ACL Reconstruction Rehabilitation

6 Keys to the Early Phases of Rehabilitation Following ACL Reconstruction Surgery

Rehabilitation following ACL reconstruction surgery has evolved significantly over the last 25 years.  We have progressed from casting the knee to allowing immediate motion and weight bearing in just a short amount of time.  As our understanding of rehabilitation concepts continue to evolve, our focus has shifted towards functional exercise and rehabilitation progressions, which is integral to maximize results following ACL reconstruction surgery.

We are now seeing professional athletes absolutely dominate their postoperative rehabilitation.  Adrian Peterson is now going to be the poster-boy for return to sports after ACL surgery after tearing up the league and winning NFL MVP just months after having ACL reconstruction surgery.  While, AP is definitely the exception, not the rule, the postoperative rehabilitation is a huge factor in determining how well people recover from surgery.

While everyone wants to talk about advanced exercises and return to sport, it is probably infinitely more important to assure that the early phases of rehabilitation go well to avoid complications and allow more advanced drills down the road.  If the early phases of ACL rehab go poorly, you will surely be behind for the duration of your rehab.

On that note, I wanted to discuss the 6 keys to the early phases of rehabilitation following ACL reconstruction surgery.  Master these basics and the advanced phases get easy.

Diminish Pain and Inflammation

early rehabilitation following acl reconstruction surgeryThe first key to ACL Rehabilitation is simple, diminish the pain and inflammation associated with the surgery.  While this is a no-brainer, it is worth reviewing why this is so important.  Really, the following list of keys to ACL rehabilitation are all going to be difficult to achieve without addressing the pain and swelling.  Here are just handful of important things to consider:

  • Pain and swelling has been shown in numerous studies to essentially shut down your muscles around your knee, specifically your quadriceps.  Even a small amount of fluid in the joint has been shown to decrease your ability to contract your quad.
  • Without a quad, it is hard to function, and you tend to walk around with a bent and stiff knee.
  • Pain and swelling will limit your range of motion progression.

So, as simple as this concept may be, diminishing pain and inflammation should be an area of focus initially after surgery.  Compression wraps, ice, intermittent compression machines, elevation, ankle pumps, electrical stimulation, and not pushing through too much activity can all help.

My biggest advice to patients after surgery is that you can’t ice too much.

Restore Full Knee Extension Motion

Loss of knee extensionRestoring full knee extension range of motion could be the #1 key to rehabilitation following ACL reconstruction surgery, however I chose to list it second here because addressing pain and swelling has implications for everything discussed in this article.  Really, though, my focus is almost always directed towards restoring full knee extension as soon as possible.  One of the more common complications following ACL surgery is loss of motion, with loss of extension being more troublesome than flexion.

When pain and swelling is present, it is just more comfortable to hold your knee in a slightly bent position.  Keep it this way too long and you run the risk of developing scar tissue, or arthrofibrosis.  Restoring knee extension immediately after surgery is so important, because once it gets tight, it’s often hard to get your motion back.  I’d much rather focus on this initially and slowly restore motion than get too tight and then have to aggressively attempt to improve motion.  That is never preferred.

Loss of full knee extension does not allow the knee to function properly, even if just a small loss of motion.  Plus, studies have shown loss of motion to be one of the most important factors associated with the development of arthritis after ACL surgery.

Luckily, with proper rehabilitation, loss of motion can be avoided.

In addition to my range of motion, soft tissue mobilization, and manual therapy techniques, I always instruct patients to perform a lot of range of motion and stretching exercises at home, essentially once an hour.  I like to show them hamstring stretches and calf towel stretches.  I don’t perform these stretches to really enhance hamstring and calf flexibility.  I perform them and instruct the patient to also work on knee extension at the same time.  So the focus is essentially knee extension.

Knee Extension Stretch ACL Reconstruction

Towel Knee Extension Stretch ACL Surgery

If loss of motion starts to become a problem, I don’t hesitate to start to introduce low-load long-duration stretching.  My goal is full knee extension by 1 week after surgery.  Biomechanical studies have shown that the stress of the ACL graft when stretching into extension is below the forces seen during common functional activities, so there is no need to avoid this motion.

This is such an important concept, that you may want to review my past article dedicated to restoring knee extension range of motion.

Gradually Progress Knee Flexion Motion

Knee Flexion Range of Motion ACL RehabilitationAlthough loss of knee flexion doesn’t tend to be as common as knee extension, it does happen and you don’t want to neglect working on flexion.  There is often a see saw between flexion and extension.  The more you work on one, the more you tend to get stiff in the other direction.  This is reduced by working on frequent bouts of gentle but progressive range of motion.

I also like to empower the patient to also work on restoring knee flexion, both by stretching as well as through functional motions like mini-squats and eventually lunges.  When the patient can control their range of motion progression, their perceived threat is reduced and motion often comes back easier.

Knee flexion is restored more gradually, with about 90 degrees achieved at 1 week and full knee flexion gradually advanced and achieved by week 4-6.

