This is Part 4 of a series outlining my recovery. There’s an impressive set of information online about how best to recover from an ACL tear, but I wanted to share my own story for a few reasons. There are a few critical resources online that made an outsized difference to me that I’d like to share. I also wanted to actualize the story I wanted to tell when I got to the other side. Finally, for me it was comforting to read the journeys of others going through the same process. I hope you find this helpful and do reach out with any questions you have.
Part 4 - The Early Rehab (weeks 2-7) [this page]
This section of “early rehab” covers the beginning of week 2 til the end of week 7. During this phase, I saw rapid progression in my flexion, balance, walking gait, and strength.
Sleep and pain levels
For the first week after surgery (outlined in Part 3 - The Surgery) I was on 4,000mg of Tylenol and 440mg of Aleve per day, and hadn’t touched the Oxycodone. My doctor suggested I begin to taper off the painkillers. In week 2, I took only half of the Tylenol/Aleve and only used them before bed. Apparently waking up at 4am when the Tylenol runs out is common. By week 3, I was pretty much entirely off of the pain meds. Although there were nights I’d wake up, I was happier to be off the drugs.
The pain levels at night were low, and would be best described as mild discomfort. After waking up I’d do heel slides to “break up the stiffness” for ten minutes. My sleep was generally good (just shy of seven or eight hours of actual sleep), but later on I started to struggle; I’d wake up far too early at 4am with a headache. When it became dire, I did reluctantly rely on fragments of Doxylamine Succinate, the non-habit forming sleeping pill from Costco. I did also add magnesium glycinate to my evening supplements. I can’t say whether it made a difference to my sleep. Ultimately, the only thing that helped was the single critical enhancement to my life that I’ve resisted for years: meditation. Within a day or two of having a mental visualization that resonated with me, I instantly had no issues falling back asleep.
I slept with my brace on every night as directed by my surgeon. I noticed that other folks were never asked to sleep with the brace (some weren’t given a brace at all). I was quite surprised by the variation in protocols, however I stuck to the guidance of my surgeon. I’m a pretty still sleeper, so it was very unlikely I’d twist my knee involuntarily while sleeping. However, I got used to the feeling of it and didn’t mind. If I didn’t have the discipline to follow my surgeon’s directions on this for a mere 7 weeks, how could I possibly have the discipline to rehab daily for years?
Showering
I took my first shower 9 days after surgery. Until that point I had done a great job of using wet wipes. Until week 4, I showered sitting on a 9-inch step stool that we already had. I didn’t want to buy a dedicated shower seat since it would become trash. At week 4, I carefully switched to standing up and showering.
For the entirety of this time period, I covered my wound with a knee protector. I considered using duct tape and a garbage bag to keep my incision dry, but in hindsight I’m extremely grateful I didn’t since this was so much easier.
Mobility
On week 2, I mostly stopped using crutches. I realized that the crutches became more of a liability indoors at that point, especially on stairs. I carried them with me outdoors as a signal to others so they’d be patient with me, but then by week 4 I left them at home for good.
On Day 10, my PT approved of me to walk with my brace unlocked (to 70 degrees) without crutches. It was scary at first, but I became more comfortable with each step. That first day of walking, only about 5% of my total steps were done with an unlocked brace. A few days later, I bumped it up to about 10%. I continued progressing, mostly walking in circles at home. Initially, I thought a lot about the mechanics of each step but soon I was moving more fluidly. Finally on Day 16, 100% of my steps were done with an unlocked brace without crutches.
On week 4, I was walking around the house without an immobilizer brace with my PT’s approval. I also started moving up stairs normally (rather than one step at time).
In the middle of week 5, for a moment I forgot about my injury and rushed down a set of stairs. I heard a pop in my knee and didn’t realize something dramatic had happened until I was halfway down the steps. There wasn’t any pain, and I actually felt great. I figured it was scar tissue that I broke. Until that moment, it felt as if there was a block preventing me from doing a weighted knee bend. From then onward, I gradually increased my downstairs walking until it was just a part of my normal routine. For the next few days I’d hear more satisfying cracks and pops as I walked down the stairs.
Flexion and Extension
I never lost extension in my injured leg. Even right after surgery, I was more or less equal to my good leg. I did hear that it was possible to lose full extension during the first six weeks, so I made sure not to slack off on continuing those exercises. Here’s a simple timeline of my unaided flexion.
