Episode 256 | Proactive > Reactive: The ACL Surgery Prep That Separates Successful Recoveries

What is up team? And welcome back to another episode on the ACL Athlete Podcast. Today, I’m excited to dive into this specific episode. It’s one that I’ve been thinking about a lot, especially with us nearing the end of the year and with the New Year happening. During these times, people are prioritizing ACL surgery just because of the holidays. They have more downtime. They might be meeting their deductibles or their insurance changes. They may either end the year try to get that knocked out with the high expenses. Or, they may start the year so that they have the rest of the year to be able to pay into the plan. I know it’s ridiculous, but it’s just the way we make decisions.

It’s something that I want to talk about with our ACLers, a good chunk of whom have had ACL surgeries recently. I wanted to share some helpful insights that we’ve been seeing as a team, and just myself and working with these ACLers. It’s just been something super interesting to see the success of certain ACLers and then also maybe the not-so-much success of ACLers coming out of surgery, and most importantly, later in the process.

I want to share that insight because we have seen repeatedly over hundreds of ACLers going through this surgery, and the differences in those short and long-term outcomes. Being super prepared going into surgery is so underestimated. Now, some of you might be listening post-op, and you might be months out. I still hope that this is helpful and valuable because there are certain things that you can look at and be like, okay, I did those things right? Maybe there are some things that were missed. But with that said, if you are a PT listening to this, a coach, if you’re an ACLer that’s getting ready for surgery or in the early post-op phases, then this is definitely something that you want to listen to because I think it’s so valuable. If you can just get this stuff lined up, if you can even just create a checklist for yourself of, okay, did I tackle all of this stuff? Do I know what to expect? That’s going to help you so much in this because there’s so much unknown, so much anxiety, especially for people who go through this. You don’t naturally just know about this process; it just happens to you. No one chooses it. And the thing is that it’s so reactive. It’s okay, the injury happens. And then after that, it’s a matter of what are the next steps? Usually, it’s imaging, surgery, and then the rehab process afterwards. It’s rare that people really get ahead of it, unless they are a little bit more research-based, maybe type A, and some people start to look into things a little bit more. But I would say a lot of this ends up being just a natural injury. You go to see the orthopedic, you do the imaging, you get the surgery, and then you start the rehab process. It’s just something that I think if we can just break down exactly what we see from the successful people, it’s going to really help in terms of making sure that you are prepared, you’re not feeling anxious, and that you feel in control of the process versus it being in control of you. 

Let’s talk through some of this, because I think a lot of times people think that the ACL surgery is the starting line. When in reality, yes, you could say that. It actually starts before the ACL surgery. And for us, that’s super important, and that’s the prehab process. Even if you have maybe one week between the injury and the surgery, now, for most people, you’re probably waiting more time, and ideally a little bit more time than just a week. Ideally, at least four, if not longer than that, to prehab, get the knee to a good place. What we’re trying to do is to make sure we optimize that period. But it’s also preparing for surgery to come, if that’s the route that you’re going. I just want to share this because we see so many ACLers come through this process, and we see both sides of it, especially the later stages of it, because people sometimes don’t find us until later. We have to take a step back because certain things were missed. We also talked through, okay, how was post-op, what were you given, what were you told to expect in terms of the post-op progressions, the exercise program—everything. And it’s crazy how cookie-cutter it can be. I think the challenges are landscapes where we don’t have as much autonomy or time to individualize the different people, because healthcare is very volume-driven. PTs don’t have the luxury to individualize things too much. And that’s the other challenging pieces with this. Plus, the specialty of ACL doesn’t really exist much. There are ACL specialists out there, but there are far few between compared to the number of physical therapists that actually rehab ACLs.

When we look at this process, if we’re fortunate enough to get athletes in prehab right before surgery, it is an absolute game-changer. For not only the early post-op process, but we’re also talking days one, two, and three, and then of course longer term into the coming months. Why though? As I had shared, it’s about preparation. I want to share that so we can make sure we are setting up our ACLers as best, and to show who those are that have solid success and momentum coming right out of surgery. I’ve done a detailed three-part series preparing for ACL surgery that you should check out if you’re heading into it or you want to recap on it. It’s something that I wanted to make sure that people have something that is very detailed to prepare them. Now, I should probably go back and update some things with it. But I would say it’s a very thorough three-part series for you to just mentally be prepared for it, and even equipment, priorities, and what to expect, so check that out if you’re heading into the ACL surgery or soon after it. 

