What is ACL?

The knee is among the most complex and stress-bearing joints in the human body. The anterior cruciate ligament plays a critical role in maintaining knee stability, especially during sudden turns, pivots, jumps or changes of direction. When the ACL tears, it can severely impact mobility, stability and long-term knee health.

In India, where football, kabaddi, cricket, basketball and other sports are gaining popularity, ACL injuries are becoming more common. Delayed diagnosis and proper treatment have forced several athletes or sportspersons to take a long break from sport, and some never return to their previous level, too.

As an orthopaedic surgeon, I have seen numerous ACL injuries, from weekend footballers around Gurugram and Delhi to professional kabaddi players, and I believe that correct, timely treatment along with rehabilitative care and prevention awareness can make a big difference.

Why is ACL Important?

The ACL (Anterior Cruciate Ligament) is one of the four major ligaments of the knee. It runs deep inside the knee joint, connecting the thigh bone (femur) to the shin bone (tibia). The primary functions of the ACL are:-

• Preventing the tibia from sliding too far forward under the femur.
• Controlling rotational stability of the knee (important during twisting, pivoting).
• Providing dynamic stability during weight-bearing, jumping or sudden direction changes.

Because of these functions, the ACL bears tremendous load during sports and activities involving rapid deceleration, turning, or landing. This is why it is vulnerable to tearing, especially in high-stress or abrupt movements.

Once torn, the ACL cannot regenerate spontaneously to its original strength or function. This makes ACL tears a serious injury requiring timely and appropriate management.

Mechanism & Common Causes of ACL Tear (With Indian Sports Perspective)

Non-contact mechanisms (most common)

Many ACL tears happen without any direct blow to the knee. Instead, they are caused from abrupt direction changes, pivoting, or faulty landing, common in sports like football, kabaddi, basketball, volleyball, and badminton.

For example:

• A footballer changes direction rapidly to dodge a defender.
• A kabaddi player lunges or twists the knee to tag or evade defenders.
• A basketball or volleyball player lands awkwardly after a jump.
• A recreational runner misses a step or lands unevenly after a small jump/stumble.

Contact or traumatic injuries

Direct impact to the knee, such as a tackle, collision, or fall, may also tear the ACL. Traffic accidents on the roads or slips and falls while hiking or climbing stairs may cause ACL injury.

Factors that increase risk

• Sports involving pivoting or sudden directional change: Football, kabaddi, tennis, basketball, volleyball, etc. In fact, according to several case studies on the Indian population, kabaddi and football have been among the top contributors to ACL injuries
• Poor neuromuscular control or weak stabilising muscles (hip, core, hamstring, quadriceps)
• Faulty technique, poor landing mechanics, lack of warm-up, and inadequate footwear
• Higher activity level, competitive sports, and an abrupt increase in training intensity
• Delayed diagnosis, continuing sport despite pain/instability, increases the risk of associated damage (meniscus, cartilage)

What Happens When ACL Tears: Symptoms, Associated Injuries, and Patterns

Typical Symptoms

• Many patients recall hearing or feeling a “pop” at the time of injury, though not always.
• Sudden pain, usually moderate to severe, immediately after injury.
• Rapid swelling, often within hours, due to internal bleeding within the joint.
• Inability to continue activity or bear weight on the injured leg. Difficulty walking, climbing stairs, or changing direction.
• Knee instability, especially when turning, pivoting, or walking on uneven ground.
• Limited range of motion and difficulty in bending or straightening the knee fully.
• Tenderness around the joint line, stiffness, and sometimes muscle cramps (hamstring or calf) if one continues to move despite the injury.

Associated Injuries. What Often Comes Along with an ACL Tear?

• In many cases, ACL tears are not isolated: meniscal tears (medial or lateral), cartilage (chondral) damage, collateral ligament injuries (MCL, LCL), or bone bruises may also occur.
• In Indian athletes, especially those playing high-demand pivot/contact sports like kabaddi, meniscal tears are prevalent.
• Delaying surgical repair or continuing sport with a torn ACL significantly increases the risk of further damage (meniscus, cartilage), which may affect long-term knee health.

Diagnosing an ACL Tear: What Orthopaedic Surgeons Look For?

Proper diagnosis involves a combination of clinical evaluation, physical tests, and imaging.

Clinical evaluation & physical tests

Experienced orthopaedic specialists perform tests, such as Lachman’s test, Anterior Drawer test, and Pivot Shift test to assess knee stability, tibiofemoral motion movement of the tibia in relation to the femur and rotational laxity. These help identify ACL deficiency. Additionally, swelling, joint-line tenderness, alignment, gait, and associated injuries are examined.

