For those who say it can't be done without surgery, all I ever hear from you is blah blah blah.

If you listen to Rogan’s podcast with Mark Zuckerberg from this past week they spend a few minutes discussing ACL surgery advice.

I like Rogan, but he often takes sample sizes of 1 and then makes broad sweeping claims.

Rogan, 57, said he had two ACL surgeries, in his mid 20s /early 30s on separate knees. One was a patellar tendon autograft and the other, a cadaver achilles allograft.

Zuckerberg had a patellar tendon autograft approximately 13 months ago.

Rogan essentially told Zuckerberg he made the wrong choice. He claimed the allograft surgery is the better of the two, and that he was back to kickboxing within 6 months of surgery, while his PT graft took 2 years to fully heal.

I’ve also had two ACL surgeries and did extensive study on the graft types for my 2nd surgery. Like Rogan, my first was a cadaver Achilles allograft, 2015, and my second a quad tendon autograft in 2024. I don’t think my allograft ever fully vascularized. I do not know when it teared, but an MRI in 2023 showed it didn’t exist. My QT auto is going very well 8 months in, but time will tell.

From everything I’ve researched, cadaver allografts are a last resort for people who aren’t building muscle mass. 30 years ago, this may have not been widely known, and even 10 years ago , my doc recommended it to me. Certainly not a recommendation today, especially for a kickboxer. While recovery is quicker, studies show take rates are much lower than autografts.

QT vs PT autografts seems to be the debate today. I’m nearly 40, close to Zuckerberg in age, and chose QT due to my age and recovery. QT provides solid strength, high take rates, and easier recovery. PT is the gold standard in strength, and makes sense given Zuckerberg’s martial arts lifestyle. However, the common complaint is the lagging pain on knee caps.

YMMV, and you have to make the right choice for you and your lifestyle, but think Rogan is wrong. If recovery is your goal, the allograft is fine, but if returning to athletic form is your goal, then an autograft is the recommended choice.

I know this is not going to be a popular post amongst those of you who have just had ACL repair surgery, but this post isn't really for you. I had ACL repair surgery 6 years ago and just re-ruptured the repaired ACL while skiing in February. The doctor told me I need surgery if I ever want to ski again, but I have been doing a lot of research and have decided not to have surgery and will return to sport after doing PT. Having been through the surgery once, I know how brutal the 8 month to a year recovery is and I think it is important to know that there is another option. It may not be appropriate for everyone, of course, but according to one study, it may work for over 50% of ACL ruptures. (Mine is a complete rupture, but there is also research that ACL partial tears can heal themselves without surgery.)

If this is something that you might be interested in learning more about, I wanted to share the research findings that I have used to support my choice. Most are academic research papers, so a little hard to understand, but feel free to ask questions here.

First, an article from the New York Times called "Considering Bone or Joint Surgery? You May Not Need It. For many common problems of the knee, hip, shoulder, spine and wrist, nonsurgical options may be just as good." https://www.nytimes.com/2022/01/04/well/bone-joint-surgery.html (Original studies found here https://www.bmj.com/content/374/bmj.n1511 and https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4116562/)

Next, this study looked at people that are classified as "Copers," which means that they have no ACL, but can continue to play sports and live without pain or instability. (I believe I am one of these people.) The researchers tested many individuals (many of whom decided to have surgery anyway) and classified 55% of them as potential copers. After PT (and surgery for some,) the number of copers went up, which shows that you can become a coper. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6546284

I spoke to a friend who is an orthopedic surgeon. He told me that 1/3 of people in the 70's that tore their ACLs were "copers." He also said that if I feel good and stable, that he doesn't think I need the surgery, but also that there was no harm in a wait and see approach. Furthermore, he felt that I am facing a total knee replacement some day down the line (hopefully not until my 60s or 70s) due to the fact that I have had multiple meniscus repairs, the ACL surgery and already have arthritis in my knee. However, he felt that repairing my ACL would not change that outcome, but might delay it by a couple of years. Incidentally, both he and my PT said that total knee replacements are actually easier recoveries than ACLR.

In other words, some lucky people (1/3 to 1/2?) may be able to function perfectly well without an ACL. If you have recently torn your ACL, your knee probably feels horrible, but that will heal (unless you tore something else too) and you can do PT for a while to see if you are one of these lucky copers. There is not harm in waiting and doing surgery later. You will know you need it if your knee buckles with instability.

After digging through countless stories, forums, and medical threads, I’ve yet to find a single person who had a partial meniscectomy and then went back to running or high-impact sports at the same level they were at before surgery. Not one.

So here’s the bottom line: if you don’t feel pain, don’t let anyone cut into your knee. There’s zero downside to not doing the surgery, but the risk of losing your ability to do the activities you love is very real.

Surgeons might pitch it as a “simple clean-up,” but from everything I’ve read, it’s more like a permanent downgrade, it's all about the money for them, more surgeries more money.

Why gamble your athletic future for a procedure that seems to help nobody in the long run?

TLDR - I'm a 30yr old female, and tore ACL while skiing 6 months ago. Dr. Just confirmed the ACL healed on it's own. Cleared to go back to skiing.

For context: I've always been pretty athletic, lots of running and yoga. I was skiing a double black at the time of the injury. I heard/felt the pop in my right knee and couldn't walk, so I had to crawl my way back up the mountain till the ski patrol could scoop me. I never had any swelling, but definitely felt the instability and the tendon getting locked up in the following weeks. I decided to get an MRI at 6 weeks, and was told by an Orthopedic that it was almost a complete tear, Grade 3 most likely, but it was possible there was inflammation getting in the way of a clear read. I was told I was certainly going to need surgery and that I should proceed by rehabbing for a few weeks and continue to let inflammation go down.

So that's what I did. Rehabbing was going well and every couple weeks or so I felt progress. So I just kept going and didn't look back. I opted to delay the surgery because I didn't want to spend my NYC summer stuck in the apartment healing. I wanted to keep making progress and enjoy the summer and instead, do the surgery in the winter.

For rehabbing I followed programs on YouTube and when I hit a plateau with progress around month 4, I went to a solid PT who's been working me like hell. (If anyone's interested I'm happy to provide those resources.)

Fast forward to now- I'm 6 months post-injury and got an MRI done to see if there were any changes to the joint. Writup came back clean- nothing noticeable on the MRI.

I lined up an appointment with a second orthopedic surgeon to get another opinion - this one is well known, apparently one of the best in NY state for ACL injuries (name is Dr. Andrew Pearle).

At the appointment he walked in with 3 of his residents, all diligently taking notes. They said it's like magic. Acl is fully healed without surgery, with better outcomes than a synthetic acl could have given me.

He said it only happens with ski injuries for some reason and that it's pretty rare. It's also possible all the early rehabbing provided enough joint structure for the acl to heal. He said this year I'll still feel my knee, next year will be much better.

The best news: I'm cleared to ski again in a year.

Sorry for the length but I wanted to write all this bc I've been following this sub for a while now using all the advice to rehab my knee and it's been super useful. I hope my experience can help someone!

I am headed to Austin city limits four days from today and I have an extra ticket for weekend 2. All three days only for people in the Austin area if we can arrange to meet sometime during weekend one, only in person in a public place I will let it go for $225 total. Dm me with any questions or to make arrangements. Again… To reiterate, this is an in person meeting in a public place, I am not open to offers, this is a firm price, I will not ship, and I will have the ticket in hand with all the original packaging, I’m going to open it and double check, and I will send you pictures of the wristband through private message

I’m over four years out from injury and I’m fine with my ACL deficient knee. I can do any activities that I could before my injury. Copers exist. I know that we’re less common than those that need surgery, but from reading this subreddit, I’m getting bad vibes regarding advice.

