Have you torn the ACL (anterior cruciate ligament) in your knee, and are wondering what recovering from ACL surgery might be like?
Maybe you’ve injured your knee and it keeps giving way, and you’re worried you might have torn your ACL?
Perhaps you’re facing ACL reconstruction surgery and want to make the very best recovery?
Or, are you someone who’s struggling to get back to sport after ACL surgery, despite doing lots of physio?
If so, you’re in the right place. Let’s talk about:
- What it’s like to tear your ACL
- Whether ACL reconstruction may (or may not) be right for you
- What to expect after ACL reconstruction surgery
- How to know if you’re ready for sport
- Why you might not be recovering – 7 common ACL rehab mistakes
But first, let’s consider the success of ACL reconstruction surgery (especially since, if it’s going to be a long rehab, you want to know it’s worth it, right?).
If you’re an elite athlete, a meta-analysis of many studies has shown that the likelihood of you successfully returning to the same level of sport after an ACL reconstruction, is around 82%.
Even for elite athletes, recovery takes a long time (6-12 months) – despite having the best medical teams around them, and often being paid to do the rehab.
But what if you’re not an elite athlete?
Well, you have an 80% chance of returning to some form of sport, but only around a 65% chance of getting back to the same level of sport you were at pre-injury.
You’ve also a risk of re-tearing your (reconstructed) ACL, which is somewhere between 20 and 25%. If you’re female, your risk of a further ACL injury after reconstruction surgery is FIVE times higher, than if you’d never had an ACL tear.
There’s clearly a big gap between the success rates of pro-athletes, compared with the success rates for us mere mortals. This is partly because life gets in the way, and rehab takes hard work, but it very much comes down to the quality of the physiotherapy.
The good news here is, that superb rehab with a specialist physio = an excellent outcome (even if you’re not an athlete).
Ardern CL, Webster KE, Taylor NF, et al
Return to sport following anterior cruciate ligament reconstruction surgery: a systematic review and meta-analysis of the state of play
British Journal of Sports Medicine 2011;45:596-606.
Grindem H, Snyder-Mackler L, Moksnes H, et al. Simple decision rules can reduce reinjury risk by 84 % after ACL reconstruction: the Delaware-Oslo ACL cohort study. Br J Sports Med. 2016;50(13):804–8.
You’ve also a risk of re-tearing your (reconstructed) ACL, which is somewhere between 20 and 25%. If you’re female, your risk of a further ACL injury after reconstruction surgery is FIVE times higher, than if you’d never had an ACL tear.
There’s clearly a big gap between the success rates of pro-athletes, compared with the success rates for us mere mortals. This is partly because life gets in the way, and rehab takes hard work, but it very much comes down to the quality of the physiotherapy.
The good news here is, that superb rehab with a specialist physio = an excellent outcome (even if you’re not an athlete).
What’s it like to tear your ACL?
I’m an actress and stunt performer, and the day I tore my ACL, my trainer asked me to perform a risky manoeuvre of repeatedly jumping on one leg with the other leg held up in the air.
The dynamics of the movement felt wrong, and when I landed, my knee collapsed. I managed to get up off the ground, and I felt pressure to continue the session; after performing a kick, I knew my knee was in serious trouble.
Mike stayed late at the clinic to see me, and after his assessment, he arranged an urgent MRI scan for me (and even phoned me on a Sunday to share the results). I was naturally worried because my livelihood was at stake, but even though the news was bad, Mike reassured me that we’d get through it, and he’d get me back into action.
Fran Katz, Actress and Stunt Performer
The ACL (anterior cruciate ligament) is a ligament deep within your knee that is an important stability component. It essentially works to keep your knee in alignment, by preventing the shin bone from moving too far forwards on the thigh bone, and it also helps to reduce excessive rotation, hyperextension, and side-to-side movements of the knee.
Most ACL injuries tend to happen during a sport or activity that involves a sudden change of direction at the knee (e.g. falling badly when skiing), or jumping and landing awkwardly (e.g. during football or netball).
