Episode 127 | ACL Rehab Must Do – 1 Prehab Visit

What is up team, and welcome back to another episode on the ACL Athlete Podcast. Today, we are diving into the episode: An ACL Rehab Must Do One Prehab Visit. Now, if you don’t know what prehab is, prehab is essentially when you have injured your ACL and you’re potentially having surgery, so it means preoperative rehab. You’re going through that rehab process before you actually go under and get your new ACL. Now, if you’re someone who’s going the non-operative route, that is great. Typically, this can still technically apply to you. You’re just doing your rehab. But if you’re someone who is getting ready for surgery, then there is this window of time between the injury and the surgery itself, and that is prehab. 

Today, I’m going to make the argument that everyone, every single person should at least go to their PT, or physio for one visit before their ACL surgery, one prehab visit, if you will. Why? Man, there’s so many reasons why. And if you guys have tuned in to this podcast before, then you know many reasons why. But I’m going to list out a few. Allows you to meet the person who you’re going to be working with, the physical therapist themselves, the physio, or the rehab professional who you’re going to be working with. It allows you to vet that person. It allows you to build trust with them to make sure they are the right fit. We can’t just necessarily have anyone for this process, unfortunately. And we know that because re-injury rates are high and because there’s a lot of problems in this area, you need to make sure you vet the person and the physical therapist or the rehab professional you’re going to be working with, as well as assess the clinic. So that allows you to do that if you get in before you have your surgery. And then it allows you to get familiar with what the rehab can look like itself, including a session, get an evaluation, get that session flow going, and also know what your post-op movements are going to look like.

A lot of times people think they’re super basic and that they’re not that important. And that, it’s just a few things here or there. I’m just going to rest anyway because it’s going to be post-op. And I’ll tell you, those post-op movements can make or break your ACL rehab process. Getting in there and being able to look at what you’re going to be doing, get cued right. Just as a good example here, is when people go to do quad sets post-op, it’s hard for them to activate their quads. So guess what? They kick on their hamstrings. Assume that they’re going to do a quad set and feel like they’re doing a quad set, but really they’re just kicking on their hamstrings and not getting that extension that we’re hoping for.

These are things that we can work through, cue you on, and allow you to be prepared as you enter this surgical process. It’s going to allow you to get pre-injury baseline numbers and make an assessment to see, okay, where is your range of motion at? What problems are you dealing with? And then it allows you to connect the dots of post-surgery and see, okay, are those things aligning? Is there a trend or a problem that we’re seeing? Or did all that stuff get cleaned up and worked on after surgery? It allows you to get those baseline numbers, especially the strength of that unoperated side. I can’t stress that enough because then therefore you have a more accurate representation as long as it’s close to the injury. But at least you have that number before you are having surgery, and then you’re not doing nearly as much, which we know strength drops.

This in and of itself, the prehab visit will get you prepared for surgery. To set the expectations, including the goals of what’s ahead, especially in that first post-op phase. Again, a lot of people brush us off and think that it’s super simple. But it really ends up being a little bit more challenging because people don’t realize how much pain you’ll go through. And then also those milestones you need to achieve that will be building the foundation for the road to come. This allows you to focus on certain low-hanging fruit and the main goals, and keep the main thing, the main thing. Because therefore you don’t get lost and you’re just like, all right, I’m just doing these exercises, but I don’t really know for what rhyme or reason you attach these and anchor these to goals which allow you to understand the expectations of this process. And the list continues to go on. You can check out my previous episodes and even blog posts on our website on why prehab is so great. 

For prehab, in general, my suggestion is to give it at least 8 to 12 weeks before having surgery unless you’re in that small percent that needs to get it due to some time sensitivity or maybe the type of injury you had. There are factors that can play into that, but many people do not need to do this, and they don’t need to rush into it. I’d say the majority 80% to 90% of people don’t need to rush into the surgery and they can have that 8 to 12-week window to just allow that knee to calm down after the injury and get it prepared for surgery. And I promise you that you will gain so much from this process of doing it and there’s no need to rush. And oftentimes what usually happens is that people will usually not go to physical therapy or their physio or start that rehab process until the post-op procedure, and that makes sense. You had the injury, and then you’re just kind of like, all right, I’m just waiting for surgery, so I’ll just do my normal thing.

