Episode 66 | How Important is Post-Op ACL Rehab?

What is up guys? I’m going to be real with you today, not feeling super hot. You might be able to notice it from my voice. But my wife and I went down with a cold. But we are here, we are going to record because we can’t miss a week for my ACL athletes. We’re going to keep this short and sweet today.

The focus of this episode and the question we are answering is how important is post-op ACL rehab? How important is that physical therapy, the rehab that you are doing right after your ACL surgery? You can even insert the injury itself because there are some similarities of course. But today, we are going to focus, especially since most people go through the surgical process on how important is that post-op ACL rehab as soon as they finish the surgery, and they’re on the road to recovery in this process and kickstarting the rehab. How important is it? 

The reason this topic and this question come up today is because I’ve been having many conversations with athletes who are in this process, who are getting ready for ACL surgery, who are trying to figure out their rehab. And I feel like I get this question quite often about the importance of the post-op ACL rehab, the prehab itself, the early, mid, and late stages, where should we put the most emphasis on. There are a lot of things that can come up because of how long this process is. And this conversation has been very specific because what athletes will ask is, okay, well maybe do I need to even worry about the early stages because it’s so ” basic” and the surgery is limiting, that maybe I don’t really need to worry about whether it’s working with an ACL specialist or expert. Or, that I shouldn’t really worry too much about the initial phases because it is so straightforward. There’s a protocol. I just had surgery so I can’t do as much. It just makes sense. And when we try to rationalize it, of course, that does make sense to us. What I will hear is that people won’t worry too much about the initial phases and they’ll start to look into more resources or to find someone better to work with once they’re in the mid to later stages.

And I am going to disagree and push back a little bit here. And I’m going to tell you my reasons why. And the main thing that I want to start with is the school analogy. And so imagine you’re trying to get into your college major without taking the prerequisites. This is something that I have used and talked about before, but I want to kind of revisit this because this is going to help lay the groundwork for the episode. I remember in undergrad we had to apply to our kinesiology department to get in. Only 50% of the applicants got in, and so a lot of this was based on how well you did in your prerequisites. So that is chemistry, biology, physics, calculus, anatomy and physiology, and so many other classes that were in this specific bubble to help get you into the specific major.

 At first, I thought these classes were just nonsense. It’s just kind of check the box, whatever it is. It’s just for the grades or whatever we think of school. There’s a lot of things where we just try to get the grades. The content itself really doesn’t matter and we probably won’t use it later. I am still really focused on trying to apply myself because that stuff was really important to me and to be able to just do well, and make sure I’m making use of the time that I’m putting in and learning that. If I do need it later, I can recall it. And so once I got into my major, we used all of this across my classes. The whole thing of like, “Oh, we’ll never use this again,” which there are plenty of things in school that we don’t. But these prerequisites that were required for my major, we actually built on. I couldn’t imagine trying to take biomechanics or exercise physiology and couldn’t understand the basics of physics or biology or even tagging in chemistry with that. Especially anatomy and physiology because we were working so much with the human body that we needed all of those foundational prerequisites in order to really make sense of what we were learning.

And then you fast forward to getting into PT school. There are certain prerequisites that you need. And those went even further into detail and built upon these foundational prerequisites and subjects. This is where it leads me into setting the foundation. And if you’ve heard any of my episodes, I’ve talked about the foundation a lot. And post-op ACL is really the foundation that you are building for the rest of the journey. You are laying this down brick by brick in order to make sure that you have that solid foundation and you want to make sure that these first steps are done well, so you can move on to the next steps and build on top of it. And while time passes, especially in the early post-op phases, there seems to be this thing where we’re following a protocol. There is ” good enough range or good enough quad strength” or whatever you want to call it, that we start moving forward. And while the squatting and the running and the jumping and all the dynamic type stuff is fun and what we want to get back to. If you really don’t have good, adequate quad strength, if you still have pain or swelling, if you’re still lacking adequate knee flexion, that is 100% going to show when you’re going to do your squats, your running, and your jumping. You do not want to be limited by this. And we need to make sure that the parts broken down all come back together in order for us to move forward with certain movements. 

And as an example is if we’re talking about squatting. Squatting, depending on the depth that you’re going to, you’re going to need adequate quad strength to make sure you don’t compensate. The other piece is that you’re going to want to make sure that you have a certain level of knee flexion. Otherwise, if you do not have it, then your body’s going to figure out a way to execute the movement, which is probably just shifting to the unoperated side. And what I will typically see is that people don’t necessarily gain this back. They learn the compensatory patterns and then that leads to them favoring that side, especially with movements like jumping where they will land or they will jump onto a box and they will land on their unoperated side. Essentially that’s doing the work because we never set the foundation appropriately, and met the phase one goals that we’re focused on. And that’s because we want to rush forward or we want to move forward just based on time, even though those specific criteria and requirements have not been met. 

