ACL Injury, Repair & Reconstruction Surgery in Bristol

The ACL is arguably the most important ligament in the knee for sport. When it tears, the knee often feels fundamentally different – unstable during pivoting, unreliable on uneven ground, and difficult to trust. I see a lot of ACL injuries in clinic, and the first thing I want to understand is not just whether the ligament is torn, but what else has happened inside the knee, what your goals are, and whether surgery is actually the right answer for you.

Treatment may be non-surgical (rehabilitation-led) or surgical (ACL reconstruction), depending on your stability symptoms, activity goals, knee anatomy, and associated injuries such as meniscus or cartilage damage.

What does the ACL do?

The ACL sits in the centre of the knee. It helps:

Control forward movement of the tibia (shin bone) under the femur (thigh bone)
Control rotation during pivoting, twisting and landing
Provide confidence and stability in cutting and deceleration movements

The ACL works together with the meniscus, cartilage, and other ligaments. This is why a "simple ACL tear" is sometimes actually a more complex injury pattern – and why I always assess the whole knee, not just the ligament.

How ACL injuries happen

ACL tears usually occur during a sudden twist, pivot, awkward landing, or contact injury. Common scenarios include:

Football, rugby, netball, skiing, basketball and racquet sports
A sudden change of direction or deceleration
Landing from a jump with the knee collapsing inward
A direct collision causing the knee to rotate or hyperextend

Symptoms of an ACL tear

A popping sensation at the time of injury (not always present)
Rapid swelling within a few hours (common, but not universal)
Difficulty continuing sport immediately after injury
Recurrent giving way, shifting, or loss of confidence with pivoting
Swelling after activity, especially if the knee is unstable

Urgent red flags

Seek urgent assessment if you have a locked knee (cannot fully straighten), severe swelling, suspected knee dislocation, numbness/weakness in the foot, or a cold/pale foot after injury.

Assessment and diagnosis

Accurate diagnosis matters because ACL tears often occur with associated injuries that change the treatment plan – meniscus tears, meniscal root tears, cartilage injury, bone bruising, and occasionally other ligament injuries.

When I assess an ACL injury, I want to know exactly how it happened, how quickly the knee swelled, whether it has given way since, and what you need your knee to do. I examine the whole knee – not just the ACL – and I arrange an MRI to confirm the tear and pick up anything else that might need addressing. X-rays are added if I need to check alignment or rule out a fracture.

The goal is to confirm the diagnosis and build a plan around your goals: return to sport, stable day-to-day function, or protecting long-term knee health.

Treatment options: rehab vs ACL reconstruction

Non-surgical treatment (rehabilitation-led)

Not everyone with an ACL tear needs surgery. If you do not play pivoting or contact sport and your knee does not give way, rehabilitation alone can work well. Non-surgical management typically includes:

Swelling control and restoring full range of motion
Progressive strengthening (quadriceps, hamstrings, glutes and trunk control)
Neuromuscular training (landing, deceleration and balance control)
Graduated return to activity based on strength and stability milestones

Rehabilitation is also essential even if surgery is planned, because a strong, calm knee before surgery leads to better early recovery.

When I recommend ACL reconstruction

I am more likely to recommend ACL reconstruction when:

You have recurrent giving way or lack of trust in the knee
You want to return to pivoting or contact sport
Instability is limiting your work, lifestyle, or confidence
There are important associated injuries (for example a repairable meniscus tear) where restoring stability supports healing

The decision is always shared. The aim is a stable knee that you can trust.

What is ACL reconstruction?

ACL reconstruction replaces the torn ligament with a tendon graft. The graft acts as a scaffold that becomes incorporated over time and functions like a new ACL. I perform the operation using keyhole (arthroscopic) surgery, usually with small additional incisions to harvest and secure the graft.

During surgery, I also address any associated problems – meniscal repair, treatment of cartilage injury, or additional stabilisation for rotational control where the examination and imaging indicate it is needed.

ACL graft choices

There is no single "best" ACL graft for everyone. I choose the graft based on your sport, anatomy, previous surgery, occupation, risk profile, and preference. The aim is a graft that matches your knee demands while balancing donor-site symptoms and recovery.

1) Hamstring autograft

This is the graft I use most often. I take tendon from the inner side of the knee and create a quadrupled semitendinosus graft – a strong, multi-strand construct. In most patients I can achieve good graft diameter using one hamstring tendon (semitendinosus) only, preserving the gracilis. I add the gracilis if the semitendinosus alone does not give enough graft thickness.

Considerations: temporary hamstring weakness and discomfort can occur early on; rehabilitation targets hamstring recovery and overall movement control.

2) BTB (Bone-Patellar Tendon-Bone) autograft

BTB uses the middle part of the patellar tendon with small bone blocks at each end. It provides very solid fixation and I often favour it in high-demand pivoting athletes or certain revision scenarios.

Considerations: some patients find it difficult to kneel on the scar at the front of the knee.

3) Quadriceps tendon autograft

Quadriceps tendon grafts use tendon from the front of the thigh just above the kneecap. It is a strong, versatile option for primary and revision ACL reconstruction, and it is particularly useful when previous graft harvest limits other options.

Considerations: early quadriceps weakness can occur, so rehabilitation focuses on safe quadriceps strength and control.

4) Rectus femoris graft

Rectus femoris is part of the quadriceps mechanism. I use this in complex situations – typically when previous surgery limits graft availability or when a specific graft strategy is needed for a revision or multiligament case.

Key point: this is not a first-line choice. It is planned around your anatomy, sport demands, and recovery priorities.

5) Allograft (donor graft)

An allograft uses sterilised donor tendon rather than your own tissue. I consider this in specific circumstances: complex multiligament reconstruction, limited autograft options, particular revision strategies, or for patients returning to non-pivoting activities.

