When an ACL Surgery & Rehab Goes Bad

Anterior cruciate ligament tears have become too common.  Most non-professional athletes just assumes that an ACL surgery is a simple procedure with little chance that anything could go wrong.

ACL reconstructions (ACLR) are often thought about in a similar manner as the Space Shuttle program was five years ago.  This huge 240,000 lbs space ship would be launched into space at over 17,000 mph and it might only get a quick 30 second side-comment on the local news.

It’s not that simple and when there is a problem, with an ACLR or with the space shuttle, the results are not good.

Here’s a look at a present ACL reconstruction situation with a friend of mine that will show you what happens when all doesn’t go according to the plan.  She’s struggling to get her knee and her athletic career back on track.

The Background

“Katie” is an athletic 42 years old rockin’ soccer player at the time of her ACL tear in June 2011.  She gave me permission to share her story with MikeRyanFitness readers.

Katie had ACL surgery reconstruction (ACLR) in mid-July 2011 with an allograft.  I was surprised to see that she used a tibialis anterior tendon from a cadaver.  When this form of harvesting tissue from the surgical patient themselves, it is referred to as an autograft.

Initial Rehab

Braced in week #1 along with ice, very little weight-bearing and no physical therapy.

Katie’s rehab started during week #2 with 50% weight-bearing, strengthening exercise only in open chain (foot off the ground) and range of motion (ROM) drills.

The brace was removed during week #4, full weight-bearing was started, only open chain exercises continued, ice and starting Russian Stimulation using an electric stimulator to aid in muscle strength.

Time for Concern

During the start of week #5, the surgeon expressed concern with the limited ROM.

His Plan:  He drained fluid out of the knee, gave her a cortisone injection and instructed physical therapist to implement closed chain activities, which is a great way to rehab ACLR patients by exercising them with their feet on the ground.

The Result

Katie has endured dozens of hours of painful rehab with minimal improvement and few examples of improvement.

“My frustration is mostly due to the inconsistency in treatment and shifting focus constantly with my rehab plan…”

This 10 to 14 week phase of rehab should be the exciting part of her knee marathon but it has turned into a painful and stressful time for Katie.

The knee remains significantly stiff, swollen and limited in range (limited by approximately 10 degrees from full extension).  Katie complains of pain during all activities and while at rest.  Her family and social lives are significantly limited.  It’s understandable that Katie is frustrated with her care and her inability to remain active.

The Plan

Her doctor wants to perform an arthroscopic surgery (“a scope”) in the next two weeks to remove scar tissue, based on the recent MRI.  I assume some form of a manipulation may be performed at the same time to regain needed ROM after the scar tissue is removed and while the Katie remains under anesthesia.

“I have let this knee consume me for months and I finally just took a mental vacation from it the past few weeks.”

After the scope, rehab will continue immediately.  A continuous passive motion (CPM) may be utilized to help the knee to remain in motion while Katie is resting and sleeping.  I think the CPM is a great tool to help maintain ROM and decrease pain.

My Advice to Katie

  • Have a detailed discussion with the surgeon before the ACL surgery.  Ask the important question:

“What do you expect to find in my knee and what are my options in managing these findings?”

“What kind of ACL surgery graft will you use with me and how many of these types of surgeries do you perform every year?”

 “Do I need a micro-fracture surgery?”

  • Your articular cartilage may be damaged and it may be the reason why you’re having so much pain and swelling.
  • Excess scar tissue is not too common but I’ve seen it with pro football players.  They did very well after a scar tissue removal scope.
  • After the scope, start your aggressive rehab ASAP. (note the capital letters!)
  • Use a CPM machine as much as possible.
  • Seek the opinions of other knee doctors and physical therapist in your area.  Remember that it’s your knee that’s in turmoil so stop worrying about their feelings.
  • As for the mental vacation, it’s needed and truly justified.  Get your mind “right” because you still have some heavy work ahead of you, Katie.
  • Keep your quad strong!!  Gains in quad strength may come in smaller chunks after the scope but it may prove to be the #1 variable if you want to be an athlete for the next 30 years.
  • From what you’ve been thru, the next phase will be a bit easier and MUCH more rewarding.

Mike Ryan’s Sports Medicine Tips for an ACLR Rehab Plan

  1. Research your doctor and his/her exact surgical technique before your ACL surgery.
  2. Get a copy of your surgeon’s WRITTEN rehab protocol before your ACL surgery.
  3. Meet your physical therapist and review your rehab protocol with her/him.  Ideally, schedule 1-3 rehab appointments with your therapist before the surgery to increase both knee ROM and quad strength
  4. Plan on a marathon.  Get your body and mind right to put in the necessary work for 6-9 months to successfully put this injury in your rearview mirror.
Let’s all wish Katie the best of luck with her ongoing ordeal.  I keep bragging to her about how smart my followers are so please share your thoughts & suggestions with Katie as she continues to follow this blog during her rehab.