Imaging studies

• Magnetic Resonance Imaging: MRI is done to confirm whether the ACL tear is complete or partial and detect the other associated injuries, such as meniscus tears, cartilage damage, and bone bruises.
• X-ray: While ACL itself is soft tissue and not visible on X-ray, X-rays are used to rule out fractures, bone avulsions, or bony alignment issues, especially if there was trauma or impact.

Treatment Options

The ideal ACL tear treatment options depend on several factors, such as age, activity level, lifestyle, the extent of tear (partial/full), associated injuries, and personal preferences/goals.

Non-surgical Management

Non-surgical management is beneficial when:-

• The tear is partial, and the knee remains fairly stable.
• The person leads a sedentary lifestyle.
• The individual does not wish to return to high-demand sports.
• There are medical comorbidities or surgical risk factors.

Conservative management involves:

• RICE method: Rest, Ice, Compression, Elevation to manage swelling.
• Physiotherapy: It focuses on strengthening the quadriceps, hamstrings, glutes & core, and improves proprioception, balance, and neuromuscular control.
• Bracing: A knee brace may provide temporary stability for daily activities.
• Activity modification: Avoiding pivoting sports, heavy loads, sudden turns and shifting to low-impact activities (walking, cycling, swimming).
• Limitation: For young active individuals or those wishing to return to sports, non-surgical treatment often leads to persistent instability, risk of re-injury, meniscus/cartilage damage, or early osteoarthritis over time.

Surgical Treatment Options

Surgical methods are suitable treatment options for complete ACL tears, especially in:

• Young, active individuals
• Sports players (cricket, football, kabaddi, basketball, volleyball, etc.)
• People who want to return to strenuous or pivoting sports
• Those whose knee shows instability or locking episodes

Graft options

• Patellar tendon autograft: Herein, the middle part of your patellar tendon is taken from your shin and kneecap. The surgeon removes the torn ACL and drills two holes above and below your knee, creating a tunnel to insert the graft. The tunnel is then sealed with the bone plugs and secured with screws. With time, the plugs will fuse with the surrounding bone.
• Hamstring tendon autograft: The surgeon makes a small incision and removes a part of your hamstring tendon from the back of your thigh. Some doctors may also create a two-to-four-strand graft bundle by stitching together the additional tendons from the same area. During the hamstring tendon autograft procedure, no bone plugs are used, unlike in the patellar tendon autograft. Rather, the surgeon uses the screws to hold the graft in place, which fuses with the bone over time.
• Quadriceps tendon autograft: During this procedure, the surgeon uses your own quadriceps to reconstruct a torn ligament. To hold the graft in place, the surgeon removes the middle part of your quadriceps tendon and a single bone plug.
• Allograft: In this procedure, the surgeon reconstructs the CAL by using tissue from the deceased donor. Several areas of the leg, such as, knee(patellar), heel(achilles), inner thigh(gracilis), and hamstring (semitendinosus) can be used as the donor tendons.

Each graft has its advantages and disadvantages. The surgeon’s experience and the patient’s sport/activity goals play a major role in deciding.

Technique & Approach

• ACL reconstruction is commonly done under arthroscopic guidance. These are minimally invasive and offer quick recovery, causing less soft-tissue damage and minimal incisions. Teh doctor aligns the graft anatomically to restore the native knee biomechanics. Proper tunnel placement, graft tensioning, and fixation are critical for the optimal outcome.

Physiotherapy and rehabilitation after the surgery

• The success largely depends on the structured phase-wise rehabilitation, under the guidance of physiotherapists and the sports-rehab team. The graft may fail, and the knee might remain unstable or weak without good rehabilitation.
• Common rehabilitation goals include reduced pain and swelling, restored range of motion, muscle strength building(quadriceps, hamstrings, gluteals, core), improving balance/proprioception, and returning to functional sport activity gradually.

Recovery timeline

Depending on several factors, including graft type, rehab compliance, patient biology, age, fitness level, etc., below is a usual recovery timeline seen in well-managed ACL reconstructions:

Weeks 1-2:

• Pain and swelling control
• Gentle exercises
• Protected weight bearing with support as needed

Week 3-6:

• Progress to full weight-bearing
• Quadriceps and hamstring strengthening
• Gentle closed-chain exercises
• Focus on improving mobility and flexibility

Months 2-4:

• Progressive strengthening
• Balance training
• Low-impact cardio, such as, stationary bike, swimming
• Gradual wearing off brace/clutches

Months 4-6:

• Dynamic balance, stability, and agility drills
• Light jogging only if the graft is stable and knee control is adequate
• More functional training

Months 6-9:

• Gradual return to sport-specific drills, such as cutting, pivoting, and sprinting

9-12+ months

Many athletes return to full sport. Some may take 12-18 months to regain confidence, performance, and minimise the re-injury risk.

