How long after ACL reconstruction surgery did you resume climbing?

Curious to hear people's experience. For example - how long after surgery until gym TR, outside TR, leading, etc. Thanks 

Hey dude, tore my ACL late August 2020, had surgery early Oct 2020. I did patellar autograft. I reasoned that hamstring graft would weaken my ability to rock over my legs or heel hook hard long term. My knee feels absolutely amazing now and I have no issues at all. If I could make some recommendations that are better for long term healing, recommended by intelligent doctors, but not recommended by most doctors because most patients are not athletic and not careful;

1. After the initial immobilization phase, which should only be a few days at most, dump the brace and never wear a brace again. Studies show that braces do not prevent a retear, and your ACL is as strong as it would ever be immediately post-surgery. Doctor's prescribe braces to cover themselves. I kicked my brace after 5 days and have not used one since. I would wear it occasionally only while sleeping to keep my leg straight during the night. People who heal their ACL without a brace experience less pain over a 5-year period and a stronger one-leg jump. Most doctors don't recommend this because the average ACL patient is an out-of-shape unathletic 50 year old who only needs to recover to the point of walking up and down steps again, but all the studies show brace-less to be the better method of recovery.

2. After only a day or two, start putting some weight and some pressure on your leg as part of a home-made PT routine. You will not retear it though it will feel super weird. If you pursue the goal of walking unassisted again, about 10 days out from surgery you should be walking without crutches, with an almost normal gait. Your gait will take about 4 months to fully normalize, but you should be walking mostly normally after 10 days-ish. 

3. Find a legitimate sports PT place with a turf field and do your recovery there. You don't want your typical medical office filled with PT tables and old people lifting ankle wrap weights. 

4. Develop a hangboard training routine and hangboard during recovery. I came out of my ACL tear significantly stronger than pre-tear, with a much higher endurance capacity. I climb 5.13 trad.

5. Drink collagen, eat grass-fed meats, hydrate well.

I want to stress that this isn't me being over-aggressive with PT and risking re-injury, this is an approximation of the guidelines recommended by Hospital of Special Surgery in Manhattan, which is the cutting edge of Orthopedics and Rehab in the country. 

In terms of climbing, I began Toproping indoors at 11 weeks. Again, no brace. This, honestly, felt too early. The knee felt unstable in ways and I think I risked serious re-injury during this session. I did one session a week based on how tired my leg felt around my 3x a week sports rehab. My second session, week 12, also felt too early, but not as dangerous as week 11. Week 13 I did one indoor TR session which felt good and I felt confident TR'ing from that point forward, modifying movement to avoid really deep high steps, drop knees, or cranker heel-hooks. I climbed trad outdoors, running easy trad up to 5.8 in this week, which felt even more comfortable than indoor TR'ing. You're not locked into the setter's movement and can work around the injury much easier.

I then essentially stuck with that routine until 22ish weeks. Sports rehab 3x a week with one session of indoor climbing and occasional outdoor. It felt comfortable and manageable and every session felt better than the last. I began bouldering around 5 months, not taking any fall-risks at all, climbing well within my limit and downclimbing to the floor on every problem. I slowly increased weekly sessions from there and began experimenting with minor drop-knees, deep high steps and slowly pulling harder on heel-hooks. I wasn't comfortable in any of those until 9-months post surgery.  About a year post surgery, Oct 2021, I had my strongest outdoor season ever, leading 8 gunks 5.12's up to 12d in a month. 

TL:DR - ditch the brace, try to start walking immediately, hangboard, do sports rehab, eat well and don't start climbing until week 13. 

Eric, thanks so much! Awesome detail, advice, and most important, inspiration. I really appreciate it.

