Episode 141 | Should You Wait 2 Weeks For PT After ACL Surgery?

What is up team, and welcome back to another episode on the ACL Athlete Podcast. Today, we are diving into, should you wait two weeks for PT after surgery? But before we dive into that, first, I just want to say thank you to all the rehab professionals, clinicians, and coaches, for their support for the ACL athlete. If you followed along two episodes ago, we announced that we were launching the mentorship. And we did launch it with 12 spots and they were filled within a few hours, which we are just honored in all honesty. We’re so appreciative that you guys would trust us. I and the team are super excited about this mentorship and it is just the start. And we are focused on not only being able to serve our ACLers but the entire community of clinicians, and coaches. 

The goal is, how can we push this forward? How can we impact as many people, as many ACLers as possible? At the end of the day, we know that we can help directly the ACLers, but we could also help the clinicians, coaches, the professionals who are working with these people and there’s a force multiplier effect. If that one physical therapist works with 20 ACLs. And let’s say there are 10 people who take this, that’s 200 ACLs off the bat that we are able to help in addition to our mission of working one-on-one with others.

We are super pumped. Thank you so much. And we have so much planned for this cohort and other cohorts to come. While there is education around the clinical side of things, there will be so much for you ACLers or any of you who are listening. Even this podcast episode is dedicated to you as the majority of them. We appreciate all the support and let’s just keep rolling. 

Now on to today’s topic: Should you wait two weeks for physical therapy, or physio after surgery? If you’ve been listening to this podcast, you likely know what I’m going to say and what my advice on this is. And if you’re looking for additional episodes to supplement this, we covered post-op physical therapy in episodes 52 and 66, check those out. 

But today, I wanted to directly answer this question. And why it is, is because usually a lot of these podcast episodes stem from gaps that exist in this space, or questions I get, or just ideas in conversations. This is a big one that I think is honestly a big misnomer. I think post-op physical therapy for ACL in general, is a misnomer, people assume is basic, and straightforward, and to some degree, you’re constrained by the injury or the surgery, I get it. But at the same time, man, you’re building the foundation. And I think there’s a lot of opinions about when to start, what to do. I think our normal rational brain thinks, “Oh, I’ve had surgery, let me rest.” The surgeon’s recommendations will dictate a lot of this in all honesty the route you go.

Today, I just wanted to tackle this because the biggest problem I’ve been hearing lately is with ACLers reaching out, telling me that their surgeon or ortho has told them to wait a week or two to start their physical therapy. And for some of the reasons given, these two exercises at home are all that you need. Another person had said, PT can bust open the stitches. What? It can risk infection. It can mess up the surgery. And look, I get some of these, and it’s also probably because maybe they had someone who went to physical therapy too early, and the physical therapist wasn’t equipped. You get a new grad and you’re their first ACL, guess what, they’re going to be worried and panicking because the last thing they want to deal with is a post-op ACL. Or maybe their PT has set in their ways, or they just didn’t pay attention. There’s a lot of factors that play into the experience, so maybe the physical therapist did a bad job and something happened like busting open the stitches, or maybe someone did get infected, or maybe the graft something happened. But in most situations, this is not going to happen. You’re going to have a trained licensed medical professional who is helping you. There are those one-off bad apples or instances that happen. 

I’ve had someone who’s gotten an infection. But who’s to say how they got it? There’s no way to really know because you’re not with the person day in and day out. This person didn’t have the best hygiene, but it could also just been a luck thing. With this said, that is something that can happen. But it shouldn’t be necessarily this blanket statement that I think sometimes these people get or these surgeons just give these ACLers just to be able to protect the surgery. And I get that. Don’t get me wrong. But I think that it is actually doing more harm than good in a lot of these situations. Because a lot of times what can happen is that this just creates a lot of issues postop. After you have surgery, a lot of times they will give you this sheet of paper that are some basic postop exercises like quad sets, heel slides, straight leg raises, on that sheet of paper and think that it’s good enough.

Some of those things are good to get started. But I honestly think this is the wrong approach with ACL surgery. I truly do. If we can fix some of these things that fall through the cracks and assumptions that are made that people are good enough with what they get, we could probably resolve a lot of postop issues if we were to get in front of even just this delay or even eliminating this sheet of paper. Guess what? If you did prehab, you could have potentially eliminated any of these worries. But not everyone in our system promotes that. If you’re having surgery and it’s coming up, or maybe your insurance is limited, then you might have to go straight into it. And that’s what most people do.