Author: Mike Ryan

After 26 seasons as a full-time certified athletic trainer and registered physical therapist in the National Football League, Mike Ryan has outstanding first-hand experience. His unique professional and athletic background has sharpened his skills in the arts of sports injury management, elite rehabilitation, performance enhancement and injury prevention. Mike is now taking his experience to mainstream America. His mission is simple: Sports Medicine advice that is easy to use and brings fast results. Learn more about Mike Ryan

48 thoughts on “When an ACL Surgery & Rehab Goes Bad”

  1. Very good advice, Ryan! I seem to be the magnet for the failed ones, after multiple steps have went bad at another therapy clinic. There’s been a discussion about so-called “pre-hab” on LinkedIn lately, and I’ve found that having a few visits before surgery has been THE key to fast progress, and significantly lower therapy visit utilization after surgery. I was a therapist in the US Army, and the therapists were the first providers to see ACL tears, and managed them through orthopedic referral, reconstruction, and return to sport. No patient that starts with me has to worry about getting anywhere close to their yearly therapy limit.

    Research shows that with any knee surgery, the only determinants of future rehabilitation need are 1) Passive Terminal Knee Extension, 2) Active Terminal Knee Extension, 3) Flexion >90 deg. Nothing else matters. We (in the Army) liked to see all three of those goals in the first week, and we usually did if we had the patient before surgery and the surgery went well. The faster these milestones are met, the less therapy is needed, and the more focused and skilled that need is.

    If the patient has a knee flexion contracture prior to surgery (and so many do!) then getting rid of it and teaching the patient to obtain terminal passive/active extension ASAP after waking up from surgery is worth it’s weight in gold.

    1. THAT’s the kind of smart & aggresive knee therapy I love to see! Thank you for sharing those great points, Guy. Having a well coordinated plan BEFORE surgery and immediately implementing that plan after surgery is so important. Your rehab system is strong, Guy, and your patients are very fortunate to have their injuries in your hands!

      1. Take in mind however that the sinovial fluid does not become normal till about 9 to 12 months. It has absolutely no lubrication properties the first three months. So dont be too aggressive, especially running up.and down stairs for the cartilage on the trochlea.

        1. Good point Peter. The joint will be infusing new synovial fluid with the old so there remains moderate lubrication as the properties improve. The time frames of the ACL rehab (joint compression) and synovial fluid replacement (lubrication) should matchup with his rehab is managed properly by an athletic trainer or physical therapist.

  2. Another great article Mike! I like the comment on prehab as I think it is a very important component in any surgery of this type. I see a lot of patients pre and post surgery with chronic knee flexion of the injured knee. I think the flexion that may be there may be attributed to compensation to pain. Regardless of the cause, use of a heel lift on the flexed knee side will help to decrease some of the foot, ankle and knee stress related to walking or rehabbing on the ball of the foot since a chronically flexed knee will force the heel off the ground. Bring the floor to the foot and you may find a much easier time with your treatments. Good luck and nice article!e.

  3. In my experience with this injury and subsequent rehab is that there is a build-up of scar tissue which can be re-oriented with massage therapy. All the PT also contracts and creates trigger points in all the muscles attaching in and around the knee, creating pain and adding to the pain.

  4. I like the start rehab ASAP in capitals – i had my ACL reconstructed in 2002 using Patella tendon – at the time the choice was that or hamstring.
    I was warned pre op that using the patella tendon can restrict range of motion but the rehab was pretty aggressive and IMMEDIATE!! i actually woke up after surgery with my leg strapped to a machine which elevated the knee but also made it bend and stretch constantly – from what i remember i was in that for the first 4-5 days – my range of motion is as good as it was before and stability matches the other knee too.
    I know i’m lucky as I have met others who haven’t got full range of motion and I think keeping it moving immediately after surgery helped me.

    1. Great account of your successful ACL reconstruction & rehab, Jill. I love to hear of successful outcomes like yours. The use of a patella tendon graft, a quick start to your rehab, immediate use of a continuous passive motion (CPM) machine and the willingness to work hard = a great sports medicine result. Thanks for sharing this, Jill.

  5. I agree completely with obtaining the above ROM goals ASAP, especially terminal extension. Closed chain activities should be started as soon as the surgeon permits, our ACLR treatment pathway (endorsed by local physicians) has the patient start closed chain PT day one, unless WBing is limited by the surgeon.

    I can foresee future post op patients having s shorter initial round of PT, 10 to 18 visits, a thorough HEP, then returning to PT or their ATC 3.5 to 5 months post op to implement specific return to play protocols that include perturbation training and exercises already proven to prevent ACL tears.

