Episode 232 | You Had a Cyclops Lesion Removed—Now What?

What is up team? And welcome back to another episode on the ACL Athlete Podcast. Today, we’re talking about your priorities after a cyclops lesion removal, and let’s get into it. Number one, if you haven’t checked out previous episodes (episode 50 and 212) on cyclops lesions and diving into the details of it. And if you can prevent one, I suggest looking into those episodes. I know that this is something that people can sometimes go down rabbit holes with. And it’s important to be well-informed about this. 

To give a little bit of a synopsis before we dive into it. A cyclops lesion is where there’s scar tissue forms in the front of the ACL. A physical block that prevents the knee joint from locking out into full extension. People typically will have trouble getting their knees straight. If you’re listening to this and you can’t get your knee straight, I don’t want you to jump straight to this. A lot of times, people will just be like, Oh, that’s a cyclops lesion. I can’t get an extension. It is a very multifactorial thing, but it can be one of the factors that can prevent full extension, especially for people who are just constantly working at it, and the knee can get there, but then it regresses back. You can’t get full extension. 

But again, this is where working with a professional who knows this stuff, a physical therapist, can help to tease this out and see if that’s the case. But with that said, you might feel like a possible audible clunk with this or like a snap while walking. Not always just to let you guys know, but it is possible to feel that. The symptoms associated with it could be like anterior knee pain, sometimes some posterior knee soreness, like the calves, the hamstrings, and the back of the knee. I’m sure a lot of you’re like, yeah, I feel all of these things. I have a cyclops, and it’s not always, but I know it’s challenging to tease this stuff out, especially with the sensitive knee early on.

The other couple of components that I want to mention are just like poor patella mobility. It’s hard to get that thing moving again. And then also like a weak quad that won’t come back. Again, very common in ACL rehab. I don’t necessarily love all these descriptors. The anterior knee pain is probably the one that I notice the most, and then just people who have trouble really getting there after working hard on it. It could be a possibility. 

Now, what we’re going to do is assume that you’re having a clean-out procedure to remove the cyclops and the scar tissue, or have already had one at this point. What is the game plan immediately after? I think sometimes people think that once you get it, you’re good to go, and you just move forward. You just pick back up where you were. But it doesn’t stop there. And what we need to do is make sure we get very intentional about our rehab process and the game plan. With cyclops, usually, extension is the challenge to get back. This is our number one focus, along with getting those quads to fire.

With that said, the overall theme is coming back to the post-op, or what we call our restore phase goals. Restoring a quiet knee with a specific bias to focusing on extension and your quads a lot. As a reminder, the quiet knee goals are: knee extension range of motion, specifically getting full extension, matching the uninvolved side. And then the same thing with flexion, quads are active and doing their thing. You see that thing engage, and you’re not contracting your hamstrings with it. You’re getting that heel pop. That’s essentially what our goal here is. If you can get that heel pop and match what it is on the other side, that is golden. And every physical therapist will just cry. I would cry because we are just so happy to see it. Anytime I see a heel pop, it’s just tears of joy. 

With that said, those are going to be the main focuses, along with the quiet knee and decreasing pain, and decreasing swelling, which you want to get down because you’re about to have surgery. Therefore, that means that’s something that we want to make sure we get down after that clean-out procedure. We want a happy knee, one that’s quiet and not grumpy. 

Now, a lot of times, people don’t know what to expect coming out of the surgery itself, so I do want to share this a little bit. I’m just going to talk about the scar tissue, cyclops removal, which is very typical. It’s nothing close to the pain or the discomfort of the ACL surgery reconstruction itself because it’s just a clean-out versus bone tunnels and taking and putting graft in. Even if you get an allograft, they still got to make the tunnels and be able to screw those in. You’re just going to be dealing with a whole host of… The knee doesn’t love it post-ACL reconstruction because they’ve done carpentry work on that knee. But when there’s a clean-out, they’re just going in to clean things out versus having to like mess with the structures, and especially with bone. Just to let you guys know, bone is super sensitive, which is also why there’s a lot of sensitivity post-ACL as well. You’ll still have some pain and swelling after this clean-out procedure, given the incisions and it’s a surgical procedure. But you’ll bounce back pretty quickly. Usually, if the rehab is done right and load is managed, aka don’t overstress your knee. Don’t try to go off and start walking a lot right after. We want to manage that load right out of the gate to make sure it adjusts appropriately. You’ll typically have some soreness in the knee joint along with the pain and the swelling. Some familiarity of the post-op ACL feeling symptoms will be there, but not nearly as limited or the degree of pain and swelling, and immobility.

Now, crutches. Will you need them and use them? What I will often see is that surgeons and their staff, whether it’s assistants, people among the staff, will try to get you off crutches ASAP. I don’t get the note here on this, but I’ve noticed this quite a bit as a trend of, “Hey, let’s get you off the crutches. Hey, this is a nothing procedure; get off the crutches. You’ll be fine immediately after surgery.” And contrary to this popular opinion, I think this can come at a loss. And hear me out, because I want to make my case. Because this is something that we need to take on a case-by-case basis. Don’t get me wrong. Some people who come out of this do well, and we get off the crutches within the first few days to a week. And just like any ACL rehab, we’ve got to take this case by case. Putting blanket statements like this on procedures sets people up for failure because everyone is going to respond differently. I will assess to see how their knee is doing right after the clean-out procedure, especially pain and swelling, and we may adjust. Maybe it’s two crutches, maybe it’s one, and we slowly get off of it. 