Today, I want to share some themes that we use with our in-person and remote athletes that are key to their success right after post-op, and here they are: 

Number one is that we are so intentional about trying to make sure that we gather all the information initially before they just jump straight into surgery. We want to know who you are as not only an athlete and what makes you tick, but also as a person, it’s super important to us. And that way, we’re not talking to you right after surgery. I think people underestimate how much surgery influences how they’re going to interact with their overall well-being. You just went through anesthesia. You had an ACL major reconstruction. You are in pain, you’re in swelling. You’re a little hesitant to move the knee. The last thing we want to do is introduce ourselves immediately in that moment.

Now, does that happen? It happens in the majority of ACL situations because that’s the way the process works: people start their rehab after surgery. Therefore, they see their PT.  You’re having these conversations immediately after surgery, which is fine, totally fine to do that. But we’d like to try and tackle this before this surgery because then we can get super clear on, okay, what is driving this person? There’s no influence of the surgery, the post-op process, the anesthesia, the pain, and the mental barrier that the surgery after hits on people. We’re discussing key details one-on-one. We’re trying to gather baselines of their functional range of motion, their abilities to move, and certain strength profiles. We’re trying to gather that prior to the surgery; therefore, we could just make sure that we have that information as we compare it to the rehab process. We talk through shorter and long-term goals and get ultra-specific on why it’s important to you and why it is something that we need to make sure we map out through this process.

We’re also going to talk about how we’re going to build this around the lifestyle, the schedule, because people think that this process happens in a vacuum. And maybe for the first week, two weeks, and if you’re lucky, four weeks, you just don’t do anything besides this. But at some point, you have to resume life, and that could be school, work, kids, or travel. We need to know those things. We need to know what life is going to entail when you go back to “normal.” Any roadblocks that may come along reintegrating back to work and back to life and back to school. 

The thing is, we’ve had people where, they’re teachers, have a six-month-old, are professional athletes, like they are someone who is in school. It’s crazy the variety that we work with. But then at the same time, we also have to understand that each context is so different. What are you going to do whenever you have a six-month-old, and you’re a mom who tore your ACL and had surgery, and you can’t carry your six-month-old for the next four weeks because you can’t put weight on your foot. We have to be ultra specific in this and make sure we understand, okay, what is it that we’re planning for coming up? And then most importantly, building that plan before surgery, the day of, and the immediate days to come, and weeks. And we’re trying to do this ahead of time and being like, okay, this is our game plan. Versus being reactive and being like, all right, let’s let the surgery happen, and then we’ll figure it out. Let’s create a game plan together and then just adapt it once the surgery happens based on the details. 

The next piece is that we go hard on education. We are so foundational in education. That’s one of our core pillars as a company. We are going to educate our athletes in a very simple way. We’re not going to throw everything at them and try to do water through a fire hose here; we’re trying to tastefully add in certain educational components through this process, and we space this out based on the timing of how athletes are with us. We talk through our understanding of one’s capacity thresholds. It’s going to be a little different when you were pre-surgery versus post-op. The number of steps you can take, the amount of time it takes to get back to the normalcy of day-to-day, is going to be different. We need to understand what those thresholds are because they’re going to influence symptoms and the strength gains in your range of motion. For example, setting expectations, the graft type, how we prehab the graft type that they’re going to get. Also, help with choosing the best graft that they could get if that’s still a decision point for them. We have consulted with athletes where they’re like, what graft should I get? And we walk through this framework to help them decide and make it fit them. Versus the surgeon saying, you should do a quad graft, or you should do an allograft. Instead, we’re like, what are your goals? What do you want to do long-term? Is there any history of injuries to your patellar tendon, quad to your hamstrings? What kind of sports do you play? What kind of activities do you want to do? And then also the surgeon’s expertise. There’s so many layers to picking a graft type versus just being like, the surgeon does this, this is what I’m going with. If you’re a wrestler and you get a patellar tendon, guess what? You’re on your knees so much.  It might actually be the worst decision because if you have kneeling pain, guess what? You’re on your knees all the time wrestling. It’s going to be very different versus a hundred-meter sprinter, who is going to play college, or compete in college if they get a hamstring graft. We gotta know the implications of that because the hamstrings are so involved with sprinting that if we take one of this athlete’s hamstrings, guess what? They’re going to lose some speed, and they’re likely more prone to hamstring strains, and getting a full cycle of that knee when you go through the sprint cycle is going to be influenced. But these details are not usually discussed. It’s just, Hey, this is the graft that I do. Yeah, you could get some other ones, but this is what I do, so take it or leave it. We’re going to talk through this stuff with you, especially if it’s still a decision point. We help walk through this with the athlete, but then also know what to expect if you already have the graph set on it. Also, knowing what that looks like with a quad, patella, hamstring versus an allograft? And knowing what to expect is huge, including our bears or even repairs, which are also gaining traction. We talked through what non-weightbearing might look like, what weight-bearing might look like, how meniscus-related decisions impact this and other concomitant issues. If there’s an MCL injury, PCL and LCL, other cartilage-based injuries, bone injuries, and fractures. Several things can happen with the incident that happens whenever the ACL is injured. We have to understand that a meniscus is typically a common one. We want to make sure we understand, okay, are they going to repair it, or are they going to cut some of it away via meniscectomy? 