And then eventually, you’ll have the surgery and you’ll start your rehab. I would argue that this is the wrong way to do this, but this is typically the way that most things go. And along with this, it makes sense logically to just take it easy post-op. That’s what a lot of people do. They think, oh, just like when you’re sick. Just take it easy, rest, and let your body recover. And that is fair to a little bit of a degree. But you don’t actually need to. You actually need to find that sweet spot and make sure that you move within your own limits and focus on those goals. You’re not going to start running or doing a ton of squats. But you do need to move and you need to make sure you keep that conditioning up and keeping the other side strong. 

And especially even those few days post-op, you want to make sure at the minimum you’re hitting that range of motion, especially your extension and quad activation the day of day one. And you’re not going to hurt anything unless you go crazy doing stuff. There’s that sweet spot of not just bedrest, watching TV the whole time, but also working on your ACL exercises anywhere from three to five times a day, especially the range of motion and quad work. If you’re weight-bearing, you’re starting to put weight on it and starting to try and walk. With your crutches, all this is going to come back to what your restrictions are and the guidance that you’ve been given. But you are not to be basically not doing anything for the first one to two weeks. Day one: You should start doing stuff after post-op. 

Again, another reason why the first visit for prehab pays its dividends and knowing what you need to do, knowing those expectations, and knowing those post-op exercises to know that, alright, I’m on a good starting track instead of starting behind the line. And that helps so much. And if you have a really good surgeon, they’ll advocate for prehab. Any good surgeon I know is like, yeah, go do prehab. Meet your physical therapist. Start getting that leg strong. Walk into your surgery as if you know you don’t feel like you really need your surgery. That’s kind of some of the things that people will say, of course, give or take, depending on the injury and the status of the knee. But you want to get back to that normal, at least functional state. Instead of this knee that’s blown up. Can’t straighten, can’t bend, a lot of pain, because you’re about to just redo that process all over again and set yourself back even further so the surgeons will recommend it.

Hopefully, and if you don’t have a good surgeon, they may just say like, ah, or maybe they do not weigh it very heavily. They might just say, ah, just wait. Start it a week, two, two weeks post-op. Or maybe it’s just not advised in general. You know, it’s crazy to think that that’s not really this like very particular, all right, I need to see this person. Within the first few days of their surgery, sometimes it’s recommended to just immobilize and not do anything for two weeks, which is something I strongly disagree with. Because there’s nothing that you’re going to do harm to unless you have this 0.1 type percent of procedure that you know most ACLers don’t get.

There is a very strong argument to get into physical therapy at least one time for your rehab. And here’s an example of how one visit itself can do wonders. I just had an athlete have ACL surgery. He got in one week before the surgery for just an initial evaluation. The parents were surprised. I wanted to get him in. As they weren’t told they needed to get in before the surgery. And I was like, yeah, let’s try and get him in. I love it. It helps to do all these things that I had just mentioned. What we did was we tested his range of motion to see where his baseline was, to test the strength of his uninjured side, and even just to see how he was doing on the injured side. Set the expectations, and goals, and prepare him for surgery from the goals I have set for him to the extension work, the flexion work, quad work, getting his NMES unit set up, and applying the frequency of how much he needs to be doing stuff.

All the stuff plays in so much of that early post-op. And I said, your number one goal is to get that heel pop and that knee extension. Let’s get the quads active, and get your extension back. It will be a game-changer. Guess what? A few days later after his surgery, I got a video of him getting his heel pop so quickly after surgery and it was amazing. He was excited about it. I was excited about it. As a physical therapist, it’s the thing that you literally want to see for any of your athletes is, can they get that heel pop? And as early as you can, man, it builds an incredible foundation and it makes a big difference. And I think it is a very severely underestimated part of this ACL rehab process.