  6. I had a knee ACL knee op 10 months ago. Straightening the leg is no problem and I have full range of motion that way. Flexion of the knee is not however and I can get my knee to my bum so to speak only after lots of stretching exercises. I fear my knee will never be as loose or mobile as it was. I have to kneel on an angle and there is clicking inside of the knee behind the knee cap. My Physio seems to think there is no problem and that the flexion will come however I am starting to doubt this. Any advice would be greatly appreciated. Thanks

    1. Your concerns with your post-OP knee ACL reconstruction is common Jack. The fact that you have full extension is very important and it typically indicates that your new ACL graft is properly positioned: A huge thumbs up!
      As for flexion, you may loose 5-10 degrees of this after such a surgery and it’s not a problem with 95% of athletes. Your pool cannonball splashes my be a bit asymmetrical but that’s not a concern. 🙂
      My biggest concerns from your comments is the “clicking” behind the kneecap or patella. Aggressive quad strengthening past 90 degrees of flexion will apply significantly high compressive forces on the back of your kneecap. That may lead to more arthritis and chondromalascia, which will complicate the health of your knee both short-term and long-term.
      My advice:
      1. Become a daily user of a roller on the front, side and back of your thighs to keep your muscles loose and mobile.
      2. Continue to massage and mobilize (“mobs”) your kneecap before all activities.
      2. STRENGTHEN your knee from 90 to 20 degrees from full extension while you STRETCH your knee towards full flexion.
      3. Place a small towel or hand behind your knee when you bend your knee into full flexion.
      4. Post a comment on MikeRyanFitness.com in 4 weeks to tell me and our readers how great you’re feeling.
      Go get healthier, Jack! MDR

  7. Hey there! I had my acl reconstructed in Dec 2012, 3 months ago. Neither my doctor nor the physio therapist stressed on the significance of exercises immediately after surgery. As a result I’m limited in complete leg extention. I’m really worried! Will I be able to get full extention without the scar tissue removal surgery? Is surgery my only option? If I have this surgery, how much time does it take to recover from it? Your opinion is highly appreciated. Thanks in advance!

    1. I’m sorry to hear of your poor rehab situation Manas. Stress not, you may be able to avoid surgery. Getting to a sports-related orthopedic physio therapist ASAP is the first step. Aggressive joint MOBILIZATIONS is very important and note this is very different from MANIPULATIONS. They may be needed But I word hold off on that option for now. Always remember to make sure your therapist and Dr. speak openly and consistently for your benefit. A great deal of the success of your rehab comes from the exercises, stretches and range of motion activities that you do it home. Your therapy at the clinic is just a small part of what is needed for you to make a full recovery. Your therapists and Dr. need to EDUCATE you on all the exercises that you should be doing on your own.

      I highly recommend you use a roller and massage therapy all around your knee to keep the soft tissue pliable and kneecap mobile. Keep me updated on your progress and let me know if you have any questions regarding your rehab and knee function. You have a lot a work of head of you but it will be worth the effort! As with any significant injury, 50% of the success comes from the surgery and 50% comes from the rehab.

      1. Hi, thanks so much for your advice. 🙂 During my rehab, I kept doing knee extention exercises everyday. I even get a little hyper extention after some aggressive stretching exercises. Once I stopped the extension exercises every day, the extension lag is coming back! The lag increses when I walk for a long time or jog a bit. I don’t understand this. I’m ready to give my everything Mr. Ryan, I want to get back on the field ASAP. Also, I met my doctor and he didn’t seem to be worried. I’m still very concerned. Is this a case of scar tissue?

        1. Hi Manas, The leg extension exercises are good if your kneecap cartilage is healthy but not every day if the intensity is high. Get with your physical therapist to develop a program for quad, hamstring, hip flexor, gutes and calf strengthening. With knee extension work, via leg press, squats or lunges, avoid the last 20 degrees of extension to avoid hyper-extension.
          If your quad strength is good, the extension lag is probably coming from limitations with the mobility of your kneecap. Aggressive massage, patella mobilizations and rollers need to be started asap. “Loosen up and immediately use it to keep the mobility” needs to be your theme.
          Keep me posted. Thanks for sharing my info. MDR

  8. Great Article!

    Injured knee skiing early February. One week later I had a scope and the Doctor identified. A torn ACL. One week after this I had an Allograft replacement. It all happened so quick and maybe I should have prehabbed, but felt since I was in good shape that it should get done.

    Suffered through a DVT in second week after the surgery.

    I am know 13 weeks post op and struggle to get 110 degrees of flexion and am just off 0 with extension. I go to aggressive physio twice a week and feel I am diligent with home exercises.
    The knee still flares up after a stretching session and throbs after time on the bike.

    In your opinion can physio still improve my ROM? I am making small gains, but am starting to feel like a Manipulation under anesthetic or arthroscopic debridement may be my option.

    Keep working through it with physio or is it time to get another procedure?

