Episode 60 | When Can You Walk After ACLR?

What’s up guys, and welcome back to another episode on the ACL Athlete Podcast. Today is episode number 60, and we are discussing when you can walk after ACL reconstruction. The golden question that everyone asks because you want your independence, and no one wants to deal with crutches. This is essentially the episode where you can figure out when you get to ditch your crutches and get back to walking, hopefully. If you’re someone who is early in your post-op and you are trying to figure out some questions and some answers to when you can drive again, when you can go back to work.

Today, we will answer the question of when you can walk again. But we’re trying to tackle some of these common questions that we will hear. And that you know you have some evidence behind it, some data, and some principles to be able to create your own game plan. And hopefully, a game plan that your PT and your surgeon are helping assist you with. But making sure that you are in the driver’s seat with all of this and being able to make sure you’re making the best decision. And it’s not just something based on solely a protocol or time alone.

Before we get into this, one thing that you should know especially about walking is that this is going to be important to be cleared by your surgeon and physical therapist. Make sure you talk to them in this situation as you’re trying to build this back up. And I know everyone has this feeling of wanting to get off the crutches, so make sure you’re in communication with them to know what that expectation is, and even a rough estimate or timeline for most of the people that they work with, especially based on your specific case and how that fits.

To dive into this question, when can you walk after ACL reconstruction? This can also go for injury. If you’re someone who’s post-injury, this can be something that you can take with you, in terms of being able to apply to your situation. But as I mentioned before, these are the things that really depend on person to person. And today, I’m going to break down some important factors to determine when you can walk “normal” again. Some advice from athletes I’ve worked with, some things that I’ve seen that they may struggle with, that I’ve noticed if we implement it this way, it ends up being much more of a benefit in the long run, instead of trying to rush things.

I want to revisit time because what you will typically hear with this process, it could be 7 to 10 days after. But roughly what you’ll hear is two to six weeks is roughly the timeframe that most protocols, surgeons, and physical therapists will give out there. And to reiterate the previous episodes, that time is not completely irrelevant, but it helps us to get an estimate on what we’re trying to set our sights on. You’re trying to know, okay, if I have this coming up, when can I be able to walk normal? And that’s just going to be something that you want to know and time helps to anchor that for us. But just remember, it serves as a proxy and an opportunity to develop these things. And these other additional factors that we talk about today are going to be much more important in terms of dictating when you could truly walk and ditch the crutches.

And one thing I want to make sure is that you guys are safe and do not rush things. The thing that I always ask my athletes is, if this is a nine-month process, at the least, why are you trying to rush the first two weeks, the first four weeks? Make sure you take your time and set that foundation so you can have a good foundation to build the rest of your rehab. Otherwise, what I typically see is that if people rush, they have to take steps back in order to catch back up on the range of motion or basic strengthening, or maybe it’s even walking which is the important factor we’re talking about today. 

Now, let’s dive into some factors that need to be considered. Your pre-injury status where you normal walking with good strength up until surgery, where you doing prehab. If so, that’s going to help benefit you to get back to walking pretty soon after, without crutches. Typically in prehab, being able to build back to just kind of a normal baseline and building strength, allows you to get used to the movements, as well as people who do prehab end up having a better outcome in the long run. So that’s why I really stress prehab as well as making sure your pre-injury status. You can try and get back to that baseline with normal range and strength and all the things with your knee in order to make sure you have a good process coming out of surgery as well.

The injury itself and concomitant injuries, and concomitant injuries just mean like, okay, so you tore your ACL, was there anything else that happened? So a meniscus tear, an MCL. Maybe it is something where you had some bone bruising or a fracture. Those types of things will impact the joint and how it responds. If there is some bone bruising, you can expect a little bit more discomfort in the joint, some stiffness, and some increased swelling because the knee is reacting to more than just an ACL tear. And those things will impact how your normal walking because you might have increased swelling, you might have increased pain which is going to impact your range, your strength, and your ability to just normally walk.

And you got to think about this, especially if you have surgery quickly after the injury. Let’s say you do have a very complex injury, then you need to factor in if you have surgery immediately. Some surgeons will really jump to surgery really quickly. And I’m not really sure why. There’s a lot of factors that play into that that we won’t get into. But when you jump to surgery really quickly after having the injury, then that could be something that can impact even the outcomes afterwards. And then you just got a really, really grumpy joint from the injury, from the surgery. We have to remember the surgery itself is another trauma, it really is. You’re going to go through some bone drilling, especially if there’s an autograft. They’re going to take a harvest site from your patellar tendon or your quad or your hamstring. Are they doing an MCL repair, do they have to go in and do some stitching and repair of the meniscus, the type of surgery itself? Surgeons have different processes as well as now you’re starting to hear more different types of surgeries for ACL, whether it’s a reconstruction or a repair. And then the method of it. All of these things will significantly factor into the recovery and the healing of the joint after the surgery.

