Episode 151 | Why Offloading is Important for Post-Op ACL

Show Notes:

In this episode, we discuss the importance of offloading after an ACL injury or surgery. We dive into this concept and how it applies to a knee that’s been through a lot, the healing process, and a practical approach to make sure you’re not limping or dealing with grumpy knee later on.

What is up team and welcome back to another episode on the ACL Athlete Podcast. Today, we are discussing why offloading is important for post-op ACL. This is something that will actually apply to post-op ACL surgery or even post-injury. This is something that we’ll have a little bit more application for the surgical process because there had been two essential injuries to the joint, but this applies to both. You can take this if you are someone who is post-injury or for post-op. 

Offloading is something where you can essentially assume we are taking weight off the injured or that surgical leg. This is where we were trying to essentially offload that leg to be able to allow for many things that we will discuss. So if you’re standing normally on your feet with no injury or surgery, for example, you’re likely putting 50% of your weight into each leg to equal 50% of your body weight into the ground. So why is offloading important for post-op ACL or post-injury? And so we’ll usually after both the injury and surgery, you’re given some type of weight-bearing guideline, usually after surgery is very specific. This might be something where it’s weight-bearing as tolerated, or you might see it written as WBT, that’s weight-bearing as tolerated. Basically, weight-bearing, as you can tolerate or it’s maybe partial or toe-touch weight-bearing or the other one you’ll see is non-weightbearing (NWB). And that is something where you’re putting no weight on the leg. These are our three buckets that people will fall into, especially post-surgery as their guidance for putting weight on their leg. With most people probably fall into weight-bearing as tolerated. There used to be a lot more non-weightbearing guidelines after surgery. But as time went on, surgeons started to adopt allowing athletes to put more weight on it as soon as the surgery happened, which is great. I think that that is the thing that we need to move towards more. 

The only caveat here is if it’s a complex surgery or injury or if it’s something where potentially you had a meniscus. Then surgeons will often create some sort of non-weightbearing restriction for a certain amount of time. We usually see this between two to six weeks. It could be weight-bearing as tolerated. But a lot of times we will see on average something like four weeks where someone is non-weightbearing or maybe those first two weeks they’re non-weight bearing, and then gradually they’re able to put weight on their foot. Essentially, this will vary based on what the restrictions you are given after your surgery. But what we will often see a majority of the time athletes will be weight-bearing as tolerated. And the thing that will happen with this is that you might have your physical therapy early. And then therefore you have some guidelines around that, of like what that truly means. And usually, people are a little bit apprehensive to do that post-surgery because they’re worried about the knee. Is there going to be anything wrong with it? Just know that that surgical process is locked in and it is not going on anywhere unless you do something really dumb. Weight-bearing as tolerated is usually fine, but that’s why it says as tolerated because you need to be able to build up a tolerance to it and can’t go hot out of the gate. 

One, you’re maybe locked in a brace. Two is that your range of motion is not necessarily there immediately post-op. You’re starting to get your muscles a little bit more active and then obviously going through and putting weight through that leg, that’s creating compression at that joint, nothing bad. But it’s something that is going to create stress on different structures. And so then therefore we got to make sure that we are progressing appropriately. 

What we will see with this typical guidance or restriction with weight-bearing as tolerated post-surgery is that people will progress too quickly and they want to get off the crutches. And I know I’ve talked about this before, but it’s something that we commonly see and I want to touch on this. And the importance of why offloading or why the crutches are given to you. And what happens is that people rush off of this which leads to the joint and the knee getting grumpy. And it’ll have some increased swelling and pain in many cases when it is rushed. This is accompanied by some limping or skipping, some range of motion through the gait cycle, especially something like extension. 

Now we’re not saying here in terms of this,  to offload and to just completely not let the leg come down or being able to go full weight-bearing immediately and as quickly as possible. We’re not saying do one end or the other on the spectrum. What we’re saying here is that we want to make sure that we appropriately and progressively offload. And why is it helpful? Well, you’ve just had a joint that’s had a fairly traumatic injury, especially if it’s recently and then you have surgery. There’s another traumatic injury in a sense. It is a lot for the knee. It is something that is putting it through stress. Our body is going through this natural healing process post-injury and then even post-surgery. This is something that it does with any type of injury. But especially when you have something like an ACL tear, maybe there’s a meniscus, maybe there’s bone bruising, maybe there’s a fracture, maybe there’s an MCL sprain, there are a lot of things that can play into the injury itself. And then we got to go in and we got to do surgery. 