    1. Hi Neal, Thanks for your kind words of support and I’m sorry to hear about your knee. Here’s my thoughts:

      > Your knee flexion (bend) is below from where you should be. When you hit the 120 degrees mark, the range is much more comfortable and increases in ROM come much quiver. Often the position of the new ACL graft is a problem and this can contriubte
      > Yes, your phyio is going to be your MVP with your rehab. Get with him/her, stress the flexibility, joint mobs and joint stretching.
      > Get YOUR surgeon’s recommendation.
      > A new scope may be needed if aggressive physical therapy does not help.
      > Manipulation is not a procedure to be done quickly. Articular damage is the biggest concern.

      Keep me posted on this Neal and keep working hard.


  9. Some great advice here!

    Hope you can give me some as well.

    I am 3 1/2 months post op from an ACL Allograft. I have been having a hard time getting Range of Motion back. I am stalled at around 110 degrees flexion and 2 degrees extension. I am working with a competent PT who is pushing me and I feel I am working hard at home as well.

    I had the procedure right after my ski injury (which included a Gr 2 MCL) and suffered an early set back with a DVT.

    I am wondering if at this stage I should be looking for further intervention from an Orthopedic surgeon. I have three options (as I see it maybe you can suggest another)

    1) Manipulation under Anesthetic
    2) Arthroscopic Debridement and Manip
    3) Continue with PT and hope I can get ROM back so I can move on with the PT protocol I am on

    What do you think I should do to turn this rehab from BAD to GOOD?

    1. Hi Neil,
      Thanks for your question. Based on the summary of your situation, your 3 options are correct. You need more than 110 degrees of flexion although your -2 extension is not overly concerning. I’d be curious if you either gain more flexion during rehab and fail to retain it or if 110 degrees is all you get. I’m assuming it’s the later of the two, which is more concerning.

      The bottom line is that you need to get to at least 120+ degrees of flexion which will allow you to really improve your function. Your goal is over 130 degrees.

      My suggestion: Sit down with your physical therapy staff to review all that you do in rehab and at home to regain your range. Are you do everything necessary? Have you tried a CPM at home at night? Don’t get away from your strength exercises, soft tissue work, patella (kneecap) mobs and such just for the range issue.

      Next, get to the best knee doctor in your area to discuss the first two options on your list.

      The bottom line is you need more knee flexion, sooner than later. The reason for your limited range can be a few factors ranging from the position of the graft to the rehab. NOW is the time to know that and to do something about it.

      I wish you well and please keep me update on your progress. MDR

  10. I am 48, have jogged all my life, left ACL repair allograft and MCL repair, now 5 weeks post op. Used CPM machine starting day 2. Walked without crutches day 5. My concern is aggressive rehab vs graft failure.
    I have some stiffness and edema, no pain, mild limp, appears to be full extension and flexion. The limp and mild edema and stiffness I feel I can workout but how much rehab can I do without risking graft failure? My job requires walking about 4 miles daily 3 days a week-back to work in 3 weeks. I elevate the leg at home. No problems at work just mild limp.
    My doc and rehab people say just no sports but walking is fine. When is jogging ok? I want the limp and edema gone so I stretch a lot to get full extension. I walk straighter after all the stretching which I do daily with strength exercises.
    Am I progressing as expected? When will limp be gone? Thanks.

    1. Hi Tom,
      Thanks for sharing your situation. I get lots of ACL questions b/c it’s an injury with lots of questions.

      First of all, I’m happy to hear that you have full range of motion but I’m concerned to not hear you say anything about formal rehab. Having the opportunity to rehab, even if it’s only a couple of times per week, in a structured sports medicine center is priceless. Learning how to strengthen and stretch properly along with the vital hands-on massage and soft tissue work will help you now and down the road.

      As for the “edema”, I’m assuming that is more of an effusion, which is swelling inside the knee joint. That is common but it should be improving weekly. If it continues to be significant, it’s telling you that the joint is not happy. Joint surface stress, irritation of the back of the kneecap is a factor or the MCL injury are common factors.

      The walking is great. The limping is probably coming from the effusion/swelling and quad weakness. Look at your thighs in the mirror and compare the size. Is the round muscle just above and to the inside of the kneecap much smaller? Probably. A smart and consistent let strengthening program designed for a post-Op ACL and MCL surgery is what you need.

      Icing that knee after exercise, long walks and whenever is is feels warm/swollen will really help. Ice is your best friend.

      Look into using a knee brace or sleeve to help support the MCL and stabilize your knee while it regains its strength.

      Get strong, Tom, and keep me updated on how quickly your improve. MDR

  11. I can’t stress the importance of Prehab enough!

    I am 46 and tore my ACL and medial meniscus. Was in prehab within 2 weeks of the injury and did that until reconstruction at +6 weeks. Was in PT 24 hours after reconstruction and have been doing that 2x/week (I am now 4 weeks post-op).

