Episode 216 | 8 Ways to Finally Get Rid of Swelling After ACL Surgery – Part 1

What is up team and welcome back to another episode on the ACL Athlete Podcast. Today, we are doing a two-part series with part one today, doing a deep dive into swelling, the bane of our existence, and what we loathe as PTs coaches, especially as ACLers. It is just something that we have to deal with, with this territory of just getting injured and with surgery. And swelling just loves to be a pain in the butt. 

With that said, the thing with swelling is that it can be a little bit more challenging compared to pain. Now these are both things that people feel after an injury or for surgery. Pain is something that we can navigate around, especially if it’s not sharp. Sharpness is a little bit more challenging with the early post-op and post-injury because things are just really at high sensitivity, may be something in there that’s truly damaged. But then as time goes on, whether it’s after injury or surgery, that sharpness slowly starts to decrease, and then we start to just have dull pain, aching, all the things. It could be from a, a number of reasons. 

But with swelling, it’s also something that is typically accompanied whenever there is an inflammatory response and whenever the body is noticing there’s a threat, and especially when healing needs to take place because it’s taking all of these white blood cells and all these things we need to get there to help repair torn tissue over and all the things. It’s something that can just be a bit more challenging and it makes the knee feel tight like a balloon, especially if we’re working into more flexion-based work. It can make it feel stiff. It can really impact the strength, especially with the quads as we know, just weakness feeling around the joint. And there’s just so many things that people will report. 

And trust me, I’ve had my own fair share of knee swelling with my two ACL injuries, my reconstructions. And honestly, over the past 17 years since my first ACL injury, I’ve had experiences with this. And it’s just something that just becomes a real big pain because sometimes it’s not even actual pain itself that’s limiting, is just the tightness and fullness of the joint. Feeling like it’s just like a very, very tight balloon, especially if you bend the knee into flexion positions. But we still notice that when we’re standing, it just makes things feel stiff. And it’s something that creates a massive barrier for ACLers and clinicians and coaches working with ACLers. It’s shown to persist for an average of three months post-ACL injury and up to 12 months post-ACL reconstruction.

[Freble] in 2008 had reported that. And this can really span across a lot of different timelines based on the person and a number of other factors. And piggybacking off of this, there was a study by Tore in 2000, where they injected the joint with 20 to 60 milliliters of fluid, and it reduced quad strength on isokinetic testing by 30 to 40%. That is just some insight and how much some swelling can really influence things. And we see this firsthand with ACLers when they’re dealing with swelling. And as we know with AMI, it’s a big thing that we deal with arthrogenic muscle inhibition and swelling is a very big connection with that and how it influences the activation of the quads and some of the more complex neurological system as well. In terms of this AMI. 

It’s interesting to see that even just putting fluid into the joint influences quad strength in this study and just injecting the joint with fluid. There are other studies on this that I think is really cool, not in the best way for ACL rehab, but it gives us a lot of information regarding how much swelling influences things. I will be diving into a future episode talking about this particular subject of studies injecting the joint and the byproduct of that. But as we know, the quads are impacted.

Some people are just naturally more prone to swelling, effusion compared to others. And there are so many factors that influence this. We can’t pick just one thing. We might have an idea of one thing based on just tracking people’s history and maybe more obvious things, but there’s a lot of things at play. Think about the history of your knee coming into the ACL injury and the surgery, your age, your genetics, the injury itself and what all was injured, the time between the injury and if you have surgery, the surgery itself and all that was done, the graft type, weight bearing status immediately after, was the meniscus impacted, was it repaired, was a menisectomy bone bruising, makes a huge impact on this or any type of fracture, any other ligament damage. Just think about all those things that could play a role in this and then also the surgery afterwards. An isolated ACL versus an isolated ACL plus MCL plus meniscus. Knee is probably going to feel a little different based on different structures being impacted versus just one single structure.

And then all those different structures also have just different responses to the way body responds to it from pain, swelling, and just a healing standpoint as well because of blood flow. All those things will be influenced based on the different structures and tissues within the knee. And then other things to think about, is going to be just your due diligence of elevating, compressing, doing your rehab stuff, maybe doing too much or too little, the crutch use afterwards.