I tore my ACL and meniscus in June of 21 and had it repaired July 19, 2021. I had a quad graft and because of the meniscus repair was in a locked out brace for 6 weeks. I did all the PT they'd allow and still rode a bike with one leg, did lots of lifting with my good leg, upper body stuff (especially antagonistic training) etc...Similar to Eric, I was TRing around 10 weeks and doing very easy leads with very little fall risk around 14 weeks. I did a trip to the creek for a few days around 16 weeks and hiked up to the climbs with a light pack and got in TR laps with careful jamming and a tight rope. I had my PT's approval to do so. I was back climbing and leading ice with my surgeon's blessing by the first week of Dec. I was lucky in that my care team was willing to help me be a bit more aggressive and that they realized climbing isn't quite as demanding on a graft as the "normal" sports such as soccer/football/basketball.

I did set myself back slightly early on by over doing the PT once I was out of the brace. Classic "if some is good, more is better" thinking but not the case. Give yourself time to recover in the early days! I'm exactly a year out now and still get a bit of pain here and there after big days with a pack, but there is still healing of the quad tissue to be done. I don't worry about the knee blowing at all though and have climbing lots of ice, snow, cracks, taken falls etc....Some dark days early on feeling like I'll never be back to normal, but it'll all be good. Do the work, let yourself have those bad days, and keep going.

Hey! How’d your knee end up?

@ Eric--we've disagreed over a great deal on this site, but that's damn good physical therapy and rehab advice.  I've had several surgeries and rehabs, and appreciate the work and effort it takes.  It's also cool that you checked in with the OP.  Solid work. 

It is worth mentioning that, at least from my research, an ACL surgery is considered successful by the medical community if you get back 80% of your pre-injury functionality: for most people ACL surgery will leave them significantly less athletically capable than before surgery.  For some reason no one mentions that.  

I 'walked off' a partial tear (a doctor who specializes in sports medicine said it was 'completely missing' and I should get surgery right away...), and I'm glad I took that road. Less than a year out I'm climbing just about anything I want (still cautious around knee twisting moves, but no issues so far with the few I have done), I can sit on the heel of the injured knee, I can extend my knee completely straight and get that very satisfying stretch, and I'm back to deadlifting heavy and doing multiple heeel-to-butt pistol squats on the injured leg.  I still wear a brace only for athletic activity and will continue to do so for another few months.

Eric’s advice is in most ways quite right and some important ways seriously wrong.  It is inaccurate to say that “your ACL is as strong as it would ever be immediately post-surgery,” and I’m quite sure no Dr at HSS or DPT ever said this.  Related, climbing again at 12 weeks may or may not be ok depending on the specifics of your age, severity of injury (all  ACL tears are most definitely not the same  - what was the collateral damage to your mcl, pcl, meniscus etc), type and outcome of surgery, and response to rehab.  What will for sure nor be the same is falling in a way that loads that knee, so you had better be 100% sure that will not happen.  

Bottom line:

1. Listen to your body

2. An acl reconstruction is not tennis elbow.  Don’t get medical advice from the internet for an injury of that severity.  Talk to your surgeon.

Eric is 100% right about the difference between sports PT and non-sports PT tho.  If your PT facility doesn’t have at least a 3:1 ratio of obvious (often high school).athletes and out of shape ppl, you’re probably in the wrong place. 

I appreciate your kind words, but I’m also 100% right about the strength of your ACL immediately post surgery. The ligament is strong, as it’s brand new, it then degrades for several weeks after the surgery as your body revascularizes it. It then builds back again. The easiest point to tear your ACL is consequently ~ two months post surgery. You can google this.

I also am not necessarily recommending my 12 week approach, climb within your limits, but attack the injury and you’ll come back stronger than ever. My knee feels like nothing ever happened and I also had complicating meniscus tears. I’m sure the arthritis setting in will change my thoughts at some point.

Still wondering how it went!

