Pain Management After ACL Reconstruction

Don Johnson MD
Director Sports Medicine Clinic Carleton University

Assistant Professor Orthopaedic Surgery University of Ottawa


Outpatient Anterior Cruciate Ligament Reconstruction

Figure 1 The setup for ACL reconstruction

            We have only learned a few things over the past decade about ACL reconstruction. First of all, mark the site that you are going to operate on. This should be done outside of the OR with the patient awake.  We know that the choice of graft is probably immaterial, but the most important factor in a satisfactory stability outcome is to put the tunnels in the correct position and fix the graft adequately. But, from a patient’s perspective, the biggest improvement is in pain management. This is an important aspect nowadays as all ACL reconstruction is done as an outpatient. So what do we do that is new and improved? This is the list of pain management modalities that we currently use for outpatient anesthesia in ACL reconstruction:

Pre-emptive Multi-modal analgesia

            IV 30 mg Ketorolac (Toradol)

            Intra-articular injection of Marcaine and Morphine

            Incisional Injection of Marcaine

            Femoral Nerve Block


Post op NSAI – Vioxx/Celebrex



Accelerated rehab


Lets look at some of these techniques in detail.

Multimodal Analgesia

            Multimodal or balanced analgesia [1] means to make use of multiple modalities to augment the anaesthesia. In our protocol it refers to the IV ketolorac, the femoral nerve block and the intra-articular injection of marcaine and morphine.

Figure 2 The femoral nerve block done with a nerve stimulator

The femoral nerve block is done with the patient awake and sedated.  The nerve stimulator is used to locate the nerve,. This is one of the safest blocks that can be performed. We have done over 4,000 anterior cruciate ligament reconstructions with this block. Even though physicians with varying degree of skill have performed the block, I have not seen a significant problem or complication as a result of the femoral nerve block.

Figure 3 The injection of the anterolateral portal and the joint

Figure 4 The injectionof the incision for the harvest of the hamstring tendons


The portals, incision and the joint are injected with marcaine and morphine before the leg is prepped and draped. Turner [2] has demonstrated the benefit of infiltrating the Incisional site with local anaesthetic.  Numerous authors have shown the efficacy of the joint injection with Marcaine and/or morphine [3-10]

            We have been performing the nerve block, intra-articular injection and the IV Torodol pre-emptively since 1999 when we found that this improved the VAS score in the recovery room[11]. The long-term improvement in the pain score was not as dramatic as we had expected due to the nature of the hamstring reconstruction that we were studying. There seems to be much less morbidity from the hamstring harvest from the ipislateral knee compared to the patellar tendon harvest from the ipislateral knee. We had been convinced of the effectiveness of the femoral nerve block since our first study in 1987[12]. The femoral nerve block had been described by Ringrose[13] in 1984 for post operative pain relief after open knee surgery. This year at the AAOS meeting a poster presentation by Thomas et al[14] also found improved VAS scores when the block was done at the beginning of the case. In 1993 we[15] found that the intra-articular injection of Marcaine and Morphine improved in the post-op VAS scores. Shelbourne [16]has also emphasized the importance of pre-emptive analgesia. He uses IV Ketorlac, and local injection of the wound with marcaine pre-op. Immediately post op in the OR, the CPM and cryocuff are applied. The Cox-2 inhibtors are started the day of surgery. We have been considering starting them on the morning of surgery. 



We felt that the tourniquet may be a factor in increasing the pain post-op. In a study[17] to compare tourniquet versus no tourniquet we found no difference in cases that only took about 1 hour. Tourniquet pain may be more of a factor with longer cases.


Post-op NSAI and Cox-2 Inhibitors

            Since McGuire[18] pointed out to us the advantages IV ketolorac, we had been using Toradol both pre op and post op, but have switched to Vioxx about 1 year ago. We have not done any randomized study of this but have the impression that there are fewer GI complaints with Vioxx as compared to the Toradol. Reuben[19] has shown that the rofecoxib given 1 hour before surgery lengthens the effect of the blocks. He further found that rofecoxib was better than celecoxib over the first 24 hours.  The preferred regime now should be the rofecoxib taken on the morning of surgery with sips of water.


