Episode 185 | 10 Ways To Improve Your Post-Op ACL Rehab Outcomes

What’s up guys? Welcome back to another episode on the ACL Athlete Podcast. Today, we are diving into 10 ways to improve your post-op ACL rehab outcomes. But before we do that, I have two things: One is that if you’ve been with me for a long time, especially from the beginning, you know that I used to operate the podcast out of our apartment and there would always be this yard work going on every single time that I recorded. It was just the perfect timing and the day that I decided always to do it. And then now the beauty is that we are in our own spot, but now I have a five-month-old at the time of the recording of this podcast. It works out when he’s about to take a nap. You might hear him start to scream and get upset because he’s five months old and he just wants to stay awake and he’s got a lot of opinions. Anyway, the way that our house is designed is that he is fairly close, then that way I get to hear him, all the laughs and the giggles, but then also all of the screams and cries. Any parents who are listening, you guys get this. Anyway, that’s the replacement of the lawnmower and the blowers that I used to have when I first started the podcast, so enjoy. 

Number two is that we have the ACL Athlete Mentorship cohort number three, starting September 9th. Enrollment starts less than a week from the time of this podcast. Enrollment opens August 19th and that will be at 12:00 PM Eastern to the waitlist. If you are someone who works with ACLers listening to this podcast, you can sign up on the waitlist in the show notes. There should be a link there for you to be able to do that and get all the information regarding our next cohort and the ACL Athlete Mentorship, where we teach you about taking an ACLer from injury, all the way to full return to performance. For our framework that I’ve designed and the ability to see this phase by phase, our testing criteria, your ability to build athletes up, literally from post-op and post-injury dealing with complex cases. We talk about how you can get into dynamic training, into good strength and conditioning, being able to tackle a lot of the issues that we see and things that we don’t learn in school and through education. This has come through a lot of just growth on my end, through my own ACL experiences, and through spending a lot of finances on continuing education through putting in the reps with hundreds of ACLers at this point, building a team around this. You’ll get prerecorded lectures, you’ll get live mentor and coaching calls to go through this stuff, go through concepts, go through case studies program design, being able to understand how to really work with ACLers; not just in theory, but also practically. 

This is something that we haven’t spent a lot of time working and building. This is really something that I’m excited to continue to do and to really push the field of ACL rehab, to really redefine the way that we do things. We do have a limited number of spots. We’ve got over 200 people on the waitlist. If this is interesting whatsoever, you want to level up your ACL rehab and the way that you do things, then join the waitlist. That’ll at least get you information, that way you can just stay in tune. And if you’re interested in joining us, come hang out. 

Now, on to the actual episode today, talking 10 ways to improve your post-op ACL rehab outcomes. Let’s get straight into it. Post-op ACL rehab—it’s assumed to be super easy or straightforward and this is something that I’ll have a lot of conversations with ACLers and even clinicians. Where they’re just like, yeah, it’s very basic. They’re going to start off with just like quad sets, range of motion stuff, and being able to start doing some basic exercises, straight-leg raises, all the things. The thing that is always interesting is that we will get ACLers later in the process or we’ll talk to PTs. They will still be struggling with basically the things that should have been straightforward early in the process, that athletes are still dealing with three months later, six months later, nine months later. I think a lot of times it’s because maybe the initial post-op process was overlooked a little bit. I think it is one of the most overlooked phases in this process. Because I think there’s this assumption that is straightforward but in reality, there’s a lot of nuances to it. 

A lot of people do start off with similar things. But you got to think about the nuances of, is it an athlete’s first, second, or third ACL injury and then compare it to the other side, right? Is it a second injury on the other leg? Then your normative values are a little different. What kind of graft type did they get? Is there any concomitant injuries? Is there other stuff like meniscus repair, MCL repair? Are there any other procedures that were done in this process, maybe it was an LET. Therefore, we’re going to make sure that we are mindful of the post-op process and that’s going to also impact the way that we design our programs, and the way that we guide athletes. 

