Episode 214 | When Should You Schedule ACL Surgery?

What is up team and welcome back to another episode on the ACL Athlete Podcast. Today, we are answering the question: when should you schedule ACL surgery? I’ve talked about this question, if you will, in the past, but this is something that I wanted to directly answer for people because what has happened recently…well, it just happens all the time. But, especially recently, I’ve been talking to ACLers and they are feeling like they’re rushing into surgery, and that could be a number of factors. It could be, whether that’s the surgeon convincing them I. Or they just want to get it over with. Life is just like happening and so they just want to get it over with. 

And I get this logic, but it’s not the best place to come from. Now hear me out. And this rushing into surgery has cost them. They’re in a ton of pain after the surgery because it’s so close from the previous ACL injury and the trauma. Essentially, two traumas in a short period of time. This can manifest in a slower post-op recovery, getting the symptoms down, getting the range of motion, getting the quads to wake up again, swelling being such a big culprit for the quads, essentially being asleep and getting off the assistive device. Typically, crutches take longer or they just have a limp that sticks around. The thing that’s really crazy with this, I had an athlete that we just started working with as a team and she ended up going to the surgeon and the surgeon booked her in for the next Thursday. And she had just had an ACL injury. She’s not a professional athlete. There’s no time sensitivity. The surgeon was like, “Hey, I’ve got a spot on Thursday open, let’s have surgery.” The thing that’s always challenging with this is that we don’t know what we don’t know. It’s no fault of the athletes themselves. It’s more so we are trusting in a medical professional and a healthcare system to help us with this problem. And while we are really great with keeping people alive in our healthcare system, we’re not great at being proactive or making sure it’s an individualized process.

And let me tell you, ACL surgery, this rehab, this recovery, needs to be individualized. It’s challenging with a situation like this because this person did not know any better and they had to go into surgery because they were like, cool, I’ll get it over with. It’s fast, I trust this surgeon. The thing is most surgeons are confident, most surgeons are going to give you a very specific, yeah, this is the problem and this is the solution (a.k.a. you tore your ACL confirmed by an MRI). You also had a mechanism or some sort of accident that typically happened. Your knee doesn’t feel great. You want a solution. Most of the time, people are not coming into an ACL injury with a lot of educational background around this injury and the process. The surgeon or the office tells them to have surgery. 

Now, there are tons of surgeons we work with and athletes we work with where they do their due diligence. They’re like, “Hey, we’re not gonna have surgery for at least four to eight weeks or until the knee quiets down.” Awesome, I respect that. And they’re big proponents of prehab. This person and some other people ended up going into surgery and guess what? They’re dealing with the outcomes related to this. And that is the thing that I had just mentioned earlier. They were getting a huge influx of symptoms, their knee was just so irritated and there’s one thing that always gets missed here is that usually with an ACL injury, there’s a bone bruising. Think about any bruises that you get. 

For the most part, they’re super sensitive to the touch and our bones are no different. The joint interaction is not going to feel as great. It’s super grumpy and usually when the body knows that there is a threat or something has happened, it is going to send inflammation, it is going to swell the joint up, it’s going to protect that thing to try and make sure it doesn’t get destabilized, if you will. Or in a sense just making sure that the threat is eradicated, so it just locks it down and that’s what happens after an injury. In this situation, a back-to-back injury plus surgery just makes the knee really freak out. With that said, that just makes it a harder climb back up and especially immediately post-op. 

My question is always why rush? When you’re scheduling this ACL surgery, why rush? The two most important things that come up with this is usually the surgeon or the medical guidance around this. And then it’s just athletes who want to get this over with. They just want to get over the hump and get beyond it to get into recovery. Most importantly, getting back to the thing they want to do. And again, I said that that’s all fair and logical, but when you know better, you have to do better. In this situation, if you’re listening to this, or if you have a surgery coming up, or if you know someone who is going to have surgery, this is worth taking the advice and making sure you do your due diligence before you rush into the surgery. Because I promise you guys I worked with hundreds of athletes at this point. And the thing is that the ones who rush into it are the ones who are usually the ones struggling post-op. The ones who take their time, do some prehab, go into the surgery with a good baseline, come out of surgery doing so much better. I get you might want to get on with your life and have those goals.

