- The complexity of pain in ACL rehab
- Factors that influence pain
- Guiding principles I use with my athletes
- Feedback loops to help navigate the process
- Questions to ask yourself
What is up ACL Athletes? And welcome back to another episode on the ACL Athlete Podcast. Today, we are starting a two-part series about pain. And how to deal with it in ACL rehab. It’s one of the components I discussed in the Quiet Knee episode. Everyone deals with it and it seems to be this monster under the bed that we can fear a lot of the times in this process and can really hold us back.
Anyone, really who has existed, has experienced pain, and it sucks. And in this process of ACL rehab, it can be very difficult to navigate. I hope that with some proper education and some principles that will be discussed today, it will help guide you and help you to navigate this process and make it feel a little less daunting, a little less scary. And that way you can feel. A bit more in control with this and realize that it is a monster that you can tame.
This is part one where we’re gonna talk about pain itself. Should you move into pain? Should you only train whenever you’re pain free? How much pain is okay? And hopefully by the end of this episode, you’ll be able to grasp some of these principles that will help guide you in this process.
Part two will be diving more into some tactical approaches. So five different ways to train around pain. And I’m gonna use actually a real case example with one of my ACL athletes and how we’ve navigated pain through the process and being able to change or modify. And so I want you to have some tactical ways to apply to your own rehab process.
And before we get started, I think it’s always important to know, every person’s situation is gonna be different, and that this is not medical advice specific to you. It is purely educational and entertainment, and if you are dealing with this, this is something that needs to be navigated with a healthcare professional. So just make sure you keep this in mind as you take this information and move forward with it.
So pain, it is a very complex topic. I’ve worked with so many people with so many different issues, whether that’s a joint or an ligament or an injury to a muscle, ankles, necks, a lot of knees… just all over the place.
And you guys probably hear me say it depends a lot. And if there’s any question that “it depends” answers the best, it’s around pain because it really does, it really does depend. It depends so much on the context, you know, whether that’s the timing of the injury itself. Is it an acute injury that has just happened? Is it something that has been going on for a very long time? Is it three months? Is it a year? Is it 20 years? And that adds another layer of complexity to it because the longer that a pain experience goes on, there’s more changes, not only locally at areas where things can heal, but it also can be changes in the brain, actually.
So that’s important to just kind of understand what this process is, the timing, the type of tissue involved, meaning is that a muscle, a tendon, ligament, bone, cartilage, you name. It can be so many different things whenever we’re talking about pain. Obviously in this case we’re talking about the knee and the joint itself, the ligament, the muscle surrounding it.
Was there a mechanism of injury? You know, was there a specific moment where this injury happened or was it just something that gradually started and that’s gonna make a huge difference on how you navigate this process? How we tackle an acute hamstring strain is going to be very, very different than someone who’s been dealing with low back pain for 20 years.
And then there’s other things to consider with this, right? Like your lifestyle and psychological factors. Are you someone who is incredibly healthy, you eat really well, you sleep, you know, the normal seven, eight hours that you would need. Are you making sure that you’re managing your stress really well? Or is it something where you feel like life is just crazy and you sleep five hours a day? Then that could be a huge issue that contributes to your pain experience. So all of these different factors are going to be important based on the context, and this list is not exhaustive whatsoever.
There are a lot of things that also play into this, but I want to get you thinking about all these different pieces that do play into this experience itself, and especially with acl rehab being so long and there’s so many different parts to it that is helpful to know. It might not just be one specific thing.
Let’s take for example, an ACL injury, immediately post-injury, post-surgery pain, a lot of times is gonna be because of the trauma, right? There’s an injury to the ligament. There might be injury to the bone where there might be some bruising or a fracture. The meniscus might be damaged. A lot of times you’ll see maybe your MCL will also have some sort of stress to it, and so you might have a sprain at that ligament as well.
So this is something that would be important from a pain experience as opposed to, let’s say, during the rehab process itself. You might be healing from that surgery, but then maybe later on in the process you might start getting some donor site pain. So maybe you got a quad tendon and there’s a little bit of discomfort where that incision was, or maybe a hamstring tendon and you strain your muscle in that area.These are all things that could happen along the rehab process.
I remember when I had my first ACL surgery that I had a lot of issues with my hamstring tendon and where that graft was harvested and the issues there. I’m not trying to push you away from this, but this is just my own experience and I would get repetitive strains and donor site pain. And that was something that I had to work through with my physical therapist to make sure that I was taking care of the area, I was loading it appropriately. I was managing the pain. So some questions that are important to just think about is, you know, when does it start? What are you feeling? Where is it at? And and more importantly, what is the plan in place to be able to make sure you’re navigating that appropriately?
If you guys can’t see a theme here, the plan in place and someone to support you along this process is pretty big. So this is something where whenever pain occurs, you want something in place to make sure this isn’t something that’s just gonna completely stop the process, and that there’s ways to pivot and navigate around it.