If you get a quad tendon, guess what? We’re going to be a little bit more intentional about certain positions and also about pain compared to maybe a hamstring graft. But I think what happens is that all these protocols just kind of generalize them. And there’s this assumption that, okay, well, as long as you don’t have a meniscus repair, you can kind of stay steady with the same exercises and progress at weeks four, six, and eight. When in reality, there is so much variance as you guys know through this ACL rehab process. 

This is something where I just want to share some 10 different ways that you can improve your outcomes post-op ACL rehab. This applies to post-injury as well. But this is something that can really make a difference, especially not only in the post-op process. But I’m talking about the mid and late stages when you are at, let’s say six months or nine months, or even like 12 months out. This can make or break the difference of you being in a certain place where you were expecting to be, or where in theory most people would get to, or is it something where you’re kind of delayed? Often I see this because maybe this post-op process wasn’t taken seriously enough, or maybe there wasn’t good compliance with the athlete. There are a lot of things that can play into this. Even the healing of the body, which there are controllables and there are uncontrollables, which is biology. We can’t control all those things. But we do want to focus on the controllables and that’s what we’re going to talk about today with these 10 different ways. Let’s get into it. 

Number one: Don’t rush the first six weeks. I’ve seen a lot of people try to overdo it in this phase and they go hot out of the gate. And then that’s something that can really flare the knee out. Or maybe on the flip side, they don’t take it too seriously. For us, we look at this first, especially six to eight weeks, we’re really building a foundation. And I’ve seen this really delay the ACL rehab process. Because if you go hot out of the gate, you’re going to also flare the knee up. And if you don’t find the right consistency and repetitions and hit the right criteria for extension, flexion, trying to get the knee quiet, getting pain down, getting swelling down, being able to normalize your gait. Some of those different pieces are going to play such a big role in setting up that foundation. But also, you’re just trying to get back to normal life. If we can find the sweet spot with this where you’re not doing too much, you’re not doing too little, you have certain goals you’re targeting, then it’s a huge game changer. But what I’ve seen is that if you rush that six-week process, then it’s something that can really set you back, in terms of where you’re at at three months, at six months and so on because of rushing it. 

Number two: Use NMES on your quad. This is electrical stimulation. NMES stands for neuromuscular electrical stimulation, specifically. You can not use a TENs unit. The most important thing that I want to stress here is that you cannot use a tens unit. TENS unit is for pain. You might get lucky with a diamond in the rough here where a TENS unit is a combo of NMES unit. It’s sometimes also called an EMS (electrical muscle stimulator) that’s probably more the umbrella term if you will. But NMES has a very specific setting and output that we want to have. We want to make sure that we get a specific NMES unit. I know a lot of people have either parents or friends or maybe a partner or somebody who’s got a TENS unit because they got it from Amazon. And it’s cheap and it helps with pain.  I think that’s the goal we want to make sure we address here is not for pain. It is for electrical stimulation of the muscle. It’s going to be a different setting. You can control it, typically. There are fancy ones out there. We recommend the Balego NMES device. I think roughly 60 bucks on Amazon. We have no affiliates with us. The thing is that is just the most affordable, it’s the easiest that people can get quickly and it’s just something that we want to make sure athletes are doing post-op. 

The tip I want to recommend to you here is that it should be an uncomfortable, but tolerable intensity. People will kind of set it and they’re like, okay, I could see my quad kind of come on and stuff and I feel it. But this thing needs to be strong, man like you need input to that quad. And we need to make sure that it is strong and you’re uncomfortable, honestly, but it’s tolerable because you’re not going to do it forever, but you are going to try and hit this. It’s something that we want athletes to try and hit one to three times a day. With physical therapy, the thing that’s interesting is that it depends on the frequency of when you go, typically in person. It might be two times a week, it might be three times a week. That’s only three times of the whole week that you were getting that input. It’s maybe just that one bout, so it might be 30 minutes total in your whole week. Think about the spread of a whole week: How often you’re hitting a range of motion stuff? Thinking about if you can really do that one to three times a day. You think about how much that can accelerate your quad’s ability to contract and be able to get input. And that’s what all of our athletes do. We get them a device in person or remotely. They order it, they get it, they have it in there and they’re hitting that thing one to three times a day. And the research shows how effective it is. There’s nothing to argue against it not being effective. If your PT is not doing NMES, especially post-op, then that’s a problem in and of itself. But this is something that you need to do, from battling arthrogenic muscle inhibition (AMI) to connecting that mind-muscle connection. 

