Episode 239 | Normalize the Setback: Why Never Having One Can Be A Problem in ACL Rehab

What is up team? We’re diving straight into the episode today. We’re talking all about flare-ups, normalizing them. I’ve talked about this in previous podcast episodes, but this particular topic has been weighing on my heart. And something that I’ve just been talking with our team about, talking with my ACLers about, and just something that I want to share with you guys because I think it will be helpful. Hear me out in this episode. 

When we are going through this process, we are testing the limits of our human body and our knee, specifically after a major injury and surgery, that’s if you have the surgery. There’s some people who don’t, and they still will have to rebuild from the injury. But let’s say also if you’ve had the surgery, we’re including that within this, which is most people. But with testing the limits during this process, that means we could sometimes push too far. That’s honestly normal. Each rehab session is a data point for us to trend across time. We are not too isolated or focused on one single session, but it’s more of what does that look like across time?

This is where I’m more focused as a physical therapist, as a coach, this is something that we want to look at, in terms of the trend is positive, is it flat, or is it negative. The latter two are not great. And sure, while there might be time points in that where it can trend in that negative direction or maybe even plateau or flat line, we know it’s not always going to be positive. That’s 100% sure, but we want to make sure that this trend isn’t steady flat and isn’t steady negative; we’re doing something wrong. Of course, we want that positive, but that doesn’t mean each day is positive, or even a week, maybe even two weeks, maybe even a month, for example. But when we zoom out, it should trend in the positive direction. 

You guys know the expectation versus reality. The expectation is that linear line is going positive from A to B, and instead, the reality of life. And this process is A to B. But instead it’s like that squiggly line where it just goes up and then it goes down, then it goes sideways, then it goes up, then it goes backwards down. It’s just like a squiggly line until it gets to point A, until it gets to point B, and then that is that positive trajectory. But we know that in the minutia of it, or the day-to-day, it might not always be positive. This is ACL rehab, but the thing is, we want it to trend positive, just like the stock market. If we zoom out, the stock market in and of itself is positive. If we zoom in, depending on where you look at it, let’s look at 2020, for example. There are parts of it where it was absolutely awful; 2008, not great. But let’s zoom out and look at it from a 20-year span or even a two-year span; it’s positive. Let’s look at this year. In April, it definitely dived, and then it went right back up. There’s volatility, and that’s going to be ACL rehab, to be honest, especially in the earlier process of this, because we are working with a more sensitive knee. The further out you get from injury and from surgery, you get less sensitive, if you will, of a knee. Sure, you’ll still deal with the ebbs and flows of it, but the volatility of what you feel with that knee will be heightened post-op and earlier than it will typically mid and late stages. That’s where means there could be less bandwidth to tolerate stress. 

Let me explain this analogy. I’m going to share two different ways. What I want you to do is essentially take your hands, and you have them both in front of you. I want you to hold them one foot apart. What you’re going to do is have both palms facing each other, almost like you have them one foot apart in length. This is your bandwidth of the knee and the ability to tolerate stress prior to injury and prior to surgery. Before any of this, that’s how much your knee and body could handle stress-wise. Just take that for what it’s worth, that amount of stress put on the body and bandwidth. Now bring that in three inches apart, so we’re narrowing this down a lot. This is your bandwidth of the knee and the ability to tolerate stress after injury and/or after surgery. The goal is to bring this beyond that one-foot baseline we just marked out that you had prior to this injury and surgery. That’s always our goal, is not to get you back to where you were before, but better than before. And that is truly possible in this process if it’s dialed in the right guidance, planning, and all the very doable things. We’ve had people who will get back, and they’re like, I’m stronger and fitter than ever. And that’s the goal. But this takes time, y’all. Getting back to that beyond one-foot baseline of that bandwidth, it takes time. 

And with that means sometimes we overstep that bandwidth or expand beyond it, and it results in maybe more pain, more swelling, more sensitivity in the knee, maybe some regression in the range of motion, maybe you’re limping a little bit more. This is what we would call a setback. Basically, things are not going positively, and you’ve been set back because the knee has reacted. We have that three-inch bandwidth, or maybe it’s a little bit more as you move along in this. Maybe it’s four or five inches, but it’s not fully back to where it was before. Therefore, the knee can’t tolerate nearly as much as it used to. We’re trying to increase this over time. But the thing is, as we do this rehab process, we’re also trying to press those limits. By reaching those outer limits of that bandwidth, that’s going to allow us to also expand it and get it bigger and be able to tolerate more. But it’s a dance, we can’t just constantly overstep that. We also don’t want to do too little. It’s a sweet spot with this. 

