Episode 234 | When Sh*t Happens in ACL Rehab: What to Do (and What NOT to Do)

What is up team? And welcome back to another episode on the ACL Athlete Podcast. Today, we are doing an episode that I honestly can’t believe I haven’t done an episode on this. I’ve been thinking about this a lot between the ACLers we work with on the team, as we meet each week, we talk about our ACLers’ cases, what’s going on, what happens, even things that are going on in their life. We want to talk through this as a team and make sure that we are able to give the best advice and game plan to make sure these athletes are moving along in their process, and just knowing that life is complex.

The other side of this is also just through my own personal journey through rehab. For those of you who might be new or who might not have caught previous episodes on this, but some background, I have had two ACL surgeries in the past, a long time ago. I pull a lot from that information, which resonates with this episode today. But more recently, I had a hip procedure on my hip where they had to put some metal plates around the ends of it because I was having some early arthritis. It has been quite a journey and a pretty extensive surgery at the end of March. I’ve been doing my rehab and recovering from that since then. And so that leads me into the topic for today, which is: Sh*t happens… Excuse my language. I try to keep this pretty clean here since I have a variety of aged listeners. Yes, I can be vulgar at times, but I try to retain that and try not to put that out there because I just don’t think that I have to do that all the time to get the point across.

But for today, I think that there’s no really good way to really say this, make it hit home besides sh*t just happens y’all. It happens. It happens in life. It happens in ACL rehab. It happens in hip surgery and rehab. It’s just a thing that we will inevitably deal with. We have fires that come up that we have to put out or just manage to make sure they don’t turn into bigger fires. And it just happens, right? It is just the way that we operate with just this complex world, complex bodies with just so many different factors in life, depending on what age you are, what kind of different space you’re in terms of whether you’re in school or work, or maybe not doing either of those, maybe as family family-based, or maybe traveling. There are so many different factors that play into just what life is, that things are just going to happen. 

The thing that triggered this two days ago, I strained my groin for the third time doing something super simple. I’ve done it before. It was just a position that my hip was just like, “Nope, I’m good.” It is something that I had done before. And immediately my brain was like, “Cool, another delay, another setback.” I was like, man. And the thing was, is that it wasn’t even this big jump, but sometimes it just happens. And I know a lot of you can probably relate to this as you go through this process, it just happens. And most importantly, it’s okay to give yourself some grace. I wanted to look back and be like, man, I should have known this, or I should have done this differently. The thing is that we will always look in hindsight, to blame ourselves. And I’m sure some of you guys will do that. I think the question you have to ask is: were you following the game plan or the guidance you’ve been given? Or, did you go off route and decide to do more or do more consistently over time and that added up to being too much, and you reached a threshold or a breaking point,  and your tolerance was like not built up to that point?

And that’s something we have to understand if we put ourselves in. There’s no one to blame but ourselves. But in the majority of cases, it can just be doing our training in our rehab. And just knowing that sometimes there’s nothing to blame and knowing that sh*t just happens. And that is just moving along the path, doing what we’ve been told, and then the knee flares up. You might get a tweak in your hamstring or your quad pulls. Or maybe, you flare up your front of the knee, the anterior knee pain. It just happens, right? We want to create a story around this. And yes, it is important for us to understand this, especially from the rehab standpoint. Especially us, as the physical therapist and coaches, to play detective in knowing what has happened. And the thing is as though, we just want to make sure that we understand what potentially triggered this, but then also just normalizing that things like this happen as we are trying to rebuild something and stress something. And with ACL rehab, we know there is a lot to stress and build up.

