Episode 10 | Top 9 Reasons Why You Should Do Prehab/Physical Therapy Before ACL Surgery

All right, welcome back everyone to the ACL Athlete Podcast. Today is episode number 10. We’ve got one-zero. Now, double digits. So if you’re tired of me, I don’t care because I love talking about this stuff. So here we are today, we are talking about prehab. So prehab is something you may have heard of before in the past. It stands for pre-rehabilitation, and it’s a term that’s become more standardized in the rehab community and in the fitness space as something related to injury prevention.

But when you look back, it’s really just preparation leading up to surgery for an injury. So today we’ll be talking about prehab leading up to ACL surgery, and I’m going to be talking about nine reasons why I think this is a must. Now you’re probably thinking nine, really, Ravi, but I just couldn’t sell you guys short on this.

I tried to reduce it down, but I think that there will be a lot of value that comes from this. So let’s just get into it. So number one is meeting your physical therapist. I cannot stress how important this is because there needs to be a relationship that’s formed. Nothing is more daunting than having your surgery and then walking into physical therapy the first day and meeting your physical therapist, trying to get to know them, which is great, but you’re also just trying to recover from a new surgery.

So there’s a lot of variables that you’re thinking about. I think being able to meet your physical therapist or whoever you are working with to recover from your surgery is very important, and that relationship gets established. You start developing rapport and it just allows you to hit the ground running with your ACL rehab process.

Number two, setting the expectations in education. So when you meet your physical therapist, a conversation that should be had is what this process looks like in terms of the time, which no matter who you are, you’re looking at 9 to 12 months. I don’t care what timeframe, that should be the expectation set but that’s a good thing to talk about, knowing, okay, this is what this process is going to look like. Especially right after you have the surgery, looking at the pain that is going to be there, what you’re going to be doing in terms of the rehab process, especially straight out of surgery. I think another piece is looking at the fears that you may be having.

So that may be you know, when you can get back to your sport. Maybe it’s getting back to running, or even just being able to drive your car, for example. All these things might be looming in your mind, and it’s an opportunity for you to be able to dress these things. And get clear about what that looks like.

And for me and my athletes, education and setting the expectation is a huge foundation of just our relationship and making sure that the process can be as easy as possible. Number two, normalizing and restoring the knee joint itself. So you had an ACL injury and a lot of times what I will see is that people rush into surgery too fast and they never restore the normal mechanics.

So let’s say for flexion, but especially extension of that knee joint, there are so many times where I will ask athletes, did you get your full extension before? And they’re like, no, I just went into surgery. And to me I think that that is a big red flag that is something that needs to be addressed before going into surgery.

And that can be done if prehab is in the cards. So being able to normalize that range of motion, especially extension, and work on quadriceps because you’ll start to see some atrophy just from the injury itself. We want to make sure that the quadriceps is not losing muscle mass, but it’s also getting strong. In ACL athletes, I cannot stress how important it is to get these basics before you go into surgery.

Range of motion, quadriceps, strength, mass– making sure that you can optimize that as much as possible because it will improve the outcomes long-term of your surgical process. And also getting back to sports and activity. This leads me into my next point, which is getting used to the rehab process itself.

So when you have your surgery, and let’s say you didn’t have the prehab, you go into the first physical therapy visit and it’s all a bit of a shock. You’ve had surgery, you’re in pain. There is a lot going on, and what is important is to make sure that you can get used to this process as quickly as possible with the exercises, whether it’s range of motion or quad sets, or with the frequency of how rehab is, or the frequency of how much you need to be working on specific things on a daily basis. 

I think that’s the thing that when I see athletes immediately post-op, they will be surprised with how much work they need to do. It’s the basic stuff of knee flexion and extension and quad sets, all these things that are going to help start the process off, but they’re surprised by how much they need to do it every single day.

It’s essentially a job, so this allows you to just make a seamless process from the prehab to having the surgery right into getting back into the exercises that you need to be doing to make sure you set yourself up for the best outcomes possible. 

Number five, crutch training. So I see a lot of athletes who don’t really know how to use crutches. And the last thing you want to do is to learn it after you’ve had your surgery. And this can especially be important for someone who has a meniscus repair. Let’s say that they can’t put their foot down for another four to six weeks–they really need to be good on crutches and make sure that they are at their appropriate height, that they know how to especially climb stairs and come downstairs.

I legit remember when I tore my first ACL and I was at the high school gym and I was at the top of the bleachers because it was the only seats left for this event that was going on. And I was trying to go down the stairs and the term that’s used is good leg go to heaven, bad leg go to hell.

