve got a complete/grade 3 tear of my ACL after a crash (on the last day of course). I saw an orthopaedic knee injury specialist today who showed me some movements definitely not normal for a knee and shin (and drained a lot of fluid out of it), with an MRI tomorrow to confirm.

I gather some people proceed without surgery even with a grade 3? I just thought I’d see if anyone can share their experiences of the same injury, and thoughts on surgery vs not.

An initial chat with the consultant suggested that without surgery I would struggle with the injury in the long run, particularly for the things I like doing (dh, steep trail running and big days out hiking/backpacking). I’ve heard a few stories of people who develop early arthritis post surgery, as well as those who have had no issues even without surgery. I’m 31 for context.

Cheers!

ACL full tear – what’s the prognosis

This may give some useful info. Good luck with the rehab whichever path you choose!

Did the same when I was 30. Had surgery then 9 months of proper rehab. I’m now 46 and knee is fine. I continue to Ski, MTB, CrossFit, football, run, hike. I’m sure others have horror stories but for me it’s been all good.

I ruptured my ACL early in 2016 and didn’t actually know as physios suggested it was cartilage damage. After my knee recovering I’d go back to sport and I’d end up with it “collapsing” when side-stepping or putting a sideways load through it. When it was recovering I’d wear a knee brace and then stop wearing it when it was “better”.

Eventually I got a bit fed up of the issues and went to see a specialist who got a MRI done and confirmed the ACL was ruptured. This was in 2019. She said as I’d managed to continue doing all the sports I like to do (more on that in a minute) I could elect not to have surgery and then if I found it causing issues further down the line I could then do so.

I’ve been able to keep going with all my normal sports. I’ve never had any issues mountain biking, cycling, or running, and I’ve done some trail running/Munros with no problems. I play tennis and that’s been ok. The only sport I’ve had issues with is touch rugby, as there’s a lot more lateral movement. When I play that I wear a knee brace. I’ve played in the last few European Championships and have the World Cup coming up this year, and although it is just age grade level as opposed to the open teams, I’ve got on fine.

I also went skiing this year for a week with no issues. I wore the knee brace for that as a precautionary measure but never felt there being any issues.

I have a friend who ruptured their one years ago and, at the time, was playing for the Scottish women’s rugby Union side. They recommended not to get surgery and she went through a strengthening regime of all the muscles, etc round the knee and went back to playing international rugby.

And maybe better to rupture your ACL on the last day of your trip rather than the first!

Everyone is different is the honest answer. Some people will have significant stability problems and others (once recovered fro the initial injury) seem to manage perfectly well.

There is not a right or wrong answer, early onset of arthritis can happen regardless of surgery. It seems more dependent if there was an associated meniscal injury.

A good knee ACL knee brace can be a game changer (that allowed me to play tennis, without it I couldn’t hit a backhand).

Personally, I would try rehab fist and see if that was sufficient to allow me to do all my activities, if it didn’t then I’d consider the surgical route. Rehab will not be wasted as it will put you in a better position if you do require surgery.

The rehab post op is 6 months long (for return to everything) and absolutely essential. If you cannot commit to this then do not have the surgery, you will not have a good outcome.

Thanks folks.

@dlabz was yours a complete (grade 3) or partial?

Good note on the physio, I can feel my muscles working hard to keep it stable as it is, so I’m thankful for having strong legs anyway. I’ll discuss this option with the consultant when I see them next.

Get on with physio as early as possible.  even pre surgery If you can move it. Hydrotherapy was really good.

@spicer it was a complete rupture. I did it playing touch rugby, and it hurt a bit when I did it, but didn’t get much swelling around the knee and so the physios assumed cartilage damage. When I eventually got it scanned the specialist confirmed I didn’t have an ACL in that knee.

