ACL Surgery

Your anterior cruciate ligament (ACL) is an important ligament in your knee that stabilizes and connects your femur (thighbone) to your tibia (shinbone). An ACL injury is a sprain or tear of this ligament and often occurs when playing sports or injuring yourself in a fall.

ACL injuries can be treated with or without surgery, depending on the type and severity of your injury.

UPMC has been a leader in ACL reconstruction surgery and knee injury treatment for decades. We take a personalized approach to ACL surgery, which helps us deliver the best possible results for you.

When reconstructing your ACL tear, we have two main goals:

Restore your knee anatomy to how it was before.
Help get you back to the level of function and activity you had before your injury.

We have an entire team ready to help you through ACL surgery, from orthopaedic surgeons and physician assistants to nurses, physical therapists, performance coaches, and nutritionists.

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What Is ACL Surgery?

ACL surgery repairs a tear in your anterior cruciate ligament — one of four ligaments in your knee joint. The ACL connects your tibia (shin bone) to your femur (thigh bone) and helps stabilize your knee.

ACL injuries, called ACL tears or ruptures, are common among athletes.

If you only partially tear your ACL, you may not need surgery. Sometimes, physical therapy and bracing can help it heal.

For a complete ACL tear, you may need surgery to reconstruct your ACL. Your surgeon will use a graft — a piece of tissue from either your body or a donor — to do this.

At UPMC, we perform ACL surgeries arthroscopically assisted because our orthopaedic surgeons have advanced training in this less-invasive technique. This technique allows us to make tiny cuts and reconstruct your ACL using a small camera and instruments.

Although ACL reconstruction surgery is typically an outpatient procedure, it is still considered a major surgery.

Types of grafts for ACL surgery

To reconstruct a torn or ruptured ACL, your surgeon will discuss graft options with you.

We can:

Take the graft from one of your own tendons, called an autograft.
Use donor tissue, called an allograft.

Your orthopaedic surgeon will discuss graft options with you.

Graft decision is based on many different factors so that you can:

Make a complete recovery.
Have the best chance of returning to your pre-injury condition.

Autograft

An autograft most often comes from your patellar, quadriceps, or hamstring tendon.

Your surgeon will review the risks and benefits of each type of autograft with you, taking into consideration your anatomy and the activities you plan to return to.

Allograft

For many patients, allograft tissue is the preferred option for your new ACL. This may be based on age, injury to additional structures in your knee, and the activities you plan to return to.

Why Would I Need ACL Surgery?

If you have an ACL tear and instability in your knee and are hoping to return to a moderate or high activity level, you may be a candidate for surgery.

Is ACL surgery right for me?

ACL surgery is especially beneficial if you're:

An athlete who wants to return to your sport.
A highly active person.
A person whose job or work requires a high level of activity and physical effort.

You may also have other knee damage from your injury that only surgery can fix. About half of ACL injuries involve damage to the meniscus or other ligaments.

Will I have ACL surgery right away?

After deciding to have ACL surgery, your surgeon may recommend waiting. Better outcomes with surgery are noted when the knee is in a more favorable condition going into surgery.

Goals before surgery include:

Reducing swelling and inflammation.
Regaining normal range of motion.

Your surgeon will discuss the best timing for ACL surgery based on your injury and overall health.

Alternatives to ACL surgery

Nonsurgical treatment for ACL injury includes:

Activity restrictions.
Braces.
Physical therapy and rehabilitation.
Rest, ice, compression, and elevation (RICE) to reduce swelling.
Anti-inflammatory medications.

What Are the Risks and Complications of ACL Surgery?

ACL surgery is very effective at giving you a stable knee again.

But as with all surgeries, it comes with risks, including:

Bleeding.
Blood clots.
Infection.

Your surgeon will give you medicine and use special techniques to help reduce those risks.

Other risks and complications of ACL surgery include:

Graft re-tear.
Loss of range of motion in your knee.
Pain or weakness in your knee.
Failure to return to full activity.

Following your surgeon’s instructions before and after surgery can reduce your risk of these complications.

What Should I Expect From ACL Surgery?

