Introduction
A torn ACL (Anterior Cruciate Ligament) is one of the most significant sports injuries an active person can face. The sudden pop, the swelling, the realization that months of recovery lie ahead all come with a diagnosis that changes your immediate reality, and sometimes your year. Moreover, if a neglected ACL tear can affect the rest of your life.
At New York Bone & Joint Specialists, we have guided athletes and active New Yorkers through every stage of this injury, from the moment of diagnosis through the final return-to-sport clearance. Our belief that preservation is the key to longevity is particularly appropriate when it comes to ACL injuries. An ACL tear leads to an unstable knee joint, and an unstable joint can lead to the degeneration of that joint. We need to make sure your knee is stable for you to have a healthy and functioning joint for a long lifetime to come.
Our approach begins with a conversation: not every ACL tear requires surgery, and when it does, the details of how it’s done determines how well you recover.
ACL reconstruction is among the most technically demanding procedures in orthopedic sports medicine. The outcome depends not just on whether the surgery is performed, but on graft selection, tunnel placement, fixation technique, and the quality of the rehabilitation that follows. Our surgeons are fellowship-trained in sports medicine, operate at Northwell Lenox Hill Hospital, and coordinate directly with our in-house physical therapy team at every stage of your care.
What is ACL Reconstruction?
The anterior cruciate ligament (the ACL) is one of the four major ligaments that stabilize the knee. It runs diagonally through the center of the joint, connecting the femur to the tibia, and is the primary restraint against rotational instability. When it tears, the knee loses its ability to handle the cutting, pivoting, and deceleration forces that are fundamental to sport and an active lifestyle.
ACL reconstruction replaces the torn ligament with a graft (a tendon taken from another part of your own body or from a donor source) which is then secured inside bone tunnels drilled in the femur and tibia. Over the following 12 to 18 months, the graft undergoes a process called ligamentization: it gradually transforms from transplanted tendon into a functional ligament, developing the mechanical properties needed to stabilize the knee under load. [7]
The procedure is performed arthroscopically (arthroscopy is a minimally invasive technique with small incisions using a camera and specialized instruments) which lessens tissue disruption, reduces post-operative pain, and accelerates early recovery compared to open surgical approaches.
Are You a Candidate for ACL Reconstruction?
Not every ACL tear requires surgery. The decision depends on your age, activity goals, the severity of your instability, and whether you have concurrent injuries to the meniscus or cartilage. At your consultation, we will review your MRI, assess your knee stability, and discuss every option available to you (both surgical and non-surgical) so you can make an informed decision. [6]
ACL reconstruction is typically recommended when:
- You have a complete ACL tear confirmed on MRI and clinical examination
- You participate in pivoting or cutting sports and intend to return to them
- Your knee gives way during daily activities or lower-level sport
- You have a concurrent meniscus tear that requires repair and benefits from the stability of a reconstructed ACL
- You have tried physical therapy and activity modification but continue to experience instability
Non-surgical management may be appropriate for older, less active patients or those with isolated tears and minimal instability. We will present both pathways honestly. If surgery isn’t your best option, we will tell you.
| Note: New Patients with ACL Injuries: Prompt consultations are available at our Upper East Side and Midtown locations. Bring any existing MRI or X-ray imaging to your first visit. If imaging has not been obtained, we can arrange it in-house. |
Graft Selection: The Most Important Decision Before Surgery
The choice of graft is one of the most consequential decisions in ACL reconstruction, and it’s one that should be made with your surgeon based on your anatomy, age, sport, and recovery goals, not as a default. There is no universally superior graft. Each has distinct mechanical properties, harvest-site implications, and evidence behind it.
| Graft Type | Best For | Key Advantage | Consideration |
| Patellar Tendon (BTB) | High-demand athletes, contact sport, revision cases | Highest mechanical strength; gold standard for return to pivoting sport | Anterior knee pain possible; kneeling discomfort in early recovery |
| Hamstring Tendon (Autograft) | Patients prioritizing anterior knee comfort; recreational athletes | Less donor site morbidity; good outcomes in recreational population | Slightly higher re-tear rate in young athletes returning to cutting sport |
| Quadriceps Tendon | Larger patients; revision ACL; prior patellar tendon harvest | Large graft cross-section; excellent when other autograft sites unavailable | Less commonly used; growing evidence base |
| Allograft (donor tissue) | Older, lower-demand patients; multi-ligament reconstructions | No donor site; useful in complex multi-ligament cases | Higher re-tear rate in patients under 25; not recommended for young athletes [10] |
At New York Bone & Joint, graft selection is an individualized conversation, not a default. We review your age, activity level, sport, and anatomy together and arrive at the choice that optimizes your long-term outcome. In our surgeons’ experience, we usually prefer to use your own tissue graft (autograft) because we believe the best tissue is your own tissue.