A lot of times people just ditch their crutches too fast. Those are things that we see a lot of the times, life itself, whether you are working, the type of work you do, are you a remote worker, do you use a computer or are you someone on your feet, a teacher, a nurse, a doc who’s in the ER doing 12 hour, 24 hour shifts might be a little different. Whether you’re traveling or a wedding’s coming up, like there’s all these things that play into life that we don’t necessarily look at, but it is crazy how much this influences people and their knee and how it’s feeling. And it is just something about being on your feet. It’s the gravity of it. It’s just the compression of joint. There’s a lot of things at play. And I haven’t even named all the factors in this, but those are ones that do happen along with other things going on. So just keep that in mind that we can’t always just narrow it in on one thing because there’s usually a lot of different things at play because of the complexity of the knee, the complexity of the human body, the complexity of our lives.

But our goal immediately post ACL injury and post-surgery is to get that swelling out. Now everyone out there can say, ah, we need swelling and inflammation for the healing. Don’t mess with that. Yeah, that’s fine, but that’s going to take its place no matter what. And let’s get the swelling out because we know at this point, current day 2025, swelling equals not great for the knee and not great for the quads. Guess what? One of our goals is post-op and post-injury. Get those quads going, get your extension back and swelling just really rears its head against that because one thing that’s important with this is to consider just the joint mechanics when swelling is in there. Whenever the knee is fully straight, it’s in its most compressed position in terms of just not having as much room within that joint. So then it adds pressure to that joint when you’re in full extension and it’s open pack position or just like a bend in that knee is where that knee has a little bit more room to breathe because those joints aren’t pushed together. Therefore, that’s why the knee always likes to be in a slightly bent position after an injury or after a surgery. Even though it’s “locked” in a brace, I promise you that knee is not totally straight. It is still slightly bent by some degrees after surgery and after injury in the most part, even if your brace is zero degrees, if your brace is negative five degrees. It’s probably still hanging out in there because those straps aren’t perfect.

With that said, that influences the pressure in the joint and it also influences the way that the joint is feeling in terms of that swelling. As I mentioned, the goal after post-ACL injury and surgery is to get that swelling out, as part of our goal to achieve the quiet knee. We want our symptom profile calmed down. That’s our pain, and we want swelling to also go down. And as research has shown with AMI as I’d mentioned, the arthrogenic muscle inhibition, it’s basically a neurological disconnect of your quads wanting to kick on. There are other things at play, but the way you can think about this is you got a Christmas tree and you have lights on it and it’s fully lit up. And what ends up happening is that when you go to actually plug it in or light it up, it’s only halfway lit up. The other 50% of the bulbs aren’t turning on. Basically, it is not firing at the rate it normally should with our motor unit recruitment. And there’s a lot of things going on in terms of the neurological system, locally and centrally in our spinal cord and brain. It’s crazy, y’all. There’s a lot of things that change after an ACL injury, and it’s not just a knee joint injury or a muscle injury. It is something that is way more complex than any of us can ever explain. But with that said, the swelling and effusion has shown to play a massive role in this AMI, which is why our goal is operation—get the freaking swelling out. 

We focus hard on this swelling management post-op and throughout the process, which is why today I want to share with you eight ways to improve swelling after ACL injury and surgery. The reason I’m bringing this up is because we need practical ways to do this. My goal today is to share this with you guys. I’ve shared some of these ways before, but I want to go into a little bit of a deeper dive so then that way you have strategies to do this, ways to assess it and be able to put it in play for yourself because it’s something that we all deal with. The ways that we help our athletes manage the swelling and be able to try and get rid of it, because we want to try and get them back to the thing. And this thing ends up being a big, big barrier for a lot of folks. 

The first way is to assess it, and that is to use a stroke or a sweep test. I know the literature refers to it as a stroke test. A lot of times people refer to it as a sweep test to gauge it daily or semi-regularly. And it’s a five-point scale that you can utilize yourself, you can look it up yourself. It’s pretty simple to assess. You don’t need some sort of massive degree for this. You can do it. And we teach a lot of our athletes how to do it. It usually has a lot more value once you’re out of the early post-op phases because it’s going to be so obvious you have swelling, for most people. And then as you start to just increase like your training, maybe you start running and do dynamic stuff, like that’s when sometimes it can rear its head and it’s not as noticeable. And so that’s when this can have a lot more value, but it’s also good to just assess as you go to see, is it going down? It gives you a little bit more of an objective scale to it. There’s five different points that you could be on this from no swelling, all the way to swelling is there no matter how I stroke the inside of the knee and then the outside of the knee. It’s not moving at all because it’s just full of fluid. And there’s the whole range in between. You can also use like a circumference measurement around the center of the knee joint, for swelling to monitor it. But I prefer the stroke test myself. It’s something that we teach our athletes and it’s something that helps us to monitor this.

