ACL Injury Recovery – Random Short and Long Term Things

The following article is based on anecdotal stories from a wide range of sources. Nothing here is from any official medical source. And not everything is strictly medical. Some of it is practical or experience-based. As always, everyone’s experience is different and everyone is returning to a different level of activity; day-to-day life, recreational sports, seriously competitive sports, and so on. These are just some of those ‘random little things’ that some people come across that others might not.

Things to Consider Doing

Comfort: Footwear

Take care in footwear selection. A lot of folks, (myself included), have been able to take advantage of some great modern footwear choices for ‘slip-on’ type sneakers post surgery. (Kizik, Zeba, Skechers.) Those shoes may or may not make sense in an ongoing way. The point is, to take care to select things that are stable. And also, proper footwear can help with posture and gait. (While I’m trying to avoid picking favorites, I have to tell you that Kizik’s are my favorite. The slip-in seems to work best and they seem the most comfortable to me. You really need to try multiple pair though given how personalized shoe fit can be.)

We want:

• Stability & Support; Firm heel counter, arch support, and torsional rigidity. Why: Helps maintain proper alignment and reduces lateral knee stress.
• Shock Absorption: but not too much. Cushioned midsoles (e.g., EVA foam or gel). Why: Reduces ground reaction forces that can irritate healing tissues.
• Traction: Non-slip soles with good grip. Why: Prevents slips or unexpected twists, especially in early phases of rehab.
• Proper Fit: Snug but not tight; room in the toe box. Why: Poor fit can alter gait mechanics and increase compensatory movements.
• Heel-to-Toe Drop: Slight heel elevation (e.g., 4–8mm drop). Why: Aids forward motion and reduces strain on the posterior chain.
• Avoid Minimalist or Worn-Out Shoes: Why: These can offer little to no shock absorption or support, which is risky during recovery.

Tip: Bring your footwear to physical therapy appointments so the clinician can evaluate its impact on gait and recovery.

Specialty Shoes, high-heels, etc. On occasion in online forums some are concerned about fashion. Everyone has to make their own choices. But it should be somewhat obvious this type of footwear poses some risk. High heels shift your center of gravity forward, increasing anterior knee load. This stresses the ACL graft and surrounding structures, especially early post-op. There are altered “gait mechanics.” Heels shorten the Achilles tendon and change hip/knee alignment. There’s reduced stability and risk of twisting or sudden knee motion is high; dangerous for a healing ACL. Heels increase pressure behind the kneecap, often irritating healing knees. Poor biomechanics in heels can interfere with neuromuscular retraining and proprioception gains.

Again, everyone has to make their own choices, but if return to sport is at least 6-9 months post op for proper graft integration, those considering such things might want to add that as part of their decision process. Maybe consider lower, wider options.

Ongoing Self Care

Consider paying more attention to knee care in general. This means after exercise, an athletic event, or even if just generally sore, consider ice or heat therapy as needed. This means owning some cooling / heating aids, which can be as simple as a bag of ice and a washcloth and a heating pad. Or any of many types of wraps designed to hold frozen gel packs and similar. Usually, cold is applied directly after some kind of event in order to reduce swelling. Later, (perhaps a day or so), heat can be used as this can help increase blood flow. The increased blood flow from heat is due to dilating blood vessels, which can help deliver more oxygen and nutrients to the tissues, which supports healing and helps remove waste products. Use elevation pillows similar to how you did post surgery. This can also help alleviate swelling directly after exercise.

Consider weight management more carefully. We’re all inundated by advertisements for weight loss programs, apps, medications, and so on. Clearly weight management is an issue for all of us. However, for those with joint problems, such things can be more problematic. Consider using the unfortunate reality of a knee injury as motivation to lose a few pounds if appropriate. You will quite literally help decrease pressure on your knees and decrease risk of cartilage and arthritis.

Stretching and Exercise in General. If you’re going back to an exercise program, (gym or sport), great. But don’t forget the stretching! This isn’t just for knees of course. However, making sure to stretch your various leg parts can loosen tight muscles in general and especially around the knee. You probably did this in physical therapy. There’s no reason not to continue such exercises as long as your doctor says it’s safe to do so. You do not have to go crazy with this to the point where you risk hurting yourself. If you struggle with trying to find a balanced program, discuss with your doctor or physical therapist.

Nutrition: See Nutrition for ACL Recovery

Things to Look Out For

Blood Clots

In this case, we’re not talking about common clotting of a skin surface wound site, like a scab. This is a solid mass that can form someplace like a vein, which can block normal blood flow or even break off and travel to other areas, potentially causing serious problems. Clots are not common, but can happen. Higher risk factors can include smoking, birth control or hormone therapy, obesity, family history and prolonged immobility.

Any time we experience uncommon situations such as an injury like this, we may experience some discomfort where we’re not sure if something is serious or not. If there’s any question about such things, you shouldn’t hesitate to contact your care team. If it’s out of office hours, you need to assess if the issue seems bad enough to seek out immediate alternatives.

