Episode 140 | Why You Should Know What’s Done in Your ACL Surgery

What is up team? Getting straight into it today — why should you know what’s done in your ACL surgery. And this comes up from a topic where I have had a lot of conversations with ACLers and I can’t tell you the number of times where they’re like, I don’t really know what they did. They just did ACL surgery and that was it. Maybe you know the graft type, maybe there was a meniscus repair or something like that, but that’s kind of it. And don’t get me wrong, sometimes that is just it. All of this is going to be based on how the initial injury was, and what was on the MRI report. And then when they get into the knee itself, and being able to evaluate it, and then decide what they need to do. Usually, this is predetermined, but then you never know when you get into the surgery. 

There’s been athletes who had a hamstring graft that they were going to get from themselves. And guess what? The person was super short. The surgeon didn’t consider that. And then the hamstring was too short for them to use, so then they had to use something else or combine it with a cadaver. Not only did they take the hamstring tendon and say that it was short, but they also combined it with a cadaver. Instead, that could have just been completely avoided by being able to take a different graft site or just considering the person’s height. You may wake up and there could have been something different with the process or the thought because they got in there, such as a graft or maybe it’s a meniscus issue. And they got in there and was like, oh, we thought it was going to be something that wasn’t a problem and you had to repair it. So that impacts your first four weeks potentially by not putting weight on that foot compared to what you could if you had a meniscectomy or maybe there was no meniscus injury. This is all to say, that when you go into surgery, there’s not always this 100% predetermined. This is what we’re going to do and this is the outcome.

You may go in and something else they might have to pivot and do because of the situation or what they see in the knee versus the MRI. The whole point here is that knowing what’s on the MRI is helpful because that’s going to help determine what’s going to be done in the surgery. And then once you have the surgery, then obviously you know what is going to be done to the knee, and that is kind of the final point of any changes, hopefully, within the knee.

The reason we are talking about this today is because I think it’s really important to know these details. Now, you don’t need to be some radiologist-type person where you need to know the minutiae of it. But you do need to know in general what was injured and then also what was done in the surgery because that can have implications with guiding your rehab process.

We might not think it’s that important, but seriously with all of our ACLers, we dial in all the details about their surgery, their injury, and how they injured it, being a non-contact versus a contact makes a huge difference. You tore your ACL because there was nothing around you versus you tore your ACL because someone tackled you and slammed into your leg. That’s going to imply something based on your readiness before, and we’re going to take that into consideration. The actual things you do in the surgery and in the injury will actually help us to know what we need to look out for and what we potentially don’t need to worry about. 

The other thing here is that let’s say you don’t even go into surgery. You might go to the non-operative route. That’s going to also help us to be able to determine what’s the game plan here. Was there an MCL injury with your ACL? Was there a meniscus issue that turned into a bucket handle tear? Are there certain things that are going to be impactful for your non-operative process? So that’s going to be something that we consider no matter who you are after this injury. And then especially after surgery because there’s going to be some changes to the knee as we know. And there’s so many nuances that I don’t want to dive into in too detail, but this is going to truly impact this rehab from start to finish.

This starts with knowing what was wrong with your MRI. I get that some of that stuff looks foreign but just know the main pieces. Again, because let’s say you’re doing the non-operative approach, that’ll have those implications on what we do. Then, of course, if you’re going to have surgery, there’s going to be changes that are done there. We need to know what that was and what structures have been impacted and changed.

We might be loading more carefully based on whether there’s a meniscus repair versus a meniscectomy. We might be restricting some range of motion to 90 degrees because, maybe the surgeon said, he doesn’t want it to go that way or she said that it’s okay to go full range of motion. So that’s going to help us to know how we navigate, especially those early postop phases. Let’s say the graft type, you’re going to get a quadriceps autograft versus a hamstring. Well, that’s going to have implications to the atrophy of the muscle and then also the pain in the donor site areas where that was taken from. So that’s considerations that we work around. Maybe the hamstring engagement postop with the hamstring tendon is going to be impacted. These are just different pieces that we’re going to be dialing in. 