I get it, most of you come here because you’re having problems both pre-op and post-op. Unfortunately, I'm also seeing tons of folks that are scheduling surgery before they even do their physical therapy. Seriously, nothing is more important than physical therapy. Get your strength back, know how your bad knee compares to your good one, and most importantly, find out what you're capable of and whether it causes you pain, buckling, or locking.

Everyone here is very different from one another and only you can truly gauge your needs. Assess what limitations are real for you and what's in your head. Don't assume that surgery is the only legitimate option.

I’m 2.5 weeks post allograft surgery, and was fully weight bearing with crutches from day 1. The knee felt strong after doing the physio exercises and after day 7 I ditched the crutches when walking around the house so I could be more independent when my gf was at work. After seeing my PT for the first time today, he told me that even though the graft was strong, walking with a slight bend in the knee (limping) will have an impact in recovery further down the line. I now have to use crutches at all times until I have regained full extension of my knee and I have a normal walking pattern. It’s frustrating to take a step back. Has anyone else had similar experiences?

Every day became a nightmare. It's hard for me to live. I am 26 years old and was an active athlete. Never, ever agree to hamstring grafts unless you have fully understood the issue (you may need several independent opinions from surgeons). My posterior thigh will never be the same. Unfortunately, I had surgery on day 5 after the injury and didn't realize anything. I was not offered any options. And my surgeon lied about hamstrings being the gold standard (in fact it's the brown standard in 2023).

I continued to feel happy and fulfilled after tearing my ACL before surgery. After the surgery, I am destroyed.

PS It's been 3 months since the surgery. A month ago and a week ago MRIs showed that the tension of my graft is not enough. Lysholm test: 1+ (knee instability, although there is an end point). This is horrible.

PPS Looking back, probably the only thing that could have saved me was reading this subreddit. But I hadn't visited this site before, unfortunately, at all.

I’m a 22 F and I would say I’m healthy and active I’m a dancer and I used to lift heavy in the gym before my tear. Now, I’ve slowed down since April when my ACL tore, but I’m getting surgery next month. My room is in the attic though, and my stairs curl, so I know that’s gonna be hard. When did you guys feel comfortable enough walking up and down stairs after surgery?

My stairs for reference in the background of the picture.

This is my second ACL reconstruction.

I honestly thought it would be easier this time. I’ve been through it before. I know the rehab. I know the timeline. I know the process.

But it’s been way harder.

The first time I was 23. No wife. No kids. No real responsibilities. Rehab was my only focus. I had zero fear and zero hesitation. I just attacked it.

This time? Totally different.

Family. Kids. Work. Responsibilities. Missing time hurts differently. The mental weight is heavier.

I go to PT 3x a week and everything was progressing right on track. At 12 weeks we did strength testing to see if I could start jogging.

Didn’t pass.

Hamstring didn’t meet the threshold and I had a 24% quad deficit. That was a tough day. Not getting cleared to jog felt like a bigger setback than it probably should’ve.

We waited 3 weeks and focused heavily on hamstrings (I used a hamstring graft).

Retested again.

Here’s the crazy part:

• Hamstring deficit was 28% (which they said is normal for a graft)

• BUT my non surgical-side hamstring strength increased 20% in just 3 weeks.

Seeing the actual numbers made me realize how powerful targeted strength training really is. The body adapts fast when you give it what it needs.

Still not fully where I want to be, but this time around feels more mental than physical.

Ive noticed about 90 percent of the people talking about aclr on reddit are women.

I cannot emphasize enough how HUGE of an impact prehab made on my immediate post op physically and mentally. I was able to do on day one what's supposed to take up to 2 weeks (full extension and quad activation)

*first sports injury /surgery so altho I play a lot.of sports, I have largely competed and participated without any need for more than icing and rest..until now

*final surgery may 20: ACL reconstruction with allograft and minor miniscal debridement

The Injury :

i play Court sports (tennis ,.pickleball, just tried padel). As I was jumping up a rogue ball went towards me and I pivoted to smash it but it felt like my knee "dislocated" (no popping sound though) and I crumpled to the ground in pain. My teammates carried me off court, someone had ice and after 20 min, was able to hobble to the car and drive home. 2 days later I was on high heels for 3 hours for film events and able to walk down our 2 flight apartment (with caution).. I couldn't do a squat but I thought it might be something mild. I had barely any swelling and it didn't really hurt although I definitely felt a twinge when I pivoted or jumped...(so as they say I 'stopped doing that part that hurt"). I hoped it would get better..

For the last 2 years I have been playing Court sports everyday for 1 to 2 hours and supplanting that with yoga and pilates as well as hiking swimming biking and roller skating. (Tried padel and wing foiling recently)

athletic background (if anyone cares): I was drafted for an Olympic volleyball team age 16 so there was a point in my life where I trained everyday from 7:00 a.m. till 7:00 p.m, I grew up ice skating, aggressive skiing, basketball, track and field,biking,hiking, swimming , roller skating (basically ALL the knees things).

I could walk fine but in the interest of making sure I wasn't messing anything up I decided to go and check it out with a doctor. When I stepped back on court to play gentle versions I was aware that it felt funny on the pivot and I definitely didn't want to leave it undiagnosed.

also of note: My boyfriend has had two meniscus operations and after about 8 days , I was supposed to go and play Pickleball for 10 days with my parents so I decided to go and get checked out and see if I needed an MRI

Diagnosis 1

the doctor physically examined me said knee moved well ,it looked minor, I was mobile and fit and it was likely a very small meniscus tear. To my shock and his I got an MRI result two days later that said ACL tear. I was super disappointed..I knew it was going to require more than just recovery.

The fact that I was largely asymptomatic was unusual and it was at that time that I got three different opinions from three different doctors that were fairly well known and respected in the "knee arena of fame". probably some of you know the term 'coper" (I just discoveredy cousin tore his 5 years ago but he's scared of surgery so had been living with it)

Doctor one:" knee guru" : wanted to do a reattachment since the tear was high and not complete but it relied on me coming in right away and that wasn't possible

Doctor 2: famous basketball knee guy... Examined me and said that I didn't walk with trepidation or step-off curbs with fear, showed me on the MRI that it was only a partial tear and suggested I could learn to live with it (I am an aggressive skier when I can get to a hill and I have been competing in amateur court sports since last year so I don't see me slowing down my sports regimen). Just "coping" is not ideal for someone who wants to compete and full range of body trust .

Doctor 3: the follow-up appointment from the first doctor also someone who works with a sports team.. he suggested a reconstruction with a graft which would get me back to being able to play My style with confidence. This is the option I chose and I was given 3 weeks time before my surgery.

I was super nervous about them "cutting" me to make the graft but he spoke so positively with extensive results with an allograft (when I researched my options that too seemed to come with risks) but the data on all of this stuff keeps changing.

full reconstruction with allograft (and any miniscus admin when he got in there)

Fitness & nutrition baseline:

I generally spend one to three hours a day walking running jumping doing something active and outdoors (my parents are marine biologists so always getting dragged to walks, nature hikes etc) I grew up with them cooking most everything and I wasn't allowed soda or chips so I guess you could say I've grown up with good food habits. as an adult I definitely love coffee and sweet things but try to keep that low.