Eric's approach is fairly bold and the risk of re injury is fairly high.  Another important question to know is whether you damaged the meniscus as well since this is very common and would affect your recovery.  The argument that your knee is totally strong post surgery is not really accurate though.  While the graft is initially pretty strong the shock and injury of surgery dramatically inhibit your muscles ability to support the joint and a lot of your knee's stability come from the musculature surrounding it.  I injured mine in April 21 and had surgery that June.  after surgery the knee was pretty unstable even though the graft was strong due to the muscles inability to support the joint so the rick of it collapsing underneath you is fairly high.  I had great pt which started only 2 days post op and the first couple sessions were mostly needling to get the muscles to "wake" back up.  while I did wear the brace for significantly less time than would normally be recommended it is still a good idea for the first week or 2 to support the joint as it comes back on line.  He is correct that the weakest point is about 4-6 weeks after surgery as the graft gets rebuilt from a tendon into a ligament and the research says that the graft won't be fully rebuilt and strong until about 3 months. It will take quite a bit longer to rebuild the muscle and rebuild proprioception.  I lead an easy trad pitch outside about 4 months after surgery and it felt like I was pushing it but luckily nothing happened and I had no pain.  I'm about 2 years out now and the knee feels great and I have climbed a lot since then. I only use a sports custom brace to ski and not at all to hike or climb. One thing to note is that a more aggressive rehab will heal a bit faster but if you do happen to reinjure it repairing it a second time almost never has as good a result. Is the risk of re injury really worth climbing a month earlier in the long run versus the risk of permanent limitations if you happen to damage the repair. To each their own but taking it slow doesn't cost you anything except a bit of time.  Erics approach is definitely the "free solo" approach to rehab.  If nothing goes wrong it will rehab fast but if you make a mistake you'll be screwed.

Dan Mydans wrote:

 The argument that your knee is totally strong post surgery is not really accurate though.  While the graft is initially pretty strong the shock and injury of surgery dramatically inhibit your muscles ability to support the joint and a lot of your knee's stability come from the musculature surrounding it...if you do happen to reinjure it repairing it a second time almost never has as good a result. 

100% this. With respect to the risk of reinjury, your ACL reconstruction is most decidedly not as strong as it will ever be immediately post surgery.  Maybe one specific sub component of your knee is, but if your knee fails at the ACL again it is not going to matter much that the graft itself wasn’t the problem  

As with climbing, every individual has the right to make their own assessment of risk and benefit and act on it. It’s great that Eric’s high risk / high reward choice worked out well for him, but for others considering their choices it’s important to be up front about the level of risk involved.  I‘d strongly recommend getting rehab advice from your surgeon and DPT because it will tailored to your specific situation. If you trust an Internet forum more than you trust your surgeon and DPT for rehab guidance that’s probably a sign that you should reconsider your surgeon and DPT. 

It’s worth noting that I didn’t do my surgery at HSS, I did it at Orlin and Cohen on LI. While I was in rehab, unstable, weak, and chuffing around with a full brace on and crutches, a very out-of-shape 300+ Lb man came WALKING into the rehab place with a fresh ACL scar and no brace. I asked him how far along he was(thinking about 6 weeks)and he had his surgery only two days sooner than I did. My jaw hit the floor. He told me he went to HSS and provided me a copy of their guidelines. I was still looking at 4 weeks of no walking without crutches and this very unathletic guy was walking around a week out. I dropped my PT place that day, took the brace off fully, kicked the crutches within 3 days of that, and was walking everywhere I went unassisted that same day I kicked the crutches. Your body adapts to the stress you put it under.

Call it “free-soloing” all you like, and you seem fairly uncomfortable with this fact, but the approach was adopted from HSS and applied to my life in a rational and safe way. If you’re fully in the camp of “trust the doctors” I’m betting the doctors and the recommended protocols of HSS are far more qualified than any dr in Louisiana or CO. I may have the protocol laying around if anybody wants it in an email, DM me.

Eric Marx wrote:

It’s worth noting that I didn’t do my surgery at HSS, I did it at Orlin and Cohen on LI. While I was in rehab, unstable, weak, and chuffing around with a full brace on and crutches, a very out-of-shape 300+ Lb man came WALKING into the rehab place with a fresh ACL scar and no brace. I asked him how far along he was(thinking about 6 weeks)and he had his surgery only two days sooner than I did. My jaw hit the floor. He told me he went to HSS and provided me a copy of their guidelines. I was still looking at 4 weeks of no walking without crutches and this very unathletic guy was walking around a week out. I dropped my PT place that day, took the brace off fully, kicked the crutches within 3 days of that, and was walking everywhere I went unassisted that same day I kicked the crutches. Your body adapts to the stress you put it under.

