Episode 253 | The Most Underrated Load Management Tool After ACL Surgery

What is up team? And welcome back to another episode on the ACL Athlete Podcast. Today, we’re diving into something that is massively underrated. Something I talk about with my athletes, literally, every single week, especially early on, and something that can really make or break your progress, especially after an ACL injury and surgery.

And before I talk about this. I’ve also talked at length about how load management is incredibly important in this process. This is where we need to balance the overall stress and recovery on the knee, a.k.a. managing the load on the knee itself. The challenge is that people anchor themselves to what they have done in the past. There are a lot of people who are like, I used to do this, or I could do this before I had the injury or the surgery. The goal is to try and get back to that level as quickly as possible, but that can throw a wrench into things because we have to be very strategic about the way we approach that.

There is a healthy dose of reality, if you will, of what the needs capacity is because it’s now been through the injury, it’s now been through the surgery. If you had surgery, and it’s a sensitive joint, especially after this process. You think about the trauma that happens. And so what happens a lot of times is that a lot of ACLers will think more is better, or this won’t hurt. And they’ll try to really nudge things forward a little bit more aggressively, especially for the ACLers who may have a hard time sitting still, maybe my high-energy folks. And that’s the thing that early on in the process, I’m not saying, stay seated the entire day, but it is also something where we have to find a sweet spot to understand the context of the injury, the surgery, and what the recovery is needed in that moment.

And the number one thing I see is that step count and being on their feet is super sneaky, especially early on in this process. What I want to do today is share our step count framework we use with ACLers early on, so we can properly manage the stress to the knee and balance the recovery. Also, allowing for healing while also moving the needle forward with the higher priorities of getting a quiet knee and getting that knee super happy. If you want more of a zoomed-out perspective on the topic of load management and what plays into just the overall stress on the knee and what you’re balancing and what you want to account for, you could check out episode 226, where I talked about just different buckets, if you will, that will factor into things like your physical activity levels, your non-physical activity levels, your sedentary behavior. All things that basically total up to the amount of stress you’re going to put on your need and influence your management of load, and also why swelling might stick around in this process, and maybe pain, and you’re slower to get moving in this process.

Today, we are going to be focused on specifically step count because I think it’s just such a massive player, so underrated in this process. How to just use this load management framework so the knee can stay calm, your knee swelling stays down, and you can stack these winds instead of hitting setbacks in this process. I think that’s a huge part of this, that swelling always feels like you’re just holding onto the brakes. You’re pressing on the brakes while you’re trying to hit the gas with the other stuff. I’m focused more on swelling because pain is going to exist. Yes, pain and swelling both go hand in hand. You might have one or the other. Oftentimes, after surgery and injury, you’ll have both. And it will be influenced a lot by activity levels, just your body, the surgery itself, the injury itself, and the type of graft you get. There are a lot of factors that play into this. And then the other player that is going to be super important is, is there any meniscus work that’s done? Specifically, a meniscus repair that can influence, maybe how much you can bend your knee post-op, maybe only to 90 degrees for the first four weeks. And most importantly, is how much weight you can put down on that leg. And that’s something that really throws people for a curve if they have not been told there’s any meniscus damage or they thought they were going to get some of it cut away and they get it repaired and all of a sudden they’re restricted in 90 and they can’t put weight on it for four weeks, which really influences life for those next four weeks. Because the expectation of that is really influential because then therefore you’re thinking you’re going to put weight on it immediately. The meniscus plays a big role in this. 

When we talk about other concomitant injuries and maybe procedures. If there’s like an MCL repair, if there’s any other ligament repair or anything else that’s being done, you may have some restrictions on the amount of weight you can put on it, the amount of bending you can do. In every surgeon, we’ve worked with so many different surgeons across the world. There’s so many different restrictions and protocols that we’ll see for even an isolated ACL. Nothing else has been done. But an isolated ACL, we’ve seen someone brace with no rehab for six weeks, all the way to no brace, full-weight bearing as tolerated, moving that knee as much as they can, day one. It really runs the spectrum, and this is where having a plan and making sure that you have that dialed in based on the most up-to-date research and the most up-to-date principles of the way that you can manage this is going to be so key here.