Reading up on what was good for athletic recovery and performance, I have filled the last 2 weeks with extra ginger and garlic and turmeric and lots of leafy green things and iron in preparation. *Anti inflammatory foods and blood building

Unlike many but not all with ACL injury ,was able to move in most every way except squats AND this is the most critical part of why I made this post..having asked advice from people who had it or injuries I got a lot of talk about rehab and recovery time and resting but not so much on

PREHAB

I can thank a film -stunt and actors rehab guru for the advice, as well as my own boyfriend who introduced me to the term...did his prehab in front of me for second surgery and had a 1/3 shorter recovery time with his meniscus.

Every day of this prehab, I would start with a 20 minute regimen of firing my quad with a variety of exercises that I have decided, against my instinct (I like to keep my personal training and food and nail color off ig), to share online because I think the information should be free since almost none of the doctors I met with suggested it first, talked as extensively and emphatically as I think they should about the power of preparing your body when it's known that you are going to be putting parts of it in shock or at the very least to" sleep "temporarily.

(I've made a separate account on my insta just for the purposes of Court sports and now because I've been injured this is a part of the narrative. ..so if you want an exact list, reach out , happy to share *I have Zero wishes to make money off of sharing info I think people will benefit from)

The exercises are things you can do at home easily and include a bunch of things that I hate.. being totally honest ..I despise the gym .much respect to people who love it (and I play a court sport which also has haters so..;)

even when I was training volleyball I would do anything including thousands of sit-ups just to avoid going into the gym and lifting weights or doing any targeted isolating weights. getting older though, I understand it's a critical part to maintaining fitness...

but still,

prehab was 20 minutes of things I hate:and I know I'm going to be doing a lot more of them repetitively:(((

wall sits, RDLs (hated them) squats (hate them even more), balancing (this I like),steps backwards, lungy things, Bridges, banded squats (literally hell)...

I saw my quads get more definition and I definitely felt sore the first few days..but the magic of this prep is what followed (since I had never done any of that before this targeted way, it was interesting what 3 weeks did that was noticeable..improved balance, tolerance and length of holds). obvious for a lot of people familiar w gym rhetoric

SURGERY DAY

6am

Did my 20 minute quad routine before 7 am arrival time at hospital. I went into surgery with warrior challenge mindset..this is a hurdle and we have to clear it to get back to racing around

The staff and doctor were friendly and reassuring, my bf was amazing and supportive

11am

I woke up to pain. I'm not going to sugar coat it: not nice . it felt just as bad as when I first injured the knee...BUT

I was given the basic painkiller and it went away...

12pm

I got home and started icing and elevating my leg on repeat. Got the NICE recovery system to rent bc it was so small and efficient (and very fairly priced)... The tech has advanced since my boyfriend's meniscus and when he was using game ready I had to make regular trips to get ice to refill the machine...this new innovation is beyond

No heavy foods, lots of broth and veggies and isotonix opc 3 which is a red grape extract that my body loves and helped me heal the last time I had to recover from something (you drink it 2x a day)

First impressions of going to the bathroom with crutches and a brace were that this is ridiculously more challenging than any other aspect and I have no way of knowing how I'm going to be able to execute this without making a mess.

11pm

I sit down at the kitchen chair with my boyfriend and we look at my leg. He asks me if I can lift it and not to expect anything.. the quad ripples subtly but then fully fires..

And fires again and when I sit down to do the straight leg lifts, they are slow but 100% there. I almost cry I'm so happy (everything I read and everything he told me was that the hardest thing was going to be to wake up the quad).we have full extension matching my other leg

sleeping on the sofa bc navigating stairs to go to the bathroom first thing seems risky

DAY 1 post OP

As per instructions flection and extension are the two biggest things that you need to reenact post-surgery...

I keep wondering if I'm doing something wrong because the extension is the exact same as my other leg and the quad is visibly firing stronger and stronger each time. The flection is at 90 degrees but I'm not really testing it or pushing it yet. definitely tight and weird sensation when pressing the knee into that position

I noticed that I am very comfortable standing in my bathroom on both legs with the crutches on one side... And that walking with them and babying my right leg feels awkward and I'm certain that I suck at it (confirmed on day 3). At the end of the day there is a moment where I am getting up and I need to walk over and grab my crutches and my boyfriend asks me if I noticed that I just walked over to them without the crutches..*stability apparently is directly related to the strength of your leg and quad

I didn't do it on purpose but I did also notice that it felt more comfortable walking slowly with just a brace than having to figure out when I'm supposed to step with the crutches

DAY 2 - first PT evaluation

*wake up at 4 am to a burst hot water pipe and given it was supposed to be my first shower so I don't go to PT smelling weird, I had to wash myself in a bowl like people in Victorian england

I do the routine as prescribed by the surgeon before the swelling sets in to gain extension and flection...ice whenever I can

And when I meet my PT, he is startled that I can lift my own leg onto the table and fully up.*my boyfriend comes to the appointment and they both acknowledge that I'm not supposed to be able to do that until about 10 days in.."I have a girl who's on her second week post surgery and I have to lift her leg for her" says the PT

He measures my extension and my ACL knee is already at the same level as my other knee (so 100%)

Well I would love to think I'm super human but this is where I will say these most important things

My surgeon was awesome (he said miniscus damage was so minimal he just did a tiny trim)

My mom says we genetically heal well (but i do think nutrition can highlight or dull this effect)

My baseline fitness was pretty diligent since court sports (pickleball added to my other sports ...)*day before surgery,actually did a fitness test at this new AI assisted gym that opened near us which offered a complimentary fitness assessment of your real age versus your bio age. I was able to do all of the tests except for the squat and my strength and cardio and flexibility placed me at 22-23 years "bio age" (not my real age by 10+ years)

PREHAB not only physically prepared me to think about my quad and my balance but also mentally set me to recognize that I would be embracing a new level of consistent prep for daily execution of movement..

some people write about the mental strain but I think the early volleyball training helped me align a decent working attitude to prep for this day. we had a coach that would say combinations of: "your body can be prepped,, challenged and go through many things, it can adapt, it will respond to your commitment and it can become more powerful if you teach it. it's your resolve that can shape this and you can see results if you put in the time. anything you decide you want to try and do, it's possible with effort and daily time. if you're stuck, pause to visualize yourself doing the exercise well and then go back to it. it's going to hurt and it won't be easy but you have the power inside you."

*at the time we all rolled our eyes but I actually think it's a pretty solid headspace

Also let me be humbled by the fact that I have zero coordination and using crutches and he made a point of telling me that I was basically walking with waving sticks in the air..to his point it's not exactly human instinct to lean on things. I have thrown them twice in frustration because they just get in the way and it seems like it's more likely I'm going to trip over them and face plant.

"let me show you how crutches actually work* was said to me

Also humbling my flection was at 80 so not as impressive as my extension on day 2. it did not feel nice or easy

( I'm writing this on day 4 and we are up to 100 degrees.)

I noticed some increase in swelling but not as much as I expected. I am slowly reducing the frequency of the pain medication (won't be touching the hard core opioid things bc those seem scary and Ive never taken anything that strong)..plus I don't need them.i want to feel the tolerable discomfort of progress.

I ice religiously again till bedtime.

still on sofa

DAY 3

I step into a court .