Maintain Patellar Mobility

Patellar Mobilization ACL RehabSometimes one of the reasons that range of motion is reduced is because patellar mobility is lost.  Full patella mobility is required for knee flexion and extension.  As the knee is painful, swollen, and difficult to move, scar tissue can form and limit patella mobility.  This is especially true if a patellar tendon graft is used for the ACL reconstruction surgery.  If patellar mobility is neglected, the chances of loosing range of motion goes up significantly.

Soft tissue mobilization around the knee and patellar mobilization is performed immediately after surgery.  I also like to instruct patients on how to do this themselves and add it to their homework.

Restore Volitional Quad Control

NMES quad ACLAs previously mentioned, there is a reflexive inhibition of muscle control around the knee after surgery due to the pain, inflammation, and swelling.  In addition to address these factors, there are techniques that can be performed to help restore volitional control of the quadriceps muscle.

Lynn Snyder-Mackler, at the University of Delaware, has produced dozens of articles on the use of neuromuscular electrical stimulation (NMES) on the quad follow ACL surgery.  Essentially, NMES helps restore quad strength and function faster that just exercises without NMES.

Naturally NMES becomes an important component of the early phases of ACL rehabilitation.  I will superimpose most early quad exercises that we perform with NMES.  This includes quad sets, straight leg raises, and knee extension exercises.

An added benefit of all these quadriceps contractions is that this also helps restore knee extension range of motion.

Restore Independent Ambulation

Retrowalking ACL Rehabilitation

Now that we have addressed the pain and swelling, started to restore motion and patellar mobility, and can now turn on the quads, we put it all together to work on being able to walk without limitations or a limp.  If any of the previously mentioned areas of focus have not been addressed, independent ambulation is often going to be difficult, or at least impaired.

I usually have people weight bearing as tolerated around week 1, unless other structures were damaged or need to be protected.  We may continue to use the crutches for up to two weeks, however, I still want them to be able to walk and just use the crutches as assistance, rather than, well, a crutch…

I have found weight bearing exercises like weight shifts that focus on transferring your weight and locking out your knee can be helpful initially.  I also tend to use cone walking drills to help groove the pattern of shifting weight and transitioning to single leg stance.  I have also found backward walking while stepping over a cone to be helpful to rock the body back over the foot and assist with achieving knee extension.

Learn Exactly How We Evaluate and Treat the Knee

Those are my 6 keys to the early phases of rehabilitation following ACL reconstruction surgery.  I try to focus on each one of those keys during each session I have with a patient.  These 6 keys are so important, that I would rather increase my visits early in the rehab process to assure that these are all addressed, then try to conserve visits (per our insurance limitations).

Really, this is just the tip of the iceberg.

online knee seminarIn our online course at we discuss the many pathologies of the knee, including ACL reconstruction. We outline a progressive program that starts preoperative and goes until the athlete is ready to return to their sport.  If you are interested in learning are full approach, our course has a lot to offer. You’ll learning exactly how we evaluate and treat the knee and become an expert at knee rehabilitation.

106 replies
  1. Caz
    Caz says:

    Hi I had ACL reconstruction 2 days ago! I got up the day after felt good so did my rehab exercises, then everything swelled!! So not done anything more than quad engagements and ankle pumps since and icing and elevating… Worried I am not doing the exercises enough but think I should concentrate on getting swelling down.
    Any advice??

  2. Jonathan Kantey
    Jonathan Kantey says:

    Hi Mike,
    I’m having my 3rd ACL in the space of 10 years and this time I’m having meniscal repairs simultaneously. Can I start with mobility exercises immediately after the procedure or will that endanger or compromise the meniscal repairs?

  3. Shyam Sunder
    Shyam Sunder says:

    last year my left leg acl reconstraction done, but still is problem to walk, cant walk smoothly, i cant bare all my weight at my left leg

  4. Mansi
    Mansi says:

    Hi Mike,
    My doc asked me to start the rehab exercises after more than two weeks that is after the removal of leg was in brace bandagebfor almost 2 + weeks .I am worried now as the knee area is stiff and I can’t do flexion of my knee…have I delayed my recovery .please advice.

    • nikhil arora
      nikhil arora says:

      hi mansi,its been 2 weeks since my acl surgery…i am facing the same problem of flexion…i ve reached about 90 degrees…cant extend beyond that…my surgeon has asked me to wear the brace for about one more month…i would like to know your progress,,,and if u could give some advice to increase the range of motion and discuss your experience

      • Mansi
        Mansi says:

        Hi Nikhil,
        I am walking with a limp and piercing pain ,after 6 weeks of my ACL surgery. But once I started with my PT exercises gularly for around two weeks I have been able to reach flexion upto 120+ degrees.

        However my leg shows light negligible bent when fully extended.And the inflammation is yet around my knee. These are the issues bothering me.