The thing is that with this process, when we’re talking about step count, it’s super sneaky and something that I cannot tell you how important it is to manage as soon as you get out of injury and from post-op. Basically, we use this analogy of essentially when people have been training and when they’ve been at the peak of their fitness. Let’s just say you’re at a level 10 in a 10-story building. When you have this injury, you’re automatically going to drop a little bit because your strength decreases. You might not be able to bend your knee as much, so your overall ceiling is lower now because of the natural tendency of this injury to bring things down.

Now your goal is to try and climb back up before you get to surgery. So then that way the drop isn’t so far. The challenge is that when you have the surgery, you’re going to drop again. And so that capacity or that level of what you can handle after the surgery is going to be very different because your strength has decreased. But you also have a very sensitive joint. You just had a major trauma to the joint from the injury and then also the surgery. And now we have to be mindful that it is just not okay, got a graft in there, let’s rock and roll and go. We have to be very mindful of the biological healing process that takes place right after an ACL injury and after surgery. And when we factor in other procedures that go into it, like taking your own graft from your quad, hamstring, patella, maybe a meniscus repair, or any other procedure like getting the IT band anchor to the outside, like an LET. These are all additional traumas to the knee. Therefore, we need to make sure that we manage the sensitivity, manage the symptoms, and give it the love that it needs. And sometimes step count is a sneaky one that can play against us. 

Now, most of the time, what we’re looking at here is more of the accumulation of steps throughout the day. And that’s the thing that’s going to be super important. It’s not just okay, you did one thing, and that’s the thing that influenced it sometimes. But it can be the accumulation of steps in the day. It could be you’re on your feet a little bit more. Maybe it’s you ran errands, maybe you just couldn’t sit still, so you felt like you needed to get up, go walk around the block, take your dog for a walk. Maybe it’s work, maybe it’s school, and this is all going to be influenced by your specific life, the timing of the surgery, and also how quickly you have to get back to your normal life. 

What I want to do today is essentially just provide a comprehensive step count framework for you to make sure that you can understand if you’re a post-op, if you’re a post-injury, if you’re a rehab provider, or an ACLer listening to this, you know how to tackle this. And there’s a little bit more of a practical approach to this versus just watching your step count and making sure you don’t increase it. But we also want to give you an idea of what that looks like on the ground, so you know how to calculate it, you know how to look at certain variables within it, and also know what to estimate. That way, for the first 4, 6, 8 weeks of your ACL rehab, if you guys can lock in on this, I promise you, the rest of the process will be massively better because you manage your step count and you also manage, more importantly, the symptoms of that knee, most importantly, swelling and pain.

Why does step count matter in this process? It’s a load to the knee. You know the thing that’s super important, it’s load to the knee. Every step is a compression. You go through a cyclic loading cycle through the joint. Early on, especially post-op, the knee is sensitive. It’s super sensitive. You go from a place where the knee has gone into surgery. It comes out, you had some screws put in, you had a new graft put in, and you had a graft potentially taken. Other surgical procedures, possibly a meniscus repair was done, or a meniscectomy. Those are all going to influence things. When we go to put our foot down on the ground, it’s good for the knee, but at the same time, it can also be a lot, especially if we are post-op and the knee joint is very sensitive.

What does that mean? If swelling spikes, usually it can be because we’ve done too much walking, too much standing, or had a day that looked very different than the normal baseline of a day. I think it’s going to be important to know that in the early days, gravity is not your best friend because that’s going to pull swelling into the joint. Therefore, if you’re on your feet more vertically and you’ve been dealing with swelling, then it’s very natural for the knee at the end of the day to just feel stiff and full and tight. It’s that balloon feeling when you try to bend it. This is something that ACLers will consistently report. I have personally felt this on several occasions, so there’s something to this, but it’s also just the way that fluid will travel because of gravity. That’s the whole point of trying to elevate your legs early on and with swelling, because that’s going to help gravity pull it down and push it back towards the heart. We’re able to get a swelling out of the joint or work to do that.

