Episode 169 | “It’ll Get Better With Time” Illusion in ACL Rehab

What is up team? My ACLers, supporting members , clinicians, coaches, parents, all the people who are listening to this, and trying to just improve their ACL rehab and their care. Let’s get into it for today’s episode: “It’ll get better with time,” the illusion, if you will, in ACL rehab. This is a notion that people assume that their knee will just get better with recovery with time. And it’s this kind of false hope if you will. And to be really honest with this episode, because I’m never not honest. But with that said, let’s break this down a little bit. So you know where I’m coming from. 

Sure your knee will “heal” over time. You have this injury, you have the surgery and the further away you get from it, the better the body takes hold of it, if you will. It does his biological thing to help heal it. So whether that’s damaged tissue that, that graft that we’re talking about, that can take up to two years of healing, if you will, from what we see in the literature called ligamentization, where it basically goes from a tendon to a ligament. Our body’s doing this thing. If you have other structures that were either surgically repaired, or maybe it was damaged during the injury, let’s say a meniscus (an MCL), it could be a cartilage issue. All those things play into this. The body’s going to do its thing. 

For example, you have a cut, your body is going to do the inflammatory process. It is going to scab up that cut. It doesn’t continue bleeding. And then it’s going to go through its proliferation phases and the maturation phases, which are basically the body’s natural healing process. And so that’s essentially how it’s going to come back into skin and be able to heal. And so with that said, that’s a very simplistic view of the biological healing of the body. And so your knee’s going to go through somewhat of a similar process for those structures that have been damaged and need to be recovered and healed. 

I wish that this was always the case with the ACL itself, but of course, sometimes we need to put a new ligament in there because those sites don’t necessarily come back together. Although healing could be a potential, but we’re not going to get into that today. But the whole focus of today is to know that this will heal over time. But there are certain things that won’t improve over time. I think that’s the biggest thing that I want to make sure we hit home today, is that we think that things will just improve. The further away we get from surgery from the injury itself, it’ll just get better. What about that pain? What about the swelling, range of motion, the muscle size? We see the atrophy of the quadriceps, especially your strength, your jumping abilities, running, all those things, etc. The athletic dynamic components, do those just get better with time? Well, these are different and you might get lucky with the pain and swelling and it should naturally improve from the acuteness of the early stages of the injury and the surgery.

I remember with my two ACLs when I had my injuries, they sucked. It hurt. You get that like sharpness of pain, the knee gets swollen, all of these things that come with any type of mechanism of injury and the same thing with a surgery. It’s another injury and trauma to the knee in and of itself. You’re going in and getting a cleaned up if you’re getting a new graft, if you’re getting new bone tunnels, the screws are put in, all of these things happening to your knee. And so therefore it’s another trauma so your body is trying to recover from the acuteness or that injury in and of itself, too. And so therefore your body’s going through some very acute pain. That’s saying, “Hey, like let’s protect this joint because it is very sensitive and it’s needing to be healed in this current state its in.” So then therefore, everyone knows that you kind of go through this process of the pain is really high. You have a lot of swelling typically. There’s stiffness, there’s a lot of apprehension, all those things. And then once we get out of those 5 days, 10 days, if you will, for most people that acuteness or that sharpness starts to level out. And that’s something that I know with my surgeries, especially, initially there was a lot of pain, but then over time that improved. Same thing with swelling to some degree because of the knees sending all that stuff there and protecting it. That’s why the pain and swelling is there. But what we’re trying to do is get away from that as time goes on. And typically that does happen. 

Now that’s not to say pain won’t stick around. People deal with all kinds of different other aches and pains. It could be some sharpness, some dullness, usually not to the degree of what it’s like post-surgery, but it is something that people will still continue to deal with. I know a lot of you’re shaking your heads about this and also swelling. But it’s typically not nearly as bad as that post-injury or post-op. And so, yeah, that improves with time. But what about range of motion, what about that muscle size, the strength, the ability to jump and run, as I had mentioned before. This is where honestly, it just won’t get better with time iff there’s an issue or a deficit, to be very honest here. The only way that you’re going to be able to truly tackle this is that there’s intentional programming, there’s a plan behind it, there’s guidance to address these gaps or these problems. And it’s not like a sickness, if you will, or a biological healing of the graft where the body will just kind of naturally do its thing and bring it back to as normal state. This is very much a kind of, you use it or lose it type case. And in this sense, it’s about providing overload or stress stimulus to help get the adaptation we’re hoping for aka range, muscle size, muscle strength, qualities that are being improved, such as explosive and reactive strength, which gives us the ability to truly run, jump, cut, etc. 