        To make the problem worse,I slipped at my work place today. Suffered a terrible jerk at the injury which balancing myself. Now I have excruciating pain around my knee ,mainly on the patella.l just praying nothing serious has happened .
        Hope you get well soon .

        • Shyam Sunder
          Shyam Sunder says:

          HI Both
          last year my left leg acl reconstraction done, but still is problem to walk, cant walk smoothly

  5. Jen
    Jen says:

    A week ago Friday I had my ACL fully reconstructed using a cadaver tendon. I had Pre-Op therapy because I wanted to be in the best shape going into it. I followed post op instructions to the letter and did the PT excerises immediately. I was off pain meds by day 3 and off crutches by day 3, I can bend my knee past 90 degrees and walk on it (a slight limp) all within the first week. I went for PT On Friday and they were freaked out saying it was I was going too fast, not to bend my knee past 90 degrees and very baffled I’m walking, can almost have my leg fully extended & flat. I’m not trying to over do it or be zealous but merely followed instructions. Everyone is shocked how well I’m doing- I’m getting concerned maybe the graph didn’t take? Why is this not so crazy bad? I see my Doc Tuesday. I must be doing something wrong or the surgery didn’t work?

    • Denita Davis McKnight
      Denita Davis McKnight says:

      Hello Jen wondering how you are making out? I myself had ACL surgery on May 4th 2016, I have full leg extension even hyper extension. I have been told by the surgeon to move slowly, I can get by with one crutch no problem and want to continue the recovery. Looks as though you are progressing great has the physio and or surgeon instructed you to slow done?

      • happygirl
        happygirl says:

        ACL reconstructions can result it too much tension or be too loose. It can depend on how good a job the surgeon did. Were you able to hyper extend your knee before the injury?

      • Simon
        Simon says:

        Denita – how are you 3 months down the line? I have hyperextention back (I had it before) and can flex beyond 90 all in the first 4 days. Mine is a revision. 1st time I had a patella graft, this time I had a cadoveric/allo. Last time I had to work very hard at straightening and flexing, but this time it’s happened so quickly. Do you know if this is good or bad?

  6. Mandy
    Mandy says:

    Hi I broke my patella feb this year had surgery been wired up but am still finding it hard to bend my knee only got 95 bend al so getting a lot of pulling below the knee and al so pulling behind my knee please can any one help me to stop this thanks x

    • Mansi
      Mansi says:

      Hi Mandy and Mike,

      Mandy ,I can understand what you are going through. I empathize with you as
      I had ACL surgery on the 9 th of May and I have started walking with a slight limp since a week now.
      I experience terrible pain around the incision area below the knee.
      I dint know why I yet experience this pain even after 5 -6 weeks post op.

      Unfortunately, today I slipped at my work place and had a terrible jerk on my knee. I am experienced excruciating pain on my patella and at either sides of the patella.
      I just hope I have not damaged the reconstructed ligament or anything around it.

      Dear Mike
      Please advise if I should take PT exercises during such pain described above.

      • Avinash
        Avinash says:

        Hi Mansi.
        You should avoid going to office/work first of all.
        Second thing do every exercise till it starts paining. Or do the exercises that give you less pain. The jerk pain will be gone in 3-4 day. But you should not stop doing exercises. try to achieve 90 degree flexion. In a week or two you’ll be able to walk. Wear the brace whenever you’re walking and when you sleep. Eat painkillers. And if the pain is still there then contact your doctor ASAP!
        Even I had a jerk 3 days after my surgery. But eventually the pain went away.
        I hope all this helps you. :)


        • Vishal
          Vishal says:

          Hi guys, I am 6 weeks post op. Interested to know how you guys doing after 8-9 months now. are you cleared to return to all activities like sports etc now?

  7. Sasha Cohen
    Sasha Cohen says:

    Great article! I recently had the misfortune of having to under a pretty intense knee Surgery. I had to undergo some reconstructive surgery in order to correct a severe trauma. The whole process leading up to the surgery was traumatic for obvious reasons. I don’t want to go into too much detail but during my surgery, my team used a FAW blanket called the Bair Hugger and it helped so much with my post surgical recovery. I credit my super quick recovery to the blanket. I was able to get back to hiking in no time. Here are some facts about the system

  8. Nika
    Nika says:

    I found this to be very helpful. I had Acl surgery on Jan 14 it’s been almost2 months and i can’t fully bend my knee to 120, I’m at115. My hamstring muscles really hurts and prolongs my bending. Can you help?

    • Gagan
      Gagan says:

      Hi nikq I hav also the same problem with don’t have full knee extension … If u can contact me pls contact me on +91 8502929447

    • Sumeet Kumar
      Sumeet Kumar says:

      Hi Nika.. I had my ACL surgery on Jan 14 this year.. I am 2 months out now and I am stuck at 115 degrees too. Beyond that looks impossible to me now.. Wanted to know how are you doing now? I guess the reason why I am stuck is because I exercise only once a day.. But this is getting very frustrating.. Please advise..

