Episode 162 | Should You Push Through Pain in ACL Rehab?

What is up guys and welcome back to another episode on the ACL Athlete Podcast. We are on episode 162 — 162 weeks straight rolling — should you push through pain in ACL rehab? This is a question I get all the time from ACLers. 

I think there’s this typical work-hard stigma of no pain, no gain. I remember hearing this in high school and thinking, yeah, push harder, but it’s all within context. Sure as humans, you have to embrace some discomfort to grow, whether that’s mentally, physically, etc. I’d say this is better suited for people who aren’t going through an actual physical injury because the lines can get blurred here.

Now I want to provide some context here to help kind of set the stage for this episode. I got an email from an ACLer saying they’re eight weeks post-op and still dealing with pain and feeling like they just need to bear down and accept the pain and push through it. This can be especially true from what I see and hear from people who are further out in their ACL reconstructive process or post-surgery because they feel they should be further along. So then they start resorting to more aggressive options while it might not be the best for their situation. 

And then the other thing I want to mention here is that I got tagged in a bunch of Neymar’s videos. The one where he’s like just crying and cussing and screaming. It’s a video of his team working on his range of motion. I’m sure some of you listening have probably seen this. And the thing that sucks about this is it’s just a terrible example of how this process should look. And especially from one of the best soccer players in the world. 

Now, I don’t know his situation or case. No athlete should ever be held down and pushed through something like that for their rehab. It shares also the wrong message, especially when you think about our youth athletes, our teenagers and people going through this who are super young, who were like, man, this is the best player in the world. And maybe they really love him and this is what they’re doing. I have an ACL surgery, so maybe this is what I should be doing. 

So then they start bearing down and pushing through pain or having their friends or whoever rehab professionals really pushing down on them and grinding through it. When this is something that is not honestly healthy and could actually be counterintuitive, to being able to progress in this process. And so that’s where I want to answer this question. Should you push through pain in ACL rehab?

Now, this is not an easy question to answer because pain operates in the gray area. So there’s no black-and-white answer of: Should you push through pain? Yes. Should you push throughpain? No. It’s actually just kind of it depends. And we’re going to try and answer that as best as we can. But first thing is first we don’t need to demonize pain as bad. Just know it’s a normal response from our body, giving it to you for some reason.

Some people refer to it as an alarm. And the thing that I want to kind of press on you is could you imagine if we didn’t feel pain at all? On initial thought that sounds awesome. Don’t feel any discomfort. And especially as I’m getting older, I’m starting to feel things here or there. And so I’m like, oh, that sounds great. But what if you stepped on a nail you’d never know, and then it’d probably get infected, and then you probably have to lose your foot or something. Pain is good because it lets us know it’s kind of this alarm that lets us know something is going on and then we need to tend to it in some degree. Plus with ACL injury and surgery, you just had some major changes to the knee. That’s normal to feel the pain and is normal for that to be a bit heightened too. 

Now I’m going to bring this back around to say that there is a sweet spot in pushing through this pain. Can’t wait for the pain to be completely gone because you might be waiting really long time. You think about it. You had an ACL injury and then you had an ACL reconstruction. If you fall into this category, so you’ve had two major knee traumas. And for you to wait until the pain is completely gone, you would wait for a long time. Because when we think about just the healing process of our biology and how that works, it can range anywhere from two to four weeks to something major like this. You are looking at weeks and weeks and months. And if we talk about even the ligament or the ACL graft itself, man, that thing continues to turn into a ligament after a year up until two years, based on what we see through the ligamentization process when we look at the research. 

And so with that said, though, when we’re thinking about pain, we’re also thinking about that kind of initial acuteness of the surgery itself, where the injury. And so this is something that’s really normal and we will obviously want this to come down. But here’s where we’re going to kind of talk about pushing through pain and making sure that we find this sweet spot if you will. And so this is where we just want to make sure we just don’t go ham immediately after postop. 

I know from my aggressive athletes or who want to get on the move with it, they’re doing all the things nonstop. And you might be a no-pain, no-gain-type person. The thing that can happen though, is if you try to push through it, there can be this negative feedback loop that can be created. You’re feeling pain and maybe you’re like, all right, I’m sick of this. I’m just going to bear down and push through it. And so when you do that, the knee can react negatively by sending more pain and swelling. And then as a chain reaction to that, you have to back off because of the increase in pain and swelling. You’re kind of back in that same spot and you have to decide to send it again and then you repeat the cycle again. This is something that we commonly hear about and it’s not good. 

I know many ACLers we talked to find themselves in this kind of negative feedback loop, where they do push through that pain because they don’t feel like they’re moving as quickly as they should be, or they just want to be aggressive and push through it. Then yeah, they have that increase in swelling and pain or the knee reacts negatively. You have to almost like take a step back because the knee has reacted and you’re in pain and swelling. Therefore, you have no choice but to reduce what you are doing. And then you’re back to that kind of like that same baseline. So you’re almost one step forward, one step back, or sometimes it’s almost like one step forward, two steps back is probably what it feels like most of the time. It’s this kind of negative feedback loop that people can get stuck in this cycle. This is where we want to make sure we can find the sweet spot. This can be a little bit of a moving target, but think about it just like Goldilocks principle.

