When ACL Surgery Isn’t Enough: Could You Have an Untreated ALL Tear?
- Dr. Daniel A. Romanelli, M.D.
- Apr 8
- 3 min read
You’ve had ACL surgery. You did the rehab. You followed the protocol. But your knee still feels unstable—like it might give out when you pivot, turn, or push off quickly.
If this sounds familiar, there may be more to your injury than just the ACL. You might be dealing with an untreated tear of the anterolateral ligament (ALL)—a lesser-known but important stabilizer of the knee that is often injured alongside the ACL.
Let’s dive into what this means and why your knee might still feel “off,” even after a successful ACL reconstruction.
The ACL + ALL Connection
The anterior cruciate ligament (ACL) is one of the major stabilizers of the knee, especially for front-to-back and rotational motion. But there’s another, often-overlooked ligament called the anterolateral ligament (ALL) that also plays a key role—specifically in controlling rotational stability.
The ALL runs along the outside of the knee, connecting the femur (thighbone) to the tibia (shinbone). When the ACL is torn, the ALL often tears at the same time—especially in injuries involving sudden twisting, cutting, or pivoting.
The Problem: Persistent Instability After ACL Surgery
ACL reconstruction is highly effective for restoring knee function—but in some cases, instability lingers. Patients report symptoms like:
The knee "giving out" when changing direction
A sensation of looseness or “pivoting out of control”
Lack of confidence during sports or workouts
Difficulty trusting the knee under pressure
These symptoms are often signs of residual rotational instability, and they may indicate that the ALL was injured—but never treated.
Why the ALL Was Overlooked for So Long
The ALL wasn't formally recognized until 2013, when orthopedic researchers clearly identified and named the ligament. For decades before that, it wasn’t consistently included in anatomical models or considered during ACL reconstruction.
That means thousands of patients may have had incomplete treatment following an ACL tear—especially those who continued to struggle after what was considered a “successful” surgery.
Today, orthopedic specialists are much more aware of the ALL’s importance, particularly in:
High-risk athletes
Patients with failed ACL reconstructions
Cases with ongoing pivot instability or poor outcomes
Diagnosing an ALL Tear: Why It’s Tricky
Unlike the ACL, the ALL is a small, thin ligament that can be difficult to detect on traditional MRIs. Sometimes the only way to confirm an ALL injury is during surgery, especially if your surgeon is specifically looking for it.
Clues that point toward an untreated ALL tear include:
Ongoing instability after ACL reconstruction
Repeat ACL tears
Positive pivot shift tests
Failure to return to sport despite full ACL graft healing
The Solution: ALL Reconstruction (And Why It’s Gaining Momentum)
If your surgeon suspects an untreated ALL injury, ALL reconstruction can be added to revision ACL surgery—or even done preventatively in high-risk patients. This procedure typically uses a tendon graft to recreate the ligament and restore stability.
Benefits of combined ACL + ALL reconstruction include:
Reduced risk of ACL graft re-tear
Improved rotational control
Higher return-to-sport rates
Lower revision surgery rates
In short, treating both ligaments gives your knee a better chance at full recovery.
Trust Your Instincts—And Your Knee
If your knee still doesn’t feel right after ACL surgery, it’s not just in your head. There’s a chance something important was missed—like an untreated ALL tear.
The good news? Today’s advanced imaging, surgical techniques, and ligament expertise make it possible to get answers and move forward with a more complete treatment plan.
Still feeling instability after ACL surgery?You may need more than just rehab—you may need a fresh look. Contact us today to schedule an evaluation and explore your options for long-term knee stability and strength.
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