  9. Louis
    Louis says:

    Hi, I had acl surgery 9 months ago and I am now back playing football. I am experiencinf swelling and stiffness in my knee. Is this normal.

  10. Madi
    Madi says:

    Great article! All of these things happened to me after my surgery and I was so scared at the time that what I was going through was abnormal. Wish I’d seen this last year!

  11. Brian
    Brian says:

    Hi Mike,
    Excellent article. What is your ideal crutch/brace management initially after surgery if the MD does not give specific instructions? Thanks.

    • Mike Reinold
      Mike Reinold says:

      Dependent on many factors, such as meniscus involvement, bone bruise, graft source, age, amount of swelling, etc. My typical ACL is off by 2 weeks but must be gradual and controlled. I would feel better if a medical professional helped advise you on this to assure it’s in your best interest.

  12. nakisha
    nakisha says:

    Hello mike.
    I had acl reconstructive surgery on 9/3. I aspirated during surgery so I was behind in therapy because I was hospitalized.
    I have not started therapy but I have been stretching and bearing some weight on my leg. I do have swelling but not a lot of pain. I am starting therapy this week but do u have any suggestions for me to get on the move and back to walking. I try to bend my knee but it feels weird and I don’t wanna mess anything up

  13. Alexis
    Alexis says:

    I had a tear in my meniscus and a cadaver acl put in 8 weeks ago. This past week my knee has become very stiff and hurts to walk. My knee seems swollen and warm to touch. Also my ankle swells up almost daily. Is this normal or should I worry?

  14. Tom
    Tom says:

    I played at quite a good standard of football before rupturing my acl 7 years ago… 3 operations later it still isn’t right and now the doctor has told me the cartilage between my femur and tibia is so fine that if I participate in any physical activity I will eventually end up with athuritus in my knee joint… Is there anything I can do???

  15. Loren
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  16. Mick
    Mick says:

    Hi, everyone, 6 months ago I had surgery on my left knee, acl full thickness tear and meniscal tear. They took a graft from my hamstring…pretty much had to learn to walk all over again, 8 months later I’ve Toally lost the teardrop mussel in my leg. It still hasn’t come I’m at the stage of doing a intense gym program to try and retrieve that mussel.

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  18. Spenser
    Spenser says:

    I have torn both ACLs, I’m currently about 2 weeks out of the second one. With the first and second one the orthopedic center I had received both surgerys from they have put me in an Immobilizer brace, each times they have not bent my knee to the fullest in the early stages at all.. With the first one it took me about 2 months to reach full range of motion (give or take a few weeks) and I was back freeskiing within 4 months post-op. That being said I don’t agree with the article, what are the benefits to this approach?

  19. Erin
    Erin says:

    Hello! I would love to follow a more aggressive rehab protocol such as this, and I wonder if it’s possible given the nature of my reconstruction – ACL & PLC using hamstring grafts from both legs and meniscus repair… a rather bad tear from what I understand. I’ve been told NO weight bearing for 2-4 weeks, no Physio until the staples are out, zimmer splint for 2 weeks and then I need to get a custom one that bends at the knee.

    Is this common protocol, because it feels very conservative to me? I should also mention I have hyperextension syndrome if that makes any difference.

    Thanks in advance!

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  21. Nadia
    Nadia says:

    Thank you for a great article. I’m 3 days out of ACL surgery & near to 100% full extension. My flexion is ok but I’m get that back little by little everyday until my physio. I cannot stress enough how right mike is about icing. I’ve done it for every hour on most of my lower leg at the same time as putting my foot on a towel & letting the knee slightly hang as was told this is a good way to get back extension. It hurts but only from surgery nothing excruciating. I also agree with mike about pre surgery regime. I’m a “action actress” & I dance, do martial arts & gym it! I was doing gym 3 times a week plus physio at Isokentic twice a week & they were saying nothing is more important than strengthening up the leg & almost making it feel like u don’t need surgery. Boy were they right. I’m walking ok crutches quite well considering I’ve had surgery. You have to put the time in & after get the swelling down. As I’m icing I’m also pumping my ankle to get the blood pumping.
    It’s easy to get down after the op but just keep being positive & ice is your friend! Thanks mike!

  22. DDS
    DDS says:

    I had knee surgery Dec 20 to remove – believe it or not- cement left in by a previous doctor in surgery in October. I had been in horrible pain and my knee was swelling all the time. Now I am in PT. It hurts a lot for like 2 days after PT- is this right? Also, now I apparently have bad arthritis in that knee and it hurts all the time- esp when walking. Can surgery (multiple knee surgeries, foreign bodies in knee) cause or exacerbate arthritis?

