Healing time and recovery following anterior cruciate ligament (ACL) reconstruction surgery may be based on multiple factors, which can encompass everything from prior fitness level to activity goals, surgical procedure, and post-operative protocol guidelines. However, there are a few general guidelines common to many patients, and the timeline below offers a reference for post-surgical expectations following an ACL injury.
The initial three weeks after surgery are the most important for healing time. Diligence toward good nutritional intake and use of ice to control excessive inflammation is critical to promote an ideal healing environment. During this period, the body is recovering from surgery and requires an optimal environment to ensure readiness of the muscles to make necessary strength gains Regaining control of the leg muscles, especially the quadriceps (thigh) muscle, is essential to achieve normal gait and improve strength for activities like stair climbing and standing from a seated position. Improving mobility of the knee is also necessary to improve function and serves a secondary (but just as important) purpose for healing, helping distribute vital nutrients to the healing tissues.
It is during this period in the post-operative timeline that remodeling of the tendon replacement, or graft, occurs. When an individual uses their own tendon (a portion of the patellar or hamstring tendon are the most common graft choices) as a replacement for the torn anterior cruciate ligament, this tendon must undergo remodeling. During remodeling, the tendon will break down (or remodel) into ligamentous tissue suitable to withstand forces required of an ACL. By the end of this stage, patients note the greatest improvement in recovery. As long as no other structures were repaired in addition to the ACL, many patients may be able to walk without an assistive device or brace provided their quad recruitment has improved sufficiently. Due to a decrease in inflammation, they may also gain satisfactory mobility to perform activities like bending the knee to put on pants.
During this phase, the knee is capable of accepting greater loads and individuals may note the greatest gains in functional strength 6-12 weeks post-operatively. Patients will begin working on more activity-specific strengthening and weight bearing exercises, such as squats, ascending and descending stairs, and balancing. They can also begin biking with resistance. The muscles begin to recover their normal function and gait becomes more normalized. Since the 6-12 week phase involves a lot of repetitious activities, diligence during this phase is critical as patients focus on building lower extremity strength, endurance, and control to enable progression to impact exercises in preparation for return to work, sport or other activities during the next phase. It is important that motivation and commitment remain high to ensure success in the next phase.
By this time period, enough bony healing has occurred and the ACL has gained sufficient strength to enable patients to return to running and jumping, or impact activities. Greater recovery in muscle control and stability is also typically achieved. While the ligament can be subjected to greater forces, patients usually continue to exhibit poor coordinated lower extremity function. Therefore, ensuring the exercises are executed with good form and control is imperative to avoid increased stress to the reconstructed ACL and surrounding tissues. Training the leg to control jumping and landing properly is necessary to minimize the risk of re-injury when the patient returns to sports or recreational activities. Once sufficient lower extremity control is noted with jumping, hopping and squatting, individuals can return to cutting activities. Ensuring good form with cutting is essential to full recovery as rotational motions such as pivoting and cutting mimic activities that are common to mechanisms of ACL injury. Often an individual will sustain an ACL tear due to poor leg stability or control during activities such as pivoting and landing from a jump, which is why full recovery in function is essential to minimize the risk for future injury.
When an individual demonstrates good functional strength and stability with squatting, hopping, jumping, running and cutting, they are usually cleared by the physician to return to activity, such as work or sports. Evidence shows that return to play should be based less on time and more on objective criteria. While the 6 month time frame is typically the earliest patients are allowed to return to contact sports, graft healing and recovery can take up to 12 months or more. Thus an individual must be mindful to continue monitoring lower extremity alignment and control during performance of cutting, running and landing to minimize risk of re-injury.
The healing process after ACL surgery can be a long one, but the proper rehabilitation can help you return back to the sport you love. Make sure to consult your physical therapist if you have any questions during your recovery process. For information about Athletico’s ACL 3P Program, which can help athletes progress after an ACL injury, please email ACL@athletico.com.
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