Day 8 - 110 degrees
Day 15 - 120 degrees
Day 22 - 134 degrees
After that, I stopped measuring since it was just a few degrees short of my good leg. Stretching my quads felt great while standing, even though I didn’t have that full range of motion to get my heel to my butt. At the 7 week mark (on Day 49), my PT asked me to try and sit on my heels from a kneeling position. It felt scary at first, but I was able to do it.
Mental state
Seattle was hit with a mild heatwave on my second week, which massively sapped my motivation for a few days. Most Seattle homes, including the one I live in, don’t have air conditioning. I reluctantly got through my exercises, since laying in bed seemed less appealing.
I did feel better having my mobility increase each day. I felt more independent and by Day 9, I was making my own meals, cleaning up after myself, refilling my ice machine, and getting myself to PT with the bus.
Sharing my video clips (see day 14, day 21, day 44) of my progress on the r/ACL subreddit felt great, especially getting encouraging and positive comments from strangers. I also benefitted greatly from the group chat I made with fellow ACL-rehabbers. Sharing kind and supportive messages to them when they were down made me feel just as good as when they’d do the same for me.
As the weather got nicer, thoughts about what I was missing out on began to creep in. Although I loved being on my spin bike, I was really looking forward to being back on my road and gravel bike. In addition to wanting to be cleared by my PT, I needed to personally feel confident enough to blitz through hills. I didn’t want Leah to miss out on mountain biking, so I encouraged her to ride with friends and meet with new people.
I had a lot of time on my own to think about my situation. Every day I became more determined that I didn’t want to let this challenge I was in go to waste. I wasn’t satisfied with returning to a slightly better version of my pre-injury self. I had a vision of a version of myself with bulletproof knees. I knew this meant keeping a laser focus not just for a few months, but for years ahead. I would have a new obsession, which conveniently would support my passion in the outdoors and give me longevity in the sports I cared about. There was also a strong positive feedback loop: the more often I exceed expectations in physical therapy, the more confidence I had that what I was doing worked.
Doubts
The biggest concern I had was that I was either progressing too fast or not fast enough. My flexion, extension, and quad activation came back quickly, so I was cleared to do exercises and movements at PT and at home that normally wouldn’t begin until weeks later. When I looked at Dr. Khalfayan’s rehab protocol for the Seahawks, I was always about a week ahead. This all sounds like great news, but I was concerned since my PT hadn’t treated anyone progressing so quickly. Would Nelson (my PT) become too eager and put me on exercises that I wasn’t ready for yet? Or is it possible he wouldn’t take advantage of my fast recovery and I’d be dragged down into a more conventional rehab timeline? Both of these concerns weren’t valid, as Nelson did a great job finding the sweet spot for the first four weeks.
Another big concern I had was whether all this flexion so early was good. I saw several comments where patients were told to avoid flexion beyond certain amounts to ensure the graft didn’t get too loose. My PT dismissed this concern by noting that while under anesthesia, the surgeon manipulates your flexion quite a bit. Pushing your flexion early is only a problem if you’re forcing it. Mine came back naturally. At my week 7 follow-up with my surgeon, he did caution me about aggressively pushing the flexion with quad stretches and butt-to-heel sits.
It was tough seeing my calf, quad, hamstring, and glute muscles get smaller, especially because I figured I’d have less atrophy since I was progressing quickly. It’s obviously possible I did have less atrophy than what’s normal, but the smaller muscles were still demoralizing to look at.
Finally, I also needed to ask myself whether my ego was potentially going to put me in danger. By writing about my recovery, I was putting a spotlight on myself. Would it be possible for me to irresponsibly push myself too hard because I had an audience? Absolutely. However, I also knew that I didn’t want to tell a story about re-tearing my ACL. Forcing myself to write about the recovery absolutely impacted my rehab; every day I thought about the story I wanted to tell.
Driving
I had surgery on my right leg, which meant that I’d have a longer return to driving. I didn’t want to rush back into it given the harm I could cause to others or myself if I was wrong. Leah and I did a two-minute test drive in an empty lot on Day 20 and I had no issues. This was a big milestone for me; it brought more independence and severed the short tether to home. On Day 21, I drove myself to PT (30 min each way). I was mildly uncomfortable but never felt unsafe.