I’ve followed (not in the literal sense!) this girl for a while, she’s recovering from a damaged ACL. She talks through her recovery and physio. She’s also a skier so you should have something in common! 😀

https://www.youtube.com/@DelilahCupp

I tore mine playing rugby about 20 years ago. Keyhole surgery to tidy it up and did a load of physio to get back, you’re basically looking to build leg strength so the muscles do the work of the ACL. Was all fine until a drunken fall and instability in the joint and surgeon suggested an ACL replacement, which involves grafting some hamstring. Lots more physio for recovery, which was painful and hard, you need to work at it to get the range of motion back. Now 15 years later I don’t notice it at all, done marathons, fell running loads of riding and don’t notice any difference to my good knee. Amazing what they can do.

Just as an update to the other thread on this topic, my son’s is a complete tear plus fairly catastrophic meniscus damage,

In the words of the consultant “This is as serious as it gets without needing a new knee”.

The MRI didn’t show the full extent of the damage, which was a root tear; it was explained to me as follows: imagine the roots of a tree – this is how your meniscus is attached to the bone. Your son’s meniscus & all its roots have been ripped out of the bone, so it was just floating around inside. It was also torn almost in half & folded back on itself.

In the first operation the meniscus has been sewed onto the bone & he’s now 3 months into his rehabilitation. The strengthening & stability exercise regime he’s been given is brutal, & he struggles with it, but the results are slowly coming.

That said, & this is where it relates to  you @spicer he can now perform most movements  including basic ball skill, lunges, squats & any “closed chain” exercises without any great issues.

Had he been just a snowboarder or cyclist they would leave it at that & forgo the ACL repair/replacement; the fore-aft movement is now minimal as his muscles are literally taking up the slack, so it’s perfectly possible to have an active life without an ACL.

Thanks everyone, it’s really interesting to read these replies and the other thread.

I’ve got a surprising amount of strength and stability back over the last few days after making an effort to keep it moving and keep the muscles working, but range of motion is very limited (I’m not sure what exactly is causing that) and I don’t need the MRI results to know there is some damage to the Lateral ligament too.

However, this small progress and some of the comments here are giving me some reassurance that I’ll get back to normal, whether it’s surgery or not. Let’s see what the scan says on Tuesday!

@Spicer

I managed fine with a knee brace for tennis for >5 years before I went for the reconstruction. I played squash, ran, HIIT and skied with no problems at all (and didn’t need the brace).

Unfortunately my knee was unstable walking and after it gave way 5 times in less than 1 mile I bit the surgery bullet. Surgeon couldn’t believe I had no problems with squash and skiing yet couldn’t walk to town without giving way but everyone is different.

Tore mine with an unplanned dismount almost a year and a half ago. Unfortunately due to my age they wouldn’t even consider an MRI to check the extent of the damage let alone a repair 😔 (diagnosed with anterior drawer test).

I was 3 months off the bike and with physio regained a good range of movement by around the 6 month mark – probably a little longer before I could kneel properly. Walking reasonably normally now although some days I limp like the OAP I am 😂 and my knee does occasionally give way. I wear a hinged brace for biking (mainly BMX trails) and my strength doesn’t seem to be affected but anything involving twisting movements is definitely a no no.

Good luck with the recovery and yes, definitely go for the repair 👍

Thanks folks. I just thought I would give a little update: surgery is booked in for mid-may, which gives me time for ‘pre-hab’ to get movement back and for the swelling/fluid build up to go.

It’ll be a fairly standard hamstring graft surgery, with support from a synthetic brace.

I’m surprised how much better movement has got in the last week- it’s come along a long way!

I may have just spent a fortune on LEGO for the recovery period! 😀

Good to hear. Good luck with the recovery – keep us updated 👍

I thought I’ll update this every now and then incase anyone else goes through this and wants to know what to expect 🙂

Surgery was 1 week ago today. They used a hamstring graft and ultratape internal brace to support it. 3x keyhole holes and 1x 8cm cut under my knee, stapled together.

