What is the optimal treatment for ACL ruptures?

This question was submitted by a Chiropractic Student:

“I have a friend who plays college football in the US; he has asked me to offer an opinion on how to properly manage his ACL tear (complete). The coaching and training staff at the college has advised that he should keep playing following conservative therapy. He wants to know if there are any long term implications of continuing high level activity on an ACL-deficient knee.”

Answer: The proper management of ACL ruptures has long been debated in the scientific literature. Current research allows us to make evidence based recommendations on the most appropriate course of action, however the most “appropriate” action will differ depending on the expectations of the individual. A summary of the current evidence-based recommendations is as follows: The initial management (4-6 weeks) of an acutely injured ACL in not debated. Conservative, “first-aid” treatment should be done in the first 4-6 weeks in order to allow the hemarthrosis (bleeding within the joint) to settle and allow restoration of the range of movement. After this, successful reconstructive surgery in the patient with an isolated ACL injury reduces the rate of subsequent meniscal damage, and may reduce future arthritic/degenerative changes in the joint. Reconstruction of the ACL should be done by replacing the damaged ligament with a piece of the patient’s patellar tendon (“bone-patellar tendon-bone graft”), or with a piece of the patient’s hamstring muscle. Literature has shown both to provide excellent clinical results in ACL reconstruction, thus the decision is based on the preference of the patient and surgeon. ****After isolated ACL reconstruction, approximately 90% of patients can return to their previous activity level. If conservative management is selected, patients must be counseled against high-risk activities to prevent recurrent injury (ie. If a very competitive athlete would like to continue to compete at a high level, conservative management may not be the best option). Therefore, conservative management may be recommended for those who will eliminate “knee-strenuous” exercise and activity from their lives. For those who cannot, surgical options should be explored. The patient either has to modify activity to suit the knee, or modify the knee to suit activity.