Recovery Phases after an ACL Rupture & Reconstruction Surgery

Phase 0 - Pre Operation: Decisions & Preperation

After injuring and rupturing your ACL (anterior cruciate ligament), you will have to decide if you want to operate or not. As an athlete willing to get back to sports, your decision will mostly fall in favor of an operation. Only in some cases would you decide against an operation, but this involves giving up demanding or competitive sports (or in some cases if you are a child with open growth plates). In any case, this is a topic you will have to talk about to your medical professional.

If you have the chance, I would advise visiting a couple of surgeons for a consultation. Firstly, discuss the different options to operate with (here you can find a scientific article from 2012 about the possibilities). Secondly, you will get a feeling for the person operating you. Go with the doctor you trust more. Trust in your gut feeling. If you trust the person operating you, you will feel better about the whole situation and procedure.

Parallel to these decisions, you have to prepare for the operation physically.

Your knee will be swollen, aching, and unstable. Firstly, you have to rest it and decrease the swelling. Do this by cooling your knee 10-20 minutes every 2-3 hours with an icepack (wrap it in a towel to avoid hurting your skin!). A compression bandage during the day will help with the swelling too. Because of the rest and the use of crutches at the beginning, your muscles will weaken.

It is important that you regain full range of motion in your knee and some strength in the knee-stabilizing muscles before the operation. Your knee should have a full range of motion, especially when straightening it (full extension). The stronger and healthier you are and the better your range of motion, the quicker your recovery will be (it will be hard and tough nevertheless). Once the swelling is gone and you can walk normally, you will want to strengthen your muscles. It is essential to strengthen both legs to avoid imbalances. You can find our suggested daily home-exercise routine of strengthening and stretching here. It focuses on mobilization, strengthening and balance. And hopefully will help you stabilize your knee. Be sure to consult your physiotherapist before, as we are not aware of your injury's specificities.

Operation Day

Well prepared, you can now go to surgery. It is a tough day and will be demanding psychologically. Everybody reacts differently to operations and it is definitively not easy. Most likely, you will not be in your comfort zone. The operation lasts for about 45-90 minutes. Prepare mentally for your body to be pretty shaken up and probably in pain (don't worry, you will get pain killers, but it will still be very uncomfortable). When you wake up, your leg will be fixed in a brace at 0° (straight) and there will be wound drainage tubes coming out of your knee too, which are often removed on the first day post-operation (can vary). Focus on cooling and remind yourself that this was the worst part. From now on, your recovery takes the highest priority.

Phase 1 - Post Operation: Activate Muscles & Mobility (Weeks 0-3)

Phase 1 is the beginning of your recovery journey that will take about six months. Your return to sports comes between 6-9 months post-operation (depending on progress in recovery and severity of the injury). The main goals of Phase 1 can be summarized as muscle activation and mobility. The first tasks are for you to decrease the swelling and pain. You must take your Thrombosis prevention shots in the first weeks! A Thrombosis can not only be dangerous if not addressed but will also prolong your recovery. (I was unlucky and had one. I noticed, as I still had intense pain in the hollow of my knee two weeks post-operation). Again, and similarly to Phase 0, cool your knee 10-20 minutes every 2-3 hours with an icepack (wrapped in a towel to avoid hurting your skin). For the first week, your leg will be fixed at 0°. Starting after that, you will begin with the first mobility exercises.

After the swelling is controlled, you want to increase your range of motion and reach full extension. Mobilizing and stretching your hamstrings and calves and activating your quad muscles will aid in the process. You also want to start massaging and mobilizing your kneecap to reduce stickiness and ensure that everything can move smoothly. Ideally, you will be able to return to a normal walking pattern (with crutches) after this phase. Start by walking with your crutches. Once you walk normally with 2, start only using 1 crutch before putting full pressure on your leg again and walking without crutches. The time this will take also depends on the therapy your doctor recommends – with or without a knee brace. After about 4 weeks - somewhere between the end of Phase 1 and the beginning of Phase 2 you should be walking without crutches and with a normal walking pattern. Note that all time-intervals are relative and vary from case to case. They act as rough guidelines, not as fixed timelines. Here are some home-exercises we recommend (* Consult your doctor and/ or physiotherapist before attempting these exercises).

