Episode 117 | How Important Is Knee Status Going Into ACL Surgery?

What is up team? Getting straight into today’s episode 117: How Important is Knee Status Going into ACL Surgery? When I say knee status, we’re talking about what that knee feels like. Looking like from a range of motion, from a strength standpoint, how you’re functioning in your day-to-day, and how has it healed since that initial ACL surgery. And we’re going to talk about how important that status is as you approach your ACL reconstructive surgery.

I recently saw an ACLer where she had just injured her ACL about a week ago. She injured her ACL, she had some bone bruising, she had an MCL sprain and she had a meniscus tear as well. Overall, her knee was pretty mad. It was swollen, it was painful, it was pretty stiff. And she’s already seen two surgeons since then. One said, let’s get you into surgery next week. The other said, let’s wait to get the knee back to a better baseline and then we’ll have surgery. This is a very interesting approach from two professionals who do the exact same surgery. Now, who is better? And while the initial thought is, wow, next week, that’s fast. I can get it done. I could be on the road to recovery. But I would actually caution against this thinking. And especially if a surgeon is saying, “Hey, let’s get you in as fast as we can.” There’s a little bit of red flags or even just a little bit of caution that needs to be thrown up here.

And my thinking is always, why rush? Especially for such a major injury and surgery. It is not something that is just, all right, let’s go in there. Let’s just cut a few things and then we’re good to go. No, this is a super major surgery and I think that this can get underestimated because I guess you could say it’s very routine. A lot of people tear their ACLs. A lot of surgeons do ACL surgery. So yeah, it’s a routine thing in and out, but not so fast. And I want you to imagine something that is important to you that breaks, and you have to fix it. You have to have a game plan in order to figure out how to fix it and what that’s going to look like.

Let’s say, for example, a house. I know I use a house analogy a lot. But it fits perfectly here. Imagine a tree falls on your house, or something gets damaged in the house or a certain part of the house. And then now you have to go through the process of, all right, now we got to clean it up. We have to protect and shelter whatever it is that has been damaged. And then we have to create a game plan of how we’re going to fix this. And what we typically will do is you have to go through the insurance, and then you’re going to have to look at different contractors and people coming in to give quotes on these things. And you’re probably going to field out a few different people based on their reviews, what their techniques are, and what their goals are for the process of trying to build the house back up, as well as what you want that to look like. It’s got to blend and we got to make sure everyone’s on the same page here.

And I don’t see ACL surgery being any different from this process. We need to make sure that when the knee gets injured, we are trying to come up with a game plan. It’s not just someone as an authority figure telling us, hey, this is exactly what you’re going to do. You’re in, you’re out, we’re done. Let’s take some time, let’s consider our options, and let’s make sure that we have a good solid game plan. And you feel happy and your gut is telling you, yeah, this is the right move. And you feel very informed and educated in that choice. And while you are leaning on professionals to help you with this, this is where getting multiple professionals to help is great. Even when people consult with us or work with us, I always encourage a second opinion. Or if someone needs to feel it out, like make sure it’s a good fit and that they feel they’re making a good decision, an investment in the plan and the choice they’re making. I want to bring this back to a big problem that I see and that we hear from ACLers that it can be pretty common for ACLers to get rushed into surgery. I’m not exactly sure of the reason. And I don’t want to go into any of the factors too much. Sure, there can be monetary, and there can be an increase in caseload volume. Maybe the surgeon’s like, hey, it doesn’t matter.

I’ve seen different outcomes from this. I’m not sure. I don’t see the whole reason why we should rush into an elective surgery like this, especially if there are many things to consider from a rehab and recovery standpoint. Why not take some time to consider all the factors that are going to be related to this process? And I’m not saying all surgeons do this. We have seen plenty of surgeons and awesome surgeons who are like, hey, let’s take our time. Let’s get the knee settled before we rush into this. But having this athlete just recently come in and the surgeon was like, yeah, I’ve got an opening next Thursday. Cool, but that’s not going to be to the benefit of the patient. There’s no reason just because you have an opening means that we need to get the patient into surgery. And I think that this can be at the detriment. And as I’ve always told you guys, the transparency on this podcast is so key for me to share with you my experiences with all the ACL athletes that we work with.

Then that way, okay, this is what we see in this world. How can I make the best-informed decision in my process? I’m not this number that has a re-injury or has a poor recovery just because someone set me up poorly to do so. And I want to talk a little bit on the reasons why you would maybe rush into surgery because I don’t want to bat that down as everyone doesn’t need a rush into the surgery. There are some people who might need to. And let’s talk about those reasons why. You might be a high-level athlete where a particular game or a season is on the line, or for your career. 