The Procedure: What Happens in the Operating Room
ACL reconstruction at New York Bone & Joint is performed as an outpatient procedure under regional or general anesthesia. Patients go home the same day. The surgery typically takes 60 to 90 minutes.
The key steps:
Graft harvest: If using an autograft (your own tissue), the graft is harvested through a small separate incision. The harvest site is repaired carefully to minimize donor site complications.
Arthroscopic joint preparation: A camera is inserted through two small portals to inspect the joint, confirm the ACL tear, and address any concurrent injuries to the meniscus or cartilage at this time.
Tunnel drilling: Bone tunnels are drilled in precisely measured anatomic positions in the femur and tibia, replicating the native ACL footprint. Tunnel placement is the most technically demanding step and has the greatest influence on rotational stability outcomes.
Graft passage and fixation: The graft is passed through the tunnels and fixed at both ends using hardware appropriate to the graft type. Graft tension is carefully set before fixation to optimize stability without over-constraining knee motion.
Closure and dressing: Portals are closed and a post-operative dressing and brace are applied. Most patients bear weight on the leg before leaving the facility.
Concurrent procedures: Meniscus tears, cartilage lesions, and partial MCL injuries are commonly identified and addressed in the same operative session. We will discuss any anticipated concurrent procedures with you in detail before surgery.
Recovery and Rehabilitation: Phase by Phase
ACL reconstruction recovery is a process, not an event. Most patients return to sport between 9 and 12 months, and the quality of the recovery program matters as much as the surgery itself. At New York Bone & Joint, your surgeon and physical therapist work in the same center and communicate directly at every milestone.
| Phase | Timeframe | Goals & Activities |
| Phase 1 | Weeks 0–6 | Swelling control, restore range of motion, begin quad activation. Weight-bearing as tolerated with crutches. Brace worn for protection. Physical therapy begins within the first week. |
| Phase 2 | Weeks 6–12 | Full weight-bearing without crutches. Progressive strengthening of quads, hamstrings, and hip stabilizers. Stationary bike and pool exercises. Brace weaned. |
| Phase 3 | Months 3–6 | Jogging progression, lateral movements, sport-specific conditioning. Strength and symmetry testing begins. Single-leg assessments performed. |
| Phase 4 | Months 6–9 | Agility training, sport-specific drills, reactive neuromuscular exercises. Functional testing including hop tests and strength indices. |
| Return to Sport | 9–12 months | Criteria-based clearance, not time-based. Requires: limb symmetry index >90%, passing hop test battery, psychological readiness assessment, surgeon and PT sign-off. [4] [5] |
| New York Bone & Joint’s Return-to-Sport Protocol: We don’t clear patients for return to sport based on time alone. Clearance requires objective functional testing, including single-leg hop tests, quad and hamstring strength symmetry indices, and a psychological readiness assessment. Research consistently shows that criteria-based clearance reduces re-tear risk compared to time-based clearance alone. [4] [5] [11] |
Risks and Considerations
ACL reconstruction is a well-established procedure and like any surgical procedure there have been complications reported. New York Bone & Joint believes that advanced surgical skills, an experienced full scope of knowledge, detailed understanding, and unwavering care for the patient’s wellbeing are the keys to minimizing complications.
Re-tear rate: The published data shows re-tear rates ranging from 4.4–10% in the general population and 15–25% in young athletes returning to cutting and pivoting sport. [1] [2] Based on New York Bone & Joint’s own surgical outcome data, our ACL re-tear rate is approximately 1–3%. New York Bone & Joint minimizes re-tear risk through experienced surgical technique, appropriate graft selection, precise tunnel placement, and neuromuscular rehabilitation with criteria-based progression. [11]
Donor site morbidity: Autograft harvest can cause temporary discomfort at the harvest site, such as anterior knee pain with patellar tendon graft; hamstring weakness with hamstring graft. Some patients develop numbness at the harvest site. Most patients fully resolve these issues by 6–12 months.
Stiffness (arthrofibrosis): Uncommon. Minimized by early motion and supervised physical therapy. Pre-operative physical therapy is incorporated to regain optimal range of motion before surgery. The better the motion pre-operatively, the better the motion post-operatively. [8]
Infection: Surgical site infection occurs in less than 1% of cases. All New York Bone & Joint procedures follow strict sterile protocols.