Cryotherapy and CPM

Figure 5 The CPM and cryocuff

            We have been extremely happy with cryotherapy over the past decade. Some patients like the cold pack so much we have to surgical extract the pack from the leg after a couple of months. The efficacy of cryotherapy has been documented by Cohn [20] Shelbourne [21]and Barber and McGuire[22]. Shelbourne was one of the early proponents of the Cryocuff. In the 1994 study he showed less narcotic use with the use of the pneumatic cryocuff. This group also showed an improvement over the application of ice packs. This may be due to the compression and the use of the cryocuff while ambulatory. Barber and McGuire found less Vicodin use and better VAS scores with the cryotherapy group. Barber [23] has also shown in a clinical trial that the cryotherapy is superior to crushed ice to cool the knee.

            There have been several studies to examine the efficacy of the CPM after ACL reconstruction [24-30] The consensus seems to be that the range of motion is not significantly improved, but there is less swelling.  Richmond [28]examined the use of the CPM and found that the use for 4 days post op was as effective as 14 days. In summary, the main use of the CPM is to keep the knee elevated post op, and consequently this reduces the pain and swelling.


Accelerated Rehab

            The champion of accelerated rehab has been Don Shelbourne[31-33]. However, no one else that I know has been misquoted so often. This program is not something that he thought up one day, but is the result 20 years of experience of listening to the patient. He would fine tune one thing at a time, look at the outcome, and use that change or reject it.  I will try to summarize what he does, and not mangle the protocol too badly. One day when he is not too busy, maybe I can convince him (Or Tinker) to write a short summary of his concepts. But until then here is my take on it.

 The early phase of the accelerated program is designed to regain the range of motion, and reduce the swelling of the knee. He keeps the patient down with a CPM and cryocuff for the first 5 days. They are doing active slides for flexion and full hyperextension. The second phase is to regain the strength and keep the range of motion. He felt that these 2 goals were at odds when he was harvesting the graft from the same knee. After one satisfying result from harvesting from the patellar tendon from the opposite knee, he developed a rehab program that split the rehab into the 2 knees, one to regain the strength of the harvested knee, and the other to regain the range of motion of the reconstructed knee. This concept works well in his hands, as he is meticulous with follow up to prevent problems and complications. He allows early running at 4 weeks and sports specific exercises at 6 weeks, ie shooting hoops. The average return to sport after contralateral harvest of the patellar tendon is 4.2 months.

            The rest of us can learn from him that the program must be well monitored to anticipate and prevent problems. Everyone must select what will work in his hands and his setting. The message is to listen to the patient, answer his questions, but try not to make the mistakes that many of us have made in the past. 


For further information on Cox 2 inhibitors and pain management see:





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2.         Turner GA, C.G., Comparison of peroperative with postoperative lignocaine infiltration on postoperative analgesic requirements. Br J Anaesth, 1994. 72: p. 541-543.

3.         Joshi GP, M.M., Hurson BJ, McCarroll SM, O'Rourke P., Effects of Intra-articular morphine on analgesic requirements after anterior cruciate ligament surgery. Reg Anesth, 1993. 18: p. 254-257.

4.         Reuben, S.S., et al., Intraarticular morphine in the multimodal analgesic management of postoperative pain after ambulatory anterior cruciate ligament repair. Anesth Analg, 1998. 86(2): p. 374-8.

5.         Stein C, C.K., Haimerl E, Yassouridis A, Lehrberger K, Herz A, Peter K., Analgesic effect of intra-articular morphine after arthroscopic knee surgery. N Engl J Med, 1991. 325: p. 1123-1126.

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