Episode 226 | The #1 Mistake After ACL Surgery That Keeps Swelling Around

What’s up y’all? Welcome back to another episode on the ACL Athlete Podcast. Today, we are talking about sneaky ways that swelling can stick around or interrupt the ACL rehab process. And I’ve been more on a swelling kick because of just conversations we’ve been having, talking with ACLers, talking with the team, and different ways that we’re seeing this show up. And swelling is always something that we are tackling ASAP in ACL rehab, as soon as possible. We are trying to get this thing out. A lot of times, people will say, oh, well, we want swelling there, and the inflammation there for the healing process. I promise you, as far as what we know now from the research and from the way the natural way that the knee moves and for the sake of our quads, for range of motion, we want to get the swelling out as quickly as possible. And that is one of the biggest dreams and biggest goals for not only ACLer, but especially for your physical therapist or rehab provider. If we can get that knocked out and get your extension going, get your quads awake, you are on the road to some solid success early on.

But the big thing is, it’s a challenge because, of course, as the surgery happens, as the injury happens, and all the other factors that play into it, the injury and the time between injury to surgery: how bad the injury was, are there any other issues in there like bone bruising, other concomitant-type issues that also arise during the injury, any additional procedures that need to happen like meniscus or MCL. Maybe there’s a tibia plateau fracture in addition to harvesting an ACL graft from one of the sites or an allograft. And then of course, putting that thing in there, getting the bone tunnels, putting the screws in there, all the things right. Therefore, we understand why the knee is mad and angry after a surgery like this. It is healing, and it’s our natural healing process. 

But with that said, people have different reactions to swelling. We’ve had some people whose knees don’t swell up, and you are one of the lucky few. While most other people have a normal response to swelling, to maybe a very extreme response to swelling. And then, of course, other live factors play into this. What I want to talk about today is just thinking about what our daily lives and rehab and things of that nature will play into how maybe swelling can stick around, especially in the knee joint and what we can do about it.

And I’ve seen many situations where people are trying to improve all the things, and it’s something we do, especially early on. We’re trying to work on flexion, extension, and pain. People are also limping with their gait, their quad activation, trying to also exercise outside of this. And when they prioritize getting their swelling down, we typically see that the rest of these different buckets or different pieces tend to improve, and improve a lot. If we bring swelling down, their extension improves, their flexion improves, their pain improves, their limping improves, and guess what, their quad also starts to improve with waking up and getting activated. That doesn’t necessarily mean it’s a one-to-one, okay, if swelling’s gone, then therefore these things will automatically just improve and get better. It just gives you a better opportunity and a better stimulus, if you will, to be able to work on these things because swelling does butt head with these areas. When you have more fluid in the joint, it’s going to limit all these things because it is just naturally impacting the way that that joint moves, the pressure, and also the way that muscle activation is around the joint.

And that doesn’t necessarily mean that we just forget about everything and just work on swelling, we work on all the things. But then we are going to heavily prioritize swelling management, especially early on. We have to plan and manage these things, and that’s where a good program individualized to you going through this process, but then also good guidance to adapt it as we go. Because guess what, life’s going to happen; things are going to change. Therefore, we need to make sure it’s an adaptable plan that is guided. 

And if you’re looking for a swelling management strategy, I did a two-part series on this: episodes 216 and 217, where I dig into some of the research, as well as practical swelling management strategies. And that’s something that I want to make sure is out there for you to be able to look at and be able to utilize. And maybe there are some things that you’re not tapping into that you weren’t educated on, or maybe something that you’re like, oh, I didn’t know that this was an option. And something that is just an easy low-hanging fruit for you to implement, especially if you’re dealing with some fluid and with some swelling in the joint. 