Could the person go without them? Possibly. But why stress the knee joint, and let’s get it set up for success by managing the load on the knee and symptom response along with solid rehab. And the thing is, why really rush this? And it’s so helpful to have the crutches to be able to manage the stress on that knee joint. We want to offload it to some degree because it just had surgery. Therefore, when there’s loading on it, sometimes the knee can respond by sending more pain, more swelling. Therefore, there’s a sweet spot with this. And that’s where judging it case by case is helpful versus just saying, “Hey, most people don’t get back on crutches, you’re gonna be fine.” And then what happens is you have pain and swelling that stick around, and your quads don’t want to activate as well because the swelling still sticks around. Your extension isn’t dialing in as much as you’d hope, even though you’re working hard on it, because your quads don’t want to activate, and they’re swelling there, and it’s painful. And instead, what we can do is just use some crutches to be able to help manage the load. And so I’ll typically have ACLers use it at least once, but we’ll go from the two to one based on judgment, and then wean off quickly based on how they’re doing. My goal is to also get them off crutches because the last thing you want to do is be on crutches again. But with that said, it will help you in the long term to make sure that you get back smoothly to your normal loading and not have a sensitive knee.

And then we’re tackling the quiet knee goals. We may add in some other loading that might have been what they’re doing. Maybe they were doing some machine-based work, or maybe some compound-based work in addition to isolated strength movements. But I want to make sure we do our due diligence to set the athlete up for success with really hammering extension work. We hit extension-based work throughout the day, elevating and compressing to get swelling down and manage the pain response. We don’t want to lose any of that newly gained extension, because what happens is they’ll clean it out, and then they’ll passively put it into the extension to make sure it can get there.

From the surgeon’s perspective, it’s like you got the extension, and keep in mind, you were under anesthesia. No muscles guarding. Your body was loose. You didn’t have this tight like active system around the knee, especially with the muscles. And it was able to get there ideally, and what we would assume in the surgery. Therefore, we want to maintain that. Our main priority, especially in that first one to two weeks with some other stuff sprinkled in within that tolerance, is going to be working on that extension. You’ll hear that the scar tissue could come back, and that’s not completely wrong. I’m not here to say, “Oh, once it’s gone, like you don’t have to worry about it again.” There are situations where it can come back. But when we have ACLers who have this procedure for the most part, and get after it with their rehab, and do the right stuff, it rarely does come back. And we see that pretty consistently. And for those that did, they are typically more prone to their knee and body laying down scar tissue for some reason.

Hard to pinpoint exactly why, but there are some people whose knees just love to send extra scar tissue and build up around the knee, especially after a surgical procedure is done. They may have some underlying inflammatory processes, maybe autoimmune-related things, or maybe it’s just naturally just their body and biology and what it does after something like this. What you want to avoid is rushing these steps. People assume because it’s cleaned out and they’re typically months out from the ACL reconstruction, that they can just move along and just go from there. Just pick things back up as if nothing ever happened, or that clean-out procedure happened. But here’s where I caution and say, you need to do your due diligence because you do not want to overlook this and do the other fun lifting stuff, then pay for it later because you just didn’t prioritize it.

And I’ve seen this happen, I’ve seen this where people are like, oh, the extension’s back, like it’s been cleaned out. And then they don’t take it as seriously. And then you can see the extension regress a little bit. And that’s something that you want to make sure at the end of all this, that you have done, your due diligence and a loss of extension or this procedure wasn’t at a loss, and that it’s not due to you not being compliant with things, which I know you guys, if you’re going through this, you’re like, I will do anything. Just make sure you stay on top of it. ACLers often feel like this derails their ACL rehab process when they have a cyclops and then have to have it removed. And don’t get me wrong, it is a detour, but with the proper game plan, it’s a one-step back and three steps forward. I see it all the time. We deal with this as a team. We tend to get right back on track with the programming and with the guidance as long as it is dialed in, versus delaying things months and months out. 

For example, I had an ACLer who had developed this later in their process. They were around about 10, 11 months, and they had a cyclops that came out of nowhere. She was crushing it, but then a sudden extension regressed, and it looked like we don’t have all the details on cyclops when started. There’s some people where it starts like months out. There’s some people where it starts months and months out. It can spread across, or maybe it was there and it just built over time.

We sent her to get an MRI, and they found the cyclops got it cleaned out immediately. We spent about three to four weeks in a block adjusting her game plan to focus on these things I mentioned. And she was right back to where she was before, crushing it versus regressing drastically because of this procedure. She got her strength and symmetry back quickly. We were back to doing on-field progressions like running, cutting, and jumping as we ramped it all back up. But that’s because we went into it dialed in. We had a plan right after she got out of it and then. Immediately after that, we made sure to progress each week based on how she was doing, listening to the knee, focusing on these priorities, and then being able to get right back into things because we also worked on the strength components within what she could tolerate.

But that’s the difference in having us all a game plan with experience navigating a road bump like this. She got worried about it taking months off her rehab. I was like, if we stick to these basics, if we stick to these priorities and these principles, you’ll be back much faster than you think. And we see this pretty consistently with our ACLers who have cyclops lesions and then go to get cleanouts. We just want to make sure we have a plan in place. We set our priorities and make sure that the plan is progressing based on how the athlete is doing, versus slowing things down drastically, versus speeding them up very quickly, too. There’s a sweet spot, and every ACLer’s case is different, which is why we need to individualize things to you based on where you’re at and how your body is responding to this procedure and to this overall recovery.

I hope that this is helpful, y’all. Just to be able to have an idea. If you have a cyclops clean out, what should that game plan look like right after? Until next time, team. This is your host, Ravi Patel, signing off.