    Was weight bearing immediately, lost the crutches at 10 days and am generally walking with only moderatley impaired gait. I am at full extension and about 130 deg flexion, again at 4 weeks.

    I still have a lot of swelling and am wondering how long that will take to resolve. I have a cold therapy machine which has been great, but the patella itself has been limited some by the swelling. I have no doubt if i could get that down some more I would be able to get the rest of the way.

    1. I love hearing that kind of a proactive approach by athletes, young and old, determined to take their recovery into their own hands with outstanding guidance by highly skilled sports medicine specialist. Who taught you so well? Thank them hard.
      My thoughts to help you decrease your swelling:
      1. Swelling is expected but it should continue to decrease w/ time. “…a lot of swelling” tells me your knee is not happy and the swelling inside the joint (effusion) will limit your quad strength. The swelling can come from a combination of the joint capsule, the joint surface, the new ligament or the back of the kneecap.
      2. Don’t be too quick to get walking crutch-free. “Normal” walking patterns, even with 1 or 2 crutches, is the important thing so the stress on the knee is normalized while reducing the compression. Limping may look braver but your knee won’t like it.
      3. Keep icing the knee often to decrease pain, joint metabolism and swelling.
      4. Your ROM is great. Make sure your patella mobility of full so those strengthening quads direct the forces where they need to be.
      5. Ask your doctor if you have a bone bruise or any articular cartilage damage. If so, where is it located and how does it impact your exercises? If you do and you don’t alter your rehab accordingly, you can rapidly accelerate both your swelling and arthritis.

      Keep me posted on your rehab Paul.

  12. Hi Mike,
    I had my acl surgery 2 weeks ago and im really worried about my flexion. I used the CPM from day 3 to day 8 and only got it up to 70 degrees. I started PT around day 10. Ive been doing all the exercises provided to me and to this day, my flexion is only at 40 degrees. At this point I am very worried and it doesnt seem to be getting any better. Some advice would be greatly appreciated!

  13. Hi Mike,
    I am about seven weeks into my right knee ACL reconstruction. Three days after my surgery I had to aspirate. However, my knee got infected and had to be cleaned out arthroscopically. The clean out was ok – based on the Doctor’s feedback – but for two weeks after one of the incision sites wasn’t healing. I came to another Doctor and he said that the graft itself is infected and needs to come out in addition to the graph seeming to be in the wrong place, which he will verify by MRI today (Monday). I had 90 degrees of flexion after the initial surgery, but after the clean out, my knee was sort of ‘scared straight’. The new Doctor said that my knee will never be the same as my left knee again. Given this scenario, are you able to say what is meant by ‘never be the same as the left knee again’? I play Volleyball, and Tennis, in addition to weight lifting with ATG (ass to grass) squats being a regular part of my workouts and am scared that it means that I won’t be able to do these things again. Please, can you offer me some feedback even if it isn’t what I want to hear. Thanks.

    1. Hi Curtis, You certainly have much to deal with based on your comments regarding your ACL surgery. I want to help you. I have worked with athletes with bad ACL surgery and graft removals. #NotFun. Knee infections suck, period. Going forward, your rehab will be VERY important to regain as much quad strength and knee range of motion (ROM). Both of those variables will determine how athletic you will be in the next 9-12 months. What your new doctor means with his/her comment: “Your knee will never be the same” is based on the reality that your knee WILL lose ROM and have more arthritis than you left knee. Your ATG days are gone. Even if you had a perfect knee, I would suggest the same b/c that excessive knee flexion is bad for your kneecaps.
      My suggestions for you: Get your knee cleaned out, get the new ACL surgery and get with the best knee PT you can find. You have lots of work to do but you can get over this with time and proper rehab. Your knee will not be perfect and that’s ok once you know that. Any feeling sorry for yourself, which reduces the quality of you rehab and your attitude, will only hurt your outcome. You have a big challenge in front of you, Curtis. Get busy chipping away at that mountain. Some days will be tougher than other and you know that. Focus on the top of your mountain and know a much happier, tougher and content Curtis will have a great view up there.
      I wish you well and look forward to your updates.

  14. Hello Mike,

    Thank you for this blog post and to all the people that have commented as well. I had ACL reconstruction surgery (cadaver tissue) and meniscus repair on May 01, 2015. I was fit before and never had knee issues. I went on the CPM 8 hours a day right after surgery (though a 2-day delay because it was not ready on date of surgery, could that be key to my issues?) and then did physical therapy 3 times a week at a PT clinic and multiple times a day, every day on my own for months. Stability and strength were never issues, however, from the start, there was very limited ROM. Now nearing 1.5 years after surgery, my default ROM is 10% extension and flexion maybe 100 degrees if that unless I loosen up. I have discomfort and pain in the knee, again from day one after surgery. At the end of July 2015 my surgeon recommended scar tissue removal surgery just based on a quick physical exam of my knee with his hand. I wanted to try PT more first. Now, it is clear no amount of PT and knee strengthening is going to get ROM back.