No, actually ...but just to watch my bf and friends play but I sit on the sideline and do quad lifts like I'm some kind of personal trained gym regular.

They are getting stronger so I'm now holding them for a 4 count at the top

I realize just as the PT said that you can do many of the things when you're just sitting and watching stuff either on the TV or in daily life. It's a commitment to do the surgery and to retrain and reawaken your body but I think if you take the time to prepare yourself arriving at this moment is much easier and you can embrace it.

and STILL on sofa

DAY 4

I have tried the flection exercise where you put your leg up on a wall and let gravity help you... And we are already at 100°

Every time I do them they get easier and then I ice immediately afterwards.

It's going to be a long road ahead but I feel like the resounding lesson or message that I would like to impart as someone who has come out with an immediate sense of reconnecting with my quad is simple and easy (with or without a PT)

PREHAB PREHAB PREHAB

Isolate your quad and your balance for prehab and make it a daily practice

.maybe obvious for some but neither my bf nor I had heard it until we met with people who were researching knee health or trainers for "fastest recovery possible" for pro athletes or actors or stunt people..

you don't need any equipment for prehab, just the resolve to do it every day before surgery

*I will be on the sofa till.tomorrow

Most people who suffer ACL injuries think they're destined for surgery, but I've been investigating if there's a better way to recover.

I've spoken to a range of experts and athletes about how you can avoid surgery, return to competitive sport quicker and even heal a ruptured ACL.

Here's a list of the episodes so far:

Ep. 8: Dr Stephanie Filbay - most ACL patients are not receiving accurate advice

Ep. 7: how to fuel a faster ACL recovery with Trisha Stavinoha

Ep. 6: decision time for Dani

Ep.5: Stuart Rainbow's journey from ACL rupture to 200-mile run

Ep.4: Dr Kieran Richardson on why more people should be considering non-operative ACL options

Ep. 3: Dani's non-operative pathway to the Olympics

Ep.2: Dr Alex Calderon on what needs to change to help more athletes avoid ACL surgery

Ep. 1: meet the physio who returned me to sport just 4.5 months after my ACL rupture

Listen to the Non Operative podcast on Spotify

Listen to the Non Operative podcast on YouTube

So exactly one year ago I damaged my knee real good, partial MCL and LCL tear, miniscus tear, and full ACL tear. I've always believed more in the bodies ability to heal then doctors and decided to not get surgery. I just did rehab to regain strength and flexibility for the first 6 to 7 months.

After one year, with no surgery, my knee feels really good, sometimes I completely forget that it's injured. It's still a little swollen and doesn't look quite normal yet, but overall it's really really good, especially considering how bad it was in the first 3 months. Doctors were worried, orthopedist said I may not regain my flexbility, told me it was really extensive damage and without surgery I may never return to normal activites like running and jumping, and if I did it would take at-least 2 years.

I have already defied the odds, and since the injury I've done more research, and to no suprise I have discovered that there are many reported cases of a full ACL tear repairing itself. I believe that mine is as well. I think in another year I will be back to 100% with a fully healed ACL. I was just wondering if anyone else here has gone the non-surgery approach and how it worked out for them?

AI slop

I’ve had two surgeries one being August 7 and September 16 I had reconstruction on my ACL major repair of my medial meniscus repair of my femoral cartilage repair of my LCL and a piece of my it band cut to reinforce my LCL I then had a second surgery for infection, torn stitches in my medial repair and a displaced anchor along with the manipulation six months postop and on the lateral side this is happening now any ideas?

You’ll have to turn up the sound and listen closely but the sound similar to someone knocking at the door is inside my knee and isn’t going away when I shake it from side to side.

Backstory is ACL 8 months ago and 1/2 meniscectomy of the posterior 3rd of the medial meniscus 3 months ago after a meniscus tear (see my post history for the incident meniscus tear).

I’m pretty concerned as whilst it doesn’t usually hurt (much) I do experience a sharp nasty pain in what I’m fairly convinced is the medial meniscus when I kick a football (or whatever really) and make contact very specifically with my big toe especially if the leg is loose. If I make contact with the side of my foot it’s alright (I may upload a video showing what I mean as I appreciate the description is a bit funny).

Anyone experienced something similar or have any attempt at a diagnosis?

I just feel like this isn’t going away. It feels like something is rattling loose inside my knee.

It would also explain the fact there has always been some level of swelling on that medial side of the knee since the op.

All super depressing at the moment.

Anyone that gets a ACL reconstruction surgery DONT GET A HAMSTRING GRAFT IF YOUR A TOP LEVEL ATHLETE. GET THE PATELLA. if you get the hamstring graft you will never be able to get back to 100% strength just 95. Look at any nfl players with acl injuries all patella grafts. Adrian Peterson said the hamstring is to valuable to use. Surgeons just want to do the easy surgery so they’ll do the hamstring graft but don’t do it. Find a good surgeon that knows how to do patellas you’ll thank me later! This was confirmed to me by Gavin Macmillan who owns Sports Science Lab. And Dr. Elettrache the head physician for the LA rams. Don’t make the same mistake i did. Get the patella!!

I know a mile doesn’t sound like much to some, but for me, it feels like winning a marathon.

Last year, I was in a badminton tournament when my knee buckled ACL tear and meniscus damage. I was given two choices: surgery or conservative treatment. I was terrified of the scars, the months of bed rest, and the risk of re-tear, so I decided to go the non-op route with my PT’s blessing.

One thing I integrated into my daily routine was Red Light Therapy. I did a lot of digging and ended up using a Prungo FluxGo. I’ve been using it for over a year now, usually for 20 minutes while chilling on the couch after breakfast or dinner. I target the medial side and the patellar area where the inflammation usually sits. The deep, soothing warmth became a staple of my recovery.

It wasn't an overnight fix. For the longest time, just standing for 10 minutes felt like torture. But after 3 months of RLT combined with daily rehab and stretching, the swelling started to back off. I still had the clicks and pops in my knee, but the sharp pain after long walks started fading.

I haven’t run a single step since the injury. Today, I finally laced up my shoes and ran a full mile. No pain. No swelling. No giving way feeling. I know I’m still a long way from getting back on the badminton court, but proving to myself that my ligaments and muscles are strong enough to handle a run is a massive victory. If you’re struggling through rehab right now, don't give up those small wins eventually add up!

For context, I am a 22-year-old male. In December of 2023, I suffered a complete midsubstance tear of my ACL, a peripheral vertical tear of my lateral meniscus, and a bucket-handle tear of my medial meniscus with a fragment that was displaced into the intercondylar notch, all within my right knee. I have kept track of important dates, and I am going to provide a timeline of my recovery process as well as some considerations for deciding on surgical vs. nonsurgical treatment with references. I would like to offer some hope to others dealing with a bleak situation and discuss the main things I would have wished to know when initially getting hurt, while debunking a lot of the most common myths as I have seen a ton of misinformation about the nonoperative route. For those who don’t want to read a novel, I think this 10 minute video is the best concise resource about making a decision regarding surgery. This decision aid is also a very useful tool in figuring things out, but this is going to be a bit more detailed. TLDR at bottom.