Now, this is going to influence a lot. Because a lot of times, if it’s a repair, you’re going to have a non-weightbearing for a period of time and maybe limited flexion. That’s gonna be super important in this process because we need to make sure we understand, okay, if we’re not weight bearing for four weeks, that changes things versus weight bearing as tolerated from the get-go. We also let our athletes know, sometimes it’s a game-time decision for the surgeons. They may say one thing, they go into the surgery and they may see something different, and they may have to do something different. And guess what? You wake up. You thought you were going to have a meniscectomy and could put weight on it, and they restrict you because it’s a complex meniscus repair, and you can’t put weight on it for six weeks.

Your life changes for the next six weeks. I promise. It’s very different. Therefore, that is going to influence the recovery and the rehab, and also mentally, how you progress into the next phases. And that’s something we need to talk through to make sure you understand what is worst-case scenario is and what best best-case scenario is.

Side note, if you have a meniscus repair in the short term, it sucks, but I promise in the long term it’s great. Because you have that cartilage that’s preserved versus meniscectomy, they have to cut some of it away. Now that’s great in the short term because you can put weight on it. But with that said, longer term, maybe a little bit more risk for osteoarthritis. I had to have a meniscectomy on my left knee when I had my second ACL. I just know that comes with the territory now. But again, it could be a game-time decision. And the last thing you want to do is wake up not knowing this and being like, oh man, we’re gonna do this. And then now I’m locked in this brace, or to 90 degrees, and it’s going to be like this for four to six weeks. Very different. 

We talk through what this can look like. We talk through the bracing, we talk through nutrition, protein goals. Stuff like this is super important because it’s overlooked, but it can make a huge difference in this post-op process. So that’s all around the education and setting expectations.

And then we roll through our process of what does it look like to rebuild the ACL athlete, what are the needs for their specific goals, their activities, and their sports, and what are the demands of that, and what we’re trying to get back to. We talk about autoregulation, which is dosing proper intensities and volumes, so making sure we can get that accurately to get the right stimulus. We talk through feedback loops, which is how to navigate pain and swelling. Look, we’re not there with you day to day, every single moment. We can’t necessarily say, hey, you have to do this in the same moment, and no PT is ever going to follow you like that. You may be seeing your PT in person three times a week, max. Usually, it’s two times a week, maybe once a week, maybe it’s every few weeks. Through working with us, we have constant communication throughout the week with our athletes through messaging, so you get a quick response. But with that said, it’s important to put this into your own control, to educate you, so that way if your next PT visit isn’t until two days from now or next week, or you can’t get a response within the six hours. You know what to do if something acts up from a pain standpoint, swelling. You know these particular principles and feedback loops to follow. And that helps you feel in control versus feeling, Oh my gosh, what just happened? How do I navigate this? We talk about pain management. 