Swelling is a thing that is super important for the knee because it’s just one thing that we have shown with the latest research. When we’re looking at arthrogenic muscle inhibition, when we’re looking at  AMI, it’s showing that essentially it will influence the way the neural connections to the quad are. You can think about it as shutting down the quad. It delays strength gains, it delays the input to the quad. It takes more effort to get the same amount of output from the quad. If we can reduce the swelling, if we can influence the neural connection to the quads, therefore, we’re going to be able to get things going a little bit better. But swelling most importantly, what you will see is that it’ll influence the quad from gaining activation from strength. It influences the range of motion so much more than we give it credit. It will influence how much you can get your knee extension, especially your flexion, I promise you. It slows a lot of other things down. This is the important piece of this load management. And the kicker is that most athletes don’t realize how many steps that can really influence, and they’re actually taking in a day that might be playing into this. This is all going to be influenced a little bit by, of course, how much you were doing before the surgery and maybe your normal everyday day-to-day step count. 

And then of course, post-op, you’re going to be a little bit more limited. You’re not going to go and do 10K steps immediately post-op. But with that said, there is going to be some sort of baseline. If we think about general activities, maybe a normal day at home, it could be two to 4,000 steps. If you don’t go out and you have a normal, lazy day at home. Let’s not even consider the ACL surgery. If you have the ACL surgery, obviously, in that first week, it’ll probably be less than that. A quick workout at the gym could range anywhere from 1,500 steps, even if you exclude cardio, especially if you’re doing mostly equipment-based work. You go out to the grocery store, it could be 1,000 to 2,000 steps. You go to an airport, you got to fly out, fly in, usually around 4K to 6K day. And then, let’s even just say a 30-minute walk with your dog. That could be up to around 4,000 steps by itself. The thing is that if we stack these together, then this is where things can accumulate and symptoms can start to pop up. I think it’s just really important for us to check ourselves with the things that we’re doing in our day-to-day in order for us to understand, okay, these are the things that are very essential to the day from a movement standpoint. And then you almost want to be able to prioritize, okay, this is going to be important to do today. There might be some things that you’re just like, Is it really that worth it right now? Versus, maybe I can get to this in a week or two weeks. So that’s where it’s going to be really important to be able to audit this. 

When we’re looking at essentially the biggest mistakes that we see early on. One thing that I do want to add as a caveat, especially with something like this, is essentially getting rid of your crutches too fast. You dish your crutches too fast. I’ve done podcast episodes on this. I’ve talked about this before. But this is one thing that consistently we see, is that people start to get to a point where they’re like, okay, I can make the steps to the bathroom, or I can get across the kitchen. And they don’t need their crutches. If you are in the right place in your rehab, then that might be okay. But a lot of people get into trouble when they stop using them too quickly.  With their crutches, I even had an athlete yesterday. He is 11 days post-op, and he went to his surgeon’s office. He met with the PA and they’re following this straight protocol. They said, ditch the crutches and walk with your immobilizer (the knee brace). I think that ACL rehab world and what we see on a lot of surgeon protocols is that they want to keep someone in the immobilizer or in the knee brace and then get rid of the crutches. It’s the most backwards thing that I have seen in majority of protocols. I think sometimes it’s interesting because it is one of the things that if there was conversations with a physical therapist who works with this, then there could be a clear understanding of if we can get rid of the brace first, then we can keep the crutches longer. The outcome of how this knee progresses absolute game changer. The thing about this is that the knee brace itself, there’s this assumption, in a major accident, the knee brace, let’s say you’re out in ice or water and you slip, then yeah, it’s nice to have that knee immobilizer on in order to protect that knee so it doesn’t have some crazy movement. Outside of something super major of an accident, you have to do something pretty stupid in order for that knee to really be in a bad situation. If you’re in a public place, I get it. You might need to use the knee immobilizer. But with that said, the crutches, the big thing about this we got to think about is the goal. If the goal is to help the knee reacclimate to walking, to making sure you normalize your gait, to reduce swelling, to get the range of motion better quads, better you staying on crutches versus using the knee brace is going to be an absolute game changer. The crutches are the thing that helps to truly offload the joint. Because when you think about crutches and even just your two feet, you have 50% of weight going into each foot. When you have your ACL surgery, let’s just say that you have weight bearing as tolerated, so you can put weight through the joint as soon as you have the surgery afterwards, the crutches are going to help to take on that 50% that foot was supposed to do. You can slowly acclimate that load to the knee joint. It’s not shocked with so much weight into the knee joint after a surgery. You can slowly allow it to get adjusted after it’s been so sensitive from the surgery itself.