By week 6, I was doing two-hour one-way drives without much issue, however sitting in traffic became even more dreadful and frustrating.
Diet
I largely stuck to the same diet as my first week (outlined in Part 3 - The Surgery). Between Day 8 and 20, I was assembling refrigerated items or frozen meals from Costco or Trader Joe’s. By Day 21, I was back to cooking meals from scratch. I did need to be mindful about not being on my feet for too long. If I wasn’t, I’d feel pressure in my knee from the blood pooling up. Propping my foot up on the counter while I cooked required some flexibility but helped a lot. I continued to avoid booze and the only sweets I indulged in were small bits of really good dark chocolate.
I added creatine to my supplements, even though the benefits to athletes recovering from ACL reconstruction wasn’t definitive. I was concerned about gaining several pounds of water weight, but that never happened. I lost four or five pounds from my “active healthy weight,” which I attributed to some quad muscle loss but primarily trimming down on my belly fat from the core exercises and eating salads for lunch every day (something I never did before).
Physical Therapy
I was scheduled to visit my PT twice a week starting on Day 8. Generally we’d start with measurements of flexion, quad size, and some light massage before exercise. For every visit with Nelson (my PT), I’d exceed his expectations and he’d question out loud whether he thought I should get some advanced exercises.
Ultimately, I made the decision to entirely switch to a different physical therapist on week 6 for a few reasons.
Scheduling - It was clear there was more demand for my PT than they had capacity for. I even overheard them referring new patients to other providers. For me, this meant booking time slots at inconvenient hours.
Personal attention - Although I liked my PT, he’d only spend 30 min with me before passing me off to an aide who would swing by occasionally to point me to the next exercise. For the most part, a PT session didn’t feel any different from being at home.
Familiarity with athletes - Most of the patients seen by my PT’s office were older folks or generally not athletic. Their recovery timeframes would be vastly different from mine, and so would their goals. My PT hadn’t seen anyone recover at my speed, and seemed less confident whenever I nudged him to progress me.
Bigger facility - Most of my ACL rehab inspiration came from watching athletes running around on astroturf, throwing medicine balls at walls, and dragging weighted sleds for yards. I didn’t see how any of this would be possible in the small facility I was currently in, so I sought out a larger one.
I wouldn’t have had the confidence to make the drastic shift to if not for the earlier advice of my friend Zander about baseline expectations I should have. Fortunately, I found Sports Physical Therapy Factoria which rehabbed professional athletes (e.g., Seahawks, Marlins). Within the first day, RJ (my new PT) tested me my asking me to go through a range of motions I hadn’t tried since surgery, like lunges and deep squats. He agreed I was ahead of the curve, but didn’t seem overly impressed (which I took as a good sign). He then set me on a battery of exercises where I was soaking in sweat within just the warmup. I was a bit incredulous at what he had me doing, but it felt amazing to get a proper workout in. I also loved that he said that we’d exercise both legs rather than focus on rehabbing only the injured leg.
After that first session, I felt great until I got home. As RJ noted, there’d be swelling and we’d need to use that as an indicator of whether we’d pushed too far. My knee felt stiff and tight for the first time in weeks, and I reluctantly reached for an Aleve. When I told him this at our next visit, he didn’t flinch and we did another intense battery of exercises which would’ve challenged me even without a recent surgery. I shook off my skepticism when I realized he was right. The swelling wasn’t as bad the next time, and my body began to adapt to the new load.
By the end of week 7, I was doing exercises at PT that would have been physically demanding even without the ACL reconstruction (e.g., single leg box squats, goblet squats, dynamic side lunges with a medicine ball, weighted sled pushes, reverse nordic curls, squats on an inverted bosu ball etc). Since everything felt hard and I’d be out of breath, I wasn’t sure anymore if I was falling behind. RJ (new physical therapist) repeatedly gave me the confirmation that I was still doing well.
Exercises at home
Each round of PT exercise at home would take about 1 hour. Between Day 8 and 16, I’d do the following exercises three times a day. If my reps weren’t perfect, I didn’t count them. I found that buying a tally clicker helped me focus on the movement instead of trying to remember the count.