We assess psychologically how they’re doing, getting an objective number connected to this. We’re getting an idea of this threshold and where someone is. We also talk about the roadmap. What does this look like for their specific journey, your specific journey as an ACLer? How can we mold this to you and make sure that step by step? What are the key milestones and the objective criteria? And then tapping into some mindset-related work is going to also be key starting day one, and each week with that. These are things that are super important for us from an education standpoint, along with many other things that we layer in. But it seems like a lot, but we spread it out, and we try to educate this more visually. Therefore, our athletes are very familiar with this. They see this, they’re like, okay, I got control of this. And we’re right alongside them, walking them through this day to day. 

And then the other pieces that I’ll share here. Setting up your environment for success is underestimated. But making sure you get everything properly set up and understanding what the ins and outs of that looks like versus getting home and being like, Oh, my stuff’s upstairs, but I’m downstairs. And then navigating stairs. So all that’s like reactive, and we want to make sure we are proactively setting things up. Post-op exercises: Everyone will likely get a sheet of paper from their surgeon. I hate that thing. I wish they had never given it to people. But it’s something where it might be just basic post-op exercises. I can tell you 99% of them. It is quad sets, straight-leg raises, which no one should be doing, and they should take ’em off. It’s heel slides. It is typically glute sets. It is typically a four-way hip. Those are the main ones. There might be some other ones in there. But those are the main key ones that you’ll see.

I’m not saying they’re bad. But at the same time, it is something that we need to make sure we tailor to each person through this process. And that’s something that’s going to be really key here. With the post-op exercises, we don’t want to overlook these, but we also want to get these a little bit more tailored to each athlete. We set out specific buckets to tackle based on the number of factors: graft, weight bearing, surgeon’s restrictions, and, most importantly, the criteria we’re driving towards, especially looking at the quiet knee and other areas that we want to work on. We go through a range of motion streams, which are focused on extension and flexion. 

We look at isometric streams to make sure we are still activating muscles in a proper way and not losing all the work that we had in prehab or before that. We want to make sure we can start dialing those in early, versus waiting. We don’t need to wait until the range of motion is full or a certain point, but start activating and starting to work these muscles in isometric positions, and then working them through the range of the different muscle groups. Gait and running mechanics can start literally day one. People are so surprised by this, but we dial in these mechanics and make sure that people are feeling good and that they can start hitting the ground and being able to get their gait going, and that’s going to slowly evolve into running mechanics.

We want to make sure their specific dosage and cues are lined up so they’re familiar with this and what to feel in the specific benchmarks of each. I think that’s super key when someone’s doing a quad set when they’re using NMES, when they’re doing a heel pop, when they’re doing an isometric knee extension. We want to make sure that they know what they need to feel, what is normal, and what is abnormal. That’s going to be helpful to make sure, okay, this is feeling like it’s in alignment of that, and this one feels a little different. These all seem to be a little extra, but with what we do, especially from our remote coaching side of things, we educate our athletes through this process in a number of different ways. And can also provide this framework visually and for them to go through, and for us to communicate easily through it. 

The thing is, with this, even though it seems extra or extra detailed, it makes all the difference. And the beauty is that you’re ready for them. And then we tailor it once we finalize and know what happens in the surgery and after. That way, when you are going into the surgery, and after, these exercises are like, I’ve seen these. I know what these are. And versus being able to say oh, these are unfamiliar and now you’re trying to tackle these while you are post-op and a little bit more out of it. And the feel of it just doesn’t feel right. It’s much more than just basic stuff, and it’s something that can be a huge catalyst in this process. 

We look into this a little bit more, we’re gathering proper equipment and getting used to it, and setting it up before surgery for the maximum benefits. Electrical stimulation using a neuromuscular electrical stem (NMES). If BFR is in the mix, blood flow restriction, we’re getting them used to that, getting the occlusion pressure, getting that used to what we’re going to be doing. Taking it for multiple test drives until you feel fully dialed in. You could set up that MES, you could set up the BFR, you could set up any other type of equipment you might be using in the process to make sure that’s dialed in.

The one thing I want to share is that we’ve had four fresh post-op ACLers these past two weeks, and they’ve all been cruising since surgery. All sharing how they felt since day one, which has been really awesome to hear. And it’s something they knew what to do, what to expect, and mentally and physically they felt ahead. Instead of surgery being this big roadblock, it was just like a speed bump. And they kept rolling as they went past it. The funny thing is that this is also despite a couple of surgeons saying, don’t do anything for your first week or so until your first post-op visit with the surgeon. And that’s very common. You have the surgeon, and then the post-op visit follow up where they might check the knee, change the bandage, whatever it might be in that, maybe take out stitches. But the thing is like some will give exercises, and I will say, just wait until you see me. And then you can go to PT. 