The crutches work to essentially offload that joint and slowly reacclimate it back to walking. It helps you get from point A to point B. It also helps you to not have to overload the knee joint after the surgery. The brace does not do that. The brace is something that is there for more of a mental protection, ensure, like an accident based protection. I think it’s something that has been given and been done with history. But I see consistently, athletes who are in braces, athletes who are not in braces post-op, the ones without a brace tend to do so much better than people who are post-op braced. And that’s pretty consistent for me, and as I work with ACLers and our team does, too. 

Now, with that said, as we talk about the crutches, let’s make sure we don’t dish those too soon. We always want to make sure that we come off those very slowly. What we see is that sometimes athletes will either come off their crutches too soon, or maybe their surgeon or the office will say, get rid of the crutches, but use the immobilizer or the knee brace. Then what happens is that they get cleared and you go from basically using two crutches and then eventually your no crutch. It’s a spike in load in that knee joint. The thing is that it’s challenging because as time goes on too, that your normal lifestyle will pick up too. Not only do you have normal step counts that are starting to progress, but then you’ve almost increased the stress of that knee with a huge spike. These are things that we really see that can be challenging. And the thing about crutches is people think it’s weakness. It’s actually a tool to help offload the joint and allow that dimmer switch to build tolerance. What is important is to build this from two crutches to one crutches to none. You’re going to gauge this based on criteria of your swelling, your pain, your range of motion, your quad activation, and your gait quality. You should be crushing it with crutches and almost be etching to get off the crutches and looking so smooth without the use of crutches, of course, in order to really be discharged from them. It shouldn’t be this big jump just because two weeks later the protocol says let’s get off the crutches. I think that’s an important detail to make here. 

Now, let’s switch to the dimmer switch principle. We use the dimmer switch principle idea a lot in this a rehab process. It’s one of my favorites. And with walking is no different. You don’t flip the switch from going 1,000 steps to all of a sudden 8,000 steps in one day. You’re not going to go from running one mile to going to six miles of running. Your knee is going to respond to volume and not just the intensity of it. What we need is small gradual changes over time to keep the knee calm and also check in on it. Instead of giant jumps in this process, we are looking for steady symptom-guided progressions. I think that’s really important. Symptom-guided progressions, adding a bit more when the knee can tolerate it. And then we can hold there or we could pull back when it doesn’t. The thing is that if we’re objectively tracking this, which we’ll share here in a second, then therefore this is going to allow us to be able to know, okay, I did a little too much, or maybe I did this thing plus this step count. And that’s probably what really triggered that knee. The dimmer switch mindset is also what’s gonna protect you from having these flareups or setbacks in your ACL rehab that I see a lot of people deal with, in that first three month process because that first. Six weeks, if you can nail this down, I cannot tell you how much the rest of this process will feel for you compared to people who I know who rush these first six weeks or underestimate it and don’t take it seriously. And then they pay for it for the next three to six months because it just lingers and it makes it super challenging. I want to make sure that you have a helpful framework in order for yourself to know, okay, what do I need to do in order to tackle this more practically? 