To give you guys some practical advice on what I did in the moment once I felt that tweak. I noticed that it happened. It was like a sharp kind of weird sensation that I didn’t love and I’m familiar with it. I know what it is. And most of you can probably tell whenever you are off your baseline, especially if there’s an incident like that. But even whenever you may wake up and you’re like, wow, my knee is like a little bit more grumpy today. The baseline is going to be important in this. But when we look at what I did from the practical standpoint, the first thing was, I just want to make sure it was nothing major. It was a tweak in my groin. My initial thought was to avoid it, to rest it. Let fear set in, be like, oh man, this is my third setback. I just need to step away from this. But then I’ve always had this thought stuck in my head: if I get scared of it, I’ll build up even more fear and apprehension. Like a little kid falling off their bike. If they fall off their bike and they get hurt, for example, then there might be this apprehension to get back on the bike. You build more fear or you can try again and leave on a positive note and know it’s safe and okay. It’s okay to just make sure that you do that thing, but of course, don’t do it, maybe at the intensity or maybe have some guardrails around it. I still did a modified version of the movement to let my groin know it’s okay. 

Now, had I like really strained this thing. I was in 8/10 pain, 10/10 pain. Then yeah, maybe let’s back off of it. And that’s where we use our traffic light system. If it’s green or yellow light, we’re going to be okay in that. Making sure we avoid anything super sharp. And then anything the red light zone or as high levels of pain, or six and above, we’re going to stay away from because we are going to pay for that later and it’s not even worth pushing into that pain. The thing is that with this situation, I wanted to try and leave on a positive note. I did that modified version of it, and I did let it sit in that green light zone. It got into the yellow light zone where it was into mild to moderate levels of discomfort versus calling it a day and feeling defeated, and just saying I’m done. Important not to let that fear set in, like doing your first jump, for example, and the knee gets super grumpy. Doesn’t mean you just go off and do a bunch of jumps afterwards to make sure there’s no fear, but good to let the knee and your brain and just your overall mental mindset piece of how we do this process. No, we’re fine. Yes, we are stressing the knee. 

When we are applying stress, it’s okay sometimes for there to be a little bit of discomfort or there to be a little bit of soreness. And yeah, sometimes that leads to something flaring up because we push it. But that’s what we’re doing in this rehab process. We’re not sitting in this like comfortable 20% range of our strength. We’re trying to push boundaries and with pushing boundaries you’re going to stress the knee and sometimes it doesn’t necessarily respond as well, and that might lead to being grumpy or pulling something, or straining something, and that can be okay. It doesn’t need to happen all the time, but it’s going to happen, I promise you.  If you’re going through this process and you never have any flare-up or any type of setback, you will be the 0.000001% of ACLers going through this because every ACLer will have some sort of setback within this process, even if it’s minor.

The thing here is to make sure we don’t walk away feeling defeated and not let that fear set in. What we need to do is just make sure we’re fine and the goal is for us to get ourselves back to at least a good baseline. Of course, in that moment, baseline might not be there. But hopefully over the next day, a few days, maybe even weeks, we’re getting you back to baseline, depending on the degree of how much it has flared you up. People think that when something flares up, we just need to rest or stop. It’s like after ACL surgery, people are like, I’ve had a major surgery. Let me just like chill in bed for seven days, 14 days, and not do much. Guys, we’ve had people who they’ve been on bedrest for two weeks, three weeks, and it’s because usually there’s a gap in the surgeon telling them to go do physical therapy or they can’t get into physical therapy. And it is crazy. We have had people who have had actually been told to rest for two weeks.

The thing is that we do not need to rest after surgery. Yes, we need to respect the healing. We don’t need to push the gas as hard as we can, but we also don’t fully pull the emergency brake and stop everything. We are going to slowly let on the gas a little bit and just let the car accelerate a little bit. We are trying to at least do what we can within the boundaries of what our knee can tolerate, and then each day we’ll add up and compound interest grows from there. I promise you no one needs to just fully rest after any injury or any surgery. I know that’s the RICE protocol, but that thing is outdated. It is not in use anymore and shouldn’t be in use. I’ve shared with you guys before, POLICE (Protection, Optimal Loading, Ice, Compression & Elevation) is a very simple one for you to know. Optimal loading means just finding a tolerance that you can work within. Protect it, of course, and don’t make it worse. And then ice, compression, elevation, great things to be able to add into the mix. 