The thing is that this doesn’t just apply in terms of the swelling pieces early on to post-op ACLers or post-injury ACLers, this can also go for the ACLer who might be out of these earlier stages and months in, but still dealing with some swelling, is typically lingering from the earlier stages more often than not. This is always an important point if an ACLer we are consulting with or working with brings up dealing with swelling. We’ll have people say that they are “following” the plan. They are following all the details of the plan, all the guidance that’s been given, whether they are working with someone else or maybe they’re working with us. And they’re saying like, yeah, I’m listening to everything. I’m doing all the stuff, and then their knee is still feeling tight and swollen and symptomatic. And this typically leads to a delay in the progress during the ACL rehab process. We can’t necessarily move forward if the knee is not responding well to what has already been given. And the word we’re looking for is tolerance. It is not tolerating the stress that is being placed on it, the knee joint itself. That leads to symptoms, typically pain and/or swelling. There are people who are dealing with pain who don’t have swelling, and there are people who don’t really have pain, and they’re dealing with swelling. Can often go together, especially the earlier you are in this process. But with that said, the symptoms are manifesting themselves, especially the swelling piece, because the knee joint is not tolerating what is being placed on it. We are exceeding the capacity and the tolerance of that knee joint. 

As rehab professionals and coaches, we have to play detective. And while it could be a super tricky and symptomatic knee, those do exist while following the plan. More often than not, it might be what the ACLer is. Or (if you will, or is not doing outside of their ACL rehab). And so this is an important point here. We have to start asking questions: When did it start? When did it start to potentially spike, if you will, in terms of these symptoms, and specifically talking about swelling here or fluid in the knee joint? It could be just a little bit, or it could be a lot. There’s a range of how much that could be. What variables have changed since this started? Did you go too hard in a session? Did you go too hard in multiple sessions back to back? Did you take a rest day? Were there any other factors contributing? And what we often see is that people think that there was no change, and it just happens out of nowhere, or sometimes it’s something that they connect the dots with, but it ends up not being that thing. It ends up being okay, well, let’s say, for example, someone gets sick with a cold. If we had no understanding of what cold medicine does? Usually, a cold is a virus, and therefore, cold medicine that we buy over the counter. You’re like, oh, well, the cold medicine made it go away. And really, it just dampened your symptoms. The cold medicine is not healing your virus or taking the virus out. It is actually something that is just helping to dampen the symptoms that way as your body is fighting this virus, that it is essentially going to take the time it needs to be able to fight this thing off and heal.

But that’s where it’s really important here, where sometimes people will say, like, well, this was the reason why. Or sometimes when people are doing certain things during their ACL rehab, they will often say that they were doing, you know, X movement, and they’re like, oh, it’s because of X movement that’s why this happened. In reality, it’s not always just this one-off, while it can happen like this, but especially with swelling. A lot of times, there can be these things that can kind of play into it and it’s just not something that just happened out of nowhere. Sometimes that does happen, of course, but like I said, it is rarely that, and it’s usually something that is maybe non-exercise-based activities or live things that can sneak in, and I see this all of the time. And we as a team talk about this all the time, where someone is still dealing with swelling, and they’re like, we’re following things and tackling it to a tee. And then I just want to share a couple of examples of recently, here of just some things that we’ve talked through with some ACLers to help hammer this home, and this might connect for a lot of you. 

We had an ACLer who was crushing it after two years of lots of issues. Two years of a lot of stuff going on, a lot of poor guidance here, and then they came to us, started working with us, and he was doing well. And then his knee randomly started to get puffy and had some pain. And I was really thrown off by this because the athlete was doing so well. Therefore, things like this can happen where maybe their knee kind of flares up. They do some sort of awkward movement, and the knee just twinges, if you will. But oftentimes, whenever something like this happens, where like, okay, is there anything that happened that you noticed of and they’re like, no, not really. And then I started to dig deeper. And this athlete in particular said he was trying to focus on losing weight. He had it on his mind. He had gained a little bit of weight since he had torn his ACL and not been able to exercise like he wanted to. He decided on his own to start an incline treadmill every morning for a week, for an hour at 15 degrees of incline, and then his knee flared up. He never mentioned adding this in. And I think in his mind, he’s like, oh, it’s not a big deal, or it’s not too intense, it’s just walking. It’ll help me lose weight and probably help the rehab itself get my knee stronger. 