A lot of times what I see is with this stroke test is that sometimes athletes are like, yeah, I don’t have any swelling. And then when we go to see this, you can actually see just a small little bit of fluid within that joint that moves when they do this stroke test. It might be trace, or it might be one plus for example, but it’s not absent. And so that influences potentially extension, the way the knee feels from a stiffness standpoint. The quads just feeling like they’re really doing their thing to just all the other activities and impact things that they might be doing. Assessment is helpful to make sure we can keep tabs on this. As you guys know, we’re big on testing and connecting numbers to things. Using the sweep test is a high value add to your ACL rehab. 

Number two is going to be your load management. This is probably the biggest player that gets overlooked, but it’s the thing that influences swelling and joint effusion more than anything. And what load management essentially means is think about all the stress that you’re cumulatively putting on the knee within a day, within multiple days a week, multiple weeks, a month. We’re basically looking at what does that trend look like over time and are there any spikes in that? And we want to manage the volume and the intensity of those things to make sure that it is not too big of spikes. A lot of times what we see is that people just might be doing too much too soon. And the challenge is that a lot of times people are super active prior to the ACL injury and surgery; therefore, their threshold of high activity might be super high. Therefore, when they think they’re just like walking around the block or being able to walk to school and back, for example, that’s so low compared to what they could do that that shouldn’t influence thing. But it’s all relative to where you’re at in the most recent place you’ve been at. 

With load management, it is just basically you might be doing too much too soon. And this is also after a time where you might not have been doing too much. A lot of this can come back to a lot of injuries to be honest. It’s just been under loaded or we just haven’t been able to keep a high capacity for it, so then we make jumps back to our regular lifestyle and people just end up blowing the knee joint up or it ends up being probably not a good thing to say on the podcast. They just end up making the joint pretty grumpy. And it is just challenging because what happens is there’s pain and swelling and it might regress a little bit from range of motion and just muscle standpoint.

With load management, you need to adjust your training and your volume to a level that your knee doesn’t get swollen. A simple example of this is running three miles creates swelling, but it’s fine at one to two miles. It stays at this a little while longer. Add smaller increments as you progress. Maybe instead of a big mile jump, maybe you do a quarter mile or a half mile jump. These are ways for us to be able to monitor the volume of things and see how the knee responds to it. It’s a dose response. 

We use as the 24-hour feedback loop to see what you did the day before is making it better, worse, or the same. If it’s worse, do less. If it’s the same or better, cool. Keep moving forward. If it’s much better, then you can progress a little bit more, but don’t make those big jumps so that’s going to be really key. Now within load management, step count is so huge. It’s something that we talk to every single one of our athletes, especially post-op and post-injury, but especially as they might be getting back to something they need to do with a certain step count. For example, the teacher, I reference, or the nurse, or maybe it is someone who has to commute to work or the high school athlete who is walking to school and walking around school, same thing with a college athlete. All these things are super important and it is highly underrated. This is something that is going to be really important. This is load management in a nutshell, guess what? We have smart devices now where your phone can track it. You have a watch that probably tracks it. Any smartwatch does it and they’re super cheap things that you can get out there to be able to manage this and track it from a data standpoint, but put numbers to it.

And one of my athletes, she’s a high school athlete, and she was wanting to be able to walk back to school with her friends. And the thing is that she was having a little bit of a slower time with recovering post-ACL injury with just the knee being a little bit more grumpy. We had to just check out and see like, what was she walking before? Walking to school? And then also how much steps did she take at school? And so we just tried to look at the averages of those and then we were able to compare, okay, where you are now versus where you were? And then we have a number to go off of. And so maybe we slowly titrate that and see if we can increase the step count as long as the knee doesn’t respond in a negative way. Step count is huge. Also huge if you’re going on a big trip, and a lot of times people walk around, they might go and do things, and so the step count is elevated. Therefore, is just something to reference because a lot of times there’s a relationship between when step count skyrockets and increases, and especially if it’s back to back to back days. If it’s one day, you might be okay to recover if you have a down day after like high-low days. But if you have back to back to back days, like one day, two day even, or three day, just like with traveling, or maybe you just aren’t paying attention and you just ramp things up too fast, then the knee can respond in a negative way—aka swelling and pain. Step count management is going to be key here, just like you would progress any type of other thing. Running tends to be the best example here because people understand you’re not going to go just from a half a mile to a five mile jump. But in step count territory, you go from a very low step count to something super high, typically because of normal day stuff. One thing to consider within load management. 

