What to Do After ACL Surgery: Laying the Foundation for a Strong Recovery

ACL reconstruction is a common procedure for athletes and active individuals recovering from a torn anterior cruciate ligament. However, surgery is just the beginning—successful return to sport or activity depends heavily on a structured, progressive rehabilitation process.

Rehab after ACL surgery follows both time-based and criteria-based milestones. Time-based progressions are informed by the biology of healing, particularly the process of ligamentization—where the graft gradually transforms from tendon to ligament-like tissue. This process begins immediately after surgery but continues over several months and even years.

Criteria-based progressions, on the other hand, are groupings of physical tests that often align with time-based milestones but focus on ensuring that each patient meets specific benchmarks in range of motion, strength, and neuromuscular control before advancing to the next phase of rehab. This approach helps reduce the risk of re-injury and supports better long-term outcomes.

So when patients ask, “When will I be able to do X, Y, or Z?”, the answer isn’t simply a matter of time—it’s if and when. If you're not consistently meeting objective physical benchmarks—verified through in-depth testing—then it isn’t safe or appropriate to advance to more demanding phases of rehab.

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Early Phase Rehab (a.k.a. Damage Control)

The early phase of ACL reconstruction rehab—often referred to as the "damage control" phase—sets the tone for the entire recovery process. It typically spans the first 2–3 weeks after surgery and focuses on two primary goals:

• Restoring full knee extension

• Reactivating quadriceps function

These two objectives are critical. Full knee extension must be prioritized early because it becomes increasingly difficult to regain if lost, and limitations here can negatively affect gait, squatting mechanics, and long-term function. Equally important is restoring quad activation, which is commonly impaired due to arthrogenic muscle inhibition (a neural shutdown caused by swelling and trauma).

A frequent question in this phase is: “When can I stop using the immobilizer brace and crutches?” The answer depends largely on quad function and walking mechanics. After ACL reconstruction, the quadriceps are often significantly inhibited. Until the muscle can fire effectively—demonstrated by the ability to perform a high-quality straight leg raise without compensation—continuing to use the brace and crutches is strongly recommended. These assistive devices help protect the graft from instability due to sudden knee buckling.

Crutches also serve another purpose: ensuring a normal gait pattern. Walking with a stiff knee or limping due to pain or limited extension can lead to faulty movement patterns that are difficult to correct later. If you can’t walk with your knee fully straight or without compensating, you’re not ready to ditch the crutches yet.

This phase may seem simple, but it’s one of the most important in the entire rehab journey. If these foundational elements—full extension, quad control, and clean gait—aren’t addressed properly and consistently, it can lead to setbacks and compensations that delay later progress.

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Conclusion: Start Strong for a Better Recovery

The first few weeks after ACL surgery are crucial. Regaining full knee extension, reactivating the quad, and walking with proper mechanics lay the foundation for long-term success. Skipping these steps or progressing too quickly can lead to setbacks that delay your recovery.

Consistency, guided progression, and hitting key milestones—not just time—are what move you forward. Stay patient, stay committed, and lean on your physical therapist to guide the process.

If you’ve recently had ACL surgery, schedule your first visit with us to start rehab the right way. We’ll help you build a strong foundation for a full recovery.