I wanna dive into some guiding principles that I use with my athletes every single day to help navigate the pain experience and especially when it comes up. Because let’s be real, it’s going to happen, but let’s make sure that we can address it and move forward. So the first one is, the protect or exposed continuum, and this I learned from Greg Lehman, who is a very, very smart man, especially in the pain science realm.
He uses this example of: there’s one side, let’s say for to the very far left, that’s. “protect”, and then to the right of the continuum is “expose” and you have to just decide, is this a certain phase where there might need to be more protection to allow for healing and for the symptoms to calm down and then move forward towards exposing, which is exposure to stress and making sure that whatever it is that we need to load or to expose stress to is able to get that appropriately to meet whatever goals you have.
For the protect aspect, it might be someone with acute injury or sensitivity. So if you’re someone who literally just injured your ACL or just had ACL surgery, then you’re gonna be in this more protection phase.
Pain is going to be a guiding factor because it is so fresh and there has been some trauma to the area. So you want to make sure that you’re protecting it in a very thoughtful way. So this might be lower level activities. You might be decreasing the amount of volume, decreasing the intensity. So after an ACL injury, typically you’re not gonna be doing nearly as much as what you were doing, but you want to kind of find that sweet spot where you can continue to do stuff, but you’re also protecting the area.
Then, if we switch over to the expose, that might be working into the pain and into what is going on. And typically, this also has to do with more time. Your tissue has been healing and it’s been going on. Pain has also been around for a while, and so you might be able to push towards more volume and more higher level activities and higher intensity. So that’s where knowing where you’re at and where you need to go will be really helpful.
Now, I want you to imagine a traffic light with red, yellow, and green. And then I want you to think about the pain rating scale. So it’s typically 0 to 10, where zero is no pain and 10 is the worst pain –usual reference– you’re going to the emergency room, it’s the worst pain you’ve ever felt. With this traffic light, I want you to imagine the green is zero to three on that pain scale. The yellow is four to five out of ten. And then the red is six and above, so six to ten. So that green is a safe zone. The yellow is an acceptable zone, and the red is excessive, similar to how we’re driving, right?
You can drive through green, yellow, you better be cautious, but then red, you’re stopping. So this helps to anchor this experience. Now I don’t really care about the number itself. I care more about what category it really falls into. And I know that this seems a bit arbitrary, but it can allow you to know, is this more of a low, a moderate, or a high pain?
And this is going to give you some feedback to know, is it okay to keep going? Should I be a little cautious, or is this like a little too excessive? And that’s how I want you to look at this. So if it’s in the green light or the zero to three–keep going. It’s okay. It’s that safe zone. If it’s four to five, just think of it as that yellow light. Be cautious, but it’s acceptable. It’s okay to keep going, but be careful not to push past this. And then if it starts getting into that higher pain region, that 6, 7, 8, out of 10, then it might be excessive. And then you gotta ask, is it worth it? Is the risk worth the reward? This is only going to be known based on your specific situation. In most instances that I have personally experienced, and also working with other people, and when we also look at the research surrounding this, if you stay in that low to moderate pain threshold, then you might be okay to move forward because you can continue to load the area. Then being able to see, okay, is my body gonna respond to this?
Now, here’s where a good feedback loop is going to help you with guiding this specific process. So I want you to think of this as this 24 hour feedback loop, and you’re going to assess one: how do you feel after you do the exercise? Is the pain increased, is it the same or is it less? You know, sometimes I find people, whenever they do exercises and they get the blood flowing, they feel better. And then now we need to see, okay, is the pain stable 24 hours later? Is it increased after that 24 hour period? If so, then we might need to change something. Now. That’s where it’s going to be important to look at the variables that might have increased the pain. But then on the flip side, maybe it’s less, then great. We’re heading in the right direction. The thing that I always tell my athletes is if it is getting worse and progressively worse, something needs to change.
It just needs to change because it’s not going to add up to something that’s beneficial. And if we’re continuing to battle pain, it’s going to get in the way. So this is where modifying is very important, but first we have to zoom out a little bit to really understand this. And this is where all the variables that play into our pain experience are so important.
So, the big piece is movement, which is very important with all of this, and which can typically trigger the pain and what we’re feeling in most situations. The other pieces are your nutrition. What are you putting in your body? Are you hydrating? Are you eating enough protein? Are you eating anti-inflammatory foods?
Like all these things are important and will play into your pain. Experience your sleep. You better be dang sure that you’re at least sleeping seven, if not eight hours. And if you’re not, change that right now. But this is something that’s really important and there are a lot. Associations and research, connecting sleep and pain together, especially in the chronic pain population.
But sleep is going to be so important because it’s a part of our recovery. It’s how our body regenerates, and especially all the work that you’re putting in. So if you’re an athlete, sleep should be one of your number one things, including nutrition.
And then the other big bucket to this is stress. So stress is a very big umbrella and it can fall into very many different things, whether it’s related to personal life or work or just school. Also what you’re dealing with on a daily basis from anxiety and fear and worry. All of these things play into our pain experience.
So as we are looking at all of this, that is what I want you to keep in mind when you’re starting to ask, okay, is my pain getting worse? And especially if it’s over a long period of time and you’ve been dealing with it for a very long period of time.