The other thing that I want to make sure we mention is age. Kids and teenagers heal like crazy. Their bodies are still developing and growing. The healing rate for someone who is 14 is pretty crazy compared to someone who is 35. And that is just the reality of it. And I started to notice this after I got out of college that I don’t bounce back nearly as quickly as I did whenever I was in high school. This is something that I know everyone can relate to, but it’s something to keep in mind so that will factor into your ability to walk after surgery. The healing can be faster, but there are all these other factors that play into it that will impact your ability to walk. 

We’ve had surgery. Now, let’s talk about postoperative restrictions. This will come down to the surgery itself and what’s happened, and also the surgeon’s preference of what they want to do to protect the joint or to enable the joint. Typically, what you will see in most situations is that, if there is some sort of meniscus damage, if there is something where they try to repair it and they stitch it and preserve it, a lot of times what you’ll see is non-weight-bearing for a certain amount of time. This can be anywhere from two weeks to four weeks. I’ve even seen six to eight weeks with some surgeons depending on the case. And so that’s something that impacts return to walking more than anything, honestly, in this process. What is the weight-bearing status after surgery? Did they have to preserve something? And so then the terms, what you’ll hear, so the overarching or umbrella term is the weight-bearing status or the restriction. And then what you will see is, is it non-weight bearing? Is it toe-touch weight-bearing? Is it partial weight-bearing or is it weight-bearing as tolerated? If there is nothing really done to the joint besides an ACL reconstruction, a lot of times you’ll get away with weight-bearing as tolerated. And so then that’s pretty much how can you tolerate the pain. How is your body cooperating with it and slowly over time, that ramps up like a dimmer switch over time. 

Other things you might see are with the meniscus tear, there’s non-weight-bearing for anywhere from two to four to six weeks. And so then obviously, you will not be able to walk at all during that time. There might be some exceptions. Some other restrictions you might see are maybe not being able to bend the knee past 90 degrees because of some sort of process that was done in the surgery. Again, it comes back to your restrictions. So that will impact a lot of trying to get back to walking again. 

The other things that we’ll talk about are pain. Pain is something that you kind of work with. Everyone knows it feels very uncomfortable and it varies so much, especially early post-op where there’s sharp pains, there’s weird pains, you feel like you’ve done something bad to the knee every hour or so. But in reality, the pain is something we have to work through. And sometimes people are taking medicine to help with the pain, take the edge off. There are all of these things, but that will impact the way we walk. Our bodies are very, very smart, smarter than we think we are. And it’s one of those things where if we assign it a task, so if I am like, okay, I need to walk from point A to point B, and I have pain somewhere in my knee, then my body is going to figure out how can I accomplish that task and be able to offload or avoid the pain in order to make sure that I get to point B. It’s not too worried about, hey, let’s do this technique right? That has to be more intentional. And whenever you’re gait training and doing the mechanics intent is so important because otherwise, our bodies are just going to figure it out. We’ll swing the leg around, we’ll keep the knees straight, and we’ll put most of the weight on the unoperated side. I’ve seen anything and everything that an athlete can do in order to compensate or to just get from point A to point B, especially when they want to try and get back to walking as quickly as possible. 

Next up is the range of motion. We’ve talked about this before, but you need a certain prerequisite range of motion. You need to make sure you have that knee extension range full, and matching the other side as quickly as possible. That’s going to be important as we go through the gait cycle, especially on heel contact. And then as we roll through, we need a certain amount of flexion in order to go through that process and not swing our leg around. And so that’s something that we want to make sure we’re aware of. The range of motion is coming along and with that is our quad strength. We talk about this all the time post-op ACL, and we see quad deficits so long in this process. We want to make sure that our quads are active, they are contracting well. And this will go along with working on your knee extension range of motion. But this is something where you want to be intentional about activating your quads, quad sets, making sure you’re working that and weight-bearing status when you can. And being able to understand, okay, well, my quads are going to kick on when I hit heel contact. And making sure that when my knee bends, that my quad doesn’t really give and that we’re working through that range in order to strengthen it and being able to translate that over with walking. And so that will be very important because our quad accepts a lot of loads and so get that thing really strong and that’ll be a big prerequisite to make sure we can walk well.