But in reality, in combination with his workouts plus this specific input, it was just too much. It flared things up. And that wasn’t something that was communicated because a lot of times, what happens is that ACLers, you just want to move, you want to do your own stuff, you don’t feel like you need to say every single detail, which I understand that. But it can make things a little challenging because this stuff isn’t just a one-off. It’s usually an accumulation that ends up adding into this. Plus, you got to think about all the other variables in life, and also your rehab itself. This is something that he wanted to throw the towel in all of a sudden because of this and his long stint prior to working with us in two years of just going through this process. He was doing well, but then this knee flared up and we had to redirect it back. We had to educate and we had to be like, hey, look like this was a spike in your training load, 15 degrees incline for an hour is a lot on anybody, especially whenever it is back to back to back days in addition to your rehab, in addition to just your daily life. There was a spike in training and step count and volume that we had to play detective and figure out that he was just like, oh, it’s not a big deal. Anyways, redirecting this helped us to understand why it happened. And then for us to game plan and adapt things as we go. 

Another example of this is that this is an ACLer who is older. She had a cadaver graft early on post-op. She said things were going over overall really well. But she can notice the knee feeling tight. I’m sure some of you can probably relate to this, where the knee feels tight, but it doesn’t feel swollen. You wouldn’t necessarily say, yeah, my knee is swollen and then when you look at both knees, maybe it is just a little different around the kneecap, on the ACL operated side. But you wouldn’t categorize it as like, yeah, my knee is really swollen. The thing that is usually communicated, especially when it’s visually not able to see it as much, is that the knee feels tight. And usually when you go to bend it or flex it, that’s when it’s even more noticeable because it approximates that joint and puts more pressure into the joint. If you have any extra fluid in there, guess what, it is going to tell you whenever your knee goes into that deep flexion.

She noticed the knee was feeling tight. She said she had been walking a mile every day. She was early post-op, and she was wired as a mover, never was sedentary, and she was itching to move. She thought she was in a good enough place in her rehab to start walking. This was just consulting with her. She just set just this arbitrary goal to walk a mile and there’s nothing wrong with that. We just always want to make sure that it aligns with where the person is and meeting them where they’re at without the detriment of their progress. The challenge was that she was also rehabbing. She just thought it was normal when in fact she had spiked her step count post-op. We had to back off things and improve it a lot and that was the big goal here. When she did back off of it, man, the swelling settled down. And then it happened again, where the knee swelling came back. She started feeling some tightness. She mentioned no changes, and the plan was being operated as had been discussed. Then, she mentioned she started standing at work more, adding more walking back into the mix here and there. And instead of the five-minute reverse treadmill that might be in her warmup, she went for 30 minutes every day. Y’all, people who love to walk, I know you can relate here, and this is something that makes it a little bit challenging for us and challenging for your knees. 

Again, not following the plan and creating spikes in their overall load or stress to the body and the knee. And I see this a lot with people who go and travel. I just did a recent episode on this about traveling and setbacks, and just understanding what that looks like in terms of training in your rehab. But we see this a lot with people who are traveling because you’re on your feet more. Athletes with potential school or going to college and walking around and maybe they get the two weeks off for a certain break, but then they got to get back to school. You may get some assistance there. But in general, you go from not walking a lot post-op to potentially a big spike. And it might not be even close to what you were doing. Maybe you were hitting 10,000 steps a day, maybe you’re hitting 15,000, maybe even 20,000 for some of you guys. And that’s the thing, especially if you’re a runner, if you’re on your feet a lot, then that is nothing out of the ordinary for you. When you’re early post-op, you’re like, well, what’s 2000 steps? I used to, could do like 10,000 or 15,000 on average. The thing is that the body is going to just do what it does; therefore, we have to understand that when you putting yourself vertical: one, gravity is working. But then two is that there’s just being load and stress on the knee and the body after such a major injury, and especially a major surgery where there was a lot done.

This can be challenging, especially for those folks who do go travel or people going back to school or college, or people who have jobs where they have to be on their feet. I’m talking about nurses, talking about ER physicians, thinking about long shifts, 12-hour shifts, 24-hour shifts. Maybe you’re a teacher. There are so many different occupations that we work with, where people have to be on their feet. And guess what, you’re just at a general disadvantage early post-op compared to the folks who are remote or able to sit down and just prop their legs up. And that just comes with the territory of just what you do or what you have to do. These all make a massive difference, especially with a post-op knee, that is sensitive, and especially that is dealing with swelling. 