Before: How to prepare for ACL surgery

Before surgery, your knee surgeon will design a complete plan based on:

Imaging studies
Physical examination
Your goals

Your surgeon will also discuss the recovery time after ACL surgery so you fully understand your rehab plan.

Testing before ACL surgery

Before surgery, your doctor may order tests to learn more about your injury. These tests may include x-rays and MRI scans to take precise measurements of the bones and structures of your knee.

Your test results help your surgeon:

Check the anatomy of your knee for any unique needs and decide how to operate.
Predict the size of your ACL before your injury and plan the size of the new replacement graft.
Understand the type and extent of the injury to your ACL and surrounding tissues.

Physical therapy and rehab before ACL surgery

Before surgery, doctors often prescribe physical therapy or “prehabilitation.”

Pre-hab can help to:

Improve strength in the muscles around your knee.
Improve range of motion in your knee.
Reduce swelling in your knee.

Your doctor will discuss what exercises are best for you to do before surgery.

Nutrition and diet before ACL surgery

At UPMC, we counsel people who need help with their nutrition needs before having surgery.

We may suggest that you:

Limit or stop using caffeine, nicotine, and alcohol in the weeks leading up to surgery.
Take certain nutritional supplements before surgery, such as multivitamins, vitamin C, and zinc. These all help promote wound healing during post-op recovery.

How long does ACL surgery take?

Most ACL reconstruction procedures take two hours or less.

The time depends on:

Graft choice: autograft may take longer since the graft needs to be harvested from your body.
If you have damage to your meniscus that needs to be addressed.
If your surgeon needs to repair or reconstruct any other ligament(s) in your knee besides your ACL.
If your surgeon finds other damage during arthroscopy that they didn’t see in your pre-surgical tests.

During your ACL surgery

ACL surgery is usually outpatient surgery, so most people go home the same day they have surgery.

Your surgeon will talk to you in detail about the surgery and explain each part.

There are four steps to ACL surgery:

Step 1: Anesthesia

You’ll meet with an anesthesiologist before surgery. Together with your surgeon, they’ll decide which type of anesthesia is best for you.

Common types include:

General anesthesia — You’ll get an IV, and the anesthesiologist will run medicine through the IV that makes you fall asleep.
Regional anesthesia — Also referred to as a nerve block that is a local anesthetic that numbs the operative leg.

Step 2: Diagnostic arthroscopy

Your surgeon will use an arthroscope to look at your knee joint to assess:

The extent of the ACL tear.
The medial and lateral meniscus for injury.
The articular cartilage for injury.

Step 3: Graft harvesting

If the surgeon is using an autograft to reconstruct your ACL, they will harvest the graft from either your:

Patellar tendon.
Quadriceps tendon.
Hamstring (usually part of the semitendinosus and gracilis).

Your surgeon will make a cut at the harvest site, extracting part of the tendon that will become your new ACL. They will only take the amount needed to make your new ACL graft.

Step 4: Reconstruction surgery

To reconstruct your ACL using the graft tissue, your surgeon will:

Inspect what remains of your native ACL to see where and how it attaches to your femur and tibia. The torn pieces are shaved out to allow room for your new graft.
Mark the areas on your femur and tibia for attaching the graft to reconstruct your ACL.
Drill tunnels in the marked areas of your femur and tibia. The size (diameter) of the tunnels will match the size of your graft.
Use a suture to shuttle your new ACL graft into the bone tunnels and pull it into place.
Affix the new ACL on the femoral side with a fixation device. There are many kinds of fixation devices. The one your surgeon chooses will depend on a few factors, including the type of graft you're having.
Hold the other end of the graft and bend and straighten your knee repeatedly. Since the graft tissue tends to stretch out at first, these motions help remove that initial stretch.
Pull the graft tight and attach it on the tibial side with a fixation device while bending your knee at about 20 degrees. This is the position where your ACL is naturally the tightest.
Look at your knee through the arthroscope to ensure your new ACL has good tension.

Depending on your case, you may have other damage to your knee. Your surgeon will perform any other necessary repairs before finishing surgery and closing your incisions.