Pain: Regular painkillers are required! I’m just taking paracetamol and ibuprofen though, which is working well. They gave me Codeine and Oramorph, but I haven’t felt the need to take them, so they’ll go in the first aid kit once I’m back on the bike 😉

What you probably won’t realise before is how many different bits of your leg will hurt. Your quads will have a hole drilled through them to reach the bone. Your hamstring and calf will be very sore from the hamstring tendon graft. The knee is obviously going to hurt. But the worst of the pain is from cutting/drilling through muscle.

Mobility: extension is pretty good, which is the most important thing. I can’t bend it much, but not fussed about that at the moment as that won’t come back until the swelling has gone down anyway. Don’t expect loads of mobility after 1 week. It’s just starting to improve a little, but it’ll take time.

By day 3 I’d basically decided I didn’t need crutches anymore, after getting over the mental barrier of realising you can load bear through that leg still. I carried the crutches about with me for a few more days, but didn’t really use them. Don’t expect to be walking far though- 400m round the block is enough for me 1 week in.

All in all, not as bad as I was expecting if I’m honest, but a long way to go.

Hi Spicer, good luck with the rehab. As a fellow hamstring graft recipient, take it easy for a little while and don’t push it too soon.

They probably told you about timescales for the graft, but it takes a while to settle down as the body incorporates it into the knee, and my guidance was that at 8-12 weeks it would be at it’s weakest while that process stabilised.

Good news is that once it’s settled down you should be back to full fitness within a year or so.

Another monthly update for anyone else who goes through an ACL reconstruction. I’m about 2 months post-op

In a nutshell- weeks 5-8 were a huge improvement over the first month. Consider your first month recovery from surgery, and month 2 as a proper start to getting some strength and mobility back.

• I’ve got full extension back if I rest my ankle on something and let my knee sag. I can’t fully extend under muscle control yet, but it’s not far off. Basically, it’s improving by this point and nearly there, so much less to worry about.

• So I’m walking pretty much normally, but not quite due to the lack of full extension and limiting it to about 5,000 steps a day (swells up a bit if I try and do more than that on consecutive days)

• First 4 weeks were rubbish, from week 5-6 it really started to pick up and get some strength back. I’m now in the gym starting to do 5 mins on a spin bike with moderate load at a time, and other basic gym stuff (20k leg extensions etc).

• Lots of physio which is actually quite fun- lunges, various squats etc. It’s great to feel progress.

• the hamstring feels like the weakest part of the recovery- just feels ‘wrong’ to push it too hard but this is less important than the quads so progress is fine in reality- but it’s feeling like it can take moderate exercise now (e.g. bridges on an exercise ball)

Feeling much more positive and feeling confident that I’m going to come back to the bike stronger and fitter than I was before the accident

I’m about to make the surgery or not decision myself – full rupture a few weeks ago. Already into the prehab exercises and coming on well.

Trying to decide whether to go for the Internal Brace or not bother with surgery at all. It’s not particularly unstable even with my quad not firing particularly well yet, and my main worry is going through a ‘normal’ graft procedure and then rupturing it again after nine months of hard work!

Datsun, why would you rupture again after 9 months? Unless you were overdoing the rehab, or doing too much too soon?

Spicer, good to hear your rehab is going well. Keep it up 🙂

@susepic oh I probably wouldn’t, just being pessimistic. 😀

And @spicer, good to hear your recovery is going well. I’ve decided to book mine in asap.

@datsunman obviously it’s early days for me, but the recovery is not as miserable as reading other experiences on the internet led me to believe! 2 months in and I’m basically walking about as normal (ok, no hiking or uneven surfaces), but I’ve had to ditch biking and running for the gym instead (it’s actually kind of nice to have a break after 15+ years riding!). My point is, don’t the recovery put you off deciding to get surgery.

I can’t compare a non-surgical outcome to a surgical one, but I’ve got biking friends who never had their fixed and have been fine for years (but wear a brace for big hikes). From what I’ve been told not having surgery can lead to a higher change of arthritis later in life and more damage from small injuries you might not even notice- stuff having an ACL/fix in plate is likely to have prevented.