If you’ve torn your ACL, you might experience:
- hearing or feeling a ‘pop’ within your knee
- sudden onset of pain (although not always)
- difficulty getting up if you’ve fallen
- difficulty bearing weight on your leg
- rapid swelling of your knee
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4205204/
Many people report knowing that something had happened to their knee, or that the knee ‘just didn’t feel right’ from that moment onwards. Some people experience their knee giving way, feeling untrustworthy, or ‘odd’ when walking downstairs.
If this happened to you, you might have taken yourself to A and E.
You may have been seen by a doctor or nurse and had an X-ray to confirm nothing was broken. You might have been given some first aid advice about icing and elevating your knee, and perhaps told to see your GP if your knee continued to be troublesome.
Many people feel a little lost at this stage, not knowing what to do for the best.
Here’s where I come in.
If you’ve injured your knee, I’ll take you through a thorough assessment. I’ll ask you lots of questions, carefully listening to your story and the mechanism of how the injury occurred.
I’ll want to know how the knee has been behaving since the injury happened, any previous injuries or medical issues you’ve had, and how this injury might potentially impact your activities, sport and lifestyle.
I’ll examine you and your knee closely, looking for signs of swelling, tenderness, and instability (using tests such as the ‘Lachmann’ and ‘anterior drawer’ tests). I’ll want to see if you can contract your quads muscles, and perform movements such as a single-leg squat, a step-down with good control, and maybe even jumping.
If it becomes apparent that an ACL tear is likely, I’ll be recommending that you have an MRI of your knee, as an X-ray or ultrasound are not adequate to exclude deep injuries within the knee.
Some ACL tears happen in isolation, but it’s more commonly combined with additional injuries to structures within the knee, such as the menisci (the fibrocartilage wedges between the end of the thigh and shin bones), the medial collateral ligament (which connects the thigh and shin bone on the inside of the knee), and the articular cartilage surfaces. Bone bruising is also common.
If you’ve torn your ACL, you essentially have two options:
- Undergo surgery to ‘reconstruct’ the ACL by replacing it with a tendon from another area of the body (e.g. the hamstring), followed by extensive physio.
- Try to make a full recovery with physio alone
At this stage, you might choose to seek an opinion from a knee surgeon or sports doctor.
ACL surgery may be a very good option for you, but it’s not needed, or appropriate for everyone.
Should I get ACL surgery?
Many factors influence the decision around whether (or not) to have surgery for your ACL tear, and you’ll want to spend some time thinking about this and getting advice.
There’s no rush to have to make a sudden decision about this. It’s always best to get your knee into optimal condition before having surgery, so you’re not going to ‘miss the boat’.
You might want to consider ACL construction surgery if:
- Your knee is fundamentally unstable and it’s making everyday life awkward
- You’ve also damaged other structures within the knee (such as the menisci or joint surfaces)
- You want to return to sports that require jumping, pivoting, and turning, (such as netball, football, rugby, skiing, martial arts, and gymnastics)
- You’re prepared to put in the time and effort to do the rehab
ACL reconstruction surgery may not be in your best interests (or necessary) if:
- You’ve only partially torn your ACL, and your knee isn’t unstable
- You’ve significant osteoarthritis (wear and tear) within your knee
- You’re not interested in pivoting or twisting sports
- You’re an adolescent and still growing
- You’re not well enough medically to undergo surgery
- You recognise that you’re not going to be able to fully engage in the rehab that’s required.
Some people, with a good amount of excellent physio, can happily return to ‘straight line’ activities, such as running and cycling, without undergoing ACL reconstruction.
When I tore my ACL, I didn’t experience any pain, but my knee didn’t ‘feel right’. I spent several weeks doing rehab and exploring what was possible in terms of activity. In the end, when I did decide to go ahead with surgery, my knee was really well prepared for it.
If you’re undecided about whether to have surgery, you’ve nothing to lose, and everything to gain, by going through rehab first (even if it eventually turns out to be prehab!)
What to expect after ACL reconstruction surgery
Prehabilitation
To undergo ACL reconstruction surgery, your knee needs to be in the best shape possible:
- Your knee should be comfortable and not swollen
- Your knee should have a full range of movement
- Your quads muscles should be strong and firing well
It’s so important to have well-functioning quads going into ACL surgery.