  23. Kay
    Kay says:

    Hello. Before I ask my question, here’s my history. I had an unusual scenario. At age 38, I tore my meniscus (which was a bucket handle tear) and tore my ACL at the same time, while skiing almost a year ago (mid April ’13). There was a 4 week delay between my accident and my last surgery. To start, it took me a week to be seen, after not being able to walk b/c my knee was locked and b/c (although unknown at the time) I had no ACL. Apparently, my MRI didn’t show my ACL was severed and I guess my doctor didn’t have a good ACL available, and after seeing inside my knee, he realized that he could ‘repair’ my meniscus, which I guess is rare (less than 5% chance) b/c the tear was on the bloodline – and even more rare that someone my age and weight (ie I’m on the heavier side) and almost 40, would have a healthy enough knee, that he would risk a repair. So, we schedule my 2nd surgery – 2 weeks later, b/c my husband/caretaker would be out of town the week before. I woke up from the 2nd surgery in the worst pain I ever thought possible. My outpatient surgery (16 hour release) turned into a 3 day stay hospital stay and another 4 days of agonizing exhausting pain at home. Oxycontin didn’t touch the pain. Day 7 I stopped taking all pain pills (accept ibuprofen), went through a severe 24 hour drug withdrawal, with terrible anxiety, for the following 3 days — note I’ve never been addicted to anything and rarely even drink. Day 10 saw my physical therapist, twice a week for 3 months and continued for 3 more months, once a week. B/c of the meniscus repair, I was kept in a brace, which allowed for slow extension increases every week. At home and at physical therapy, I had to force my leg to bend and it was a VERY painful process the first 2-3 weeks! Once I got to 90 degrees it got easier and I’m now at 120 or so. I workout 3-5 days a week, with the goal of 5 – doing strength training and water aerobics. However, I’m concerned that although I don’t feel any knee pain while walking unless it’s a lot, my knee does get stiff and hurts to bend and straighten it. I also still feel uncertain using stairs, confidently. I hold onto the rail like I’m 80. I know every patient and scenario (especially mine) is different, but what is the likelihood, this pain and stiffness will continue? And was the delay between my accident and surgeries have any bearing on anything, my pain, my recovery, and/or my continued stiffness?

  24. K Smejko
    K Smejko says:

    Hi Mike,

    Great article, wish I had seen this 6 months ago when I had my ACL op. I’ve spent a lot of money on physio and I still don’t have 100% flexion.

    Due to this I have been told I shouldn’t road run yet but to do 15 mins running on the treadmill. It sounds like I am miles behind where I should be – any suggestions?


  25. Viijay
    Viijay says:

    Hi Mike,

    I undergone ACL reconstruction surgery on 5th Nov 2012. After 6-8 months of continuous cycling, I got good muscles around my knee.However once I stopped doing that I have lost all the muscles and my operated leg has also become very thin.

    Further more I have developed varicose veins in my left leg and they are more prominent in the below knee part of operated leg.I have visited couple of doctors but they have different views over it, some says that I should not do any exercise which puts strain on lower body as it will increase varicose veins problems and some doctors are advising me to undergo another surgery for varicose veins.

    I am totally confused now about what I should do now, whether I should start doing exercise to strengthen my operated leg muscles or should undergo varicose veins surgery first.

    Please suggest something.

    Thanks in Advance!!

      • Vijay Kaushal
        Vijay Kaushal says:

        Hi Mike,

        First of all, I would like to thank you for taking some of your valuable time out and going through my query. A big thanks for that. :)

        Regarding your question, I am not too sure about what should be more important for me, as I have very little knowledge of varicose veins, the only knowledge that I have about varicose veins is the one that I have acquired through Google or from the doctors whom I have consulted till date, and I have got mixed replies, some doctors say that varicose veins are not that dangerous and I can continue exercises except those which puts strain on lower body, while some doctors are suggesting me to undergo surgery for varicose veins.

        And frankly speaking I am sorry to say that ,I have stopped believing in doctors here in India, because in our country most of the doctors are money oriented and doesn’t give proper advice, all they want is money.

        So I am quite confused and frustrated about what should I do.

        Are varicose veins really harmful or are they only cosmetic flaws??

        Please suggest something, I desperately want to be fit and healthy again.

        Thanks in Advance!!!


  26. Kris
    Kris says:

    Hey Mike, I have just done my ACL surgery on 28/2/2014, and I am 3 days post-op.

    My knee is doing extremely well, with little swelling and pain. I can achieve about 90-100 flexion and almost full extension now without pain. Is it normal? Or is something wrong because the progress appears too fast compared to others?

    Thank you!

  27. cindy
    cindy says:

    Mike, my son is 9 wks post acl repair. Was doing extremely well. Last week Pt notice his one quad muscle interior was not building up the exterior is fine. She recommend some exercise. The one ex that I was worried about was a lunge with the knee out to the side, rather than the knee straight over the foot. Yesterday he went to step out of a bus and he said the knee popped out. And today just walking down stairs with out a brace on he said it feels just like it did before surgery, he see his dr on thurs. I am very worried he has over done something and the surgery is no longer holding, Do u have any suggestions? Cindy

  28. shereen
    shereen says:

    hi, i just briefly browsed through this article and im worried now. i had acl reconstruction on 31st dec 2013. its over 45 days now but i am still experiencing pain in my knee. from yesterday my ankles have also started swelling up. i dont know technical terms but i cannot fully bend my knee backwards as in heel to butt. i also cannot squat fully. and the part below my knee..the shin…it is swollen with some kind of hard swelling and very less sensation. i can only feel pain there if i press very hard. i am in a place with no access to doctors or physiotherapy. i am also overweight. i walk with a slight limp but otherwise have no difficulties. am i in trouble? do i need to consult a doctor immediately? or is this all normal. is there anyway to self rehabilitate without the help of a physiotherapist?

