Episode 15 | Dealing with Pain in ACL Rehab – Part 2

What’s up guys, and welcome back to the ACL Athlete Podcast. Today we are talking part two of dealing with pain in acl rehab. If you haven’t listened to part one, go to the episode before this episode number 14, and listen to it. And don’t you dare listen to this episode without listening to part one.

First, it’s like m&ms or peanut butter and chocolate, or the Georgia Bulldogs and not winning championships. They just go together. So go listen to part one. We dive into some of the guiding principles and factors to consider with pain during this process. And honestly, it’s something that can translate to just more than just acl rehab or your knee you could be dealing with something else or someone else that you know, and these principles can still be very helpful, including this episode today, which is part two. We’re focusing on more of the tactical side and using even one of my ACL athlete cases as an example, so you can get a full picture of how to utilize this.

But before we get there. I get this question all the time and I just wanted to kind of talk about it because it’s related to pain, and people will often ask me how long till they’re gonna be pain free. When will my pain go away? Do I have to deal with this forever? And this is a very difficult question to answer.

And one of my friends, Nick Hannah, who is also a PT used a very good analogy that I like. It’s similar to weight loss. It’s very, very multifactor. It’s going to be dependent on factors such as your commitment, your consistency with what you’re doing. The time in general from the injury. There are so many different things that will play into managing the stress of it, your sleep, your recovery, the program you’re following, other activities outside of just the program.

There are a lot of things that play into it, which is why you just have to think about it as there’s no endpoint, you can get maybe a rough framework of it or an idea but it’s all going to really depend and you’re gonna have speed bumps along the way, especially if you’re going through that surgical process and you’re trying to rehab through this long-term plan.

As you’re stressing the knee, things are going to come up. It’s inevitable. And anyone who has gone through this process knows this. They’re like, why is my knee hurting? Well, you had it cut into, you had a new ACL put in. Even if you didn’t, you injured the knee and it is having to heal. So there are all these things that play into it.

It’s very hard to predict, but one thing that I would suggest is really committing to the process, setting those expectations, and having these principles in place to help guide you along with a good plan and a good coach to be alongside with you. 

Now remember, this process is not linear. . It’s not this perfect here’s point A, here is point B, and we’re just gonna get there without any issues. And that’s what I mean by those speed bumps. And so one of the things that I want you to think about is a graph, or like this image. And the two things that we’re focusing on is pain and your activity level. So, The amount of pain is your left or the vertical y axis, and on the bottom is time, which is that horizontal X axis.

So I want you to think about that. So one of the things that I have to highlight with a lot of my athletes because of the way that pain and your body works, is that. . Sure the goal is to aim for less pain, lower pain, so we can move forward and get back to what we want to be doing, especially training. But let’s say that pain wants to stick around. If that pain over time stays the same, but you see that line of activity increasing going up, that’s a win. If you start to see that pain start to increase with that, then we gotta change things. But if you notice that pain stays steady, even if it’s at that low, like two or three level, when you’re doing stuff and you’re continuing to build in, maybe you’re increasing more mileage, maybe you’re doing more repetitions, more movements, more dynamic stuff, and that pain still kind of stays lower. That’s still a win in the right direction. 

Now the end goal is to hopefully at least get towards a very low level to zero but making sure that that’s going in the right direction. So maybe you’re going through this process, take a little bit of a step back, am I increasing my activity and my pain staying lower? That’s good. If it’s not, then it might be time to readdress some things. Maybe take a step back so you can take two steps forward as we talked about in the last episode. But just some things to think about as you’re going through this process 

Now into more of the fun stuff. Five ways to train around pain is how we’re gonna start this. And I think that these principles are going to be important and they’re really helpful to be able to modify movements, continue to train at a higher intensity without having to completely abandon ship. And a lot of times what will happen is people will say, okay, we’ll just rest. But during that rest time, you might feel like you’re de training, which is actually happening. You might lose some conditioning, you might lose some strength. So instead, what if we just kind of change some things and modify to make sure we’re still getting some changes that we want, but with less pain? 

