Recovering from ACL Surgery

An anterior cruciate ligament (ACL) rupture is usually a non-contact injury experienced during jumping, pivoting and rapid change of direction as found in sports like soccer, alpine skiing, football, basketball and volleyball. It is one of the most debilitating musculoskeletal injuries. Women are 2-8 times more likely to experience ACL injuries than men. 88% of patients with ACL ruptures also have structural knee damage to cartilage, the meniscus and other knee ligaments. The incidence of post-traumatic osteoarthritis and scar tissue formation are high. In the US, ACL injury affects more than 200,000 people each year, and over 70% are sports related.

ACL reconstruction is the usual treatment for athletes after ACL tears, followed by evidence-based physical rehabilitation therapy to restore function. It has a 95% success rate. Preoperative nerve and muscle function is predictive for knee function and return to sports after ACL reconstruction.

Physical therapy is essential to the success of ACL surgery. Healing and recovery are based on a patient’s fitness level prior to surgery, the surgical procedure and the post-operative protocol guidelines. Rehabilitation after surgery is focused on early weight bearing, pain management, restoring normal range of motion, decreasing joint swelling and improving quadriceps and hamstring muscle strength.

The goal of rehabilitation after ACL surgery is to address knee neuromuscular function, sport-specific training and eventual return to sport at pre-injury levels as quickly as possible without exposing the athlete to an undue risk of re-injury.

Rehabilitation focus on the restoration of hamstring function is important because deficits are associated with an increased risk of osteoarthritis, altered gait, altered quality of sport-like movements, and increased risk of reinjury on return to sport. This becomes most noticeable after the initial 3 weeks post-surgery and must be overcome as part of the functional recovery process.

Evidence-based sports medicine rehabilitation protocols are designed and validated through research and help facilitate a successful return to activity after ACL surgery. Dr. Petrigliano works closely with your physical therapist to help you regain range of motion, strength and function. Various functional milestones are used throughout the postoperative rehabilitation protocols to ensure that the athlete meets their goals and to provide markers for advancement to the next phase of rehab. Average time to full recovery ranges from 8 to 9 months after surgery. However, young athletes who return to knee-strenuous sport before 9 months after ACL reconstruction are at increased risk of a second ACL injury.

General rehabilitation guidelines

Rehabilitation begins on the day of surgery. You will be wearing a brace with the knee fully extended and use crutches as directed by Dr. Petrigliano. Crutches are only used for comfort for the first 7-10 days unless the patient has had additional ligament surgery, or meniscus repair. Full weight bearing is gradually increased as tolerated.

General common guidelines:

• Phase I – These first two weeks after surgery are focused on controlling pain and swelling with pain medications, elevation, and icing to control inflammation and regaining full knee extension by riding a stationary bike. Then the focus turns to increasing the function of the quadriceps muscles which control gait and activities like climbing and standing from a seated position. Then progressing to range of motion. Improving mobility aids healing by helping to distribute nutrients to the healing tissues. Dr. Petrigliano will determine when it is safe for you to begin driving.
• Phase II – Weeks 2-6 – By this time, your swelling should have decreased, and you may be able to begin weight bearing as tolerated. The focus is on strength training, regaining full range of motion and improve endurance and proprioception with a treadmill, elliptical or step machine. By six weeks most patients experience signficant improvement in function, and you may even be able to walk without crutches assuming your quadriceps are ready.
• Phase III – Weeks 7-12 – Focus is on active range of motion and increased intensity of exercises for thigh muscles and hamstrings for activity specific strengthening and weight bearing. Walking or swimming are important to improve cardiovascular fitness and regain confidence in the knee. Proprioceptive Neuromuscular Facilitation (PNF) is a stretching technique utilized to improve muscle elasticity and has been shown to have a positive effect on active and passive range of motion.
• Phase IV – 4-6 months – The bone has healed, and the new ACL has gains strength sufficient for running and jumping.  The focus is on meeting the sport specific return to sport criteria. Dr. Petrigliano will determine when you are cleared to resume full activities. The goal is to return to sport safely.
• Phase V – 6-9 months – Continued strengthening, balance, control, endurance training and sport specific exercises.

Dr. Frank Petrigliano is an internationally renowned orthopedic surgeon and is the Chief of the Epstein Family Center for Sports Medicine at Keck Medicine of USC in Los Angeles, CA. He is a sports medicine expert who specializes in arthroscopic knee ligament reconstruction. His goal is to return his patients to the life they love and the sports that make life worth living with minimal interruption. Contact him at one of this three convenient locations to schedule a consultation and receive the correct diagnosis, all your treatment options, and expert personalized care.