As Scary as It Is, Tearing Your ACL Is Not a Death Sentence to Your Riding Career
You can probably pinpoint the exact moment when you heard—and felt—that excruciating knee pop. You spent the next few days unable to bear weight, diligently practicing RICE (rest, ice, compression, elevate) while waiting for your X-ray and MRI results. Then, your doc confirmed the no-good, very-bad news: You tore your anterior cruciate ligament, or ACL.
It sucks, but it happens—to a lot of us. While the exact number of ACL injuries is tough to pinpoint, a 2017 scientific review estimated there are about 350,000 ACL reconstructions—the procedure often recommended for anyone with a grade 3 injury, or complete tear—performed annually in the United States.
Which means not only is there a strong community of people available to support you—check out The ACL Club and ACL Recovery Club on Instagram for proof—but also that you can have ACL surgery, recover, and get your butt back in the saddle. Here’s what you need to know before going under the knife.
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Can an ACL tear heal without surgery?
First, it’s important to clarify that an ACL injury and ACL tear are not the same. A tear is a type of injury, and the severity of said injury determines not only what grade it’s assigned on a scale of one to three, but also whether surgery is necessary.
For those with a grade 1 or 2 ACL injury—typically indicative of a mild sprain for the first level and a partial tear with the second, according to Johns Hopkins Medicine—surgery may not be required. “Athletes who sustain partial ACL tears, in which more than 50 percent of the fibers remain intact, may be candidates for rehabilitation rather than surgical reconstruction, as long as they remain asymptomatic,” says Cordelia Carter, M.D., orthopedic surgeon at NYU Langone Sports Health. “Similarly, those who do not suffer from functional instability of an ACL-deficient knee may be candidates for rehabilitation and close observation.” Translation: If you’ve partially torn your ACL but aren’t experiencing any instability (think: knee locking, sudden weakness, or buckling), then you may just need a hefty amount of physical therapy, and possibly a supportive brace.
However, if your injury is grade 3, meaning it’s completely torn through and providing zero stability to the knee joint, then it’s likely you’ll need reconstruction surgery. Not only will the ligament likely not heal on its own due to a lack of blood supply to the ligament, but Carter notes the instability could also interfere with athletic performance and increase the risk of additional injury to other structures of your knee joint.
What does ACL surgery entail?
Simply put, ACL reconstruction involves taking something else and creating a new ligament out of it, says Moira McCarthy, M.D., sports medicine surgeon at Hospital for Special Surgery. It’s a multi-step process that first requires you and your surgeon to choose whether you want to harvest tissue from yourself or a donor to fashion the new ACL, Carter says. (Research shows both are highly effective in adults older than 25, though using your own tissue is more cost-effective and typically the first choice.)
From there, you choose where said tissue comes from—the most common being the patellar, hamstring, or quadricep tendons—before your surgeon makes one incision to insert a camera into your knee, and a second to insert an arthroscopic probe, Carter explains. The surgeon is then able to both visually inspect and manually test the other structures of the knee, like your meniscus and articular cartilage, to see if there are any associated injuries. If there are, the doc will treat it then.
Once that’s settled, Carter says your surgeon will drill tunnels into your femur and tibia to recreate the exact anatomic position of your original ACL, then pass your tissue graft through said tunnels before securing it in place—usually using buttons or screws—effectively replacing the torn ACL.
Is ACL surgery painful?
Anytime you have surgery, it’s likely there’ll be some level of pain or discomfort, and ACL reconstruction is no exception. Between harvesting your tissue, the arthroscopy (inserting of the camera and probe), the femoral and tibial drilling, and the constant infusion of saline into the knee to give your surgeon visibility, McCarthy says it’s common to experience anywhere from a couple days to a couple weeks of postoperative pain as you work to reduce the amount of swelling in the knee and start to regain range of motion.
Still, most patients are able to go home the same day as surgery, Carter says, and can manage their pain levels with medication. (The amount of pain you feel will also ebb and flow as you work through the rehab process.)
How long does it take to recover from ACL surgery?
Rehab protocols vary based on associated injuries, graft choice, and a variety of other individually-related factors, but Carter says it’s typical for patients to use crutches and a protective knee brace for two to six weeks post-surgery. It’s also common—and important—to start physical therapy right away, as your PT will use a variety of techniques to help reduce stiffness and swelling in the knee, regain range of motion, and rebuild strength and endurance.
That said, it takes time for your new ligament to fully form and heal, so the entire recovery process can take anywhere from nine to 12 months (sometimes even longer), says Kaan Celebi, DPT, CSCS, founder of ACL Academy. “[It’s all] dependent on the sports and activities you’re getting back to…[and] passing a series of strength tests and functional return-to-sport tests.”
The good news is you’ll experience plenty of progress and “little victories” along the way. “Many patients will be able to jog, cycle, and swim three months after surgery,” Carter says. “Continued endurance and strength are the goals between months three and six to [get back to] pre-injury levels, [and] most patients return to sport between six and 12 months following surgery, once higher-level, sport-specific skills have been taught, mastered, and assessed.”
Should I consider prehab?
To recover as fast as possible, it’s best to think about what you do even before surgery. Once you’re able to bear weight again after the initial injury, Celebi recommends six to eight weeks of prehabilitation—either by yourself or with a PT—instead of jumping straight into surgery. “This will give you a chance to decrease pain and swelling, normalize your bending and extending range of motion, and increase strength, particularly in the quadriceps muscle,” he says.
Research suggests doing this prehab could improve your recovery time, Celebi continues. You’ll know you’re in a good place for surgery if there’s minimal to no pain and swelling, your injured knee has the same range of motion as your non-injured one, and your quadriceps strength is about 80 percent of your other quad, he notes.
When can I ride again?
One of the biggest obstacles of recovery after ACL surgery is stiffness in the knee. Getting on the bike can be helpful in this regard, working to keep the knee moving, break through to new ranges of motion, and build strength and endurance in the leg, Celebi says.
You will have to take a beat before riding hard again, though. Typically, patients can get on a stationary bike and work the pedals back and forth—without going all the way around—within two weeks of surgery, Celebi says. Around the four-week mark is when you might be able to perform a full revolution, says Wesley Wang, DPT, performance physical therapist at Healthy Baller in Rockville, MD.
Riding outside takes a little more time, as terrain—and the risk of falling—adds another dynamic to your recovery process, Celebi says. “My prerequisites for road biking on a flat environment are little to no pain and swelling in the knee, full range of motion, and 70-80 percent quadriceps strength achieved,” he says. (Strength should be at 90 percent for those who want to ride trails, as this places more variable stress on the knee, Celebi adds.) “These milestones can be met at different times, but usually it occurs between four and six months.”
How can I recover faster?
Once you’re out of surgery, it’s crucial to master the basics early on, Celebi says. “As swelling and pain calms down, it’s imperative to get the quad muscle going, as this muscle group becomes weak and inhibited after surgery,” he explains. You also want to restore extension and flexion right away. Checking these three things off the recovery list quickly will assist in a smoother recovery, moving you into the strengthening component of your process faster.
Still, it’s important to focus on the quality of your recovery, not the speed. “Every patient truly recovers at their own pace,” Wang says. “The number one priority should be to find a physical therapist who understands the recovery process in its entirety, and to be diligent with exercises and following guidelines.” With that little bit of guidance—and a whole lotta consistency—you’ll be back on your game in no time.
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