Episode 217 | 8 Ways to Finally Get Rid of Swelling After ACL Surgery – Part 2

What’s up team and welcome back to another episode. We are continuing this two-part series about eight ways that we can improve swelling after ACL injury and surgery. If you did not catch part one, I highly suggest going back and doing that because it lays the groundwork for this. You’re probably going to have a lot of aha moments in that, especially if you’re an ACLer or clinician or coach. This is going to be something that helps with the swelling process and most importantly, just practical ways for us to tackle this. Some of the things that we talked about were the impact and why behind swelling in part one, the assessment piece, tackled load management and elevation. Today, we’ll dive into the other five components of this comprehensive approach for swelling management. 

The next thing on the list, before we talked assessment load management and elevation, now the next one is compression. We have athletes use compression sleeves to help keep fluid out. That is huge for us. Usually, a lot of times ACLers will have an ACE wrap that is given to them, and that helps with just protecting the joint, covering it up, easy to take off. They don’t like to rub anything, and it also allows to create some compression if it’s applied appropriately. But eventually you’ll move out of that, and then we will want to use something else.

Now, some people do well and they don’t necessarily need the compression if their knee is not dealing with swelling, but that is the minority of ACLers in this process. Most people are dealing with some sort of fluid that kind of sticks around, especially as they get back to normalizing their life. And therefore, what can we do and that’s where that compression sleeve comes in. We’ll also use potentially like a Voodoo floss band for a more aggressive option. It’s a fancy term for basically this like a rubber bike tube looking thing that you can get off of Amazon. It’s essentially just something to put on their tight and compress the joint a little bit to help push some fluid out. All we are doing in a nutshell is creating pressure to move fluid out, but then also prevent it from coming back in. And that’s where Pascal’s law comes into place—areas of high pressure move to areas of low pressure. That’s just the nature of what it is, also referred to as Pascal’s principle. 

The one thing that we had to look out for is sometimes if we just do it, it can rebound back, which is why important for us to stay consistent with keeping it compressed. For us, like with the compression wrap or the compression sleeve, you can find a cheap compression sleeve on Amazon or any local store for the most part. You could use an ACE wrap as well if that’s all you have, but the goal is to give the knee a nice hug. And people tend to feel like it feels good. The knee just in general feels this different perception. I’m not saying it’s magically changing all the pain and all the things in there. But sometimes people are like, man, my knee feels pretty good with these knee sleeves on. I’ve experienced it myself. Lots of ACLers we work with are just like, it just feels good, and I’m like, cool. It’s not really hurting anything. As long as you’re not so dependent on it that if you don’t have your knee sleeve, you’re not going to go do a darn thing. And so that’s where the knee sleeve is going to be so helpful for us to, especially for this Sometimes people think, oh, it’s going to help with preventing my ACL tear or add stability, not doing any of those things. That little stretchy little fabric that is a little tied around your knee is just adding compression and a different perception of the knee. Therefore, what this is doing is it’s going to give it that nice hug. It’s going to help to push some fluid out and also minimize fluid getting back into the joint. Because again, coming back to Pascal’s law, areas of high pressure move to areas of low pressure. So that pressure will push that fluid into areas of low pressure (out of your knee joint ideally). Now, is this perfect to a tee? No, because the amount of pressure influences things. Therefore, if we could just have compression on there, that knee has less room to expand, and it’ll go different places.

Sometimes people see a little bit of swelling that might go into the shin or into the foot a little bit, that can happen from time to time, not as common. But then hopefully that fluid is being pushed more towards your groin and towards just the natural flow of circulation for your body. This is going to be super helpful from a management of swelling standpoint, is to compress that joint. But again, you’re not trying to cut off blood flow. You’re just trying to get a really solid hug to the knee. We’ll ask ACLers to grab a neoprene sleeve off one of those sites, or just somewhere local. Make sure it fits well. You can do a full leg sleeve if you want. Some people have that stuff and it just keeps the whole lower body compressed.

But sometimes that could be a pain, especially if you are someone who is having to wear pants or you know you are in shorts. You might not want that whole thing. Maybe you just want a knee compression sleeve. It’s great to also just have a knee compression sleeve only, but we just don’t need the buckles on the side. We don’t need the hinges. We just need something that is going to compress that joint, and allow that fluid to just be managed a little bit better. 