The other thing I’d like you to visualize is a cup. This is taking that same principle. We just have a cup in front of us, and the cup size is what we can handle before the injury and the surgery, and the stress you put on that knee and your body is the water in that cup. Imagine a cup you have in front of you, whatever that may be. That’s what it was, pre-injury. And then the stress you put on it is the water. Then we have the injury and or the surgery, the cup shrinks down, and the amount of water we can handle is less. We can only have two things from here, or things that we can impact. We can remove water; less stress on the body. Or we could build a bigger cup; more capacity and the ability to handle more stress on the knee and the body. Of course, we ideally do both in this process strategically, but the cup can’t increase in size if we don’t stress it the right amount. Just like I was saying, the bandwidth doesn’t increase just by nature of doing less; it actually needs to be stressed at its limits to increase more. 

It’s the same thing with muscle. When we get stronger, we’re not going to get stronger doing light stuff. You need to do heavier stuff. You need to push the limits of fatigue, go to failure or close to in order to stimulate an adaptation in order to get stronger and improve performance. This is no different. We have to get to those edges in order for us to be able to improve and move the needle on things. The biggest thing here is that with post-op, especially, or post-injury, we just have less bandwidth. We are going to have a smaller cup post-injury and post-op. It’s okay, and that’s sometimes something that we overstep from time to time. As I mentioned, that’s okay. The biggest thing is that we don’t want to repeat the same mistake over and over and over. And as you work with someone who’s more experienced, they can help save this; they can help prevent these from happening, and look ahead and warn you.

For example, your rehab is cruising along, but then you decide to go for a walk. And you’re like, oh, I won’t hurt anything, or you have a trip coming up. But we want to adjust these things, and that’s where having good help can help to guide and navigate these circumstances that we may overlook, because that may push it over the edge. But the thing is that we don’t want to make sure we repeat these stakes over and over. If a setback happens, we adapt and adjust the game plan now once we understand the data point. These two analogies are for you to help conceptualize this biggest thing here. 

I would be more worried if someone had never had a setback in this process, to be completely honest with you. I’m gonna repeat that. I would be more worried if someone had never had a setback in this process, to be completely honest. As I shared, we’re pushing limits very strategically in this process, and we’re not always 100% spot on. Some of this is trial and error. This is just navigating a very difficult recovery and injury, surgery, and working with the human body. While your knee might feel good doing less or not pushing it as much, it just means that you’re being underloaded more than likely, and I can feel pretty confident about this.

For example, I just talked to someone two days ago who said she was doing straight leg raises, four months post-op, and still doing them. I was just like, wait, can you repeat that? And she was like, yeah, I’m still doing straight leg raises four months post-op. And I’m like, the return on investment on that exercise is maybe in the first two weeks, if you want to do that, maybe four weeks in some very unique situations. This girl’s situation was not it; she just didn’t have a progressive program. She was being severely underloaded by a hip flexor-biased exercise that she thought was working her quads. And while her knee might feel fine doing it, or she may feel like a quad burn some here and there with that, this is incredibly underloading and a disservice to this person, along with everything else that she was and also was not doing yet, based on where she was. She thought her knee was fine. She just needs to be progressed more, which makes sense. But the thing is that she just hadn’t been challenged enough, either, or been taught how to make sure to push her limits a little bit in order to move her knee along much further. And she was complaining about knee pain, still dealing with some periodic swelling, and couldn’t take stairs yet. There were a bunch of things that layered into this. I was like, man, this is just like not being loaded appropriately. And she was like, well, I’d never truly felt a setback. Yeah, she couldn’t take stairs or like the knee was a little buggy from time to time, but she never had a true setback. She never pushed her limits. This was just really interesting to me in this situation. And the thing that I would be more worried about is if people are months and months into this process and never feel their knee “overdo it” or flare up sometimes. It would mean basically that you’re underloading it, as I had mentioned, and taking it really too easy. It is a dance of finding the Goldilocks spot, the sweet spot—not too hot, not too cold, not too much, not too little. And we’re not always trying to just get perfect on this, but just enough within that range to move the needle on things. And that’s where these principles of solid rehab, solid strength, and conditioning come into play, which translate across and provide feedback loops to monitor symptoms and progress things based on what the science, the data, and the research show. That is the foundation of this process as we layer it into your own ACL rehab.

