What is up team, and welcome back to another episode on the ACL Athlete Podcast. Before I get into today’s topic, I want to tell you about an ACLer I’m working with right now. She had her ACL reconstructed, so she had the normal ACL reconstruction most people know about after an injury. She did everything right—found a surgeon, went through with surgery, and committed to rehab. As she progressed through the process, she expected to feel like herself again, which is what most ACLers expect after putting in the work. You go through this process believing that if you do everything right, you’ll come out on the other side feeling whole again.
But for her, something was off. Her knee never felt right, and there was laxity that shouldn’t have been there. It felt unstable, and there was discomfort that stuck around longer than it should have. She had this sense that the joint just wasn’t doing what it was supposed to do. So she went back to her surgeon, raised her concerns, and was told that nothing was wrong. She was essentially told to keep rehabbing and that things would eventually get better.
So she kept doing exactly that. Months went by, and her knee still didn’t feel right. And here’s the hard part about being told you’re fine when you don’t feel fine—ACL rehab is already messy because there are so many variables involved. It could be rehab-related, surgery-related, your body adapting, life stressors, or something else entirely. There are so many factors that can influence success—or lack of success—in this process. That uncertainty can make athletes question themselves in ways that are incredibly damaging.
After a while, you start wondering if maybe it’s just you. Maybe you’re not working hard enough. Maybe your pain tolerance is low. Maybe you just need to push through it. Then your knee gets flared up again, and you start wondering if this is simply your new normal after ACL surgery. That doubt can be one of the most damaging things that happens during this process because at that point, it’s not just the knee—it’s the story you’re being told about it.
We eventually got connected because she had heard about us specializing in ACL rehab. I evaluated her history, symptoms, and previous surgical reports. There were several things that immediately felt off. The tunnel placement looked questionable based on the operative report. She was also dealing with pain, stiffness, range-of-motion limitations, and very specific symptoms that raised concerns.
I suspected she had a hardware-related issue. I also suspected that the ACL graft may not have been positioned correctly. It was clearly a complicated situation. I referred her to another surgeon for further evaluation. That surgeon confirmed there were legitimate concerns with the original reconstruction. Specifically, the tunnel placement was more vertically aligned than it should have been.
It was non-anatomic, which explained why her knee felt unstable. Her ACL had technically been rebuilt, but it hadn’t been rebuilt correctly. For many ACLers listening, this may be surprising because most people don’t realize tunnel positioning can create these kinds of issues. There are different surgical techniques used in ACL reconstruction. Some older approaches can create more vertical tunnel placement. More anatomic approaches are designed to better replicate the ACL’s original positioning.
On top of that, her tunnels had widened over time. She was also dealing with hardware complications. Eventually, it became clear that revision surgery was the best path forward based on her goals and symptoms. But this wasn’t going to be a simple redo. It required a two-stage revision procedure. And that’s exactly what today’s episode is about.
We’re turning this into a two-part series because there’s a lot to unpack here. While this impacts a smaller subset of ACLers, it absolutely happens. There also isn’t enough clear education available around this topic. I want this episode to be practical for ACLers, clinicians, and coaches alike. My goal is to help you better understand what this process actually looks like.
In part two, we’ll dive deeper into the research. We’ll discuss what studies say about outcomes. We’ll also break down the surgery itself in more detail and what recovery looks like. This process is complex, and I want to make sure you understand it thoroughly. So let’s get into what a two-stage ACL reconstruction actually is.
Most people picture ACL surgery as a straightforward process. You tear your ACL, have surgery, get a graft placed, and rehab your way back. For most ACLers, that model is accurate. But for some athletes, that path isn’t available. Sometimes the original surgery fails, tunnel placement is incorrect, or tunnel widening becomes severe. In those situations, a single-stage revision may not be enough.
That’s where a two-stage revision comes in. Think about renovating a house. You want new walls, floors, and a roof, but then you discover the foundation is cracked. You guys know I love a good house analogy. You wouldn’t build on top of an unstable foundation. You’d repair the foundation first before rebuilding.
That’s exactly what stage one does. The surgeon removes the old graft and hardware. They clean out damaged bone tunnels and fill them with bone graft material. I like thinking of it like putty because it helps athletes visualize the process. The goal isn’t rebuilding the ligament yet. The goal is restoring healthy bone structure first.
Sometimes surgeons also address meniscus issues or clean up other joint problems during stage one. They want to make sure the knee environment is healthy. They also want the tunnels filled properly so future drilling can happen safely. Stage one is all about rebuilding the foundation. It prepares the knee for a more successful reconstruction later. That foundation matters.