So there are two different approaches that people will take sometimes. One is called a top down compared to the bottoms up approach. And what I mean by top down is that we start with where you’re at and we just take one step before that. So if you have pain with a front squat, for example, maybe we just decrease the weight a little bit or maybe we decrease the range of motion. We still keep the same stimulus, but we might modify it in a sense.

But we’re still getting that same adaptation we want. Instead of the bottom up approach might be, oh, well you have pain with squats. Let’s stop everything and do some quad sets or some band terminal knee extensions. While that stuff can be good and fine and feel good, you still are not gonna get stronger unless you start to load that muscle with adequate weight and load. 

So that’s where, for me, one of my guiding philosophies and principles is always a top-down approach to make sure we can maintain the stimulus that we want. Now I’m gonna give you an overview of these five different ways, which are weight, range, tempo, variation, and different exercises. So we’ll go through each of these so you have a little bit of context to each one, but the main goal here is that I want you to take away is that you want to make the least changes possible to the movement, and it’s going to depend on each person, depending on the pain you’re dealing with whether it was something that was from a specific instance or maybe it was gradual.

Again, all those factors matter here, but I’m just gonna give you some strategies to think about. That way you don’t just kind of jump ship and have to rest. Instead, it’s like, okay, let’s keep going with what we’re doing. Let’s just modify it.

 So the first one is weight. And this could be as simple as decreasing the weight. So let’s say for example, your knee pain starts when you hit 185 pounds in a front squat, but you might not feel that at 165 or 155. Maybe just dial it back and work at 155 and then build that back up. You don’t need to back all the way to air squats or anything like that. If 155 feels fine. 

The next one is range. So changing or decreasing the range of motion. So instead of going that full range of motion, maybe it’s just going half of that distance or three quarters. So your knee pain occurs at the bottom position of your front squat. Limit your depth to maybe three quarters of the range.

Tempo. This is one of the things that I believe is incredibly, incredibly underutilized. In training, just in general, we just kind of go through the motions. We might load it up. You do a squat and you go down and you bounce right back up. Tempo is one of those things where we can utilize this principle called time under tension, where we’re loading the muscles. And I also think that it allows us to better own that range. It makes us focus on actually using the muscles instead of having to focus on momentum in these different positions. So, tempo is really great. There’s the lower, there’s the isometric hold position or where that transitions from the lower to going back up which would be the concentric phase. So these are things that can be manipulated.

And so let’s say for example, knee pain only occurs at 90 degrees. You can try to utilize some isometric holds at that. And see if that makes it feel better. You could do a 3, 2, 3 count where you go three seconds down, pause for two seconds, three seconds back up. The options are endless here and it could be a way for you to be able to figure out, okay, within this kind of range, I feel some pain. So maybe I just train above that and add a little bit of tempo to still get more outta the exercise.

Variation is another different example. So for example, you can use a different variation of the specific movement, so you still might be training the specific pattern still. So for this example, let’s, since we’re rolling with squat variations we’re gonna use a squat example of that specific pattern. 

So, We might just be changing where the load or the stress is being placed. For example, a front squat brings pain to your knee, but then trying a back squat or a box squat, a goblet squat, zercher squat, it’s still everything that we’re trying to get in terms of the stimulus. It may shift the load a little bit, but we’re still getting that pattern that we want.

And lastly, we’re looking at number five, which is a different exercise. So try a completely different exercise to help get the same training stimulus for that muscle. For example, instead of a squat variation, which we talked about in number four, switching the variation, this is a different exercise.

So for that squat, instead, our goal is to train the quadricep, for example. So that’s that front thigh muscle. So maybe we do a seated knee extension or a step up or a lunge variation. So these are just things that you can think about that can really help to still get a similar stimulus that we’re looking for and that way we can continue to train around that pain that you’re feeling.