I know sometimes that can’t always be changed. You have to go back to work at some point; therefore, we can’t necessarily change that in your situation most of the time. I think it’s a matter of controlling what you can, especially early on. And that’s what I want to drive home here. It’s also not about trying to smart the system, thinking it won’t hurt, or this little bit will not hurt. And oftentimes, I do get that some people don’t know that it’s a big contributing factor, and it’s rarely ever just one time. It’s usually the accummulative effect of it repeated over time. Yeah, one mile walk might not be that bad, and then if you don’t do it at all after that for a period of time. But then when you do that more consistently day after day after day with asymptomatic knee, that’s still early on. That’s getting used to load bearing again, being able to be stressed, and also you’re stressing it with rehab and pushing the joint. That’s maybe that altogether is going to be the thing that might push it over the edge and keep the swelling and the symptoms continuing to stick around.

What I want to do is be able to provide a helpful framework to understand how swelling might sneak in based on human movement. In general, we want to think about movement as a total load, sometimes referred to as an allostatic load. This concept is important because if this load is too much over a period of time, chronically, especially, it can create problems, in this case swelling, where there may be some sneaky factors playing into this; total load we’re not considering.

Let’s walk through this very briefly in terms of what this looks like. Number one, there is a structured physical activity that is typically exercise-based, and we’re going to throw our rehab into this. Number two is going to be non-exercise physical activity. It can be seen as NEPA, and then there are activities of daily living or otherwise known as ADLs. And then number four is just sedentary behavior. That’s just us sitting, not moving very much, doing things stationary. Now, I want to dive into each of these very briefly. When we talk about number one, structured physical activity, of course, that is very obvious here, but this is typically exercise-based, rehab-based, it’s intentional, it’s planned. It is a very goal-directed movement aimed at improving your fitness or rehab, or function. This could be aerobic exercises, this could be resistance training, it could be mobility, or flexibility work. It could be rehab-based work, it could be sports and recreation-based stuff. But this is stuff that is going to be your structured physical activity, usually to help someone from that rehab standpoint or to help improve physical fitness.

And then there is the non-exercise physical activity (NEPA). This is the sneaky one, unstructured movement, not intended as exercise, but still contributing to energy expenditure, and physical function, daily movement, walking to the stores, taking the stairs, household chores. Occupational-related activity, physical jobs, especially construction, and standing at work. As I had mentioned, maybe it’s a teacher who has to be on their feet a lot, a nurse, an ER physician. There’s so many occupations out there that people have to be on their feet, or especially physical labor where they’re doing some hard work. And then there’s leisure activities, gardening, light yard work, playing with your children. Not classified technically as a formal exercise, but you’re on your feet and you’re moving. This can also be something that is referred to in the research as neat non-exercise activity thermogenesis. But this is essentially all physical activity that is not deliberate exercise. That’s going to be important here because this NEPA is going to be the sneakiest one of them all.

You have number three, which is activities of daily living. This is basically your self-care stuff you need to do every day for independent living. You have your basic a d ADLs, like getting a shower, bathing, dressing, grooming, toileting, feeding, and then you have instrumental ADLs. That’s like cooking, cleaning, shopping, and using transportation. These are things that, in a sense, are just like activities of daily living for us to just thrive as humans. And then the last piece is sedentary behavior. This is usually when you’re awake, and then, therefore, it’s low energy expenditure, and typically you’re seated, maybe you’re reclined, whatever that might be. Maybe you’re lying down. But with that said, it might be sitting at a desk, remote work from this standpoint, watching TV,, driving, being on a computer, playing video games. This is essentially very different from physical activity being physical inactivity. This is something where people can still meet their exercise guidelines or physical activity guidelines, but they could still have high sedentary time, if you will. You might go exercise for 30 minutes to an hour, and then therefore the rest of that time is spent seated for the most part. Nothing bad with that, it’s just more of a terminology that is utilized. 

