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What Is the Revascularization Phase After ACL Surgery? | Columbia SC Physical Therapy

If you’ve recently had ACL reconstruction surgery, your knee is now going through several phases of healing—and one of the most critical (but least talked about) is the revascularization phase.

At Vertex PT Specialists, we help patients across Columbia, Cayce, and Irmo, SC safely navigate this crucial stage so they can get back to sport, training, or everyday life without setbacks.

What Is the Revascularization Phase?

After ACL reconstruction, your surgeon typically uses a graft—often a patellar tendon, hamstring tendon, or quadriceps tendon—to replace the damaged ligament. That graft is initially avascular, meaning it doesn’t have its own blood supply.

Over the next several weeks, your body begins a process called revascularization, in which new blood vessels form within the graft. This helps deliver oxygen, nutrients, and immune cells to the healing tissue, and sets the foundation for long-term graft integration.

Timeline: When Does Revascularization Happen?

  • Starts: Around week 4 post-op
  • Peaks: Between weeks 6–12
  • Clinical significance: This is the time when the graft is biologically weakest, even if you feel stronger

This is one of the most dangerous times to do too much too soon.

⚠️ Why You Shouldn’t Rush ACL Rehab During This Phase

Even if the swelling has gone down and your range of motion is improving, the graft is still structurally vulnerable. This is when a misstep—like trying to jog early, jump, or pivot—can lead to a re-tear or failed reconstruction.

Our Columbia-based ACL physical therapists often tell patients:

“This is when you feel good—but the graft isn’t ready yet.”

✅ What You Should Focus On Instead

During this phase of ACL rehab, your physical therapist will progress you through targeted exercises that promote healing without overstressing the graft. These may include:

  • Active and assisted range of motion to maintain mobility
  • Early quadriceps and hamstring activation, including isometrics and light band work
  • Swelling and inflammation control to support tissue healing
  • Progressive weight-bearing as tolerated, focusing on quality of movement
  • Foundational glute, trunk, and hip stability exercises to prepare for loading phases

As your knee tolerates more, your therapist will begin layering in low-load strength work and neuromuscular control drills that build toward return-to-sport milestones. The goal during revascularization is steady, structured progression—not stagnation or aggressive timelines.

Clinical Insight from Vertex PT

At Vertex PT Specialists, we see a high volume of ACL reconstructions, especially among athletes, tactical professionals, and active adults in the Midlands region of South Carolina. Our experience has shown that:

  • Skipping ahead during the revascularization phase increases the risk of graft failure
  • Adherence to evidence-based protocols yields faster return-to-sport timelines and lower reinjury rates

Every rehab plan is individualized, based on graft type, sport demands, and tissue healing.

ACL Physical Therapy in Columbia, SC

If you’re looking for ACL rehabilitation near Columbia, SC, you’re in the right place.

At Vertex PT, we help patients through every stage of the ACL recovery process—including the often-overlooked revascularization phase. With clinic locations in Cayce, Irmo, and Downtown Columbia, we’re trusted by orthopedic surgeons, coaches, and athletes alike.

Ready to Start Rehab or Reassess Your Current Plan?

Whether you’re 4 days or 4 weeks post-op, we’ll build a program that meets you where you are.

Contact Us Today

Reference

Sawyer GA, Anderson BC, Christiansen BA. The Revascularization Phase of Tendon and Ligament Healing and its Relationship with Fibrosis. Curr Rheumatol Rep. 2021 Feb 10;23(3):16. doi: 10.1007/s11926-021-00972-y.

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Squatting with Knee Pain

So, your knee is starting to give you a little trouble when you squat. Many times, people come to us having been told they need to stop squatting and rest it, or that “squatting is bad for your knees, you should never go that low.” And don’t get me started on the “knees shouldn’t go past your toes” myth… All of this couldn’t be further from the truth! If your healthcare provider is telling you otherwise, it’s time to find someone else. A big part of getting you back to 100% is volume management. This means your recent squat volume may have been a little too much for your tissues to handle and we need to take some time to calm them down and build them back up. But in the meantime, we can still find ways to get after it in the gym!

