Hopefully, you don't know this from experience. But chances are, if you are reading this article, you might know it already. You can indeed tear your ACL and your meniscus at the same time.

At that point, you have a couple of options. Do you fix the meniscus with its own surgery and the ACL with a second surgery?

Or do you have your orthopedic surgeon fix both injuries at the same time? That's what we'll cover today.

How Do The Meniscus and ACL Tear at the same time?

What often happens is the ACL tears from twisting, and as the rotation of the knee continues, the meniscus tears next, often resulting in the cushion cartilage being “flipped” up into the wrong place, actually blocking or hindering the ability to fully straighten the knee.

You may have heard of this referred to as a bucket handle tear, flipped meniscus, or even a locked knee. Now two things need to be repaired, the ACL and the meniscus.

Everybody I know wants to have everything done all at once, but the question is whether it is smart to do so. Let's dig into the topic here today.

What is the ACL?

Let's hit some anatomy here first so we're all on the same page. ACL stands for "anterior cruciate ligament." So, it's a ligament, one of the most important in our knee when it comes to stability. This is why active people dread tearing the ACL so much. With a torn ACL, you will lose stability in your knee, making it very hard to perform at a high level.

What Does An ACL Tear Feel Like At The Time Of Injury?

A typical ACL tear looks like this:

Your foot is planted
You rotate or twist, causing the injury
You hear or feel a "pop"
Within 1-2 hours, your knee gets "big and swollen”.

When all this happens at the time of the injury, you’ve probably suffered an ACL tear.

What Are The Symptoms of ACL Tears?

So you tore your ACL...what will it feel like after the injury? Well, for the first two days, you'll feel a lot of pain and swelling. If it swells up more in the first 1-2 hours after the injury, it's more commonly an ACL tear and less commonly a meniscus tear. Of course, we are talking about both injuries here, at once. But many people tear the ACL while damaging the meniscus, as well.

After the first couple of days, an ACL Tear will stop hurting in terms of pain. However, you will still be dealing with feelings of "instability", with your knee giving out on you or buckling on you. When people talk about having a "trick knee" they are usually dealing with an ACL that has been torn.

What is the Meniscus and Why Is It Important?

Now let's move on to the meniscus. While the ACL is a ligament, the meniscus is actually cartilage. It's the "cushion cartilage" of your knee, acting like a shock absorber. So you can see why this cartilage is so important. Without meniscus cartilage, the bone begins to rub together, causing arthritis.

What Causes a Meniscus Tear?

So how does a meniscus tear happen? Real simple. Compression, and shear. So the knee must be compressed, and then rotated to cause this injury. The meniscus becomes trapped between the femur and the tibia bones, and the added twist causes the tear.

So you can see how a traumatic event that causes the ACL Tear may also cause the mensicus tear if there is enough compression and shear involved.

What Does a Meniscus Tear Feel Like?

So how do you know if you have a meniscus tear? Well, the symptoms are what we call "mechanical". So, if you have a meniscus tear you will be dealing with

Catching
Locking
Swelling

Many people also report the "pebble-stuck-in-shoe" feeling (but in the knee) when they are dealing with a meniscus tear.

But You've Torn The ACL and The Meniscus...So What Now?

Historically, these have often been done in two different settings. First the meniscus gets put back into place and sewn together. Rehab the knee for 6 weeks and come back to fix the ACL at that time.

There has certainly been some discussion on how to best handle this scenario in the orthopaedic sports medicine world. In my world, this injury to both the ligament and the cushion cartilage isn't that uncommon, because skiers going fast face some of the ultimate risk factors of having these injuries occur at once.

That is, they are going very fast and they have the tendency to get very out of control if things don't go as planned. A skier careening down the mountain at high speeds trying to hold on to their line as they lose control is a recipe for a major knee injury, as we've seen.

The Traditional Method - Multiple Surgeries

Back up 25 years, and we were all doing these in multiple stages. That's because the biggest risk was having permanent stiffness in the knee.