And why I’m bringing this up is because people will be misled either by their healthcare providers or just assumptions of the process. Whether that’s them saying it’s a 6-month process by your healthcare provider. We hear surgeons say this all the time. Insurance cuts them off at 20 visits, or maybe it’s 40-60 visits. But that didn’t take you all the way to where you want it to be. Maybe you’ve been told you have “graduated.” I’ve done a podcast on this before, so you haven’t caught that. Go and check that out because this term is kind of almost this false hope if you will, of maybe you just maximize your insurance visits. So you’ve graduated that small phase of the rehab process, but doesn’t mean you’re done. But sometimes PTs because they can’t serve you anymore, they can’t help you. They’re like, Hey, you’re graduated. Go and do run, jump, cut, keep working up to whatever you want to do to be able to get back to your goals. That’s challenging because honestly the mid to late stages are probably the hardest in terms of navigating by yourself. 

I’m sure the early postop, there’s apprehension but there’s a little bit more straightforwardness if you will. Because the injury and surgery itself will constrain you to some degree. You have to work with what you can because you can’t just go and do anything and everything in the gym immediately post-injury or post-op. This is something that can be a little bit challenging. And they say, okay, you’re graduated. But you know, kind of in your bones, you’re not at that pre-injury status. And you’re not back to feeling like your confident self, a 100%  like you were before. You’re given kind of that false sense of being ready, or maybe you just stopped because you weren’t being compliant, which again, that could be on you. Or maybe you just didn’t see the value of what you’re getting, which I know a lot of athletes who come to us, they mentioned, Hey, like I felt like I saw my PT for a few minutes. I got pawned off to the student. And I’m just going through this protocol and it’s no different thanBertha who’s 85 years old with that total knee replacement, who’s doing the exact same things as I’m doing. And I’m 25-year-old, high-level athletes, or maybe you’re a skier who really takes things really seriously. But everything should always be a little bit more individualized and it shouldn’t be just this cookie cutter approach. 

I think that’s the thing that makes people want to get away from their in-person rehab or what they are getting, because they just don’t see the value in that. You’re given that false sense and that makes it really hard. This will lead you to having to invest outside of your typical healthcare that’s being provided your physical therapy or your coaching. And side note here in majority of ACL rehab cases, you’re going to have to invest and find something outside of your typical rehab you’re getting because it’s not going to get you all the way there because the medical system that currently exists in the U.S. I know in other countries, because we have athletes all over the world. They’re not set up to get you all the way there for the most part. It’s basically getting you back to normal function. And in the U.S., it’s very much dictated on insurance visits and the care that you’re getting, what the experience of that physical therapist is. And then of course, this also translates over to other countries as well. So that’s the thing. 

As this side note is to expect as you come through this process. So then that way you can be better prepared to get the help that you need when it’s time to do so. And then that way you’re not having to be reactive to that. So whether that’s your insurance or your healthcare coverage finishing up and you had great PT, or maybe it’s just not serving you anymore. I know people who have hundreds of insurance visits, but their physical therapist is still having them do straight leg raises 5 months later. Guess what? That’s an opportunity cost that you’re just like, I don’t care how many insurance visits you have. That’s not going to serve you very well. So with that said, you either got to find someone else who is going to help fulfill and serve you in that phase that you’re in. A lot of times that’s after your healthcare finishes, which I’d say on average, most people “finished” their physical therapy or physio, and graduate probably around the 3- to 4-month mark. In the gut of the physical therapist, they might say you’re graduated or they might say like, Hey, like, you know, this is kind of where our road ends. And you get to kind of keep working on stuff. But a lot of times it’s dependent on their network and what you’re trying to get back to and seeing if there’s like some sort of plan that can be created. Oftentimes, it just kind of trickles down into like, you kind of left on your own to kind of figure it out. I hate that that’s the case, but that is what happens. So you either have to invest in PT or coach who can help you, whether that’s in-person or remote. Or what often happens is you take matters into your own hands.