When you injure your knee and it swells, the quads shut down and decline in terms of their strength and firing rates. Studies have shown that if you have a preoperative quads strength deficit going into surgery, it will have a negative outcome on the function you can achieve, one year after the operation (even if you try to make up the deficit after the surgery).
In other words, it’s a no-brainer to get your quads as best prepared as possible before surgery.
Rehab after ACL reconstruction
Most ACL reconstruction occurs as a day case surgery, meaning you get to go home on the same day. It’s not possible to stitch the ends of the ACL back together once it’s torn, and so the ACL is ‘reconstructed’ using a tendon which is typically harvested from the hamstring muscle (although patella tendon grafts are sometimes used).
Pieces of the hamstring tendons (usually parts of the semitendinosus and gracilis tendons) are stripped out from the side of the knee and are then folded and stitched together to make a robust, chunky tendon.
ACL graft preparation
Holes are drilled into the tibia (shin bone) and femur (thigh bone) and the graft is threaded through and fixed in place with screws. It’s all done through keyhole incisions, which are less than a centimetre in size.
Most surgeons will encourage you to start loading weight onto your leg on day one and to start walking if comfort allows. You’ll likely use crutches for a few days, to give your knee a little support.
This is when the hard work begins, but despite what you may have read, going through ACL rehab isn’t as bad as you think it’s going to be.
The initial rehab goals are to get the swelling down, get the knee fully extending, and get excellent activation of the quads and hamstring muscles.
How much time will I need to devote to doing my rehab exercises?
It takes commitment to do your rehab exercises, but it is very possible to fit this in alongside a busy work and family life.
In the first month, it’s all about little and often; low-intensity amounts of exercise, e.g. 10-15 minutes, carried out 3 or 4 times a day. You could do your first little session before you start work at your desk, then another at coffee break time, lunchtime, and at the end of the day.
As your rehab progresses the physicality of the exercises becomes more intense, and that means, you’ll need more recovery time in between. In terms of commitment, this could look like 40 minutes, 3 times per week.
ACL recovery mistake number 1
Not being prepared for surgery
It’s my experience that many patients don’t get optimal prehab before surgery, and some go into surgery too soon. There is a tendency for surgery to be offered six weeks after the date of the injury, but what if you’re not yet sufficiently prepared? Take your time and do the necessary prehab, first.
ACL recovery mistake number 2
Not including open chain exercises to strengthen your quads
There has been much controversy over the years about the right kind of exercise to get your quads into good shape. A lot of debate exists about ‘open chain’ and ‘closed chain’ quads exercises.
Closed chain exercises are ones where your foot is either in contact with the ground (e.g. during a squat) or fixed to an object (such as a spin bike pedal). Open chain quads exercises are ones where your foot is not on the ground and is free in the air (e.g. knee extension exercises).
Some surgeons have prescriptive protocols for how they want a patient’s rehab to be progressed, and there has been a vogue in the past for open chain exercises to be banned.
The thinking behind this was that too much load might be placed across the new ACL graft, potentially leading to it being overly stretched.
On the flip side, open chain exercises such as seated leg extensions, are an excellent way to build quads strength.
Thankfully, the up-to-date advice is shifting; open chain quads exercises initiated from six weeks post-surgery improve strength and don’t adversely affect the ACL graft.
ACL recovery mistake number 3
Not testing progress frequently enough
How do you know if you’re really progressing during rehab?
The answer is that we have to test, test, and test again. Too often I see patients who are following a generic, ‘one-size fits all’ protocol, which is typically time-based and doesn’t take into account how well the patient is actually progressing, and what their individual goals are.
What do I mean by testing?
It’s looking at pain levels, joint swelling, tolerance and sensitivity to activities, how well thigh muscles are being recruited, the execution of squatting and jumping, and how well landing is controlled, each and every time the person comes to the clinic.
This is particularly important in the later stages of rehab, when planning a return to sport.
