I am fortunate enough to work closely with some excellent and talented orthopedic and sports medicine surgeons. They are extremely experienced, skilled, conscientious, and get excellent post-operative outcomes. However, no matter how many of these traits they possess and no matter how great their outcomes are, they are not able to fully prepare you for your post-operative rehab journey after an ACL reconstruction.
There are a variety of reasons, but perhaps one of the biggest reasons is the unmistakable truth that each person’s rehab experience will be different and varied individually. Everyone is “wired” differently and possesses variable genetic, physical, and psychological traits or characteristics unique to them. This variability contributes to a unique perspective and individual experience. Which brings us to our first point….
- You are going to hear lots of advice from others that have gone through ACL rehab in the past themselves or known someone who has completed ACL rehab
There is some utility and benefit from hearing from others that have undergone an ACL reconstruction, but accepting their own experience as inevitable dogma and the standard for your expectations can be problematic for the reasons outlined above. Your own lived experience will likely vary to some degree from others, and comparing your own rehab and expectations can be dangerous for that reason. Everyone will progress at a different pace and hit various established rehab benchmark goals or criteria at different time points. Attaining these rehab benchmarks should dictate and guide progression of your rehab versus pre-determined “cookbook” timepoints based on time out from surgery. (Myer G et al. 2012)
While each person’s experience will be varied and different, there are some commonalities and frequent trends in observations I have seen in my 25+ years as a physical therapist to help prepare you for the rehabilitation process after surgery.
- ACLR rehab is humbling
There will be things you took for granted prior to your injury like the simple ability to raise your leg without assistance and walk normally. These seemingly simple tasks will now take exponentially more concerted focused effort in the early post-op period and will be surprisingly difficult. Restoring the range of motion and strength in your knee does not just inevitably improve with time, but rather results from consistent, relentless, and focused effort and a targeted plan.
- ACLR rehab is frustrating
It would be fantastic if each week of recovery during ACL rehab produced steady tangible results and linear improvement. Unfortunately, it rarely works that way. There will be weeks with significant milestones and appreciable progress, and there will be weeks where there is no progress that may prompt you to question whether your rehab is effective, if you are doing something wrong, or if all this effort is worth it.
- Early ACLR Rehab can be monotonous and a grind
Initial ACLR rehab can be monotonous and boring at times. You will perform many of the same repetitive proven exercises designed to address your loss of range of motion and strength. These exercises will be designed to target your biggest deficits and areas of need so it will often feel like a struggle. However, reaching early established rehab milestones like restoring full knee extension and mitigating quadriceps atrophy and muscle activation deficits will make the rest of rehab smoother and set you up for future success. (Cavanaugh JT 2017 and Noll S et al. 2015)
- Consistency is a key
Even on the days you feel like garbage or the weeks when you are not seeing significant progress, performing those monotonous exercises is key to restoring range of motion, strength, and normal movement mechanics. Attending physical therapy is beneficial to monitor your progress, revise and update a treatment plan to target your deficits, and provide you with necessary education. However, the majority of your post-operative success will be determined by the consistency and compliance with the work you put in with home exercises outside of your physical therapy appointments in clinic. (Khubzan WD 2025)
- There will be discomfort
There is an incision often in conjunction with an autograft harvested from another tissue in your body, and related swelling in the joint. As a result, there will be expected discomfort related to those changes in your joint. In the presence of a patellar or quadriceps tendon autograft or quadriceps weakness, there will be some related anterior knee discomfort. This level of discomfort will fluctuate, but the presence of pain does not necessarily mean that anything sinister or catastrophic is happening or that something went wrong with the surgery or happened to the ACL graft. In fact, the graft is strongest at day 0 when it is implanted and if you are following the provided post-op instruction and precautions, it is likely harder to damage that graft than you think it is. Additionally, when your ACL is reconstructed you are taking tissue for the new graft from an alternate location with different physical and structural properties than the original ligament, there is some expected discomfort. There will be discomfort related to the harvest site but also as the new graft tissue adapts to the new stresses. Using prescribed medications to control this pain can allow improved exercise compliance and effectiveness. (Secrist ES 2016)
- Psychological and mental health issues are NOT uncommon after ACL injury and likely underrecognized and underappreciated
ACL injuries are often traumatic experiences and resulting psychological or mental health issues may manifest differently in everyone. Some may experience significant fear of reinjury related to the initial injury mechanism. The related pain, stiffness, weakness, and concerns about the surgical construct may produce kinesiophobia (fear of movement) after injury and ACL reconstruction. Depression is increasingly recognized after ACL injury related to loss of identity as an athlete, social consequences related to removal from a team environment and competitions, and general uncertainty. Athletes should not be afraid to seek mental health services to optimize their rehab success to address some of these concerns that may impede rehab progress. (Conley CW 2023)
- At some point your confidence will be shaken
Sensations of lower extremity buckling or instability related to loss of neural control and quadriceps weakness are common after this surgery and may feed into some of the negative psychological concerns and uncertainty noted above. There will likely be altered sensations with certain movements that were previously pain-free or did not require focused effort prior to injury. There may be moments when the leg or specific muscles may shake uncontrollably during certain movements or tasks due to alterations in neural control. While this is not “normal”, this is often a related consequence of stressing the system to address specific impairments in an effort to promote normal function and balance in this system. Apprehension or discomfort following resumption of running or jumping are not unusual or uncommon and are not indicative of anything catastrophic. (Zheng X 2015)
- Some swelling is normal, but…………..
