ACL Reconstruction and Knee Ligament Treatment

knee ligaments adelaide

Treatment options for ACL injuries and other ligament damage to the knee

The ligaments in your knee play a critical role in maintaining joint stability, especially during activities that involve twisting, pivoting, or rapid changes in direction. Injuries to these ligaments, particularly the anterior cruciate ligament (ACL), are common in sports and high impact activities, but can also occur due to falls, accidents, or sudden trauma.

 

ACL tears and other ligament injuries often lead to pain, swelling, a sense of instability, and limitations in physical function. In some cases, non-surgical management such as physiotherapy may be appropriate. In others, especially where the knee is unstable or the patient is highly active, surgical treatment may be recommended to restore function and support long term joint health.

This page explores the role of knee ligaments, common causes of injury, and the surgical treatment options available, including ACL reconstruction and procedures for other ligament injuries such as MPFL (medial patellofemoral ligament) repair, PCL reconstruction, and multi-ligament knee reconstruction. You’ll also learn what to expect before, during, and after surgery, and how rehabilitation plays a key role in recovery.

Understanding knee ligaments and how injuries occur

Your knee is a complex hinge joint supported by several key ligaments that stabilise and guide its movement. These ligaments connect the bones of the upper and lower leg and work together to keep your knee stable during walking, running, jumping, and changing direction. When one or more of these ligaments are stretched or torn, it can lead to pain, instability, and long-term joint problems if not managed appropriately.

Key ligaments in the knee

How knee ligament injuries occur

Ligament injuries often result from high-impact or twisting movements. Common mechanisms include:
Ligament injuries range in severity:
Some injuries involve more than one ligament and may be associated with meniscal damage, cartilage injury, or bone bruising. Understanding which ligament is affected, and to what extent, is critical in determining the most appropriate treatment, whether that be physiotherapy, bracing, or surgical reconstruction.

How ligament injuries are diagnosed

When a knee injury occurs, identifying which ligament is affected and the extent of damage is essential in deciding the most appropriate treatment pathway. Dr George Awwad uses a combination of clinical examination and advanced imaging techniques to accurately diagnose ligament injuries, including ACL, PCL, MCL, LCL, and multi-ligament trauma.

Initial assessment and medical history

During your consultation, Dr Awwad will begin by discussing how the injury happened and reviewing your symptoms. Important aspects include:
Understanding how the injury occurred helps Dr Awwad narrow down which ligaments or soft tissues may be affect

Physical examination

Dr Awwad will carefully assess your knee using specific clinical tests to evaluate the stability of each ligament. These may include:

Swelling, bruising, reduced range of motion, and the presence of a joint effusion are also considered.

Imaging tests

Imaging helps confirm the diagnosis and rule out other knee injuries. Dr Awwad may recommend:

When immediate diagnosis is not possible

If the knee is acutely swollen and painful, it may be difficult to perform a complete examination straight away. In this case, Dr Awwad may recommend a short period of rest and follow-up imaging once the acute inflammation has settled. This allows for a more accurate diagnosis and surgical planning, if needed.

Surgical treatment options for ACL and other ligament injuries

When a knee ligament is completely torn, or if conservative treatment has not restored stability, surgical reconstruction may be recommended. Dr George Awwad offers a range of advanced ligament reconstruction procedures tailored to the specific ligament injured such as the ACL (anterior cruciate ligament), PCL (posterior cruciate ligament), MCL (medial collateral ligament), LCL (lateral collateral ligament), or multi-ligament injuries. These include:

ACL Reconstruction

ACL reconstruction is one of the most commonly performed knee ligament procedures. In this surgery:
Dr Awwad uses modern, minimally invasive techniques and evidence-based surgical planning to optimise graft placement, tensioning, and long-term knee function.

PCL, MCL, and LCL Reconstruction or Repair

While isolated injuries to the MCL or LCL may heal with non-surgical care, severe or combined injuries often require reconstruction:

Multi-Ligament Knee Reconstruction

In high-impact trauma or knee dislocations, multiple ligaments may be injured. Dr Awwad has experience managing complex multi-ligament reconstructions, involving:
These cases require an individualised surgical strategy to balance knee stability, motion, and long-term joint protection.