The first thing is we need to make sure we know what your baseline is, what’s normal for you. Before injury, maybe you used to walk 5K steps in a day. Maybe you did 8,000 steps in a day. Maybe you ran a mile every morning. Maybe you had a retail job or a hospital job and you hit 15,000 steps in a day. It’s not abnormal for us to get athletes who have 20K steps a day. And then we have some who have remote jobs, and they may hit 5,000 steps a day. It really depends. But your long term step goal is based on your normal. I think that’s super important here. Everyone’s always what step count do I need to get up to? And the thing is that we want to get up to what your normal is and a little bit beyond that, to be honest. It’s not a generic target of 5,000 steps, 10,000 steps. Of course, the more the better in this case. But we need to find what you need so we can make sure we can have a good enough ceiling, so you can do all of the steps that you need within a day and a week. And then also be able to account for you rehabbing and all the other things that life may throw at you. That’s why I always ask athletes, what’s your typical daily step count when you know it’s normal, not considering the knee or the ACL injury or surgery? What would that look like? 

Now, you’re going to get a gauge for that average daily step count. But here’s where it’s going to be important, is that not every day is the same. Because even for weekends, some people might be different than the weekdays. What does a super busy day look like for you? And then what does a low activity day look like for you? This allows you to find the floor and the ceiling of what you’re looking for or the range. If we have something like a work or a job, and then we’re looking at maybe school, then we can also ask, okay, what’s going to be required of that? It’s going to be a little different for some of our freshmen or sophomores who are walking campus, our high schoolers or middle schoolers. Or maybe it’s our athletes who are traveling for work who are consultants, or maybe it’s the nurse who has a 12-hour shift. Or maybe it is our remote worker who works from home five days a week. These are all going to be so important and it’s going to be our specific north star for each athlete and building back to that gradually understanding, okay, what’s our floor we’re aiming for? And then what is our ceiling we’re aiming for and beyond that?

One of the things I want to share to help from a perspective of common activities is what that step count can look like. Here’s some references. Let’s just say a general home day, not super active, you’re just in the house, maybe a lazier day. Did some things around the house. It can range up to around 2,000 to 4,000 steps in a day. An hour long lift could be up to 1,500 steps, give or take if you’re not considering cardio work in there. A 10-minute dog walk could be up to 1,200 steps. A 30-minute dog walk could be up to 4,000 steps. You go to the grocery store, 2,000 steps. You go to a Costco, it could be more than that just because of how big that area is. Let’s say an airport a day, I shared earlier could be 4,000, could be 7,000 steps; a one-mile walk, 2,000 to 2,500 steps and then a one mile run,. I’s going to be less because you’re going to be able to change your step length and the frequency. For a one-mile run, it might be 1,400 to 1,700 steps. These numbers, and you can look these numbers up, there’s usually general rules of thumb for averages of these. These will help you to anticipate load before it hits you, instead of being surprised by it later. You could be a little bit ahead of it, I’ve got to go to the grocery store and you know you’re the one that’s in charge of it. You’re no longer in this first week post-op window, you’re three weeks in. You can walk a little bit. It’s the thing that you have to do for week three, therefore you can account for that. Here’s the thing that’s going to be really important, is being able to establish what does your previous step count look like and what does that normal look like? And then what you want to do is look at your past seven days. 

You can get your Apple Watch, your Fitbit, whatever you use. You can even use your phone as long as it’s been in your pocket for the most time. The challenge is if you leave your phone around and you try to use that as a target, you’re going to definitely miss some details with the phone is a little less accurate. But if you have something like a smartwatch, then you can easily track what your steps are in the day. Let’s look at if you are post-op. Or you’re someone who’s dealing with swelling. The knee is not in a great place. Then let’s look at your previous seven days and let’s just see, okay, what does your step count look like? And let’s just say for reference, someone is early post-op in that first week or two, and you’re maybe hitting, et’s just say around 1,500 to 2,000 steps. The other thing that we need to consider with this is also think about, okay, what does this look like if I am on crutches with two crutches, and then also I’m weight bearing as tolerated? You’re still putting weight on your foot, but your two crutches are the things that are still helping you to manage the weight and included in that step count. That’s going to factor into that in terms of how many steps you’re taking. 