Most people don’t go to the prehab course. They end up getting scheduled for surgery and then next. After that, they’re going to start their postop process. Getting back to this two weeks should you wait or there’s a recommendation of seeing your physical therapist or starting physical therapy after two weeks, let’s even say a week, right? This is because they have been guided by their surgeon and ortho to do this. Here’s where they run into a few problems. These are the same athletes who reach out saying they have a lot of pain, a lot of swelling, a lot of stiffness, and lack of range of motion, those quad activation issues, limping later on, and not to mention fear associated. It all makes sense, right? You’re postop. And these things come with the territory. You just had a major surgery. It’s not like these shouldn’t exist, but everything’s on a scale: low, medium, high. 

And sometimes it just becomes really excessive when it could have been prevented by just good guidance and education and understanding what they need to do postop to start building that foundation immediately. This is what can happen with those people in terms of just like their progression postop within that two weeks if they have no real guidance besides a sheet of paper and maybe a check-in with the surgeon or maybe it’s a call just to make sure everything’s cruising. Of course, things are fine, but you’re just like, oh, well, maybe this is just normal a part of the postop process. But again, it’s a spectrum. And a lot of times we can get in front of these pieces. 

Another problem is, let’s say that these same people wait two weeks for the follow-up with the surgeon, and then they get the green light to schedule their physical therapy session. Well, we’ve been two weeks, and we don’t really account for the lag time between these sessions and check-ins and whatnot. It ends up dragging out a lot further. PT clinics are usually pretty busy because there’s a lot of people with pain and injuries. It’s very rare for them to be empty or low volume. Another thing, especially if you’re in the U.S., towards the end of the year, they get even busier, way busier because people have met their deductibles. People are trying to maximize as many visits as they can. A side note, if you are someone in the back half of the year, especially in quarter four, you’re going to be busier at a PT clinic. You got to get that stuff scheduled and locked in. 

But let’s just say you’re going that route, you checked in with your surgeon two weeks later, they said to schedule the PT. And then the other thing you might run into is that you might also have an additional one to three weeks of waiting to get in because the physical therapist is backed up. Their schedule is booked for the next one week, two weeks, three weeks. And with each day postop, there is an opportunity cost. It might not seem like much, and you might be thinking how hard is it to straighten and bend it and just squeeze my quad. I’m supposed to be laid up for surgery anyway. That is not truly the case. I think that’s the biggest thing that I want to make sure I make clear here. Is that with every single day that you don’t get into physical therapy or have the guidance and the right support — it could be remote, it could be in person. This is something that will play into your recovery. And you won’t notice that until you’re further down the road. This is where hindsight really meets reality, is like “Alright, you don’t really know what you don’t know.” But then also the thing is, is that once you’re four weeks out, six weeks out, let’s say you want to start running at three or four months and your surgeon said so. But you didn’t get into physical therapy until four to five weeks.

Do you think you’re going to make enough ground to be able to cover that much to start running? Likely no. And so this is just something that I want to make sure that you guys walk away understanding the clear answer of this, which is, should you wait two weeks after surgery to go to your physical therapy? My answer is no. It’s a hard no. And only times where I see physical therapy might need to be delayed after postop is if you have very few insurance visits and you’re really trying to spread those things out. You’ve discussed it with your physical therapist because you did prehab with them and you got that stuff locked in so maybe you don’t need to go in immediately a few days postop. Or, maybe you had some massive multi-ligament reconstruction. But it’s likely that this does not apply to 95% of you unless you’re in a huge traumatic incident. There is a very rare situation where you tear multiple ligaments within the knee. 

Now, let me share with you guys why you should get in ASAP. I love seeing athletes the closest to surgery possible. That is my rule of thumb. We get things rolling. And it’s so helpful for them and it’s so helpful for starting our work and the postop process. You literally just had a major reconstructive surgery, you’re in pain, and you’re terrified to move the leg. I remember all of this with my two ACLs. It was super scary. I was in pain. I thought I was going to tear the graft. Anytime I moved it or felt something, you’re scared you’re going to mess up the surgery or pop something, especially if you start working on flexion. That knee is swollen, it’s painful, it’s stiff, and the thing you’re going to feel is like, am I stretching this graft? When in reality, you’re not. It’s actually just because the knee is swollen up like a balloon. It’s creating more and more pressure within that joint. But it’s normal to feel all this. Every single one of you who has had surgery listening to this, or you’re going into surgery, just expect that that’s normal.

There’s so much fear in seeing and working with a trained healthcare professional will help ease even just that aspect. The mental side of just knowing like, hey, I’m okay. I gotta do something really bad to mess this surgery up. And that’s super helpful if you are able to work with your physical therapist immediately postop. 