I remember when I had my first ACL and I had the NMES device on my quad. Before I did that when I was trying to contract it, it just felt like I could not connect it, I couldn’t contract it. It’s like when you try to flex your bicep, you can feel that bicep. But when you try to do it and you look at your quad, it’s like just that hotdog that’s sitting there. You’re just like come on flex and you can’t. All my ACLers know this feeling. When you have the NMES on there, it sends this signal that allows you to be able to connect your brain to that contraction, that mind-muscle connection. You start to feel a fire and then you start to feel that wiring starts to connect faster and faster. Think about the more frequency and input you get it, the faster you can get those quads to get rolling, the better you are early post-op from a strength standpoint, from being able to get your extension back, from being able to take stairs, all the things that build off of just getting your quads to wake up. That’s going to be key because then that’s going to help you to get stronger and then therefore get to the things potentially sooner, rather than having a delay in muscle strength. 

The other thing that I want to mention here is that I’ll have athletes do it into the mid and even late stages of ACL rehab. It’s not just this post-op thing. There are research groups, University of Delaware, for example, and they will also look at this. They’ll even have athletes do it up to 70% to 80% of symmetry. It’s not just this post-op, four-week window. This can be used in the mid and late stages if you’re still getting some delay in the quads and up to a certain level. There’s no set cutoff. I think it’s just assumed that like once the quads get going we don’t need it anymore. Now you might decrease the use of it as you get into the mid and late stages. But what’s the harm in it if you have the opportunity to do it, and you’re still trying to chase down quad strength? 

Number three: Get your swelling down ASAP. In my opinion, this is literally the biggest bottleneck in ACL rehab. Even outside of pain, sure,  pain can be a limiter here, but I think swelling is one of the biggest bottlenecks. It shuts down the quads and we know through the research on arthrogenic muscle inhibition (AMI) that swelling is not great for this. It limits your range of motion from flexion and extension when you get that balloon feeling in your knee. It just wants you to compensate whenever you’re trying to go into a squat or a lunge or step up or anything with the knee. You’re going to try and offload that leg because it just doesn’t feel great. I know this feeling of that balloon feeling, it feels puffy. You don’t want to sit back on your heels. You don’t want to go into the position. You’ll torque your body or your hips or your shift to the uninvolved side and you want to offload the stress. 

Therefore, we’re not even stressing the proper tissues because of that swelling. It just has a heap of issues that we want to try and get the swelling down. We don’t want it to hang out. We want to get it down, especially post-op. Usually, if there’s a sign of swelling, it means that your knee is not tolerating what’s going on after that post-op or post-injury phase where there’s that acute rush of swelling due to the trauma. Once you’re later in this process, you want to get a swelling down because otherwise, that’s telling us the ability to tolerate the stress is being exceeded. Your capacity is being exceeded basically like we’re overshooting that. We need to adjust things to do that, especially on the early front end. This is going to be important because you’re going to start accumulating steps. If you have a vacation plan, be on the lookout, because that is something that can accumulate some steps and trigger the knee. People don’t assume this and I get it. But it is something that I’ve seen time and time and time again, someone has surgery. They’re early, they haven’t accumulated steps, they can start walking and then they’d go off on this trip and they accumulate 10,000 steps, 20,000 steps, and their knee blows up because you’re increasing how much your vertical. You’re putting a lot of miles on your knee and it’s just not used to it. The load that you have accumulated and your step volume haven’t built up to that. That’s one of the things that can be sneaky so consider that into this with your swelling. Also, impact-related work can stress that knee. That is also something to factor in that once you start adding in some jumping or some running the knee can also get a little tricky and feel some swelling and some puffiness. Just some things to look out for early on, but get that swelling down ASAP. 