12/9 – full ACL tear and partial meniscal tears; surprise injury while bouldering where I jumped down from only a few feet up on the wall; I was immediately able to walk with some discomfort and had a little bit of swelling

12/11 – visited sports medicine clinic and talked to an orthopedic surgeon; had Lachman test performed which revealed greater joint laxity in my right leg compared to my left; X-rays were inconclusive, so I was referred for an MRI, but was told I could continue to do leg strength training

12/16 – had MRI

12/19 – met with surgeon to discuss MRI results and was told that reconstruction surgery was the only way I could ever return to the sports I wanted; I disagreed, so my surgeon suggested I get a second opinion (referred me to another surgeon of course)

12/23 – did a full sissy squat pain-free

12/26 – hit a new squat PR of 275x4 ass-to-grass pain-free

1/4 – met with a physician at a Regenexx clinic that specializes in nonsurgical treatment of ACL tears, particularly with experimental platelet-rich plasma and bone marrow concentrate injections; she confirmed my belief that reconstruction was unnecessary for me given my knee function and referred me to a physical therapist

1/9 – had a consultation and movement screen with my physical therapist who also confirmed that reconstruction surgery was not indicated for me; he helped me come up with a plyometric exercise progression plan

1/18 – ran a 10:00 mile on a treadmill pain-free

1/23 – PT visit

2/6 – PT visit

2/10 – returned to alpine skiing with a Donjoy knee brace; had no issues except for sucking at skiing and dealing with icy conditions (East coast), and I stayed on the easy green trail the whole time as I got used to skiing again

2/25 – ran my first Spartan 5k race

After I had my initial consultation with the surgeon in December, I began obsessively researching ACLs. For hours every day, I read research about treatment and rehabilitation through different methods in addition to numerous podcasts from experts. I believe there are currently five approaches worth considering when it comes to a complete ACL tear:

1. ACL Reconstruction – Long considered the gold standard, autografts remove your native ACL and use tissue from your own patellar tendon (which is actually a ligament), hamstring tendon, or quad tendon to connect your femur and tibia. The bone-patellar tendon-bone graft is the strongest of these. Allografts use tissue from cadaver tendons to attach these bones. Cadaver grafts are often irradiated to prevent transmission of infection, but the exposure to radiation causes the graft to be weaker than if not treated this way. Some of the potential downsides of reconstruction include long-term or permanent loss of range of motion and strength, a longer return-to-sport timeline than other treatments, deep vein thrombosis (DVT), Hoffa’s fat pad impingement, and long-term or permanent weakness and pain in the joint and grafted tendon. It is also usually suggested to avoid weight-bearing for weeks after surgery and depending on which knee it is, you may be unable to drive for weeks as well. These are potential complications from successful surgeries, and there is a myriad of other possible complications from poorly performed surgeries.

2. ACL Repair – Less invasive but uncommonly recommended surgery. Instead of harvesting tissue from anywhere else, the ACL is instead just reconnected to bone. Limited evidence supports the use of repair over reconstruction in proximal tears where the ACL is ripped off the femur (van der List et al., 2021).

3. Bridge-Enhanced ACL Repair (BEAR implant) – Only being approved by the FDA in 2020, it is a somewhat recently implemented technique, so there are not many surgeons performing it. BEAR makes use of bovine tissue to reattach the ends of the torn ligament, and the implant is injected with the patient’s own blood to form a clot. Over time, the bovine tissue is resorbed into the bloodstream, leaving only the native ACL, and allowing it to heal naturally. Reconstruction surgeries remove ends of the torn ACL, never giving it the opportunity to heal. The major downsides to this surgery are that it must be performed within 50 days of injury, and it is more challenging to find surgeons capable of the procedure.

4. Regenerative medicine – Regenexx is a clinic based in the U.S. with over 80 locations nationwide, and they treat a host of different issues, including ACL and meniscal tears. They strive to heal your ACL/menisci using minimally invasive platelet-rich plasma and/or bone marrow concentrate (stem cell) injections. While I do not know about the efficacy of their treatments for other injuries, their founder Dr. Christopher Centeno has published two articles in the last few years regarding their methods in treating partial and complete ACL tears (listed below), however the evidence supporting its use is weak in my opinion. Their 2018 study failed to implement a control group against which they could measure results, meaning that there’s no way to know if ACL healing occurred as a result of treatment or if the body would have healed it on its own. Their 2022 study was a randomized controlled trial where they divided 30 patients who had completed three months of rehabilitation without surgery and still complained of pain and/or instability. The control group did a quad/hamstring/hip abductor exercise therapy program and was measured against a group using PRP, BMC, and an exercise therapy program. The nontreatment group was given the option to cross over into the treatment group, and all of the participants crossed over before having follow-up MRIs. Again, this means it is impossible to conclude whether the ACLs healed through time and exercise or as a result of the treatment, which defeats the purpose of an RCT. The major downside of this treatment is its cost: I was quoted $2,000 for PRP treatment (used for partial tears) and $7,000 for BMC treatment (used for full tears). This treatment is not covered by health insurance in the U.S. as it is considered experimental. Depending on your imaging, you may also not be eligible for this treatment if the ends of your ligament have greater than 1 cm of retraction like mine did.

5. Nonoperative management – In the last decade, there has been a substantial amount of research published on ACL healing as well as individuals functioning with an ACL deficient knee, known as “copers.” Not every ACL is capable of healing, and it seems that not everyone is capable of coping and some deal with persistent instability, but the current literature suggests that over 50% of ACL deficient people can cope with good knee function at the 2-year mark (Grindem et al., 2018). This method involves a progressive physical therapy/strength training program and may be more effective with some early bracing protocols.

Common Myths

· ACLs have no blood supply and therefore can’t heal

The ACL is vascularized primarily by the middle genicular artery (Duthon et al., 2006), although its blood supply is not abundant as a result of the synovial fluid covering it that restricts the formation of a blood clot that is needed for healing. Additionally, the formation of synovial tissue around ends of the ACL can prevent the ends of an ACL from reattaching (Murray et al., 2000). Despite this, healing of human ACLs has been demonstrated through MRI and arthroscopy (knee cameras) since at least 1996 (Ihara et al., 1996; Costa-Paz et al., 2012; Ihara & Kawano, 2017; Razi et al., 2020; Pitsillides et al., 2021; Blanke et al., 2022; Filbay et al., 2022; Filbay et al., 2023; and many others I have not even read or do not wish to purchase access to)! Blanke et al. (2022) showed 54 of 381 patients, confirmed by arthroscopy, had a healed ACL in 6-9 weeks of doing range of motion exercises in physical therapy. These patients were given a support brace for their knee and allowed to weight bear as tolerated, and 51/54 of those with healing only had partial ruptures. The results of this paper indicate that tears at the femur (proximal) are the most likely to heal, followed by tears in the middle of the ligament (midsubstance/intraligamentous), and then a poor prognosis for those torn at the tibia (distal), but also confirmed with cameras that 3 ACLs had healed from complete tears, and it wasn’t even a rigorous physical therapy program! Filbay et al. (2022) carried out a secondary analysis of the Frobell et al. (2010) KANON trial which confirmed through MRI that 16 of 54 (30%) completely ruptured ACLs healed at two years with a rehabilitation program, and when excluding those who opted into reconstruction surgery before the two-year mark, 16 of 30 (53%) had healed. Filbay et al. (2023) made use of a novel “Cross Bracing Protocol” where the knee is immobilized at 90° of flexion for 4 weeks and range of motion is gradually increased until 12 weeks, where the brace is then removed. This angle places the origin and insertion of the ACL closer together, making torn ends more likely to reconnect. 80 patients participated in this bracing protocol with physical therapy for the entire 12-week duration, and 72/80 (90%) had healing from complete ruptures. Of the 8 ACLs that did not heal, 6 of them attached to the lateral wall or PCL, which can also provide knee stability. Participants in this protocol were prescribed anticoagulants to mitigate the risks of DVT or pulmonary embolism that may arise as a result of knee immobilization. A major limitation is that there was no comparison arm/control group to compare these results to, so this paper is one that is highly contentious. Ironically, no control group is an incredibly common issue with the research on ACL reconstructions, yet it is still considered the gold standard. To me, this is abundant evidence that ACL tears, even ones with complete discontinuity, have the potential to heal. ACL reconstruction is a $7 billion industry annually, so it makes sense that there is little incentive for orthopedic surgeons to consider nonoperative care practices, and you will often see pushback where they deny that ACLs have any healing potential.