    I do not know how to proceed. I now live over 2 hours from my surgeon, and it would be hard logistically to get someone to drive me there and back even if I wanted to have scar tissue removal surgery. My thinking is the ACL surgery was not done correctly because I had always been fit then followed PT to the letter before and after surgery. I do not know the path to proving the surgery was done incorrectly (malpractice, error) or if the cadaver donor tissue never fully took. My thinking is it would be nice to have an MRI to see inside and know for sure what is causing the lack of ROM, or is an MRI not necessary for that? Local orthopedists here where I am now would not even see me for a second opinion until 6 months after surgery.

    Any advice on a path to getting ROM back, pursuing options to have the scar tissue removal surgery for free, or proving the ACL surgery was not (or was) done correctly with MRI, etc would be greatly appreciated. Every day I feel sick that I can never play sports again. I even sold my bicycle because I cannot even pedal all the way around!

    1. Wow, Jason, I feel badly to hear of your problems. Lots to discuss….You need to get your range of motion (ROM) back and it will take lots of work. Hear of your location issues, get the knee warmed up (bike, walking, pool), be aggressive with rollers, get massage work around the kneecap, and then MOVE the joint. Once you get more motion, you need to do any exercise in that new ROM to help maintain that ROM. If you gain 10 degrees and you can keep 5 degrees, great. Baby step are still steps!
      You may require a scope to clean out the obvious scar tissue that you have in and around the knee. If so, do it. Follow up with the ROM-enhancement plan noted above.
      Jason, I’ve seen knees that looked like they were fused! Picking away that the ROM with persistence and hard work with those knees produced wonderful results. I want to reference you in 9 months as another one of those success stories!
      Go buy that bike back, give it a new paint job and….”get on your bike and ride!!”

      1. Hello Mike….thank you for the quick reply and encouragement. I will contact my orthopedist and see about the scar tissue removal surgery. I will bookmark this page and hopefully will be able to reply again with improved ROM to report and give hope to others as the comments above have for me.

  15. Hi Mike. I am 44 yrs old I had aclr surgery using allograft in the left knee on 10/12/2016. I sure wish I had found your site before I had the surgery! For reasons unknown to me, my surgeon had me wait 3 weeks before rom excercises, then another 2.5 weeks before pt. I have begun week 2 of pt, & am seeing slight improvement on extension, however no gains on flexion yet. It seems to be stuck at 85 deg, right after stretching, which is where it has been since surgery. I feel that I am doing my daily exercises pretty well, swelling is moderate, & pain is minimal, but the lack of progression in flexion is beginning to get worrisome. In your opinion, am I too eager in looking for better results at this point, or would this be considered a red flag? Thank you for your time!

    1. Man, Brandon, I hate to her stories like yours. THIS is the reason why created and build MRSM: To help inform non-professional athletes simple ways to help you stay healthy and avoid being the victim of poor advice such as you had with very delayed rehab following an ACL surgery.
      To answer your question: NO, your knee is not helpless. You need to regain your knee range of motion (ROM) ASAP. Get to the best knee doctor who treats football players and skiers. Next ask for his/her recommendation for the best knee physical therapist and athletic trainer. Aggressive soft tissue work, mobilization, maybe a manipulation is in order.
      As of now, your kneecap, knee joint, muscles, joint capsule, fascia, tendons, meniscus and ligaments are thinking your limited 85 degrees of motion are “normal”. You NEED to change that, one day at a time.
      One of my favorite quotes: “Think with the end in mind.”
      What’s your end look like Brandon?

  16. Hi Mike,

    A fascinating read and very informative – thanks in advance.

    I am 25, young and fit. Complete rupture of my ACL with a grade 3 tear of MCL playing football in October 2016. Also had sprains of the LCL and PCL – made a right mess of the knee!

    I have done ‘rehab’ every week and have my ACL surgery on 5th January 2017. We’ve been waiting for the knee to stabilise and the MCL to heal sufficiently before they operate on the ACL. Currently, I can partially weight bear, have full extension and about 120 flexion. Will this enhanced pre-op ROM improve the ROM post-op?

    Cricket is my main sport and involves a lot of squatting (I am a wicketkeeper – similar to backstop in Baseball). I am hoping to getting back to the sport ASAP and would love to continue playing at the same standard.

    Would you have any advice pre-surgery for exercises that I could be doing as soon as possible after the operation? Chances are my post-op physic will involve once a week sessions and I probably won’t have access to those snazzy machines that manipulate the leg. Really determined to get back to work and sport so any advice would be greatly appreciated.

    Many thanks.

