Episode 238 | Pro Athletes vs. The Rest of Us: The Truth About ACL Surgery Timing

What is up team? And welcome back to another episode on the ACL Athlete Podcast. Before we dive into today, I just want to take a second and just wish you guys a good day. Now, into today’s episode, five reasons why pro athletes might have surgery faster than most ACL athletes. And the reason I want to tackle this particular episode is because I recently had someone ask as many podcasts, titles and conversations spark from talking with ACLers, consult calls that I have with people, people we’re working with, and just things that I want to share with you guys. 

But with this one, someone had asked why they shouldn’t just have this surgery, the ACL surgery, specifically right after their ACL injury ASAP. It’s what the pro athletes do. And it’s funny that we always refer to the pro athletes in this process in terms of, they are the gold standard for this. And they’re maybe it looks like outside looking in that, yeah, they do all the things right. They have the best of everything. But in reality, there are some things behind the scenes that we don’t get to see or talk about that aren’t necessarily always the best. 

But with that said, today I want to tackle this particular point of the timing of surgery. I’ve done previous podcast episodes on this, but the timing of ACL surgery is one of those things that looks inconsistent until you zoom out on the context of the person and where they are. And this is so, so important. Because we will compare things to pro athletes and what they do, but in reality, the context of you listening, most people who are probably not pro athletes listening in this podcast, is that it might look a little different. And that doesn’t necessarily mean that we need to do exactly what the pro athletes do. But I want to put to bed this idea that we should just do what they’re doing. And in this case, having surgery immediately after ACL injury. 

It is one of those things that’s easy to reference, pro athletes getting it the next day, or often within 48 to 72 hours after their ACL injury if it’s a confirmed ACL tear, or at least that’s what we hear and see on the news. Keep this in mind because this is important. Let’s break down the five reasons why this is different for you. And in this situation, I am going to reference most people listening. Basically, people who are non-professional athletes, or let’s say, even at the highest level of college or whatever that level might be, right before they become a professional athlete. Someone who is going on to play pro. Let’s say it’s in their final season of college football, for example. You might be a junior in college, and you’re going to declare for the draft. Therefore, you are on the cusp of becoming a pro athlete. Or maybe you have a vital season ahead that is going to dictate becoming a professional athlete. These are factors that will play into this, but we’re just going to bucket those people as professional athletes. And then there is the 99.999% of us who are not professional athletes. I’m sorry, but this is just the way the cards were dealt. The same thing happened to me. The same thing is happening to you. Here’s where we’re at:

Number one, prehab versus performance demands. The general population, that’s all of us who are not professional athletes. That’s the category I’m going to use here. Even though you’re a high-level athlete and anyone who is not a professional athlete that is getting paid for a living to play their sport, or ones who are about to step into this, that’s going to be important for the context of this. Basically, we want your knee to recover from the initial ACL injury. That is going to help the post-op and long-term outcomes, believe it or not. The research shows better outcomes when you wait to have surgery versus rushing into surgery. There’s also benefits to doing prehab, which is preoperative rehabilitation, versus just going straight into surgery. The long-term outcomes are better. And people are picking up on this, which is awesome to see. I think it’s almost kind of a byproduct of there having to be more time between the injury and the surgery, just by nature of the steps that need to be taken from MRI, to seeing the surgeon, to scheduling the surgery itself. People are like, Oh, maybe I should work on this. Or now it’s easier to get educated on this a little bit more and start working on some things before surgery, which is awesome. But this is the goal for us general population, if you will.

Pro athletes already have a solid baseline of fitness, and I’m not saying you guys don’t. But the thing is, these are professional athletes, so therefore, genetics tends to play in their favor a little bit more. You watch anyone in the NFL or the NBA, and I promise you that their genetic profile is a little bit different built than most of us normal people. And yes, I’m saying normal people. But most importantly, they have the medical team that can aggressively help them manage this immediately after this injury. As soon as the injury happens, they go into protocol mode. They have someone with them, they lay out the next steps, they go into these surgeries in pretty solid shape overall, usually if it all kind of lines up, and their care team can get this handled.

Number two, resources and monitoring. The general population has limited access to PT, especially fast, equipment and resources. Access to them is not as quick or as easy—it takes time. There’s just less time availability than typical in our normal day, just to focus solely on this. Plus, the majority of medical systems, as I just shared, can’t get someone into surgery within two to three days of an injury, just based on how it takes time for that MRI to get insurance approval. If you’re in the States and using that, seeing your surgeon, getting that appointment, the equipment needed around this, scheduling life around the surgery timing, usually it just doesn’t happen in a matter of two or three days. The only exception will be if there is an emergency, like you have obstructed a very major blood vessel or maybe some neurological issue. There are certain situations where there are other concomitant issues that happen from a more collision-based, let’s say, you’re in a back car wreck, let’s say you had just an awful contact injury. Then there are situations where you have to be rushed into surgery to salvage certain parts that are potentially suffering.