Of course, as you reduce the crutches that you’re using, then you’re going to be able to be a bit more accurate on what that step count looks like. If you go down on your crutches, go from two crutches to one crutch to no crutch, you might want to step back a little bit on how many steps you take, because before you had support and now what you’re doing is you don’t have support. We want to be able to work back up. Those are things that are going to be really important is knowing what your last seven days are, and then being able to know what is your target for the ceiling of step count, and then also what is going to be the floor of the step count. You’re going to see what are things going to look like over the next four weeks, six weeks. And what we say is, let’s go ahead and target the next three months, for example. Let’s just go ahead and see the next 12 weeks. Is there any big trips coming up? Is there any type of travel? Is there any type of work-related stuff? And really just stuff out of the ordinary. We’ll have athletes who are like, I’ve got a wedding in two months. I’ve got a concert in three months. All kinds of different things that they have on their radar. We need to know that and we need to also plan for it. And it seems like tedious or pecific. But if we’re talking about how can we create success in this process, and if I could share just something of seeing so many ACLers who just don’t realize it, and also who have reactively been like, oh yeah, I did this and my knee blew up. And then guess what? They’re trying to get back to a baseline for the next two to four weeks. It just really delays the process. It influences their pain, it influences their progression strength. It’s just something that if we could get ahead of it and be very strategic about the plan and make sure that we account for it, absolute game changer. This is where you can win the first six to eight weeks and it’ll help so much in the rest of the process. This is all going to be important to factor in on what’s the first three months look like. We can account for anything outside of normal activity. 

With that said, that’s how we’re going to look at things, approaching in this process and account for your steps, the step count itself, and being able to make sure that we’re managing it and using our feedback loops. Feedback loops are going to be super important. This is where we’re going to manage the swelling, the pain, see how it feels later that day, and the next day when you wake up. Is the knee feeling the same or better? Awesome. Then keep rocking, keep moving forward. It’s probably responded pretty positively. If it has felt more swollen, more stiff, more painful, then we might need to pause and we might need to think about okay, what did I do the day before? Did I take too many steps? Or, is this something that maybe you just increase your activity level of like you hit the workout way longer. You did more activity in the day. Maybe you were at work longer, on your feet longer. There are other factors we have to account for. That’s going to be super important. That’s going to help us to guide us and as we titrate over the coming weeks, that’s how we’re going to slowly look at this is the dimmer switch. If we have, 1,000 to 2,000 steps, then we’re going to slowly look to increase that over the coming weeks, 3, 4, 5, 6, 7. If we have a target date, let’s say in eight weeks, we need to be at 5,000 steps. Then we’re going to slowly titrate up and make sure we can get this athlete up to that point and maybe a little bit beyond based on how their knee is responding and the symptom response to their knee. And that’ll be helpful instead of being like, okay, I’ve only been doing 2,000 steps for the past eight weeks, and all of a sudden I need to go hit 5,000 steps on week eight. That’s going to shock the knee a little bit. This is where I want to share this full framework to keep it super simple for you guys.

The biggest thing is going to be to know your normal. What does a typical day look like? The long-term target for us? Be able to identify what is essentially your floor and your ceiling of busy days versus non-busy days. Track your steps for the past week. Use your watch or your phone, and so that way we can actually know what day you’re actually doing certain things on your knee. You also want to account for other activities like your workouts, other things that might be going on in the day, and then being able to make sure that we also account for, if we’re using crutches, and then also how much weight you’re putting through that leg. With the crutches, you’re going to go down from two to one to none. You’re going to use swelling and pain, and especially how your gait looks to really guide this. In terms of usage of crutch, use it much longer than you think. Some people think that using crutches for four weeks is ridiculous. I don’t think so. I think you’re going to be laughing at the people who are still limping around at weeks eight and 12 when you’re off your crutches and you’re gliding beautifully at week four. Take the time that it needs versus what the protocol says at two weeks, because every ACL case is different. 

I’ve had some athletes who can legit get off the crutches in five days, and I’ve had some athletes who need eight weeks to get there. I’ve had a few athletes who’ve taken 12 weeks. They have unique circumstances to do that. But with that said, every case is so different. What the protocol says for an ACL repair or reconstruction with a quad graft and a me medial meniscus repair, I could line 10 of you up and you’re all going to progress a little differently. It’s not going to be the same across the board. And the other thing that’s not factored in is your life. When you have the mom with twins versus the high school athlete who has to get from science to math, all the way across the school versus the remote worker. It’s all going to really differ based on how much load you put through that knee. Those are going to be super important pieces with this. 