I think the system that we have built has just been like, all right, injury happened, surgery, and then rehab. And I think the way that it should go is actually injury, rehab and then let’s give it some time. Unless you’re that small percent that needs to move and get it done, and that is something that you do, and then you have the surgery, guess what? It might inform you you might not need it. And then, therefore, those are data points you’re collecting during your prehab process to know maybe I don’t need the surgery. Maybe I can allow myself to do this thing where I don’t need it. There’s more research coming out with ACL healing, which we don’t know really much about yet, but there is some promising research. Why not just give yourself a shot? especially if there’s no time sensitivity to it. And there’s more pros to it than cons. 

If you’re someone sitting here, I would say go and do this somewhere where you can get into your physical therapy before the surgery. Do your prehab if you can. If you’re coming up close to it, ask your surgeon, if they will write you a prescription and get connected with your physical therapist early. I know this seems silly, especially maybe your knee is a little bit more functional. But just say like, hey, I want to get in. I want to know what I’m doing post-op. What are my goals? And then again, it allows you to assess and see if your physical therapist is legit. Is your clinic legit? And from there, you’re able to know, all right, maybe I do need to start thinking about pivoting earlier, or maybe I’m in a good spot.

As I mentioned, there’s so many perks that will dramatically help to know what to do and what to expect more than anything. This ACL surgery blindsides most people because they don’t realize how limited they will be post-op, the pain that they’ll deal with, and just all the things that kind of come with it. The immobility, the just like kind of fear of just like, all right, moving the knee. There’s a lot of things that go on that we just. Don’t expect no one to prepare us for this. Your surgeon doesn’t, most physical therapists don’t, and it’s just one of those things where you’re like, all right, I’m ready for the day.

Let’s do the thing and then it can blindside you. This is where getting into your physical therapy can help initially, especially since this surgery is people’s first major surgery. Not to mention how anesthesia and medicine impact people’s mental capacity to critically think in those first few days. And you’re not going to want to do any of that the day of the next day. Within the first few days depending on your pain levels, and how you’re handling all that stuff, you don’t want to be figuring things out and learning things like new exercises from the get-go as soon as you’re post-op. See if you can nail that stuff before your surgery. Therefore, you are like, oh, I’m ready, I’m good to go. A legit builds the foundation to start the process. This starts before the surgery. And each day after the surgery, more and more. 

One visit prehab or pre-surgery is a non-negotiable in my opinion. And I think it’s something that we need to push more in this profession within ACL rehab. And of course, this is going to come back to the rehab quality you get. Maybe someone walks in and does a prehab session, and they’re like, oh, that really wasn’t much. And I apologize if that’s the case. But usually, there should be a lot of educating, a lot of things to just know what to expect, as well as making sure that you know what you need to be doing based on what’s going to happen post-op. And we know what’s going to happen for the most part in 80% to 90% of cases. Sure, there might be some curve balls thrown in where someone goes in and maybe there was a fracture that wasn’t noticed or something like that. Or maybe there was a meniscus that needed to be repaired, so you’re non-weightbearing. Or maybe they decided to do an LET, which is an anchor to the outside. And so that’s going to be something that could change things potentially. 

But with that said, we know majority of the time you can extend your knee, you can activate your quads, you can bend your knee to some degree, and then potentially put some weight on it, depending on your restrictions. But there are a lot of things we can do, and we have to make sure that we own all of those from the injury from the day of surgery and on. And I will leave you with this, there’s not a single person I’ve ever worked with and talked with who said prehab was a waste of time. I shouldn’t have done it. And most people will always say how thankful they are to have been doing prehab and prepped and going into the surgery, whether that’s in-person or remotely. It is a huge game-changer.

Your big takeaway today? If you are approaching ACL surgery, you’re working with people who are going through this process, an ACL rehab must do, one prehab visit before that surgery can make a world of a difference just like the athlete that I had mentioned earlier. If you guys have any questions, you know where to find me. 

Thank you all so much for listening. This is your host, Ravi Patel, signing off.