Welcome to the second installment of our ACL rehabilitation timeline!
The first post of this series discussed the importance of “prehabilitation” and what it means for your post-operative outcomes. Prehab covers the timeframe from point of injury up until the day of surgery, exploring the very beginning stages of your recovery and what you can do to prepare for the oncoming rehabilitation journey.
Now, this second blog will review what happens from the day of surgery (and what you can expect throughout the process) through your first month of recovery.
Are you ready?
Physical and Mental Preparation for Surgery
Okay, “ready” might not be the first word you’d use going into surgery (which is beyond understandable). The day of your ACL surgery may be filled with nervousness and trepidation — but much of that fear is caused by the unknown (and the “what-if’s” of something going wrong).
However, just because it’s natural to be concerned doesn’t mean you have to be. It’s entirely possible to go into your surgery feeling prepared and calm, and that’s exactly what this blog is for.
Let’s start out by putting things into perspective: approximately 100,000 ACL reconstruction surgeries are performed every year. Although the procedure seems daunting, it’s completely routine in the medical world, and there’s a good chance that the surgeon you’re seeing has performed many ACL procedures before. So, realistically, you have little to worry about when it comes to mishaps or issues during the actual procedure.
As for preparing for surgery, you’ll have plenty of guidance from your doctor. Typically, they will provide you with specific instructions during your pre-operative appointment, including instructions around fasting or other necessary preparations.
On the actual day of surgery, you’ll check in with your medical team, who will then prepare you for the procedure. This prep may feel a bit repetitive, mostly because you’ll be asked the same series of questions several times (i.e., your name, date of birth, and side/location for your surgery) to ensure that they have the correct information before operating. Once your information is confirmed, your surgeon will speak with you to describe the procedure and ask if you have any questions about the process.
From there, you’ll be wheeled into the operating room and given anesthesia. Before you know it, you’ll be drifting off to sleep and dreaming of your glorious return to the field for that game-winning touchdown (or goal or basket or what-have-you).
Immediately After Surgery
Congrats — you’ve made it through the first major hurdle of your ACL recovery!
As you wake up from surgery, you can expect to feel pretty groggy (and maybe a bit nauseous from all the anesthesia). A nurse will come check on you to discuss your pain levels and how you’re feeling as the medication begins to wear off. Some doctors may give you a nerve blocker that causes your whole leg to go numb, making it feel hard or even impossible to move your leg, foot, or toes at first. But don’t be alarmed; the effects only last a few hours at most, and the nursing staff will frequently check in to make sure you can eventually move your toes and feel pressure in your feet.
As you’re recuperating from the procedure, your doctor will meet with you again to discuss the outcome of the surgery. More specifically, they’ll review how your ACL ligament, cartilage, and overall knee health appeared, as well as what they did to fix your ACL.
Once you’ve been briefed about how the procedure went, a medical team will take you to a patient room to teach you how to go to the bathroom and how to use crutches properly. It’ll be a bit awkward at first, but it’ll get you used to the movements while ensuring your pain still feels under control.
The good news is that most ACL patients are discharged from the hospital on the same day as the surgery, so you’ll likely head home just a few hours later. That being said, since you’re still fresh out of surgery, it’s important that you’re well-prepared for the ride home, too — at this point, you’re still not going to be able to bend your knee, so it’d be helpful to be picked up by someone with a larger car. Additionally, you’ll probably benefit from sitting in the back seat with your windows rolled down, since you still may feel some nausea from the anesthesia.
The First Week After ACL Surgery
After arriving home from your procedure, you may finally start feeling a bit of relief. The surgery went well, and your ACL is repaired — the hard part is over, right?
Well, sort of.
As mentioned before (and will certainly be said again), ACL rehabilitation is a constant and lengthy process. Usually, it’s not until a few days later that you realize how much of an impact the surgery has on your day-to-day functionality.
So, why not learn more about what to expect to help make the transition easier, eh?
Learning How to Move Post-Surgery
Here’s where it gets a little less relieving. By day 3, the nerve block in your leg will have worn off completely, and the pain will start to set in. This will typically cause a throbbing ache around your whole knee, and your doctor will prescribe a pain medication to help you manage the discomfort.