They used to do ACL reconstructions with two big incisions, and we really had to push people to get back to where they were before the injury, with a buildup of scar tissue being a huge risk.

Remember from some of our previous posts, that the most common complication from any of our surgeries is the buildup of scar tissue.

In fact, scar tissue that is bad enough that it needs more surgery occurs in about 4% of patients following arthroscopic surgery.

Meniscus repairs often need a much slower rehabilitation than an ACL reconstruction so the thought has been to decrease the risk of scarring by doing these in two stages.

Getting You Back To Your Sport Faster and Better

What we really want for the ACL is the aggressive rehabilitation, getting that range of motion back as quickly as possible, so you don't form the scar tissue that can be so problematic.

The meniscus is a little different in terms of therapy. While we also want to avoid scar tissue here, we have to go slow in the therapy so the meniscus properly heals. In fact, the slower we go with the meniscus, the higher the chance to heal.

So while the ACL does good with motion (in terms of healing), the meniscus needs more time before we introduce a high amount of motion.

So that's where the controversy lies. If your knee is super stiff going into surgery and the meniscus tear is bad, your surgeon may recommend that you have it fixed in two surgeries.

If your surgeon feels that he can be aggressive with rehabilitation due to the specific condition of the injury, chances are that he will recommend doing the surgery for both the meniscus and the ACL at once.

The Advantage Of A Two Staged Approach:

Now let’s talk about the option of doing the meniscus repair and the ACL reconstruction in one surgery. Here are some of the benefits:

The ability to reduce the risk of scar tissue by minimizing the amount of surgery in the first stage.
Being able to evaluate the healing of the meniscus tear at the time of the ACL reconstruction.
More aggressive rehabilitation may be permitted following the ACL portion of the procedure as the meniscus will already be healed.

The two staged approach was popularized by Dr. Shelbourne back in 1993 and had been adopted as the standard of care for many years.

With modern techniques and minimally-invasive ACL reconstruction coupled with all-inside meniscal repairs, we make the risk minimal now when it comes to doing both the meniscus and ACL surgery at the same time, in the vast majority of cases.

Okay, Doc, What Do You Tell The Pros in This Situation?

As we mentioned, back in the 1980s and 1990s, our surgical repairs of the meniscus often necessitated large incisions creating more trauma and much higher risk of scar tissue. The old two-incision ACL reconstructions were also very painful and subsequently also increased the risk of scarring. We had to push people really hard in rehab to get their range of motion back because the surgeries hurt so darn much.

With year 2020 techniques to repair the meniscus arthroscopically only, and minimally invasive ACL reconstruction techniques (often utilizing less painful graft choices) and better postoperative pain control techniques, the risk of scar tissue forming is very much less than it ever has been.

Some postulate that the meniscus has the best chance of healing in the face of the growth factors released from the surgical trauma of an ACL reconstruction.

More and more of us seem to be comfortable with performing the majority of ACL and meniscus tears in one setting rather than two. Even in the NFL now, it is rare for these players to undergo a planned two-stage repair and reconstruction.

Make Sure To Give Your Sports Medicine Docto a Call

As always, take this advice with a grain of salt because I'm not answering your specific issue— that's why we encourage you to get in to see your sports medicine doc as soon as possible!

We seem to have to slow people down in their rehab more than we have to push them as the pain from our reconstructions are so much better controlled.

So the decision between one stage or two-stage reconstruction of your ACL and meniscus tear needs to be a shared decision between you and your surgeon. You'll be discussing the following:

Is the risk of scar tissue greater than the risk of a second anesthetic and surgery?
Does one strategy allow more reliable healing to take place than the other?

It may come down to the amount of trauma from the injury, the types of surgical techniques planned, and the surgeon’s comfort level or experience with one game plan over the other. In my practice, if the ACL and just one of the meniscus is torn, even if displaced, we will typically feel very comfortable with the predicted outcomes in a single-stage procedure.

If you want to schedule a visit (or telemedicine visit) with Team Sterett, reach out to us today and we'll get you taken care of.

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I tore both the ACL and the Meniscus. Do I need multiple surgeries?