Episode 207 | 10 Key Strategies For Better Sleep After ACL Surgery

What is up team and welcome back to another episode on the ACL Athlete Podcast. Today, we are diving into sleep, all things around post-op sleep. It could be even also applied to post-injury as soon as you have the injury or have the surgery. I just want to talk to some how tos about this and guidance around this. But just know that this is not medical advice; it is purely educational. Consult with your healthcare professional to get specific guidance in your specific case.

Now, the reason this has come up is because I’ve recently had some people reach out asking about sleep. And while this may seem straightforward, it is also something that can be a little daunting. You fall asleep, your post-op, am I going to mess something up? What’s the best way to do this? I know all of you guys are coming here to get the most information, to equip yourself with the best recovery possible.

I’m going to give you guys a lay of the land here when it comes to sleep and helping it apply to your situation, or if you’re a coach or a clinician listening, being able to help guide your own athletes through this. Because we know sleep is super important and it gets hit really, really hard as soon as you have this injury and as soon as you have this surgery and you’re post-op. It’s for the healing process. Sleep is going to be super beneficial. Of course, as we know it. To recover for your own mental sanity, your energy and all the things in this process. Especially as you are starting to build strength, as you’re trying to retain muscle strength, we want sleep to play a big role because that’s where our body is going to do, a lot of the rebuilding. We want to set ourselves up for success from the get-go. 

It’s just a challenge if I’m being completely honest after this surgery. From here on out, I’m just going to reference it as post-surgery. But if you’re post-injury or maybe you hit a road bump in this and your knee is flared up and you want some guidance because you’re having trouble sleeping, this should apply across the board. With that said, especially after post-op that’s when we are really trying to be as intentional about the way we sleep and being careful. We’re wanting to make sure we set ourselves up for success. And as I was sharing, like, it’s going to be uncomfortable because you literally just had major reconstruction of the knee. There was some bone drilling going on, some screws put in, a graft potentially taken. You might have some things cleaned up, repaired. We’ve got a lot of work going on and there. It’s not too far from just carpentry work, instead of it being a house, it’s literally in your knee. And it’s something where I’ve observed this surgery, there’s a lot going on and that’s where it makes sense why your knee is so angry after. It’s having this acute response like what the heck just happened. Some tissues have been impacted. And now it is going through this acute process of healing and this alarm system. Now we are trying to just really get on the road to recovery.

From a comfort standpoint, our goal is to try and manage our pain and swelling as much as we can. But of course, after we are post-op and I remember this myself, you’re just kind of feeling weird. You wake up after this surgery, it happens in an instance. You have your post-op anesthesia. You’re feeling that weirdness like out of it. Your leg is wrapped up. You possibly have a brace on it. There’s a nerve block that is typically taking place, whether it’s in your quad, your femoral nerve, or your adductor, or maybe a spinal, or maybe you didn’t get one at all. But with that said, there’s typically a nerve block that plays in to help minimize the pain immediately post-op. And then don’t forget just about this general pain and swelling that you’re just going to be feeling immediately after the surgery and some fear, apprehension, anxiety around it. That’s normal y’all and I felt that way. It’s typically people’s first major surgery. You’re also like, I don’t want to mess anything up. Am I going to do something wrong? And lifting your leg like it just feels like a foreign thing on your body. Any of you guys who have had the surgery and are listening to this, you’re like, yeah, this feels pretty accurate. I felt this way with both of my ACLs, two different kind of experiences, if you will, but it’s similar feelings of this just general post anesthesia, how the leg felt. 