    1. I hope your rehab is going well since your surgery last week Lee. I hope your PT is being performed more than 1x/wk. Rehab for an ACL reconstruction is a DAILY plan. Smart move getting MCL tight before ACL surgery. NOW is the time to gain your knee range of motion and control your swelling.
      Keep me updated on your progress.
      Can you teach me the rules of Cricket?? 🙂

  17. hi mike, you give great professional advice and was hoping you could shine some light on my situation
    i had acl surgery hamstring graft, could not move my knee into hyper extension i guess im hypermobile
    so anyways, the graft was removed but that is not even my biggest problem. I felt a sharp pain while doing hamstring curls early in rehab and now i have a gap in the back of my leg, i have poor leg control and a hard time standing and walking normally. the whole thing was a disaster and im quite miserable because of it

    im diagnosing myself here but i think i ruptured a hamstring tendon or the one they took for the graft didnt regenerate
    what do you think?
    should i have acl revision or should i address my hamstring first, is there surgery for hamstring tendons?

    sorry for all the questions but if you could answer even just one i would really appreciate your opinion
    thanks for your time

    1. Hey Joe,
      I’m so sorry to hear about your unexpected ACL surgery nightmare.
      Based on what you’ve told me, here’s what you need to know:
      1. The Hamstring tendon they took for your surgery will not regenerate. The bell of that muscle will scar down to the hamstring tendon behind it.
      2. You need to have a stable knee if you want to be active. A brace is an easy option but it will not be as stable as a solid inner knee ACL tendon.
      3. Your thought on focussing on hamstring is good but not great. Getting your knee right it a higher priority in my book.
      4. How old are you? How active do you want to be?
      5. You need to get with a very good knee surgeon who is NOT in the same office as your previous surgeon to get another opinion on how to manage your knee.
      6. Based on what you told me, you currently have what we called an “ACL deficient knee”. This will drastically accelerate the arthritis in your knee and quickly result in meniscus tears if you perform stop & go and/or change of direction activities.
      I hope this helps you Joe. Keep me posted. Mike

  18. thanks so much mike, i have heard the tendon regenerates after they take it but thank you for answering my questions
    i am now waiting for an appointment with a good knee surgeon in toronto. May have a revision acl with allograft

    do you recommend a revision even though ive lost motion from the first acl disaster?

    1. If it was my knee and my patella tendon was strong, I’d opt to use the middle 1/3 of my patella tendon. It’s known as a Clancy Procedure and most consider it the gold standard of stable ACL grafts. An allograft (from someone else) is the easiest procedure and rehab for an active person but BUYER BEWARE….5 years from now you will probably wish you used an autograft (tissue from you). Do your research, as around and make the smart decision which works for you now, in 5 years and in 20 years.

  19. Hi Mike, it’s been 2 months since my ACL reconstruction using a cadaver, also had a torn medial meniscus repaired and partial repair to the lateral meniscus.
    I am at about 80 degrees in flexion and about 2-3 degrees off from full hyper extension but it’s getting better.
    My concern is the flexion, I just can’t seem to get past the 80 degree mark for the last 2 weeks. I go to therapy 2-3 times a week and exercise at home.

    1. I’m concerned as well. You, your physical therapist and your doctor need to be on the same page. Is your doctor limiting your range of motion due to your meniscal repair? Maybe but you need to know that asap! I see many ACL patients who suddenly find themselves 4 months post-op with very limited ROM and the doctor and the patient are very unhappy for good reason. If your doctor wants your PT to be much more aggressive with ROM exercises, NOW is the time to know.
      Remember SM, they all work FOR you. Don’t be passive or you’ll regret it for years to follow.
      Got it? Keep me posted. You need much more range, per your doctor’s direction.

  20. Hi Mike,

    I am 5 weeks post ACL surgery and my progress has been incredibly slow. Although it has been slow my flexion improves a couple of degrees everyday. I am currently at 95 degrees flexion and have just been able to peddle backwards on a bike today. I started at about 20 degrees flexion. I go to my physio twice a week and do my exercise 3-4 times a day. I also go to the hydro pool 3 times a week and practise walking. I am at 0 degrees extension and gaining quad strength again. I have a top surgeon and physio. There is not really any pain but I am very tight in quads, hamstring and ITB. Am I just a slow progress or could it be more?

    1. Jem, I think you’re doing very well with your progress following ACL surgery. At 5 weeks post-surgery, your range is great, your quad strength is improving and your home exercises are consistent. Stay the course, ice your knee after all your workouts and communicate consistently with your physical therapist and doctor to avoid any setbacks. You have 1 change to get your knee right and you’re doing just that! STAY STRONG!

  21. Hi Mr. Ryan,

    My son had two injuries in June of 2017. He tore his LCL, ACL. He had his LCL operated on first and later his ACL was operated on in August. He is currently 6 1/2 months post op from ACL surgery and he still seems to have ROM problems and not a smooth running gait. He is a junior in high school and is really concerned about returning for his senior yr and has hopes of playing in college. He has been consistent with PT and was released (going regularly) at the 5 month mark. He still does have a trainer/pt assistant running him at school twice a week and he does do workouts at home. We are doing hamstring work with a band and he does single leg squats, box jumps figure 8’s, bike and treadmill work a couple of times a week. Do I need to do more with him? what are my options?

    thanks so much for the insight!

