Episode 52 | When Should You Start Rehab After ACL Surgery?

What’s up ACL athletes, Happy Thursday! Hope you guys are having a good week so far. Today, we are talking about a recent question that I got from someone on Instagram. One, that actually comes up often, so I wanted to talk about this today–when should I start rehab or physical therapy or physio after having ACL surgery? Or, really, in this case, it can also fit if you just had an ACL injury as well. But we’re going to focus mainly on ACL surgery.

What I’ll often hear is that the ACL surgery is approaching, it’s coming up, or maybe they’re already days out of surgery and they still have a week or two before getting into the physical therapy office to do their session. It can really vary. But sometimes it’s almost delayed too much. They’re not really doing anything. They are at home, hanging out, the knee gets super stiff and the quads get really weak and atrophied. And the common assumption is to rest which you should be doing. You just had a lot of work done to the knee, so you should be resting. But it needs to be active rest. There needs to be something in place to make sure that you start doing things from the get-go.

And the other thing that I’ll hear is that, if it was important enough to schedule, then the surgeon’s office would have told me. But their emphasis isn’t, hey, get into physical therapy as quickly as you can. And it also depends on their philosophy and the way they go about with their surgeries connected to the rehab. But the main focus for them is getting the surgery done and then getting the physical therapy is on you to get that scheduled and get it knocked out. There might not be as much of an urgency on their part.

But for you, there should be urgency and there’s a sweet spot with this of doing some rehab, as well as allowing you to rest and let this surgery and body heal as well. You’re in this protection mode, but we need to make sure we make the most of this time. And so that’s why you can’t necessarily rely on the surgeon’s office to kind of hold your hand through this process. They have so much going on as well, and their main goal is to get the surgery done and make sure it goes well and you’re safe. The next step is typically to start physical therapy. 

Now, this all needs to start and take place as soon as you are planning the surgery itself. And you have to take initiative and you have to be proactive. To answer this question: when should I start rehab or physical therapy after having ACL surgery or having an injury? And the answer is immediately. You should start as soon as possible. And this can take place in many different ways. One of the things that I’ll tell my athletes to do after surgery, if they remember, is as soon as they wake up, start trying to do some quad sets. We need to connect that mind-muscle connection. And sure, if you’ve had a nerve block, there’s pain, your knee’s probably immobilized. You might not be getting that much into it or getting that much engagement. But it’s something that you just want to kind of kickstart the process as soon as you come out of surgery. And those repetitions will go a long, long way as you take it day by day, hour by hour. You can essentially visualize as you putting this work or doing these repetitions as laying bricks down to build a wall. And instead of trying to build that wall in a day, you want to think about building brick by brick, and that starts from day one. 

Now, let me explain. Here’s some things to think about. Initially, post-op, you’re going to be limited by the surgery, by the pain, by the walking. It’s not like you’re going to do a full training session. But as soon as you’re out of surgery or the injury, the quad starts to atrophy. We all know this, if you’ve been through it, you’ve seen this. The research shows that you can lose up to 350 grams of muscle tissue and a reduction of 30% of muscle protein synthesis for every two weeks you immobilize after surgery. A 350 grams is the size of an average heart. Now, this is a pretty extreme example. But guess what? Your quad is going to shrink. It’s going to be okay. You’re going to survive. 

I remember when mine did and it was something that I had to work really hard for. And it’s something that I have to remind my athletes all the time of making sure that we get those quads back. And we can mitigate this by starting as early as possible. It starts day one. And what I want to kind of talk about is a game plan and make this a bit more practical for you guys. If you had the ACL, one of the things that I’ve talked about before is you need to get in and do some prehab with a PT, with a physical therapist. You need to get some stuff going to get the knee back to its normal function, as well as maintaining the strength and conditioning of your body and your knee. And it’s going to help you that much more going out of surgery. And research has supported this numerous times of the impact of having prehab. 

Now, if you can get one session, that’s great. I know some people with insurance limitations might not be able to get in until after the surgery, and that’s okay. But you need to be doing some prehab on your own, if you can, leading up to surgery. And I’ll talk about in a minute of some of these priorities and focuses of what you need to be doing during prehab. Also, I’ve done a previous podcast on this, so if you have not listened to that. I highly suggest listening to it because we talk about that in more detail. 

You have the injury, you try to do some prehab if you can. One of the things that I’m going to highly recommend is that you figure out how many insurance visits if you’re planning to use insurance and let’s say you’re in the U.S. Model. I know other countries have different models. But if you’re going to be using insurance, then you need to know how many you have in total. Because that is going to impact the way that you strategize the weekly sessions, as well as the long-term outcomes. And the way that you’re going to structure that for your ACL rehab. You’re looking at nine months. Most of the insurance and the way that is strategized with physical therapy is typically around anywhere from 20 to 40 visits, as well as people usually do their physical therapy. If I had to just estimate, it’s usually the first three months. That’s just kind of the way the system is built and it’s been done.

You need to kind of figure out, okay, how can I stretch this out? And a lot of this starts with knowing how many insurance visits do you have. Call your insurance. They should tell you how many you have. And that way you can start thinking of a long-term game plan. This will play into new scheduling of your first post-op rehab immediately after your surgery. Do this ahead of time. I like to see my athletes within the first three to five days of surgery, if possible. They have the surgery. And sometimes I’ll see athletes the day after or maybe a couple of days after. And it’s great. Because then we can kind of lay the groundwork. 

Now that the surgery’s in place, we can work with the constraints of what they’re feeling and set the expectations even from there. And being able to know, okay, here’s what our main goals are. I don’t want you to stress about anything else. And this is what we’re going to do. And it really helps. Instead, of taking maybe seven days or two weeks, which I hear all the time, whether it’s someone who wasn’t able to schedule in time or their surgeon’s office had told them, you know, wait a while. I am going to push back on that because it’s going to really depend on you and the surgery. But there’s not very many cases where someone needs to completely do nothing. There is not at all and actually is going to play against you in the long term. 