I do feel confident hitting the prehab hard has made a big difference, so keep at it. I haven’t lost all that much muscle mass tbh, but it was very weak for the first few weeks- that would have been a real struggle if I had chicken legs to start with!

Good luck with the surgery!

Great to see your updates Spicer. I had a complete tear of my ACL 30yrs ago and my son did his 3 yrs ago, both playing footie.

My lad, who is very good footballer, had a patella tendon repair and did huge amounts of physio. It took him ~18months to get back to full competitive fitness. He has no issues now.

Mine back 30yrs ago, was a very invasive surgery option with lots of long term issues (“you will need a knee replacement in 20-25yrs). I gave up all the less knee friendly sports, squash, running, footie and concentrated on cycling. I’ve raced at a high level and I’m still biking (Alps in 3 weeks) and I have the same knee. I get the odd niggle and I’m careful about some movements.

Hopefully it all continues to get well for you! Try to avoid the worst sports for your knee.

Thanks @spicer – appointment on Tuesday to book in the op, lesser of two evils as I like to run offroad and climb too, so worth it long term I think.

Keep us updated, good to hear you’re recovering well. I’ll add to the thread in a few weeks with any luck!

Following with interest @spicer.  Tedious story time:

19 days ago I tore mine as well.  At my first fracture clinic appointment (day 3) the anterior drawer test confirmed that.  4 days later I had an MRI (on the NHS! 4 days!!).  At my second fracture clinic (day 10) the report hadn’t come in yet, but my orthopod went and spoke to the radiologist and his verbal report said full ACL tear, MCL sprain and no meniscus damage.

His suggestion was that with no meniscus damage, and not playing football/rugby etc, I should manage the injury conservatively without surgery.  Wear a knee brace for 12 weeks to aid the MCL healing, and do plenty of range of motion physio, and he’d see me again in 3 months.  He also advised that I could weight bear with immediate effect, which after 9 days on crutches was a delight.

However.  I was sceptical about the non-surgery route.  I felt he didn’t really understand what “downhill mountain biking” meant.  Both in how important it is to me, and how demanding it can be on our knees.

I emailed his secretary to get a copy of the MRI report once it had been written up, and – lo and behold! – it DOES now say I have a meniscal tear.  I’m undecided if this is bad (will onset early arthiritis) news, or good (pro-surgery) news.  Time will tell.

So… I nagged at her and have another appointment to see him on Monday (day 24).  I’m curious if his opinion will now be that I need surgery because of the meniscus tear.  I think (as much as it’ll suck for 6 months) I WANT surgery.  But I’m happy to listen to his opinion.  And then maybe seek a second one… :facepalm:

I’ll certainly be showing him some clips on YouTube.  I’ve no doubt that being ACL-less is fine when ON the bike, riding without error.  And I’m also sure that an unlucky or particularly bad crash will have bad knee outcomes whether I have a reconstruction or not.

But… what I REALLY want to get clarity on from him is… the outcome with or without surgery for all of those SMALL moments.  A dab here, a tumble there.  Hell, just trying to do a track walk on a tricky section!

These are the things I worry about, going forwards.  Not riding.  Riding is the easy bit, knee-wise.

@downhiller – you’re almost identical to me, albeit I don’t have the meniscus damage, ‘just’ a fractured tibial plateau… I was offered both surgical and non-surgical options, also with a ‘either will work’ approach.

I also am not bothered by the riding bit, it’s awkward ground, running off road, climbing too. Those are the bits that I was bothered about. My main driver for the repair was that if I did the same again without the repair, the damage would likely be catastrophic, so that’s why I chose the reconstruction option.

@datsunman – oddly my x-ray appeared to show a fractured tibial plateau, but it’s not mentioned at all in the MRI report.  Something else I should ask about, just for my own understanding!

