Episode 118 | Why Waiting for ACL Surgery Might Be the Best Decision You Ever Make

What is up team? If you are new to this podcast, welcome! If you’re a longtime listener, I thank you. Thanks for hanging out with me and for being on this ride with me. Now, let’s dive into episode 118: Why Waiting For ACL Surgery Might Be The Best Decision You Ever Make.

Last week, we covered the importance of knee status going into surgery. Today, I want to piggyback off of that and highlight why waiting and not rushing into ACL surgery can provide a lot more than just a solid knee status when considering this ACL reconstructive pathway. 

I mentioned how most ACL injuries don’t need to be rushed into surgery, with the exception of a few situations: time sensitivity, career goals, life-threatening or bad instability-type situations where you can make the knee worse, healthcare system issues or work life and you just got to make it happen. There are situations where it makes sense. But for the majority of people we see, we talk to, and most people, they don’t fall into these buckets. They’re the ones who have more flexibility and can wait in terms of having ACL reconstructive surgery. And there are tons of perks to waiting.

But before we dive into those perks, if you are someone who is listening and you’re like, I didn’t get to wait for my ACL surgery, whether it was the timing or just the recommendation by the healthcare professional, or maybe you just didn’t know, I was in a similar bucket, so don’t feel bad. And that doesn’t necessarily mean that you can’t have a good outcome or a good process. This is just something to highlight for any of you ACLers, or maybe if you’re a coach or clinician listening to this. 

For people who are considering ACL surgery, and maybe you are in this kind of situation where you have to decide, do I have ACL surgery now or do I wait? What should I do? Well, I want to talk about the reasons why that could be beneficial. But if you had to rush into it, there’s still so much upside to being able to make sure that you can have a good recovery process and to make sure that you can rehab the right way. There’s no one way to do it. There’s just a lot that is upside to waiting. And now there is no perfect time, of course, for how long to wait or why to wait, as it will be context-specific for each person. But I do want to break down some of the reasons for those upsides and perks of waiting.

Last week, I mentioned it allows the knee to heal from the injury and quiet down, so that is one major perk here. Remember, ACL injury and surgery are two separate traumas to the knee. The knee needs to heal from the first trauma, that first injury, and allow it to get back to baseline, get stronger, do that prehab if we can, get the range of motion better, get all the things that we mentioned before to get better. Before you approach this second trauma to the knee, which is ACL surgery. And I use that analogy of dropping instead from the 10th floor to the 7th floor. Well, how about we do prehab and get back to the seventh floor so we don’t drop as much or we’re going to drop even lower, which is going to make a harder climb back up. We want to make this as smooth as possible and feel familiar to you because it’s going to be a long road ahead. Setting expectations is probably one of the biggest pieces in this process, and just getting familiar with rehab. 

If you seek out help from a healthcare team, including a PT, hopefully, this allows for a conversation to talk about what the journey for ACL rehab is going to look like and what that roadmap is. Also, you’ll be able to get used to what you’ll be doing, aka it’s not a walk in the park for ACL rehab, setting expectations about this process, how there will be ups and downs, having the specific criteria and goals to meet phase by phase, making sure that you don’t get so stuck on time. There’s so many conversations every single session or every single week I have with my athletes where we are talking through a lot of these educational pieces to understand the expectations. And also, what does our path look like ahead so we can make sure we’re in the best mindset? Because that is going to be so key to having good outcomes in the ACL rehab process. 

Next up is that it allows the opportunity for prehab. Prehab, as I had mentioned, is preoperative rehabilitation. And research, time and time again shows us that better long-term outcomes happen for people who integrate prehab into their ACL rehab process. Maybe you do that for a few weeks, maybe it’s four or eight weeks, maybe it’s 12 weeks. We always tell people to at least give four to eight weeks at a very minimum, if it’s possible with your schedule, timeline, and everything to do. This allows you to get back to a solid baseline, allows that knee to heal, and allows us to also grab pre-surgery data, which is so crucial to this process, especially for the unaffected side. We have a comparison before we get all inundated with this entire ACL rehab process. And potentially the uninjured side also decreases in strength and its overall capacity. 

Another perk is that it’s an opportunity to see if you’re a coper. And what we use in this ACL world is coper versus non-coper. These are basically people who tear their ACL and we’re trying to see, can they cope without an ACL? And people can vary all over the place here. But we do see a category of people who can be a coper, which means that they are able to carry on with their lives and with most of their activities without the ACL. And it’s always going to come back to the knee status, the goals, and also your own risk-reward of what it is that you choose to do. For example, if the knee is super unstable and you have high goals of getting back to a high-level cutting, pivoting, sport like soccer or rugby or something where you’re going to really demand high load and cutting and pivoting and jumping on the knee, then that’s going to be tough without an ACL. But there are people who do it. And those people can potentially be copers. But then if the knee continues to give out, or let’s say that you’re continuing to have problems with it or it doesn’t align with the goals, then you might fall into that non-coper category. But this prehab that you do, or the time between the ACL injury to surgery, allows you to see if you do fall into potentially a coper category.

