ACL Recovery Timeline: What to Expect

Recovery Timeline by Phase

Phase 1: Immediate Post-Op (Weeks 0-2)

Primary Goals: Control pain and swelling, protect graft, restore extension

• Day 1-3: Hospital discharge, ice and elevation, pain management
• Weight bearing: Weight bearing as tolerated with crutches and brace
• Range of motion: 0° extension critical, flexion to 90°
• Exercises: Quad sets, ankle pumps, straight leg raises
• Milestones: Full passive extension, minimal effusion

Phase 2: Early Rehabilitation (Weeks 2-6)

Primary Goals: Restore full ROM, normalize gait, begin strengthening

• Week 2-4: Discontinue crutches when able to walk without limp
• Range of motion: Full extension, 120-130° flexion
• Exercises: Stationary bike, leg press, step-ups, balance training
• Restrictions: No pivoting, cutting, or jumping
• Milestones: Full ROM, independent ambulation, minimal swelling

Phase 3: Strengthening (Weeks 6-12)

Primary Goals: Progressive strengthening, proprioception, endurance

• Criteria to begin: Full ROM, minimal effusion, quad control
• Exercises: Squats, lunges, hamstring curls, single-leg exercises
• Cardio: Swimming, elliptical, bike progressing intensity
• Balance: Single-leg stance, perturbation training
• Milestones: Quad strength 70% of uninjured leg

Phase 4: Advanced Strengthening (Months 3-4)

Primary Goals: Build strength to 80-90%, introduce impact activities

• Running: Begin straight-line jogging if cleared
• Plyometrics: Double-leg jumping, box jumps (low height)
• Strength goals: Quad strength 80%, hamstring/quad ratio >0.6
• Testing: Isokinetic strength testing

Phase 5: Return to Sport Training (Months 4-9)

Primary Goals: Sport-specific skills, agility, confidence building

• Agility drills: Cutting, pivoting, change of direction
• Sport activities: Progressive return to sport-specific movements
• Functional tests: Hop tests (single, triple, crossover, timed)
• Requirements: Limb symmetry index >90% on all hop tests

Phase 6: Return to Competition (Months 9-12+)

Clearance criteria - must meet ALL:

• Time: Minimum 9 months post-op (12 months preferred)
• Strength: Quad strength ≥90% of uninjured side
• Hop tests: Limb symmetry ≥90% on all four tests
• Psychological: ACL-RSI score indicating readiness
• Clearance: Surgeon and physical therapist approval

Critical Milestones

• Week 1: Achieve full passive extension
• Week 2: Walk without crutches and limp
• Week 6: Full range of motion equal to uninjured knee
• Month 3: Begin running program
• Month 6: Start cutting and agility drills
• Month 9-12: Return to competitive sports if criteria met

Clinical Pearl: Achieving full extension early (week 1-2) is the single most important factor in successful outcomes.

Potential Complications

Extension Loss (Arthrofibrosis)

• Risk factors: Delayed surgery, inadequate early ROM work
• Prevention: Aggressive extension exercises from day 1
• Treatment: May require manipulation under anesthesia if severe

Quadriceps Weakness

• Common issue: Quad activation dysfunction post-op
• Impact: Delayed recovery, altered gait mechanics
• Treatment: Neuromuscular electrical stimulation, biofeedback

Graft Failure

• Risk: 2-5% with proper rehabilitation timing
• Risk factors: Premature return to sport, inadequate strength
• Prevention: Meet all objective criteria before return

Maximizing Recovery Success

• Attend all PT sessions: Consistency critical for optimal outcomes
• Complete home exercises: Daily exercises accelerate recovery
• Respect timelines: Healing can't be rushed - patience essential
• Communicate openly: Report setbacks or unusual symptoms immediately
• Focus on extension: Priority in first 2 weeks prevents complications
• Don't rush return: Meeting objective criteria more important than time
• Consider neuromuscular training: Reduces second ACL tear risk by 50%