Phase 2 - Post Operation: Mobility, Early Strengthening & Normal Gait (Weeks 3-6)

Phase 2 is all about developing your mobility. The goal is to achieve a full (or close to full) range of motion in your knee when straightening (extension) and bending (flexion). To do this, you will be working on some stretching exercises which will not only be limited to your knee, as your other joints and muscles will be tight too. The focus will lie on both legs, as your healthy leg will have lost strength as well. More strengthening exercises are added and you will work on balance and coordination exercises (proprioception). During this phase, you will most likely achieve a normal walking pattern. You will be able to work on early cardio exercises using a stationary bike at home or with your physio. You might progress to an elliptical trainer if you achieve the relevant strength and flexibility. Only progress if your physiotherapist confirms you can. You want to make sure you are not performing any compensation movements as hip hinges. Here are some home-exercises we recommend during this phase.*

Phase 3 - Post Operation: Strengthening, Fitness & Coordination (Weeks 6-12)

As you can see, phase 3 is a little longer than the previous phases. You will notice significant differences between the beginning and the end of this phase. During this phase, you should have reached your full range of motion and it should be completely pain-free. The strengthening exercises will become more functional and the balance exercises more demanding. You will be using products as a BOSU Ball, Blackroll, or trampolines. Furthermore, you will progress to more intense cardio (e.g. walking more quickly on a treadmill and increasing the stationary bike's resistance). There are a lot of exercises you can do in this phase. Here are some home-exercises we recommend.*

Phase 4 - Post Operation: Strength, Agility & Early Plyometrics (Weeks 12-16)

Phase 4, now you will be feeling good, as you will have made good progress and most likely passed the half-way milestone. Strength and flexibility exercises will continue and become more challenging as time progresses. However, it gets more exciting during this phase. Some sport-specific strength, endurance, and balance exercises are added to the therapy. For example, ladder agility drills and early plyometric exercises as jumps (plyometric exercises combine speed and strength and are often explosive and athletic movements) and even some jogging exercises on the treadmill. Here are some home-exercises we recommend.*

Phase 5 - Post Operation: Agility & Plyometrics (Weeks 16-20)

In phase 5, you will slowly be getting back to your old self. You will be doing agility, plyometric exercises, and a lot of balance exercises to get ready for returning to your sport. Your cardio will also become more sport-specific and will include jogging with turns and accelerating and decelerating. Home workouts may be limited, depending on the space you have. You might have to go outside or to the gym to exercise. However, here are some home-exercises you can do.*

Just as a side note of advice: Towards the end of phase 4 and in phase 5, you might feel as if you are further than you are. Be sure to focus on the exercises your physio recommends and not getting ahead of yourself. Do not get carried away and return to your primary sport too early. A friend of mine did this, injured himself and ended up having pain in his knee, lengthening his total recovery by another two months. Focus on your recovery, be diligent, and do not skip any steps.

Phase 6 - Post Operation: Get Ready to Return to Your Sport & Functional Training (Weeks 20-24)

Phase 6, finally, you nearly did it. In this final phase, you will get ready to return to your sport. You will be working on strength, agility, explosiveness, and balance. The goal is to have fully and symmetrically strong legs after this phase. Upper body strength exercises are added in this phase too. You can also slowly return to your specific sport, but only for specific skills. In conclusion, this means no full scrimmages at first. You will work yourself upwards so that you can return with as little risk as possible after this phase.

It is a very long recovery journey. The proposed 6 months of recovery time are an estimate. There are good chances that your recovery will take between 6-9 months before you can return to your specific sport at 100%. Don't be discouraged if you need a little longer. The only important thing is that you feel healthy and fit afterward. You need to feel good about yourself and your injury should not be on your mind anymore!

Don't forget to post your recovery updates in our communities, either on our website or Facebook. Your experiences can help many others.

#recovertogether

* Consult your doctor and/ or physiotherapist before attempting these exercises