Twist and Shout: Suffering from an Anterior Cruciate Ligament Injury?

An anterior cruciate ligament (ACL) injury can affect both athletes and people who are active in everyday life. Located inside the knee, this ligament plays an essential role in joint stability. Whether it happens during sport, a quick change of direction, or an awkward movement, this injury deserves a prompt assessment and appropriate care.

Where is the anterior cruciate ligament located and what is its role?

The anterior cruciate ligament is located in the center of the knee, within the joint between the femur and the tibia. Together with the posterior cruciate ligament, it forms the central pivot of this joint. The ACL plays an important role in stability: it limits the forward sliding of the tibia relative to the femur and helps control rotational movements. This stabilizing role explains why an ACL injury can cause a feeling that the knee is “giving way,” especially during pivots, braking, or changes of direction.

Knee pain? ACL sprain and tear: what are the causes?

ACL injuries frequently occur during activities involving sudden movements. Quick changes of direction, abrupt stops, jumps, and unbalanced landings place the ligament under high tension. Soccer, basketball, hockey, and skiing are among the sports where this type of injury is common.
The classic mechanism is often the same: the foot stays planted on the ground while the body pivots, creating excessive twisting of the knee. These twisting movements can cause a severe sprain or a rupture of the anterior cruciate ligament.

What are the symptoms of an ACL rupture?

Symptoms of an ACL rupture usually appear immediately and may include:

• A cracking sound or a “pop” at the moment of injury
• Sharp, immediate pain
• Rapid swelling of the knee
• A sensation of instability or the knee “giving way”
• Difficulty moving the knee normally

A prompt assessment allows for better management and helps guide the next steps.

How to treat an ACL injury in the first few days?

Today, for acute and subacute soft-tissue injuries, the PEACE & LOVE approach (British Journal of Sports Medicine) is increasingly discussed. This approach replaces older reflexes such as complete rest or systematically applying ice, and instead emphasizes protection, elevation, patient education, then a progressive return to weight-bearing, movement, and exercise.

In the first few days, this generally means:

• Protecting the knee without falling into prolonged complete rest;
• Adjusting weight-bearing according to pain, using crutches if needed;
• Elevating the leg to promote circulation and limit swelling;
• Avoiding pivots and movements that worsen symptoms;
• Consulting promptly with a physician or physiotherapist for an appropriate assessment;
• Gradually resuming movement as tolerated.

Book an appointment quickly to support your recovery. The central idea is not to rely solely on passive solutions, but rather to prepare the knee early for active recovery.

ACL rupture without surgery: conservative treatment

An ACL rupture does not automatically lead to surgery. In many cases, the first step should be a well-structured conservative approach, with the goal of improving knee function, stability, strength, and movement control. Many people regain good stability with this approach. For example, some high-level athletes can return to sport without ACL reconstruction when their knee demonstrates sufficient stability after complete rehabilitation.

This rehabilitation may include:

• Gradual return of joint range of motion
• Strengthening the quadriceps, hamstrings, and gluteal muscles
• Stabilization exercises
• Proprioceptive training
• Motor control work
• A gradual return to sport when the knee allows it

To learn more about knee stability exercises, a personalized assessment remains essential.

When should ACL surgery be considered?

Surgery is considered when the knee remains unstable despite complete and progressive rehabilitation. The indication is based on real functional stability, persistent episodes of giving way, and response to conservative treatment. Current data suggest that about one third of ACL ruptures may require surgery when the knee remains unstable after full rehabilitation. In some cases, an ACL rupture may show signs of spontaneous healing.

The decision must be individualized for each patient based on:

• Symptom progression
• Knee stability in daily life
• The demands of the activities practiced
• Progress achieved in physiotherapy
• The presence of other associated knee injuries, when applicable

Reconstruction can help restore sufficient stability when rehabilitation alone does not make it possible. Like any procedure, ACL reconstruction represents an additional stress on the knee. It should therefore be considered when the expected benefits outweigh the risks, particularly when instability persists despite rehabilitation. Some people regain a high level of activity without surgery, while others will need reconstruction to achieve satisfactory stability.

Rehabilitation timeline and exercises after an ACL injury

Whether treatment is conservative or surgery is eventually required, rehabilitation is at the heart of recovery from an ACL tear. The goal is to regain a knee that is mobile, strong, stable, and able to gradually tolerate the demands of daily life, work, or sport.

Return to sport should be based on functional criteria, not only on a fixed timeline. In general, the complete process takes 6 to 12 months depending on the severity and progression of the injury. It is important to respect contraindications to avoid setbacks.

Frequently asked questions

Is ACL surgery mandatory?

No. As mentioned, surgery is not always necessary. In many cases, well-managed conservative rehabilitation is the first approach. Surgery may be considered mainly if the knee remains unstable despite comprehensive care, with persistent giving-way episodes that interfere with daily activities.

Is it possible to walk with an ACL injury?

Yes, it is often possible to walk with an ACL injury. However, certain movements such as pivots, rotations, or changes of direction can cause a feeling of instability.