Another point within this is reduce how much you’re standing in the day in the first two to four weeks. A lot of people want to get up, they want to move around and I used to be like, yeah, let’s get you moving. Let’s get things going. And there are time and place for that, don’t get me wrong, for conditioning effects and working out other places outside of just the knee itself in that area. But with that said, your knee is going through a lot and you need to understand that like when you’re standing, gravity is not your friend. Therefore that influences how much it wants to send fluid down because gravity only works one specific way.

That’s why I truly believe we need to make sure we are very intentional about how much we’re standing in the first, especially acute period of ACL rehab, after surgery, after injury, because that won’t influence how much that swelling and fluid will stick around. Anytime I ask people who have a remote job or they have time off after surgery and those people just chill and they stand when they need to stand, get to A to B, do their exercises, maybe even do some off feet conditioning. But outside of that. If they are just chilling, like their knee is responding, typically a lot better than the person who is up and about and moving around and not able to sit still on those first few weeks. It makes a huge difference in your standing volume and so that’s something to also monitor that gets overlooked.

Last point with load management that I want to make is don’t get off your crutches, gradually wean off of them. Yeah, everyone’s familiar with our philosophy of don’t ditch the crutches too early. The brace is what it is. If you can get off that, that’s awesome. Not a big proponent of braces, in general in ACL rehab. But with that said, don’t get off your crutches too fast. Use your crutches longer than you think. And most of my athletes love to give me a little bit of eye roll, especially my high schoolers. But through this process, I have learned so much that being able to offload this leg is so important and manage all the input and stress that goes into it. And the reason they give you crutches is to get from point A to B. But then also to offload this joint so it doesn’t get stressed immediately. It has been traumatized (with lack of a better word) because of an injury and a surgery and therefore, we need to manage the amount of stress we input into the knee.

The goal of crutches is to really help that and let that knee joint heal and give it a very like comfortable state for it to do that. Progress off the crutches gradually, even though you’re cruising and doing well, go from two crutches to one crutch longer than you think, and then to no crutch versus like a cold Turkey. I get it, you’re sick of having them with you. You’re sick of people looking at you like, why is that person on crutches? You get stared at a little bit if you’re in public. You’re in the house, right? You’re in your comfort zone. You’re like, how hard is it to get from A to B? And I can kind of hobble over there. And I get that, I did it myself. I’m not here to point any fingers. But the thing that I have learned is that with being able to gradually come off this people, swelling improves, their pain improves, their gait pattern gets a lot better over a shorter period of time, even though they think getting off the crutches within a few days or a week or so will do them better in the long run. I oppose that. 

And the other thing is because a protocol says that, the protocol doesn’t know your situation, your knee, your lifestyle factors, what was done specifically in that knee. Therefore, with that said, the protocol timing, use that super loosely. Yeah, should you be off crutches after probably like two months or three months. Yes, of course. But with that said, the variance of crutches can really depend on the person and just a lot of factors within their life in the surgery itself. Don’t be ashamed if you’re somebody who is four weeks, six weeks, eight weeks, honestly even 10, 12 weeks out, and they’re still using a crutch. We’ve had situations where this has had to be in play. They’re unique situations. But with that said, if you have a meniscus repair, guess what, you’re probably non-weightbearing for a minute and you’re going to have to gradually come off that crutch. If you hit the two-week mark, six week, four week mark, six week mark, and you’re just like, oh, cool, it’s been long enough. I just need to come off. I’m non-weight bearing. Now, weight bearing is tolerated. Still use this progression because guess what? You’ve unloaded the knee for a longer period of time, and as soon as you start to put weight through that thing, that thing is gonna experience some shock. Therefore, take your time with getting off crutches no matter where you are in this process, and do it longer than you think.