For example, collegiate professional athletes. Let’s take a professional soccer athlete aiming to play in the World Cup and tears their ACL six to nine months before that World Cup starts. How are you gonna feel? Pretty terrible. The World Cup is one of those things that every athlete in soccer aims for. It’s one of these gold standards that you’re just like, I’ve made it, I want to play in this, represent my country and it’s awesome. I get it. That’s a time-sensitive thing that you need to get back to. And in most cases, this athlete has a time-sensitive goal that is career-related and there’s consequences to that, personally to them. And that could trickle into their professional career, into the money that they make, the longevity of their career, and their status. There’s so many things that impact that if they’re not back to their sport within a reasonable timeframe, that’s fair when there is a time sensitivity on the line like that.

Another factor might be you’re at a significantly high risk of making things worse after your ACL injury. This is very rare, but of course, outside of things that are super emergency-related, like nerve damage where your foot’s dropping or vascular damage where there’s something blood flow related that you’re concerned about. Again, so rare, and usually it is something where you’ve had a serious car accident or some sort of trauma like that. But let’s say something like that does happen. And you’ve had a car wreck or some impact where you’ve landed on the ground from a high height, unfortunately. And there’s a multi-ligament injury and a bone fracture that might have happened that needs surgical intervention before it starts to heal down in the wrong way. Or there’s major joint instability that can compromise the joint. That is a fair situation where you might need to get into surgery to make sure that that joint is stable and to make sure that fractures are in place or any vascular issues or neural issues are intact. That’s fair. 

There are a couple of other reasons that I want to touch on that I don’t want to miss the medical system that you live in might have only available for something very soon because something opened up versus maybe you have to wait 6 to 12 months. And I get that that is a very long time to wait. Usually, the waiting time in the U.S. where we live is not that long. People can get in usually within anywhere from like a month, two months, or three months, and they can get the surgery done. Just like in the example I gave you with the athlete I had just seen. They were able to get in next week. So that is something that is possible. But we also work with ACLers all over the world and some of these people don’t have choices, but to either get the surgery immediately or something comes open from the surgeon or they have to wait six months, nine months, 12 months. And I know Covid made this even harder for people. So anyway, with that said, I get if there’s a medical system where it might not be as viable to just pick your time. 

And then one last factor that can play into this, and I don’t want to overlook is work. I think that people have different situations and circumstances, especially if you require a more labor-intensive job. Hopefully, you have some type of worker’s compensation or benefits that play to your benefit and that can help you out. But if not, I get it. Sometimes you just got to do your thing, you got to have the surgery. And we have had some people, unfortunately, in these situations where they’re like, I don’t have any financial means. I’m in a tough place. I tore my ACL. I have a labor-intensive job. It’s either do this or try to rehab as quickly as I can. Or I get laid off or something like that happens and then they’re in a worse place. I want to be very mindful of these situations when people have to go into surgery sooner than they want. 

But I’m going to argue that most of these people that I had just listed are probably 5% to 10% of all ACL injuries. If that is probably less. And if you’re listening to this, you’re probably of the 90% to 95% of people who fall into this category of not having to rush necessarily. And I’m always going to come back to the question of why rush. What’s the point? And sure, you might want to get on with your life and have goals that you want to meet, whether it’s physical or just travel or whatever that might be. And this knee is getting in your way. But they’re not set in stone, time-sensitive, like the previous examples I mentioned. And while it might seem like you will get ahead by having the surgery sooner, I promise you, you might pay for that later. And you have to extend your rehab as long as it needs to be to get done with the process.

And I’ve seen this time and time again. There’s a massive upside to waiting and not a lot of gain from rushing besides getting it over with. But that could be to your detriment. I’ll talk more about this next week. But today, I want to focus on the knee status itself going into surgery. I want to talk about the specifics. As I had mentioned earlier, meaning what state is the knee in going into ACL surgery? When was the ACL injury? How bad was it? How’s your range of motion, swelling, pain, ability to walk, and navigate what we call ADLs (activities of daily living)? Basically, navigating your everyday life to exist as a human. Nothing extracurricular per se. But just being able to do your thing every single day.

Now, the difference in someone going in with all of these areas back to baseline or normalized or better can dramatically impact the recovery after ACL surgery. Versus people rushing in, well, let’s just say a grumpy knee, meaning they have some limitations in their range of motion, a lot of swelling, and pain. Their gait is all jacked up. There’s a lot of things that are playing into the status of their knee and it’s grumpy. And a lot of that could be because of the injury itself, or it could just be how quickly it’s been between that injury and the time you’re going into surgery. And so the status of the knee is that someone goes into their ACL reconstructive surgery with a terrible baseline or those things that I had just mentioned, limited range, pain, swelling, their quads can’t activate. 

Often what we see is that these people have a harder time after surgery in the post-op phases and even throughout the process, getting that range of motion back, getting the swelling and pain under control, and getting their quads firing. Because it’s this vicious cycle in this process, when we think about, especially the pain and swelling, those things are going to counteract against us wanting to move the knee or to activate our quads, which will help to move the knee because it is just this cyclic process where we want to let it be, let it rest. And pain and swelling will dictate a lot of that, especially in the early phases. 