The other thing is, let’s say there’s swelling and pain that you’ve been dealing with a lot. And maybe it’s because there’s just a lot of damage to the knee. I’ve seen some pretty rad MRI reports where people have jacked the knee up. It’s ACL, MCL, LCL, tibial plateau fracture, there is meniscus damage, and there’s a posterolateral corner issue. There’s so many things going on in the knee that no wonder you’re dealing with a lot of pain and swelling versus someone who just had a sole ACL. The feeling of everything is going to make a very big difference also the recovery. When you’re thinking about this, you want to think about all the tissues involved and especially thinking about some of the bone, too. Because if we have a bone bruise versus a fracture, that’s going to implicate things as well. 

I can go on and on about this, but as you guys know, I always want to give you tactical advice on this podcast for you to walk away so that you know from your injury, from your surgery, you know what went down. Let’s take this step by step. You have your ACL injury. And then you’re going to go get an MRI, typically. Then you’ll have a report of that MRI. Typically, you are using that with your surgeon in order to know what’s happened, confirm the ACL tear, anything else going on in the knee, and potentially what you’re going to do for surgery or maybe a non-operative or different process. But that’s going to help and the thing you’ll get with it typically is a radiologist report. It would basically just be a lot of medical terminology of things going on in the knee. And boy, have I read some crazy radiologist reports where it just seems super foreign and I feel like I’ve been exposed to a lot of medical terminology in my day. There are some words that I still have to look up because I’ve never heard them in my life. I’ll ask our team or other people and they’re like, yeah, I don’t know what this means. Obviously, we look it up and it’s like, oh, okay. But in general, I think that’s just like going in the deep end.

What we can do is gather so much information from radiologist reports and it can help us to know, all right, well, this is at least a general idea of what they found based on the imaging. And then that’s going to help guide potentially the next steps. You find out what was done on the MRI, you just have that copy, make sure you know just the big bucket bullet points like it might be ACL, it might be an MCL sprain, it might be a meniscus injury, it might be some bone bruising, any of those things that could kind of show up, right?

And then next, you got to know what’s done in the surgery. And what’s cool is you can get a postop report sharing what was done. Sometimes when these athletes come to us they’re like, “Yeah, I don’t really know what they did.” And so we’ll just be like, “Well, go ask them for a post-op report. And let’s see what it was that was done. In my opinion, it should have been communicated to you and made very clear what was done and maybe they did and you didn’t remember, or honestly, it can get skimmed over is like, yeah, you had an ACL reconstruction and that’s it. Whatever that is, get the postop report. And then this is where we’re going to make sure we break down into buckets that are helpful. You already had the MRI. 

Now, you are diving into the surgery report or what they have told you. And so basically, you’re trying to figure out the type of surgery. Did you have a reconstruction, an ACL repair, or maybe something else? A repair is typically fixing the native ACL versus a reconstruction is using some sort of other graft, whether it’s an allograft or an autograft to be able to replace the ACL, essentially. This is something that will be important to know. Was there also something else done? Maybe an LET? Which is a lateral extra-articular tenodesis to help with rotational stability, which is becoming newer and more common, especially in places like Europe. Maybe an internal brace was used with your graft, or maybe you had a BEAR procedure. All of these details will be very key. 

And of course, you might get a prescription for PT or whatever that might be, but there might not be as much detail. I might just say ACLR with hamstring graft or a BEAR procedure which, if you’re bare procedure, typically there’s a very strict protocol, but with these other procedures, there might not be as much detail about the procedure itself besides the general stuff. So that’s going to be important to know. 

Graft type: were you using an allograft, autograft, where it was taken from yourself, allograft cadaver? Where is it from? The type of cadaver tendon, or is it a quad autograft, or hamstring autograft? Is it a patellar autograft? Those are usually the big three. You need to know what those are, any other ligaments that were impacted or repaired during the process. Any certain regions within the knee — bone, how is that impacted? Was there bone bruising, or a fracture? Was there any repair done to that? A cartilage issue? Was there an impact on the cartilage around the patella, the femur, and the tibia? Those are the three different bones that make up the knee. 

What about the meniscus? Which side? Is it on the inside, which is medial? Is it on the lateral, which is outside? Are there any specifics about what type of tear potentially? And then what was done? Was it a meniscectomy where they cut it away? Or a repair where they maybe stitched it down? Or maybe it was left alone. Are any tendons, or muscles impacted? If you have an autograft, obviously this is going to play a bigger role because that’s taken from a tendon typically. So that’s going to be something that you want to know. Typically, that is usually there. But sometimes you’d be surprised. Some people are like, I don’t remember where it was taken. We have to kind of almost do some detective work to figure it out.