Strength compared to body weight is an important factor here. The heavier you are, the more difficult it can be because one leg has to take on more load. It has to take on all of your body weight besides what’s on your crutches. So that’s where heavier you are, it will impact things. The stronger you are will actually help to impact things as well. That’s something that you want to be able to account for, is making sure how you can navigate, and strength will be a big piece of this. The other piece here is that strength will typically decrease because when people are immobilized or non-weight-bearing, you’re not getting as much load through the joint. That’s where being able to focus on quad sets and all the things that you can do that’s non-weight-bearing is important and getting that quad strong as well as the other surrounding muscles in the joint of the ACL, the knee, the hip, the ankles, all of the above. And so that will help us to make sure we can get back to walking normal because we are able to keep that threshold or that capacity of the knee as high as we can.

So my advice for you ACL athletes, the goal is to try to walk as normal as soon as possible. I know that that’s everyone’s goal. How can I get off these crutches? But make sure that you are strategic with it and you’re intentional with it, and that you make sure you talk with your surgeon and physical therapist, especially because they’re going to be the ones to guide you through this, and especially with the gait training and all the prerequisites that you need. We just talked about getting there. Part of this in the early phases is to get the knee quiet. We want to get that full extension matching the other side as soon as we can, making sure we get flexion coming along. Our quads are active and going, decreasing the pain and swelling. And then the gait training is a big piece. These are the big factors post-op that you were focused on. And you want to make sure that that gait training, that there is a method to the madness with it. And that’s going to be something where you will initially be on two crutches, where you won’t be putting too much weight due to the pain, or maybe you’re restricted. And then once maybe your weight-bearing as tolerated or even partial weight-bearing, then you can start to put more weight onto it. You want to work through that range with the true crutches. The way you can think about it is to help offload how much is on your arms and on the unoperated side and start to shift a little bit more onto the ACL-operated side.

And then eventually, you reach a point where you’re like, the two crutches are almost kind of limiting you a little bit, and then you go to one crutch. And that’s where I think that people probably move too quickly and I get it. I know that everyone wants to get away from it. But this is one where I would highly suggest making sure that you spend a little bit more time with the single crutch before you move on to no crutch. What can happen typically is that the move from two crutches to one crutch happens, and then from one crutch to no crutch happens really quickly because you’re in that middle phase. You’re like, I’m good, I can kind of like swing my leg around. But in a realistic nature, what happens is, is that our body starts to learn these weird maladaptive which essentially means just these poor ways to complete the task. We are going to get to point A to point B however we can. And we’re not going to think about really trying to roll through heel-to-toe and trying to get that gait back to normal as the other side. And so we’ll just kind of slug it along, essentially. And then that could be something that can get put on the back burner.

The other thing that I want to give as a piece of advice here, is because of meniscus repairs, you might be non-weight-bearing, for let’s say four weeks. Keep in mind the joint loading as soon as you start to put weight back onto it. Typically, what will happen is if there’s a meniscus repair, four weeks you can’t put any weight on that leg so you’re on crutches. And all of a sudden, you get cleared to start putting some weight on it. The thing that I would highly recommend is that you make sure that this is gradual. And don’t be too surprised if the knee swells up a little bit or gets a little grumpy after you start that. Because you are reintroducing weight-bearing into the joint and it’s a different type of load into the joint and a different stress. And that’s going to be a little bit of a shock to the system, especially for a meniscus that potentially has been repaired. And so this is something that can come as a shock, so just be aware of it. It might not happen at all, or it might happen some. I’ve had some people who have had some pretty reactive knees where their knee kind of swells up after they start weight-bearing again after the meniscus. But it’s just something to keep on your radar.

So again, instead of thinking about a light switch of non-weight-bearing to weight-bearing, think about it as a dimmer switch. The best way to think about this process is ACL, in general. But in any of these movements, the crutches from two crutch to one crutch to no crutch is to really think about it as a dimmer switch. And make sure that you really take it super slow as no light is on, and then you slowly start to brighten that light. Instead of thinking about this on-and-off switch, you have been cleared to put weight on it. Just go full speed. Usually, that doesn’t work too well when our bodies are trying to acclimate. The dimmer analogy and the style with it will help your body to acclimate better. And the thing that I’m going to tag on with this is that I get the question all the time about walking with a limp. People who are post-op six months, 12 months, you might see it years after because they never focused on the first initial phase as well. They might have got poor rehab, they might have just stopped doing rehab. There are a lot of factors. But a lot of times this comes back to they didn’t do the basics really well, and then their body adopted this pattern and then they just ended up being stuck with it and not working on it.