And then there’s peace and love, which is a very long acronym that you can look up yourself. But it’s also a more up-to-date method that includes these things as well as some other components. But I like to keep it simple with POLICE and that checks most of the boxes here. And so that’s what we try to do, especially here at the ACL Athlete to make sure we keep our ACLersw going.  This is what I did myself. The thing here is that there’s a time and place, but to, maybe, rest, especially when it’s super extreme. But in most of your situations, there’s always a way to modify, train around it, and plenty of other areas to work and still get some input. And I get that this can’t just blindly be applied to all situations because context is so important of where in the process you are, variables are like what graft type, restrictions, symptoms you’re dealing with, the goals that you have and time sensitivity, and it’s a dance between a lot of these variables and many more I didn’t even mention.

The biggest thing here is to know how to do this, and that’s where proper education and guidance come in. I readjusted in the moment and then I connected with my remote coach, let them know, and he helped me to modify a few things so then that way we are progressing a little bit better with the certain movements based on the conversation we had. We adapted the plan. He helped to provide some input on this based on the data points of leading up to this, and that is something that we’re just going to move forward with and adjust. It’s a slight adjustment to the game plan versus being like, all right, rest. Don’t let this get angry, and then guess what? All the work I put in is just going to drop. It is going to be sluggish getting back into the gym and there’s no point in that. For some reason when pain happens or when a flare-up happens, people think I just need to fully rest. And that is the worst thing that you can do to be completely honest. What is important is to make sure that we adjust, it’s an adaptable plan, and that’s what ACL rehab should be.

Another good example here is I just had one of my ACLers who was walking his dog, rolled his ankle. He stepped off a curb and rolled it. The guy has a history of ankle sprains with playing basketball in the past throughout a lot of his younger days, high school, college, and for a long period of time at different levels. And now we are doing a non-op ACL rehab process because he’s just not in the place to be able to have surgery and he wants to try and do it without having a reconstruction done. And the thing here that I want to share is that people sometimes think that this rehab process, it happens in a vacuum and it does not. I just talked to somebody recently and they’re going to have to go back to work literally in five days after ACL surgery. And it is not a remote job fully. They’re going to be on their feet moving around a little bit, and they’ll modify. But I’m like, that’s going to affect your rehab a lot. I think assuming that this process happens in a vacuum. It’s very challenging. I think people come into this mindset, all right, I’m going to have this perfect plan, I’m going to do these perfect sessions, I’m going to go do these things. But the thing is that yes, maybe for the first four weeks or six weeks, or if you just have no other responsibilities and are planning not to do anything besides this process, then great. But that is not the majority of folks.

I have ACLers who have gone to a camp for three weeks. One has been traveling and they want to travel before… it’s their senior year as they come to play soccer. I have another one who is trying to get back to working as a nurse. And then I have another person like this one that I said, who rolled off a curb. He’s got kids. There’s so many ACLers that we work with and sharing that they have live things that come up. I think that’s the thing that is important to understand in this process that sh*t is just going to happen.

And other scenarios we’ve had AERs deal with, just to give you an idea. They get sick, like a stomach bug. They have some sort of other health issues. Someone has a family event that happens, like we’ve had family members of some of our ACLers who they passed away. That’s just going to happen. They have to go. And depending on the closeness, the degree of it, like they may have to just step away for a second. It’s an emotional toll as well as it is just like a physical toll on them. Because they’re also out of their normal routine. We’ve had ACLers gone through breakups, divorce. Those are hard situations emotionally to go through, and your life just changes. People injure other areas. It might be related to work. They’ve been dealing in nursing with other things, like a low back pain issue. Maybe it’s a shoulder issue. We’ve had ACLers where they’ve had both ACLs torn and they’ve had to navigate having surgery on both. We’ve had people where they’ve dislocated a shoulder while they’ve also rehabbed an ACL. Therefore, we are trying to nurse different things through this process, so it makes it complicated, something we have to navigate.