  29. Hani
    Hani says:

    Hi Mike,
    Thanks for the useful information.
    I did my acl reconstruction surgery about 3 months ago (19th of Nov 2013). My ROM before the surgery was about 120 degrees flexion and with hyperextension. I told my surgeon about it and he said Ok to perform the surgery with limited ROM. Now, after 10 weeks of intensive rehab i can achieve about couple of degree of hyperextension and around 130 degrees with assistance. However, these flexion degrees tend to go away after the PT. The worse time is when i wake up. My flexion in the morning around 100-110 but as i start moving around, it starts to improve. Is there any chance i could improve my flexion ROM or i will live with this for the rest of my life?

  30. Nancy
    Nancy says:

    I’m a victim of runner’s knee, worst injury ever!! I like your tips & advice for recovery. In my experience the epsom salt bath worked sometimes, but sometimes it triggered pain too. Mine was really wacky, kept me off running for 4 months. I can’t stand runner’s knee. I hate that every time I run it’s always in the back of my mind that it can flare up again. I’m sorry to hear it lasted so long. It’s the worst!

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  32. Dawn Loyd
    Dawn Loyd says:

    My son had ACL surgery 09-21-12,and they released my son (Seth) back to reg. activity 5/2013. He plays Baseball, football, and basketball. We are not sure what exercises he needs to be doing to build the muscle around his knees. I have been told he is to never do squats with weights or lunges. Is there any way you could let us know what we need to be doing?? Please we need help on this. It has been a year and 3 months since surgery.

    PLEASE HELP!!! He is a major athlete and is has scouts watching him.

  33. Bill
    Bill says:

    I have a player who is 17yrs old on my fastpitch softball team who had ACL reconstructive surgery on the 26th of December. Her doctor tells her they aren’t really doing physical therapy after acl surgeries anymore?? I went through the same surgery 16 years ago and physical therapy seemed to be the most important part….what does she do?

  34. abhishek
    abhishek says:

    Hi mike,

    I just had acl surgery 2 weeks back.I have been getting around on 1 crutch for the past few days.I have full extension and pretty good flexion.Today after pushing the heel slides a bit too much, I feel little unstable while walking and hurts the back of the knee a bit.I am just paranoid about having done damage to the graft.Any ideas?

  35. Pavithra
    Pavithra says:

    Hi Mike,

    I had my Acl reconstruction surgery using hamstring graft on Oct 17 th 2013(4 weeks back).
    I have full extension (0 degree). When will I be able to get full flexion ( leg touching the butt)? Also how to get minus degree extensions?

    My flexion is a lil over palm size more to touch the butt.

    The swelling has gone down considerably but there is still slight swelling around knee and on thigh around knee. Is it normal and will gradually reduce or should I concentrate on reducing it more? I am taking 1 Advil every night for anti- inflammation.

    I hstarted walking without crutches after 2.5 weeks and occasionally don’t wear brace around house.

    Also I go out for walking. Is it safe to walk for long time say an hour at a stretch?

  36. Vonny, ottawa, canada
    Vonny, ottawa, canada says:

    Hi Mike,

    I stumbled across your site about 3 weeks ago. Had ACL surgery on Wed Nov 6th, 5 days ago, have followed your 6 rules to a tee, already have full extension, about 95 flexion, using crutches more out of fear, but I actually can weight bea, albeit tentatively, am icing it constantly, especially through the night the first 3 nights. My first physio appointment is next Wed, but Ive been doing all your recommended exercises at home. THANK YOU for all the info. I am committed to a full recovery and to get back to playing tennis, squash and skiing…….and I am 57.

  37. fhdesai
    fhdesai says:

    Hi Mike,

    I had my right knee synovectomy arthroscopy surgery on 10th july, 2013. I still have swelling above knee cap area and it varies with exercises and it cause little pain when touched.

    I am doing PT exercises except squats taught by my Physiotherapist. I am also doing cycling on stationary cycle for around 3 minutes at present.

    Is it normal to have swelling after 2 and half month of synovectomy?

    What should i include/avoid in my activity to get rid of swelling?

    Thanks and Regards

    • Mike Reinold
      Mike Reinold says:

      Kate, depends on a lot of things based on you, your injury, and your surgery! Sorry! Swimming with a straight knee in a pool isn’t too aggressive. Check with your surgeon.