Again, not the majority of ACL injuries, but that is an exception to this. You will be rushed into surgery if there’s a neurovascular compromise. But with that said, that’s not most. All this is going to take a little bit more time to get the resources and just the monitoring in general of the knee. If we take pro athletes, this is all expedited because of the level that they are at. They have millions and millions and millions of dollars at their disposal, and they are having these operations around them, the medical team, the performance team, all the people, HR, everyone who manages these athletes, and getting them set up. Let’s get this athlete set up for what they need as quickly as possible. They have an entire team at their side all day to help service them. And not to mention if they are a very high-level, high-profile athlete, if LeBron James tore his ACL. Guess what? He’s going to have everything at his disposal because of all the resources around him. If someone, et’s say, Messi tears his ACL. He’s going to have all the resources around him to get this knocked out within a day or two. This is different because of the level they play at. They can also spend all day on rehab, and someone is with them to do it all day. Literally, be there by their bedside, be in the training room, the rehab room all day, working with them.

They also have MRI results within typically the day of or the next day at the latest. And then the surgeon is typically the team surgeon. They already have that contract and relationship. If it’s a pro athlete, the surgeon makes it happen on their schedule and they make room, I promise you. If LeBron needs an ACL, there will be surgeons jumping at the opportunity to be able to do LeBron surgery. They will come in on a Sunday to do that, or they’ll do it on a Monday. Like that’s just the reality of the way that pro sports work and why things move along a lot faster. 

One of the most important of these, I think, and probably that dictates this the most, without being negotiated or talked about too much, is just contracts and career timelines. Time is money in pro sports. Missing four weeks, six weeks, eight weeks for even just prehab can mean losing a season or returning to play at a very important time. You think about someone who gets injured at the end of an NFL season or playoffs, they’re playing with time, a little bit of getting back to the next season. If they’re pushing that surgery off too long, they can miss a good part of the next season. And guess what? This is also a business; therefore, pro teams are going to be looking at this and calculating immediately what that timeline looks like. Of course, without the cost of like just throwing people into it. But again, it’s a business. I’ve seen some not-so-great stuff even at the college and lower levels, which is just so sad. But with that said, this is going to be calculated immediately after surgery, and being like, okay, what does that clock look like? And we’re trying to work against the clock to get this athlete back. It’s a business, but for both sides, players want to also get paid and play, and teams want to be playing. Think about the athletes who are up for a renewal contract for their rookie contract, for example. If they tear their ACL, guess what? They’re going to be busting their butts trying to get back so that they can get signed and make sure that they make more money, because that’s a part of them playing. They’re going to rush into surgery so they can get back and make sure that they can hit this contract, the right timing, and get paid the right amount. 

Unfortunately, for the general population, this is just not the case. Our careers are not on the line, and money is typically not on the line for a lot of what we do with ACL rehab. Unfortunately, that’s just most of us. It’s just the nature of the injury. But contracts and career timelines are typically not time-sensitive for us. Now, some do have job sensitivity of getting back to things, and yeah, that means we do need to get you to have surgery in a timely manner, but usually there’s a little bit more flexibility versus needing to be two days out, three days out. 

The other thing I would consider here is to think about athletes who are in the Olympics. If they’re going to compete in the Olympics in certain categories, then this is going to be something that’s going to be important. Let’s say they tear their ACL nine months before it happens, or let’s say even eight months before the Olympics happen, and they’re supposed to be a top contender for a particular sport, let’s say rugby. What do you think is going to happen? They’re going to go jump into surgery even if their knee isn’t in the best place because of time sensitivity and this career aspiration that they’re aiming for. Again, not most of us. 

Let me bring in number four, the nature of the injury. Sometimes it’s not just the ACL; sometimes it’s also the meniscus or other ligaments or cartilage or structures within that joint that need to be repaired, which can dictate the speed of surgery. Like I said earlier, with neurovascular compromise, you might jump into it really fast to save something. Or it might also mean we need to wait a second because this needs to normalize a little bit, meaning on the flip side, if the knee is swollen and bad, even pros won’t have surgery on it immediately. The thing is, you just won’t hear about these as much. How often have you heard a pro athlete tear his ACL? We’ll wait for ACL surgery because of X. The knee is flared up, the knee is swollen. Never.  Because that’s just not going to get shared on the news. And most teams are just not going to share that kind of information. They’re just going to be like ACL torn. That’s it. Especially if it is someone who needs more time. But they will mention the surgery if they’ve undergone surgery because it’s a big headline to set the path for recovery and the return for the public. Let’s take the example of LeBron. If he tears his ACL and he immediately has surgery, they’re going to say he just had surgery. Because then that lets people know, okay, he is back on recovery, and now we can at least expect, hopefully, a nine-month process. Again, it’s pro sports, so you never know, it could be six months, it could be seven, it could be 12. We just don’t know. But the thing is that it is a part of the media, a part of news, a part of just this process of sharing certain important information for athletes, whether it’s withholding it, or whether it is sharing it with the public just for the benefit of sports and of that athlete’s current status.