Number four: Regain active knee extension; matching your uninvolved side. A great proxy for this is getting your heel pop. So that means trying to do a quad set and seeing if that heel can pop up off of the ground without compensating into your glutes and hamstrings. I like to get athletes on the edge of the treatment table, where their heels are hanging off. Basically, their Achilles tendon is the thing that is on the edge of a table. I get them to do a heel pop on their uninvolved side and then I’ll get them to do the heel pop on the involved side. So that’s a quad set if you will. We’re trying to match that on the involved side. And then once you do achieve and get this, work on to maintain it because it can regress.  People assume once you get it, you can keep it. And yeah, you can to some degree. But I’ve noticed that if you don’t work on it, there are some people who can regress and then they start to feel that their extension is starting to lose a little bit. Therefore, this is always a check-in point every single week for yourself to keep working on it, to make sure you have that heel pop. It doesn’t take, but just a second to check on it, to see the differences. 

The other thing that I will mention is at zero degrees is not enough, unless it is on your uninvolved side. There are some people I’ve worked with where they sit in a little bit of positive, or maybe a zero degrees. And that’s okay because that is their normal human anatomy. But majority of humans have hyperextension at their knee, that means they go beyond zero, roughly five degrees, 10 degrees. If you’re someone who’s hyper mobile and you get to 15 to 20 degrees hyperextension, then you can slowly work towards 5 to 10, and then don’t worry about the rest. Because there is a certain point for this particular population of hyper mobile athletes where you don’t need to rush to get that back. But for majority of people, you’re going to want to get that matching to your uninvolved side. That is your goal, that is the proxy, which is going to be the heel pop, which is what we use at the ACL athlete. Get your hyperextension back. 

Number five: Let swelling be your guide. One of the biggest things here is making sure pain is not equally in gain here. Swelling is a sign, as I had mentioned, that your knee’s capacity and tolerance has been exceeded. Respect that healing process, especially early post-op and then find that greenlight zone. We give our athletes this traffic light feedback loop. If pain is dullish and making sure it’s not sharp and then it’s in that 1-3 out 10 range. So that’s our greenlight zone 4-5 out of 10 is that yellow light and then six and above (6, 7, 8, 9, 10 pain out of 10) is the red light. Don’t touch the red light. Yellow light you’re you could be cautious. But we want to find movements and intensities where you’re in the greenlight zone, where we’re not triggering such a high output of pain, and that’s going to help us to progress forward and know are we moving forward in the right direction or not? 

Number six: Work intentionally on gait mechanics. It does not come back naturally. I don’t care what your PT says, I don’t care what your surgeon says, I don’t care what Bertha at the corner of your clinic says. It’s not going to come back naturally and it’s something you need to work on. It’s a skill, just like anything else, lifting, running, jumping, cutting. Work on it daily. It’s something that is important to learn how to walk normal again. Because again, proprioception is one of the things where we are trying to make our knee aware of the space it’s in. Basically when you close your eyes, how do you know where your hand is? It’s proprioception. The same thing with our knee and our foot and the way that we walk, we’re not looking down at it, but we do have to reingrained this pattern and where it is. So that helps by working on the skill and the mechanics of gait and that means you need extension, flexion. You need to make sure that you can go through a heel-to-toe type process or the gait cycle, if you will, to be able to do this. It needs to be intentionally worked on. 

Number seven: Ditch your brace before your crutches. Now, I’m going to add a caveat here because everyone has surgeons, precautions and restrictions and all the things. But the thing that I see the most is that ACLers see braces, the brace on the knee as protection and crutches as a limiter. People want to ditch the crutches. But they want to keep the brace because they think it’s protecting the knee joint. And I get that, I even thought that. But now working with a lot of ACLers, talking with surgeons and seeing different approaches, the brace is actually the limiter and weaning slowly off their crutches, going from two crutches to one crutch will save you from being that limper. 

The thing that I see the most is people get off the crutches too fast. They don’t have their full range of motion. They have this brace locked into a straight extension. And they’re just limping around and they’re whipping their leg around. I know you want to get from point A to point B, but this is not the way to do it. Be able to get off your brace as soon as possible within your surgeons restrictions and then slowly wean off their crutches. I know they’re annoying, but I promise you that it will be worth it to get your gait back normally, and to get your swelling down.