And the reason that I’m stressing this point so much is that I talk to athletes all the time who are maybe three, six, or nine months down the road. Or, they might even just be six weeks post-op. And I’m talking to them about where they are, what they’re feeling, maybe the barriers that they’re limited with. And a lot of time it comes back to the care or inadequate rehab or guidance. But this is something that is really tough and it ends up being something where we have to take a massive step back because they have not had these prerequisites met. And a lot of times the post-op ACL program or what they were doing was not sufficient enough. And they maybe got to zero degrees extension instead of maybe the minus five or minus 10 that we’re looking for, usually similar to the opposite side. We have to reverse a little bit because they’re not getting the full extension, which means they’re probably not getting full quad engagement, which means that that is playing into their quad strength, which is playing into all of the movements that they are doing. You guys see a trend here. They build on top of each other. And it makes it really difficult because when they come in, they want to make sure that they can start on a new game plan and make sure that they can move forward. But the thing that is tough is that we typically have to take a step back. Because the foundations in the post-op ACL rehab were not addressed appropriately. 

I want to share this one story that really pulled out the heartstrings if you will. I had this athlete who came in last week. His mom wanted me to start working with him because she was a little worried about his rehab, his progress, and where he should be. I evaluated him at six weeks post-op ACL. He had a quad tendon. No other issues. And this dude was struggling. Pain, range of motion, and a lot of things were going on. And while I am not so tight to timelines, this guy was a week, week, or two out, essentially. But he was kind of hobbling along. His extension was still maybe like positive 10. His flexion was around 110 and he’s six weeks out. The injury itself wasn’t super complicated. The surgery and the surgeon said everything went well. I was curious, why is this guy in a place where, especially being young, he’s 16… why is he struggling so much with his ACL rehab and his progress?

And when I started to dig in deeper, I started to realize that he was not getting very good guidance. And he started blaming himself for where he was at and why he was not progressing. Even though he was like, I’ve been doing everything. The mom has a different story where he might do things once every few days, if we know in the post-op ACL rehab process, you got to hit consistently multiple times a day. It’s just the way it rolls. I started to realize that at rehab I was asking, what are you doing? What are you getting? A good example of this is that he was doing straight-leg raises with an assisted band to help him get up. And while every exercise has its reasonings and rationale, you should not really need a band to help assist you with a straight-leg raise. It means you’re not getting your quads active and you need some assistance to do that. And while there’s an assisted extension that you could do, the straight-leg raise that’s not going to fulfill it. Without getting into the weeds here, he was essentially doing movements he had no business doing. He was not doing any gait or walking drills yet. He was walking around without a crutch. There were a lot of things wrong with this. And this guy broke down. He broke down frustrated with himself. He is worried because there is a possibility of having to get a manipulation under anesthesia. This is all real. 

I’m sharing this because this is the reality of some of these situations. And this is coming back to the core question of how important is post-op ACL rehab. It’s really important, it is going to set the foundation of this process. And we got to make sure that we have the right game plan in place for a post-op ACL. The things that I give my patella tendon versus my quad tendon versus my hamstring tendon versus an autograft are all going to be different from the get-go based on each different graft, as well as any other restrictions or injuries. So that’s why the protocol isn’t always going to serve each person because it’s too generalized. We need to make sure that this post-op program and plan for each person is attacking the specific goals we need for that phase. And we need to make sure that we are making progress towards that and not moving too fast in setting the foundation.

Another point that I want to bring up about the importance of the post-op process is that you can get ahead of any issues. And what I mean by this is that if things start to pop up or you’re starting to notice certain strategies that you’re taking or compensations or even aches or pains within the knee, that are worth talking about and bringing up to the physical therapist that you’re working with. You can get ahead of any issues rather than waiting till three to six months down the road. And then having to address it while it’s been going on for much earlier. And that’s where working with someone who specializes in ACLs is really helpful because they will see common patterns that will potentially pop up and help you to game plan to avoid this. 

I’ll give you a simple example. Something like if you are non-weight-bearing, you can’t put your foot down on the ACL side. Maybe there’s a meniscus repair for six weeks or four weeks. That there needs to be a slower progression with the gait and especially the number of steps you take because the knee will need to get used to weight-bearing again. And often swelling can kick in, especially if someone starts to ramp up their walking a lot and they might’ve had some bone bruising with it as well. Then we need to make sure we progress with the gait patterning and the steps slowly. Because what can happen is that the knee can ramp up and start to swell because of that compression force that it was not used for the first four to six weeks. But in most protocols, that’s not accounted for. It’s just like,” Hey, like start walking as soon as you get the clearance.” But there needs to be parameters around it. And that’s some of the things that you can get ahead of, especially working with someone who’s specialized in this. But also making sure that we just don’t, brush over the post-op ACL rehab process.