“if I did the same again without the repair, the damage would likely be catastrophic, so that’s why I chose the reconstruction option.”

When I posited this issue to him he said something along the lines of “my reconstruction wouldn’t survive a serious crash anyway”, which I totally get.  It’s the minor things I want it to survive, that’s what I need to stress when I see him on Monday.

I hope you get a timely surgery date – you on the NHS or private?

Sounds like a very similar conversation – I figured that the reconstruction would give me the extra support for the minor things. I also agreed that it won’t stop the same happening again, but if it did then the reconstruction would take some of the load and leave the remaining ligaments etc less likely to fail too.

Pencilled in for 6th August, privately. So another three-four weeks of prehab (done ten days so far) then hopefully fixed.

@downhiller how did you injure yours?

Personally I’m not at all worried about biking and the accidents that come with it when it comes to the ACL. It takes a hell of a lot of twisting force to damage it, and I don’t think you see those sorts of forces on the bike.

You’ll have some impacts from dabbing etc as you say, but not twisting, which is what you need to worry about.

It took me rolling completely over at around 30mph with a ski still clipped in (so, twisted my leg completely) to do mine, I can’t see how biking can put those sorts of twisting forces through a leg, even in a crash. But my (non-expert) opinion is that having the surgery will help prevent smaller injuries in the future. Like @datsunman I’m also a trail runner and far more concerned about that and backpacking through the mountains than biking.

I’ve got a mate in his late 40’s who’s had no ACL for years and rides everything I do. For reference, there’s nothing we don’t ride other than jumps going bigger than 35ft, it causes him no issues on any trails from local XC to the steepest stuff at Dyfi and he doesn’t worry about it with crashing.

Just another little update for those guys going through it ^^ 14ish weeks post surgery

• It feels like the muscles are pretty much healed at this point, but the joint itself takes a lot longer to get back to normal so still have to take it easy
• Strength: I’m back to the same weights I was pre-injury, but just don’t have the stamina to do as many reps, and shouldn’t be pushing it this hard often as it’s causing a bit of swelling. For reference I’m 73kg, leg pressing 160kg (both legs), leg extension 40kg (single leg), squat 80kg (both legs!). The consultant commented on my lack of muscle wastage that they normally expect.
• Walking: pretty much as normal. But can’t walk too far- it’s just repetitive loading on the knee and causes swelling which triggers tenderness and reduced ROM. I can probably maintain 5k steps a day and be OK. I’m still spending my working days on the sofa with my leg up, else it stiffens up a lot, this is making a big difference
• ROM: Pretty good, almost full extension and bending about 10-15 degrees off the good side
• Pain: no pain other than when I lock my leg completely straight and load bear or contract the muscles. I’ve been told this is normal for the first 6 months or so and will ease with time
• I have a clicking when I near full extension (felt but not heard). We believe this is the knee catching on a bit of scar tissue from the old ACL, hopefully it will improve over time but there is keyhole surgery for it if it’s an issue
• I’m starting return to running!!!  Wohoo. I used an ‘anti-gravity’ running machine with the physio last night at 70% load. Very exciting

It’s not as bad as I thought it would be from all the horror stories online if I’m honest. I really believe hitting the physio hard to strengthen up before the surgery has had a huge impact

Your post comes at a good time for me, I’m now three weeks and one day post surgery and in a bit of a no mans land mentally – good to hear your progress.

I managed to get my leg straight in week two, can bend in slightly more than ninety degrees now. Still a bit of tension in there so not pushing it too hard. Regular daily ROM exercises are helping massively.

Still got a bit of swelling but not too bad considering the timeframe. Morning post-op knee is 0.5cm bigger than non-op knee.

I can walk with approx 90-95% of normal gait, it’s coming on well but not for too long, gets sore if I walk too far so still using crutches to take some of load off if I need to go any distance.

