ACL Rehabilitation Timeline:

As some of you know I am a huge Boston sports fan.  In my opinion there is no greater sports town.  There is so much history and passion in Boston sports that brings a tremendous energy and fervor that is infectious.  If you are not from Boston and you find yourself moving to the city it is likely you will catch the sports bug and become a crazed fan.  Although I have moved and now practice physical therapy in San Jose California my sports roots remain in Beantown

The New England Patriots currently are undefeated, awesome, but recently lost their dynamic and versatile running back Dion Lewis.

Lewis recently tore his left ACL during a non-contact movement.  As he was approaching a defensive back he attempted to make a left “juke” and that is where his knee buckled into valgus and femoral internal rotation.  This is the most common biomechanical movement error that results in an ACL injury.  Lewis is out for the rest of the season as he rehabs from his recent ACL surgery.  Typical recovery from ACL reconstruction is 9-12 months, although biomechanical movement errors can persist through 18 months. Recovering from ACL surgery is a physical and mental struggle.  In order to ease the doubt and worry that many patients face I decided to write a timeline of ACL rehabilitation.  By having a reference for healing times, protocol milestones, and complete recovery expectations an athlete can plan their training to return to the sport they love.

Great Example of ACL Timeline I will be writing one blog for each month of ACL rehabilitation through the 9 month mark.  I will detail objective information and share subjective experiences of myself and previous clients of mine.  The posts will also try and follow the recovery of Dion Lewis to provide some context.  This post will detail month “0” or the pre-rehabilitation or “prehab” period.

The Injury and Immediate Physiological Changes Week 1 Following Injury

Anyone who has torn their ACL can tell you it is traumatic, painful, and a life changer.  Immediately following the mechanism of injury, contact or non-contact, you will experience swelling (edema) around the knee joint, pain which limits walking and joint loading.  This inflammation is initially helpful to protect the knee and keep you from further injury. You will also experience decreased range of motion and sometimes, but not always, knee instability.  Knee instability is the most variable part of the first days following your ACL injury as some people have very little instability.  As time progresses your surgeon and physical therapist will help you evaluate the stability of your knee and determine the best option of care for your specific goals. You will likely be given crutches to help limit your pain and prevent further injury while your knee is susceptible.  Typically, crutches are suggested on an “as needed” basis based on your comfort, knee control, and daily movement demands.  If you are a student or work in a busy environment you may also be given a stabilization brace.  The brace provides some security for you and helps others to avoid you once they see your knee brace.

Week 1 Objectives:

  1. Decrease edema and swelling with RICE (Rest, Ice, Compression, Elevation)
  2. Protect the knee with brace, ace wrap, and usage of crutches
  3. Meet with an orthopedic surgeon for evaluation, MRI, and consultation
  4. Meet with a physical therapist to begin “prehab”
  5. Educate yourself regarding surgery, healing times, and rehabilitation demands
  6. Consider your athletic goals and begin mental preparation for a new type of training (rehabilitation and recovery versus performance)

Weighing Surgery vs. Non-Surgery

Depending on your sports, athletic goals, and level of play you will be evaluated to determine if surgery is absolutely necessary and, if surgery is needed, how soon it should be scheduled.   Typically high school, college, and professional athletes will undergo ACL reconstruction very soon after injury to preserve valuable time post-operatively.  The longer you wait the longer you will be out of sport for the coming year.  For those who wish to participate in activities that involve cutting, sprinting, jumping, and changing direction surgery is advised.  The determination to have surgery is largely based on the athlete’s pre-injury function and future goals rather than inherent objective measures.  Although screening and testing for knee joint laxity is performed it is not a good predictor or rehabilitation outcome.   Those who are not interested in returning to sports, or perform sports such as cycling that are straight with low levels of cutting and jumping, may choose to avoid surgery.  There is growing evidence that those with a stable knee following injury can rehabilitate to a functional level without surgery.  This is a tough determination for those that are young since it is challenging to predict what activities you may want to participate in later in life.  The literature seems to suggest that the non-surgical option is most useful for older individuals who know their activity levels and have very little demands for cutting and changing direction.
Weeks 2-4 Following Injury