Recovery after ACL surgery

After surgery, you'll move into the recovery room. Your care team will check to ensure you have no problems from the surgery and anesthesia before you are discharged home

You will need someone to help you when you first go home from ACL surgery. Based on how physically demanding your job is, you can expect to be off work for a few days to a few weeks.

Initial post-operative care after ACL surgery

Your surgeon will provide discharge instructions reviewing:

Bathing, wound care, and dressing changes.
Ice and elevation of your leg.
Weight-bearing status, brace use, and crutch use.
Exercises/activity determined by the complexity of the procedures that you had done. You will receive instructions on home exercises to begin right after your surgery.
When to begin physical therapy (PT) – this might be as early as a few days after your surgery.
Post-operative medications to use for pain management and blood clot prevention.
When to follow up in the office for your first post-operative appointment. This usually occurs 1-2 weeks after surgery.

When to call your doctor after surgery

At any time during your recovery, call your doctor right away if you have:

Blood soaking through the bandages.
Discharge coming from the incision.
Swelling or pain in your calf.
A fever above 101.5°F.
Pain that doesn't go away with medicine.

Physical therapy and rehabilitation

At UPMC, we have injury and sport-specific physical therapy programs. Your surgeon and physical therapist will work together to clear you for a safe return to your full daily routine or sport.

There are three main treatment goals of ACL rehab after surgery, including:

Stabilizing your knee if it's unsteady to help you return to your daily routine.
Strengthening the muscles that support your knee to help you get to the same activity level as before your injury.
Reducing the risk of reinjuring your knee when you return to sports.

You'll work on strength, flexibility, and sport-specific exercises in the coming months. Plan to attend physical therapy at a local rehab center one to three times a week. You will also be provided with home exercises from your physical therapist.

UPMC’s science-based approach to ACL injury rehabilitation consists of five phases. You'll need to complete all five phases before your knee surgeon and physical therapist clear you to return to full activity.

Restoration of range of motion and mobility.
Management of pain and edema.
Initiation of strengthening with emphasis on the quadriceps.

You will begin with jogging on a treadmill or track once you pass a screening test and are cleared by your physician, usually four to five months after surgery.
Running will progress per specific guidelines and begin with slow, comfortable speeds for short durations and distances.

Once you pass a screening test and are cleared by your physician, you may begin agility drills, usually five to months after surgery.
Agility drills may include lateral shuffling, forward/backward shuttle runs, carioca, and ladder drills.

Once you pass a screening test and are cleared by your physician, you may begin jumping with two feet for both take-off and landing, usually six to eight months after surgery.
After perfecting vertical jumping, you will progress with forward, side-to-side, rotating, and box jumps.

Once you pass a screening test and are cleared by your physician, you may begin hopping and cutting, usually seven to nine months after surgery.
Hopping will follow the same progression as jumping, and cutting will progress per your physical therapist's guidance.
You will continue working on aggressive strengthening.

Takes place generally nine to 12 months after surgery.
At UPMC, we offer ACL Return to Sports Testing through our physical therapy department to determine readiness to return to play and identify deficits to improve upon prior to return to play.
Once you pass the ACL Return to Sports Testing and your physician clears you, you may return to full activity without restrictions.
At UPMC, we also have a Return to Play Program for athletes with ACL injuries.

Estimated return-to-sport milestones summary (based on graft healing time and passing functional testing):

Jogging – 4 to 5 months
Low-level Agility – 5 to 6 months
Jumping – 6 to 7 months
Cutting – 7 to 8 months
Return to Sport – 9 to 12 months

What’s the success rate of ACL surgery?

ACL surgery is a highly successful procedure. It can help you return to everyday activities, sports, and hobbies. Your doctor will discuss expected success rates with you.

Why Choose UPMC for ACL Surgery?

When you choose UPMC for ACL surgery you will receive:

Access to world-class orthopaedic expertise — Our world-renowned experts treat the full spectrum of knee disorders using the latest surgical and nonsurgical techniques.
Advanced diagnostic care — We’ll work with you to understand the extent of your injury and develop a comprehensive treatment plan.
A full range of treatment options — We offer nonsurgical care, traditional surgical approaches, and cutting-edge technology, depending on your individual care needs.

By UPMC Editorial Staff. Last reviewed on 2025-03-13.