Treatment selection in acute anterior cruciate ligament tears

Traumatic hemarthrosis associated with rupture of the anterior cruciate ligament is one of the most common ligament injuries encountered in sports medicine today. Its management is difficult because of the combination of presenting pathology as well as the multitude of patient profiles encountered. Crucial to the decision on proper management of a particular patient is the accumulation of data concerning the patient's social and sporting life as well as a detailed physical examination. When doubt exists, the physician can use other tests, including arthrograms, examination under anesthesia, or arthroscopy, to confirm and expand his diagnosis. Generally, the patient will be easily categorized into one of three areas: those who require surgery and reconstruction, those who do not, and those whom a decision is not clear. In the treatment of rotatory instability of the knee, no single approach has proved to be a panacea. The multiple procedures available attest to the complexity of the situation. It is not easily decided who will do well with conservative treatment and who will not, although data show that many individuals with mild or moderate instability can be treated effectively this way. The patient must be involved in the decision process, although it is clearly the physician who brings his bias to bear. The key factor in the successful management of the knee with rotatory instability is the patient's individual ability and willingness to modify his activities and select those sporting events compatible with his level of instability and general coordination. Rehabilitation is important for optimal results in both the conservatively and operatively treated groups and involves the four principles of (1) protection during the healing phase, (2) prevention of reinjury, (3) achievement of previous performance levels, and (4) postponement of late degenerative changes. The role of the physician is to guide and support the patient in learning to accept his knee disability. The best medical management and advice are ever-changing. Future technologic breakthroughs may provide optimal solutions for knees with rotatory instability and may create surgical and rehabilitative techniques that will prove desirable to those patients who presently are unwilling or unsuited to take the risk of major surgical reconstruction and the long rehabilitative process associated with it.