Call it “free-soloing” all you like, and you seem fairly uncomfortable with this fact, but the approach was adopted from HSS and applied to my life in a rational and safe way. If you’re fully in the camp of “trust the doctors” I’m betting the doctors and the recommended protocols of HSS are far more qualified than any dr in Louisiana or CO. I may have the protocol laying around if anybody wants it in an email, DM me.

People from NY always crack me up with how superior they think everything is in NY. Considering the US ski team is based in Colorado and some of the best orthopedists ion the country are based here I have a hard time believing they are in any way inferior to a dr from NY. My surgeon is in fact a US ski team dr and travels with the ski team and does their procedures. In addition the Steadman Hawkins clinic is 1 of the most respected orthopedic units in the country.  

I don’t provide the ratings for the hospitals, I’m just stating a fact. HSS is the cutting edge. I didn’t decide that. Their reputation and patient outcomes decided that. It hasn’t a thing to do with being from NY you dope.

If you want to get back on topic, you can continue to argue why your thoughts and ideas on ACL surgery and rehab are better than HSS.

“Patients who returned to level I sports had a 4.32 (p=0.048) times higher reinjury rate than those who did not. The reinjury rate was significantly reduced by 51% for each month RTS was delayed until 9 months after surgery, after which no further risk reduction was observed. 38.2% of those who failed RTS criteria suffered reinjuries versus 5.6% of those who passed (HR 0.16, p=0.075).”

Simple decision rules can reduce reinjury risk by 84% after ACL reconstruction: the Delaware-Oslo ACL cohort study

I love when people quote the abstract of a study they haven't actually read.

The study was conducted on level 1 sports, which they've defined as "jumping, pivoting, and hard-cutting sports" and further defined as, "Football, handball, basketball, floorball." I'm not, and haven't advocated for a return to playing soccer and basketball at 3 months. I did say returning to easy TRing with a focus on protecting your knee felt totally and completely fine. I even said I avoided deep heel hooks, pistol squat motions, and deep drop knees.

Of the 106 people this study was conducted on, only 74 returned to level 1 sports. 4 of them returned to sport less than 5 months after surgery, and all suffered a 100% reinjury rate. Of the 49 who returned to sport between 5-11 months after surgery ONLY SEVEN passed "Return to sport" criterias. 11 of 20 who RTS between 12-24 months passed RTS criteria. In total, only 18 of 74 patients passed RTS criteria by the conclusion of the study. Only one of them was injured. HALF of the other patients were injured.

"After adjusting for age, patients who participated in level I sports after ACL reconstruction had a 4.32 (95% CI 1.01 to 18.40, p=0.048) times higher reinjury rate than those who participated in LOWER LEVEL sports (figure 1). "

"Of the 55 patients who failed RTS criteria, 21 (38.2%) suffered knee reinjuries (figure 2). Only 1 of the 18 patients (5.6%) who passed RTS criteria suffered a knee reinjury. Patients who passed the RTS criteria showed a not statistically significant 84% lower reinjury rate (HR 0.16 (95% CI 0.02 to 1.20, p=0.075))."

I can keep quoting the study but you can read it yourself next time. I passed my return to sport criteria at 3 months because I followed the guidelines from HSS and rehabbed at a sport specific rehab clinic. You quoted a study you didn't even read about a bunch of people who did subpar sports rehab for high-impact pivoting sports and used that as evidence of why my method of returning to climbing was dangerous. 

Dan Mydans wrote:

People from NY always crack me up with how superior they think everything is in NY. 

I plead guilty to thinking this way...or at least I admit that when I was younger I thought this way.  Some people have probably seen the New Yorker cover attached below.  Perhaps the funniest thing about the cover...is that is exactly how people from NYC think!  It was true in 1976 when the cover way made and it's still true today. 