As I had mentioned, the buckets that’ll be important are going to be the knee status, the instability that it feels, and the goals you’re trying to get back to. As I had mentioned, that risk-reward of do you want to force things with the ACL not being there versus not. And some research can show that the ACL can heal over time. There’s a recent one that came out over the last year that has shown that. But with that said, we’re not really sure about some of these details. Maybe about the structural integrity of what is healing exactly. Is it scar tissue? Is the ACL mending back down? And then also, what is that component, or how does it exactly work? Does it work like the original ACL? Does it not? We’re not really sure, but we have seen some people where healing shows up on the MRI over time. And it’s something important to consider, especially if you’re not doing higher-level cutting, pivoting-type movements. 

And let’s say, for example, your knees responding really well, or you had a good baseline going into it. You were super strong. All you do is maybe straightforward running and maybe you like to just do some hiking. There’s some reason to say, okay, let’s give this a shot and see. I worked with an ACLer last year where he does jiujitsu. And he decided to go with a non-operative approach. And he really just wanted to see, okay, can he be a coper? And it turns out he was. There were a few situations where maybe his knee got a little dicey with jiujitsu, but a lot of the time he never thought about it. It never really translated or it never went out of place and he felt super stable, which is awesome. With that said, he was someone who was able to be a coper without an ACL intact. And this gives him an opportunity to see that, between the ACL injury and the ACL surgery. It gives you an opportunity to see that as well if you’re trying to make that decision and go that route. 

Lastly, and most importantly, I save the best for last, it helps to make informed and educated decisions. This process is a lot. It’s so much freaking info. You’re just like, what am I doing? Who do I see? What graft do I get? There’s so much different information to filter through. It’s like drinking out of a fire hose, literally. It’s like you went up to a fire hose and you just put your face up to it and you turned it on. And you’re like trying to figure out, how can I drink out of this? How can I sift through this information and figure out what is the best situation for myself? And people have different opinions. Even in healthcare, you go from the U.S. to Europe, to Australia, to South America, to Asia. There’s so many differing opinions based on the type of medicine they practice, maybe the research that they’ve read and the surgical techniques to the rehab techniques. 

There’s so many things that are in place, that there’s so many different opinions which is great to have a variety of opinions. But it also makes it harder as a patient and as a person on the consumer end to make decisions. So that’s where we need to make sure we field professionals who are very well-educated, who give you a gut feeling that we’re making the right decision and possibly fielding multiple opinions. I think it’s so important in this process, whether it is a surgeon, whether it’s a physical therapist, even a coach, or whoever you’re working with, to be able to consult multiple opinions. And I encourage that from ACLers, even if they’re looking to work with us or consult with us. I encourage them to make a very educated choice on being able to see their options and what feels right to them, and who’s going to give them the best opportunity to guide them back to where they want to be. And I think that that’s so key. 

I think the other side to this too, is that there’s opinions from actual ACLers. You might have Bertha in the ACL Facebook group saying: “The BEAR plant is amazing.” And you’ve got Ron on Reddit saying “that you should get the quad tendon because it’s the best tendon around.” And then you’ve got some mojo saying like, “Hey, you should go allograft because it doesn’t cause any pain. And it’s the best.” This what makes this process so hard is that there’s a lot of anecdotes. And I think it’s important that while anecdotes can be helpful, it’s also important to consider the research, professional opinions, and experience with any type of injury or recovery, but especially ACL injury and recovery. 

Our re-injury rates are way too high for us to just take an opinion off of Facebook or Reddit. And I think that that is what is key here, is being able to make sure that we have time to make informed and educated decisions. Waiting allows you to research to build your ACL team and to make these informed and educated decisions about what you want to do and feel confident in those choices. This isn’t just some removal of scar tissue or stitching something down; it’s major surgery. I want to make sure we stress that and I want any ACLer, coach, or clinician listening to this to be able to help support and to make sure on this journey know that it requires time to make good decisions and there’s tons of upside to waiting, in my opinion. Not a whole lot of downside really.

So that is going to be it for today, guys. I hope that this is helpful. This is something that I just wanted to reiterate more than anything because I think I see a lot of people just rushing into the surgery. And I hate it because what ends up happening is that they get out of it and they’re like, yeah, I just didn’t have much time in between my injury and my surgery. In most situations, they had the chance to be able to push it a little bit, but there’s someone maybe telling them, oh, there’s a slot available, or they’re thinking, let me just get this over with. And while that can be a fair rationale or fair reason to move forward, I’m going to push back against that and say, here are some perks of why waiting can be so beneficial.

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