Now, if we zoom back in on some of this area from a movement standpoint, and let’s say all the other places, so your stress, your sleep, your nutrition– all that stuff has been under control and consistent, then now we can dial in, okay, maybe it is movement based, and then now we need to look at the program that you were following and see is it a specific exercise or a movement? Is it maybe too much intensity in one specific movement? Maybe it’s just too much volume in general, and you haven’t allowed your body to really recover. So these are all gonna be important factors to consider.
As you’re moving forward with pain and being able to navigate this process, some questions that I just want you to reflect on and think about: Is when you’re evaluating your pain, is the pain the same as the original pain? If yes, then in this sense it’s good, right? If it changes, then that’s something important to note. Is it tolerable? So going back to that traffic light and seeing the green and yellow, is it tolerable? Then, okay, keep moving. If it’s starting to move into that red, then maybe we need to back off a little bit.
Does it interfere with daily function and life? If your answer to this is yes, then something needs to change. Does it keep getting worse day by day? If your answer to this is yes, then something needs to change.Then has my nutrition, sleep and stress been the same or different? I think that this can be very helpful to zoom in on certain variables.
So if one is different, let’s say like work has been really nuts and you’ve only been averaging four to five hours of sleep every night, then you need to adjust and see how you can work with this. If you feel like these variables of nutrition, sleep, stress and other factors are pretty much the same, then it might need to be just the program and the activities that you’re doing that need to be adjusted. So these are the things to consider and questions to ask yourself.
Times when it might not be best to not push into pain or having no pain would be, in my suggestion, when you have an acute strain. Let’s say for example, a hamstring strain is one of those where you want to try and move towards no pain because it is a tear of a certain muscle tissue, so it might be something that might be better to allow some time to heal and not push into too much pain. Also, highly sensitive conditions where there might be a lot of volatility like up and down with the pain and it’s hard to control. And that might be something where you might need to move towards no pain or very minimal to be able to make sure you have control of the situation. Otherwise it’s going to just be miserable and you don’t want that. And then other things like fractures, you don’t want pain with fractures because you wanna make sure the bone is healing. So that is always something good to consider.
And as you guys can see, pain is very complex, and it’s why there’s courses, it’s why there’s physicians specifically who focus on this. There’s physical therapists. There’s an entire realm in all of healthcare that focuses on pain because it forces us to move and make decisions, and especially if it gets bad enough or it gets in the way, then it’s something that we need to address.
All right, so in review, pain is complex and it’s multifactorial. The timing injury itself, the type of pain you as a human being is very important. We gotta take a zoom out and look at other factors such as your sleep, nutrition, stress. Those are gonna play an important role in this process.
Some guiding principles to help you:
One is protect or expose. Am I in this protection mode right now? It might be early in my injury or surgery. Or maybe it’s later and I need to be more in this, exposing it to stress the traffic light of the green, yellow, and red, where zero to three, four to five, and six to 10. And this allows you to know it’s okay to proceed with the low to moderate, but making sure we stay away from a high, high level of pain.
And then using that 24 hour feedback loop. How is my pain feeling the next day? Is it better? Is it the same or is it worse? If it’s worse, then we need to adjust something. If it’s the same, it can be okay to proceed. And if it’s lower, then that’s good. You just have to be mindful about the pattern and not just these one day, one off things, but the pattern is what’s most important.
We talked about some questions to ask yourself to see is it getting better? Is it something that could be related to nutrition or stress or sleep? Is it something that’s getting worse? So if you ask yourself these questions, you might be able to know if you need to adjust or just to keep proceeding forward.
And then we talked about times when it might not be okay to push into that pain, whether that’s a strain or a highly sensitive injury or pain or fractures. So with all of this said, consult your medical professional, especially if things are getting worse. This is not something to play around with. And as someone who has experienced a lot of injuries specifically ACL related stuff, and then also working with a lot of people with this, you just want to make sure that you have something in case this type of stuff comes up, because it will and it will help so, so much to navigate this process and my athletes know these principles because it’s important. It’s important for our communication. It’s also important that way they don’t always need to contact me and if there is an injury, let’s say later down the road, or they’re dealing with pain, they have some principles that guide them and they, maybe it’s not for their knee anymore and it’s for some back issue they’re having, or maybe they’re dealing with some shoulder pain. They can try and navigate the process with themselves initially, and if it’s not getting them to where they want to be, then they can always reach out. But it’s just something that can be very helpful with all of this.
All right, guys. That’s it for this episode. I’m excited to talk about this and I think it’s something every one of you are dealing with, so make sure that you go back and listen to it, understand what’s going on, and please always reach out if you have any questions. I’m really excited about part two, where we’re gonna talk about some strategies that you’re gonna be able to take with you to be able to work around pain.
And then I’ll also bring in some examples with one of my ACL athletes. So that would be really cool, and hopefully that’ll be something practical that you can take away and use to navigate your own process. So thank you all. Wow, 23, almost 24 minutes later. What are you doing, Ravi? Thank you guys all so much for listening. This is your host, Ravi Patel, signing off.
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