But in most situations, people don’t have a significant time sensitivity, and you’ll see this with pro athletes a lot of times. The argument is that, well, athletes go straight into surgery right after their ACL injury. It’s like one, they’re professional athletes, they’re anomalies. Number two, they have the best medical access. It’s their full-time job. They’re usually getting paid hundreds of thousands of dollars, if not millions of dollars. And so time sensitivity is of the essence for them. And the surgeon will also dictate if that knee is really beat up, they will delay that surgery. And we don’t know the nuances of it. It depends on the status of surgery. And there are a subset of ACLers when they have this injury. They don’t have swelling, they don’t have any issues. Their range of motion restores pretty quickly, and yeah, they could go have surgery pretty quickly after that. It’s just not the majority because most people’s knees freak out after the injury, and then therefore, we need some time to get back to a good baseline. Restore that knee to a good place and then go into this surgery. 

I know that always seems so counterintuitive because you might as well just deal with it while it’s already angry. But the body does not respond really well whenever it’s been insulted once and then insulted again without being able to recover back. That’s the biggest thing here, and we see it time and time again. That’s why I’m really stressing this point here, because we see people rush into this. They just have such a challenging recovery, and while you want to rush into it and get over the hump of it, that could also be extending your timeline, if you will, by maybe three months, six months. Just because of rushing it and you didn’t get your extension back, for example. So then you’re working on it for three to four months. It’s taking super slow time versus allowing that need to settle down, get it back, and maybe you save time in the long run by taking a little bit more time to do some prehab and get it to baseline.

There’s massive upsides to waiting and not a lot to gain from rushing, besides just getting it over with and maybe getting back to your goals faster. But I put an [*] on that because I often don’t see that with people who rush into it. Our goal at the ACL Athlete is a minimum of four to eight weeks of prehab, if possible, post-injury, to get these baselines as best as possible. The aim is for a quiet knee. If you’re not sure what it is, check out previous episodes on this and really get the strength back up. We’re not trying to get you back to dynamic movement and stuff like that during prehab, unless you’re taking a non-operative route. Or maybe that is something that is imperative for you,then we can talk about it depending on what your status is. But we also don’t want to risk the ACL and the knee without it being there. Therefore, we don’t want to just force a ton of dynamic work like cutting and jumping, and then all of a sudden your knee buckles, you maybe damage something else or some swelling occurs. We are trying to keep this thing as quiet and as strong as possible because that’s going to set you up for success. 

In the previous episode, I dove into an analogy that really connects with this on the whole time of not rushing into it and establishing some prehab time. It’s something that I really do love and is helping to frame it for ACL injury, the prehab, the surgery itself, but it’s talking about the 10th floor versus the fourth floor versus the seventh floor. Imagine we are trying to establish a baseline, and this is pre-injury. You’re on the 10th floor, this is your fitness level. What happens is that you drop after your ACL injury automatically because there’s a deconditioning effect. You lose some strength, you lose range of motion and you’re just not able to be as physically active. Therefore, there is a drop in your fitness and your overall performance as a person. Now, we can either rush into surgery and continue to drop down floors. You could go to the fourth floor, if you will, or maybe you just drop a few floors and then you climb back up to the seventh floor, for example, because you did some prehab. Therefore, as you have the surgery, you might drop a little bit more, but you’re not starting from a place that’s the fourth floor and you drop even more. You’re starting at a higher floor, maybe it’s the seventh floor and you drop a little bit, and so then that allows climbing back up a lot easier. Therefore, athletes that we have, every single one that we’ve done prehab with has always been like. Wow, I didn’t realize how massive that was. There are so many benefits from it, but it also serves as a proxy to get the knee status settled and in good shape for surgery.

After seeing so many ACLs, it’s a huge factor that gets overlooked to be honest. And it’s when these people often don’t get the range of motion like extension, or they don’t get their flexion back, or they just kind of deal with persistent swelling and pain for longer periods of time. These are the people who just have the challenges afterwards, after surgery.

Now, there’s benefits to waiting and more so just not rushing and scheduling it out. It allows you to let the knee settle down after a major trauma before having another surgery, which is a trauma. Again, I said it was counterintuitive, but I promise you that it will have such massive benefits for you and it makes the post-op process even more rough if you do rush into it because it’s gone through a lot already. It allows you to set expectations and get familiar with the rehab process ahead. You’re familiar with some exercises, you’re familiar with how the knee responds, the feel of things because when you’re post-op the knee is sleepy, the knee is really restricted. You’re not going to want to move it much, so then that’s not the best time for you to start learning how to connect your mind to your quads. You want to do that prior to the surgery and as much as you can during prehab after the injury.

