ACL reconstruction

Anterior cruciate ligament (ACL) tears are relatively common sports injuries and usually occur when pivoting on a planted knee during a match. They are more commonly non-contact injuries but can also occur during tackles. Physiotherapy may be appropriate for people not wanting to return to pivoting sports. However, there is now high-level evidence that superior clinical outcomes are achieved with ACL reconstruction, compared to non-operative treatment. ACL reconstruction involves passing a graft across the knee through bone tunnels and fixing it at both ends.

Graft choice

There are four main graft choices:

  • Hamstrings
  • Quadriceps
  • Patellar tendon (bone-patellar-bone)
  • Allograft (donor tissue)

Each graft option has specific pros and cons. It is really important that you speak to your surgeon about which graft may be most suitable for you. The most suitable graft choice for a ‘weekend warrior’ is often different to an 18 year old professional rugby player. Nick Smith likes to run through pros and cons of each graft option in person, so that your operation is tailored to your needs.

Lateral extra-articular tenodesis

This is an additional procedure, performed at the same time as ACL reconstruction in selected patients. It involves taking a 1cm strip of iliotibial band on the outside of the knee, keeping it connected to the outside of the shinbone (tibia) and securing it to the side of the thigh bone (femur). The latest high-level evidence shows that this additional procedure can dramatically reduce the failure rate of ACL reconstruction in selected patients.

Meniscal tears

The menisci are relatively commonly injured at the time of ACL injury. Tears that can occur include medial (inner) sided RAMP tears, lateral (outer) meniscal tears and lateral root tears – where the back attachment of the meniscus is torn. The meniscus is a cushion in the knee and helps to spread the forces evenly through the knee on activities. Patients with a non-treated meniscal tear are at higher risk of osteoarthritis and therefore it is vital that repairable tears are identified and treated at the time of surgery.


Physiotherapy following ACL reconstruction is very important to ensure safe return to sports. The muscles around your knee play a big part in control and therefore a well rehabilitated knee is very likely to have better outcomes, with a reduced risk of further injury. Nick Smith has developed protocols with a number of physiotherapists in order to ensure the best physiotherapy is delivered.

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    The meniscus is a cushion in the knee. It helps to spread out the forces through the knee when doing activities.