This is where good expertise, planning, and testing really come in to constantly keep a pulse on this journey and make updates. This is something that I’ve been personally sharing with my ACLers, talking with the team as well about this, about just flare-ups coming up, about the knee, having a little bit of a setback in ACL rehab. We’re pushing limits and boundaries. Plus, life continues to happen. This rehab isn’t happening in a vacuum. There’s work, there’s school, there’s kids, there’s travel, there’s weddings, there’s stress. You still have to go on, and you’re not a professional athlete, more than likely, so you have to keep doing things in addition to managing this process. The thing is, we want to increase that bandwidth and build a bigger cup. We want to make sure that we can push those limits, but we want to make sure we do it strategically. And with that, we know that setbacks can happen—it’s inevitable. I’ve had my own setbacks with my own ACL injuries, with my own rehabs. My ACLers have had it here and there. But if you haven’t had one happen yet, you’re either number one, really early in ACL rehab, where you just haven’t had a lot of data points yet, or you’re just not being challenged enough. 

This is more common with the people who are months and months out, and this is where I’d be concerned because that often means you’re being underloaded, underprepared. Or maybe somehow you’re the lucky 0.001% who hasn’t had a flare-up, and you’re absolutely crushing the process with no problems. I promise you, you are an anomaly in this ACL rehab process, and there are very few of you. We’re pushing limits. Give yourself some grace. If it happens, just make sure you adjust appropriately so it’s not happening repeatedly. If it is, you need to make a change, whether that’s the plan, the things you’re doing, the things that you may not be doing, or maybe it is who is responsible for navigating this for you or helping to guide you in this, that is going to be the ultimate player in this. But the big thing here today is that I want to try and normalize flare-ups. That doesn’t mean just go out and push as hard as you can and then recover from it. The thing is, it needs to be very strategic. It needs to be very intentional. It also needs to be adapted very specifically as soon as something like this happens. 

I had an athlete who is progressing along really, really well. She had a setback at two weeks post-op. We didn’t start working together until a few weeks back. She was moving along really well. And then all of a sudden, the knee acted up from doing something. We were just like, okay, let’s see what we need to do here. And this is the reality of this process. We can’t control it perfectly, but we are pushing the boundaries for her, and she’s making strides in all other domains, and the knee just acted up a little bit. What we did was take a top-down approach. Instead of being like, all right, we’re not doing anything, let’s just do quad sets and go from here. We kept in everything that felt good, and we modified a few things that may have made the knee feel not as spicy, if you will. That’s the way we adapt. But we need to be strategic, and we need to make sure this isn’t a repeated event, and we learn from it. We adapt things and we adjust them. And that’s what’s so key in this process is that it has to be an adaptable plan and an adaptable program with really solid guidance to make these adjustments on the fly.

And the thing that’s going to be important is to give yourself grace when these happen, just make sure you make those adjustments appropriately so it’s not happening repeatedly. In terms of flare-ups themselves, let’s normalize this in this process. Please, it’ll help our mental health as ACLers in this long journey, knowing you’re not crazy. And especially if the surgeon or the physical therapist, or honestly, people who haven’t worked with us enough or just kind of see a small glimpse of this, and it isn’t with you in the day-to-day, and don’t see a lot of ACLs, they’re not going to really understand this. But in reality, this is the case, and it’s to be expected. We just need to be smart and make strategic adjustments, have good guidance, and make sure that we continue to push the boundaries within reason, and also make sure that we make the adjustments as we need to.

I hope that this is helpful, y’all. I want y’all to go, do the thing, normalize flare-ups. Don’t be down on yourself. Just make sure that it doesn’t repeat and that it is going to be normal. I hope that y’all can take something away from this episode if you are someone who has been struggling with this and you’re just needing that flip of a switch to make the adjustment and make sure that things are dialed in to keep things moving along in that positive direction. Until next time team, this is your host, Ravi Patel, signing off.