ACL and meniscus injuries are two fairly common knee injuries, especially in individuals who actively participate in sports. When an MRI reveals an ACL or meniscus tear, one of the first questions often arises:
"Doctor, does this require surgery?"
The answer: not necessarily.
Not all ACL or meniscus tears require surgery. The decision regarding treatment is not
solely determined by MRI images, but must take into account complaints, clinical examination, knee stability, tear pattern, other accompanying injuries, age, activity level, and the patient's needs and goals.
We don't treat MRI results. We treat patients.
Getting to Know the ACL and Meniscus
The ACL ( anterior cruciate ligament ) is one of the main ligaments in the knee that plays an important role in maintaining stability, especially when making sudden stops, turning, landing after jumping, or changing direction.
The meniscus is a crescent-shaped fibrocartilage tissue located between the thigh bone and the shin bone. Each knee has a medial and lateral meniscus.
The meniscus is more than just a "cushion." This structure plays a role in distributing load, absorbing impact, aiding joint stability, and protecting cartilage.
For this reason, the current principle of meniscus treatment increasingly prioritizes preserving as much meniscus tissue as possible .
How Do ACL Injuries Occur?
ACL injuries often occur without direct impact.
Movements that often cause injuries include sudden changes in direction, sudden stops while running, turning movements with the foot still on the ground, and poor landing after jumping.
This injury is often found in sports such as soccer, basketball, futsal, badminton, tennis, and other sports that require pivoting movements or rapid changes in direction.
Patients sometimes hear or feel a "pop" at the time of injury. The knee may then swell within a few hours, and after the acute phase passes, some patients may experience instability or a " giving way " in the knee , especially when turning or changing direction.
How Do Meniscus Injuries Occur?
At a young age, meniscus tears often occur due to trauma, for example when the knee rotates while the foot is supporting.
However, in older age, the meniscus can undergo degenerative changes so that tears can occur after relatively light activity or even without obvious trauma.
Complaints can include pain on the inside or outside of the knee, swelling, a feeling of catching, difficulty bending or straightening the knee, or even a completely locked knee.
It is important to differentiate traumatic meniscal tears from degenerative tears because the treatment approach is not always the same.
Does a Torn ACL Always Require Surgery?
No.
Some patients with ACL injuries can undergo non-operative therapy in the form of structured rehabilitation, especially if the knee remains stable in daily activities and the patient does not plan to return to activities that require a lot of twisting motion or rapid changes in direction.
However, ACL reconstruction is more often considered if:
- The knee experiences repeated episodes of giving way or instability.
- Patients want to return to sports with pivoting , cutting , or rapid changes of direction.
- The patient has high physical activity demands.
- There is an accompanying injury to the meniscus, cartilage, or other ligaments.
- Instability continues to interfere with function despite adequate rehabilitation.
In young, active patients who wish to return to high-demand sports, ACL reconstruction is often an option to restore knee stability and help protect other structures within the joint from repeated episodes of instability.
If ACL reconstruction is indicated for acute injury, the procedure should not be delayed without a clear reason because episodes of instability and too long a delay can increase the risk of additional injury to the meniscus or cartilage.
Does a Torn Meniscus Always Require Surgery?
Also not.
A small, stable meniscus tear that does not interfere with movement and does not cause serious complaints can be treated non-operatively through activity modification, pain control, and physiotherapy.
Surgery is considered more if there is a displaced or unstable tear in the knee
completely locked or restricted range of motion, persistent complaints after adequate conservative therapy, or a tear pattern that has good potential for repair.
In certain acute tears that can be repaired, meniscus repair may be an option.
Save the meniscus whenever possible.
Why?
Because loss of meniscus tissue will reduce the knee's ability to distribute load and in the long term can increase pressure on the joint cartilage.
Therefore, when surgery is necessary, the goal is not simply to "clean" the meniscus, but to preserve as much functioning meniscus tissue as possible.
What about Degenerative Meniscus Tear?
This is a part that is often misunderstood.
In middle-aged or elderly patients, MRI findings of meniscal tears are quite common as part of the degenerative process of the knee.
This means that the presence of a tear on an MRI does not automatically mean that the patient needs surgery.
In many degenerative cases without a specific mechanical condition requiring treatment, exercise and rehabilitation are an important part of initial management.
Therefore, MRI results must always be correlated with complaints and clinical examination.
When the ACL and Meniscus are Torn Simultaneously
ACL and meniscus injuries occur together quite frequently, especially in sports injuries.
In this condition, the goal of therapy is not only to restore knee stability but also to maintain meniscus function.
If ACL reconstruction is performed and the meniscus tear is still repairable, the doctor may perform meniscus repair at the same time.
Maintaining the meniscus is important because this tissue plays a major role in protecting the cartilage and the long-term health of the knee joint.
Is an MRI Always Needed?
Diagnosis begins with a story of how the injury occurred and a physical examination.
For ACL injuries, doctors may perform stability tests such as the Lachman test and pivot shift test . If a meniscus injury is suspected, tests such as joint line tenderness , the McMurray test , or other provocative tests may be helpful.
MRI is a very useful imaging test for viewing the ACL, meniscus, cartilage, and other structures within the joint.
X-rays may also be necessary, especially to assess the bones, alignment, degenerative changes, or to rule out certain bone injuries.
MRI is part of the diagnostic process, not the sole determinant of therapy.
What to Do After an Injury?
In the initial phase, avoid activities that aggravate the pain or cause the knee to re-injure itself.
giving way .
A cold compress can help reduce pain and swelling. If necessary, a walking aid or brace may be used depending on the examination results.
Once the acute phase is under control, rehabilitation becomes an important part of treatment. Its goals include:
- Reduce swelling.
- Restores the knee's ability to straighten and bend.
- Restores quadriceps and hamstring strength.
- Improve neuromuscular control.
- Restores balance and knee function.
Even in patients who ultimately undergo ACL surgery, the condition of the knee before surgery remains important. Knees that are still very swollen and stiff generally require rehabilitation before definitive treatment is performed.
Surgery Is Not the End of the Journey
Another thing that is often forgotten is that the success of ACL and meniscus surgery is not only determined by the surgical procedure.
Rehabilitation after surgery is equally important.
Return to exercise should also not be determined solely by how many months have passed since surgery.
Muscle strength, knee stability, range of motion, ability to perform functional activities, neuromuscular control, and patient readiness need to be assessed before returning to sport.
Returning to sport is not just a matter of time, but also about knee readiness.
When Should You Get Your Knees Checked?
Immediately carry out an examination if after the injury you experience rapid swelling, are unable to support your weight, the knee feels repeatedly giving way , the knee cannot be straightened or locked, the pain and swelling does not improve, or the function of the knee is increasingly impaired.
Early examination helps determine the injured structures and appropriate treatment strategies.
Conclusion
ACL or meniscus injuries do not always mean surgery is necessary .
Some patients can achieve good results with proper rehabilitation, while in certain conditions surgery is a more appropriate option to restore stability, repair injured structures, and maintain long-term knee function.
This decision should be made individually based on the type of injury, knee stability, complaints, activity level, concomitant injuries, and the patient's goals.
Don't make a surgical decision just by reading the MRI results.
MRI helps us see injuries.
But it is the patient - not the MRI image - that determines the direction of treatment.
Article written by Dr. Akbar Rizki Beni Asdi, Sp.OT, Subsp.PL(K), FICS, AIFO-K (Orthopedic & Traumatology Specialist, Hip & Knee Consultant at EMC Pulomas Hospital).