The next one is elevation. A lot of you may remember this from the R.I.C.E acronym (Rest Ice Compression Elevation) after an acute injury. Not a big fan of that one. And I know that there has been some pushback on the rest piece. Even some of the other ones like ICE for example. But in reality, there are new ones that can be more helpful. There is peace and love, which I think is way too long. But with that said, police is a super easy one that I like. It’s protection, optimal loading, that’s the O-L of police. And then there’s ice compression, elevation. We want to make sure we find the sweet spot with loading. We don’t want to just completely rest for two weeks, four weeks, etc. We want to find the sweet spot with loading either the affected area, surrounding areas, or maybe it’s the unaffected areas. Being able to load the other leg or being able to load the upper body. But we want to just find the sweet spot with that because it is helpful instead of just completely unloading, unless it might be something like a bone injury, for example—someone has a fracture. But then there’s still other things that work around to continue loading and to continue to keep fitness up and strength up and whatnot. Elevation is a part of the police and it’s something that is important with swelling. And here we are using gravity to assist you by elevating your leg above your heart level so we can push that fluid back towards your heart. And gravity is your your friend here. It could also not be your friend if you’re too vertical, which is why if you’re on your feet and standing for a long time, guess where fluid wants to go towards your legs and towards your knee, because that is the place where it is finding it’s s needed. Therefore, that’s why we’re saying get off your feet, elevate your leg and get it above your heart because it’s going to help to push that fluid back towards your heart and away from the knee. We always say elevate the leg early and often get it high above you as you can, not too high to where you’re just constantly hanging out on a wall and you’re vertical like a 90-degree angle. There are times and places for that which we like and it should be totally fine. But getting that thing elevated and using just pressure to be able to allow that to come down just by nature of gravity. That’s something that we love to do is elevate the leg. It promotes venous return and lymphatic drainage because of the elevation and that gravity assisting. This allows it to reduce that pooling of that excess fluid in the knee joint.

There was a study by D Giovanni in 2013, that showed this with elevation and the venous return and lymphatic drainage. It’s just something by nature of the way our human bodies work and the biology of it, and our physiology, like that’s the way that is going to help to be able to get fluid out. And that’s where lymphatic drainage comes in. We have a lymph node system, right, or a lymphatic system, and we have lymphatic vessels and lymph nodes. They absorb excess fluid that is within our joints and areas; including inflammatory fluid from the swollen knee, for example. And they move it towards like different regions of different lymph nodes. 

For example, you have a popliteal lymph node that is behind your knee. And then that will help to be able to push fluid up towards your inguinal lymph nodes, which is in the groin region. It’s basically this highway system, just like your bloodstream, that is a lymphatic system as well, and that’s going to help to move fluid along in our bodies. And once it’s filtered, the fluid will actually reenter the circulation through the thoracic duct and then gets back to the bloodstream. For you guys to understand this circle of what happens with fluid is that there is this whole system in our body built to help circulate the fluid and it comes out through our thoracic duct and then it gets back to our bloodstream.

So that is something that is super important, but different from our circulatory system where the heart is pumping blood through the body. The lymphatic system relies actually on movement and muscle contractions to transport fluid. That is huge for us in this process because we want to make sure we can use that to our advantage to move fluid, swelling, effusion out of the joint. Yeah, propping the knee up on some pillows or up on a wall for a period of time is going to be helpful. We will tell our athletes, hey, yeah, do this when you can, especially post-op, post-injury, even if you’re later in the process, just get that leg up above the heart and hang out there. Hang out there for 15 minutes, 30 minutes, 45 minutes. Do it multiple times a day and just see how the knee responds. And typically that helps a lot with getting some of that fluid out. 

These are the main points I wanted to cover for today’s episode, for part one in this series, so stay tuned for part two coming up because I’ve made this episode long enough as it is. How did you only touch on three points? There were points within that. We had to lay the groundwork here, and so this is part one. Catch next week where we will dive into part two, talking about more of these different ways to improve swelling, strategies, important principles around this, and at the end of part two, I will also make it a bit more practical for you guys. That way you know what to take away from these episodes. But it’s important to give you context, understand the why behind this. That way you’re more educated with this. Therefore, if you ever experience something in the future, you’re like, okay, cool. I know what to do and I have strategies around to do that and pick and choose what makes the most sense for you. Stick around for this series. It’s one that is long overdue to be honest, and I’m excited to dive into part two. Until next time, team, this is your host, Ravi Patel, signing off.