So take that for what it’s worth. It’s essentially you lead with your good leg up and then your injured leg whenever you’re going down. So I did the opposite going down the stairs and I legit, almost fell down the stairs in front of everyone. But one of my friends caught me, thank God, but it was very daunting.

So I would highly recommend doing some crutch training before and maybe avoid going to high school gyms, especially where there’s a lot of stairs to climb. So, that is very important I think, in this process. 

Next is number six–collecting baselines. So in the return to sport process and throughout the entire ACL rehab, the uninjured limb, so the one that you didn’t tear, hopefully is what is used as a comparison for your strength measures, for your range of motion. It’s just used as a baseline. And a lot of times what happens through the process, and there’s a lot of research that supports this, where the uninjured limb actually de-trains, it gets weaker and it will throw off the comparisons or the numbers that you’re using to be able to return to sport, which is usually around 90% of the unaffected limb.

So with that said, if you can get baseline measures before. The rehab process and before the surgery, especially whenever the injury is fresh, that will help you to be able to know, okay, this is where my leg was right when I got injured, so then that could be a more accurate baseline going into the rehab process.

And especially when you’re trying to get back to return to sport, you’ll have the data for it and it’ll be so valuable and you’ll be so glad you did it. 

Number seven, maximizing insurance visits. Now, I did an episode specifically on episode nine, so if you haven’t heard that one, go back to it where I take my own insurance, which was 40 visits and I span it across an ACL rehab process. If I were to go through that process, this is how it would look based on the insurance visits that I get. So check that out. But here we’re talking about how we can maximize insurance visits by using prehab. So you’re probably thinking, well, I’m using visits as a part of my plan, I should just move all that to my rehab process.

But I would argue that if you can do at least a few sessions before your ACL rehab surgery, then you can actually plan out the first, you know, maybe four to six weeks with less visits because you know what to do, you know what to expect. Maybe your physical therapist has given you exercises to make sure that you can just start the process as soon as you have the surgery and it requires less in-person visits, which I think is a huge win, and you can use that further along in the process. So I take that as a win for longer term care and then, hopefully that means that there’s a game plan in place to make sure that you are optimizing your visits number. 

Non-operative versus operative option, and I think that this is something that is really important and should be stressed, especially as more research is starting to show that non-operative ACL rehab is very good and there are a lot of people that can actually have really good outcomes from it.

Now there are certain criteria that are important to see if that works for you, but it is assumed that if you have an ACL injury, that you need to have surgery soon after. And a lot of times, people don’t even get the option to take a non-operative approach. Now, this is all going to be dependent on the goals and how your knee is responding to the rehab and all of these different things. It gives you this opportunity to see, okay, I’m doing my prehab and maybe I don’t need surgery. Maybe my knee is doing really well. I’m able to do a lot of these activities, and I’m getting really strong. It’s an opportunity to see, okay, maybe I don’t need the surgery. I don’t need to go through this process.

And worst case scenario, you end up having to get the surgery. But the non-operative approach should be something that should be presented as an option, and the prehab process will actually give you a better indication of whether that’s a possible solution for. 

Alright, so number nine. The final nail in the coffin for prehab before ACL surgery is the research and there’s data that supports the value of prehab before ACL surgery. So we’re looking at two studies that have both utilized prehab and have studied the long-term outcomes of people who did the prehab and who did not do the prehab. And you’re looking at one year, two year outcomes. And the people who did the prehab had better outcomes.

And based on the things that we mentioned today, it makes sense. There are a lot of things that I see as a big benefit for prehab.

So to recap the things that I mentioned today, meeting your physical therapist, setting the expectations in education, normalizing and restoring the knee joint, getting used to the rehab process itself, crutch training, collecting baselines, maximizing insurance visits, exploring nonoperative versus operative approaches, and the research. These are nine reasons why I think prehab is a must before ACL surgery, and it’s just my opinion that I think that you should at least try one visit if you can talk to your surgeon, to your physical therapist, or know the clinic that you’re going to.

Even if it’s, let’s say a telehealth visit, that could still be of incredible value as you’re preparing for this process. If anything, it might just save you from falling down the stairs, and that itself will be of a ton of value. So that’s it for today, everyone. These are my nine reasons and I think that it’s something that should be pushed more.

And if you have any feedback or any comments, maybe you have nine more that you wanna list out, please let me know. Reach out to me via email or on Instagram, ravipatel.dpt, and let’s chat. But that’s it for today, everyone. Thank you all so much for listening. This is your host, Ravi Patel. Signing off.