ACL Recovery: Your Return After Surgery

ACL RecoveryYou had an ACL surgery.  Whew! The hard part is over…So you thought. Your ACL recovery takes a lot more than just surgery.

The real work starts now.

Your surgery is a significant component of your ultimate recovery, but it is only one aspect.  There are a number of other very important obstacles that need to be overcome before safely returning to your sport will be possible.  As a result, a “one size fits all approach” is not practical. Your recovery may and likely will look different than your friends’.

Fortunately, however, much of what determines success is in your hands – That is, with the help of your surgeon and some other very important guides and advisors.

After ACL surgery, three areas of recovery are critical: ACL healing, functional preparedness, and psychological readiness. All three of these must be accomplished for your recovery to be successful.

Let’s take a look at each of these.

1. ACL Healing

There are some components of your healing that are pretty straightforward. The trauma and swelling after surgery will usually settle down within 4-6 weeks.  The ligament will have early healing to the bony attachment site by 2-3 months depending on the type of graft used. Although, with some grafts, it can take as much as 7-8 months until the graft attachment appears to fully mimic the normal ligament connection site.

Graft Maturation…

In addition to the graft ends healing to the bony attachment sites, the graft itself must “heal”. No matter where the graft is from, whether from you (autograft) or someone else (allograft), it must undergo a maturation process in order to achieve optimal strength and function.  This maturation involves the incorporation of new blood vessels into the graft and thickening and strengthening of the graft.  Additionally, there are changes on a cellular level that result in the graft becoming similar to your native ACL. Unfortunately, most of the science about this process comes from animal studies. As a result, there is little agreement on how long it takes for grafts to fully mature in humans. Times that are thrown around are 1-2 years for autografts.  Allograft maturation likely takes even longer.

Traditionally after ACL surgery, your return to sports would be solely based on the time from your surgery.  As a result, inevitably the very first question I’m asked after recommending ACL surgery is “When can I go back to X”. An understandable question…but not so simple.  Although time is an important factor, by itself it’s not enough. Although among patients, graft healing may be relatively consistent, functional preparedness and mental readiness, vary dramatically.  As a result, it is often these two milestones that determine when your return is safe and possible.

2. Functional Preparedness In ACL Recovery

Most of my patients come into surgery thinking that a surgical fix is a lot like fixing a broken widget.  Turn a couple of screws, replace a part, perhaps exchange the whole unit and we’re good as new.  Unfortunately, orthopaedic surgery, particular ACL surgery, is not like that.  Your surgeon and surgery start the process but it’s you and your physical therapist…and a lot of time and work…that will end it.

The injury and surgery result in all kinds of disruptions apart from the ligament injury. Weakness, pain, swelling, and stiffness are inevitable.  This leads to muscle atrophy and impairments in your gait and coordination. All of these, not just the torn ligament, must recover or be corrected…and this takes time.


Furthermore, when you rupture your ACL, the nerve fibers that run through it are disrupted along with the ligament.  These nerves are important in assisting with proprioception – the ability of your brain and musculoskeletal system to know where your joint and its components are in space.

Proprioception is critical for joint health and protection. It works like a thermostat to alert our muscular system when our joint or limb is beginning to go out of alignment. This awareness works through reflexes undetected by our brain. It enables our neuromuscular system to make minute corrections before our joints get into a more precarious position.  When this reflex is no longer functioning, like after an ACL injury, problems may not be noted and corrections not made until it’s too late. That is, often after the damage is already done.


A proper postsurgical rehabilitation program will aim to correct all these functional impairments. It should be graduated. So as your symptoms improve, your graft matures, and your capabilities increase, you and your knee are continuously challenged through increasingly complex and taxing functions

The program typically begins with modalities and exercises.  These are geared to help reduce symptoms and their negative feedback loops as well as restore basic functions such as range of motion and strength. More complex tasks such as balance, jogging, sprinting, plyometrics, and agility training should follow. Once you master these, sports-specific skills, as well as exercises that help develop protective endurance, should be introduced.

Unfortunately, many of these final and more complex skills are often not achievable within the limits imposed on standard physical therapy by most insurance companies. So I almost always recommend that my patients enlist in a return-to-sport ACL prevention program after the simpler skills have been successfully relearned. These more advanced rehabilitation programs have been shown to reduce the risk of ACL injury by more than 50%.

By the end of your rehabilitation, your body should be sound and ready to return.  But that alone is only part of the battle. If you aren’t fully prepared psychologically, returning at your preinjury level will still not be likely.

3.  Psychological Readiness In ACL Recovery

Don’t underestimate the effect that your mind and thoughts have on your recovery.  Your psychological state is actually a better determinant of your ability to return to your activities than your physical state. This is worth repeating.

A person’s psychological status correlates better with their likelihood of returning to their sport than their functional outcome.

Why is that?

Many of those who sustain injuries such as ACL tear, often can suffer from a number of psychological disturbances. Among these are self-blame, resentment, anxiety, depression, and even symptoms of PTSD.  All of these can adversely affect not only your functional recovery but even your physical healing.

Often people recovering from an ACL tear continue to relive their injury.  They will often have thoughts of self-doubt (what did I do wrong?), shame (I’m not good enough or I let my parents, coaches and team down) and fear (I won’t be as good as I was or I may get reinjured).  These thoughts can impact one’s ability to return to their sport and can affect performance even if they do.

Additionally, in more severe cases, some will experience profound loss, despair and even clinical depression. Sometimes these symptoms can lead to substance abuse and even, in the most serious cases, thoughts of suicide. Obviously, anyone suffering from these severe states will not only be much less likely to return to their preinjury sport but will likely suffer in many other aspects of their life.

Overcoming the psychological aspects of recovery…

Staying optimistic and focused is critical so that you can persevere over the lengthy recovery (Here is a wonderful Podcast that discusses the psychology of this phenomenon) . This, unfortunately, is easier said than done for some.  Many will do fine with self-encouragement and assistance from their physical therapists, surgeon and personal support networks.  Eating and sleeping well is important.  Mindfulness exercises can be helpful as well. Taking a break from your recovery and allowing your brain to rest can provide the respite needed for you to push through. For others, a sports psychologist or psychiatrist may be beneficial.

The ultimate goal is for you to gain confidence in your knee and your capabilities and to lose all self-doubt and fear.  You are truly ready when you are able to perform your sport with complete focus and without any thought of your knee.

As you go through this process, it is important to be aware that the feelings you may be having can be normal and are often shared by many others in the same situation. In order to completely return to your pre-injury capabilities, you must view your psychological recovery with the importance you give your physical recovery and to ask for and get the help you need to succeed.

Recovery from ACL surgery is like a three-legged table.  For full function, all legs are needed.  These “legs” in ACL recovery are providing enough time and a suitable environment for graft healing, restoring your preinjury function and recovering your mental outlook and focus. It is not an easy task.  But it can be achieved.  With the right mindset and work ethic, along with expert guidance and assistance, you can make it.


Share This