Now, here’s the overall concept. Pain comes on. And again, this varies person to person. You scale back the movement slightly based on one or more of the principles that we had just discussed. You train that movement. You adapt to it, you continue to progress the difficulty, adapt to it, give it some time, and then hopefully you are at least back to the prior level, and then you continue training and progressing.

You use this as a small little setback, if you will, or bump in the road and then you learn how to really pivot and navigate that process instead of having to take such a big step back or stopping and then having to pick back up. Now we’re gonna go through a case example for one of my ACL athletes that I’ve been working through their ACL rehab and we’ve been working remotely. And we’re gonna try and combine some of these things that I’ve talked about and then also his specific case and see how this all connects together and how it was utilized. 

So he came to me four months post-op, ACL reconstruction after being somewhere else doing rehab where he was not necessarily getting the results he wanted, especially being four months out. He had a patellar tendon graft. And one of the main complaints that he had was that he had pain at that patellar tendon site where the graft was taken and a lot of movements would really aggravate the knee. And he was really plateaued, and wasn’t really seeing progress. Pain started getting in the way, and so we started working remotely together to try and see if we can make some changes.

Now, whenever I talked to him, we talked about the details of the pain itself, you know, when, what, how, all those things that are important to get information about. And then we’re like a detective, figuring out how we can trace it back and what we can do to make a game plan going forward. So we realized that he was not getting appropriate loading.

He was four months out and still doing straight leg raises and quad sets. Oh my God, don’t get me started. So anyways, that was one of the big issues.He was essentially being under loaded. When we tested out his squat and some other movements, he would go up on his toes a lot and he would end up really driving his knee forward. And that would create a lot of issues. And he was just kind of in a pretty bad flare up at the front of the knee.

So we had to figure out, based on the information that we had assessed and some of the baseline testing we did, we found a starting point. We knew that the front of his knee was pretty aggravated. So as I mentioned in the previous podcast, we had to almost calm things down first before we could move forward with stressing it a lot.

So it’s in this protection mode. So let’s see what we can do to help mitigate some of these symptoms. So we created a plan. We used the three out of 10 that I talked about in the last podcast as the guide for, okay, if this exercise hits a three out of 10, it’s okay. And then let’s just kind of see how it feels in 24 hours.

That’s our feedback loop for the symptoms. If it’s at the same place. We’re okay. If it’s less, then that’s even better. If it’s a lot more, then we need to continue to shift and change. So at first what we programmed was starting with some goblet squats to full depth. And just to give you an idea of what this exercise is, for those of you who can’t picture it, it’s holding a kettlebell at your chest, and then you’re squatting down into full depth and then coming back.

So that would cause him some pain with 25 pounds. So we had lightened it up and that still was not working too well. So what we ended up doing was actually changing the depth. So we actually got him a target, which was a bench, and he just squatted to the bench and back up and did not feel very much pain.

So we are in a good spot. So we not only changed the weight to a lighter load, we also changed the range or the depth to which he was going to, to work with the pain that he was dealing with that patellar tendon. And then we looked at some of his accessory work and we built in some knee extension isometrics.

So that’s where you’re just kind of kicking into a band up to a resistance where that pain really sat at a three, four out of 10. And that’s how he would engage for a specific amount of time. And then we added some wall sits in for some other isometrics. And the reason I harp on isometrics, which will be a podcast in and of itself, but isometrics can have some benefit to managing some pain, especially from a tendon standpoint. So we introduce that to help still load that area. But also not have to go through that full range in case that’s what’s aggravating it. 

And so the other thing that we looked at was split squats. So instead of split squats where he would go up onto his toes, really drive his knee forward. We had to back off of that and we ended up focusing a little bit more on a vertical shin initially because that stressed his tendon less and he also noticed a lot less pain.

So that’s a good way to continue loading it without having to focus on completely shifting because. A split squat is a very valuable movement and a vertical shin will help. We also added a slower tempo to be able to control the range more. He can also dial in and see, is that pain getting worse, and if so, we just kind of manage the depth or that position.