An experienced PT will not only assess your knee and design an appropriate loading program, but evaluate your squat mechanics, make future programming recommendations, and most importantly, find a way to keep you moving! Our goal with physical therapy is not about telling you what you CAN’T do, but helping you figure out what you CAN do. Rather than telling you to stop squatting, we work with each patient to figure out a squat variation that allows them to continue moving without increasing their symptoms. This could simply be moving them toward a more hip dominant squat to decrease the demand on the knees.

An easy rule of thumb is to move across the squat continuum to variations that utilize a more vertical shin. For example, if you’re having symptoms when you front squat, try a high bar back squat. When the load moves from the front rack to the upper back, the torso angle changes and the squat becomes more hip dominant vs ankle/knee dominant. Having an issue with high bar back squats? Try a low bar variation, or try box squats. This will let you really load the hips and keep your shins more vertical. From there we can keep adjusting by increasing the height of the box, decreasing range of motion to further remove the demand on the knees. There is a variation out there that will let you keep squatting, you just have to find it!

Over time, as the specific interventions for the knee continue to progress, we can gradually work back into the variation of the squat that was causing symptoms. Your rehab should be an active process, and there is no reason you can’t keep squatting!

Have questions? Send us a message at josh@vertexpt.com

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Not All ACL Injuries Require Surgery: Understanding Your OptionsPictured above is the iconic statue of Mickey Mantle outside of Oklahoma City’s Bricktown Ballpark. Mantle, the legendary New York Yankees outfielder, started his rookie year in 1951. In Game 2 of the World Series that same year, he sustained a right ACL injury that was never reconstructed or repaired. Despite this, Mantle went on to win 3 MVP awards and a Triple Crown in 1956—all without a functional ACL. What does this tell us? Mantle was what we call a “Coper”—someone who can function at a high level despite having a torn ACL. The ACL: Why It Matters The anterior cruciate ligament (ACL) is one of the main stabilizers of the knee joint. Its role is to: Prevent the shin bone (tibia) from sliding forward on the thigh bone (femur) Provide stability for cutting, pivoting, and side-to-side movements ACL tears are common, especially in athletes. One study cites an incidence of 68.6 per 100,000 people. Contact injuries: when another player collides with your knee in a way that ruptures the ligament Non-contact injuries: more common, often from planting and turning, or a hyperextension moment Research suggests up to 75% of ACL ruptures are non-contact. Female athletes are at higher risk due to anatomical, hormonal, and neuromuscular differences. The “Rule of Thirds” After an ACL Tear Recovery after an ACL tear doesn’t look the same for everyone. Experts often use the rule of thirds: One-third can resume normal activities without limitations (copers) One-third require modifications to improve stability One-third need an ACL reconstruction to return to their desired activities Do You Really Need ACL Surgery? The answer depends on your activity goals: Weekend warrior runners: Surgery may or may not be needed, depending on knee stability after rehab. Active parents: If your goal is walking, light exercise, or playing with your kids, you may not need surgery. Competitive athletes: For those who cut, pivot, and jump in high-demand sports, surgery is often required. Why Pre-Hab Matters Pre-habilitation (pre-hab) before surgery—or instead of surgery—is key for better outcomes. Pre-hab focuses on: Reducing swelling Restoring muscle activation and firing Improving movement patterns Setting realistic expectations Many patients find that after pre-hab, they can do everything they want without surgery—meaning they may be a coper. Why See a Physical Therapist First? When an ACL injury happens, your first step should be a consult with a physical therapist. Here’s why: PTs can assess whether you may function without surgery PTs see many post-surgical patients and can recommend trusted orthopedic surgeons if needed PTs can start your recovery immediately, restoring range of motion and function faster PT gives you the best chance at returning to activity—with or without surgery The Bottom Line Not every ACL tear needs surgery. Some people thrive with rehab alone, while others require reconstruction to achieve their goals. Your activity demands, goals, and response to pre-hab should guide the decision. Start with a physical therapist—you’ll get clear guidance, an individualized plan, and a faster path to recovery. References Plutnicki, K. (2014, May 4). Mantle’s Knee Injury Was Just the Start. NY Times Kaplan, Y. Identifying Individuals With an Anterior Cruciate Ligament-Deficient Knee as Copers and Noncopers: A Narrative Literature Review. Journal of Orthopedic and Sports Physical Therapy, 2011; 41(10), 758–766. Boden, B., Sheehan, F., Torg, J., Hewett, T. Non-contact ACL Injuries: Mechanisms and Risk Factors. J Am Acad Orthop Surg, 2010; 18(9): 520–527.