The other thing that you’ll be anticipating is some sharp pains that’ll come and go when you move the leg. Randomly, if you just move, it just feels like a sharp little nerve or a little pain shooting sensation that shoots into your knee and in your leg and you’re just trying to be careful moving your leg around. Probably, it scared some of you, if you are preparing for this and if you haven’t had the surgery yet, but trust me, all of this is normal. You’re not doing anything wrong. It’s just what comes with the post-op process and what to expect. I’m not going to sugar coat that at all. If you had an amazing process and you’ve been through this, then that’s great. But in reality, the first 24 to 48 hours, especially, you’re just trying to get through it. You’re trying to just take it hour by hour. With this coming back around to sleep, you’re like, I just want to sleep, man. Just tell me how to sleep. 

Let’s talk about how you can optimize your sleep and safely do that with some guidance around it. Tje thing about this is we need to talk about like what the goals are and we need to make sure, how can we make sure we go through this in a very simple fashion. With ACLers, we want to make sure we comply with our post-op precautions. The restrictions that we might have, whether that’s sleeping in a brace. You might be locked into extension. There might’ve been some other procedure in addition to what your ACL that was done. With that said, usually there are surgeons specific precautions given to you that you might have to add here too. Some people are non-weightbearing, but there might be even specific ways to keep your knee locked in a position. Those are things to just kind of keep in mind. 

From a goal standpoint, the biggest thing here is to make sure you set yourself up for success. We’re trying to let this knee heal while giving it the TLC that it needs. Your goal is to essentially hit like a quiet knee post-op. What that means is building towards full range of motion, full knee extension, getting your knee from 90 to 120 to full flexion. Of course, this might be limited based on your precautions. You might be having to work on your quad contraction, which is typically a very, very big goal for us with extension, minimizing pain and swelling and then of course, getting you back to walking normally. And those are really the big focuses, if you will, without getting bogged down in any other minor priorities that we might have. 

Let’s go through this list. There’s 10 different things that I want to talk to you guys about that I think will be super beneficial for this and to walk you through being prepared for sleep post-op/post-injury all the things so you are set to go. You’re going to start off on your back whenever your post-op. And of course, that’s probably unlikely how most of you sleep. I don’t sleep that way. I sleep on my side and kind of on my stomach. But that’s what is recommended, that’s what we recommend because it’s just going to put you in the best position. It helps it keep the knee straight and avoid any unnecessary pressure on the incisions. Keeping it in this bent state, especially if you’re on your side or your stomach. That’s why being on your back is so beneficial. I know some people like to use the recliner as this can help. Put them in a good position to elevate and to be able to lean back and be able to get out of the seat a little easier versus a bed. 

Eventually as the incisions heal, you’ll be able to do some side sleeping. And this might be where you sleep on your uninvolved side with a pillow in between the involved and the uninvolved leg. So that means that your ACL operated side would be on top. Your uninvolved or non-operated side would be on the bottom. And so that’s the way you would try to do that once you are in a good point, but you are typically going to be starting on your back. And then eventually being able to progress towards your side, if that’s something you do, and then your stomach will still take a minute, just because we want to make sure we’re not putting too much pressure on those incisions. Everything is healed up well, and it’s also not impacting too much of like your knee flexion because being on your back also helps to just naturally let gravity pull us into extension. If we prop our leg up, it sets us up for success to get that extension. 

Now, a question I’ll always get, should I worry if my foot turns out to the side or my leg turns out to the side or bends while I sleep? No. That is just something that can naturally happen. Of course, if it does just go to reposition that because your body is going to naturally fall into most comfortable state when we sleep. It’s kind of relaxed. But when you’re aware of it, correct it, see if you can get it back into a good position so it’s not in a bent state. But it’s normal to do that, especially with people’s different hips and just the way that they might be laying and things like that. I wouldn’t stress too much about it. At the end of the day, we still do need to make sure we get the sleep versus just having the perfect position to sleep in. Because if you’re in the perfect position but you’re miserable and you can’t sleep, that’s almost more counteractive to what we’re trying to do versus being able to let our foot flare out to the side or bend a little bit and get better sleep. But I’m not saying we’re trying to just let that knee stay in a bent position. We’re going to try and find the sweet spot with all of it. Position will be key here of being on your back. 