Another example is kids. Kids throw a huge factor into this, especially for our parents. Because if you have a six month old, how are you going to reason with a six month old who might still be breastfeeding and that  can’t necessarily be left unattended. And so that’s even harder whenever you have a 1-year-old, a 2-year-old who’s running around. But you can’t logically say, “Hey, I’m just doing my rehab. Can you just sit to the side and be quiet?” What about someone who’s having a tough time at school? Someone’s having a tough time at work.They just got fired from work. They have to go to work, and they have a specific event. Even though it’s not in their best interest, they still need to go to make it happen for their career. And then there’s just the plain old something just got tweaked or got injured. And that is just life, y’all.

That is just the complex human body, and we don’t have full control over it. And that is something I know 100%. I wish we did. I wish we could control the inputs and outputs. And that’s what we try to do in this process. And it is a dance because of all these factors and the way our human body is so complex. But this is why the timing of the surgery, the graft you get, the physical therapy that you do, the rehab process itself, and having a plan, a structured plan and process for this and an expert guide is so key. I say this all the time and I hold to it, that your rehab provider will make or break your process. They will. And the thing is that it’s going to help make the process adaptable so that when these moments happen, and key word here is “when,” not, if not if they happen, when these moments happen, there is a quick adjustment. I always use the analogy of going on a detour. You’re on this path, you are driving in your car,  or maybe you’re riding along and then all of a sudden something comes up. There’s a detour that you have to take. And imagine this is the injury or just the setback that you’re having.

The thing is that detour could either be long off the path, which adds a lot of time complexity, or unknown turns along that path, or it could be just a quick little detour off. Maybe you’re just grabbing some gas. Maybe you have to just stop by and take a few turns, and then you get right back on the interstate, for example. That is the difference in an adaptable plan— a GPS that is going to be there to make the adjustments and that is what we need in ACL rehab, y’all, because this process is dynamic. We are complicated humans. There are so many factors in play. And the thing is that it’s just not going to be linear. And the thing is that it’s going to help with this because it’s going to help reduce the fear and anxiety when these things happen. It saves time. I can’t tell you how much that people just get stuck and l trying to figure it out or doing it themselves, or just bad rehab and bad guidance, and they’re like, oh, hopefully it’ll get better with time, and it just doesn’t. It ends up costing them maybe three months, six months. It costs them limping at their wedding. It costs them not being able to go on this trip with their buddies. It costs them not being able to get to college without being on their crutches.

There’s an opportunity cost to all things, but having the right guidance and team in your corner is going to save you time, is going to give you peace of mind. I think the important thing that we need to take away from today, that I hope I got the point across, is that y’all, it’s going to be okay. Sh*t happens. Give yourself some grace, please. And then the important piece is that you want to make sure you have a game plan, you have expert guidance, and making sure that it is an adaptable GPS and roadmap at any given point, at any given setback because they’re going to happen. It could be the difference in saving you a month, six months, a year, multiple years, and even long term thinking about osteoarthritis and just the ability to do things that you may have not even thought of before. Those are going to be opportunities that could be saved by just making sure that you have the right team and right guidance in place. But just know that sh*t does happen. Don’t blame yourself in these situations. Do an audit of it and just make sure that you know what to do. That is going to make all the difference in this process and especially getting you back to doing the thing. 

I hope that was helpful y’all. If y’all need anything, we are here to help. Please reach out with any questions. I appreciate all of you who have sent messages, who have been very supportive in this process. And if you got anything out of this or any of our work in previous podcasts, please leave us a five star review that helps us reach more ACLers, continue to push the mission forward, make more of an impact. And most importantly, for us to redefine this space, redefine ACL rehab, do it different, change the standard, and elevate it. And that’s something that we are here to do. So please do that. If you have a second Spotify, Apple Podcast, anywhere that you’re listening to this because it does go a long way, and I appreciate you guys so much. If you need anything, we’re here. Until next time, this is your host, Ravi Patel, signing off.