And then we added some other accessory work like a Spanish squat. A Spanish squat for people who can’t visualize this, you take a band, anchor it to a stable vertical bar. A lot of people will do this on a squat rack, and you’ll take this big band and you’ll hook both legs into it, and then it’ll allow you to just kind of lean back with gravity and your own weight and be able to just keep your shin very vertical. And another way to think about this is you’re sitting back in a chair, your shins are completely vertical, and then you’re just sitting back and trusting and knowing that that’s there. It’s a repetitive movement that helps work the quads.

Anyways, with that, we implemented it because it’s a good way to work the quads without stressing that patellar tendon as much. So he found it very helpful and it was a way for us to incorporate a different exercise that was still getting a very similar stimulus that we wanted.

With changing all of this stuff up, we still use that three out of ten pain guideline and that feedback loop of 24 hours. And as that improved, we also changed the exercises and we progressed them. So going back to the same things, the goblet squats turned into lower depth as he started to tolerate it more to a med ball, and then we took it away.

And then we progressed him to a front squat, to full depth. And for the isometric knee extensions, we actually started adding more movement into that and loading it. Whether that was into the 40 to 90 degree range or we went through full range as soon as he was comfortable with it, cuz that’s the best way to load our quads.

And then for the split squats, we kind of changed how we loaded it. So instead of that vertical shin, we just shifted the weight forward. So imagine keeping your foot flat and you’re into that bottom split squat lunge position, and your knee is touching a foam roller that is a few inches in front of your foot.

That’s a way for us to reinforce getting that knee forward without having to focus on a vertical shin and still getting the adaptation that we want, which is knees forward, making sure that we’re safe in that position. 

So now let’s look back at what we did and see what the principles were that we changed.

So for the pain with goblet squats, we lowered the weight and then we changed the range to a box, which he was comfortable doing, and then we progressed. Tempo. We slowed it down to help control that range. Getting more time under tension. We changed the variation instead of the knee extension, isometric, we ended up progressing from that to knee extensions and then a different exercise.

We used a Spanish squat to still work the quads in a very similar way without stressing that tendon as much. These are different ways to use these principles, but remember that you are different. Your situation is different, but you can still utilize these. But I would highly recommend working with a professional that knows how to do this so you can take that guesswork out of the process and just make sure that you can trust them and that they’re guiding you in the right direction, and that there’s always a way to pivot and change as you need to. That’s where you know you have a good coach and helping guide you on your ACL journey. 

So in review, pain is like weight loss, very multifactorial. It’s non-linear. If your pain is staying the same or getting lower, but especially if your activity is increasing during that time, still take that as a win.

I talked about five different ways to train around pain. We used weight range, tempo, variation, and even a different exercise. All different strategies that can be used individually or together. A lot of the time, I use them together. There’s not a single athlete that I’ve worked with who has not seen tempo work. They hate it, but they’re better for it and they always thank me later…sometimes.

We walked through a case example with an athlete of mine who was dealing with patellar tendon pain. That was their donor site and they were also four months post-op ACL with significant underloading, and so we had to find an entry point for them to continue to get the stimulus that they wanted, get training progress in their rehab while managing a very flared up patellar tendon.

And now he is crushing it. He’s jumping, running, cutting, sprinting. So it’s been really cool to see where he started and where he’s come. And a lot of that is due to the work that he’s put in, in a very strategic plan that we’ve built for him.

So I hope that was helpful guys. I wanted to bring on this live example because I think it’s really important that you get actual scenarios that make sense, and that could be related to a situation you’re going through and these principles that you can really use for life.

So if you guys have any questions, please don’t hesitate to reach out on Instagram or Facebook or my email Ravi@theaclathlete.com. Please send me a message. I would love to hear from you, learn how you’re using some of these strategies, or if you just have something to share with me, I’d love to hear from you.

So that’s it for today, guys. Thank you all so much for enduring another 24, 25 minute episode. I promise they’ll get shorter because no one wants a long episode. As always, everyone, thank you all so much for listening to the ACL Athlete Podcast. This is your host, Ravi Patel, signing off.