One of the most frequently asked questions is what is the recovery after ACL surgery, and how soon can patients walk.
Today we will like to share our recommended rehabilitation protocol as well as some useful rehabilitation exercises for post-op patients. As the recovery period following ACL reconstruction can vary for patients with different physiological profiles, we strongly advocate to base your recovery progress on functional criteria instead of a fixed recovery timeline.
The focus on evaluating the functional aspect in your rehabilitation process is important as it prevents recovery setbacks that can be caused by adhering to ill-advised recovery milestones. The tissues in the knee need to be completely healed before progressing to the next stage of rehabilitation. If you increase the intensity of any activity too much or too quickly, it may result in re-injuring your knee and risk complicating or even prolonging the recovery process.
After ACL reconstruction surgery is successfully performed, the body immediately begins its healing process. Your doctor will offer specific guidelines on controlling the swelling and recommendations on pain management after the surgery. The key objective is to restore stability and function to your knee by closely following a structured rehabilitation plan. The general recovery time for most patients is about six to nine months while sport activities can usually be resumed after eight months. That said, you should always consult your physical therapist if you have any questions regarding your recovery progress.
ACL Recovery Timeline
0 – 2 Weeks
The first 2 weeks are critical in your healing process and patients are advised to use a cold compression knee wrap or ice their knee to keep any excessive inflammation under control. They should also limit their mobility while keeping their knee raised as much as possible to reduce swelling. There will be pain, swelling as well as the buildup of excess fluid around the knee joint. Some bruising along the thigh or ankle may also be seen. Patients can commence ankle pump exercises, they help to reduce venous pooling, and are useful to reduce swelling and prevent Deep Vein Thrombosis (DVT). Patients may also take pain-killers to alleviate the pain.
Usually, after ACL reconstruction, the operated knee is allowed to bear weight. However in some instances, patients undergo a repair of the meniscus or cartilage as well, and if so, the operated knee may not be able to bear full weight during this period. If that is so, the use of crutches may help in patient’s mobility. Patients are often given a knee brace to help protect the operated leg from undue stress and offer stability during the recovery period. It is important during the first 2 weeks to aim for full knee extension, and to be able to do a straight leg raise without any lag.
2 – 6 Weeks
After the second or third week, you should able to move without the use of crutches. Patients may progressively wean their walking aids, as long as there is no increased pain or swelling, and they are able to walk well without a limp. Knee braces may be allowed increased motion, once patients are able to exhibit adequate control of their operated leg (ie. able to perform straight leg raise with good control without lag).
This is the stage when you start incorporating strengthening exercises while also working to regain full range of motion on your operated knee. Exercises to do during this period include calf raises, quadriceps contraction, straight leg raise, clamshell exercises to strengthen the hip.
6 Weeks – 3 Months
Your goal is to return to regular physical activity and this can be achieved by progressively strengthening the muscles around your knee and further improving flexibility. Strengthening of the hips is also important. The length of your recovery program can vary widely, ranging from two months to six months or beyond. This will be a good time to work with your doctor on a physical therapy program specific to your objectives.
As your knee continues to heal and grow stronger, you may be allowed to participate in low-impact activities such as cycling, swimming (flutter-style swimming strokes), and walking. However, it is still important that you consult with your doctor or physical therapist if you wish to progress to weight-bearing exercises such as squats or moving up and down staircases.
At this advanced stage in your recovery, your knee should have healed sufficiently for you to resume impact activities such as running and jumping. There should also be better muscle control and stability with the ligament able to be tolerate greater forces. However, there must be careful attention to ensure that any challenging exercises are properly executed, with an added focus on avoiding any undue stress or unnecessary impact to the reconstructed ACL and surrounding tissues.
ACL tears are often the result of improper control and leg stability during activities like pivoting or landing from a jump. This is why it is important that you have full recovery in function before attempting any activity involving rotational or cutting motion that may increase your risk of re-injury.
Early Exercises After ACL Surgery
There are a few core objectives to aim for when beginning rehabilitation exercises. These exercises should include movements to bend, straighten and strengthen your leg.