With that said, these are the four components that are going to be important structure of physical activity, exercise-based if that makes sense. And that’s what the rehab process is, and where we assume you are stressing the knee. Non-exercise physical activity (NEPA), this is the one that if you want to say “the silent killer,” if you will. This is the one that most people overlook as nothing, but I promise you it adds up and could be playing into why your knee stays swollen. In terms of activities of daily living, this one can also be like a sneaky secondary silent killer, where you might just be on your feet a lot doing stuff, especially if you have kids. I know that that’s something that you can’t just get rid of your kids. You have to take care of your kids. We have people who have six-month-olds. We have people who have 2-year-old, 4-year-old, 6-year-old, multiple kids, twins. Therefore, it makes it challenging because you can’t just sit down, you have to make sure that you’re taking care of your children as well. These types of things can add up. And then, of course, the sedentary behavior piece, we’re not too worried about, unless you’re just not moving at all in your day. Then, of course, that’s also not good as well. When we are looking at this, there’s always a sweet spot with this. I think the best way to manage this is through knowing what your rehab programming is, and then also knowing your step count as an easy proxy. That’s easy starting point with this. If you do not have an Apple watch or some sort of way to track your step count, typically, most phones do this. It is not as accurate. But with that said, like most people have their phones on them, and you’re able to track your step count roughly. Right now, give or take, depending on how often you have it. Maybe you set it down somewhere. But at least it gives you some sort of frame of reference for movement, depending on how much you have it on you. But yeah, your rehab programming and your step count are going to be such easy proxies for us to measure and be able to look at. 

Now, as I mentioned, not perfect, but it is helpful to keep it objective and also adjust the dose response. Maybe it’s 5K steps, your knee doesn’t feel great. Then stay there as you continue to build your load and your capacity, maybe it’s at the 4K. You’re like, I feel good in the day. And then slow cook this thing. Do not rush trying to build up your step count because I promise you from a swelling and symptom standpoint, your knee will be like, I’m good, and it’s going to slow your rehab down and. Being in this rush mode or trying to force it, is definitely not going to feel very great. Don’t rush it because I promise you, as long as swelling is there, even the littlest bit in that joint, you may not even notice that is going to impact potentially your range of motion, your quad strength gains, your pain, and more importantly, moving along in this process as a whole.

I compare it similar to putting the e-brake on while you are trying to drive. You may be moving along, but it’s not moving like it should, and it could be better. Imagine getting in your car, you throw that brake on where you press in with your foot, or maybe it’s a hand brake, and you’re trying to drive with it. And your car will be moving. The thing is that you just know it doesn’t feel right. And that’s how this happens, especially when you’re dealing with pain, but especially swelling, because that is going to influence the joint. I know I’m like really being a dead horse here, but like the thing is like this is so important and something that does impact people’s overall process. It can make a massive difference in how the rest of it goes. 

My encouragement to you here is to evaluate these things in your own ACL rehab. Of course, there might be things you can’t control, like our athlete who has to get back to school, as I had mentioned, and walk the halls during the day. Or the teacher who has a kindergarten classroom or the ER doc who has a 24-hour shift. But when you can make adjustments, do it. And for those who love to walk or love to move and are itching to do so early and thinking they’re fine, I would recommend making sure to follow the plan and don’t add too much too soon. Talk with your rehab provider. Ask them if it makes sense to do this, even if it’s just like a half-mile walk for you, and you’re like, I’m used to walking five miles a day. It can add up, and it can accumulate. 

My goal here isn’t to scare you from moving, that’s the last thing I want to do, and our goal is always to have people hit their physical activity guidelines, do this rehab well, and get them moving as soon as possible, up to a certain threshold and sweet spot, but not at the detriment of your rehab. Instead, what I would say is like, see if you can scratch that itch by doing off-feet conditioning, bike is a good option here. Once the range of motion is good for flexion, or using the fan or assault bikes, where you can have your leg off and use the arms. Same with like a rower where you could put that ACL leg on a slider, a skier where you’re sitting down, maybe med ball circuits, and so many other implements we can use to create a circuit, create a cardiovascular effect, feel like you’re working and to scratch that itch,  to be able to hit those physical activity guidelines without compromising the knee joint. It is off-feet conditioning or off-feet loading that you are able to do that isn’t going to impact the knee joint as much as being vertical, and especially increasing your step count, especially early on or for people dealing with lingering swelling issues. 

