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

all patients

1st line – protected weight bearing, rest, ice, compression, elevation, and medication (PRICEM)

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ACUTE
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all patients
1st line – 

protected weight bearing, rest, ice, compression, elevation, and medication (PRICEM)

The main goals of treatment for an isolated anterior cruciate ligament (ACL) tear are to alleviate symptoms, restore function, and minimize complications. The PRICEM acronym defines the initial treatment of all patients: protected weight bearing, rest, ice, compression, elevation, and medication.

Nonsteroidal anti-inflammatory drugs (NSAIDs) or other analgesics (e.g., acetaminophen) 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

OR

acetaminophen: 325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

Consider – arthrocentesis

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ACUTE
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all patients
Consider – 

arthrocentesis

Treatment recommended for SOME patients in selected patient group

Arthrocentesis can be considered if there is a large joint effusion. Aspiration may decrease pain and help patients recover early range of motion and knee function.[74] The technique may be utilized if clinically warranted but with appropriate consideration of the risks versus benefits.

Consider – physical therapy

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ACUTE
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all patients
Consider – 

physical therapy

Treatment recommended for SOME patients in selected patient group

Patients with low intensity demands should start physical therapy. There is evidence to suggest that nonsurgical management may be an appropriate choice for some patients with moderate to high intensity demands, and that physical therapy should be considered as a primary treatment option in these patients.[79][80] However, a conservative approach may not be tolerated by some patients regardless of the severity of injury or activity level, and so the decision should be individualized.

Gentle (pain-free) active range-of-motion exercises can be instituted within the first few days of injury. Physical therapy (home or formal) can then proceed with treatment frequency based on the patient's specific situation.

Initial therapy goals include relieving pain and swelling, and re-establishing full range of motion. Subsequent goals include regaining strength, proprioception, and dynamic stability. No methodologically sound evidence has shown superiority of any one particular rehabilitation program.[75][76]

If the patient experiences recurrent tibiofemoral subluxation episodes or knee instability, this can lead to further attritional injuries including meniscal tears and articular cartilage damage. Activity modification should therefore be encouraged to minimize the risk of instability episodes.[77][78]

There is limited evidence about the benefits of customized bracing for nonoperative treatment. However, while patients are regaining strength, an off-the-shelf brace can provide temporary physical support.

Follow-up visits are important to assess progress. If the patient is not able to achieve their activity goals or has repetitive knee instability, surgical consult may be required to explore surgical treatment options.

Consider – surgical reconstruction

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ACUTE
|
all patients
|
with moderate- or high-intensity demands
Consider – 

surgical reconstruction

Treatment recommended for SOME patients in selected patient group

A surgical approach is usually recommended for patients with high intensity demands. It is also an option for patients with moderate intensity demands who are not able to achieve their activity goals or who have frequent knee instability.

Anterior cruciate ligament (ACL) tears are usually treated with reconstruction rather than repair, due to the lower risk of revision surgery compared with repair.[44] Although primary ACL repairs have historically had poor outcomes, repairs with new techniques are emerging and may be warranted for tears that meet certain anatomic features.

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. Early reconstruction is recommended as the risk of cartilage and meniscal injury begins to increase within 3 months.[44]

Surgeries are usually performed as outpatient procedures under general or spinal anesthesia, with or without an intra-articular anesthetic. 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.[85][86][87][88] The choice of graft type should be individualized. 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.[44] Typical autograft options involve the patellar, hamstring, or quadriceps tendons. Graft choice varies widely based on a number of factors, including patient and surgeon preference.

ACL bony avulsion injuries may be treated with closed, open, or arthroscopic reduction.[89] 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.

Physical therapy begins within the first few days postoperatively. Immobilizer use and specific physical therapy regimens vary.[90][91][92] Functional bracing is generally not recommended following ACL reconstruction. Limited evidence shows that bracing does not benefit a patient’s return to full activity.[44][93] However, the surgeon-patient discussions may consider use of a functional brace during the transitionary phase back to full activity.[93] The potential psychologic benefit of a functional brace may support the various ranges of kinesiophobia that could exist when patients transition from physical therapy to full activity, however, little investigation into this condition exists.

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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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