I’ll be looking to see how well the person performs the following:
- Single leg vertical hop test
- Single leg drop test
- Triple hop test
- Y Balance test
ACL recovery mistake number 4
Neglecting your hamstrings
If you’ve had an ACL reconstruction with a hamstring graft, your body will try to make good on the tendon loss, through a tendon regeneration process. Studies estimate that this process occurs in around ¾ of patients within the first year after the hamstring tendon was harvested.
Not unsurprisingly, many people experience power deficits and altered biomechanics as a result of the tendon graft being harvested from their hammy. It’s also common to experience hammy pain.
Your physio must focus time on hamstring rehab. Sometimes there’s a tendency for the focus to be all about quads strengthening, and the hammy strengthening gets overshadowed. This is a problem because we know that loss of strength in knee flexion (the role of the hamstrings) increases the risk of ACL re-injury.
ACL recovery mistake number 5
Return to sport rehab is too generic
No two bodies are the same and no two sports are the same.
The rehab you’ll need if you love Brazilian jiu-jitsu is very different to the rehab you’ll need if you’re a five-a-side footballer.
Sometimes a person’s rehab stops after the ‘you’re ready to start jogging’ phase, or if their health insurance deems that returning to sport is a ‘bit of a luxury’.
A successful return to the activities you love means that you can meet all the functional requirements of the sport you’ll be playing, and that requires that your physio has an excellent working knowledge of the demands of your sport and factors them into your rehab.
ACL recovery mistake number 6
Not including sufficient perturbation training
When we participate in sport, we may be moving around on uneven terrain, and potentially colliding with other individuals. To prevent injury and to perform well, we need excellent reactive balance. It’s our ability to be able to right ourselves, or control our centre of gravity, when we’re about to lose our balance or if we are landing from a jump in an unexpected manner. In other words, it’s about controlling movement we weren’t anticipating.
Studies have shown that people who’ve had ACL surgery are overly reliant on their vision to correct the imbalance, and they particularly need to regain good activation of the proprioceptive system (this is the kinaesthetic system that enables the body to ‘feel’ where it is in space).
The good news is that perturbation training (aka reactive balance training) can help us to rapidly re-learn this skill, particularly if we reduce the amount of visual information the brain is receiving (e.g. with eyes closed exercises).
ACL recovery mistake number 7
Not getting your head in the right place
It’s very natural to feel a little concerned about how your knee will handle returning to sport. Many people have fears about the risk of re-injuring their knee, and it’s a significant factor in why some people never make it back to sport.
Psychological readiness is key when returning to sport successfully, so as well as preparing the body, we need to prepare the mind, and a big part of this is goal setting.
During ACL rehab, we set weekly goals (e.g. in the first week post-op, the goal might be to achieve full extension) and we document achieving these goals. Because it’s a long rehab journey, it’s important to be able to look back and see how much you’ve achieved, and it’s my job to help maintain motivation in this process.
Knowing you’ve done all the hard work, and have gone through all the necessary rehab stages, as well as proving yourself to be physically capable, is very empowering, and it will enable you to truly feel ready to return to sport.
I’ve previously torn my other ACL, and the experience of rehab with Mike was beyond amazing. I’m an athlete and Mike gave me the confidence to trust my body and progress swiftly.
His experience of working with athletes and elite performers means he has an excellent understanding of the demands placed on my body. Not only do I need to be strong, but my dance movements need to be aesthetically pleasing too. Mike made absolutely sure that I could fully and gracefully take my knee to full extension.
Throughout my rehab, Mike gave me confidence, he pushed me when I needed it, and he was immensely patient with me through the ups and downs. He was in constant communication with my surgeon, and I felt so supported. I’m getting ready to return to work, and if you’re going through an ACL recovery, I cannot recommend Mike enough!
Fran Katz, Actress and Stunt Performer
I’m a specialist physiotherapist who’s worked in professional rugby to return players to elite sport, and I’ve twice been an ACL injury patient myself, experiencing all the emotional ups and downs it brings.
If you’ve torn your ACL, are considering ACL surgery, or if you’re not getting the results you need from your rehab, book an appointment to work with me, and let’s get you back to the sport you love.
Author – Mike Brent
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