Editor’s note: This article is part of an eight-week series about ACL, MCL and other knee injuries, featuring professional and first-hand info on surgery, rehab, recovery and prevention. See the Summit Daily sports section every Friday or Saturday for the next installment, and head online to SummitDaily.com for past articles.

Every sports injury — small or large, blown ACL or sprained ankle — comes packaged with physical therapy.

Or at least it should, if you want your body to be as strong and reliable as it was before the injury, according to orthopedic surgeons and physical therapists. Even a mellow rehab program is essential for people who ski, bike, hike and play if they want to return stronger than before — and avoid future injury.

But that doesn’t mean it’s easy, and the first lesson is patience.

“Simply put, it takes the body time to change,” said Eric Dube, a U.S. Ski Team physical therapist with Howard Head Sports Medicine in Summit County. “Post-surgical swelling causes pain, stiffness … and reduces muscle activation. Our bodies have a system in place to deal with swelling, but it takes patience and just the right amount of PT and activity to get that inflammation down, and keep it down.”

The first few weeks after surgery are rough, but they’re just the start of a long, sometimes hard road. To help along the way, local doctors and PTs talk about the ins and outs of knee injury rehab: what to expect, what to do, what not to do and why it’s all in the name of a better you.

Meet your physio

Within days of injury or surgical repair (if you go that route), orthopedic surgeons recommend meeting with a physical therapist to start getting back to normal.

In those first few days and weeks, Dube said PTs focus on four things: restoring range of motion, protecting healing ligaments, activating leg muscles and slowly returning to a normal stride. Any of these goals can be delayed if a meniscus tear is involved and you can’t bear weight while the sensitive tissue heals.

“The phases of rehab are typically based off two things: time and function,” Dube said. “It takes soft tissue time to heal and mature, and there is also the fact that muscle strength and quality movement needs to return to normal levels.”

In other words, you can’t force Mother Nature to work faster. But in the meantime, seeing a PT at least twice per week and following a home rehab regimen are the first steps. Early exercises include calf pumps, leg raises, quad pumps and calf stretches, all meant to slowly reactivate injured tissues and the surrounding muscles.

PTs also suggest keeping things even: If you do an exercise on your injured leg, do the same exercise on your good one to avoid the “risk of injuring the opposite side due to over compensation and other factors,” Dube said.

After range of motion and weight bearing are back to normal, Dube said it’s on to endurance training to “build a solid foundation” for the next few weeks of strength training, power and agility exercises, and sport-specific training. These exercises can be everything from lunges and lateral cutting to riding a stationary bike. Again, it’s all in the name of reactivating muscles that atrophied in the hours and days after the injury or operation.

“Take a look at a friend’s knee that’s been operated on,” Dube said. “If I was a betting man, I’d bet that his or her thigh muscles are smaller and likely weaker than the healthy side. It’s just very difficult to get the muscle strength and girth back after an injury.”

What’s the timeline, then, for a return to normal? There’s no one answer for any type of surgical repair, but for an ACL reconstruction, Dube said the average wait is six to nine months before someone can get back to skiing, snowboarding and other high-impact sports. Rich Cunningham, an orthopedic surgeon with Vail-Summit Orthopedics, said he’s more likely to suggest 10 to 12 months for longevity.

“We would hope that a repair is lifelong,” Cunningham said.

Beyond the clinic

Rehab exercises are well and good, but not everyone is a gym rat and cabin fever can be brutal in the weeks after an injury. What other options do knee patients have to break the monotony?

Local pro snowboarder Silvia Mittermuller has one answer: water therapy.

“Go in the water as soon as you can,” Mittermuller said. “Water is absolutely magic — it’s where you start walking and moving and being mobile again. As soon as the stitches come out, you can get back in the water. Water is a magical cure.”

Some physical therapy offices offer water therapy for PT sessions, but Mittermuller said it’s easy enough to do with free time. Along with light kicking and upright walking in the deep end, she also swims laps with a pull buoy between her legs for a cardio workout. It’s the one time she can get tired when nursing a knee injury, she said.

For others, mountain-town favorites like yoga or biking are the solution. Most knee patients can start light stationary biking six or seven weeks after an operation, PT willing, and can move to outdoor cycling within four or five months. Impact sports like mountain biking might have to wait until you have the all-clear for cutting, jarring activities from a surgeon.

Once you’ve cured your cabin fever, the work isn’t done. Diet is another major piece of the rehab puzzle, and while most PTs won’t comment on the right foods for recovery, local naturopathic doctors have suggestions for pre- and post-surgery eating.

Justin Pollack with Backcountry Herbal Apothecary in Frisco suggests a regimen of vitamins, minerals and nutrients, explaining how they help your body perform at its best, even after trauma. Take the example of natural enzymes: like painkillers, they relieve inflammation and cut straight to the root of the pain.

“The biggest thing that helps after surgery are natural enzymes,” Pollack said. “If you take them on a full stomach they digest your food, but if taken on an empty stomach they slip into the circulatory system and break down inflammatory enzymes.”

Can it happen again?

The day is here: After nine months of surgery, rehab and recovery, you’re back on skis for the first time. You feel strong, maybe even stronger than before, but you can’t shake the jitters. What if it happens all over again?

Truth is, there are no guarantees. Mittermuller has injured both knees a total of five times in a 10-year career, while fellow Breckenridge-area athletes have done the same: one for Team Summit Colorado alpine director Troy Watts, a few for pro skier Keri Herman, five for Summit High head soccer coach Tommy Gogolen — the list goes on.

There may be no guarantees, but Dube and other PTs are adamant that patience is key. He cites a 2014 study of late-teen athletes with first-time ACL reconstruction. The study, printed in American Journal of Sports Medicine, showed that teens were six times as likely to tear either ACL within the first two years after the original injury if they returned to their sport. His point: You can reinjure the same side, that doesn’t make the “healthy” side invincible. It’s why performing the same exercises on both sides is important — and why PT is a must.

“If you can appreciate every step you take like those first few after crutches, you will be so happy with life,” Mittermuller said. “What a fascinating thing the human body is: You have to break something to appreciate how amazing it is to move.”