From the physical side, you will also be assisted on movements you need to do from a range of motion to quad activation to gait training, doing movements correctly and knowing what’s normal to feel versus not, education on what to push into and focus on goal wise versus just don’t worry about that. And then from there, you’re able to transfer all of that education, information, doing the things appropriately and doing that at home. Since there’s so much frequency in the early postop phase, you’re able to just go home with peace or be able to operate from home knowing you have that guidance, the right game plan, and you’re not gonna mess anything up.

And then, therefore, you can get working on the uninjured side along with keeping conditioning up so you don’t drop significantly. It might not seem like much. But I will tell you time and time again, the people who do this from the front end and are proactive and who are going on this journey, I promise you they have better results than the people who delay this or don’t take the postop process seriously.

The last thing that I want to touch on in this episode is just calling out the gap that exists. And I’m just calling it as I see it. I told you guys from the beginning, my goal is transparency here. Give you the reality of this space, not the sugar-coated, “Oh, like, let’s hope that everything works out.” No, this is the reality of the space. I fell into the cracks of it. And I want to make sure that you guys are not doing that. 

Here’s the gap — a surgeon will do the surgery and potentially give the ridiculous one to two-week restriction for not going to physical therapy. There’s typically a follow-up to see them in that one to two-week window, so you haven’t started physical therapy yet because they want to see you first. In most cases, it’s just a check-in to see the wounds and make sure things are fine. If you have stitches, they might remove stitches. Then they give you the green light and the permission to start your physical therapy. 

What they miss, and here’s the gap, is that they’re in their own little world. They are the people who are like, alright, the surgery’s good. That looks good from our standpoint of looking at it. Now go and do your thing with the physical therapy. Now some clinics and surgeons’ offices are combined. And there’s plenty that are also not combined and the majority of the time they’re not. They are a different company that you’re going to go probably local to you to go and do your physical therapy, or whether you’re remote, it doesn’t matter, your geography, right?

So with that said, though, they are going to give you that green light, but there’s a lag in time that I want to call out and make sure you guys understand. They don’t think about the timing of what might impact you in getting into your physical therapy clinic to start rehab. Next thing you know, it’s three to four weeks postop and you have your first PT appointment. That could be the difference in you getting your knee to 90 degrees, zero degrees extension, and one crutch versus there are some ACLers I’ve worked with, they’re off crutches with a normal gait, full range of motion, and crushing it in the gym. Some of these can easily happen in that first week and then there’s a potential blame game later if someone doesn’t get the range of motion or dealing with some issue and it might be blamed on you or your rehab versus not my surgery.

My surgery was fine, we checked it, and we did everything we needed to do. And don’t forget guys, this is a team effort. It should be a team-based approach. But maybe some of it was because the timing wasn’t optimized for things early postop. And I don’t think there’s much thought given to this entire comprehensive process, and it is a little bit more like silo-based care. I do my job, then whatever you do after that is fine. Just find a physical therapist, and do your rehab. 

But in reality, this should be that team-based approach as I had mentioned. And seeing it as this journey working together as the GPS versus these silos to get you to one checkpoint versus the other. Now, I know I’m talking about ideal here. And there are plenty of situations that exist. But as I stand today, after fielding hundreds of calls and consultations with ACLers, being in this myself, talking with other professionals, whether that’s surgeons or other physical therapists, this is what exists currently today.

In the U. S. and all around the world, these are the ways that the healthcare systems work. If you are an ACLer, your goal is to get in ASAP and get into physical therapy ASAP. I haven’t found a good enough reason why you would wait, in all honesty. Sure, the post-op process might seem basic, like I said, and straightforward. But man, those who really do it right, and get in front of it, and get those postop goals, get that knee quiet, get that hyperextension back, get the knee flexion rolling, getting the pain and swelling down, being able to get your gait normalized, not getting off of crutches too fast, being able to get your quads really active and rolling.

Protecting that potential donor site, being able to minimize your deconditioning and really making sure that that drop in your overall fitness level doesn’t drop too much — game changer! And that starts from postop, not in three months, not in four months, not in five months, it starts postop. And I promise you these same people who do get in front of it, are the same ones to crush this process and not have as many setbacks.

Don’t let the system suck you in. You have to be your own advocate as I’ve said so many times. If you’re listening to this, I’m giving you permission to schedule with your prehab provider. If your surgeon and ortho recommend not to, ask why. And if it’s a very concrete and solid answer, then great. But if it is not, if it is just like, hey, just wait two weeks and go, please schedule your physical therapy either right after that or in all honesty, schedule it as soon as possible. It will do you much benefit to do that, I promise. And these are the differences between those ACLers who really do crush it and have peace of mind, versus those who have a ton of setbacks and have a lot of problems later down the road.

Be skeptical, guys. Ask questions. Be your own advocate. The ACL Athlete Team is here for you. If you have any questions, please reach out. Until next time, team, this is your host, Ravi Patel, signing off.