And then in terms of the lymphatic drainage that I mentioned earlier which was in episode one, where our lymphatic system is helping to push fluid out and move out of certain spaces. We have these lymph nodes and we have this basically system that allows us to move fluid throughout the body and circulate it, and it is driven by movement and is driven by muscle pump action. And it could also be driven by some manual pressure to it as well. People with lymphedema, there are lymphedema specialized PTs who focus on helping people when they have lymph node issues. Maybe something like cancer has stepped in. And so that is something that we had to practice and do in PT school. Of course, you can go further into that domain and get specialized. But with that said, with the manual lymphatic drainage, I’m not here to say like, do all the soft tissue and get that fluid moved out. But it could help, right? If you’re trying to squeeze every ounce of this, why not try to just like create a little bit of light rhythmic strokes, like massaging that knee, not messing with any wounds here or any scabs, but allowing to try and push some of that fluid up your system. You don’t want to push it down towards your foot, but you want to pull it up towards your system. You could just help push some of that swelling up and just see, does that help stimulate your lymphatic system?

A study on post-surgical knees with swelling found that doing some of that lymphatic drainage, that manual lymphatic drainage can help reduce some edema by just stimulating your lymphatic system. That’s Leduc study in 2009. Now, is this something that you want to put all your time into? No, it’s just something that if you’re like, what else can I do? This is something that plays into compression and stimulates your lymphatic system.

With compression, I like using a floss band for certain people. No, I don’t know what it is with this thing. It is that inner tube or that rubber material that you could just wrap around the knee. I’ve used this throughout my career with sprained ankles, with just different joints where there’s an acute injury or there’s a lot of fluid and I have no evidence to back this up. Don’t come at me with all this stuff that this isn’t research-based. I’m just using more science-based on this, and it’s just using Pascal’s Law. It helps to add some compression to that joint, and therefore that is allowing to push that fluid out because it doesn’t have any place for it to go. You’re just reducing the space it has. There’s something about implementing a floss band and being able to wrap it from, maybe it’s like your tibial tuberosity or on your shin bone right below the knee and then wrapping it towards the thigh, going from furthest away from you towards the thigh. It has that pushing direction towards your heart and being able to either prop that leg up for about five minutes, being able to go through some just gentle exercises, maybe riding the bike for five minutes. Or I’ll have athletes just do 20 reps of like an unweighted knee extension or like air squats.

There’s something about it, not only from the joint swelling standpoint, but also from a pain standpoint, in my opinion, I think it’s just a placebo thing that helps to change the perception of the knee joint. We’re not doing any long-term changes there, but if it allows for an opportunity for the need to feel better, for you to get a better training session in—that’s cool. Go for it. It’s the same thing with a foam roller. It’s not magically going to help your muscles to get pliable and stay like that forever after one time just like a massage. It’s just something that is a temporary input that can potentially give you a window to move. And if that allows us to load some knee extensions or allow you to feel a little bit better in your day, go for it. Just don’t make it the bulk of what your ACL rehab is. It could just have some value and a place in it. I’ve seen it, I’ve used it myself personally, and none of this stuff I’m not telling you to do if I haven’t tried it myself. This is something I’ve used, and a lot of ACLers I’ve worked with have used for the right situations. It just allows them to be in a better place from a swelling standpoint and just another thing to tap into from being able to add some compression. So that is the compression components. 

Next, we’re going to tap into cryotherapy or ice application. This is something that I think a lot of times people associate ice with being able to help with swelling. It’s a part of the RICEor the POLICE acronym as I had mentioned. Icing and cryotherapy itself has received some pushback in the years of like, do we want to slow inflammation down? Don’t we want to let it do its natural process and stuff? And at the end of the day, our goal right now with this episode and what we’re trying to do is get the swelling out.

With ice, what can happen is it can slow inflammation down, but don’t think it’s going to be this magic bullet. It is most effective with pain and mitigating pain, and that’s what the research shows. But with that said, with swelling, it can help with slowing some of that lymphatic drainage down, which actually, if it’s done too long, it actually cannot be beneficial. Let me clarify here. It’ll slow the inflammation down, which can be helpful, which means that it’s not necessarily pushing fluid into that joint. But therefore, if it’s also constricting the vessels, that’s essentially what’s happening is. When it gets cold, it constricts blood vessels, it constricts lymphatic vessels. That’s what happens when we get cold. We constrict blood vessels, and so that’s what happens to the local area, therefore that can slow things down. Which if the lymphatic system is something we need, then therefore we want to just be mindful if we’re slowing down the inflammation or trying to, then we don’t necessarily want this for prolonged periods, because then that could be counterproductive with using your lymph node system or lymphatic system to get some of the fluid out.

