Episode 27 | The ACL Injury Journey – Part 1

What is up guys, and welcome back to another episode on the ACL Athlete Podcast. I have my coffee right next to me. I got a good amount of sleep last night, got a workout in, so I am ready to go. Super pumped up for this topic today, which is the ACL injury journey. And this is all going to come from a resource that is called “The ACL Injury Journey Itself – A Guide For Patients.” This was put out by BJSM (The British Journal of Sports Medicine) by two authors: Connor Gleadhill and Christian Barton. I want to give them the credit for creating this guide. What I want to do today is talk through this guide, if you will. I’m going to put this link to the graphics and the guide itself in the show notes. And I’m sure if you tried to Google, the British Journal of Sports Medicine or BJSM and the ACL injury journey, it would be the first thing that pops up. But it’s really cool, it’s got these two graphics. It’s one about the treatment decision and then about the rehab explained. And then it kind of breaks it down into lower phases.

Today, I just want to give you a little bit of an audio version of this, of how I would work through this using this resource and inputting even my own journey through this process so you guys have a better idea. I’ve injured my ACL, what are the steps? I just talked to somebody yesterday who was so terrified and so confused. He was playing soccer. He hurt his knee one time, thought it was just like a calf issue, and then he ended up finding out after a second time that he hurt his knee, that he tore his ACL. And he was incredibly scared and terrified on the phone. And so that was something that was a big issue and something that we had to talk through.I thought that this would be a good topic to bring up today. This itself was published in December of 2020. So that is also good because it’s more recent. This could change with time, but as I look through this, it is very current with evidence. And one of the things that’s important about this is knowing that is not medical advice; it is a guide; it is educational and it’s for you to use on your ACL journey.

Let’s dive into this. One of the biggest principles I want you to keep at the forefront is that each person and this route should be individualized. It’s going to be the context of each person and even your case. For someone who is in high school and is trying to come back to their senior year of soccer, might look different than a mom who is in her late 30s who had just torn her ACL, maybe chasing her kids around. Another is going to be based on the context, and this is a good point to bring up with how a protocol is not going to be perfect for each person.And that’s why each person has an individualized approach as opposed to fitting them into a protocol. But then you got to take into account, the goals as well as the surgery, maybe access to the resources that they have. That is why a protocol, in my opinion, needs to be very specific and not everyone is just thrown in and doing the same stuff. Hopefully, this can help guide you with that. 

Let’s get started. The ACL injury happens, ensue the pain, panic, worry, anger, depression, frustration, uncertainty about the next steps. Guys, this is all completely normal. If you have just injured your ACL know that these feelings are normal. I remember when I tore my ACL initially, it was in my sophomore year of high school and I was not sure what had happened.What does this process look like? I didn’t necessarily have parents who were familiar with the medical system in the U.S. We had to kind of navigate that ourselves and use some people in our corner, on our team to be able to help us to help guide this process. That has happened with the ACL injury.

Next up is to gather your team. This is step one if you will. And this can include your physical therapist, your surgeon, athletic trainer, coach, family, teammates, friends. I actually did an episode on this, episode 25, building your ACL team, if you want to dive into this further. But it’s building your ACL team, which is pretty much the next step that you want to go in. Because they are going to help make a decision, help to guide your rehab, and then you got to think about your community and the people around you to help you stay motivated and check in on you because we know it is a long process. For me, for example, I had my teammates, I had my parents, I had my brother, I had my best friends. And so they were all around me, and then I had my surgeon and my physical therapist. Those were the main people on my team and what you will probably see with most ACL injury situations. Gather your team because they’re going to be important to have in your corner as you move through this process.

Next is to begin prehab. This is preoperative rehabilitation. So that doesn’t necessarily mean you’re having to get surgery, but it’s a term that we use. You get an injury, you gather your team. Number two, begin prehab. Get a normal knee function before having the surgery, in most cases. Now, there are some cases where you might have to immediately have surgery, but it’s a very small percentage. Most people will have the injury and then they will wait until a certain time to decide if they’re having surgery. Prehab is so important here. I’ve done an episode on this, guys, on the importance of it. One of the things we talk about is getting that knee back to a normal place and also knowing that after an injury that the strength around the joint, and the muscles can decrease so we want to minimize that as much as possible. Prehab entails making sure we get our range back, make sure we get the pain and swelling down, almost to nothing, getting our walking back, we call that gait, and then starting to build strength around the joint. And during this time is really interesting because now with studies coming out, we are able to see that maybe some people don’t necessarily have to have the surgery and they do their prehab, their goals are to maybe start cycling, or maybe they just want to run in a straight line. Things that don’t involve a lot of cutting or pivoting and their knee isn’t giving out and they may not have surgery.

For my first ACL surgery, there was a delay. I injured my ACL in May, and then I didn’t have my surgery until July. Most of this was because of insurance and having to work out the coverage and things of that nature—classic U.S. Medical System. But this was also a blessing in disguise because it allowed me to do my prehab and get in my normal knee mechanics and get it normalized and actually start strengthening it leading up to surgery. And yes, I had the surgery because I wanted to return to high-level sports cutting and pivoting, and my knee was still giving out every now and then. I wanted to make sure I had the surgery at that time. This is where prehab has a lot of value because it can help you to get to that normal place. You go into surgery and then you come out of surgery doing much better. There’s evidence that supports this process of doing prehab before you have the surgery. And this, I noticed for me, it was very seamless because I had been doing stuff before, and then I had the surgery. I got out of surgery and I made a quick progress because I was already so used to some of the things that I needed to do. I was able to move on to more of the fun stuff because I was having less hiccups and my knee was normalizing to the surgery and to all the rehab that was getting done. 

Number one: gather your team; number two: begin rehab, and then three is called shared treatment decision. This is a really cool idea here, which I think is really important. This is where we’re trying to decide, do you have surgery or not? Some of the factors that will impact surgery or not is your age, the number of instability episodes or when your knee gives out, other injuries with your ACL injury, like a meniscus or MCL, maybe you have a bone that gets chipped or a fracture. These are all the things that will impact the decision of having surgery or not. Then we’re going to add in, so the shape of your bones, the plans to return to pivoting or sports with jumping or landing. I think that that is something that needs to be considered. And something we talked about earlier, is your goal to get back to soccer competitively, or is it to just run around with your kids, or maybe you’re just want to just run on a track versus you want to be able to go and play rugby. The demands of those activities are really going to dictate, do we have surgery or not, along with these other factors that we had talked about. 

And then in this part comes, questions to ask yourself before choosing whether to have surgery or not. