Explore the journey of recovering from an ACL repair surgery and the key milestones to celebrate along the way.

Understanding the ACL Injury

An ACL injury is a tear or sprain of the anterior cruciate ligament (ACL) in the knee, which is a common sports-related injury. It often occurs during activities that involve sudden stops, changes in direction, or direct impact to the knee. Ever wonder what tearing your ACL looks like? Check out this video here (viewer discretion advised).  

The ACL is one of the major ligaments in the knee that helps stabilize the joint and prevent excessive forward movement of the tibia (shinbone) in relation to the femur (thighbone). When the ACL is injured, it can result in pain, swelling, instability, and difficulty with activities that require pivoting or twisting. Non-operative management of a confirmed ACL tear should be attempted first, unless the knee is consistently buckling and interfering with daily activities. In fact, a 2022 study in British Journal of Sports Medicine demonstrated spontaneous healing of the ACL in 1/3 of adults that were randomly assigned to a rehab group.¹

Understanding the nature of the ACL injury is crucial for athletes undergoing repair surgery, as it sets the foundation for the recovery process and expectations for return to sport.

Surgical Procedure and Initial Recovery Phase

ACL repair surgery involves reconstructing the torn ligament using a graft, which can be taken from the patient's own tissue (autograft) or a donor tissue (allograft). The surgical procedure is typically performed arthroscopically, using small incisions and specialized instruments to minimize tissue damage and promote faster recovery. The type of surgical procedure and graft choice is usually determined after a discussion with your surgeon. It is typically based upon your previous injury history as well as the surgeons preference. 

After the surgery, the initial recovery phase begins, which typically involves pain management, wound healing, and early mobilization. Physical therapy is initiated to restore range of motion, reduce swelling, and strengthen the surrounding muscles. This phase usually lasts for a few weeks, depending on the individual's progress.

Physical Therapy and Rehabilitation

Physical therapy plays a crucial role in the recovery process following ACL repair surgery. The goals of physical therapy are to regain full range of motion, restore strength and stability of the muscles that help support the knee, improve proprioception (awareness of body position), and enhance functional abilities.

The rehabilitation program typically includes a combination of exercises, manual therapy, and modalities such as ice, heat, and electrical stimulation to help improve quadriceps activation. The exercises focus on strengthening the quadriceps, hamstrings, and hip muscles, as well as improving balance and coordination. It is paramount to regain terminal knee extension range of motion after ACL surgery as soon as possible. This will help with your ability to weight bear and walk without compensation or use of an assistive device. 

The duration of physical therapy treatment varies depending on the individual's progress, but it usually lasts for several months. It is important to follow the guidance of the physical therapist and adhere to the prescribed exercises and activities to optimize recovery.

Return to Sport Progression

Returning to sport after ACL repair surgery requires a gradual and systematic progression to ensure the knee is strong, stable, and capable of withstanding the demands of athletic activities. Most patients are curious when they can begin to run again after an ACL-repair. The answer is not always cut-and-dry and depends on the individual and how they are progressing in their rehab. Most surgeons, however, do not clear patients to begin straight-line running until at least three months post-operatively. 

The physical therapy progression thereafter typically involves phases that focus on specific goals, such as regaining strength and endurance, improving agility and proprioception, and simulating sport-specific movements. Each phase is individually tailored based on the athlete's progress and may include activities such as jogging, jumping, cutting, and pivoting.

It is important for athletes to work closely with their healthcare team, including the surgeon and physical therapist, to determine the appropriate timeline for returning to sport. The decision is based on factors such as healing progress, functional abilities, and the specific requirements of the athlete's sport. 

It is worth mentioning a landmark 2020 study that revealed athletes who returned to sports before 9 months after surgery were 7x more likely to have a second ACL injury.² Time is only one criteria that is used to determine readiness for the athlete to step back onto the field. They must also demonstrate adequate and equal quadriceps strength, hamstring strength, and symmetrical hop testing ability. 

Long-Term Maintenance and Injury Prevention

After returning to sport, it is crucial for athletes to prioritize long-term maintenance and injury prevention. This includes maintaining a regular exercise routine to continue strengthening the muscles around the knee, as well as incorporating proper warm-up and cool-down routines before and after activities.

Athletes should also be mindful of their technique and form during sport-specific movements to reduce the risk of re-injury. Additionally, staying proactive with regular check-ups and monitoring any swelling, instability or persistent discomfort in the knee can help identify potential issues early on.

By following these preventive measures and adopting a proactive approach to knee health, athletes can minimize the risk of future ACL injuries and optimize their performance on and off the field.

Citations:

1. Filbay SR, Roemer FW, Lohmander LS, et al. Evidence of ACL healing on MRI following ACL rupture treated with rehabilitation alone may be associated with better patient-reported outcomes: a secondary analysis from the KANON trial British Journal of Sports Medicine 2023;57:91-99.

2. Beischer S, Gustavsson L, Senorski EH, Karlsson J, Thomeé C, Samuelsson K, Thomeé R. Young Athletes Who Return to Sport Before 9 Months After Anterior Cruciate Ligament Reconstruction Have a Rate of New Injury 7 Times That of Those Who Delay Return. J Orthop Sports Phys Ther. 2020 Feb;50(2):83-90. doi: 10.2519/jospt.2020.9071. Erratum in: J Orthop Sports Phys Ther. 2020 Jul;50(7):411. PMID: 32005095.