You’ll also receive a large brace with multiple straps, as pictured here. Be sure to use this brace any time you’re standing or using your crutches, as it’s meant to protect and support your knee in the initial phases of rehabilitation. Follow all of the instructions provided to you by your doctor (i.e., avoid taking a bath, or contact them if your calf becomes red or swollen, etc.). It might feel like there’s a lot to pay attention to, but don’t worry — all the post-operative details will be laid out for you, and your doctor will help answer any questions you may have along the way.
On top of your brace, you’ll also have to adjust to using crutches (which is always a bit of a clunky process). Every surgeon has a slightly different protocol for how much weight is safe to place on your leg, so they may prescribe you to use crutches anywhere from 1-4 weeks after your surgery.
But, regardless of how long you may have to hobble around with those sticks under your armpits, you can still definitely make your experience a bit more manageable. (This advice is based off the author’s own experience, having gone through TWO ACL repairs in his lifetime!)
- If your house has stairs, treat your crutches like an extra pair of feet. (Alright, that sounds weird, but hear us out.) As you’re going downstairs, make sure you place the crutch down on the step BEFORE your foot. (If you don’t, you might end up dropping your crutches or losing your balance.)
- You may start to feel pain or numbness in your arms because of the pressure against your armpits. If this starts to happen, just add some extra padding to alleviate some of that pressure.
- Make sure you’re extra careful when walking around or through wet, slippery surfaces. Crutches can be surprisingly prone to slippage, which definitely isn’t the most ideal situation for a recovering, post-op ACL.
- Keep your room clean and tidy. It doesn’t have to be professionally clean or organized, but the last thing you need is a pair of jeans snagging your crutches and causing you to fall on the ground.
Most of the battle in returning to daily activities is just being aware of what to expect and making some temporary modifications — and the same goes for your mindset, too.
Mentally Recuperating from Surgery
This is the part that no one really thinks about with ACL surgery: it can be quite a mental toll.
Although the mental aspect of recovery isn’t often discussed, it can be just as debilitating as the physical changes. After all, you’re used to exercising and playing sports, and your mind is still geared to think that you’re capable of performing at your usual level. But then that throbbing pain brings you back to the reality that you’re still struggling to use your crutches just to get to the bathroom.
It’s a tough mental transition that can leave you feeling pretty disheartened at first.
So, it’s super important to make sure you have a good network of family and friends around you — their support and positivity will be key for maintaining your motivation. One of the worst things to do during rehabilitation is to isolate yourself from others. Do your best to get out of the house and enjoy the little things. Get some fresh air, listen to some music, call your friends, the whole shebang. (Some people also choose to journal their experiences, since it can be cathartic to write out your thoughts and feelings as you progress. Who knows, it just might be your cup of tea.)
In fact, you can even leverage your surgery as an opportunity for self-growth. Most athletes who have never been injured before don’t have a full appreciation for the gift and ability they have, so spending a lot of time on recovery can be a real eye-opener. Even though ACL injuries are a beast to recover from, many athletes who have experienced ACL surgery will come back driven, motivated, and headstrong for whatever challenges they may face down the road.
Starting Physical Therapy ACL Rehabilitation
On or before your day of surgery, your doctor will have provided you with a referral for physical therapy — and this is where the rehab process begins.
As soon as you have your referral, contact your local sports physical therapist and schedule a series of appointments. Most referrals result in about 2-3 visits per week and begin about 2-4 weeks after surgery. Make sure that you’ve been practicing those recommended exercises during the prehab stage, that way your body’s nice and prepared for the oncoming physical therapy.
Waking Up the Muscles and Increasing Circulation
After going through surgery, the inflammation around your knee ends up making it difficult for your quadriceps to contract normally. This is because the swelling blocks the nerve signals that help your muscles contract. Additionally, the surgical procedure decreases the blood flow to your quadriceps, causing potential atrophy (or muscle loss).
Due to the weakened state of your quads through the surgery and initial recovery, they require quite a bit of attention to get back to full functionality.
Thankfully, though, that isn’t all that hard — all it requires is a few simple squeezes. While doing this, it may be helpful to place a small, rolled towel under your knee. The best cues to make sure your quadriceps muscles are doing the right work is to imagine that you’re pulling your knee cap up your thigh towards your hip. When the muscle is contracting properly, it tugs on the patella and draws it upwards. It’s best to do this as often as possible to make sure your quads get as much work as they can.
In a similar vein, you can also practice calf squeezes, buttocks squeezes, and light abdominal work while lying on your back, which is something many people forget — just because you had knee surgery doesn’t mean you can’t continue working on the rest of your body.