It’s important to remember that rushing return to sport or skipping rehab phases can jeopardise outcomes and increase the risk of graft failure or future knee damage.

ACL Tear in India: What’s Different & What We Need to Know

Sports like kabaddi (a native Indian sport), which involve rapid direction changes, tackles, and knee twisting under load, show a high incidence of ACL tears, often with meniscal or chondral damage.

• Contact as well as non-contact injuries mostly occur during informal games on uneven or poorly maintained grounds, with inappropriate footwear or lack of warm-up.
• Many players or individuals continue daily life/sport without a proper diagnosis, leading to further joint damage.
• Access to structured, supervised rehabilitation (physiotherapy, neuromuscular training, sports-specific rehab) is limited in many regions.
• Sometimes athletes avoid surgery due to cost, time off work, fear of complications, or because they hope to “manage with physiotherapy.”

Given these realities, awareness, early diagnosis, timely referral to experienced orthopaedic and rehabilitation specialists, and prevention efforts are especially important in the Indian context.

How to Reduce the Risk of ACL Injuries

For athletes, professional or amateur, and active adults, adopting preventive habits can significantly lower ACL tear risk. Here are a few evidence-backed strategies:

1. Strength Training & Neuromuscular Conditioning

   Focus on strengthening hamstrings, quadriceps, gluteal muscles, and core, which helps to improve joint stability. Balanced strength around the knee (flexors and extensors) helps reduce undue stress on the ACL during dynamic activities. Neuromuscular training (balance, proprioception, coordination drills) improves control during landings, pivots, and changes of direction. Several studies have emphasised neuromuscular training as key to ACL injury prevention.

2. Proper Warm-up & Technique

   Dynamic warm-up before training/games, including light jogging, hip/ankle mobility drills, activation of glutes and hamstrings, reduces the risk. Focus on proper landing mechanics (soft knees, correct alignment, avoiding valgus collapse), especially in jumping/landing sports. Sport-specific technique coaching, such as teaching the athletes safe pivoting, deceleration and cutting, can prevent dangerous loading of the ACL.

3. Appropriate Footwear & Playing Surface

   Use sports-appropriate shoes with good grip and support. Playing surfaces should be even and well-maintained. Avoid uneven, slippery, or hard surfaces, which increase the risk of knee twists or slips.

4. Manage Load & Training Intensity

   Avoid sudden spikes in training volume or intensity. Gradual progression helps ligaments, muscles, and the neuromuscular system adapt. Include rest and recovery days; overload and fatigue significantly increase injury risk.

5. Early Attention to Knee Pain/Instability

   Do not ignore early signs, such as mild pain, swelling, or discomfort. Early diagnosis and treatment by an orthopaedic specialist can prevent small tears from worsening.

Clinical Approach & Recommendations

Based on years of treating ACL tears in amateur athletes, weekend warriors, and professional sportspersons, this is how Dr. Manu Bora advises patients:

• Don’t wait: If you suspect ACL injury (pop-sound, swelling, instability), get evaluated early. Early MRI and an orthopaedic consultation reduce the risk of associated damage (meniscus, cartilage).
• Choose treatment based on lifestyle and goals: If you are active, plan to return to sports or heavy work, reconstruction with hamstring (or suitable graft) and structured rehab is often best.
• Don’t skip rehab: Committing to phase-wise physiotherapy, neuromuscular training, and gradual return to activity is essential. Rehab duration may stretch to 9–12 months or more.
• Be realistic with timelines and expectations: Return-to-sport too early increases reinjury risk. Aim for full strength, stability, and neuromuscular control before aggressive sports.
• Post-surgery follow-up & long-term joint care: Even after successful reconstruction, regular check-ups, physiotherapy (if needed), and monitoring for signs of wear/arthritis are required.

Conclusion

An ACL tear is a serious knee injury. With timely diagnosis, appropriate surgical repair (if needed), and diligent rehabilitation, most individuals can regain full function and return to their sport or active lifestyle.

In India, where pivoting sports like football and kabaddi are hugely popular, and regular gyms, weekend sports, and recreational running are rising, awareness about ACL injury, its causes, prevention, and treatment, is more important than ever.

Dr. Manu Bora urges every athlete, sportsperson, weekend warrior or active adult: “Treat your knee as an investment.” Respect the injury, choose treatment carefully, commit to your rehab, and adopt injury-prevention habits. That way, you can safeguard your knees, and many seasons of sport and activity ahead.