It is also an opportunity for us to see if you’re a keeper for the right person. And there are some people who I’ve seen who should not have had surgery, but they did it because their surgeon’s a surgeon, they saw an ACL tear. They’re like, “Hey, you need to have ACL surgery.” There’s people out there that, yeah, they believe in the non-operative approach and that they might say, “Hey, let’s see how it goes doing this.” But it’s small and few between. I guess far and few between is the right way to say that. But it’s so true. Most people that we see when they go to consult a surgeon, no matter their background, who they are, goals, whatever it is, 95% of the time they’re going to be told they need to have ACL surgery. There are other options that exist and there are some people that I truly think because of their activity, their lifestyle, their goals that they have, they shouldn’t have had ACL surgery. But their surgeon told them to do it, so they went and did it, and you can’t undo a surgery. This is something that time allows us to be able to work on.

The other thing too is that if you don’t rush, you’re allowed to access or to be able to evaluate how the timing of the surgery will impact your success. And I’ve done this in another podcast episode, how you might be able to do the surgery, but it is the environment and the current season of life you’re going to set you up for success. Just because you can have the surgery doesn’t mean your life is set up best to do that. You may want it done in two weeks, or you may want it even done in six weeks. But if you’re not in a place in life to make the most of your initial post-op process successful, it’s going to be tough. I give examples of, you know, the freshman high school athlete that has a lot of summer travel plans, for example, challenging themselves whenever they’re traveling a lot and they’re on their feet a lot. The skier that works as a teacher, and it’s January. Not going to be super easy timing wise to be able to do the post-op. You may have no choice and you may have to do it. But with that said, if you have options, maybe if you could just kind of delay a little bit, that’s going to help to be able to make sure that you are set up for success. Maybe you’re the soccer athlete consultant that travels every week. 

A curve ball here. The athlete who has terrible insurance deductible out-of-pocket maximum, and is switching jobs with a better insurance in six months. These are all things that you can think about in terms of the timing of the surgery and how it could be helpful. It’s never an easy time for this ACL surgery, to be honest, but there are definitely certain seasons or windows of time coming up that might be more optimal or it might not be so optimal, in order to make sure you plan best to give yourself your best shot. This allows us to really help make informed decisions and educated decisions. Time allows for that.

It’s honestly the most important thing about this as we lead up to it. We can expect the healthcare system to take care of us. We can try and while it’s good at keeping us alive, as I had mentioned, we still have a lot of work to do to be proactive and make sure we are advocated for the proactive place of healthcare is still coming, but we’re still not there yet.

This injury will change your life. I repeat. This injury will change your life. It’s a major injury that ends dreams, careers, physical activity, creates depression and higher suicide rates and more. And while that seems extreme, the literature supports it. I’ve talked to people every single week, thousands of ACLers that have dealt with these exact things and told me these things. No one expects it to happen to them or their kid, for example. But it does. Then they have to deal with, all right, what is this process? You need to treat this as if you’re having heart surgery. Get multiple opinions, choose the right fit, create a plan, like you’re building a house. You’re not just going to be like, “All right, cool. Yeah, let’s do that. Let’s do that. All right, we’re done.” House is built. You’re going to create a plan, especially for this house that you’re going to have. It’s going to be super important. You’re not just going to jump into heart surgery or build a house unless it’s immediately life-threatening for the heart surgery. The emergency, then you just got to do it right. You’re going to take the right steps and make sure you do it right, get the doctor, get the plan, get the right team in place. This is no different and there’s so much upside to waiting, in my opinion, not a whole lot of downside.

I hope that this is helpful y’all, in terms of when to schedule your ACL surgery, give it some time. I’m not saying you need to wait three, five months, but give it a little bit of time, at least a minimum of four weeks. That is something that I think is so important and will go such a long way. You might have a different opinion. You might be able to get more information. You might find a better PT to start in this process. You might be able to pivot a graft type, if you will, and that’s just being able to consume more information and educate yourself. And time allows that once the surgery done, it is done. I know a lot of people I’ve talked to in hindsight, they wish that they would’ve done something different, especially the timing of the surgery. Or even maybe sought out different opinions or maybe just kind of got a better PT expert in place for their ACL rehab. And that’s probably the biggest thing that I see in this. 

My goal is to share that with you guys and make sure that you are educated in this, you know what to look out for, and it’s super important to make sure that you make the best decision for yourself. Be your own advocate because no one else is going to be. Until next time, team, this is your host, Ravi Patel, signing off.