ACL reconstruction recovery, week by week

Rehabilitation after ACL surgery depends on the graft your surgeon used (hamstring tendon, patellar tendon or another), and on whether the meniscus was repaired at the same time. A meniscus repair usually means limits on bending the knee and on weight bearing for the first few weeks. Ask your surgeon for these limits in writing and share them with your physiotherapist.

The timelines below are typical for an ACL reconstruction without a meniscus repair. Recovery is judged by tests, not by the calendar. Moving to the next stage early because a date has passed is one of the most common reasons people get hurt again.

The goals are to get the knee fully straight, control the swelling and wake the thigh muscle up. Full straightening matters most. A knee that does not fully straighten in the first weeks can stay bent for good, and that causes a limp and pain at the front of the knee.

Most people walk with two crutches and put as much weight through the leg as is comfortable, unless the surgeon has said otherwise. Ice, elevation and a compression bandage help the swelling. Aim to bend the knee to about 90 degrees by the end of week 2.

Typical exercises: ankle pumps for circulation, thigh tightening with the knee straight, straight leg raises once you can lift without the knee sagging, and heel slides to recover bending. Lie with a rolled towel under the heel (not under the knee) for a few minutes several times a day to help the knee straighten.

Most people come off crutches between weeks 2 and 4, once they can walk without a limp. Coming off them early and limping teaches a bad habit that is hard to undo.

Bending should reach 120 degrees or more by week 6. Strength work moves from lying down to standing: bridges, mini squats to a comfortable depth, sit to stand, heel raises and balance on the operated leg. A stationary bike is useful once the knee bends enough to pedal a full circle.

Avoid seated knee extension with a weight on the ankle in this phase unless your physiotherapist has prescribed it in a protected range, as it strains the new graft.

The graft is at its weakest around this time while it remodels, even though the knee often feels good. This is a phase for steady strength work, not for testing the knee with twisting, jumping or sport.

Exercises progress to step-ups, deeper squats, lunges, single leg work and resistance bands. Balance work becomes harder, for example standing on one leg on a cushion or with eyes closed. Walking for exercise and cycling are usually fine.

Return to desk work is often possible from week 2 to 4. Driving a car is usually possible by week 4 to 6 if it was your left knee and the car is automatic, and around week 6 for a right knee, once you can brake hard without hesitation. Riding a two-wheeler needs good balance and the ability to put a foot down quickly and firmly. Check with your surgeon, and wait until you can stand on the operated leg confidently.

Jogging usually starts somewhere between month 3 and 4, once the knee has no swelling, has full movement, and the thigh on the operated side is at least 70 to 80 percent as strong as the other side. A physiotherapist can test this.

After jogging comes straight line running, then jumping and landing practice, then changes of direction. Landing with the knee falling inwards is a major risk for a new ACL injury, so your physiotherapist will coach how you land.

Most people return to sports that involve twisting and sudden stops, such as football, kabaddi, badminton, basketball and cricket fielding, between 9 and 12 months after surgery. Research following athletes after ACL reconstruction found that returning before 9 months carried a much higher risk of injuring the knee again.

Return should depend on passing tests, not on the date. Typical criteria are thigh and hamstring strength at least 90 percent of the other leg, similar results on single leg hop tests, no swelling after hard training, and feeling confident in the knee. Many people in India are never tested and simply start playing again when the knee feels fine. That is when second injuries happen, to the same knee or the other one.

Sport specific practice comes first: bowling run-ups, batting footwork, badminton lunges or football drills, at training intensity, before match play.

Squatting toilets: use a Western toilet or a commode chair for the first 6 to 8 weeks. Deep squatting usually becomes comfortable between month 3 and 5, and sooner without a meniscus repair.

Sitting cross-legged on the floor: usually possible from month 3 to 4. Start on a cushion and do not force it.

Stairs: one step at a time for the first few weeks, leading with the good leg going up and the operated leg going down.

Office and college: most people return to desk work or classes in 2 to 4 weeks. Travelling in crowded buses or trains needs care while you are still on crutches.