Here’s the only way that you might not need to rush off to go to physical therapy. It might be because you did prehab and you have a game plan with the physical therapist that you’re working with. To know, okay, this is what I’m going to be doing immediately after, and so I don’t need to rush in because I already know what those things are. You know how to do them, you know how to operate, in terms of functioning with the knee, getting the quad going, all those exercises that you need to be working on. And so you’re good. Maybe you can space that out a little bit. But if not, then it’s something where it’d be ideal to get in soon. 

And sometimes the surgeon will give you a sheet of paper. I know a lot of this happens where they’ll give you a sheet and is to do quad sets and some assisted knee flexion, some ankle pumps, just some things to kind of get things going, which is great. That’s going to be kind of your baseline and you need to do them religiously. I think the disconnect comes where you get a sheet of paper and are told to do something and you’re not necessarily feeling it, or maybe there’s some question about: am I going to do damage, is this going to be productive, am I feeling it in the right places. There’s always a lot of questions and that’s where I feel like getting into physical therapy visit early can help to mitigate any kind of concerns, as well as get this going of doing this well and doing it efficiently. 

Even with my remote athletes, we start getting them on these things way before surgery and they know exactly what they need to be doing the day of surgery and moving forward. When you get into your physical therapy and you start those visits and the rehab, it allows you to start building that compound interest early rather than seeing a huge dip in the range, strength, size, or your overall condition. And that way you don’t have to start way before the starting line, let’s say a week or two weeks after. And then now you’re starting to get into some movement and some exercises. What usually happens is that people just get really stiff, and it makes it really tough to kind of get things going. Our body craves and needs movement; that’s how it heals, that’s how it replenishes. That’s why it’s going to be vital early after surgery. We are laying the foundation for the rest of our ACL rehab and the rest of this journey.

My advice is: If you’re going to focus on something after injury or after surgery is just to get the knee quiet. And what we mean by that is to get it to calm down. It’s going to be swollen and painful. But if you stick to these main goals, and you take into account your precautions or restrictions, maybe it’s on weight-bearing or bending the knee to 90 degrees. It just depends on what the surgeon does. But priority number one, get your knee extension the same as the other side. Get it straight, get it flat, get it past zero, zero is not good enough, get to negative 10 if you can, or whatever the other side is for you. But focus on that; it’s very important. The further out you get and the further away from that initial surgery, the harder it is to get. Not in all cases, but in most cases it can be difficult. 

And so then with priority number two, you’re going to get your quads active and going. I use the 10 by 10 role, as well as other additional things that athletes get to do. The 10 by 10 rule means you’re going to do 10 reps every single hour and squeeze for 10 seconds. You could do this anywhere. Instead of thinking, okay, one big session, or maybe even three sessions spread out. You can add this into the mix to get a more mind-muscle connection. And really try to focus on, okay, I’m going to get input to my quads every single hour, and really be focused and intent with it. Also, instead of buying a super expensive ice pack, pressure hydrocollator, pressurizer thing, like those are great, but go for a cheaper one. And buy potentially an NMES unit. You’ll get way more out of an NMES and electrical stimulation unit than you will out of an ice pack. Just flat out, in reality. The ice packs are nice; they will feel great. There are other means to be able to do that. But if it’s a financial thing, you could buy a $50 NMES unit on Amazon, and it will make a massive difference in getting your quad going. And don’t get the TENS unit, get an NMES unit. 

Priority number three, getting your knee flexion. This will progressively come but don’t slip on it. Make sure that you’re progressively working on this as time goes on. That first milestone of getting towards 90 degrees is most ideal. And then, priority number four is working on your gait, if you can walk. If you can’t, then you just kind of build up toward that. But these are the goals in terms of how to get there. It’s going to be different for each person. So that’s where having the prehab or having the initial physical therapy visit is going to be very helpful in order to make sure that you are making your way on your phase one goals. 

Listen to your knee. Don’t try to be a hero or hit a home run on the first days. Just listen to your knee, get some input in there, do some consistent work, and it’ll pay off in the long run. If you’re having ACL surgery, get your first PT session scheduled. Call your insurance to know how many visits you have. Don’t wait. Be proactive. If you wait last minute, depending on the clinic, you may have to wait a week or two to get in. Maybe they can evaluate you or they don’t have enough room in their schedule. Or, maybe you just don’t get into the clinic that you want, and then have to settle for one, with Sally that does ice and electrical stimulation for 90% of your session. And then that’s going to be something that you’re going to get frustrated with as well. Don’t be that person. 

And make me a promise that you are going to start doing some movements as soon as you have surgery, and you’re going to schedule your physical therapy way in advance and make sure that you have a game plan in place. And don’t wait until you have the surgery and then decide to schedule things. Do it all before. You’re going to be tired and groggy and in pain. And the last thing you want to do is deal with scheduling your physical therapy. Go and do that. These are precious days, so make the most of them and move the needle early and build that compound interest, and start laying the bricks. Build that wall. Lay that brick, brick by brick, a lot of bricks. Lay the wall, build the wall. 

All right guys, that’s going to do it for today. Please do me a favor, if you have a second. Please leave a review for this podcast. The more that people review this and leave positive feedback, the more that it reaches other ACL athletes like you out there. Even if you want to kind of go down, hit that five-star, or maybe you want to make fun of me because I breathe heavy or I have really bad jokes. Please leave me a review and leave the podcast a review so we can reach other people who need this as well. But that’s it for today, guys.

Thank you all so much for listening. This is your host, Ravi Patel, signing off.