    1. Hi JR, I’m worried to hear his knee ROM is not normal and he’s running with a limp. That only set’s him up for more problems above and/or below the knee. I think he needs to have a session with THE BEST KNEE physical therapist or athletic trainer in your area to determine: 1. What are his trouble areas? (knee ROM, quad strength, swelling,,,.etc.), 2. Exactly WHAT he needs to do to get back to 100%. and 3. HOW to get back to 100%.
      Example: If your car has a wheel alignment problem and it shimmy’s and shakes on the sideroad at 30 mph, the problems will only get worse on the highway when you’re driving at 55 mph.
      Does that make sense, JR?

  22. I tore my ACL for the second time in March and had surgery (hamstring graft and meniscus root repair) about 6 weeks ago. My surgeon is an advocate of no ibuprofen and recommends the RICE methods. That said, the knee has definitely always felt really tight since surgery and has always been stiff when I wake up in the mornings and is stiff when I exercise on a stationary bike. Well, yesterday was a PT appt and we got range of motion from 0 to 125 (pervious week was 0 to 115) and that same day I took a walk w/ kids around a park focusing on my leg extension while I was walking. The knee was feeling pretty good. We came home and I bent down on my good knee to get something from the fridge and my other leg was partially extended. I stood up mostly on my good knee with some support from the other knee. There was a small pain under my knee and some minor tingling around my upper tibia but I have had these before. The thing was, after sitting down for a little, my knee felt really good. The tightness was mostly gone and I could really walk well. My wife even commented on my good-looking gait. What really got my attention was that I did not wake up stiff AT ALL the next day. My range of motion is still tight at the limits (0 to 125) but the motion of the knee between those two points is very smooth. It’s nice that it feels a lot better but I was kinda taken aback at how quickly the tightness has vanished. Is it possible that the ACL graft was providing the “stiff” feeling in my knee and that I somehow stretched it out and that is why my knee is feeling so much better? Is there anyway to test the integrity of the graft to make sure it hasn’t loosened?

    1. Nathan, I love your message b/c it reinforces a key element of ACL reconstruction rehab which I’ve always been excited about: Once the rehabbing knee gets to 120 degrees of flexion it will quickly gain multiple degrees of flexion with less effort. Why? My theory is this: At approximately 120 degrees of flexion the distance from the axis of rotation and the joint surface is greatest. Therefore, the new ACL is put under it’s greatest stretch. Having been involved with the rehab of over 70 NFL players rehabbing a torn ACL, I’ve noticed that after they cross that 120-degree threshold, they quickly increase the amount of flexion they can demonstrate with much LESS effort compared to the effort it took to get to 120.
      The bottom line is, Nathan, you are probably is a great position and your new level of motion, function, and recovery is a reward for your hard work. Raise your expectations and work hard with your physical therapist and athletic trainer to get back to sports in a big way! Keep me posted.

  23. I had ACL reconstruction on June 13th, using a donated ligament. After about a week, I was walking with my brace, a slight limp, and very minimal pain. On June 28th, I had my first PT session. My therapist was pleased with my progress at that point. I almost had full extension, about 6 degrees off, and my flexion was as 128 degress compared to my healthy leg which was at 150 degrees. At my first session, my Therapist had me doing bridges, squats, some aggressive stretches, and ended my session by putting me on an exercise bike for 5 minutes with a little tension. By the end of that night, I could no longer walk. My knee and entire leg were swollen. It’s been 9 days, and I still cannot walk. My knee is still swollen, my knee is basically frozen in a slight bend. I can no longer straighten my leg or bend it. I’m in more pain now than I was after surgery. Has anyone else had a huge set back like this after their first PT session? My doctor thinks the session was probably too much too soon. I’m worried that I’m not going to recover.

    1. Darn, I hate to read this, Gina!! I agree with your doctor that you may have been asked to do too much on your 1st day of physical therapy. What do you do now? Answer: Focus on reducing the swelling in your knee while increasing the range of motion under the guidance of an experienced physical therapist. Regaining the motion of your knee as quickly as possible is very important. By decreasing the swelling in your knee your quad strength will come back much faster. Be aggressive with this plan to help get your rehab back on track.

      Ask your physical therapist and doctor for a written rehab protocol to follow. Having it in writing is key because it keeps everyone on track and it helps you prepare both physically and mentally to the long road of recovery.

      Remember Gina, ice is your best friend. Lastly, stay on track with your rehab plan at home every day between physical therapy appointments in the clinic. Remember; the doctor and physical therapist work for YOU and not the other way around.:-)

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