The anterior cruciate ligament (or ACL) is a ligament within the knee joint. It serves as added passive stability to the knee and helps mainly in preventing hyper-extension. ACL injuries fall into contact and non-contact. Contact injuries occur when the knee is hit generally from the side or front of the leg when the foot is planted. Non-contact injuries generally occur during sports while planting or cutting and causes the knee to hyperextend and/or twist. When an injury occurs, people often hear a pop. They likely will have swelling in the knee and can feel unstable when walking. Testing may be done by an athletic trainer or physical therapist at the time, but this is usually confirmed later by MRI.
If the goal is to return to high level sports then most frequently, it is recommended to undergo an ACL reconstruction. If a return to sport is not the desired outcome, then others may be able to rehab without surgery and return to normal activities such as walking, hiking, and running. This will depend on multiple factors including if you continue to experience instability in the knee. In this blog, we will discuss the rehab timeline if you choose to undergo ACL surgery.
Pre-surgery:
This is often called prehab. It can occur anywhere from 0-8 weeks before surgery. The main goals of this phase are to reduce swelling, improve range of motion, and regain quadriceps activation. It can also be helpful for learning the exercises that you will do immediately postoperatively which makes them easier to perform when dealing with the pain and swelling that surgery causes.
Week 1:
Most people will start physical therapy within 2-3 days post surgery. Taking at least 1 day off after surgery is a good idea as there will likely still be grogginess, fatigue, and significantly higher pain. If the reconstruction does not involve a meniscus repair, then you will be able to walk immediately. Most surgeons will prescribe a full knee brace that is locked into extension immediately after surgery. This is to help protect the knee and new ACL graft to avoid a re-tear. Goals during this week include decreasing pain and swelling, achieving full knee extension range of motion, improving quadriceps activation, and training how to walk with crutches.
Weeks 2-3:
As you get to this stage, pain and swelling should be decreasing and using your knee should be getting more comfortable. Around this time, you should be able to start weaning out of your crutches and knee brace depending on your quadriceps activation. Typical exercises will include straight leg raises, bridges, and mini squats. Your therapist may integrate neuromuscular electrical stimulation (NMES) or blood flow restriction (BFR) to help assist in your rehab.
Weeks 4-6:
At this point, you should be walking without crutches or a brace in most simple ACL reconstructions. In rehab, you will be working on strengthening your lower extremity with a focus on quadriceps strength. These exercises may include things like lunges, single leg squatting, and Romanian deadlifts. Keep in mind that weeks 6-8 post op is when the graft is most vulnerable so it is important to not be reckless as you start to return to your normal daily activities.
Weeks 7-9:
This should be where you are getting more comfortable performing what most people consider typical gym exercises, including loaded squats and deadlifts, with the main goal of improving strength before your first strength test. You will have been working on your knee flexion range of motion throughout the process and it should be getting close to symmetrical at this time.
Weeks 10-12:
You should be continuing and progressing strength training. Most protocols will allow addition of leg extension machines around this timeline. In this range is when quadriceps and hamstring strength testing should happen, with either an isometric test (such as tindeq) or an isokinetic dynamometer. This testing will determine when you are ready to return to plyometrics and running.
Weeks 13-16:
Most ACL reconstruction protocols will call for running to start at week 12. However, it is best to use strength testing as the indicator for when you should return to running rather than timeline. We have found, anecdotally, that this helps to reduce knee pain and swelling when returning to running. Most people are able to achieve the quad strength needed for successful plyometrics and running around 16 weeks post op.
Months 4-6:
At this time, you should be progressing your strength training and running consistently. You may be able to progress to straight line sprinting in this time phase. It may also involve starting to do more agility drills and working on moving more quickly in directions outside of straight forward. That may include things like working on agility ladders. You will also likely be ramping up your plyometric training.
Months 6-9:
During these three months, you will continue with plyometrics and strength training. More of the focus should be on getting as explosive as possible, which would mean that on some of your strengthening days you are doing less weight and less reps, while focusing on the speed of movement. It will also likely be the time you start getting into more sport-specific drills. Around 6 months you may perform your first return to sport testing to determine if there is a specific category that you need to focus on more over the next few months including strength and power.
Months 10-12:
While typically people think of ACL recovery as a 9 month process, this is often not the case. For some individuals with a clean ACL tear and who had significant leg strength and power before the injury, then the 9 month timeline is a reasonable goal to shoot for. Unfortunately, most recreational athletes do not meet these criteria before their injury which causes rehab to take a little bit longer. The extra 3 months is very helpful for most people to get their strength and power back to symmetrical so that they can pass return to sport testing. As certain milestones are hit, you will be able to return to practice in a limited fashion and slowly work back towards full game play.
Here at Maven, we treat individuals all the way from pre-op through the whole post-op recovery and return to sport. We have a wide variety of tools and techniques to help improve your recovery including NMES, BFR, a tindeq for strength testing, VALD force decks for testing power and jumping, strength training equipment including leg extension and leg curl machine along with a squat rack. If you want guidance from one of our physical therapists at any stage of your ACL reconstruction journey you can make an appointment at Maven today.
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