Some of these might say. It’s a week, or maybe it’s two weeks, or maybe scheduling differences don’t allow for time. But for both of these, it was roughly around a week and a half from surgery till the follow-up, which is ridiculous to do nothing. We had them doing stuff day of surgery, and they went to their post-op follow-up a week and a half in, and the doc and the physician’s assistant. They were like, shocked. They were like, why does your knee look like this? And it’s because we could start this stuff, day one. And they have made a ton of progress, and it’s been awesome, but I attribute a lot of this to them getting prepared prior to the surgery and being dialed in and staying dialed in day to day. They’re not starting their starting line at a week and a half post-op; they’re actually starting the day of surgery and before that; therefore, it’s just a continuation of the process. Why do we do this? This makes it proactive versus reactive. I think proactive healthcare is the way to go. 

We want to make sure that we are proactive in everything that we do. You don’t want to wait until you get sick, until something bad happens, to do something. You want to be proactive, especially if there are certain things that you know are in your control. If you wait till after surgery, it’s just too much. If I’m being honest, in pain and swelling, you’re apprehensive. You’re working with a knee or a quad that just feels completely foreign. You can’t feel it. We have them do a lot of this before surgery, and it’s an absolute game-changer. I view this instead as having an abrupt start, starting post-op when it’s already hard as it is.

And we do it pre-surgery during the prehab. Ideally, when it’s easy, it’s a smooth continuation since you’re familiar and know it. Versus, being brand new and also abrupt after a major reconstruction. We also see the flip side of this in many ways, which sucks, but people don’t often find us until they are dealing with these problems right later on, or they notice their care is not great, or maybe insurance runs out. It’s hard to tease this out in the first weeks of post-op because it’s very basic at a lot of clinics, you’re gonna see progress even with the worst of the worst PTs because it’s just the nature of the ACL process. You go from a straight knee, you bend it some, you get it straighter, you start to get off crutches typically, but that is something that you don’t figure out until a little bit later.

Things that are really important. Then we hear what they did for these ACLs, of course, meeting them after the post-op process later on. And we hear about the bare bones protocol, basic exercises that Bertha, a 79-year-old with a total knee gets, and it’s not progressing. We see that the impact it’s having in their early and late stages, and that could be the difference between smoothly walking two weeks post-op with no crutches versus six weeks of crutches or limping around for a while after. And we see this a lot, y’all. That trickles into the later months because these initial road bumps or honestly roadblocks cause delays in their other aspects of the process, like return to running, return to jumping, getting their quad strength to a certain point, swelling sticking around for an obscene amount of time. If you’re heading into surgery, I promise you this can be the thing that makes the first six to eight weeks a win versus feeling fully anxious and impacting either positively or negatively, the weeks and ahead and months ahead. Be proactive. If you can lock in even the first visit. Second visit pre-rehab visits that’ll help get the ball rolling. I would just be prepared. You’re not gonna have this much detail going into PT. It’s just hard for PTs to find the time to do it, and also if it’s their sole focus. We’re just weirdly obsessed with this, so we’ve had years and years plus thousands of data points to dial this in to make sure our ACLers are prepared.

I just encourage you to find the proper care that can provide this for you because each person deserves it, and I believe that, truly, regardless of status, level of play, age, etc. I think that it’s something that everyone deserves good care, no matter who you are. Being super prepared, going into ACL surgery, gathering important data for our ACLers, not only as athletes, but also as a human, including baselines and what’s important to them, knowing what that roadmap and plan looks like. Education is the foundation of this. Setting up your environment. Getting individualized programming and exercise prescription that will be regularly updated, and equipment essentials is gonna be so key. Be proactive. Y’all don’t react to this. Start early before surgery, and I promise you it will make or break this process, especially in the first weeks and months to come.

I hope that this is helpful. If you need any help, if you’re finding yourself feeling lost, please reach out. We do help ACLers all over the world remotely. And most importantly, all we care about is to just make sure you find good help and expertise, and that’s our mission here. If you have any questions, reach out. Otherwise, I’ll catch you guys in the next episode. This is your host, Ravi Patel, signing off.