And to add to this same point here. It helps to not delay the process any more than we need to. Everyone knows about the setbacks that can happen and that will probably happen at some point. And the last thing we want is for this to be longer than it needs to be. Nine months is way too long. A year is way too long. Let’s make sure that we minimize as much time we have to stay in this ACL rehab process and the whole return of sport process. If I see someone who comes in from somewhere else, a lot of times they may say they’re six months post-op, but their knee and the movement might look like it’s potentially one to two months out. And this is more common than you would think. I’ve seen it a lot. And it comes down to the clinician, sometimes the patient, sometimes both, or sometimes it’s literally out of their control because the knee has had a lot of ups and downs and maybe there’s some actual physical barriers that have impacted the progress.

But what I want to focus on is the first two points of the clinician and the patient. If the clinician is not using criteria and not progressing you based on your range and your strength and other qualities we’re trying to develop, and not just going by time, then that is going to impact things. Because if we are four weeks out and the protocol says, all right, now it’s time to squat, step up, or do some other specific movements based on the protocol. But you can barely straighten your knee and get to 90 degrees of flexion, that’s going to be a problem, that’s going to be an issue. We want to make sure that those things line up, especially based on phase and criteria goals rather than time alone.

And then, on the patient side is going to be important that they are doing the work outside of the clinic because we know the clinic work alone is not going to get them where they need to be. And so that’s where these post-op pieces, you’re going to need to do so much more outside of the clinic, in order to make sure that you optimize this process. And set the foundation for the rest of your ACL rehab, which brings me to this last point, which is that it will allow for a smoother transition from phase to phase. If we know that you have your extension, if we know that you have your flexion, if we know that you have really good quad contraction and strength, if we know that you can walk really well and it doesn’t seem compensatory at all, and we know that your knee is not volatile, in pain or swelling, then man, are we set up for a really, really good foundation to move forward with. And that’s going to make a smooth transition into the next phase and into the phase after that, if we’re building layer by layer, brick by brick. And that’s going to help so much and it all starts with the post-op ACL rehab phase. 

In summary, how important is post-op ACL rehab? How important is your physical therapy, your physio, right after you have your ACL surgery or even your injury? It’s incredibly important. It is going to create the best foundation possible so that way you can make sure that the rest of your journey is as smooth as possible and that you build those prerequisites. You work really hard to do that in order for you to move forward into the next phase or your next major or your next milestone in order to build on top of that one. And that’s going to allow you to get ahead of any issues because you’re working diligently, instead of taking it easy during this process. It allows for a smoother process later. And it reduces the number of setbacks you might potentially have in this process.

Don’t get me wrong, there are going to be setbacks and some will be long, some will be short, some will be not too bad, and some will be a lot harder to get through. But having this post-op ACL rehab done to the best of your ability, and you can finish that phase and know, okay, I did as much as I can to be able to make sure I move into the next part of this process, then that is going to help reduce any of those setbacks. I might even make a big setback turn into a small one or maybe even reduce the risk or the likelihood of them at all.

 If you are an athlete who is looking at post-op ACL rehab, immediately after you have your surgery. One thing that I would love for you to think about is to make sure that you just take it very seriously and that you work really hard and be consistent. And make sure that you have those proper goals that you need to work towards in that period, and make sure that you have the proper guidance with it.

 If you are trying to debate, well, should I use my insurance or should I find someone else who’s more specialized in this? Or what I’ll hear is that people will say, I’m going to use my insurance. I’ll just use what’s local to me, and then I’ll seek better guidance mid to later stages. I’m just going to caution you here because if you don’t get really good care and really good guidance from the front end in this post-op ACL rehab process, then that is going to make it difficult in the mid to later stages.

And I hope that this episode shines some light on why it can be so important to set that foundation and to work with someone who is familiar with this and who can give you the proper guidance, set the expectations, and set the goals alongside you. And making sure that you set that foundation that way when you do get into those mid to later stages, that you don’t have to backpedal or take a step back in order to achieve those goals that you might not have post-op ACL rehab. Don’t skimp out on the post-op phase. Treat it just as seriously as your mid to later stages. Imagine it’s the exact same process and the exact same seriousness as you return to sport or return to performance. It might be more boring. You might have more discomfort, but I promise you’ll be better for it.

Wow! I told you guys that this would be a short episode. However, we were 20 minutes in and the ideas were flowing. The stories and examples were coming. Just wanted to make sure I share all of that with you so you can make the best decision for your ACL, especially for the post-op process. Because I just don’t want that to get missed. I want you to be the person that when you have your post-op ACL rehab and your physical therapy, you take it just as seriously as the middle to late stages. That way you are not having to reach out to someone else and be like, hey, like I didn’t take this seriously, or I didn’t get good guidance, and now you’re having to take a step back.

I want you to learn from any of the mistakes I may be made, or maybe that the athletes that I have encountered or worked with have made. And so that way you could have a smooth journey. Be able to be proactive and make the most of it.

All right, team. That’s going to be it for today. Thank you guys so much for listening. This is your host, Ravi Patel, signing off.