  38. Mikee
    Mikee says:

    ACL’s are done much differently than when I had my done 30 years ago. I have the 8″ incesion down the front of the knee. I was in a plaster cast from the upper thigh to my toes for 3 weeks. No rehab at that point. The next 8 weeks I was in a split cast with hinges at the knee. That was first time I was able to start moving the knee joint and start to gain mobility. Stretching was somewhat painful but necessary. I had to promise my surgeon prior to surgery that I would commit to rehab. A torn ACL is not life threatening. After the hinged cast was off, I went to phyical therapy. He measured the motion of the knee and my leg strength; he was inpressed. He released me within two weeks as I was way ahead of where I should have been. While at physical therapy, I did notice a girl who also went thru a ACL repair. Her range of motion was very limited; I felt bad for her. Either she babied the knee or had an inferior surgeon. After 9 months I was 90% ‘normal’. I did tape up the knee and wear a brace when playing sports; just didn’t want to re-injur the knee. A couple of years later I did away with taping and the brace. I continued to play baseball and eventually had a successful boxing career. While my knee is good, I still will not put it in a position where it is vunerable. One surgey is enough. Bottom line is you got to commit to rehab.

  39. LJ
    LJ says:

    My husband had ACL reconstruction (hamstring graft) combined with some of his meniscus removed 3 weeks ago. He is still in some pain and also has quite a lot of swelling around his kneecap area (despite frequent icing) which is preventing him from obtaining full extension. How soon should the swelling be reduced and will him not having full extension at this stage have consequences for the future?

    • Mike Reinold
      Mike Reinold says:

      Swelling needs to get out ASAP. If he is trying to control swelling with ice, compression, elevation, etc and it is not improving he may be too active. But it is hard to feel good and achieve your other goals with swelling present.

  40. Meredith Harris
    Meredith Harris says:

    My son has had a full ACL Reconstruction five days ago as well as a miscus tear fixed in the same knee. He does not cope well with anesthetic and is still unwell. He is still in quite a lot of pain every time he gets up it is painful and even when he moves in his bed. Is this normal to be in so much pain? He is doing some excercises like moving his toes and trying to move his ankle still very swollen and is unable to move his knee is this normal?

  41. Jami
    Jami says:

    Hello, Mike~
    I am an almost 44 year old female. I had ACL reconstruction on July 17th (5 weeks ago). My physician used a cadaver graft. I have full range of motion, as well as a full knee extension. I gave up crutches at 2 1/2 weeks. So, all seems to have gone well. My question is…how long will it be before I can walk, without limitations? I feel that I can’t even walk from one end of our mall to the other. I am supposed to go on vacation the week of October 6th. I am worried that I won’t be “normal” by then. Any thoughts?? Any specific exercises that you suggest for home? Thank you so much.

  42. Gareth
    Gareth says:

    Hi Mike,

    I had ACL reconstructive surgery three weeks ago today. I’ve still got some swelling and I’ve not got full bend on my knee yet. I was told to use crutches for six weeks and I’ve can’t get an appointment with a Western physiotherapist (I live in South Korea) until next week (week four since the operation).

    My first question, is it normal to have some swelling on the knee after three after the operation date?

    My second question, is there anything I can be doing in the interim before I start physio?

    Finally, will having physio four weeks after the operation be a massive problem for me making a full rehabilitation?

    Many thanks, all help is appreciated.


  43. Diaa
    Diaa says:

    Hi all, hi mike,

    I have the same problem as NAS, for the first 3 weeks everything was well, now I am in the 4 th week after ACL reconstruction using hamstring graft, severe intense pain behind my knee, with non stop pain, and I am limbing again, my doctor said it is normal, but I don’t think so,

    Any advise?

  44. Nas
    Nas says:

    Had my ACL reconstruction on 26th April 2013, for first 3 weeks rehab was going very well. Full extension after 1-2 days full ROM in 1st week. My PT & surgeon both very pleased. But now at week 4 a lot of swelling is back around the knee and very sharp pain from muscle at back of knee. Making it tough to fully straighten as done before. Making me walk with a limp again and causing pain in calf. Any thoughts?

    • Leisa Sullivan
      Leisa Sullivan says:

      Hi Mike,
      Just had ACL reconstruction using an Allograft on Sept.4 th. I also tore my MCL and Medial meniscus. At 48 hours in , I still have a bulky dressing and ace bandage on which is limiting my ROM. As well, my attempts at icing have been futile since the cold does not reach the site. I see my surgeon in 2 weeks and have not received instruction re exercises in the interim. After reading the articles, I already feel like I have fallen behind. Bulky bandage comes off later today. What to do?? I have crutches and I am allowed to toe touch weight bear. I feel very stiff but have only taken pain killers twice since I got home. Will my initial rehab be modified because of the involvement of the other ligament and cartilage? I am 54 and quite anxious to get back to my competitive soccer and volleyball. Also, I was to groggy when the surgeon spoke to me post op , so I don’t know the extent of the procedure. I think the meniscus was trimmed??

