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What to Expect After ACL Injury

acl kneepain physicaltherapy Nov 11, 2021

Suffering an ACL injury can be one of the most frustrating and difficult things to go through. While not everyone that endures these injuries will require ACL surgery, a majority of people will undergo ACL reconstruction in hopes of returning to their sport or desired activity. This can be a fairly long journey, so it’s important to understand what to anticipate moving forward. Hopefully the information that follows will help give you a better idea of what to expect and what to look for in a physical therapy plan of care.


Preoperative Phase: 

Going through a bout of (p)rehab before having surgery can be one of the most beneficial things for you and can significantly improve how well you do after surgery. The goal of the preoperative phase will be to maximize your range of motion, reduce swelling, and strengthen the muscles of the knees, hips, hamstrings, and calves as much as possible. You can’t be too strong pre-surgery! Deadlifts, lunges, squats, hip thrusts, step up/step down, etc. are going to be some of the main items on your pre-surgical menu. Additionally, your therapist should help you set expectations of what's to come over the course of the next 9-16 months.


Early Post-Op: 

The early postoperative phase is going to be essential to set a solid foundation for the rest of your rehab journey. In the beginning, the main focus of rehab will be to control swelling, address range of motion limitations, reduce pain, and minimize muscle atrophy by starting exercises that focus on muscle activation (especially the quadriceps). Some common exercises that help to address the things just mentioned are things like heel slides, calf stretches, quad sets, straight leg raises, and other exercises that address the hip and calf musculature. Additionally, this time provides the opportunity to work on other areas of the body. This means that early post-op rehab should include things like core exercises, upper body exercises, and low intensity aerobic exercise such as an upper body ergometer. Finally, assuming your surgeon’s weight bearing precautions allow and that you pass all criteria set by your therapist, you will begin the process of weaning off your crutches and normalizing your walking through specific gait training. 


Mid-Stage Rehab:

Once things like swelling and range of motion start to improve, we can then progress into the next phase. This is where things start to get fun. In this phase of rehab, your therapist should be guiding you through progressive strength training. The goal of this phase is to get as strong as possible (working within your tolerance), prepare you to return to jogging/running, and begin introducing low-level tasks relating to your sport, all while improving your general fitness through upper body/core and aerobic exercise. Some common exercises for this phase include things like squats, deadlifts, leg extensions, calf raises, side planks, lunges, hip thrusts, step ups/downs, hamstring curls, single leg squats, etc. Your plan should include double leg and single leg activities in order to address any side to side differences. In addition, it’s important that your rehab includes balance/neuromuscular activities with and without cognitive dual tasks. More on that later.



Return to Participation: 

Assuming you’ve passed all progression criteria set by your therapist, you’ll then begin introducing things like ball handling drills, change of direction/agility drills, deceleration work, and plyometrics, all tailored to the demands of your sport or desired activity. The rehab in the phase will allow you to practice all the activities and movements specific to your sport in a controlled environment before eventually going out and performing these in a more open environment. The overarching goal of this phase is to prepare you for the demands of your sport and gradually re-introduce you to those activities over time.


Return to Practice: 

One of the most important parts of gradually re-introducing you to your sport is going to be a return to practice phase. This phase is where you start to put everything together, while still in a relatively controlled fashion. During this time, you might start to feel ready to return to playing in game situations. You’ll likely be very eager to get back on the field or court for game situations, but it’s important to remember that a gradual return to sport will be essential to minimize risk of re-injury. This includes continuing your strength training program and successfully participating in at least 80% of your practice sessions before considering fully returning to competition.


Return to Competition: 

Once you are able to complete a majority of your practice sessions without issue, your therapist will then guide you through return to sport testing. This will include things like strength testing, hop/jump testing, girth measurements, neuromuscular control assessments, change of direction/agility tests, and an assessment of your psychological readiness to return to your sport. The other important thing to consider is the amount of time that has passed since your surgery. Research has consistently shown that 9 months is the minimum recovery time after ACL surgery. The recovery time may sometimes even take up to 12-16 months depending on a variety of factors. The important thing to know is that returning prior to 9 months has been shown to significantly increase risk of re-injury. 


If you have passed all return to sport criteria set by your therapist/surgeon and a minimum of 9 months has elapsed since your surgery, congratulations! You’ve successfully completed your ACL journey and can feel confident about returning to the thing you love most.


Need Help? 

If you’re having difficulty returning to your training/sport after ACL surgery, or are looking for more help after an incomplete bout of rehab, please feel free to reach out to us at anytime at (760) 301-6566 or at [email protected]  



This is a general timeline and progression for a relatively uncomplicated case. The actual timelines and progressions may differ based on the procedure done, the precautions set by your surgeon, any concomitant injuries, your sport, etc. It should also be emphasized that these phases are not inherently distinct and often blend with one another.

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