It’s just chronic use or using ice for way too long, which in most cases people aren’t necessarily doing that. What we tell people is to use the ice for 15 to 20 minutes every two to three hours, and it can help with the inflammation and with the general feeling.

One thing I like to say is just elevate while you’re icing. You’re killing two birds with one stone and it’s also something from anecdote. I loved my ice man. It felt great, especially early post-op and especially when I had a hard training session. I just love to just put some ice on it. It felt good. It felt like I worked hard, and there’s nothing wrong with that. It’s just something that if you’re looking again for stuff to tap into—cryotherapy ice can be beneficial. There are those game readies, there are nice ones, there are all these compression units out nowadays, and that could be something that can be helpful. You get some icing. You get some compression. It feels good. At the end of the day, we are not anti-iceers here. There can be value in this. There are even ways that we use ice for AMI to put on the knee joint before exercising to help stimulate the quads because that has been shown in some studies, so it’s not all bad. Use that as you need to. Just don’t think that that is going to be the magic bullet that is going to save you from your swelling. Just another option to use. 

Next up is muscle pump and active recovery. This is an important one. You want to prioritize your recovery days and know when to push hard and to ease off the gas, which comes back to those high-low days. You don’t want to necessarily go hard every single day because then that’s going to accumulate stress and your body’s not going to be able to recover. Some of this comes back to load management and structuring your week and your days strategically. But what we’re wanting to do is just use movement to help push fluid out. Coming back to that lymphatic system, it needs movement, and it needsa  muscle pump to do that. That’s going to be super helpful for us after an ACL reconstruction. That’s why ankle pumps are prescribed because you are no longer moving as much and we want to continue to keep that venous flow and continue to keep the lymphatic system going, to act as a pump to assist with fluid and blood circulation since you are immobilized. And the thing that happens is that blood can pull, which is where a DVT can come in in those early post-op periods. That’s why ankle pumps are always prescribed. It’s a way for us to use the calf muscle to be able to use that lymphatic flow and get the venous return back. There you are with why ankle pumps are there, but it’s super helpful and super valuable. There’s not a single athlete who we don’t give this to. But we want to take this to the next step. How can we somehow add this into keeping this consistent with the theory of keeping fluid moving, being able to maybe keep circulation going, to keep fluid out of the joint. And there are different ways to do this. You might be able to add some low-level aerobic work, like being on the bike, low intensity or resistance, but being able to cycle through to get your heart working, get your muscles working to create that pump like effect. And that’ll help with being able to drive some circulation and potentially get some fluid out of the joint.

Now, you don’t want it to be all painful. You want to be like a very low pain or no pain ideally, when you’re doing some cycling work and you want to make sure you don’t just go overboard. Biking can be helpful with this, even just controlled movement stimulates the synovial fluid to circulate out. And Harvey even showed this in 2015. That’s a study that was done around using movement to help with that fluid circulation, and it also helped with reducing that stiffness and swelling. Another way you could do this is running with that muscle pump principle, is to be able to use an electrical stimulation device. We have an NMES device that we have athletes utilize to be able to turn their quads on for a certain steady amount of time. There are also other settings we can utilize to help create a pulse-like effect. TENS units can do this. But there are other settings on a different electrical stimulation device where it’s just a pulse-like effect, where the e-stem will help us to use the pump and the muscle pump to help push fluid out. 

Another benefit to this is that you can elevate the leg while you’re doing this, just hanging out, watching TV. This allows us to use that lymphatic system, the muscle pump that is needed for movement and muscle contractions to move some fluid. We are trying to maximize swelling, so this is another option to tap into. 

The next point is nutrition. One that gets overlooked. Adequate hydration is important. It helps to improve our circulation, and also flushing of excess fluid. So stay hydrated y’all. It’s super important. An anti-inflammatory diet, I’m not here to say go be all on eating ginger and turmeric nonstop. But with that said, make sure you’re eating whole foods, getting protein in, but you can buy yourself towards some anti-inflammatory stuff, and that could be beneficial. Being able to have stuff with turmeric in it, some ginger in it, some leafy greens, omega-3, for example, like salmon or walnuts. There are just different ways for us to be a little bit more intentional to see, all right, what else can we do and tap into to help with just inflammation and being able to also help with fluid circulation. 