Swelling management is going to be the next point here. You want to elevate the leg, not just the pillow underneath the knee. And that is the normal resting state that feels good for the knee. When someone injures their knee, they actually want to keep it better because it’s a better resting state for it. When you have the surgery, of course, they’re going to put you straight, typically. There might be a slight bend in it. You might be locked in a brace. Just to let you guys know, just cause your brace is locked at extension at zero doesn’t mean that the knee in that brace is perfectly at zero too. There might still be a little bend in it. Because those braces aren’t so perfect to keep us in just perfect zero or hyperextension. 

That is something where the bending of the knee is going to be super important. We want to make sure we limit that or avoid that as much as possible. And that’s where I remember my first ACL, whenever I came home, I actually started putting a pillow underneath my knee because it felt great. It stayed in a slightly bent position. I was like cool. This feels great. Later my PT was like you got to stop this because this isn’t good. It’s going to impact your extension. I ended up stopping it. It didn’t feel great, but it was something that I needed to do to make sure I get my knee straight. The goal here is the whole leg needs to be straight and ideally elevated above the heart. This is going to help a lot with the swelling. For pillows or support, this might be using a wedge pillow or stacking pillows to be like a ramp with a comfortable incline. Think of like a slightly inclined hill, or I think about a treadmill. You can get that thing super, highly inclined. Think about like a lightly inclined treadmill. That’s what you want to do is just kind of get that knee above the heart. You don’t need to have it like a super steep hill where thatb treadmill is on like grade 15 or something. Just think about like a easy grade treadmill. And that’s kind of the incline that you want to have versus one where you are allowing like a pillow to let that knee bend, even though it’s inclined, if that makes sense. 

We essentially want to make sure it’s not one of those where there’s the bend in the knee with the sleep, or there’s just a pillow there, or it’s one of those wedge pillows where there’s like an incline and then it lays flat where you could just bend the knee and then the calf rest on the wedge. Instead, what we want is it to be just essentially like a ramp and you’ll essentially want that pillow to prop your leg up where it runs from underneath the leg asnd underneath the knee to the calf and avoiding, bending at the knee. I know I’m stressing this point here, but it is crazy. The amount of people who don’t know this. And then they’ve been sleeping like this, and they’re the ones who are having difficulty getting the extension back. This is a huge player in being able to really focus on that extension early post-op. Look, I get it. You’re going to have some pain and sometimes you’re going to want to put something underneath that knee. That’s okay from time to time, don’t get me wrong to give yourself a break, but do not stay in that state. We want to try and keep that knee as straight as we can, without the cost of it being just excruciating. If that’s the case, then we do need to find some options there. But with that said, it’s just typically a little bit of discomfort that we need to just kind of work into and have some options. If it is something that really does bug you a lot. But with that said, swelling management is going to really help get that knee extension back, get the fluid out of there,. get your quads going massive. 

The other thing too, is that you will have a wrap typically around that knee, around those surgical sites. You might have some like gauze put down or some cover to help with any blood and then being able to have that thing wrapped up with like an ACE wrap or some type of wrap to cover and protect the leg, compress it a little bit. What you will typically do is to keep that on for a little bit in that first week. And then eventually, whenever the incisions are fully healed and  the scabs will not open where you know you will not nick them and they open back up, you’re going to want to use a knee sleeve. Now this is not required, but this is something that I am a huge fan of because it is going to help keep compression around that knee. It’s going to help that knee from preventing any fluid from really building up or pushing some of it out. There are those stockings where you can get from your ankle all the way up to your thigh, that you can get off of like Amazon or other places. There’s also these like Neoprene compression sleeves that you can get for just your knee. All those are great. If you’re like, what’s the best, the ankle to the thigh is going to be best to really push the fluid up the system. But the knee sleeve will also be really great, especially if you’re thinking about you using that out and about. Something that I encourage all of our ACLers to get, because swelling is just something you’ll deal with and it’ll be just helpful to make sure we stay on top of that with a knee sleeve. And we got to just make sure that the incisions are fully healed because you don’t want to go messing with the scabs and opening up any wounds again. So that’ll be helpful from a swelling management standpoint, especially as you sleep, totally fine to sleep with this. If you feel like your skin is getting irritated, then maybe just take a break from it in the nights. Make sure you wash this thing. I’ve had some athletes where they haven’t washed this thing and it smells disgusting. Let’s not get this thing infected. Let’s protect these sites. 

