The Truth Behind ACL Recovery: Why It’s a Lifelong Process

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  • Why Physical therapy is vital for ACL recovery and how it helps regain motion, strength, agility, and successful return to play.
  • How ACL recovery can be complex and challenging, as it involves potential surgery failures, varying return-to-play rates for athletes, and long-term impacts from different factors.
  • Why ACL recovery is a lifelong healing process.

Now that you have completed the return-to-play process after ACL surgery, it’s time to talk about life after recovery from an ACL tear.

Should you be concerned about a possible reinjury? Are you at risk for early onset of arthritis? What type of things can be done to prevent those conditions? It’s natural to have these questions, and others, as you start attending practice regularly.

While we explored the ACL reinjury rate earlier in the series (read Part 1 here), let’s take some time to delve into early-onset arthritis and other challenges you may face after ACL recovery. Then, we will discuss the importance of lifetime management and how to keep your ACL reconstruction healthy in the years to come.

Several muscles, tendons, bones, and ligaments pass through the knee joint, which is one of the reasons why it is so complex. As such, there are many reasons why you could find yourself with an injury or pain.

The Importance of Physical Therapy During ACL Recovery and Rehabilitation

It’s a well-known fact that physical therapy after an ACL injury is as critical as the surgery itself when it comes to getting back to sports and exercise. Physical therapy is also a large part of whether ACL surgery is considered to be successful, and that’s because it sets the stage for what you’re able to do for the rest of your life.

For people who are looking to return to sports and exercise, physical therapy after an ACL injury is necessary to help regain range of motion, strength, speed, and agility. But what happens when that’s not enough?

Research suggests that athletes do not return to the same level of competition for up to 2 years after ACL surgery. This is one of the reasons why ACL return-to-play testing is highly encouraged. Generally, return-to-play testing after ACL surgery includes a strength evaluation, functional activities like hopping, jump/landing, and sports-specific activities, which you can read more about here. Once you pass the return-to-play milestone, research shows that you have a good prognosis for playing at the same level you did prior to the injury.

On the other hand, some milestones, like regaining full range of motion or strength, during ACL recovery may be difficult to meet. Although there are many factors that can affect overall recovery, some can place you at risk for poorer outcomes. People who fail to regain full knee range of motion, the recommended quad-to-hamstring ratio, and normal jumping/landing patterns are more susceptible to developing arthritis. Afterward, the knee joint can develop chronic inflammation that results in changes to the joint structure and damage to the cartilage.

Challenges to ACL Recovery

Unfortunately, ACL surgeries fail more often than we care to acknowledge. Data suggests that as many as 5% of grafts can retear which, in our opinion, is 5% too much.

But we are also learning that many athletes never return to their previous level of competition after ACL surgery. Studies have shown there is a return-to-play rate of about 65% for professional football players after an ACL injury, which is generally lower than expected. In high-school athletes, the return-to-play rate is 80-90% whereas, in major league soccer, it is somewhere between 70% and 85%.

Admittedly, the definition of a successful return-to-sport following an ACL injury differs depending on your goals and the surgeon’s recommendations. However, getting back to the same level of competition prior to your ACL injury is never guaranteed. One key factor that may limit a full return to competitive performance is damage to the meniscus. This could have occurred alongside the ACL injury. It’s also common to see damage to the surface of the knee joint that can further complicate recovery. Complex ACL injuries that include damage to the meniscus and joint can prolong recovery and affect long-term outcomes.

Research has also shown that a fear of reinjury can affect recovery from an ACL injury. Those who acknowledge the fear and apprehension about injuring the newly-constructed ACL graft should talk to a sports psychologist. Additionally, they can go on continuing to practice with a physical therapist.

Why ACL Recovery Occurs Over a Lifetime

We make this claim for two reasons, so hear us out.

Firstly, did you know that it takes about two years for your nervous system to reconnect with your balance and proprioceptive systems after an ACL injury? During this time, you’re extremely vulnerable to ACL reinjury. This fact highlights the importance of periodic check-ins with your physical therapist or trainer.

Secondly, about one-third of people who undergo ACL surgery will develop osteoarthritis in the injured knee within 10 years. Within two decades, nearly 50 percent will have osteoarthritis, which are terrible odds for something with no known cure.

Arthritis after an ACL injury, also known as post-traumatic osteoarthritis (PTOA), is a subtype of osteoarthritis. It develops after an injury to the joint such as a fracture or a ligament/meniscus injury. It accounts for almost 12% of arthritis cases and disproportionately affects younger populations due to a higher percentage of the traumatic injuries that cause PTOA. Other conditions that can lead to PTOA include shoulder instability, patellar dislocation, and ankle instability.

Factors for Developing PTOA

Aside from having an ACL injury, other risk factors for developing PTOA are:



High body mass index

Low levels of physical activity

Low education level


The time between injury and surgery

Poor balance and muscle strength

Pain and stiffness

Fear-avoidance behaviors

There are certain defining features of PTOA during the early stages. While there is no definitive cure for PTOA, or osteoarthritis, this means that targeted treatments could potentially prevent the disease from progressing and causing symptoms.

Unsurprisingly, the most effective way to manage PTOA is the prevention of injury and reinjury. ACL prevention programs play a large role in protecting the ligaments, meniscus, and knee joint. They can reduce the rate of injury by up to 53%. These programs should include neuromuscular and proprioceptive training, strengthening, plyometrics, balance, and flexibility exercises. They should also include feedback on technique and skill enhancement. Altogether, ACL prevention programs improve lower body mechanics and offer greater protection against future ACL injury.

One example of a well-known ACL prevention program, the FIFA 11+, was developed in 2006. It was developed as a warm-up routine aimed at preventing soccer injuries in individuals ages 13 years old and up. One study found that FIFA 11+ decreased the rate of ACL injuries by 77%. This is an impressive statistic for such a highly competitive contact sport. Although FIFA 11+ was originally designed for soccer, it can be easily put to use in other sports with high ACL injury rates.

Currently, there is strong research in support of helping those with symptomatic PTOA. Experts recommend making healthy lifestyle choices, like quitting smoking and eating well, to prevent symptoms related to PTOA. Furthermore, developing realistic expectations and finding ways to control flare-ups is helpful to manage PTOA. Things like anti-inflammatory diets, routinely engaging in physical activity, and consuming nutrients for bone health (calcium, vitamin D, and omega-3 fatty acids) are also recommended. These are recommended in order to combat the effects and progression of PTOA.

Why Myokinetix Is Your #1 Resource for ACL Injury

ACL recovery should be considered a lifetime process due to the high rate of reinjury. Also due to the risk of developing post-traumatic osteoarthritis. It makes sense to put your recovery in the capable hands of a team who knows ACL rehabilitation from firsthand experience. Trust the experts at Myokinetix and let our doctors of physical therapy become your #1 resource for ACL injury and recovery. Learn more about their ACL rehabilitation program by calling 973-585-4990 today.

Myokinetix CEO, Dr. Natty Bandasak, also wrote a book about all things ACL. It’s called The Complete Guide to ACL Rehab, which you can order here. As an athlete, parent, or coach, you’ll learn what you can expect from this recovery process. For full recovery, it’s necessary to understand ACL injury and how to best move forward with that recovery. Those answers – and more – are all inside these pages. This powerhouse of a book even contains an exercise library to do at home.

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