If you believe you have something like a blood clot, it’s generally considered an emergency. Signs can include:

• Unusual swelling in the calf, thigh, ankle or foot. Just what is “unusual” is somewhat vague, especially in that most will have some kind of post surgical swelling. Some people much more so than others. Some general indicators here might be swelling that occurs suddenly or is getting worse quickly. Or swelling that is persistent and not improving.
• Pain or tenderness in leg or calf that’s separate from the incision / wound areas.
• Redness, tenderness / tightness above or below knee, tight ‘shiny’ skin.
• Warmth and redness over a localized area.
• Development of shaking, chills or fever; which can also indicate infection.
• Significant drainage from wound sites.

Some of these signs are also related to potential infection, which should also be considered an emergency.

Post-Traumatic Osteoarthritis (PTOA)

There’s a well-documented higher risk of developing post-traumatic osteoarthritis following ACL injuries and surgeries; even when the repair is considered successful. This is especially true if there was additional joint trauma like meniscus damage or cartilage wear at the time of injury. PTOA may not show up for years, but for some, early signs can emerge within a decade. Factors like residual joint instability, altered biomechanics, or uneven load distribution can slowly wear away cartilage over time. Ongoing strength training, maintaining a healthy weight, and staying active, but not recklessly so, seem to help delay or limit the effects. Anecdotally, some people notice stiffness, swelling, or dull pain in certain weather or after high activity long before imaging picks up changes.

Knowing about this can be useful so that you can recognize any early warning signs and act appropriately.

Contralateral ACL Injury

The risk of injuring the opposite (contralateral) ACL after an initial ACL reconstruction is surprisingly high. Some studies suggest nearly as high as re-injury to the repaired knee. This seems tied to a combination of things: biomechanical compensations, neuromuscular imbalances, uneven strength development, and in some cases, returning to sport too soon. Many people instinctively favor their uninjured leg during rehab, which may leave it undertrained and vulnerable once they resume full activity. Others may unknowingly shift their movement patterns, increasing stress on the good knee. In anecdotal circles, it’s often said the “other knee goes next,” especially if someone returns to pivot-heavy sports without re-training both sides equally. Smart rehab includes bilateral strength, balance, and coordination work, even when only one knee was hurt. This can be challenging to do, as most would naturally focus on the problem leg. Also, we all only have so much time. If we’re doing a workout, or maybe in time-constrained rehab session, it might be too easy to skip working appropriately on the good leg. This can lead to unevenness though, and ironically end up with your formerly bad leg overpowering the uninjured one.

Quadriceps and Hamstring Deficits

One concern here is persistent weakness or imbalance may last years without continued training. This could lead to gait abnormalities, with subtle compensations in walking or running. A risk her is to hip, back or contralateral issues.

Meniscus or Cartilage Degeneration

If either was damaged or surgically altered during ACL surgery, there could be an increase in long-term joint wear and tear. This is just yet another reason to maintain ongoing strength training and maintaining a healthy body weight to mitigate such risks.

Hormonal or Biological Healing Variability

Especially in females, hormonal cycles may influence ligament laxity long-term. Though this may still be an unclear and controversial issue. See: Is There a Time During My Menstrual Cycle When My ACL Is Most at Risk? The result is this could impact performance and re-injury risk. However, it’s important to note that while some have questioned if this may be an issue, a somewhat recent study says no: No link between ACL injuries and periods, expert claims.

The Right Doctor for the Job

Ideally you’ve had great medical care. But there’s at least two things to consider, 1) Is your care team the right one for you, and 2) Are they right for all situations?

• The Right Care Team: If you’re in recovery, ideally everything from your first post-injury appointment through now has gone great. But if not, you can still switch. Yes, you want to stay with the same care team you’ve had if possible, but sometimes things aren’t working out. You can still get second or updated opinions. If your doctor leaves a practice, retires or otherwise becomes unavailable and you don’t like the other doctors at a practice, (if there are any), that’s fine. Whatever your reasons may be, you can go elsewhere. Though of course, you may have other limitations based on insurance coverage or travel requirements depending on where you live. The point is, you/we might not be doctors, and we have to put our trust in our professional caregivers, but at the same time we have to trust ourselves and take an active role in our own care. If there’s a problem or an event that causes you to have concerns, you can re-consider your care team.
• The Right Team for the Right Job: Your surgeon may be an ace surgeon. And a great doctor in general. But are they also an expert in dermatology? What about other issues? An orthopedist is highly likely to be familiar not only with ortho things, but other issues that are related to the injuries your facing. And where they’re not, they probably have contacts for dealing with common related issues. But maybe not. If, for example, you have an allergic reaction to something from your treatment, (e.g., dermatitis or whatever due to some surgical prep cleaner, or something else), your surgeon might not be the best person to consult. They probably will know about such things and be able to help. However, consider if you might actually need a specialist like a Demonologist. That’s just an example. The point is, Doctors that specialize may be great at their thing, but not necessarily experts at others; just like any other profession. If you’re having issues that may be related to your injury, but suggest other specialities, consider seeking out appropriate specialists. You should still have your general practitioner doctor as well and you can always consult with them.

Final Thought

Even if pain-free, a “successful” ACL rehab is rarely a return to 100% normal. It’s a new baseline that requires ongoing care and training. There are so many variables though, it’s practically impossible to say what “back to normal” means for any individual. Clearly, it’s going to be different for a D1 or pro athlete vs. middle-aged adults enjoying recreational sports. The point is to rehab as best as possible and get on with life, while at the same time taking care to continue any long term care your injury may suggest for the long haul.