Now, as somebody who actually grew up in New York City, right near 10th avenue and the Hudson River, as shown in the cover, I can tell you that I don't think Mr. Eric Marx is actually from New York.  I think he's from the outlying areas, not really from the city.  I'm going to take a wild guess that he belongs to what we used to call the "bridge and tunnel crowd" when we were young, meaning the lame people who came into the city to be cool on the weekends but went home to the suburbs where it was safer later.  

Who knows, maybe Eric really is from New York City?  Distant parts of Staten Island, the outlying areas of Queens next to Long Island, and the far reaches of the Bronx where it blends into Suburbia don't count.  You gotta be from the dense urban areas of Manhattan, Brooklyn or the Bronx to really say that you're from New York City.  How's that for an elitist attitude?

For the record:

1-Eric and I have a long history of antoginism on this site, but I think his advice about ACL rehab is rock solid. 

2-I left New York City when I was 18, lived in California for 12 years, worked in Wyoming and Montanna, and have lived in Spain and Switzerland since.  My family lives in Manhattan, but I can't honestly call myself a New Yorker.  It's an amazing city, but I'm really glad that I don't live there.

Off topic, I am from Suffolk County and grew up as upper-lower class as you could be without breaking into middle class. I generally think NY as a state is bad at most things, as I'm obviously deeply conservative. But with lots of money comes lots of highly-qualified doctors and professionals. I spent as little time as possible in the city, except for when I was working there. I'm a rock climber because I like the outdoors, and not dense urban areas. I do love broadway and off-broadway shows and that's the only reason I find myself in the city any more.

Thinking again, another suitable abstract for the quoted study could be, "Approximately 40% chance of reinjury returning to sport ANY TIME after ACL tear." I guess roll the dice lol. 

A better abstract would be "Approximately 5% chance of ACL reinjury if passing RTS criterias post ACL tear." Which seems much better.

The studies are only as good as the people skewing them.

Edit: Another option is "100% chance of ACL reinjury if returning to sport less than 5 months!" Guess my ACL is blown again and I don't even know it.

Eric Marx wrote:

I love when people quote the abstract of a study they haven't actually read...

Interesting to see your response to the simple presentation of peer-reviewed data without comment.  You seem a tad antagonistic.  Climbing is indeed not a cutting sport but if you fall and hit a ledge even from a short distance that would be no big deal to anyone else, it may be a very big deal to your newly reconstructed knee.  People coming back to climbing after a surgery may start with "easy" terrain and has been extensively noted in this sub-forum "5.easy" and "ledgy" have a fair amount of overlap.  

Anyway, now it's on the thread and any future climbers who search for ACL rehab info on this site (which seems to happen with some frequency) will have access to multiple points of view.  As expressed above, anyone who looks at this and decides that their doctor and/or PT provider are not up to speed and the available published research is irrelevant is free to make their own judgement on that; now that judgement will be somewhat better informed.  Personally if I thought my doctor and/or PT provider were not up to speed then I'd look for different providers, but ymmv.

I quoted the study, addressed the variables in the study, and showed the flaws of the study, and the inferences drawn from the study by the researchers, of which it was apparent you didn't read. Peer-reviewed or not, the study does not support whatever point you're trying to make, and instead cuts in favor of what I've said from the beginning, tempered sport-specific rehab. I don't seem to remember saying "start falling and hitting ledges at 11 weeks." but it's clear you don't want to stay on topic or stick to the facts at hand, or I wonder, even read what I'm saying. Which wouldn't be shocking because you don't seem to read the studies you quote, and if you do, you're certainly not interpreting them in a meaningful way. If I'm antagonistic, it's because I'm being told what I'm saying is innaccurate (it isn't) and that I've taken a free-solo approach to rehab(I haven't) by two people who can't provide any meaningful defense of what they're saying beyond subtle insults and studies they haven't read which don't support the conversation we're actually having.

I didn't say "eff it man get out there and climb!" If you read my initial post, it's incredibly sound, honest, thoughtful, and very measured. 

Hopefully future readers of this thread, which is rooted in good intentions, can read these conversations with an open mind.