The next thing up is pain management. Use your pain medication as the guidance that has been given by your physician and by your ortho and follow that as needed. I like to still use ice as well for this; 15 to 20 minutes, every one to two hours during the first few days. And as swelling and pain decreases, you can reduce the frequency to three to four times per day or as needed. With this, some of the guidelines are to make sure to use a barrier. Don’t just put like ice cold stuff right on the incisions or on the sites, the skin will get irritated. Make sure there’s a barrier to help protect it. Always place a cloth or a towel between that ice pack and avoid that directly on the skin to avoid some frostbyte. Make sure you monitor the skin condition. Check for like, if it’s too red or irritated, then you might need to take a break or just give it a little bit longer period of time. Or maybe the barrier between these need to change.

The other thing with the pain management is that with the medication that you’re taking, stay ahead of it. Don’t feel like you can just beast it and be better than it. Just to stay ahead of it. Because once you’re in to too much pain, you’re already in a place where it’s going to have to play catch up. Stay ahead of it. Be humble. I promise you it will be worth it. And if it’s going to help you sleep, it is worth it. But of course, use your own guidance and under the guidance of your ortho and who you’re working with.

Protection is another piece here for the sleeping. This is something that’s important for the surgical size. Just to make sure that you have some sort of wrap and usually that gauze is on there as well, to help with any blood. There will be that point where you’ll need that less, as I had mentioned earlier. Because the wounds are kind of scabbing up, so then it might be free during the day. Just to make sure to protect the area from like the sheets or blanket, preventing any irritation or rubbing the scab off, if you will. Because you want to let those things heal. That’ll allow you to start kneeling and start to just kind of progress things forward. And last thing you want to do is be dealing with like scabs that are opening like three months post-op. It’s just kind of annoying. It’s delaying some of the process. Make sure to manage and take care of those things. You can always wear the wrap as you sleep, the ACE wrap, or maybe you might have that compression sleeve once you’re in a good spot to put that on. Or maybe you might put some loose clothing on to provide a protective layer between the knee and maybe the blanket or covers that you’re using as well. But you just want to protect the site. Take care of it. 

Infection. Everyone thinks it’s not going to happen to them, but you’d be surprised the number of people it does happen to. We just want to make sure we take care of this thing and do our due diligence with that. 

Sleep environment. Setting it up for success prior to surgery is really, really key. Organize it, make sure that there’s a clear path to different areas, the bathroom, getting to the kitchen, if you need to. Just your daily stuff so that way you don’t have to be reactive when you get home. And think about the side you’ll sleep in. If you’re sleeping in a bed and getting up and out of, it’s weird, you would think like, okay, if I have my right ACL done, I’ll sleep on this side of the bed. You’d be surprised how much convenient it is for you to have that mapped out and know like, all right, cool. If I have it on this side, then this is what I’m going to do, and this is the easiest way for me to get up, roll over. And that will just like help you so much to reduce that cognitive load and just deal with unnecessary extra movement or pain that you need to, and then just to make sure your environment is cool. It’s dark. It’s quiet. You need to sleep good, man. Get off the technology before you go to sleep. I know you’re going to be Netflixing and you’re going to be watching all the things on your phone. And you’ll probably wake up at odd hours and can’t sleep and feeling pain and you’ll want to use your phone. Do what you need to do, for sure. But then if you can establish some sort of process for yourself, so then that way you can get into a good flow of sleep. 