One critical thing ACLers need to understand is that after stage one, you leave without an ACL graft in place. The old graft is gone, and the new one hasn’t been inserted yet. That’s intentional. It changes how you approach the period between surgeries. Athletes need to understand this mentally and physically. It’s a very different rehab phase.
Stage two is the actual reconstruction. Once imaging confirms the bone has healed, surgeons go back in. They create new tunnels in healthy bone and place a new graft. New fixation hardware is used. The goal is creating a stable knee built on a strong foundation. Two surgeries—but one long-term goal.
There are cases where surgeons may not need a full two-stage process. Sometimes they can address tunnel widening without fully removing the graft. It depends on tunnel size, graft quality, and surgeon expertise. This is why second opinions matter so much in complex ACL cases. Every case is highly individualized. There is rarely a one-size-fits-all answer.
I’ve worked with ACLers dealing with one tear, two tears, three tears, and yes—even four ACL tears. It happens. I’ve worked with multi-ligament injuries, bilateral ACL injuries, and athletes years removed from surgery who still never felt right. Complex cases are more common than people realize. And these athletes deserve real answers. That’s why proper expertise matters.
One of the biggest reasons athletes need two-stage revisions is tunnel widening. Over time, the original tunnels can expand due to mechanical stress, graft type, fixation methods, or biological responses. Hamstring grafts tend to have more tunnel widening compared to patellar tendon grafts. Significant widening can leave insufficient bone for secure graft fixation. That often requires stage one bone grafting.
Tunnel malposition is another major reason. This is exactly what happened with the athlete in today’s story. If the original tunnels were drilled incorrectly, new tunnels may overlap with old ones. That creates structural problems. The original tunnels may need to be filled before proper reconstruction can happen. That’s why stage one exists.
Other causes include hardware complications, stiffness, alignment issues, or infections. And yes, infections do happen. I’ve seen athletes deal with months of complications because of them. These situations are rare but very real. They can significantly delay rehab progress.
If your knee doesn’t feel right after surgery, trust that feeling enough to investigate it. Get second opinions. Sometimes everything truly is fine. But sometimes it isn’t. You deserve clarity either way. Don’t ignore persistent red flags.
Most athletes needing this surgery did everything right. They got diagnosed. They had surgery. They committed to rehab. And something still went wrong. That’s important to say out loud because many ACLers carry unnecessary guilt.
This isn’t a character flaw. It’s a clinical reality that sometimes happens. The solution may be complex, but solutions do exist. It may take longer than expected. It may require patience. But there is still a path forward.
If you’re facing a two-stage revision, understand that this is a long process. From stage one through return to sport, you may be looking at 14 to 24 months. That timeline can be hard to hear. But realistic expectations help athletes plan mentally and practically. Playing the long game matters.
The period between stage one and stage two usually lasts three to six months. During that time, your knee has no ACL. You’re still rehabbing and getting stronger. But you’re also operating with clear limitations. It requires patience, unlike anything else in ACL rehab.
And emotionally, this process is heavy. You’ve already gone through one ACL reconstruction. Now you’re facing another one that’s even more complex. Research shows psychological readiness scores are significantly lower in revision ACL patients compared to primary ACL patients. That emotional reality deserves attention.
The athlete I mentioned at the beginning is currently in stage two rehab. She’s not finished yet, but she finally has clarity. She has a team she trusts. She understands her plan. And that clarity changes everything.
It doesn’t make the process shorter, but it makes it more manageable. It gives you confidence in your roadmap. So many ACLers struggle because they don’t know where they are or where they’re going. That uncertainty creates anxiety. Clear direction changes that.
And that’s what we aim to provide. If you need help navigating this process, please reach out to us. All the information is in the show notes. We work with ACLers facing this level of complexity every single day. We’d love to help.
And before we sign off, part two will cover the research in more detail. We’ll break down outcomes, the second surgery, and what the interstage period requires. We’ll also discuss what athletes and clinicians need to understand moving forward. There’s still a lot more to cover.
And if this episode resonated with you, share it with an ACLer, a clinician, or a supporting role here who needs to hear it. And as I shared, if you’re in a situation where you need some assistance, please reach out to us. All the info is in the show notes. We work with athletes navigating exactly this complexity every single day. And we would love to help anyone who is interested. And if you have any questions in general, please reach out to us.
Otherwise, I will see you in part two. This is your host, Ravi Patel, signing off.