Pictured above is the iconic statue of Mickey Mantle outside of Oklahoma City’s Bricktown Ballpark. Mantle, the legendary New York Yankees outfielder, started his rookie year in 1951. In Game 2 of the World Series that same year, he sustained a right ACL injury that was never reconstructed or repaired.

Despite this, Mantle went on to win 3 MVP awards and a Triple Crown in 1956—all without a functional ACL. What does this tell us? Mantle was what we call a “Coper”—someone who can function at a high level despite having a torn ACL.

The ACL: Why It Matters

The anterior cruciate ligament (ACL) is one of the main stabilizers of the knee joint. Its role is to:

  • Prevent the shin bone (tibia) from sliding forward on the thigh bone (femur)
  • Provide stability for cutting, pivoting, and side-to-side movements

ACL tears are common, especially in athletes. One study cites an incidence of 68.6 per 100,000 people.

  • Contact injuries: when another player collides with your knee in a way that ruptures the ligament
  • Non-contact injuries: more common, often from planting and turning, or a hyperextension moment

Research suggests up to 75% of ACL ruptures are non-contact. Female athletes are at higher risk due to anatomical, hormonal, and neuromuscular differences.

The “Rule of Thirds” After an ACL Tear

Recovery after an ACL tear doesn’t look the same for everyone. Experts often use the rule of thirds:

  • One-third can resume normal activities without limitations (copers)
  • One-third require modifications to improve stability
  • One-third need an ACL reconstruction to return to their desired activities

Do You Really Need ACL Surgery?

The answer depends on your activity goals:

  • Weekend warrior runners: Surgery may or may not be needed, depending on knee stability after rehab.
  • Active parents: If your goal is walking, light exercise, or playing with your kids, you may not need surgery.
  • Competitive athletes: For those who cut, pivot, and jump in high-demand sports, surgery is often required.

Why Pre-Hab Matters

Pre-habilitation (pre-hab) before surgery—or instead of surgery—is key for better outcomes. Pre-hab focuses on:

  • Reducing swelling
  • Restoring muscle activation and firing
  • Improving movement patterns
  • Setting realistic expectations

Many patients find that after pre-hab, they can do everything they want without surgery—meaning they may be a coper.

Why See a Physical Therapist First?

When an ACL injury happens, your first step should be a consult with a physical therapist. Here’s why:

  • PTs can assess whether you may function without surgery
  • PTs see many post-surgical patients and can recommend trusted orthopedic surgeons if needed
  • PTs can start your recovery immediately, restoring range of motion and function faster
  • PT gives you the best chance at returning to activity—with or without surgery

The Bottom Line

Not every ACL tear needs surgery. Some people thrive with rehab alone, while others require reconstruction to achieve their goals. Your activity demands, goals, and response to pre-hab should guide the decision.

Start with a physical therapist—you’ll get clear guidance, an individualized plan, and a faster path to recovery.

References

  • Plutnicki, K. (2014, May 4). Mantle’s Knee Injury Was Just the Start. NY Times

  • Kaplan, Y. Identifying Individuals With an Anterior Cruciate Ligament-Deficient Knee as Copers and Noncopers: A Narrative Literature Review. Journal of Orthopedic and Sports Physical Therapy, 2011; 41(10), 758–766.

  • Boden, B., Sheehan, F., Torg, J., Hewett, T. Non-contact ACL Injuries: Mechanisms and Risk Factors. J Am Acad Orthop Surg, 2010; 18(9): 520–527.

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