When you add more to it like incisions, cleaning up scar tissue, or just like tissue that doesn’t need to be there anymore. The residual ACL that’s there, the stumps taking a graft potentially from somewhere on your body, like your quad, hamstring or patellar tendon. Drilling some tunnels, anchoring some screws, repairing potentially some other areas such as ligaments, meniscus. The knee might be a little pissed and it might freak out a little bit and that’s normal. This is just the name of the game with an injury like this and especially with having surgery. It’s that kind of two-step process, which most people will go through. You’ll have the injury and then eventually you’ll have the surgery. If you do, then that’s what you’re looking at. You just got to view it this way. It’s not just this brand new knee that you can magically just kind of do as much as you want on it. You have to respect the healing process. What will happen is, especially early after that surgery or after the injury, you’re going to have an inflammatory process that is spiked up. The knee is like what’s going on? It’s starting to do that healing process. And that inflammatory process is usually where you are at that point. And that’s going to be accompanied by swelling and pain.

Pain is there because you had an insult to the joint and different structures. It’s also there to kind of create a little bit of a warning, like a yellow and red light to be like, Hey, like, don’t move this because we are trying to heal this thing up and you might injure it further.  It’s always a dance between of figuring out what pain you want to work through and not. We have our feedback loops and if you want to look into that, we have episodes around navigating pain you can look at our traffic light system and our 24-hour feedback loop to help with this. The biggest thing here is that we want to bring down the sharpness in our pain. And then it should move towards kind of dullish pain and then become a little bit more predictable the further away from surgery and injury you get.

Swelling is also one of the things that is the bane of our existence because it can play against us a lot. The knee feels full. It can impact the range of motion. It can impact the quad activating. When we are post-op, this inflammatory process kicks in. Swelling and pain is there. All this stuff is normal.

Offloading the joint via crutches can help to facilitate this inflammatory process. And it can allow us to protect the joint and allow us to start this healing process and this healing phase. This doesn’t mean that you just don’t do anything and this doesn’t mean you do everything right. You don’t want the pendulum on one side or the other. You want to find the sweet spot. And this is where your physical therapist plays a big role. You want to make sure you can find that sweet spot. The way we do that to some degree is by being able to make sure that we have certain goals we’re working through and having those feedback loops, especially with knowing what is a green light for you to do, what is a yellow light for you to do, and what is maybe a red light. Let’s not step into that just yet. 

This is something that will be really key. And this immediate offloading that we do in terms of the post-surgical process is going to help with protection and healing, is going to allow us to make sure that joint is minimally stressed. That’s why we’re offloading it. We’re allowing it to do its job in that acute phase to be able to make sure that… especially in those first one to two weeks, we are giving its space and its time. When we rush to get off crutches and are loading that joint too much without the appropriate progression, this can flare that knee up and can cause some swelling and pain to stick around for longer than it should. 

And I’m sure some of you listening here are maybe past this point. And it’s something where maybe you did have some swelling and pain stick around and you rush off the crutches and you’re dealing with potentially some limping or maybe just the knee is like really stiff. And you’re dealing with kind of some of these issues. I would be curious to hear whether you got the crutches appropriately, or you just kind of ditched them and then you’re like, I’m good enough. In this case, we want to make sure that we just don’t get off of them too quickly. This can cause that pain and swelling to really stick around and we don’t want that. That’s going to play against our quad activation, especially arthrogenic muscle inhibition is a big connection with swelling being present. And then we want to make sure that we can also develop strength again, swelling and pain playing against that. 

The same concept applies to something like step count. Anything that creates stress on the joint itself, a slow gradual progression is essentially us going from offloaded towards loading progressively week over week, day over day, to make sure that the knee and the body is tolerating the stress that is being placed on it versus really trying to ramp back up with a high step count. This can be something that plays against you as well because you’re almost overloading that joint too much by creating too many steps. Next thing you know you got an unhappy knee and then that is going to make swelling probably stick around and maybe the knees swell up a little bit more. We see this a lot with our people who have to get back to work which we understand. 

Let’s say they’re on their feet a lot, like a teacher. We’ve seen this where it can just be hard for that swelling to get out because they are vertical so much. Versus our remote athletes, they’re just chilling. They might be able to prop up their leg, but not as many step counts. And while we don’t want you to decondition or be a couch potato, we also don’t want you to be using “steps” as your conditioning with early post-op. That can play against you because again, we want to manage the stress and the load in the knee, and walking and step count is not your best friend in the early post-op phases because that knee is trying to settle down and heal. And so that’s why I’m emphasizing so much why offloading can be valuable or why it can be helpful to progressively build that up during this process because it’s going to help. We’re making sure that the knee is happy. It’s able to comply with what you’re stressing it with and make sure that is all gradual like a dimmer switch, never an on-and-off process. I use the dimmer switch so much. This is something that applies so well, especially going from a weight-bearing as tolerated. This is where it plays into our process of making sure we practically apply this. 