Knee extensions, firmly pressing down for 10sec on the quad (while sitting up with a towel underneath the ankle) x10
Calf stretch with a strap for 10 seconds (while sitting up with a towel underneath the ankle) x10
Hamstring stretch with a strap for 10 seconds (while laying down) x5
Heel slides without a strap for 10 seconds (including a 2 second hold) x15
Quad sets with a towel roll under the knee for 10 seconds (while sitting up and looking at the quad to establish a mental connection) x20
Straight leg raise holding a quad set (while laying down) x20
Prone terminal knee extension for 10 seconds (while laying on my belly) x10
Prone knee flexion, lifting and slowly lowering (with a 1-2lb ankle weight) x15
Side lying hip adduction, lifting and holding the leg up for 2-4 seconds (with a 1-2lb ankle weight) x15
Side lying hip abduction, lifting and holding the leg up for 2 seconds (with a 1-2lb ankle weight) x15
Heel raise, placing toes on a staircase step for a full range of motion x20
Standing terminal knee extension, flexing the quad to straighten fully (while wearing unlocked brace) x15
Step throughs, where I practice slowly taking a step forward and backward with an unlocked brace, slowly breaking each movement down into careful steps (not looking down at my feet to practice having the motion feel intuitive) x15
Sit to stand, doing a half squat down to a bed with unlocked brace (while flexing quad and glutes when standing) x15
On Day 17, I added the following exercises. I reduced my exercise sets to twice a day instead of three times a day since the exercises were taking longer, I was feeling more of a workout because of the spin bike, and work and normal life was getting in the way.
Standing kickback, where I’d balance on a leg and kick back the other leg at a 30 degree angle (switching sides after each set) x15
Hurdle step over, where I’d step over an imaginary hurdle (forwards and backwards, alternating legs) x80 steps total
Spin bike, where I’d primarily pedal with my injured leg
For the spin bike, I was cleared to bike for 5 minutes at low resistance on the first day, and I could increase by 2 minutes each day. I made a rule that if I were to increase resistance, I would have to dramatically decrease the length of time I was pedaling. Only after completing a short duration at higher resistance could I begin to increase the duration again. I always finished each session feeling like I could have pedaled for a lot longer.
On Day 21, my PT (Nelson) had me try some new exercises, including a double and single leg press. Below are the other exercises I added to my routine (without removing any of the earlier ones). I finally reduced my at-home PT to a more manageable once daily. After a few days of adjusting to the new load, I increased the reps of all the exercises by 50% and added more resistance where possible (e.g., 1lb-2lb ankle weights, tougher resistance bands, resistance on spin bike).
Standing kickback, same as the exercise above, except I’d have a resistance band (switching sides after each set)
Balanced leg, standing with a injured foot on a soft cushion while the other foot’s toes touch behind you on ground for balance (as if in a short lunge with 90% of the weight on the balanced leg). Eventually I’d make it harder by tossing a ball to the wall and catching it to add some random stimulus.
Balanced leg blinded, same as the exercise above except balance the foot on solid ground and keep your eyes closed for 45 seconds. Eventually I did this with my foot off the ground.
Step ups, stepping up on a staircase, eventually standing straight solely on the injured leg poised to take a big step with the other leg.
Hamstring curl ball rolls, while laying down I pressed my foot down on a 6-inch ball that I’d roll in towards me while flexing my hamstring.
The only rest day I took was after my first intense session with my new PT. RJ and I both agreed that my body could recover from the load within 24hrs. However if I got poor sleep, I’d first cut out my non-rehab exercises (i.e., upper body and core). If I was really in need of a rest day, I would reduce the reps and resistance rather than sit around doing nothing. Light motion was better than no motion. RJ added the following at-home exercises (which I just tacked on to the earlier exercises from Nelson):
Monster walks w/ band at the ankles, walking sideways for 10 yards and then walking reversing direction.
Banded railroad track walk, shuffling forward for 10 yards and then doing it backwards
Skaters w/ band, sweeping a foot forwards in an arc for 10 yards and then doing it backwards
Standing Banded Fire Hydrant, for three sets of 10 reps on each leg with a band above the knees
Banded air squats, for three sets of 10 reps on each leg with a band above the knees
Massage
On Day 11, I got a new toy: the Normatec 3 Legs System. I was initially worried about damage to my incision because of the pressure, but then remembered that advanced cold therapy machines like the Game Ready are built with compression in addition to cold therapy. I also tried the device on my good leg first to feel what it’d be like.