Goldilocks—they went to the house and tried to find the porridge that was not too hot, not too cold and it was just right. This does take a little bit of trial and error. The thing that always encourage my athletes and our athletes within the team to do is think about this and I’ve used this before, but I think it’s so helpful in this process, is thinking about the steak analogy. 

You got to steak, I’m sorry if you’re a vegetarian, but you probably know this regardless, is that when you cook a steak, there’s a certain temperature people like. There’s rare, medium, rare, medium, all the way to well done. The thing is that it can be tricky sometimes to figure out when a steak is done. This can go for a lot of general food baking, whatever it is. But the thing is, is that as you’re cooking the steak, if you had to lean one way or another, would you rather overcook the steak or undercook it? I’ll let you kind of think about that for a second. 

Likely you want to lean towards undercooking it. Why? Because if you overcook it, you’ve already sent it. You’ve ever cooked it. There’s no going back. There’s nothing you can do about it. You’ve ever done it. The steak is well done, well, well done. And that’s just where you’re at. You got to either go get a new steak or just eat the steak. But if you have an undercooked steak, guess what you get to check it. You can kind of check in and see how the template looks, and what the outside look. Just to make sure. And if you’re like, Hmm, I don’t think it’s to the right point yet. You’re just going to throw it back on the grill in the oven, on the cast iron, whatever, you’re cooking it on. And you’re just going to get it up to the right temperature.

The beauty is that you can adjust based on undercooking versus if you overcook it, you’ve already fully sent it and you just don’t really have any choice. The same thing here that I encourage my athletes to do is that find a certain sweet spot that typically is guided by your physical therapist, performance coach, or whoever you’re working with at the time. Any good one is going to tell you this, but it’s to find that sweet spot. But you have to find a certain dosage that is going to be helpful to move the needle forward—what we call a minimum effective dose. 

So that’s just the minimum amount needed to be able to make changes for the right dosage that you’re given for a particular exercise or adaptation we’re looking for. And so with that said, if we’re doing a certain set of exercises or movements, I would rather lean towards underdoing it or undercooking it because then if I listened to my body, I’m like, okay, let me see how it feels. Well, if it responds positively, we’ll cool. We at least know where in a good area. But if you go full send on knee flexion, trying to walk around a ton, thinking that’s going to be better, trying to extend your knee all the time and thinking that that’s also going to be really beneficial, there’s a certain threshold where the knee is like, hey, I’m not good with this. 

Therefore, once you do send it, you don’t really have a choice but to wait. You have to let biology do its thing. Let the knee come back down and it could have been time that you could have dedicated towards allowing the knee to improve slowly and chipping away at it brick by brick. Versus going hardcore all-in and then having to take that step back because the knee is flared up. Everyone who is in this ACL rehab process usually experiences some sort of flare-up of some degree and takes that as a data point to learn about your body and understand where that sweet spot and while factoring in the other big things as well. 

How is your sleep going? How’s your nutrition? How is your stress management? How is your overall movement doing right? So those are the big bucket items that we’re looking at, just to make sure that we’re not leaving any bucket unchecked or unfilled if you will. And so this is where it’s important. 

The rule of thumb here is to undercook it versus overcook it because you can always add more. You can always put it back on the grill. You could always add more volume to it and intensity to be able to see if you need more. But if you start with too much, you just got to wait and that’s what sucks. But this is not going to be you because if you’ve been listening to this podcast for a minute we’re going to make sure that you have some of the information you need to make sure that you can at least be prepared about answering this question: should you push through pain? 

And I’ve touched on this subject many times. And here are some podcast episodes to specifically check out to help you, especially if you’re new to listening to the podcast—Episode 13: Why is your knee swelling? And then we are looking at four ways to improve your knee swelling. So that’s a follow-up to make sure that you have some strategies to improve that effusion in your knee, that swelling. Episodes 14 and 15: Dealing with pain in ACL rehab, part one; dealing with pain in ACL rehab part two, which is episode 15. There are other ones where we talk about pain. I want you to roll through the podcast, but these are good starting points for you to figure out what are some guiding lights around this. 

And the other thing we talk about is the phases that you’re in, looking at early versus mid and late stages. If you’re early, you’re probably doing a little bit more of this protection-type mode versus like as you get further into the early phases and into mid and late stages, it’s exposing you. We call this a protect-expose continuum which I learned from Greg Layman. 