  45. Nas
    Nas says:

    I had my ACL reconstruction on 26th April 2013, for first 3 weeks rehab was going very well. Full extension after 1-2 days full ROM in 1st week. My PT & surgeon both very pleased. But now at week 4 a lot of swelling is back around the knee and very sharp pain from muscle at back of knee. Making it tough to fully straighten as done before. Making me walk with a limp again and causing pain in calf. Any thoughts?

  46. haris
    haris says:

    Interesting stuff, I got ACL surgery November 22, 2011 and i dont have full range is it still possible to get full range?

  47. Mike Hopper, ATC
    Mike Hopper, ATC says:

    I was reading an article last night that talked about using open-chain exercises because research is showing there is not as much stress on the ACL as once assumed.

    • Martin van Hoppe
      Martin van Hoppe says:

      Hi Mike,
      Be careful using a traditional quads bench though. X-ray films (!) show very large tranlationary forces due to the artificial point of rotation placed upon the knee by the bench. 35 flexion to full extension seems to be safe though.

  48. BJ Stockton
    BJ Stockton says:


    What are your thoughts on regaining full knee extension with someone who has significant genu recurvatum? Are you trying to get the extension to match the other knee? Also, what are your thoughts on SAQ/LAQ for quad recruitment? I have read so many articles stating it should be avoided because of too much “stress on the ACL”. I have also read other articles stating the stress is insignificant and may be beneficial to strengthen the tendon. I also agree with Trevor that NMES is frowned upon by many PT’s, but provides great results. Thanks for the post!

  49. Dave L
    Dave L says:

    Hey Mike,

    Are you achieving 100% knee extension by the end of week 1? Or more like 90%, but still lacking some of that terminal knee extension? In my brief experience as a new grad I have found I can get the knee pretty straight after a week or 2, but that last little bit of knee extension only comes back with some work over the following weeks and is normally regained 100% around week 4-6. What are your thoughts on this. Am I missing something/are patients not being compliant enough with extension stretches I prescribe? Thanks in advance!

    • Trevor Winnegge
      Trevor Winnegge says:

      Generally, in my opinion, the further out past week 2 you go without full knee extension, the more problems you are going to have…from pain, edema, poor quad activation, poor gait, etc. get it in the first two weeks! Educating your patient on day one of PT as to what to expect and how important ROM is is key. If you scare them enough, they will do it! and get great results!

    • Mat Failla
      Mat Failla says:

      We get full(symmetrical not just 0) knee extension by week 1. Its part of our protocol milestones. The reason you are seeing patients lose that little bit of terminal knee extension in between visits is usually because lack of volitional quad control and subsequent gait deviations. They need to continually use that terminal knee extension during gait in order to maintain it. You can keep re-gaining that bit of extension each time they visit with stretching but until they use that ROM functionally they will not own it.

  50. Trevor Winnegge PT,DPT,MS,OCS,CSCS
    Trevor Winnegge PT,DPT,MS,OCS,CSCS says:

    This is a great post and a must read for anyone treating ACLs-especially new grads. Patella mobility is often neglected, and I can’t agree more that this is critical especially in patella grafts. A lot of therapists are afraid to do this too soon but it is CRITICAL! I find, in terms of the patients pain, that there is a direct correlation to their ROM. In other words, once they achieve full, or near full, ROM their pain level is minimal and essentially a non factor. So in my book, I think regaining ROM is the number one early factor. I always tell patients “Ten years from now I can always make you stronger, but if you dont get your motion back in the next 6 weeks, You are going down a road that I may not help you come back from”. So many patients/athletes want to jump into the strengthening so I think it is critical to de-emphasize the strengthening and over-emphasize the ROM early on! Re-directing their focus helps to allow them to understand how important ROM is and how it will speed their recovery. I am amazed, talking to PT’s all over, how many still refuse to use NMES for quad strengthening/activation for not only ACL but for scopes and TKR as well. I am glad you included this in your piece. In our clinic, patients with an ACL reconstruction always get an EMPI Continuum home unit for NMES at home within the first week of PT. I have no financial ties to EMPI-I am just an absolute believer in NMES in the early post of period!!!

    • Eric Avers, PT
      Eric Avers, PT says:

      Trevor, can I ask how you are charging for the Empi Continuum device? I am in the process of updating the ACL program where I work and we have been discussing ways that we can get this unit to patients for home use. Are insurances covering a rental of this or are patients paying for it out of pocket?

      • Trevor Winnegge
        Trevor Winnegge says:

        We order them through EMPI and most insurances cover it. We have a supply on hand in our clinic and issue to our patients, showing them how to use it and set them up with it. Paperwork gets faxed into EMPI and they haggle with the insurance company. Most often it is covered under durable medical equipment benefit for a short term rental (3 months). Some insurances buy it. Others dont cover it at all. contact your empi rep…alot of times they give you some patient poaners for patients who need it but cant get insurance to cover it or cant afford to rent it. If you use them enough, the reps will be more than willing to help you. Hope this helps!

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