After using it, I had absolutely no clicking, popping, or tightness in the knee between flexion and extension. My knee felt almost identical to my normal leg and it actually freaked me out. I thought I might have done something wrong and introduced too much laxity in the knee. I was relieved the next morning when the familiar tightness and stiffness came back (but to a lesser degree). Overall, I felt great with the Normatec, but I did get some light bruising in my inner thigh (and I don’t bruise easily). I decided to lay off using it until Day 14, when it became an essential part of my daily routine after icing.
I really wanted to say that the Normatec was a waste of money, but I was very noticeably less tight in the knee after using it for 30-45 minutes. I got a pro deal on it, and figured it may be valuable for recovering from big days in the mountains in the future.
Icing
I stopped icing my knee at my new PT’s recommendation on week 5. He called out that it would shunt out fresh blood to heal my knee after a workout. I went cold turkey on this and didn’t miss it at all.
In hindsight I would not have purchased an ice machine, even if it cost a third of what I paid. I found myself reaching for the ice packs in the freezer more often out of convenience and preferred the mobility it gave me.
Incision site
By day 14, all of my bruising was nearly gone. On Day 16, my PT removed the steri strips from my incision site and rubbed some lotion on the area. The patellar incision was nearly invisible and instead my eyes were drawn to the varied scars I already had that followed the many mountain biking falls over the years. I was told to begin mobilizing my patella and patellar tendon laterally to help break up any scar tissue. This would help me prevent patellofemoral pain syndrome from developing in the future.
By week 4, the patellar incision was more noticeable, with a shiny sheen on it. My PT advised me that we needed to begin mobilizing the scar itself to help break up the scar tissue and make that skin loose again. I bought a Gua Sha tool after deciding the blunt side of a butterknife wasn’t appropriate. I also went to an acupuncturist, which my insurance covered for 12 visits a year. I can’t say whether it made a difference, but I sure felt great during it.
While awake, I regularly wore an Incrediwear knee sleeve, which was far more expensive than I would have liked. Everyone on ACL forums loved them and they’re very well-built. I slept with a cheap cloth knee sleeve that my PT gave me. The compression sleeves felt nice but also protected my incision from the sun, which apparently would deeply tan or burn the incision line. I had seen photos of others with the scar — some looked better than others. I had read on a random comment that keeping it protected for a year was important for avoiding the deep tan, so I decided that’s what I’d do. Even if it wasn’t necessary for my recovery, it all fed into the question of testing my discipline.
On week 6, I noticed a tiny opening in my incision. Given how well the scar had healed, I just assumed it was a very superficial layer of skin peeling. Three days later I pushed on it and noticed a pinprick of creamy pus come out. I called my surgeon’s office and was advised to head to the ER. I spent nearly four miserable hours there and was released at 2am. Fortunately I caught the infection early and it was only superficial. I wouldn’t need to change my physical therapy at all. I decided to aid the closure of the wound by using some steri-strips to close the wound. Even though my surgeon said it wasn’t at all a setback, I’ll admit I was annoyed with myself for getting this close to having one.
My routine
For the first week after surgery (outlined in Part 3 - The Surgery), I outlined my routine in a lot of detail. I won’t be doing that for this six-week period. Here’s what didn’t change: my morning full-body stretches, hydrating very well, protein shake, salads for lunch, sleeping at a consistent time, screens-off an hour before bed. The only notable item I added was several minutes of guided meditation which became invaluable for setting my mind for sleep.
In my idle time, I continued to do Duolingo for at least 30 min/day, work on my writing, and edit photos. I did my best to avoid doom-scrolling on social media but it became harder as I spent less of my day doing at-home PT.
I had a concept of idle-time rehab as well for each week. For week 1, it was doing ankle pumps while elevating. For week 2, it was doing unassisted heel slides. For week 3, it was patellar mobilization. For week 4, it was breaking up scar tissue in my patellar tendon. If I had a free moment and nothing to do, I’d do my idle exercises hundreds of times.
Concluding thoughts & looking ahead
In the last few weeks, I’ve learned a lot about my body and started to get the sense that this ACL tear has been a wake-up call. I wasn’t actually invincible, and I was actually quite weaker than I was willing to accept. If I wanted to keep playing outdoors in the mountains for a long time, I needed to build resiliency in my body.
In the next part, I’ll outline what months 3-6 were like (unless I have a good reason to break it up into a smaller intervals).