And this is essentially, when you’re post-op or post-injury, there’s a little bit of protection going on. You don’t want to exacerbate and stress that knee. You want to allow that healing process to take place, but slowly kind of dosing the things that you need for that time being to make sure you’re not just fully just letting it go. And that is just “in this healing process.” So there’s a way to integrate some things that you need without trying to redlight this thing or being able to push high into pain. And then you have to wait for things to settle back down. 

The Goldilocks principle, as I talked about earlier, finding that sweet spot, and that’s a little bit of trial and error. If you take that undercooking framework principle, then you can essentially find that sweet spot as you go and then just kind of slowly add to it over time. And look, this is a 9 to 12-month process, you don’t have to go ham in month one. You’re going to lose this battle if you try to just go crazy in month one because you have a long, long time to go. So find that sweet spot, continue to readjust and audit this process, especially with the provider you’re working with. That is going to be so key. 

The traffic light feedback loop is so important. That’s where we do the red, yellow, and green based on your pain levels and what you’re feeling, the type of pain you’re feeling, especially avoiding any sharp type pains You have the 24-hour feedback loop, which is just checking in to see how your symptoms and that profile is doing within the 24-hour period. It might be 36 to 48 hours for you, depending on your knee. But we use just that 24-hour feedback loop.

Load management—so managing all of the essential stressors that you’re putting through your body, especially physically. So think about your exercises and physical therapy you’re doing; think about the steps you’re taking in a day; think about your daily activities that can potentially add up. Maybe it’s work-related. You’re a teacher, you’re a nurse and maybe you are a construction worker. And this is something that you had to deal with in steps, especially thinking about school, high school college. You got to take steps to get to class. These are things to factor into the overall stressors and overall load management of your system. And there’s so much more that we dive into these episodes, but this is the thing where I want to make sure I just provide you essentially with the answer to this podcast. 

So should you push through pain? I am going to give you a black-and-white answer but with stipulations with that. And the short answer is NO. There is a sweet spot though. And I’d rather you not push through pain than push through pain because pushing through pain is probably going to lead to that negative feedback loop as I talked about. Versus if you don’t push through pain, then you’re probably going to be in a relatively better spot. But again, this is going to be a sweet spot because I don’t know anyone who’s been able to move the needle without touching any type of pain early in their process because you’re just dealing with a knee that’s recovering from a major injury and reconstructive surgery. 

You’re going to deal with some aches, pains, all of these weird funky feelings in the knee, popping, swelling, all the stuff. And so then therefore we need to find a sweet spot within that to be able to move forward. There are so many factors to consider, but if you’re like Neymar or this person who’s messaged us and asked us this along with all the ACLers who have mentioned, hey, should I push through this? I feel like I’m not making progress X, Y, and Z. And they’re feeling this pressure to do that. Don’t push through it so aggressively to a point where you’re paying for it. 

At the end of the day, this is where you have to take your medical advice from your surgeon and your PT, especially to make sure that it’s accounting for your context, your case and your situation. This is not medical advice. These are guiding educational frameworks and things that you can potentially use in your process. Audit the process and what you’re doing, and make sure that the variables are accounted for. And maybe the ones that you haven’t been accounting for that are sneaking in there. Walking tends to be a big one. Maybe with your work. There are certain things that you’re doing that you’re not realizing. Maybe you have to take a bunch of stairs and you’re like, oh, this is fine. And you’re just not recovering well. Or maybe it’s just things your knees, not tolerating really well. Look at those silent little symptom provokers if you will. But then, of course, this comes back to also your knee healing to the rehab you’re doing. 

So many moving pieces, so many variables, but this is where having a trusted team with you, especially a guide, a physical therapist, and a coach in your corner to make sure you’re not operating this by yourself. And you shouldn’t be answering this question alone. This should be the thing that your provider should be answering for you and creating context around it. And being specific about it and not just being like, well, just do this one and this is fine. This exercise is fine. No, let’s create some guiding principles behind this to help you. No matter what situation you’re in. 

And the thing that’s pretty cool is that our ACLers, we work with giving them these frameworks, these guiding principles and the feedback loops. They will tell us later, they finish with us, they graduate, they might incur another injury. Maybe they hurt their shoulder or their back or something else comes up. And it’s really cool to hear. They’re like, I just use those feedback loops that we talked about and they were like, I was able to kind of get out of that versus like catastrophize and freak out about it. They’re like, oh no, it’s fine I listen to my body. I undercooked it for a minute. I didn’t just completely stop and rest. I was able to put these things in play and I was back at it, which is amazing. 

My suggestion here is to go and listen to these episodes I mentioned, huge in helping navigate pain, and swelling symptoms throughout your ACL rehab. And it’s the exact ones we give our athletes to help navigate this process. We give that to you for free. Use it at your disposal. At the end of the day, console your rehab team, to make sure that it falls within the lines for you. But to answer this: should you push through the pain? NO. But there’s typically a sweet spot. It’s not a black-and-white answer here. 

I hope this helps, team. Until next time, this is your host, Ravi Patel, signing off.