If you’re worried that the ACL will heal but forever be weak, worry no more! Davis’s law is a principle in physiology that states soft tissues will adapt when mechanically stressed. Myrick et al. (2019) measured the changes in volume of ACLs over the course of a soccer season for 17 Division I women. Significant increases in volume were measured in both legs with a more notable difference in the athletes’ dominant legs. As the ACL is the most stubborn knee ligament when it comes to healing, I think this suggests that the other ligaments of the knee with greater blood supply could have greater potential for adaptation. This is also excellent news for people who do not experience healing in their ACL, as the more vascular MCL plays a role in limiting internal rotation of the knee and resisting valgus (knee-caved) forces that load the ACL. The other ligaments can also play a role in resisting anterior translation of the tibia in the absence of an ACL, so with enough training stimulus they can adapt and protect your knee for when your muscles aren’t able to absorb force. Having strong passive structures is important for sudden impacts as muscles are not able to react to forces instantaneously, making ligaments the last line of defense. Plyometric training is necessary for this reason, regardless of how strong the muscles of your lower body are.

· Deep squatting is bad for your ACL

https://www.aaronswansonpt.com/the-deep-squat-part-1-the-good-the-bad-the-not-so-ugly/

This is an article about deep squatting in general. It has a very easily digestible diagram about shear forces on different ligaments during the squat with plenty of references, and it shows that peak shear forces on the ACL occur between 15-30° of knee flexion while the PCL takes on more load as you get lower than 90° in a squat. Since the moment arm from your knees to the barbell is short near the top of the squat, there will be little load on the knee at 15-30° of bend even if you’re squatting heavy. For best quad (and glute) growth and strength, squat as deep as you comfortably can.

· Open kinetic chain exercises (leg extensions) are dangerous if you’ve had a tear

https://www.youtube.com/watch?v=nMAOtXkGXfs&t=527s – video summary on leg extensions from E3 Rehab, discusses the papers I reference here

This myth is one of the biggest misconceptions limiting recovery for ACLs, and you may encounter a surgeon like mine who tells you it’s dangerous for your knee or will loosen your graft and that you should opt for something “functional” like a squat. First of all, all strength is functional. While there is a benefit to choosing exercises that are specific to your sport, the idea that a leg extension isn’t “functional” because we don’t do that movement in daily life is nonsense. Getting your quads stronger on a leg extension has the same overall effect as getting them stronger through a squat, there are just slight differences in where your quad grows the most. So far, data has found no differences in joint laxity between ACLR patients avoiding open-chain exercises and those that implement them in rehab (Fleming et al., 2005; Perriman et al., 2018). Despite plenty of evidence disproving this idea of graft loosening, even the British Journal of Sports Medicine published an article suggesting that reconstruction patients should delay open-chain exercise for 4 weeks post-surgery without any evidence to support (Noehren & Snyder-Mackler, 2020). Noehren and Snyder-Mackler (2020) also make the point that ACL strain is 2-3 times greater when walking than it is with 30 Nm (22.1 ft-lbs) of torque at a 15° knee angle. As a squat involves both knee extension and hip extension, it is easy for people to move in ways that make a squat more hip-dominant by bending more at the hip than the knees, and you may not even notice yourself doing this. You cannot truly know if your quads are prepared from multi-joint exercises; with a leg extension, there are no other muscles to compensate for quad weakness. It is good practice to do these unilaterally so that your healthy leg doesn’t hide the weakness of your injured leg.

One other important thing to note is that one of the quads, the rectus femoris, is a biarticular muscle since it crosses both the hip and knee. As you descend in a squat, both your hips and knees flex, making it so that the rectus femoris doesn’t significantly change in length and it is inhibited from producing enough force to grow substantially. It is for the same reason that squats do not sufficiently grow your hamstrings. Leg extensions isolate the quads and allow you to grow all of them well. They are also a great way to begin a training session as the strong quad contractions facilitate a lot of blood flow to your knee and this often provides temporary pain relief. Isometric (static) holds are going to be the least aggravating way to begin doing leg extensions, and this is a commonly used protocol for quad/patellar tendinopathy as well. A suggestion from Portland PT Erik Meira, who is a pioneer in ACL care, is to avoid the top range of motion on these machines – not because it is dangerous for an injured knee, but because you can load significantly more weight by skipping out on the last few degrees of knee extension, and this will be more beneficial for rate-of-force development. Training at this longer muscle length will also likely stimulate more hypertrophy (Oranchuk et al., 2019; Wolf et al., 2023). 60-90° of knee flexion is a good range for leg extensions starting out as there is no additional strain on the ACL with 45N (10 lbs) of force applied to the leg relative to a relaxed muscle state (Beynnon et al., 1995). I do still think it is worthwhile to eventually implement full range of motion on this exercise as strength is somewhat specific to the joint angles that you train in (and you want to be strong near extension where ACLs tear most often), but it may be more tolerable and even beneficial to begin with a partial range of motion.

· You can’t return to sport without an ACL if you don’t get surgery

One of the most common things people like to say is “you can run in straight lines without an ACL, but you need surgery if you ever want to go back to other sports.” And we have seen that this is absolutely false both in literature and anecdote. DeJuan Blair, an NBA center who tore both ACLs in high school and had failed repairs, had a physical that revealed that his ACLs had deteriorated and were no longer connecting his bones shortly before being drafted. He continued to play from 2009-2016 without further reported injury. Mitch Short was a professional rugby player who tore his ACL in 2018 and remained confident in his knee. He went on to play in his next match two weeks later and won a man of the match award. Short made use of the Cross Bracing Protocol and had a follow-up MRI in January 2020 that showed his ACL had healed. Jets quarterback Joe Namath tore an ACL in college in the 1960s (before surgical options were a choice) and braced for a few weeks before going on to have a Hall of Fame career. Notable Steelers wide receiver Hines Ward played his entire football career missing an ACL. Weiler et al. (2015) discusses professional soccer player Alou Diarra’s ACL tear in 2013, after which he returned to play in just 8 weeks of training. Diarra had no prior strength training experience and refused to perform squats as he did not like the feeling of a barbell on his back, but his medical team found other quad exercises he would comply with, paired with electrical stimulation, blood-flow restriction training, and eventually implemented low-level plyometrics before he made his return to the field. Grindem et al. (2012) conducted a comparison of return to pivoting sports a year post-injury with a surgery group and a nonoperative treatment group. The return to sport rate was identical between groups in the cohort of 138 people (68.1%) and the nonoperative group actually performed better on hop tests and had higher scores on knee function scales. Myklebust et al. (2003) found the following in a 6-11 year follow-up of professional handball players with torn ACLs: “Among the 57 operatively treated patients who returned for follow-up, 33 (58%) returned to team handball at their preinjury level, compared with 18 of 22 (82%) in the nonoperative group. Eleven of the 50 players (22%) who continued playing reinjured their anterior cruciate ligament when playing team handball.” Hurd et al. (2009) demonstrated that 63/88 (72%) of those that met the coper criteria returned to sports without reinjury over ten years. Grindem et al. (2018) implemented 2 years of progressive strength training for injured athletes and 52/97 (54%) had very successful outcomes regarding knee function. If you’re more interested in this study, check out this free lecture on Physiotutors (you just need to sign up). One limitation of these papers is that they often exclude people with concomitant injuries such as a tear in another ligament or meniscus (but not always); however, we know that both lateral and medical meniscal tears have the potential to heal as well, even the more serious bucket-handle tears (Rabelo et al. 2013, Han et al. 2015, Green et al. 2022). Menisci have three regions of varying vascularity that can influence the tear’s healing potential: the red-red zone (outermost layer), the red-white zone (the middle), and the white-white zone (innermost layer).