This is something that I have changed my mind on because before I’d be like, okay, let’s try to get you off crutches so we can get you move in. But now I really encourage staying on the crutches a little bit longer because long-term it will be so beneficial from so many of these pieces from relearning how to walk, from being able to allow the knee to adjust back to weightbearing, especially if you’re someone who has a meniscus repair and is non-weightbearing for a bit. That will be even more important because it’s going to shock your system a little bit whenever you start to put weight back on it. And you’re non-weightbearing for two weeks or four weeks or even six weeks. This is something that I think is a key piece, but of course, within the respect and the restrictions of the surgeon. If you have an issue with this, then you can talk to the surgeon and their team, and you could also have your physical therapist. If you’re PT is listening, reach out to the surgeon and be like, hey, is there any wiggle room within this for the brace? Can we open this thing up? I’ve seen athletes do really well this way and show just kind of your experience. Of course, just respect that process. Don’t try to go to the opposite end and just say, hey, this sucks. We don’t need to do this. Instead, hey, come with it with an open mind and being able to ask them, well, is there any range to be able to get out of this brace, a little bit sooner if the athlete’s doing well, or we see certain criteria to be able to do that. Something important to note in this early rehab process. 

Number eight: Break your range of motion work into small chunks throughout the day versus one intense hour. It allows you to see a dose-response relationship from the small box of work you’re doing and create micro adjustments before the knee gets grumpy compared to these like big bolus or big bouts of work. And it’s easier to fit into the day for an ACLer because then you can split it up into these small little, 10, 15-minute sessions versus this big hour-long session you need to set aside. Therefore, you’re hitting that more consistently throughout the day and you can see how the knee responds to it. 

Number nine: Focus on isolated strength and don’t rush into integrated strength. This is a big mistake I used to make. And it’s something that I want to make sure that you guys know that as ACLers and as clinicians, you want to get into the compound lifts. I get it. You want to start lifting, lifting heavy, ideally, but our body is smart and we’ll find other ways to complete the task to be able to do the movement. I did make this mistake a lot early because I wanted to get people back to lifting heavy, but I started to realize people would compensate. Now, what I do is take a lot more time on isolated capacity, isolating muscle groups, trying to focus on knee extensions for the quads, hamstring curls for the hamstring group, glute stuff, and calf stuff. I’m great with hanging out and doing more isolated work early on because that’s going to also allow us to target the right tissues. Be able to build up more hypertrophy and focus on more force output. Then start integrating those into compound-based movements and then start to work on rate or speed velocity type work. So go from isolated spend more time on this than you think, then focus on integrated work, and then be able to add in more velocity-based movements as well. 

Number 10: Set realistic expectations and have a positive mindset. The mental side of this process is so much harder than the physical and only ACLers can see this, to be completely honest. And it’s one of those things where the physical is just the visual thing we see because there’s just a knee impairment. But internally, there’s a lot going on with this ACLer. It’s so crazy and even in different stages of life, different seasons, multiple retailers versus the first one. There are a lot of things that are going on. Part of this process is setting the expectations, and not getting too caught up on timelines and protocols, which you guys know. That’s very big to know that you are running your own race. 

Having an adaptable plan and focus on the small wins. Seriously, write those out, and stack them up. It’s going to be so crucial and so key in this process. Our mindset drives our actions. This is going to be important to set the tone for ACLers, clinicians, as you’re working with your ACLers to make sure expectations are realistic and make sure they are connected to reality versus this farfetched expectation of like, yeah, you’ll get back to this thing in six months, for example, or running in three months. 

I hope these 10 points were helpful for you guys. Some things that I just wanted to share some different nuances to these pieces that don’t get talked about often. But I want to share this with my experience with working with so many athletes and being able to also just see the things that work and also the things that I didn’t do as well. This is really important to be able to set the tone for early post-op post-injury for ACL rehab. The last thing I want to mention before we sign off is, if you are interested in cohort three, then head to the show notes and you’ll be able to sign up to the waitlist. We do open that up on August 19th and then we will be starting September 9th, super pumped. We already have some people who have joined in or who have said they’re joining in and we are super pumped for this group that is coming together for cohort three. Until next time team, this is your host, Ravi Patel, signing off.