ACL reconstruction surgery: techniques and graft types

ACL reconstruction is a surgical procedure designed to restore stability to the knee after a complete or high-grade ACL tear. Dr George Awwad performs this procedure using modern techniques that prioritise accurate graft placement, tissue preservation, and long-term joint function. The surgery involves removing the remnants of the torn ACL and replacing it with a new graft, which acts as a scaffold for new ligament tissue to grow.
acl reconstruction adelaide

Key surgical techniques

Dr Awwad uses arthroscopic (keyhole) techniques for ACL reconstruction, which means the surgery is performed through small incisions with the help of a camera and specialised instruments. This minimally invasive approach allows for:

Tunnel placement is a critical part of the procedure. Precise tunnels are created in the femur and tibia to position the graft in the same anatomical orientation as the original ACL. Accurate tunnel alignment supports graft healing and helps restore natural knee biomechanics.

Graft types used in ACL reconstruction

The choice of graft is a key consideration in ACL surgery. Dr Awwad will guide you through the most suitable options based on your age, activity level, knee anatomy, and surgical history.

1. Hamstring tendon autograft

Patellar tendon autograft

3. Quadriceps tendon autograft

4. Allograft (donor tissue)

Fixation and graft integration

The graft is fixed securely into the bone tunnels using screws or other fixation devices. Over the next few months, the graft undergoes biological incorporation, where it gradually becomes part of the knee’s natural structure. This process is supported by careful rehabilitation and load management during recovery.

Revision ACL surgery

In cases where a previous ACL reconstruction has failed, Dr Awwad offers revision ACL reconstruction. This is a more complex procedure that requires:

Recovery and rehabilitation after ACL surgery

Recovery following ACL reconstruction is a structured, multi-phase process designed to protect your graft, restore knee function, and gradually return you to your regular activities or sports. Dr George Awwad and his team will guide you through each stage, tailoring your care to your individual surgery, physical progress, and personal goals.

Immediately After Surgery

Pain Management

Pain medications are tailored by your anaesthetist and may include paracetamol and short-term opioids such as Endone or Palexia. Anti-inflammatory medications are not routinely used unless advised by Dr Awwad

Rehabilitation Phases

Your physiotherapy program will begin shortly after surgery and typically continues for 12 months. Recovery is broken into five distinct phases:

Phase I (0–6 weeks): Protect and Mobilise

Goals:
Activities:

Phase II (6–12 weeks): Build Strength and Range

Goals:

Activities:

Phase III (12–26 weeks): Advance Strength and Function

Goals:
Activities:

Phase IV (6–9 months): Return to Agility and Sport Readiness

Goals:

Activities:

Phase V (9–12+ months): Full Return to Sport

Goals:

Return-to-sport criteria:

When to Seek Medical Attention

Please contact Dr Awwad’s office or your hospital immediately if you experience:

PCL, MCL, and LCL Reconstruction or Repair surgical techniques

While ACL injuries are among the most well-known ligament injuries in the knee, damage to the posterior cruciate ligament (PCL), medial collateral ligament (MCL), and lateral collateral ligament (LCL) can also result in pain, instability, and functional limitation. In some cases, these injuries require surgical reconstruction or repair. Dr George Awwad provides comprehensive assessment and advanced surgical treatment for complex ligament injuries, including isolated or combined ligament reconstructions.

Posterior cruciate ligament (PCL) reconstruction

The PCL is the strongest ligament in the knee and helps prevent the tibia (shinbone) from moving backwards relative to the femur (thighbone). PCL injuries often occur in high-energy trauma, such as motor vehicle accidents or contact sports.
When is PCL surgery needed?
Surgical technique:

Medial collateral ligament (MCL) repair or reconstruction

The MCL provides stability to the inner (medial) side of the knee and is one of the most commonly injured knee ligaments. MCL injuries are usually managed non-surgically, but surgery may be required in specific situations.
When is MCL surgery recommended?
Surgical technique:

Lateral collateral ligament (LCL) reconstruction

The LCL stabilises the outer (lateral) side of the knee. Isolated LCL injuries are rare but can occur in combination with PCL or ACL injuries (as part of posterolateral corner injuries).
When is LCL reconstruction necessary?
Surgical technique:

Multi-ligament reconstruction

In more complex injuries, two or more knee ligaments may be damaged simultaneously. Dr Awwad performs multi-ligament knee reconstruction using a staged or single-sitting approach, based on the severity and chronicity of the injury. These cases require highly individualised planning, precise surgical technique, and close coordination with physiotherapists during recovery.