And the other reminder here is that ACL surgery is a trauma itself. We need to make sure that we factor that in because oftentimes if the knee hasn’t settled from that initial injury, this just compounds that insult. You go from one injury and trauma to another injury and trauma. You have two of those. Now, it’s the goal to navigate that and make sure that the knee settles down, which can make it really difficult because you just have a knee that’s just like what just happened. And so for us, our goal is a minimum of four to eight weeks of what we call prehab which is preoperative rehab, if possible post-injury to get the knee back to baseline and as best as possible to go into surgery if you’re having surgery. We’re aiming for that quiet knee. And if you are not sure what that is, this is something I’ve talked about in detail in previous episodes. But we’re basically trying to get the knee back to a normal state, let’s just say there.

Range of motion is good, swelling is good, pain is good, and quads are active. You can walk well. Those are the big buckets that we’re tackling. And then we got to make sure we get your strength back up as high as possible because it’s going to drop after this injury. Because for some reason when you get a knee injury, especially for your quads, they tank. You look down and you’re like, “Why is my leg a hotdog compared to the other side.” I don’t know why, but with my two ACLs, it was quite a bummer because I remember looking down that all that quad size and strength that I worked so hard for had just been lost within literally a few days. The goal is how can we build that back up before surgery and then of course after surgery as well, to make sure that we don’t lose too much over that period of time.

One analogy that I’ve come to really love that hopefully can help hit this home for you guys is that imagine you are on the 10th floor of this building. That’s your baseline, that’s your ability to function, to be athletic, to be strong, that is your baseline pre-injury. And then all of a sudden, you have your ACL injury, and that thing drops you down to, let’s say the seventh floor. And that’s where your functioning, your strength, your capacity is at that point. And then let’s say, for example, you do prehab and it brings you back up to, let’s say even floor ninth. Maybe not 10 where you were before, but floor nine, where you’re feeling pretty good and strong. The baselines are pretty good. And then you go to have your ACL surgery. 

Well, you might drop down, but let’s say you only drop down to the sixth floor and you got to climb your way back up to the 10th floor or better. Now, let’s say you had the exact same situation, the 10th floor had the ACL injury and you dropped to the seventh floor. Let’s say you don’t do any prehab, and let’s say you rush right into surgery. Well, that might drop you down from the seventh floor to the fourth floor. Now you have a massive climb up from the fourth floor to the 10th floor versus when you had the ACL injury and you did prehab, and then you had the ACL surgery. And instead of dropping all the way down from the 10th floor to the fourth floor, you only went down to the sixth or seventh floor. 

I know that’s a lot of different pieces there, but essentially what we’re saying is the climb back up to your baseline or to be better is a lot less if we are able to wait and we have a good status of the knee going into surgery. But then also do some prehab and conditioning to make sure that you don’t drop too much and compound those drops over time.

The big key takehome here is the status of the knee can really impact that going into surgery. And every single athlete that we’ve done prehab with has always been like, wow, I didn’t realize how massive the prehab would be. People talk about it like, ah, I’ve just got to do surgery again. So what’s the point? But there really are so many benefits that are hard to stress enough. But it also serves as a proxy to get the knee status settled, to get it calm, to get it healed and in good shape for the surgery. And I think that that often gets overlooked and depending on the professional guiding you, hopefully, they’re keeping these things in mind to help you have a good recovery. 

After seeing so many ACLs, we want to make sure you consider these factors and see what our experience has been. Also, the science and the research show that is beneficial to wait to have surgery and just normal physiology of humans during healing times. And making sure that you just don’t have to pay for that when you get out of surgery and your extension or your flexion is really hard to get back. Or especially dealing with persistent swelling and pain for longer and longer periods of time when that could have been taken care of on the front end. When you are considering the status of your knee going into ACL surgery, it’s really important. Don’t rush the surgery. Don’t let a medical provider force you into that. 

Get a second opinion, a third opinion, whatever that looks like. Heck, if you want our advice, just email us. We are happy to help in any way, just to make sure you have a little bit of a guided opinion versus just feeling like you’re operating blindly. Get your knee quiet, get it strong. This can make a massive difference in the outcomes post-op and for the long-term ACL journey. So that’s going to be it for today, team. If you have any questions, hit us up on social media at ravipatel.dpt@theaclathlete.com. You can check us out on the website. Send us a message there, any medium, but we’re here. We’re happy to help and stay tuned for next week where we are going to piggyback off of this episode and continue talking about ACL surgery and timing. Stay tuned for that. 

As always, we appreciate every single one of you spending time with us. Until next time, this is your host, Ravi Patel, signing off.