Some other tips Im going to mention here. Avoiding any caffeine, alcohol, nicotine before bed, especially, or if you’re trying to recover. That stuff is not good for you, especially alcohol and nicotine, as you guys probably know. It’s going to impede the healing process. Let’s make sure that we just set ourselves up for success here. Don’t crush a ton of water right before bed, because then you’ll have to get up a lot. It just a little side note here. We want to stay hydrated in the day. But you’re also having to get up and go to the bathroom a lot. Be mindful of that, especially in the middle of the night, in your first few days, post-op. Keep your ankle pumps going to keep good muscle pump going and blood flow going to prevent any DVT. When your surgeon gives you the go ahead, if you have a brace that you have to sleep in or as locked in, ditch that brace whenever you can. That’s going to help your sleep so much, I promise you. I remember as soon as I got rid of that brace for my first ACL, it was awesome because then therefore, I didn’t have this bulky thing that was dragging around and hitting these random places, pressure, just felt kind of locked into that thing. I promise you while you’re sleeping that brace in reality, isn’t really doing that much to begin with while you sleep even “locked in” that extension. But I do understand some surgeons are big on wanting to sleep in that. A lot of surgeons I work with here in Atlanta, for example, they don’t care about it, especially with isolated ACL’s or even with meniscus, for example. They don’t really care for it. But every surgeon has their own preferences, if you will, but we have to respect that. But with that said, we want to make sure we get out of that brace as soon as we can, because that’s going to help us so much. But it’s important to follow the guidance of the surgeon with being able to do that.

The last thing I’ll mention here is asked for help. Don’t be the hero here. Don’t feel like you can tackle all of it. This is when you leave one to lean on your support system, have them help you and ask for help.

I hope that that’s helpful. I did want to touch base on this and just in review, think about your position being on your back, swelling management is going to be elevation and compression. Do not put something underneath just your knee to help with whenever you are resting and sleeping, make sure it’s from the back of the knee or that whole entire leg all the way towards the heel. That way, it’s just that slight incline, as I had mentioned. Pain management on top of pain meds and making sure you’re icing. Protect those incisions. Keep it very healthy. Keep it very clean and dry. Sleep environment is going to be really key here to set yourself up for success. Avoid drugs, any caffeine, limit water volume right before bed, ankle pumps in the night, ditch the brace when you can and ask for help. 

The big three from this, if you’re like, all right, cool. Let me take my big three: Sleeve on your back. Keep your knee straight. Elevate the leg. That will be the biggest things here. If you’re like Ravi, shoot it to me straight. I need this to be just very simple. Sleep on your back, knee straight, elevate the leg and you will be in a good spot. 

I hope this helps guys. I hope it helps clear up any confusion you might have with sleeping, with ACL rehab, especially with being post-op. There’s always this fear or anxiety, just know that that ACL is locked in there. You have to do something really dumb for you to injure that knee or do something to impact the surgery. But I know that it can be daunting regardless, even if I tell you that you’re just like feeling these pains, these popping things and scared to move it. You can’t feel your quad, all these things. And trust me, I was there. I’ve been there twice. All of our athletes, they share similar things with us. Make sure to just optimize your sleep as best as you can. This is where you are going to make a big comeback in terms of the recovery process. While you’re doing all the extension work, all the quad stuff, flexion, getting stronger, the sleep is going to be a huge player in this to help you move forward. People can be rehabbing, doing all the work, but if they’re not sleeping great, they’re still going to be digging themselves a hole a little bit versus the person who is sleeping really well. 

I hope that this helps y’all. If you need any assistance on this, if you have any questions, please reach out to me. You can find me at Ravi Patel.DPT on Instagram. You can email me. You can find this through this site. We have the show notes where you can contact us and find us. Otherwise, I will catch you next time. This is your host, Ravi Pate,l signing off.