And then there’s evidence and risk. Research shows that very early ACL reconstruction can increase the risk of complications. You could potentially lay down scar tissue more, you could have more stiffness. Other factors play into this. Unless you’re just one of the 0.01% who absolutely crush it, have the ACL injury, and have no symptoms whatsoever or any issues. And those people happened, we’ve worked with them where they’re like, yeah, I honestly didn’t even know I tore my ACL, but it tore. I didn’t have any swelling. My knee was also not unstable, kept its range of motion. You are the 0.1%, 0.01% who don’t have any issues, but it happens. And the thing is, you can be potentially someone who jumps into surgery. But in reality, just because of the course of this process, you won’t. But then also, most people don’t just experience that. They usually have swelling, pain, stiffness, lack of movement, and range of motion limitations. All those things come with it; therefore, that’s why you are, as a general population, myself included, told to wait because outcomes are better when you wait. And the goal with that is mainly to get that knee quiet. That’s the goal. How can we get that restored back to a normal knee? 

Pro athletes often meet the criteria needed faster due to their baseline genetics. They have good genetics, but also access to the resources and professionals around them. That would be the biggest player in this. Also, they are just willing to risk it because of the team dynamics in their career. They may be on the fence of like, maybe it’s not the best idea, the knee is swollen, but they may drain that knee. They may get it into surgery. I wish I had been just behind the scenes of some of these more complicated cases, where it’s a high-level pro athlete, and what that looks like behind the curtain. But we don’t know that. All we get is basically what the news shows, and it is barely going to tell us anything besides very black and white stuff.

The context of this is entirely different from most of us versus pro athletes, and that’s just being transparent here, from the surgery timing to the rehab process itself. While we see pro athletes jump into surgery, there’s plenty that don’t, but it is just not shared or reported. The same thing goes for people who go back to sports early; the person that always comes to mind is Adrian Peterson, who again is like a genetic freak. He went back at five months post-ACL reconstruction. That is an anomaly. There’s an anomaly across the board. There’s not very many people who can do this, who walk this earth. There’s a lot of pro athletes who also wait nine to 12 months or more, too. Those just don’t hit the news sources. They’re not as spicy in the headlines, as this person got back to ACL reconstruction after, those are just not as spicy as the person who gets back to five months post-op. That’s pretty crazy. You tend to see those more; those are highlighted more. And if someone is telling you to rush into surgery—don’t. Please don’t do it because a surgeon says they have a spot open on their schedule, whether it’s a cancellation or maybe they just have an opening. Maybe it’s next week that they have an opening, and you just tore your ACL. The logic is usually thinking about pro athletes—and a lot of ACLers will be like, well, I just tore it might as well just go ahead and get it over with quickly so I can get on the path to recovery. It’s the most classic thing I see. What will happen is that it will make your post-op and overall process harder.

I had one athlete who tore her ACL, and I saw her days after. She got in. We booked a session together. She had already seen a surgeon, and she was really on top of it. Had one surgeon consult. This was all within days of her injury, and then we connected and I saw her. I evaluated her knee, and the surgeon that she saw days after was like, yeah, I have a spot open next week. My jaw kind of dropped. Her knee was one of the worst knees I’ve seen post-ACL injury—so swollen. She couldn’t put any weight on it. Could barely move it like flexing or extending it. Couldn’t contract her quads. It was a balloon. And the surgeon was like, cool doing surgery on it because there was a spot open. It’s funny because this one surgeon I’ve seen some ACLs from this surgeon and it hasn’t been the most positive results overall, to be honest. He shouldn’t be doing ACL surgeries. He’s just like, oh, I do these surgeries and people just go to him. And he is like, I got a spot open. Sad, sad reality. But in that I was like, nope. Please wait. There’s no reason to jump into this. You don’t have anything time-sensitive. There’s nothing concerning about your knee in the sense of like internally that we need to rush to surgery. 

I hate to break your heart, guys, but if you’re listening to this, you’re likely not the pro athlete. Based on the majority of the people who also just get this injury and the total number of pro athletes in this world, it’s a very, very small percentage of the pro athletes who get it compared to the total amount of ACL injuries that happen across the entire world. I promise it will not be worth it unless you have a life-threatening issue. Like I said, neurovascular compromise or something that is like a very major thing. Otherwise, do your prehab, wait the minimum of at least four to six weeks. I tell people, ideally eight to give your knee what it needs to get the quiet knee and to be able to make sure that you go into surgery in a very good state. 

Because you got to remember, surgery itself is a trauma. The injury itself is a trauma. And if you’re listening and you’re like, “I’m not gonna have surgery, and I just had the injury.” Well, this is something that’s still important to you is like, don’t rush this process. Give it the time that it needs, and get the knee quiet. But most importantly, if you’re considering surgery, please wait. This is a big reason why there’s such a difference in the pro athlete and the timing of things and this process in general versus most of us general population who do athletics, who like to move our body and we have still torn our ACL. The thing is that it’s going to be important for us to be able to zoom out on the context of each person, especially when we’re trying to compare different people or the different context each person is in: pro athletes versus non-pro athletes.

I hope this helps guys. I hope it clears some air around this and why there are differences between that. If you guys have any questions, please let me know. Otherwise, I will catch you on the next episode. This is your host, Ravi Patel, signing off.