by Matthew Schultz, PT, DPT, CSCS
For those of you who don’t know me, I have personally undergone 3 ACL reconstructions as a teenager and in my early twenties. I find that often, ACLers have improper expectations set prior to surgery. Because of this, I want to give a general overview on what to expect as a patient. As a general overview, post-operative ACL rehab should be thought of as a marathon, not a sprint. While protocols have timelines, those are more of general guidelines than steadfast rules. Every patient who undergoes ACL rehab is going to have a different timeline and a different journey. While there are plenty of resources outlining milestones and timelines, one area of information that I believe is lacking is the overall expectations from a patient perspective.
What Does ACL Rehab Mean?
For starters, ACL rehab is extremely taxing, both physically and mentally. Full return to sport/prior level of function can be anywhere from a 9-15 month+ journey. There will be periods where you feel frustrated with progress. There will be missed activities, practices, and social outings. A lot of the time it can feel like part of your identity is lost, which can take a large mental toll. Resiliency is a large and important component during this process.
In the early stages of ACL rehab, pain management and restoring baseline function of the knee is the primary goal. It is normal to feel hesitancy and distrust of the knee as you begin to bear weight again, as well as significant pain especially in the first few days post-operative. It is critical at this point to trust that things will improve, as the pain and stiffness through the knee can be extremely discouraging. Goals in Physical Therapy during this time will be to manage swelling, restore your ability to bend and straighten your knee, and progress to walking without a limp. Exercises in this phase will seem boring but are essential for laying a foundation for everything that follows. Inability to restore normal knee mechanics in this stage can lead to a host of problems further into rehab, so it is critical to be compliant with exercises! This phase of rehab usually lasts the first month following surgery.
As walking becomes more normal and range of motion is restored, the emphasis is placed on restoring strength and stability of the surgical side. This stage is an ongoing battle that will persist in some until discharge. A large emphasis at this stage is on rebuilding the quadriceps and restoring proper knee mechanics. One of the largest challenges after ACL surgery is accepting force into the knee. Your mind and body will do everything in their power to avoid positions where your knee translates forward. Having adequate quad strength is critical to support this position and allow for transition into dynamic movements with proper mechanics later in rehab. In this phase, you should expect to be utilizing weights and loading your knee to strengthen and further lay a foundation for higher-level movements. It is also critical to be open with your PT regarding any pain you may be feeling, especially in the front of the knee. This can be a sign of doing too much too fast and a need to decrease intensity to further build foundational strength.
What’s Important About ACL Rehab?
Graft Healing Time
Another very important thing to bear in mind is graft healing time. At around the 12-18 week mark, you will reach a stage where you are feeling pretty good. This is exactly the time at which I re-tore my ACL following my first reconstruction. It is incredibly important to remain cognizant that even though the knee feels more normal at this stage, it is not back to normal yet! The urge to return to previous activities as pain decreases and strength improves will be high, but your graft is actually at its weakest point at this time, as it is undergoing a process called proliferation. This is where your body is breaking down the graft and beginning to convert it to what will become your new ligament. Trusting the process and maintaining diligence with rehab during this period is critical. As someone who re-tore during this stage, trust me – whatever activity you are looking to return to is not worth the risk of a second surgery!
Deceleration Mechanics
As quad and lower limb strength improves, focus shifts to restoring proper movement patterns, along with continued strengthening. At this stage, you can expect to again struggle to accept load into the knee initially. Restoring proper mechanics will take a lot of diligence and practice, both in and outside of the clinic (with clearance from your PT!) Decelerating is a foundational movement at this stage, as it will lay the groundwork for being able to change direction later. Other important components are jumping and returning to running. Proper deceleration mechanics take time to re-learn, as your knee will not like the feeling of impact and accepting load.
Communication with your PT
Finally, as strength is restored and movement patterns normalize, things begin to feel more normal and closer to sport. Your PT will feel more and more like a workout as you continue to progress toward returning to sport. At this point, it is still critical to be open with your PT about any pain or discomfort you may be feeling. As you transition to practice and sport-specific activity, there will be an element of foreignness with the knee. Things that used to require no effort or thought will seem frightening and foreign. I remember returning to football and being extremely hesitant with any routes that broke left despite drilling it hundreds of times in practice. Keeping an open line of conversation with your PT and sports medicine team, as well as coaches, is paramount. Things will continue to improve as you continue to drill them more. Eventually you will find you’re thinking about your knee less and less and things will flow naturally again.
ACL Rehab: Trust the Process
The largest overarching takeaway is this: ACL rehab is very difficult, both physically and emotionally. There will be missed activities with friends, missed practices, missed opportunities. In team sport settings, there is also an element of isolation, as you are typically in the training room while everyone else is practicing/working out. Please remember that this is only temporary! The urge to rush a return is strong, especially in the later stages. However, trusting the process and being mindful of the overall end game will help ensure success. It is also important to celebrate the small wins! Walking for the first time without crutches, getting a full revolution on a stationary bike, jumping, jogging, etc. are all huge milestones that deserve celebration. There is a light at the end of the tunnel, and with dedication and commitment you will reach it!