1. Straighten the Knee
One of the most common complications in the early phases of ACL recovery is due to motion loss, especially the knee’s ability to fully extend itself. This inability to fully extend the knee can result in scar tissue formation at the front of the knee joint which could in turn result in unnatural joint motion. Therefore it is important to incorporate routines to achieve at least full extension and even some degree of hyperextension of the knee. An extension stretch exercise repeated throughout the day can help achieve much-needed knee mobility.
– Gentle Knee Extension Stretch
Any stretching exercise to help with straightening your knee at this stage should always be low-load and long duration. Start by having your leg out straight with your heel propped on a pillow or a rolled towel to keep the knee gently extended. You can also add a light weight (up to 4kg) onto your thigh to help stretch your knee into extension. Do this for about 15 minutes each time and up to 4 times a day.
Here are more knee extension exercises you can do to aid in your recovery.
2. Bend the Knee
While there is usually less issue with knee bending (or flexion) following ACL surgery, it is recommended to gradually regain flexion through proper range of motion knee exercises. This helps with preventing any complication that may arise from inadequate rehabilitation and stiffness. It is understandable that any forceful flexion in the initial phase of recovery might be daunting for some patients but the reconstruction is actually more resilient than most people think.
– Heel Slides
While seated on a smooth surface (e.g. an exercise bench) with a towel under your heel, pull your heel slowly back towards your buttocks. The goal is to bring your heel as close to your buttocks as possible. Slide your heel back to its original position and repeat for as many as 20-30 reps.
3. Strengthen the Quads
The quadriceps muscles (muscles on the front of your thighs) are the biggest muscle group in your body. One of the safest exercises you can do during your recovery is to ensure that your quadriceps and hamstrings are co-contracting adequately. Gentle contraction exercises are best for ensuring that your muscle firing patterns are in order.
– Isometric Quad Contractions
Sit on the floor with your injured leg extended and your other leg bent. Slowly contract the quadriceps of your injured knee while keeping leg still. Hold the contraction for 10 seconds before relaxing. Repeat this for 10 times.
Here is a video to better illustrate the isometric quad contractions exercise.
Advanced Exercises After ACL Surgery
When the swelling in your knee begins to subside, you will gradually progress to more advanced exercises as you look to strengthen the muscles around your knee and regain better mobility and control in your lower leg. As your coordination and flexibility improve, you should aim to perform these exercises standing firmly on both legs without favouring your uninjured knee.
Once you start to regain muscle control in your lower leg, you should aim to build strength.
1. Stand with your back straight and placing one or both hands on the back of a chair for balance.
2. Slowly lift your heels until you are on your tiptoes.
3. Stay in that tiptoe position for 5 to 10 seconds.
4. Just as slowly lower your heels.
5. Repeat at least 10 times. Do this 2 to 3 times per day.
Click here for a video demonstration of a heel raise being performed.
Standing on One Leg
Standing on one leg is can be useful for building your strength and improving your balance.
1. Stand on both feet while holding on to a chair for support.
2. Slowly lift the uninjured leg and stand unassisted on the injured leg for 10 seconds or longer if you are able to do so.
3. Once you feel you are losing your balance, hold onto the chair to support yourself.
4. Repeat 5 times, 3 times a day.
This exercise is done standing while holding onto a sturdy support with both your hands.
1. Place your feet shoulders’ width apart while holding on to a sturdy table/railing with both hands
2. Slowly bend your knees and lower yourself into a half squat.
3. Hold this position for 10 seconds
4. Just as slowly return to a standing position.
5. Repeat 10 times.
Here are more advanced rehabilitation exercises you can consider as your knee continues to heal and regain more strength and flexibility.
An ACL injury happens when you tear or severely overextend the ACL ligament in the knee. You may often need surgery and extensive rehabilitation to recover from a serious ACL injury.
It is always wise to start with the safest exercises during the initial stage of your recovery and avoid putting unnecessary weight or strain on your injured knee. As the swelling in your knee begins to subside, you can progress to more advanced exercises that involves standing on both legs.
At Hip & Knee Orthopaedics, our emphasis has always been to ensure that every patient is well-informed during every step of their recovery journey. We are aware that the recovery process can be a challenging and trying period, especially for patients who have incurred serious injuries for the first time. It is therefore important to closely follow a proper rehabilitation plan to reduce the risk of further injury and a full recovery without any complications.