Some other methods that I’ll share here, but that’s going to be important to consult your healthcare professional and your surgeon. First, sometimes people use NSAIDs. If we have pain or we feel like there’s a sense of inflammation or discomfort, this is something that’s pretty common post-op to utilize for certain surgeries. But with that said, NSAIDs can be valuable for the right person. But again, consult your healthcare provider because this is not medical advice here. We just want to make sure that that could be something that we could tap into, that I know for some of our athletes can really help. And it could be a life situation. Maybe they are going to a wedding and they’re traveling. Maybe it’s a work thing and they got to get through this thing. Maybe they are presenting, and it’s like this huge thing. Maybe they have a job interview and they have to be present and their knee is killing them in a swollen, y’all. Sometimes we got to use this stuff and it’s available. It is something that we just need to make sure we use with caution and not for long-term use. But with that said, it can be beneficial for the right person, so that’s why you need to consult your healthcare professional for that. 

The other thing I’ll mention here, is that with medication there are other things that sometimes surgeons will prescribe to help with reducing inflammation and with reducing swelling. Also, one other strategy that may be utilized is a joint aspiration. Now this is something, it’s based on the surgeon, based on the situation, based on the chronicity of it. I’m not a big fan of it unless for very specific situations of chronic and it’s been a long time. Let’s just see how it works for some people and maybe they just need a little bit of a reset. All they do is stick a needle into that joint and they suck that fluid out. That’s not something that I would recommend for someone who is acute in any of these stages, whether it’s post-op or post-injury. You just want to let the knee do its thing and not disrupt it. There are certain times where it’s chronic and maybe it is impacting you as a person. You might get that thing drained and it might help a ton, and people usually feel a lot better. They feel joint soreness. It is also something that, if you’re not careful it can come back because you did not necessarily get rid of the root cause, you just got rid of the symptom. Something to just manage as you go through this process with a medical professional. Again, don’t go doing any of this stuff yourself. Make sure you consult somebody who knows what they’re doing with this.

I’ve unloaded a lot on you guys around swelling. You’re like, how can this dude talk about swelling so much? But it’s important and something that I wanted to break down in this two-part episode series. And so lastly, what I want to leave you guys with is just making this practical and send this home. 

As we go through these eight points, number one, use an assessment like the stroke test. Number two, load management. To me, is probably by far the most important in all of this. What falls underneath that is managing your step count, get a phone tracker, get a watch, get something to track your step count, a crutch progression. Make sure that you are looking at how you’re coming off your crutches and don’t get off of them too fast because that is going to be so huge.

Making sure that you are just managing your first two to four weeks being on your feet, but then also just your weekly structure. How does your rehab look like? Sometimes people will have physical therapy three days in a row. And so that makes it challenging because then they will potentially stress the joint pretty intensely for three days, and they have four days of just chilling or they do stuff at home. And that’s if you’re going in person and it’s the typical insurance base. Now, usually early post-op you can do things back-to-back days and depending on what it is, like range of motion, that’s totally fine. That’s encouraged. But with that said, let’s say you’re pushing it hard in a rehab session and you do that three days back to back, guess what? The knee’s not going to feel great. We want to make sure that your weekly structure is intentional from your rehab stuff, to your work stuff ideally, to the training sessions and just think about overall stress on the knee, how much you’re on your feet. You want to try and manage and spread that load out, and also have dedicated recovery time to put your feet up and do that.

Now, I know everyone’s lives aren’t built that way, especially if you have a little one or you have a harder intense job on your feet. That’s just the nature of this, and therefore, it’s just important to make sure we try and navigate it as best as we can. But that will play into your load management, not only early post-op or post-injury, but then also as you start to get into running dynamic stuff, as you get back into returning to sport progressions, being able to manage how much you are practicing or doing your activity and progressing and titrating that up or down as needed and looking at the dose response of it. So that’s load management. 

Elevation is number three. Get that thing above the heart, get it vertical. Use gravity, hang out there, and make sure that you try and do that as frequently as you can using a wall, using a pillow, using all the things to just get that thing elevated.

Number four, compression. Get a cheap neoprene sleeve from Amazon or a local store. Make it a good hug to the knee, but make sure it doesn’t cut off blood flow. Use it in your day and keep it on you when you sleep or even while you’re elevating. Again, Pascal’s Law goes from high pressure to low pressure. Therefore, if we can just keep pressure there, it can push pressure out and reduce things from coming back. Just don’t do it for like a few minutes, and then all of a sudden just let it g,o and then just carry on. That’s going to be key here. Manual lymphatic drainage or massage that you want to put into play, just to kind of go from being able to push the fluid from the shin up towards your body, up towards your heart. You’re just doing some gentle manual massage there to be able to move that fluid, and to stimulate our lymphatic system. Floss bands can be helpful. Again, no research to support this, but I think the compression piece is helpful to just add compression. Now, don’t be adding any numbness and tingling that is so tight to do that. You could do this for five minutes, 10 minutes, elevate it. And then also be able to just go through some simple movement. You could do some heel slides, some unweighted knee extensions, you could do some air squats. Just something to get some movement going and be able to create some compression. I like it in certain cases and can be helpful for some people, especially if they need a short-term window to do things. 