Surgical planning with imaging and graft choice

Prior to surgery, Dr Awwad will review advanced imaging (MRI, CT scans) to assess the extent of ligament damage and joint alignment. Graft type (autograft vs. allograft) is selected based on factors such as the number of ligaments requiring reconstruction, graft availability, patient activity level, and previous surgeries.

This comprehensive approach to PCL, MCL, and LCL reconstruction aims to restore knee stability, protect surrounding joint structures, and support a safe return to activity. Dr George Awwad tailors each surgical plan to the patient’s specific injury pattern, anatomy, and functional goals.

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Recovery and rehabilitation after multiligament knee surgery

Rehabilitation following multiligament knee reconstruction or repair is a structured and progressive process. It plays a crucial role in restoring knee function, protecting the surgical repairs, and reducing the risk of re-injury. Dr George Awwad follows detailed post-operative rehabilitation protocols that are tailored to the specific ligaments repaired (e.g. ACL, PCL, MCL, LCL) and individual patient factors.

Risks and potential complications of knee ligament surgery

As with any surgical procedure, ligament reconstruction or repair of the knee carries potential risks and complications. Dr George Awwad takes great care to reduce these risks through meticulous surgical technique, patient-specific planning, and close post-operative monitoring. Understanding the potential complications may help you make a more informed decision and support your recovery process.

1. Infection

Post-operative infection is a rare but serious complication. It may occur at the surgical site or deeper within the joint. Preventative measures include sterile operating environments, intravenous antibiotics during surgery, and careful wound care instructions following discharge. Signs of infection include increasing pain, redness, swelling, warmth, or discharge from the wound.

2. Blood Clots (Deep Vein Thrombosis - DVT)

Patients undergoing knee surgery are at increased risk of developing blood clots in the leg veins. Dr Awwad may recommend preventive strategies such as blood-thinning medication, compression stockings, and early mobilisation. Symptoms of DVT include calf pain, swelling, and warmth, and should be reported immediately.

3. Knee Stiffness or Loss of Motion

Some patients may experience restricted movement following ligament surgery, especially if post-operative physiotherapy is delayed or inconsistent. Adhering to the prescribed rehabilitation protocol and attending regular physiotherapy sessions can help maintain and gradually restore knee motion.

4. Graft Failure or Stretching

In ACL or multiligament reconstructions, the graft used to reconstruct the ligament can stretch or fail, particularly in the early phases of recovery or in the setting of a new injury. This may result in persistent instability and require further surgery. Dr Awwad provides detailed guidance on activity restrictions to protect the repair during healing.

4. Graft Failure or Stretching

In ACL or multiligament reconstructions, the graft used to reconstruct the ligament can stretch or fail, particularly in the early phases of recovery or in the setting of a new injury. This may result in persistent instability and require further surgery. Dr Awwad provides detailed guidance on activity restrictions to protect the repair during healing.

4. Graft Failure or Stretching

In ACL or multiligament reconstructions, the graft used to reconstruct the ligament can stretch or fail, particularly in the early phases of recovery or in the setting of a new injury. This may result in persistent instability and require further surgery. Dr Awwad provides detailed guidance on activity restrictions to protect the repair during healing.

5. Nerve or Blood Vessel Injury

Although uncommon, there is a small risk of injury to surrounding nerves or blood vessels during knee ligament surgery. This may cause temporary numbness, tingling, or weakness around the knee or foot. Most minor nerve disturbances resolve over time, but significant injuries may require further assessment.

6. Residual or Recurrent Instability

Even after surgery, some patients may continue to experience feelings of instability, particularly if more than one ligament was injured or if other structural issues are present. Additional rehabilitation, bracing, or revision surgery may be considered in these cases.

7. Graft Site Discomfort or Weakness

When a patient’s own tissue (autograft) is used—such as hamstring, quadriceps, or patellar tendon—there can be discomfort or weakness at the graft harvest site. Physiotherapy targets these areas to help restore function and reduce discomfort.