And we’ve had people start stuff like this week one. You don’t need to be a couch potato for the first two weeks or four weeks, or “rest” as maybe some surgeons might say in the first four weeks. We need to move. We need to move in a very strategic way, but we also don’t want to do it too much, and we don’t want to do it too little. This is where it comes back to having a good rehab provider who knows this stuff and has a plan, and not only just a plan that is like, all right, this is what it looks like, but it’s adaptable. Because I promise you, whatever plan that you start with will not be the plan that is going to be the same at month 2, 3, 4, 5, 6, 7, 8, 9, 10, or however long you are in this process. It needs to be adaptable because life doesn’t happen in a vacuum and rehab doesn’t happen in a vacuum. This is something where there are so many moving pieces, so we need to adapt to these things. Most importantly, getting guidance on getting this knee in a really solid spot in the first four to six weeks is going to be so key.

I promise this will make for a much smoother mid and late stages of ACL rehab if you can follow the plan well, and to be able to stick to this and be able to build this up progressively. I always use the dimmer switch. It’s not an on-and-off switch. All of a sudden, you hit week four and you can go walk a mile. Or you hit month four, and you’re supposed to be returning to run, and all of a sudden, you just start with a half-mile run. It’s a dimmer switch, and so we need to make sure we have a good entry point to start. See the dose response of this and see how it accumulates over time, and manage our symptoms and our different KPIs. That’s going to be pain, that’s going to be swelling, range of motion, different strength components. Also, subjectively, how you’re feeling with how things are going. There are going to be so many areas for us to continue to evaluate as you go, and that’s going to allow us to know, do we need to stay in the same spot? Do we need to progress or do we need to regress some things to make sure we keep this knee in a solid spot? And that’s where working with an ACL expert and someone who knows this stuff is going to be so key. 

If you feel like you’re someone dealing with this, then this is something that I would encourage you to seek out. There are plenty of people out there. We do this, and we work with people remotely. We’re happy to help here. But we’re just saying, find someone to support you and guide you in this. You are not the person who needs to make all these decisions. It should be a rehab provider and coach being able to help you with this. And the biggest thing to watch out for is that sneaky NEPA (the non-exercise-based physical activity). That’s where it gets most folks who are dealing with swelling for longer than we want, especially if they’re following the plan. And if someone’s dealing with swelling and they’re following everything to a tee very consistently, then that’s where we need additional medical assistance.

But in most cases, I would say we need to target this well and do all of our swelling management options before we start going down more medical-based interventions. And there is a time and a place for that and we have athletes who need to go that route based on just the way their knee responds. But with that said, I would say it’s not the majority, that is for sure. Look out for this, these sneaky ways that swelling can stick around. Because I promise you, it can make a massive difference in your ACL rehab, but especially if you are in these early phases or you’re someone who’s just having this linger, evaluate these areas and see if you can’t dial it back just a little bit. It’s always this one step back for two steps forward. That’s the way that we look at it, and it is going to allow you to speed up the rest of the process. If you can get past, especially these initial barriers, and that’s gonna help you the most as you go through this ACL process. If you can focus on getting that knee quiet, get it calm early, you will win this process. I promise you this because it is going to be a massive game changer, and you’ll be so thankful as you get into the mid and late stages of ACL rehab. That you focused on the basics, you followed a game plan, you adjusted as you needed to, and your knee is responding really well to the load and tolerating it well.

I hope this is helpful, y’all. If you have any questions, you can always reach out to us via Instagram, via email, or via our website. We are always here to help, whether you are someone who is looking for some support through the ACL process or whether you’re just looking for some questions and some clarity around some things based on your specific case.Until next time, team, this is your host, Ravi Patel, signing off.