Number five is ice. Can’t hurt to slow it down, but don’t think this is going to be the magic bullet as I had mentioned. It is a bit more effective with pain, but do your thing if you like some ice, just don’t be hanging out with an hour-long ice session. The compression with it is great, and we’ll often combine that so that it can be super useful. Muscle pump and active recovery, a super big one here. So you could do super low resistance on a bike and use that as a muscle pump. You could do super low resistance on a bike and use that as a muscle pump and help with circulation. You can also get a little bit of an aerobic effect from it, which is great. You could do some gentle range of motion work and some contractions to try and pump a little bit of fluid out. Again, using that muscle pump for the lymphatic system. You could elevate your foot on the wall and then start doing some quad sets up there, some heel slides, just things like that that can help to just add some movement while you’re elevating.

And then you can always add e-stim where a pulsate to contract the muscle to help get some of that fluid out and keep that muscle pump going. 

And then nutrition. Stay hydrated. Eat natural anti-inflammatory foods. Don’t go ham on turmeric or ginger and just eat that stuff by itself. Or just a full diet of ginger and turmeric. Let’s just spread it out. Get some protein, and make sure you have some anti-inflammatory foods in there. Sprinkle in some ginger and turmeric as you need.

In terms of other medical-based interventions, consult with your doctor. And this is something where it could be NSAIDs or other medications, joint aspiration. There are things that doctors can do that, if your body seems like it has exhausted all measures and you’re still dealing with a lot of issues, we need to understand why. But there are also ways to just manage some symptoms if you need it. Don’t be afraid to ask about that if you’ve done your due diligence and it’s been long enough because we’ve had athletes who have done really well with some of this stuff and you just never know. But just make sure that you are under the guidance of someone who understands this stuff and is a medical professional. Do not take it into your own hands because long-term use of stuff like this can also have some downsides. Super important with all of this and to be able to see the landscape of swelling. Different ways to manage it. And I know it’s eight ways, but there are multiple ways within that. Just wanted to talk about the main principles of the overarching pillars of this. And the other thing I wanted to share is just combining some of this stuff, you don’t necessarily need to just do individual stuff. You could do icing while your foot is elevated. You can have a compression sleeve on. Some people have those compression sleeve units with icing in them. You can elevate it on the wall while you’re having a compression sleeve using a stem device to simulate a muscle pump. And that could especially be done post-op. Can do some ankle pumps, some heel slides, some quad sets. This is all stuff to make it super practical for you guys. Tons of ways to do this. You don’t have to do all of them. And you may be someone who’s like, I don’t deal with much swelling, so I don’t think I need this. And that’s okay, but I want to make sure you guys feel super equipped to know here is swelling that I’m dealing with. It’s something that I know most ACLers are wanting to get rid of. We as clinicians and coaches care so much about this. And therefore, these are ways to manage that, and I’m sure there are other ways to do it, and I’m sure we will continue to find out more ways to do it, but I hope that this was helpful y’all.

If you found value in this, please share it with other people. Please share it on social media. Tag me in it. If you have any questions, please reach out. You can email me, or you can send me a message. Information is all in the show notes. I’ll also share some links for the sleeves and stuff like that. Please just do your due diligence and look it up for yourself as well. I’m not trying to say like, get this specific one, just some options that we share with our ACLers for this. But other than that, last request for you guys, if you do find a value in this podcast or these episodes, please leave us a five-star review.

It goes a long way. It helps us so much to reach more and more ACLers, and that’s all that I care about. Please do that if you even have like 10 seconds on Spotify or Apple Podcasts or wherever you listen to this. It would mean the absolute world to me. And yeah, let’s just keep doing the thing, y’all. It’s cool to hear the stories, the conversations around this, but I know that we still have a long way to go. But if you’re listening to this, just know I appreciate you. I appreciate the support, and let’s keep doing the thing, y’all. Until next time, team, this is your host, Ravi Patel, signing off.