Swelling is a normal consequence of this surgery related to the inflammatory reaction with tissue healing stages and trauma. However, surges or spikes in swelling should be closely monitored because they are often indicative that you are overstressing the knee joint or healing tissues. Significant increases in swelling will have detrimental effects on symptoms, knee range of motion, nerve function and neural control of muscular activation, and proprioception or joint position sense. Swelling control with cryotherapy, elevation, and compression is a critical element of early rehab. (Kikuchi N 2024)
- Early Weight bearing after an ACL Rehab is beneficial and should NOT be scary or avoided
Early rehab after ACLR, without associated procedures like a meniscal repair or articular cartilage procedure that might prohibit weight bearing is beneficial. Early weight bearing may promote muscular activation and restore normal movement mechanics earlier than with a prolonged period of disuses or avoidance of weight bearing. Altered movement mechanics and compensatory movement strategies are common with walking, stairs, squatting, etc. following ACLR. The sooner you can restore normal movement mechanics the better. (Kaya S 2024)
- A locked brace has a protective effect early in rehabilitation when you may not have full neural control at the knee or requisite endurance and strength for a normal gait pattern.
However, a brace locked in extension also reinforces an abnormal gait pattern without the normal degree of flexion or bend at the knee. Once you demonstrate sufficient strength and control of the surgical limb following surgery, you should make every attempt to discharge the brace to foster normal movement strategies, coordination, timing of muscular activation, etc. required for normal gait.
Another consideration with a locked knee brace is that many patients have a degree of hyperextension motion in their knee prior to surgery. Prolonged brace use limits the degree of extension range of motion and does not allow you to access that motion while the brace is applied. The brace is useful with walking in the early stages and sleeping as noted above. However, while at rest in sitting or lying positions, it is more advantageous to remove the brace and move the knee frequently, including trying to access hyperextension motion. (Rijal N 2024)
- ACL injuries don’t cause only physical side effects but there are also neurological changes that result from tearing the ligament.
Some of these changes alter the nerve pathways from the brain to the knee joint. Your post-operative program should include elements of neurocognitive rehabilitation to help mitigate or influence these changes. (Grooms DR 2017)
- Strength training is an essential element of rehabilitation, however unless your goal is to become a body builder, solely restoring strength levels is not adequate to prepare you for return to sport.
There are many other qualities to train in the rehab process such as power, deceleration, stability, endurance, movement quality, on-field or on-court specific training, etc. The rehab process should be comprehensive and multi-faceted. A rehab program comprised only of strength training using machines found at your local gym is not adequate to fully prepare you for sport demands. (Unverzagt C 2021)
- Post-operative protocols offer general guidelines and timeframes, but they are NOT fixed absolutes and concrete
There are rehab benchmarks to meet before you will be cleared to run, jump, perform change of direction, return to sport, etc.. However, there are two sides to a bell curve. Unfortunately, not everyone will meet these benchmarks at the same time, and some will take longer than others. (Kotsifaki R 2025)
- Your rehab program should not look the same from one phase to the next
Your training program should vary to meet your specific impairments and deficits, and should NOT look the same from one phase to the next. The training resistance, volume with sets and reps scheme, speed, intensity, etc. should all vary to facilitate progression and improvement in certain physical qualities. If it does not vary and looks the same at 1 month as it does at 6 months post-op, then you are likely doing it wrong.
- As your physical capacity and qualities improve, it is critical to introduce some elements of sports-specific on-field or on-court training.
Sport competition is unpredictable and uncertain with some degree of randomness beyond your control. If you have only performed predictable comfortable rehab activities in a controlled gym or clinic environment, it is insufficient to prepare you for the chaotic nature of your sport-activity in the context of competition situations. There must be a progression of difficulty and intensity with sports-specific training to more closely replicate the chaotic nature of sports competition. (Taberner M 2025)
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