You want to make sure that you do not rush the initial process. Make sure that you figure out what your goals are for those first four to six weeks. Especially for my athletes, they know, okay, here are our main four to five goals and that is what I want you to focus on. And that is something that we make sure that we lay the foundation. We don’t rush it. And I usually tell them when they want to get off the crutches, that we maybe need to slow down a little bit. And all of this is going to be based on how they look and how they feel. Some people do get off crutches. I’ve had people off of crutches within days. But that’s also because they have these prerequisites that are needed. They showed their competency of it. But I’ve also had people who have been on crutches for six, eight, even 10 weeks after surgery, which is kind of crazy to think about. But it was based on their case, the way that they were developing and their knee was reacting. I think that this is something to come back to making sure that we focus on the basics longer than we need to. And that way we can make sure that this initial process is as smooth as possible. We lay that foundation. 

And the other thing I want you guys to check out if you haven’t, and if you’re wondering about walking with a limp and diving deeper into it. I did do an episode where it’s titled, “Why Do I Walk With a Limp?” Check that out if you want more detail on that. In terms of working on gait mechanics and training throughout the day, I want you to really focus on that. If you’re early, you’re trying to work on this, then try to hit it at least three to five times per day, if not more. And make sure you have intentional time built out to work on it. Some of the drills I’ll give are making sure we do heel-to-toe walks; we’re going to be stepping over cones, doing it in different directions; using a gait rocker-type sequence where we can use a hand assist. Making sure that we are queuing as much heel-to-toe as possible to make sure we mimic that gait pattern and we’re flexing and extending our knee throughout that process which seems very natural. Repetition and consistency is the key here. And this is something that you want to think about. You got to retrain like any new skill you want to learn. It takes time to get it right and you don’t want to rush it. And so that is something that you want to make sure that you are working on consistently. 

And one other thing that you can also add to the regimen is – and you’ll see this sometimes in social media. But it can be very beneficial because what it promotes is reversed walking on a treadmill. Because it allows you to go rolling from toe-to-heel and emphasizes that terminal knee extension which is a big problem that a lot of people can have after surgery – is getting that end-range extension. Reverse treadmill walking can help you to emphasize that position, and then you can also build that into the normal forward gait training and other gait training that you would want to work on. 

Lastly, if you are having a meniscus repair and you can’t put weight on that foot yet, my suggestion is still to work on these things within the constraints of your restrictions. And then making sure that you could still work through the mechanics, even if you are just on your crutches and the unoperated side is supporting you. And you could just kind of kick that leg out where you feel comfortable, roll through it. I imagine your heel is touching the ground but don’t contact. And this will allow you to still get used to those mechanics and then once you do and are able to start putting weight on it, that that will feel a bit more natural as opposed to just being locked up and not doing anything with it. There are always different strategies to apply this, whether you’re weight-bearing or non-weight-bearing. And this is something that we want to make sure that we hammer pretty well and to get this knocked out because this is going to be essentially that whole. You need to be able to crawl before you walk and walk before you run. And this is one of those things that’s really important here to make sure we can walk before we run. Because one of the additional things that we will see is that if people have impaired gait mechanics and walking and strength associated that will impact the way that they run and the stress that is placed on the joint. We want to make sure we do it well, and we don’t want to rush it. 

With that said, each person will be different, so always check with your surgeon or your PT that you are working with. Typically, the gait training itself will be within the physical therapist realm. The surgeon will dictate the restrictions after surgery because they did the surgery itself. And the physical therapist or the coach you’re working with will be the person to help navigate you to get you back walking to normal. 

All right, team, that’s going to be it for today. I hope that this was helpful to you. If it was, or any other podcast episodes have, please do me a favor, go and rate this. If you’re listening on Spotify or on Apple Podcast, please leave us a review. That is really helpful because that helps other ACL athletes to see this and then that way they could be educated to make better decisions for their care, for their journey. So that way they can feel in control of this process and have the best outcomes possible. So that’s going to be it for today, guys.

Thank you all so much for hanging out with me today. This is your host, Ravi Patel, signing off.