Improving Range of Motion
On top of re-familiarizing your muscles with contraction, your joint will also need some work to make sure it’s ready for the upcoming rehabilitation.
In the initial weeks following your surgery, it’s important to start moving your knee to prevent joint stiffness and the development of scar tissue. (Granted,the ability to bend the knee varies with every individual, so be sure you’re following the instructions given to you by your surgeon to account for any range of motion limitations. Sometimes, people can only bend their knee 90 degrees for the first 4-6 weeks, especially with a meniscus repair, so make sure you aren’t overdoing it based on your surgeon’s expertise.)
And don’t worry if it’s tough to work up the courage to bend that knee after an exhausting surgery — you’re definitely not alone. It can be daunting the first few times you try to bend the joint. At this point, you’ll still feel pain and swelling that makes the movement difficult, and the pain can be both achy from stiffness and sharp from the sutures or staples used to close up your wound.
To make the movement easier, it can be helpful to place the back of your knee on a physioball and roll the ball back and forth along your calves. This is a great technique to keep your knee bent for an extended period of time while promoting slow, intentional movement at the joint.
Goals for Month 1 of ACL Rehabilitation
Your first month of rehabilitation is sort of a good news / bad news situation.
The good news is that this first phase of rehab is surprisingly straightforward in what you have to do — kind of like your preoperative training.
But the bad news is that it isn’t necessarily easy to do.
A majority of long-term impairments after surgery occur because of a poor start to the recovery process. However, if you listen to your doctor and physical therapist and find ways to maintain your motivation, you’ll ensure a solid rehabilitation.
The following goals are typically what you will be focusing on during your first month of rehab:
- Decrease edema and swelling — practice the tried-and-true RICE method: rest, ice, compress, and elevate.
- Improve range of motion (knee flexion and extension) — using exercises prescribed by your doctor and physical therapist, make sure you adhere to the appropriate amount of exercise to refamiliarize the joint to its natural movement. (Typically, the range of motion goal will be either 0-90 or 0-120 degrees.)
- Activate your quadriceps and gluteal muscles — as discussed above, it’s imperative that you get your leg muscles (namely those needed for walking and running) nice and activated. Not only does this help prevent the muscles from atrophying, but it’ll also improve your walking gait to ensure your knee doesn’t undergo additional unnecessary stress.
- Prevent circulation issues — this is directly related to muscle activation and range of motion exercises. By practicing regular leg and body movement, you’re ensuring your body isn’t subjected to unexpected circulation issues around the knee joint or in your leg.
- Start physical therapy — an absolutely vital piece of the rehabilitation puzzle. By diving into physical therapy early into your recovery process, you’ll be able to restore your walking gait, strength, range of motion, and overall bodily function much sooner. Each of these elements are imperative to ensure proper recovery (and make sure you don’t further exacerbate your knee).
- Stay motivated and positive — probably easier said than done, especially at the start, but absolutely doable (and extremely helpful). It can be tough to look on the bright side when you’ve gone through a traumatic experience and a daunting surgical procedure, but you’ve already made it through some of the worst parts, right? Take each day one at a time; you’re allowed to feel down about being on the sidelines of your favorite sport, but it won’t be forever! Continue reminding yourself that this is a progression for recovery and improvement. You got this!
Onward to Month 2
The first month of ACL rehabilitation can be super intimidating — but hopefully this post has eased some of the uncertainties that are bound to pop up throughout the process. Recovering from ACL surgery brings on significant change, so it’s always nice to have a foundation of knowledge to help set up a general roadmap of expectations and goals.
Although it can be a lot to take in, remember that you aren’t alone! Your family, friends, and medical team will help you every step of the way, and you’ll find yourself working through your rehabilitation one manageable phase at a time.
And as you're nearing the end of this second month, take some time to breathe and read up on month 3!
Originally published 12-20-2015; updated 10-21-2020.
Kevin Vandi, DPT, OCS, CSCS
Dr. Vandi is the founder of Competitive EDGE Physical Therapy — with his background in physical therapy, orthopedics, and biomechanics, he is a highly educated, compassionate specialist. Using state-of-the-art motion analysis technology and data-driven methodologies, Kevin has assisted a wide range of clients, from post-surgery patients to youth and professional athletes. When he isn’t busy working or reading research, he spends his time with his wife Chrissy and their five wonderful children, often enjoying the outdoors and staying committed to an active lifestyle.