Non-surgical alternative: For low-demand patients without instability, a structured physical therapy program focused on neuromuscular rehabilitation and quad strengthening can allow return to activity without surgery. We will discuss this option if it applies to you.
Why Choose New York Bone & Joint for ACL Reconstruction
| Why New York Bone & Joint | What It Means for You |
| Individualized graft selection | No default approach. Your age, sport, anatomy, and goals determine graft choice. Discussed in detail at your consultation. |
| Fellowship-trained knee surgeons | New York Bone & Joint surgeons have completed subspecialty sports medicine fellowships including NYU Langone Orthopedic Hospital. |
| Minimized re-tear rates | New York Bone & Joint combines experienced surgical expertise and strict criteria-based rehabilitation to keep re-tear rates at approximately 1–3%, compared to published benchmarks of 5–25%. |
| In-house physical therapy | Your surgeon and physical therapists work in the same centers. Protocol is coordinated from day one of recovery, not handed off to a separate facility. |
| Criteria-based return-to-sport clearance | Objective functional testing determines when you are ready, not a calendar. This is the single most important factor in re-tear prevention. [4] |
| Concurrent injury management | Meniscus tears, cartilage lesions, and MCL injuries are assessed pre-operatively and addressed in the same surgical session where appropriate. |
| Prompt consultations | Patients with acute knee injuries can be seen promptly. X-ray and ultrasound available at both locations on first visit. Concierge MRI scheduling immediately available. |
| In-house imaging | X-ray and ultrasound at both locations. Concierge MRI scheduling for same-week appointments at affiliated centers. |
| From Dr. Popovitz: A Case That Has Stayed with Me I have had the honor of performing anterior cruciate ligament (ACL) reconstructions for 20 years. I have done it for professional athletes and recreational sports enthusiasts. But one of the most rewarding experiences is reconstructing an ACL for someone who needs it for daily function: to be able to work, to earn a living, to support their family. One of the very first patients for whom I reconstructed an ACL returned to see me recently, for a different issue. Upon his return visit, he explained how the ACL surgery allowed him to return to providing for his family, whom he clearly cared about very much. He showed me a picture of his beautiful family and I saw his happy face. I felt such gratitude that I was able to become a doctor and a surgeon and to have helped this kind man and his family. — Dr. Leon E. Popovitz |
References
- Wiggins AJ et al. Risk of Secondary Injury in Younger Athletes After ACL Reconstruction. Am J Sports Med. 2016. pubmed.ncbi.nlm.nih.gov/26772611
- Kaeding CC et al. Risk Factors and Predictors of Subsequent ACL Injury in Either Knee After ACL Reconstruction. Am J Sports Med. 2015. pubmed.ncbi.nlm.nih.gov/25899429
- AAOS. Updated Clinical Practice Guideline for Management of ACL Injuries. September 2022. aaos.org
- Grindem H et al. Simple decision rules reduce reinjury risk by 84% after ACL reconstruction. Br J Sports Med. 2016. pubmed.ncbi.nlm.nih.gov/27162233
- Losciale JM et al. The Association Between Passing Return-to-Sport Criteria and Second Anterior Cruciate Ligament Injury Risk. J Orthop Sports Phys Ther. 2019. pubmed.ncbi.nlm.nih.gov/30501385
- Musahl V & Karlsson J. Anterior cruciate ligament tear. N Engl J Med. 2019. pubmed.ncbi.nlm.nih.gov/31189037
- Claes S et al. The ligamentization process in ACL reconstruction. Am J Sports Med. 2011. pubmed.ncbi.nlm.nih.gov/21515806
- Yasui J et al. Preoperative loss of knee extension affects post-op extension deficit. Orthop J Sports Med. 2023. pubmed.ncbi.nlm.nih.gov/36846811
- [9] Simon D et al. The relationship between ACL injury and osteoarthritis of the knee. Adv Orthop. 2015. pubmed.ncbi.nlm.nih.gov/25954533
- Kaeding C et al. Allograft versus autograft ACL reconstruction. Sports Health. 2011. pubmed.ncbi.nlm.nih.gov/23015994
- Walker PB et al. Disparities in ACL Injury and Management: The Impact of Sex, Race, and Social Determinants of Health. Curr Rev Musculoskelet Med. 2026. pubmed.ncbi.nlm.nih.gov/41843325
- [12] Prodromidis AD et al. Timing of ACL reconstruction and incidence of meniscal injury. Am J Sports Med. 2021. pubmed.ncbi.nlm.nih.gov/33166481