The other thing I like to know is the type of block. You know, was it a femoral block? Was it an adductor block? This is the nerve block. Is it a spinal block? So that will potentially imply, okay, maybe the quads a little bit more shut down because you had a femoral block. All good things to just know and have. Every PT will not ask you this question. But it’s good to know these things, especially with the more complex cases, because that’s going to help us to know what we need to expect. And I know that this might seem like a lot, and I’m not expecting you to know all the ins and outs. But that’s where the surgical report can be helpful. It’s good to have an idea of these major buckets, especially, because, for us, it will inform how we approach your range of motion, your loading, and the positions we allow you to get in. Like even a LET, for example, we might control a little bit more rotational work because you might have a little bit more aggravation, or we want to let that heal down a little bit better. So we might not add as much rotational work into some of your early phases because we want to allow for that to heal and adhere properly. We might impact that. 

And so then this is also going to help us with the education that we’re going to give you around your pain, your swelling, and honestly, the entire process. Because we have people who come in, they’re dealing with maybe tendonitis from their donor site, knee pain, swelling, range of motion restrictions. We’re going to dive into the history and play some detective work in order to understand, “Oh, well, you didn’t get your extension back before surgery.” So that might be impacting why you’re not getting it so far out. You’re already dealing with patellar tendonitis and then you had a patellar tendon graft and now we’re having to deal with that donor site plus a tendon that was already not in good shape to begin with.

So these are all just factors that can play into it. I want you guys to to know that why I’m asking or saying why you should know is because we and any really good physical therapist in my personal opinion are going to know these issues. And anything that comes up and they’re going to tailor that plan around what it is that’s going on. And more importantly than anything is that it can help inform us to know, all right, if this isn’t going according to quote-unquote plan or the timeline, well, you might’ve had a unique process or something else going on in the surgery that might be shifting the timeline a little bit and making the criteria.

Be a little bit further or maybe a little bit earlier. So that helps us so much from the education standpoint, but also the game plan. And I’ll give you this quick example. As I finished, I had a consultation call with a mom recently. Her 14-year-old daughter (this is so sad) had an ACL reconstruction. And she mentioned that she was postop, so we talked immediately postop, and her daughter was just crying. She was in a lot of pain. She was scared to move her knee. They were told to go to PT a little bit later, which I disagreed with. But, with that said, she was crying, she was upset, and she was just like, I don’t get it. I expected it to be painful, but why is she in so much pain? And then I started to ask more questions.

I was like, well, was there anything else done? And she’s like, well, they did something on the side. And I was like, interesting. Was this an LET? And she was like, yeah. I was like, oh, yeah. Basically, she’s had her quadriceps graft taken for ACL. She has one donor site. She had holes drilled, obviously, for putting the ACL in. Then there were screws put in to be able to anchor that. So that’s the normal ACL process. But then guess what? She also had technically a second procedure where they took part of her IT band and screwed it and anchored it to the side of her outside knee. And that’s something that is almost an additional procedure.

No wonder she’s in a lot of pain. She’s also 14. But the thing here is that like, she didn’t really recognize that was such a big integral part of potentially why she was dealing with more pain. She had more swelling. She was very restricted and locked up. And it’s because that little nuance of the surgery itself could actually affect things on the post-op side.

This is something that I think is important and it’s come from just having conversations with the ACLers where they’re just like, I don’t really know, or maybe, we thought we had everything and then we kind of dive in a little bit deeper because they’re still having problems with a range of motion or getting their quads going. And then we start to realize, Oh, there was something in their history or in the injury that was potentially impacting those things. And we’re able to connect the dots. It’s all detective work and knowing that history in detail will help a ton. 

I hope that this is helpful, guys. As you know, it’s all about being your own advocate in this process, know the story, know the details, know what’s being done, and then know what your game plan looks like. That’s what’s going to be key here because you cannot leave it up to anybody else but yourself, to be able to guide you and to understand that you’re going to take care of yourself. But then obviously having someone alongside you who is a good guide and an expert in this space. That is going to be the golden combo for you to be able to progress forward.

If you guys have any questions, you know where to find us. Thank you all so much for listening. This is your host Ravi Patel, signing off.