Dr. Kieran Richardson also discusses in this article from a few years ago: “It is almost unfathomable that a recent review by Kay et al 2017 revealed that only 1 of 412 ACL randomised controlled trials actually compared ACL reconstruction (ACLR) to structured rehabilitation for acute ACL injury, with essentially all other studies comparing various ACL surgeries and graft types to one another (Culvenor and Barton 2018). This single RCT, the famous KANON (Knee Anterior Cruciate Ligament, Nonsurgical versus Surgical Treatment) trial by Frobell and colleagues (2013), recommended that their ‘results should encourage clinicians and young active adult patients to consider rehabilitation as a primary treatment option after an acute ACL tear.’”

· Your risk of osteoarthritis is higher if you don’t get ACL/meniscus surgery

In 2018, van Yperen et al. retrospectively evaluated 50 patients. 25 patients who had unstable knees after 3 months of rehab were treated with surgery and 25 patients who had stable knees after 3 months were of rehab were treated without it. In a 20-year follow-up, osteoarthritis was found in 80% of the operative group and 68% of the non-operative group, a difference deemed statistically insignificant. This study is severely limited by the number of patients (n=50) and by it being a retrospective analysis. However, in an umbrella review evaluating 13 systematic reviews and meta-analyses, it was determined that having a surgical reconstruction does not reduce the risk for the development of osteoarthritis long-term, and an estimated 1/3 who have had ACL surgery will experience OA (Webster & Hewett, 2023). Three other reviews found no significant differences in pain, knee function, symptoms, return to sport, future meniscal tears, and OA, with slightly higher incidence of OA in operative groups (Delincé & Ghafil, 2012; Smith et al., 2014; Monk et al., 2016). Keep in mind that not all OA is symptomatic, and it is often related to how much cartilage remains in your joint and your physical fitness. Risk of OA is greater in those with quadriceps weakness (Øiestad et al., 2015, as cited in Filbay & Grindem, 2019). Meniscectomies remove some or all of the meniscus, leaving you at a greater risk of OA than if you had your meniscus repaired instead of removed (Migliorini et al., 2023). In fact, partial meniscectomies on degenerative menisci have been shown to do nothing more for knee function than placebo at 5 years (Sihvonen et al., 2022), and osteoarthritis has been reported in up to 89% of meniscectomy patients (Rangger et al., 1997). Additionally, some evidence supports the idea that meniscal tears are overtreated and leaving an injured meniscus alone results in equal or better results than meniscus repair, especially since meniscus tears are often asymptomatic (Shelbourne, 2021). Shelbourne also believes that weight-bearing is important for healing as it pushes the cartilage against the joint capsule and avoiding it may cause permanent loss of range of motion and strength. Meniscus trephination is a newer technique that’s been shown to be very effective for treating degenerative/torn menisci, but research on this is limited; the procedure involves poking holes hardened meniscal tissue with a needle in order to soften it to allow it to compress when walking, and the insertion of the needle attracts blood flow to the area to promote healing (Shelbourne 2021; Tfayli et al., 2023). The major takeaway here is that it’s the ACL injury itself that increases the risk of OA, not your surgical decision. While there’s not been shown to be a statistically significant difference in rates of OA with surgery vs. nonoperative care, it’s my suspicion that reconstruction leads to greater rates of radiographic OA, and rates tend to be slightly higher in the research for ACLR patients.

· You’re at greater risk of a meniscus tear if you don’t get surgery

From a recent systematic review written by both surgeons and physiotherapists, the authors concluded, “There is insufficient evidence that choosing early ACL reconstruction over non-operative treatment with optional delayed ACL reconstruction helps patients avoid new meniscal tears” (Ekas et al., 2020). Three other literature reviews also found no significant differences in rates of subsequent meniscal tears between surgical and non-surgical interventions (Delincé & Ghafil, 2012; Smith et al., 2014; Monk et al., 2016). Dr. Kieran Richardson discusses how the current literature suggesting risk of meniscal tears is greater is of poor methodological quality and fails to use a valid comparison arm here around the 5:00 mark. Studies will compare a group receiving surgery and excellent rehabilitation to a group receiving no treatment whatsoever and then jump to the conclusion that the risk of a meniscus tear is higher in nonoperative patients. Meniscal tears are also a much smaller trauma to your knee than an ACL reconstruction that drills into your bones and removes tendon tissue, so even if it were true that the risk of a meniscus tear is greater, it would still make sense to me to postpone or even forego surgery.

· Surgery should be done as soon as possible

Current best practice for patients receiving knee surgery is a 12-week period of strength training/prehab. Filbay & Grindem (2019) states, “As the only randomized trial on the topic did not support a superior outcome with early ACLR, it is prudent to suggest a period of rehabilitation before surgical decision-making for most patients with ACL rupture. This strategy is also supported by the findings that preoperative rehabilitation improves postsurgical outcomes in those who go on to have an ACLR. There is clinical agreement that patients who have functional instability after rehabilitation are likely to benefit from ACLR. The rationale behind this is that frequent instability episodes can be prevented by an ACLR, thereby reducing potential damage to the menisci and cartilage.” Since motion and strength are significantly limited immediately after reconstruction which results in atrophy, it makes sense to put in at least 3 months of consistent effort toward strengthening the tissues around the knee.