By your second week after injury, your knee pain is likely decreasing and your confidence in walking has improved.  All the icing, elevation, and rest has diminished your edema allowing you to sleep more comfortably and stand for longer periods without pain.  If you did not meet with an orthopedic surgeon in your first week you most likely are meeting with by week two.  Additionally, you may also have your MRI scheduled in week two to obtain a better image now that the inflammation from the injury is not blocking the picture. Usually during week 2 you will attend your first pre-op physical therapy session.  Your physical therapist will evaluate you’re:

  • Range of Motion
  • Ability to squeeze your quadriceps
  • Ability to squeeze and utilize your hip muscles
  • Perform a gait assessment to determine crutch use and highlight any compensations
  • Discuss your pain and ways to be more comfortable
  • Discuss your goals for rehab and your sport participation
  • Provide hand on therapy for swelling reduction and range of motion
  • Provide a home program for muscle activation, functional movement, and balance

Your first physical therapy session is designed to evaluate your functional status and begin the initial goals of prehab.  The following PT sessions over the next 2 weeks to 1 month will focus on preparation for surgery and beyond.

Prehab Goals

  1. Decrease knee edema and swelling to baseline
  2. Restore full non-weight bearing range of motion
  3. Activate and maintain quadriceps contraction and strength
  4. Maintain gluteus strength
  5. Restore level plane gait mechanics and avoid “quadriceps avoidance walking” (walk normally without a limp)
  6. Provide post-operative education for wound care, exercises, and mental preparation
  7. Maintain proprioceptive awareness (continue to practice balance and control of your leg)

Week 4 and Beyond

After completing 4 weeks of prehab, you will notice improved confidence in your ability to walk, perform stairs, squat, and maybe even run.  By this point, most people do not even experience pain unless they had an additional injury to their knee such as a meniscus tear. 

A common question patients often ask at this point is, “I feel really good right now do I even need surgery?”  It is true that daily tasks require very little lateral or twisting movements and therefore place little strain on the ligaments of the knee.  If you were; however, to sprint, jump on one leg, cut, or side shuffle you would likely notice weakness, decreased stability, and potentially fear of movement.  Despite the newly gained confidence, surgery remains the best choice to stabilize the knee for those who wish to have an active life. Most ACL surgeries are performed between 2 weeks to 6 weeks after the initial injury.  At this stage of your prehab you should talk with your surgeon about a surgery date.  Your physical therapist will send over a progress report highlighting your objective measures so the surgeon has full understanding of your pre-operative function. Research and Prehab
Prehabilitation: Preparing an individual to withstand a stressful event associated with inactivity through enhancement of functional capacity.

Prehabilitation, although a relatively unknown term in the general population, has become more common in physical therapy and medical settings over the last 5-10 years.  Its increase in practice has come about from the benefits associated with pre-operative training.  For those scheduled to have a total knee replacement who have severe osteoarthritis, prehabilitation was shown to increase strength and overall function post-operatively.  Additionally, prehab is utilized in populations seeking spinal surgery, cardiac procedures, and colectomies.

Quadriceps muscle atrophy occurs after an ACL injury due to disuse and swelling.  Having weakness in your quadriceps muscle affects a natural gait pattern.  During weight acceptance in gait, as your knee bends to absorb shock, you quadriceps lengthens and slowly allows the knee to bend.  In order to absorb shock you therefore need proper quadriceps strength.  Research has demonstrated a reduction in strength and power of the quadriceps due to arthogenic inhibition and central nervous system signal changes from ACL disruption.  Although these are protective mechanisms to prevent further injury, it is necessary to improve quadriceps strength, restore gait, and improve neuromuscular control. 
Research demonstrated that 5 weeks of prehabilitation improved patient reports knee function, quadriceps peak torque, and total ACL work.  Additionally prehab improved single leg hop distance and these gains were maintained at 12 weeks post-op.  
For those patients who participate in proprioception exercises (balance exercises) before surgery they demonstrate a post-operative success rate of 92% versus those who did not perform balance training and reported 50% success rate.


Good Luck Dion! If you have sustained an ACL tear and want the best surgical outcome then you should discuss attending prehabilitation with your surgeon.  Attending physical therapy for quadriceps strengthening, gait training, and proprioception training is vital to achieving optimal post-operative results.  Prehab is already being used as a regular care option in spinal surgery and total joint replacement patients with good success.  Get a head start on your recovery and attend prehab with your local physical therapist.

Next month I will discuss the goals, trials, and psychological factors that are associated with the first month out of ACL surgery.  Please share any stories or ideas on ways to improve ACL prehabilitation.