Considerations: allograft has a higher rate of re-rupture and failure than autograft options, particularly in young, active patients returning to pivoting sport. I am honest about this during our discussion, and I only recommend allograft when the alternatives are less suitable.

Contralateral grafts (using the other knee)

Sometimes the best graft comes from the other (contralateral) knee – particularly if previous graft harvest limits choices on the injured side, or if a specific graft is preferred for your sport and stability goals. I discuss this carefully because it does mean temporary donor-site symptoms in the other knee during early recovery.

Do I need extra stabilisation (LET / ALL) with my ACL reconstruction?

Some patients have a higher risk of persistent rotational instability or re-injury – for example, young athletes with a high-grade pivot shift returning to pivoting sport, or revision cases. In these situations, I may recommend an additional procedure such as lateral extra-articular tenodesis (LET) or ALL reconstruction to improve rotational control.

This decision is based on your examination (particularly the pivot shift), sport demands, anatomy, and overall risk profile.

Meniscus and cartilage in ACL injuries

Meniscus tears and cartilage injury are common alongside ACL tears. Preserving the meniscus and protecting cartilage are important for the long-term health of your knee.

Meniscal repair – I repair the meniscus at the same time as ACL reconstruction whenever the tear pattern allows it.
Meniscal root tears – these require careful assessment and may need root repair where the tear is suitable.
Cartilage injury – this can range from minor surface damage to focal defects and may influence symptoms, recovery, and treatment planning.

Rehabilitation after ACL reconstruction

Rehabilitation is essential for a good outcome. I use a stability-conservative (non-accelerated) protocol for hamstring graft ACL reconstruction, which protects the graft during its most vulnerable period – the ACL graft is at its weakest between 6 and 12 weeks after surgery.

Key milestones include: crutches for the first 2–6 weeks, brace weaned out by 12 weeks, no cycling or cyclical loading until 12 weeks, swimming (no breaststroke) from 12 weeks, running from 18–24 weeks (once strength milestones are met), and return to non-competitive training from 9 months with competitive sport targeted at 12 months.

The full rehabilitation programme with detailed phases, restrictions, and practical milestones (driving, swimming, cycling, golf, jogging) is set out on my return to sport after ligament surgery page. If you have additional procedures (meniscal repair, cartilage treatment, LET/ALL, or osteotomy), your early phases will be modified to protect healing tissues.

Risks and considerations

ACL reconstruction is generally very successful, but all surgery carries risks. Potential issues include:

Infection, blood clots, wound problems
Stiffness or prolonged swelling
Persistent instability or graft failure (particularly if risk factors are not addressed)
Ongoing pain or donor-site symptoms
Meniscus or cartilage problems that continue to influence symptoms

I discuss the specific risks relevant to your situation during your consultation, including how we reduce them through planning and rehabilitation.

Frequently asked questions

Do I always need surgery for an ACL tear?

No. Some people do well with rehabilitation alone, especially if the knee is stable in day-to-day life and pivoting sport is not a goal. I am more likely to recommend surgery when instability persists or sport demands are high.

When is the best time to have ACL reconstruction?

Timing is individual. Many patients do best when the knee is "calm" before surgery: minimal swelling, good movement, and good quadriceps control. This reduces the risk of stiffness and improves early recovery. I may bring surgery forward if there is a locked bucket-handle meniscus tear that needs addressing urgently.

Will I need physiotherapy after ACL surgery?

Yes. Physiotherapy is essential and is the main driver of recovery. The operation provides the stabilising graft; rehabilitation provides strength, control, and safe return to sport.

How long will I need crutches?

You will be toe-touch weight bearing with crutches for the first two weeks. Between weeks two and six, you wean off crutches as pain settles and quadriceps control improves. Most patients are off crutches by six weeks. The duration may be longer if additional procedures such as meniscal repair were performed.

When can I drive?

Around six weeks, depending on your range of movement and quadriceps control. You must be able to perform an emergency stop safely and should no longer be reliant on crutches. I give individual advice based on which leg was operated on, any associated injuries, and your progress.

When can I return to work?

This depends on your role. Desk-based work may be possible within 4–6 weeks if swelling is controlled and you can elevate the leg. Physical jobs often require longer (typically a minimum of 3 months) and may need staged duties.

When can I start running?

Running begins no earlier than 18 weeks, and only if you have full extension, good eccentric quadriceps control, and hamstring and quadriceps strength at 80% or more compared to the uninjured leg. You start on a trampette before progressing to straight-line jogging. The timing may be later if additional procedures were performed.

When can I return to football/rugby/skiing?

Return to non-competitive training begins at around 9 months, with full competitive sport targeted at 12 months. This is based on objective strength and hop testing, satisfactory single-limb dynamic control, movement quality under fatigue, and confidence. Returning too early increases re-injury risk.

What if my knee still swells after rehab sessions?

Some swelling after increasing your activity level is normal, but persistent or worsening swelling is a sign the knee is not tolerating the current load. I adjust the rehabilitation intensity based on how the knee responds – the programme is not a fixed timeline, it is guided by your progress.

Which ACL graft is best?

The best graft is the one that matches your knee, your sport, and your risk profile. I use hamstring, BTB, quadriceps tendon, and rectus femoris grafts depending on the situation. Allograft is an option in rare specific circumstances. Sometimes the best graft comes from the other leg – I will explain why if I think that applies to you.

What if I have already had ACL surgery before?

If your previous ACL reconstruction has failed and your knee is unstable again, revision ACL reconstruction may be needed. Revision planning is more complex – it often involves detailed imaging to assess tunnel position, graft strategy planning, and addressing rotational or alignment factors that may have contributed to the failure.