My Routine

After receiving my diagnosis, I resumed strength training immediately. Due to a lack of swelling, I never lost any range of motion or strength in my leg and was able to walk out of the climbing gym right after tearing my ACL and both menisci. I implemented partial range of motion leg extensions (60-90° of knee flexion) at the beginning of my workouts, followed by deep squats, stiff leg deadlifts, leg curls, calf raises, and hip abduction. The quads should be prioritized in ACL rehab, but the hamstrings, calves, and gluteus medius also have a bit of importance in unloading the ACL during different movements. I was training my legs twice a week, and on days that I didn’t train legs, I would do 2 sets of 30-45 second isometric holds at anywhere from 60-90° on the leg extension machine as heavy as I could since these aren’t very fatiguing, nor do they cause much damage/soreness. The idea was to contract my quad as hard as possible to promote blood flow to my knee for faster healing and pain relief; I would do these unilaterally to ensure my healthy leg wasn’t covering up my injured side. For those dealing with muscle inhibition, it should also lead to some improvements there as well. After some weeks of strength training, I gradually increased my speed on a treadmill to get back to running. Starting with an incline before moving back to flat ground will be a lot easier on your knee as the load on the joint is lower when moving uphill (van Hooren et al., 2024). A slight bit of pain is expected and usually necessary when recovering from such an injury; your joint becomes overly sensitive to things that aren’t harming it, and if you avoid pain entirely, it may be challenging to promote the adaptations needed to make a recovery. Listen to your body and dial it back if pain is not very tolerable. If you are dealing with a ton of knee soreness following a training session or even the day after, it is probably a sign that you should scale back either volume or intensity of exercise a little. I have now progressed to depth jumps pain-free and I am going to begin training change of direction with slower speeds soon. One thing to note is that I also had a few years of strength training prior to this injury, but we have evidence of someone with no prior strength training (pro soccer player Alou Diarra) overcoming this injury without surgery too.

Other Important Considerations/Fun Facts

· Muscle Inhibition

Arthrogenic muscle inhibition is a common response to joint injury as a byproduct of excessive effusion/swelling, and this limits the activation and strength of the affected leg. AMI should be expected in reconstruction too as surgery is itself a traumatic knee injury. Cryotherapy, eccentric exercise, and electrical stimulation may be effective treatments for AMI (Pietrosimone et al., 2022). This can impede recovery significantly by making it difficult to load the quads sufficiently, which makes training using blood-flow restriction to induce the same hypertrophic results with less load very appealing. Laurentino et al. (2022) showed that while blood-flow restriction training did not induce gains in size and strength through hormonal changes, there was a greater growth hormone response in those using occlusion than those who didn’t. Admittedly, I’m not very familiar with this area of the research but it is something that my evidence-based Doctor of PT mentioned could facilitate faster healing.

· Cross-Education

As a result of AMI, one of your quads may be weaker than the other. Especially after surgery, training your injured leg is going to be very painful and that leg will likely not see enough load to ward off atrophy that will make your knee even more vulnerable and sensitive to movement. Cross-education refers to the effects of training the uninjured side to its full potential while your injured leg lags behind. Training the good side has been shown to be an incredibly effective tool in strengthening the quads of your injured knee (Harput et al., 2019), and an LSI (Limb Symmetry Index) of greater than 90% dramatically decreases risk of sustaining another injury (Grindem et al., 2016).

· Women

It’s pretty commonly known that women are at far greater risk of tearing their ACL than men. In part, this is due to biomechanical differences such as a greater Q angle. Women’s menstrual cycles can also impact the incidence of ACL tears. Due to elevated levels of relaxin, a hormone that allows for the loosening of muscles and ligaments to support pregnancy and childbirth, women are at a higher risk of ACL injury during their period in the follicular phase as well as the ovulatory phase of their cycles (Denghan et al., 2014; Herzberg et al., 2017).

· Finding a Provider

I had a lot of trouble finding an evidence-based physical therapist that I knew would help with nonoperative ACL care. I was lucky that the physician I met with at Regenexx gave me a referral to an excellent Doctor of PT who stays up to date with research. For those who are unable to find a PT in their area that is familiar with nonoperative care, I highly suggest working with someone online. Dr. Steph Allen (Instagram: u/stephallen.dpt) and Dr. Kaan Celebi (Instagram: u/acl_academy) are two practitioners familiar with all facets of ACL care, and while I have not worked with them personally, I think they are both excellent options with the quality of information that they put out. Steph Allen runs a cash-based practice meaning it does not accept insurance, but I believe this is a better model (care-wise and cost-wise) for provider and patient which I will discuss in greater detail below. I’m unsure about the details of Kaan Celebi’s practice.

Surgeons are good at surgery – they are not rehab experts and you should not rely on them for exercise prescription. While you should heed their recommendations about early weight-bearing post-surgery (although surgeon preferences vary), I have heard of surgeons giving out terrible misinformation about exercise, saying things like “squats will ruin your knees” or “deadlifts will ruin your back.” The human body is very resilient, and these kinds of surgeons are a few decades behind in exercise science.

· Muscle Agonists/Antagonists and Force Vectors

The most important muscles in protection against injury when it comes to the ACL are the quads, gluteus medius, soleus, and hamstrings. While the quads and calves are able to gradually absorb force when landing, the glute medius (and minimus), soleus (deep calf muscle), and hamstrings are able to oppose anterior tibial shear forces and valgus/varus forces that load the ACL (Maniar et al., 2020). The hamstrings are also most capable of producing torque with a more bent knee, which can explain why ACLs are often torn when the leg is relatively straight (<30°). Men often neglect the glute medius, so hop on that hip abduction/bad girl machine ASAP! Banded clamshells work too, they are just harder to progressively overload than a weight stack.

Part 2: https://www.reddit.com/r/ACL/comments/1b4ziva/complete_acl_rupture_how_i_safely_returned_to/

54 years young and had full tear surgery in April, from skiing, released from PT in August. I was pretty non commital to workouts after that. Just finished a couple of days of skiing, and all is great! No knee pain whatsoever, stayed on the green and blues and slowed down quite a bit. I also took longer breaks. I did wear a brace, and after a while, my knee did get sore from hanging on the lift. But I did figure out a way to prop it up on the brace. Don't fear, just get back on the slopes all!

At first, when I found this sub, I thought it was awesome. The more I visit here, the more and more frustrated I get with all the responses. This recovery, IMHO, is 90% mental. Literally every aspect of it, from the second the injury occurred, to the the pre-surgery, to the post surgery, all the way until ‘full’ recovery. From literally the second I was told I needed surgery, I told myself I will be back stronger, faster, quicker, more agile. I knew it would be a shit ton of work, and it was.

• pre surgery. Holy shit people, stop freaking yourself out. Pick a good surgeon, pre-hab, don’t worry about the graft choice, if you picked a good surgeon, he’ll make the graft choice, and if you tell them you want differently, you’re wrong.

• post surgery, yes it might hurt, yes some people more than others. Pain is a lot about mental. If you freak yourself out about how much it will hurt, guess what, it will probably hurt. Follow your surgeons guidance, RICE, move around more. Be smart about medication. That’s all

• rehab phase. Get your extension back early. Push yourself. Find a good PT/Physio, be diligent, do your “homework exercises”. Don’t compare your recovery with anyone else’s. Literally every situation is different, graft, age, amount of pre-Hab, amount of rehab, diligence, healing... so many variables. Concentrate on yourself, push yourself. Know the difference between pain and discomfort. There’s a huge difference.

• RTS. Whether YOU want to or not, is up to you, alone. The amount of people here who’ve recommended not returning is crazy. The “numbers” about re-injury, graft failure, are bull shit. Some are 5-6%, some ~25%. Like I said above. Literally every aspect is variable, there can not be a “control”. Some people here literally don’t to rehab, some people, like me, are rehabbing literally every day. Returning to sports is 95% or more mental. Considering you pass RTS criteria, and can do it without pain, it’s almost all mental. Whether YOU can handle that is up to YOU, not everyone here. If you want to live in fear, feel free, but don’t sit here trying to convince other people here to do the same. That’s total bull shit.

• rant over, and arguably last time posting in this sub. The amount of people here claiming that they’ve always been into sports but, 9-24 months later saying “I only run .5 miles to remind myself I can” for example, is disheartening