Here’s the thing: If you’re not seeing a massive deficit with daily life, you feel good enough, you don’t feel like back to yourself, but you feel okay, you can walk, you can take stairs, you can do all the things in your daily life. You might not be able to necessarily run yet, but you may be haven’t tried it yet. Or maybe you have, and it’s kind of going okay. It’s not a massive issue like it was before when you were on crutches and you couldn’t walk around and you stairs, that’s a massive daily impact. But as you go, and especially the longer you’re in this, the harder it can be, because that’s where you’re kind of like, all right, well, should I just kind of figure this out on my own? 

A lot of times you’ve kind of been led astray thinking you’re good by your healthcare professional when you’re not. And that’s the thing that’s so tough is that we kind of get into this mindset of like, okay, I’ve graduated. Or my surgeon said I’m cleared, but you know, in your gut and you know, how you feel, um, and whether you, what you’ve been told or not, you don’t feel all the way there yet. And so then therefore you might just try to do this on your own. 

And a lot of times people are just going to bypass the investing part because that’s a lot of time, that’s a lot of energy and of course, finances. You got to spend money in order to get good care. And go your own route probably and hope it just gets better with time. You take matters into your own hands and aiming for it to get better with time. I know people who just start trying to run because it’s been long enough and the knee feels okay. But they’re at 50% quad deficit. And maybe their PT didn’t measure that or maybe they had been told that. But you’re just kinda like, well, I don’t have the guidance right now, so I’m just going to give it a shot. I feel okay. But you go run and it feels like garbage. You honestly, can’t outrun a weak quad and that’s going to have some compensations with it. So that’s going to be really important. And unless you have the background to do that, it makes it really difficult to plan and organize that.

Same with dealing with limited range of motion, like extension, thinking, it will work its way out over time. It doesn’t. And I know many of you who probably had lingering extension issues or still does, this is something that just doesn’t automatically just get better on its own. I’ve seen people with plus 10 degrees of extension deficits, months and years out before thinking they’d get it back in time and never did. The same applies to dealing with pain that never went away. Maybe they became less active or stopped doing what they love in order to mitigate that pain. And a lot of times, that’s what people do, that coincides with, maybe they didn’t get her strength back and they didn’t build up the rest of what they needed. So they don’t feel confident. They don’t feel strong. They also are dealing with pain and potentially even swelling, which limits them from doing what they want. So then they’re kind of in this like kind of place they feel stuck. The last point I’ll mention here is that, or maybe they never regained that muscle mass, the strength that I had mentioned, maybe they never worked on jumping or that strength isn’t there. 

The jumping just feels terrible and it feels like you got two cement blocks on your feet. It didn’t get better with time. And I know a lot of you probably listening to this are nodding your head. This makes sense. I thought that once I finished physical therapy or once time progressed, even getting to that 9-month mark, you’re like everyone talks about this 9-month mark. I’m good to go. This is awesome. Should be good. There are people who have emailed me and said like, Hey, like, you know, I finished my PT. I’m just waiting until that 9-month mark to be able to make sure I can go back to sport. But they’re like, I only did rehab for like 4 to 5 months. I’m like, yeah, 9 months is what the research shows reduced the risk of reinjury. But that’s not necessarily going to be a magic number to get your cross the line that your knee is just going to be there. When you think about this injury, it really does strip down someone’s physical abilities, especially in that particular leg. Because of the injury itself, the neuro changes, all of these complexities with the ACL that some (we still don’t know) but this is something that you can’t just get away with just 9 months passing and hoping that it’s going to just improve. It’s like hoping like you go through the full school year and you’re just going to naturally get smart without doing any work. That’s just not going to happen. And you’re not going to pass the test and you’re not going to move on to the next grade or to your major or get into the school that you want because of time just passing. 

