Post Operative ACL Rehab at Holt Physical Therapy

Suffering a major injury to your knee, like tearing your Anterior Cruciate Ligament (ACL) can be devastating for you and your family. At Holt Physical Therapy & Performance Training, we understand this. We have 16+ years experience rehabilitating patients of all ages and activity levels, including a variety of higher level high school, collegiate, and professional athletes from a wide spectrum of sports. With our experiences with higher level patients, at Holt PT we have been able to learn how quickly we can progress a post op ACL client while continually keeping in mind the healing tissue time tables. Not only do we strive to make your entire body better than it was pre-injury, but we educate you on techniques to decrease the likelihood of re-injury.

If you or someone in your family has suffered an ACL tear and is preparing for surgery, call us for a pre-operative consultation to discuss surgical options, rehab guidelines and what to expect during the entire process of making you better! We offer a physician concierge service with same day sub-specialty opinion from the area’s leading ACL surgeons, practicing the latest, most advanced techniques. Visit us and see why we have been entrusted to rehab the ACLs of professional athletes with salaries totaling over $80 million….read more »

Rehabilitation following ACL reconstruction surgery has changed tremendously over the past 15 years. As 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. Surgery to full release used to take 12-18 months. Now with proper rehab, it is closer to 6 months.

We are now seeing professional athletes absolutely dominate their postoperative rehabilitation. The postoperative rehabilitation is a huge factor in determining how well people recover from surgery.

A lot of people focus on the end of ACL rehab as critical. While that is important, we feel at Holt PT that the beginning stages are even more critical. If you start off slow or poorly in your rehab, that can set you up for a much longer rehab process and possibly as less favorable outcome.

With this being said, I wanted to discuss the 6 keys of the early phases of rehabilitation following ACL reconstruction surgery.

Controlling Pain and Inflammation
The first key to ACL Rehabilitation is simple, get rid of the pain and inflammation associated with the surgery. Pain and swelling has been shown in numerous studies to essentially shut down your muscles around your knee, specifically your quadriceps. If you have swelling in your knee, you have decreased knee range of motion, decreased quadriceps contraction, poor walking pattern and likelihood for increased arthritis.

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.

Remember, after surgery you can’t ice or elevate too much.

Getting Full Knee Extension Motion
It seems like everyone worries about how far they can bend their knee. While ultimately, this is important, restoring full knee extension range of motion could be the #1 key to rehabilitation following ACL reconstruction surgery. If you cannot fully extend your knee, you run the risk of scar tissue forming in the knee joint and then it becomes very difficult to get full knee ROM and you could end up walking with a limp. One of the more common complications following ACL surgery is loss of motion, with loss of extension being more troublesome than flexion. You will definitely be more comfortable with a towel or pillow under your knee. We DO NOT want this! It is worth a little discomfort on the front end to minimize the chance of issues later in rehab. We tell our patients, “Hate us now, but love us later!”

Gradually Progress Knee Flexion Motion
Although 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
One of the most important things your therapist can do for you immediately after surgery is patellar mobility. When you flex and extend your knee, your patella has to slide up and down. If you have scar tissue build up behind the patella, this becomes restricted. 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.

Get That Quad Firing!
As we mentioned earlier, there is poor 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.

The swelling in your knee basically shuts off the ability of the quad muscles to fire. Your quadriceps is one of the muscle groups that HAS to fire to protect your healing knee joint. For this reason, we will use things such as Neuromuscular Electrical Stimulation (NMES) to “jump start” your quad, wake it up, get it ready to do some work! We can also use manual resisted exercises and ankle PNF exercises to help re-educate the quadriceps to fire.

Restore Independent Ambulation
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. I tell my patients all the time that I want the “Locker Room” walk. I do not want a limp, I want them to walk every step like the are walking in to their teams locker room for the first time after injury.

We usually have people weight bearing as tolerated around week 1, unless other structures were damaged or need to be protected. They may continue to use the crutches for up to two weeks, but I want them off crutches as soon as possible to assist in quad activation and normal gait patterning.

I have found weight bearing exercises like weight shifts that focus on transferring your weight and locking out your knee can be helpful initially. At Holt PT, we will make sure that you get your “Locker Room” walk back!

Visit us and see why we have been entrusted to rehab the ACLs of professional athletes with salaries totaling over $80 million. Call us at (919) 803-0738 or email

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