Next, increase your steps slowly and very intentionally. Be very gradual. Think about if you have a remote in your hand or you’re in the car and you’re turning the dial on the volume, you don’t want to just blare it from 10 to 100. That’s going to go way too fast, and it’s going to shock your ears. It’s going to shock your system if you go from 1,000 steps to 5,000 steps. Instead, let’s slowly adjust that dimmer switch or the dial in order for us to find the sweet spot. This is where we’re going to be able to use that 24-hour roll and making sure the next day and even that night, is the knee more swollen? Is it stiff, painful the next morning? That is really a good proxy of okay, did I do too much the day before or not? If you did, then adjust that next day. Don’t go out and do the same thing. You might need to pull back a little bit, and this is going to be the slingshot effect. It’s going to be pulling you back to launch you forward.

This is the thing that can be hard for people, especially high performers or high people who like to get that endorphin rush with activity and step counts. Or maybe you use walking as your way of getting cardio. It is going to be something that, I hate to say, but you have to come to terms with, for these first eight to 12 weeks. We’ve had a lot of people we’ve worked with who use cardio and use walking as their way of exercise. One of the ways that they just are able to get out and it’s challenging and the thing is, they’re often the ones who have a hard time because they can’t sit still and they’re like, okay, I’m going to walk around the block. It ends up being one of those things where, if we could have just tackled this and controlled this a little bit more, therefore it could have been something we could have taken care of. It just makes the knee have some swelling and pain and stiffness kind of linger around for longer and that’s okay. Look, at the end of the day, like we can only control that so much. For that athlete, for them to be able to walk a little bit and maybe, yeah, the knee gets a little bit more puffy, if that’s something that we’ve talked about cost-benefit on and it might be worth it. But I would say in majority of cases, athletes will listen and then therefore we can guide them on here’s the best game plan.

In terms of next steps, plan for high step activities. Errands, airports, if you’re walking around campus, school, travel, big events, they all count as load to the knee, so we need to manage it. If you need to essentially get your conditioning in or you’re itching to get your heart rate working, do off feet conditioning. Do not go for walks. Don’t do something where you’re going to slightly run or something like that. Instead, use a bike, use a rower, use a skier, use something that will help get the heart rate going, but you’re off your feet when you do it. Absolute game changer because that’s going to help with the swelling and also reduce your step count as a whole. Still burn more calories, still able to get a heart rate and aerobic response, but you’re saving the stress of that knee being on your feet and the cyclical loading of it. And then reduce your steps on the running days. If we get into running, that can also add as a shock to the joint and also more steps to the day. That’s something that we have to account for. We need to balance those days. We want to make sure we don’t have any back-to-back running days once you start. There is something now for us where we take two paths. There are some athletes who want to build towards endurance running, and there’s some who want to do more of like speed-based approach. One of the things to consider, unless running is a big goal of yours, it could be something that we delay or maybe work on more speed-based activity because it’s less quad demanding.

The other thing too is that we can control the cyclical loading of the knee versus if you go out for a mile run, that’s going to be some repetitive joint loading and compression. Versus, if you do a 10 yard, 70% run, you’re probably going to be okay in terms of the knee. It’s going to be less cyclical loading and it’s actually going to respond better from the short distance running versus the endurance-based running. That low volume impact can influence how that knee responds in terms of this. We want to make sure we manage the step count on running days versus non-running days, and also buffer in between those days to balance that recovery. At the end of the day, we need to have a quiet knee. That’s going to be the main goal here, and that’s why the step count management is so key. Making sure we know what that baseline we’re aiming towards, and then also what has it looked like for the past seven days or so. And then we can start to look at, okay, I need to get back up to 8,000 steps and I need to hit this in, let’s say 10 weeks. Someone is starting at 2,000 steps at week two. We need to slowly see if we can build towards that. And if we can’t get there, then it’s either having to suck it up because you had no choice. And just knowing the process will be slower because the knee is reacting. Or, we make adjustments. I’ve had athletes who have made adjustments to work, being able to change positions, being able to alter things a little bit. We’ve had to even put in medical notes to just make sure the knee responds positively and usually in a work setting they respond well. It just depends on your scenario, and the same thing with student athletes as well. Prioritizing how we can make sure this knee is quiet and really win that first six to eight weeks is going to be key.