That’s the biggest crux of this whole process is assuming that time. We’ll just improve it. And this is not your fault. And that’s the biggest thing that I want to share here. Of course it’s an opportunity cost, which makes it really hard, but it is not your fault. Unless you weren’t compliant then maybe some of this is on you. You just didn’t do the stuff you needed to do or listen to your provider. Then that does fall on you. And there’s a little bit of accountability there. But let’s say you did do that or you didn’t get good guidance then of course, like for the most part, it is not your fault. this is something where. You know, it’s natural to think this will just kind of improve and go away. 

It’s how many ACL or feel prior to working with us. Just because it’s something that they’re just like, all right, I finished whatever care I had. I started working on my own and it just didn’t improve. They were hoping it just got better. We humans do that naturally. And think about us getting sick. We’re hesitant to go to the doc because, we think our body will figure it out, which in majority of the cases that we’ll write. So our natural rationale is to think about that. And we’re like, okay, well maybe with an injury, the same thing will happen. Your back hurts, your shoulder hurts. Majority of the time your body will slowly improve. But the thing is we’re naturally conditioned to think that way. But it’s a little different with a surgery like this. And especially with any aches and pains that don’t go away very soon after. so you gotta think that these kind of fall into a different category versus the body just naturally doing his thing and getting back to where it was before time, won’t make it better.

Time plus serial testing. So that’s basically periodic testing. Every at least 4to 6 weeks is what we like at ACL athlete. A structured plan that is individualized to you and a roadmap and then expert guidance is key to be honest, that’s our kind of three-step process. Making sure there’s testing, making sure that there’s a plan in place and make sure that you have appropriate guidance and support. That is a very key recipe for you to make sure you can progress in your ACL rehab like you want and get to that angle most importantly. 

Why are reinjury rates one in four? Well, it’s because of honestly, these issues where people think it’s fine and they go out there to do what they want and it happens again and it sucks, but it’s not your fault. It’s not their fault. At the end of the day, it is just a poor system and healthcare system fault. And I hate it. You guys know, I’ve talked about this a lot, but it’s so frustrating whenever I have so many athletes that I talk to and see, and we work with as a team where they’ve just been poorly guided. There’s usually no testing. So then therefore, how do we know if this athlete is ready to go back and do the thing? Saying you’re strong or saying you feel 100% is honestly not good enough. You got to have objective measures to make sure that you are ready to go. This is something that goes across any business, any schooling. 

Think about anything that you do that really has a lot of weight to it, whether you are in school, whether you are working, there are certain KPIs or certain key performance indicators, certain like metrics that we are tracking to make sure that you are hitting a certain threshold for us to feel comfortable to move you to the next grade, to get into the next school, to be able to graduate for example, or maybe it’s at work, right. Are the finances hitting the certain threshold we want for this month or this quarter? Are you able to produce their appropriate sales numbers? What’s that conversion rate? Marketing, right? How many people are we reaching? What are those numbers looking like? If you just told your boss, like, Hey yeah, we’re reaching more people. That’s cool. But is it one more person or is it like a million more people? You got to have more numbers to create more context and also to keep us honest for the most part, because otherwise our biases as human beings is naturally to avoid any type of negative type honest conversations, especially we’ve had people who don’t want to get tested and it’s because they potentially haven’t been doing their stuff recently. 

And they’re almost just like, ah, yeah, I’ll do it a little bit later. But the thing is, is that they know they haven’t been doing their stuff and they don’t want to deal with the facts of like knowing their numbers haven’t improved, but it keeps them honest. It keeps us honest and make sure that they are progressing in the right direction. Poor testing is a big part of this, poor guidance and programming, a protocol isn’t going to do the job here. And so that’s why we are looking at people going on to reinjury because of the testing and the poor guidance in that programming, because they’re just not prepared to go back to do the thing. When you’re only doing air squats or the weights only go up to 30 pounds in a clinic. There’s no way to overload the body enough to be able to make sure that it’s strong enough to take on the demands of what it is that you want to get back to your sport, your activity, because that’s going to be high forces. You talk about building off of that with running, jumping, cutting, even higher forces. This podcast episode, you probably like Robbie complained the whole time and made me feel bad. I’m sorry if I did, but I promise you some of you listening to this episode, you’re relating to it. You’re nodding your head. And you’re like, yeah, I feel that, I thought that it would get better with time and I’m still stuck in the exact same place. I was three months ago, six months ago. It might be years out. We’ve had people come to us 5, 10, 15 years out after their ACL surgeries, because they just never got back to it. 