8. Arthrofibrosis (Scar Tissue Formation)

Excessive scar tissue can limit movement and cause pain. This may require a structured physiotherapy program or, in some cases, a minor procedure called arthroscopic debridement to remove the scar tissue and restore range of motion.

9. Kneecap Pain (Anterior Knee Pain)

Some patients may develop discomfort in the front of the knee, particularly when using a patellar tendon graft. This may be managed with activity modification, strengthening, and appropriate load management through physiotherapy.

10. Hardware Complications

Screws or fixation devices used to hold the graft in place can occasionally cause discomfort or irritation. In rare cases, they may need to be removed in a separate procedure.

Minimising Your Risk

Dr George Awwad will discuss your personal risk profile in detail during your consultation. He uses evidence-based techniques, sterile protocols, and enhanced recovery pathways to reduce the likelihood of complications. Following your post-operative instructions carefully, attending physiotherapy, and promptly reporting any concerns are key to achieving the best possible outcome.

ACL and ligament surgery FAQs

To support your decision-making and recovery, here are answers to some of the most frequently asked questions about ACL reconstruction and multiligament knee surgery. These answers are general in nature, and Dr George Awwad will provide more personalised guidance based on your condition, lifestyle, and goals during your consultation.
What is the difference between a ligament repair and a ligament reconstruction?

A ligament repair involves stitching or reattaching the torn ligament directly if the tissue is still intact enough to heal. This is more commonly used for certain ligaments like the MCL or LCL when the tear is near the attachment site. A ligament reconstruction involves replacing the damaged ligament with a graft (usually a tendon from your own body or from a donor). This is often required for ACL and more complex or chronic injuries.

Recovery time varies depending on the number of ligaments involved and the type of reconstruction performed. In general:

  • Isolated ACL reconstruction: Return to sport may be possible from 9 to 12 months.
  • Multiligament surgery (ACL + PCL, LCL or MCL): Recovery may extend beyond 12 months, with early rehabilitation focusing on protection and gradual mobility.

Dr Awwad will tailor your rehabilitation plan to your surgery and functional goals.

Dr Awwad uses several graft options depending on your age, activity level, and specific needs:

  • Hamstring tendon autograft (commonly used)
  • Quadriceps tendon autograft
  • Patellar tendon autograft
  • Allograft (donor tissue, generally used in revision or multiligament cases)

Each graft has benefits and considerations, which will be explained during your surgical planning.

No, in most cases a brace is not required after isolated ACL surgery, however may be required if other structures or ligaments are injured. The type of brace and duration of use will depend on the number and type of ligaments repaired or reconstructed.

Video: https://drgeorgeawwad.com.au/video/when-can-i-return-to-sport-after-my-acl-injury/

  • Desk-based work: Often possible within 2–4 weeks, depending on your mobility and commute.
  • Manual or physically demanding work: Usually requires 3–6 months or more.
  • Contact or pivoting sports: A full return may require 9–12+ months, with clearance based on functional testing.

Some ligament injuries, such as low-grade MCL sprains or partial LCL tears, may heal with non-surgical treatment, including rest, bracing, and physiotherapy. ACL tears, especially in active individuals or those with knee instability, typically require reconstruction for long-term stability.

ACL reconstruction is not typically an emergency. However, delaying surgery in active individuals or those with knee instability may increase the risk of further damage to cartilage or menisci. Dr Awwad will advise on timing based on your symptoms and goals.

Kneeling or squatting may be uncomfortable in the early stages but often improves with rehabilitation. Some graft types (e.g. patellar tendon) may cause longer-lasting discomfort during kneeling. Your physiotherapy plan will include gradual reintroduction to these activities.

Yes. Rehabilitation is critical to restoring strength, flexibility, and neuromuscular control after ligament surgery. Dr Awwad works closely with physiotherapists and provides detailed protocols to support each phase of your recovery.

If a reconstructed ligament fails, whether due to trauma, early return to sport, or graft-related issues, revision surgery may be needed. This involves more complex planning, but Dr Awwad has experience managing both primary and revision ligament reconstructions.

Download PDF Rehabilitation Guidelines

ACL Procedures

PCL Procedures

LCL / MCL Procedures

If you’re living with pain or stiffness that’s affecting your quality of life, a thorough assessment can help determine the cause and guide the right treatment path.