Like you I was expecting worse, it all seems ‘ok’ so far. No real pain apart from the initial exercises on the hamstring, and that dulled after a day or two. That said, because it’s not that bad I am struggling mentally as I can’t do anything so keeping meeting up with/talking to people whenever I can.

That sounds like awesome progress for 3 weeks out @datsunman , glad to hear it’s going well for you.

Did you have a hamstring graft? If so thats amazing that the pain is subsiding already- I’ve only felt that I can do bridges or any decent hamstring exercises after the 3 month mark really (this seems to be the weakest part of my recovery).

Here’s a few suggestions based on whats worked (or not) for me:

• Keep using the crutches as you are, when you need to. I ditched them after 2 days thinking that the sooner I was on my feet the better, but in reality I think it just battered the sore and tender tissues in my knee a bit which kept the swelling present for quite a while.
• Aliexpress LEGO (much cheaper), some new playstation games, lots of books and lots of visitors kept me busy enough
• Having small goals to work towards (lots of them physio related, e.g. first time doing a single leg squat, first time using XXkg weights, first time walking round the local field etc) helped track progress and make me feel like I’m really getting somewhere (this was particularly helpful when I got fed up 2 months in and just “wanted a day where it felt normal”)
• make the most of a change in lifestyle and doing things that you just didn’t have time or inclination to do before… I’m actually able to enjoy a beach holiday without getting itchy feet now, am learning to swim (with the aim of starting triathlons next year).

Despite being a slow healing process, even 1 year goes in the blink of an eye. You’ll be back to a normal-ish lifestyle in no time

Good luck!

Thanks @spicer

Both my consultant and physio are over the moon with the straightness of my leg so working hard to keep it that way, apparently it can regress a bit as muscle use increases.

Yes, hamstring graft – my physio is wonderful/evil depending on how you look at it. 😀 She got me lifting my heel from day three (which was both impossible and painful at the same time) but the improvement has been really positive.

I can do bridges quite easily now, in fact the only challenge there is the stitches in the front of my knee are still quite sore when stretched so have to do them with a bit more leg extension than I’d like. Don’t get me wrong, it’s still *uber* weak, but getting there slowly.

Did you/are you using muscle stimulation? That’s been pretty good for me, bought a Compex unit and exercise with it every other day. Quad focus one day, everything else the following day.

My next ‘major’ goal is to get on the turbo again, I found that really good for both mobility and swelling last year (PCL in other leg but thankfully no surgery that time), can’t quite bend my leg enough just yet. Nearly there though.

Thanks for the tips, I’ve been doing most of those to keep me sane but you have the odd ‘meh’ day as I’m sure you know.

Good luck too, be on the bike again before you know it.

Yep, I used an EMS machine for a while (although probably not as much as I should of), it seemed good for the quad activation but that doesn’t seem to be an issue for me anymore, so I don’t bother now.

I do find the turbo helps keep the knee smoother, I’m sure you’ll see good results when you get back on it. I’m going to book a spin class in the next week or two and see how that goes- I’m confident by this point the muscles will be fine but anticipate the duration of exercise will still irritate the joint a bit (my brain can’t handle more than 15 mins on the turbo, I hate it!)

It sounds like you’ve had good results with the swelling, and have got it down a lot faster than I did. I found it quite restrictive for a while. Even now I can barely get any heel pop off the floor (despite having great quad strength and being able to physically push my leg another 5 degrees past that point) and get a bit of catching in my knee (when I go from full extension to bending) , both of which are down to some remaining internal swelling, but it’s improving slowly and will continue to.

It sounds like your progress is awesome, but I will also just say is there’s a fine line between pushing it too hard to get results and accepting that parts of the recovery are just going to take a while. We don’t need to be pushing it all the time; I have rest days/weeks which take some of the mental burden off. But the actual graft recovery will take a long time and there’s just no way around that, so don’t get too disheartened when an inevitable setback happens (push too hard and get swelling etc). It’s just part of the process of finding how much it can handle, relax for a bit then continue