I think the biggest thing here is stay consistent with this and avoid spikes. Keep that dimmer switch mindset. The small steady progress is going to beat these random, like hardcore days. We want to make sure there’s no massive spikes in what we’re doing in terms of step count. If we can keep it across a threshold that is healthy and the knee responds well, and we slowly nudge that with the dimmer switch, that’s where you’re going to have the most success here.

Now you’re like, why did I just spend 40 minutes talking about step count? Because it seems simple, but it’s honestly one of the most powerful levers that you have in your ACL rehab. I think that, in reality, probably 90% to 95% of ACLers miss it because it’s just not something on their radar. We don’t learn this stuff in PT school, and most clinicians aren’t thinking about step count in addition to everything else that we’re working on. I think that is something that you as the ACLer, or if you’re a coach or clinician listening to this, it’s a very powerful lever that we can use in order to manage the knee to set it up for success. If you can keep that swelling down, if you can do that and build your range of motion, get your quads back faster, you’re going to see the middle and late parts of ACL rehab really shine. The people who have swelling,  sticking around when they’re in months 4, 5, 6, 7, and on, they just have a harder time. The strength progression is harder. They have ebbs and flows with their range of motion. It’s just one of those things where it’s really annoying because it might not be a blown up knee joint, but you can definitely tell that there’s still fluid in that joint that’s influencing how it feels. They will report the tightness. They will report the way that the stiffness feels in the knee sometimes. And also just like that lack of range of motion and just the strength progression. So that’s going to be super key here. There are tactics to navigate that swelling, but I think if we can just zoom out and look at the step count, the load management of it, it’s going to be a huge game changer. The thing is using it like data. You need a data-driven rehab program and process, and so that’s going to help us to stay objective with it versus being like, yeah, I did a little less. Put on a watch, put your phone in your pocket and let’s just put some numbers to it. And we’re able to see that with our athletes and it helps so much. And having this conversations this past week especially, I felt like I wanted to share our framework and things that I think could be helpful for us to be able to use in this process, and being able to also make sure that it sets you up for success for the long term.

I hope that this was helpful. I really think that it could be something that could be very useful for a lot of ACL rehab. If you’re someone who’s dealing with swelling, if you are in the first three months of this process, just do this. Take the last seven days, and if you’re very early in it, and let’s see what your ceiling is for your average days, and then what is your floor? And see if you can just slowly progress towards that. The other caveat I want to add here is that if you had a meniscus repair, and you might be limited to weight bearing for maybe two weeks, four weeks, six weeks, your timeline is going to look a little different. When you get off of that restriction, let’s say you’re at week four and your surgeon’s like, all right, cool. You can start putting weight down on that foot after the repair and the surgery. For some reason there’s this feeling like you need to get off those crutches quick, and it’s almost like dish crutches. It’s like your knee hasn’t been loaded on the ground for four weeks. It’s going to take some time to get used to that. And the last thing you want to do is shock that joint. The same principles apply here. Start with two crutches, go down to one. Whenever everything is cruising along with your swelling, pain, your range of motion, your quads are developing pretty well, and you get that terminal extension, then nudge it forward and be able to manage that step count and then reduce it down to one crutch. Then reduce it down to no crutches whenever you get to a good point and that gait is looking super smooth while all of your symptoms, your range of motion and your quads are looking really solid. That’s the goal here. I wouldn’t even put any timelines on it, and it’s just more so of can you earn the right to get off the crutches. And that’s going to be the biggest thing here in this process. I think step count is going to be a massive player in that. I hope that this was helpful. Until next time, this is your host, Ravi Patel, signing off.