And they’re just like, what can I do? And so this is your call to action If you will, to not just assume that in time, things will improve with your knee. Especially from the standpoint of your range of motion, your muscle size, your strength, running, jumping, cutting, anything from a performance standpoint, to be honest, even from the mental standpoint. If you think that it will just improve. It’s not like grieving with a loss to be completely honest. 

There’s still things to work with. But it’s different because you’re dealing with a physical ailment as well. This is playing into of course the mental aspects, and it’s limiting you from doing something that you love to do. I know what it is. So this is something not too different if you will, from like losing weight time passing, isn’t just going to allow you to lose weight. You still have to take intentional action behind it. But this is just a mindset thing that can kick in the further down the road. And let’s be honest, the last thing you want to do is add more time between what you want to get back to doing and where you’re currently at.

Let’s do the thing, guys. This is your call to action. If you feel like you’ve been stuck, if you feel like you were hoping things would improve a time and it’s just not getting better with time, do something about it. 

Because the last thing you want to do is be here three months later, six months later, a year later years out like these 5, 10, and 15 year people and being like, man, I should’ve just done this before. And what ends up being the trickle down effect of this is that if the need doesn’t feel better, you end up being less mobile. You just naturally will not do things that you want to do, especially, whether it’s running, jumping, cutting, which is involved with majority of sports. Any activities you think about skiing, jujitsu? You think about skateboarding, you think about all the things. If your knee is not feeling up to it, then you’re probably going to do less of it. And especially if there’s pain and swelling, you’re going to probably avoid it for the most part. I know so many ACLers feel this, and it’s one of those things that it just leaves them more and more inactivity over time. And you almost feel a little bit more like you’re walking on eggshells or fearful to be able to continue to do things that are active. And then therefore that affects the mental health, your over metabolic conditioning of your body and the ability to battle a metabolic diseases if we’re coming down to physical activity and population health. And that’s one thing we want to not get into. 

The other thing I’ll say is that ACL injuries and ACL surgeries naturally opened the door to a higher risk of osteoarthritis. The lack of activity and lack of appropriate nutrition and other factors like genetics can play into osteoarthritis. But one of the biggest helpers for putting off OA is exercise. If you look across the board, meta analyses, anything that helps to combat osteoarthritis down the road, it is going to be physical activity and exercise and that is something that we can anchor to. But if the knee is not wanting to do the thing, then that increases our risk naturally for that. 

Just some things to think about, not only the short term of that happiness and what you want to do but also the long-term, what does the knee health look like? Do you want to be 60, 70, 80, and dealing with that, or even earlier where people don’t deal with it and they’re having total knee replacements at a time where they shouldn’t be. It’s usually just not getting in front of the things they need to tackle and making sure that they are healthy, addressing these issues. Just some food for thought for today’s episode, thinking things will get better with time, a lot of times it just doesn’t and that’s just not the way our bodies work. We need stress in order to be able to adapt and improve and become more resilient and be able to do things. That’s why you see all these athletes who play all these sports. They’re not just playing sports, they are doing strength and conditioning. They’re making sure they improve the integrity of the structures of their body, getting stronger, more powerful, more agile, all of these things that are necessary to feel athletic and to be able to do the thing. So that’s our goal today is to make sure that you don’t get stuck in this and to be able to make moves. At the end of the day, you can do what you love and get back to it sooner versus thinking time will just allow you to get there. 

I hope this was helpful, team. I want you to leave this on a positive note and think about taking action on this versus feeling like, all right, well, this is my death sentence if you will. That was not the goal today. I just want you to make moves on this because this injury has dramatically impacted my life and it’s impacted so many lives of the ACLers that we have worked with. It can be for the positive, but it can also be very much for the negative. This is something that I want to make sure this podcast and this platform helps to serve you. And knowing, all right, there is something you can do about this. And it’s just not something that, all right, this is just is what it is. This is your action plan and this is something to help put things in play to make the next move. So go and do that. If you need any help, we’re here. The team’s here. Myself is here. Please reach out with any questions. We help ACLers all over the world. So please reach out with anything that you need. Until next time team. This is your host, Ravi Patel, signing off.