But before we talk about this, I want to talk about protocols and the guidelines given for this. So usually you’ll be given a certain timeline, in a week you should start doing X; in two weeks, you should start doing this. There’s so much variability. I’ve seen it within a week. I’ve seen it within four weeks. There’s no clear indication. It’s just more so, have you met the requisites of being able to walk without your crutches? That’s the main thing. Do we have an adequate amount of extension, flexion? Is the knee settling down from a swelling and pain standpoint? Are your quads active? Can you do other movements that utilize controlling the quad to be able to showcase you can swing that leg through a gait cycle, like a straight leg raise even without a quad lag? Can you be able to roll into extension in a loaded position? Are you dealing with a lot of pain because that’s going to play against you? There are a lot of things that we want to make sure that we meet the criteria wise before we just let you get off to just walking without crutches. There’s no clear indication of this, and it will be a specific case to case which is why your provider is going to be so key to help with this. 

Practically, how can this apply to you as you’re listening to this? If you’re post-injury or post-op, this will be dependent on your weight-bearing restrictions initially. Let’s say you are weight-bearing as tolerated and no other restrictions. You go from two crutches to one crutch to no crutch. If you have a brace, my opinion is to ditch that first, before your crutches. But of course, make sure your medical professionals have guided you with this and are okay with that. But a lot of times people will keep the brace and ditch their crutches, and then they’re just swinging their legs around and not able to roll through a normal gait cycle. Ditch the brace first, if possible. Stay on the crutches longer and take way, way more time than you think. If you notice your knee is getting grumpy or you’re limping, my suggestion is to regress back. Nothing sucks more than going from no crutch back to one crutch. But I promise you it’ll be so worth the investment of energy and time and who cares what other people think. But you want to make sure you have an assisted version to help offload the knee. That’s the name of the game here. If we kind of look at this from a zoomed-out perspective, we’re just trying to manage stress at the joint has been injured. There’s something that has just happened from a surgical perspective that has injured the knee again. We need to respect that first one, especially four weeks. If I could give you a range here to just know, like, alright, I gotta respect this. I can’t go overdrive. I can do nothing. Let me find the sweet spot with my rehab, but especially as I start to load the leg through the ground, especially putting weight into it, we want to gradually progress that like a dimmer switch. 

My suggestion here is to go from two crutch, crush it, and absolutely make it feel smooth and good, and then go towards one crutch. You should be doing gait cycles and gait training and mechanic work to be able to accompany all this stuff that you’re doing, to make sure your gait is normalized and then going eventually down to no crutch. But you want to kind of take it progressively because you’ll be able to know, all right, is my knee getting grumpy or not? The other thing to also consider with this is that how many steps or how often are you vertical in the day, which will impact that. You want to stay on crutches probably a little bit longer if you take a lot more steps because you’re at school or maybe your work. But if you are maybe someone who’s able to be a little bit more stationary for your day and less step count. Well, maybe you might be able to kind of progress on this a little bit faster. It just kinda depends on your case. I’ve seen the whole spectrum of this. But this is something that we want to factor in, especially with offloading post-op ACL. And I promise you, this will help you so much as you get towards running and all the other fun stuff. 

But I’ve seen this play against people where they come in. And they’re working with us three months post-op and they’ve been elsewhere. And they are still limping or they’re still dealing with swelling in pain. There is something where we asked them their history and they’re like, well, got off the crutches. They told us about how they injured the knee. They had surgery right after. It was a complicated knee injury, a complicated surgery, and then they were just off crutches in two weeks. It didn’t make sense because the joint was still healing and they showed no signs of being ready to be off of it. 

Use the dimmer switch here guys. Be able to offload as you need to, and it might be something that you have to revisit more than you think. But take longer on your crutches because I promise it will be such a game changer for you as you approach the early post-op phases. It’ll help to get you towards the next phase versus feeling like you’re “stuck” or you’re that person walking around with a limp because you just want to ditch your crutches. Don’t be that person. Make sure you do it right. 

If you need any help, you know where to find us. Until next time team, this is your host, Ravi Patel, signing off.

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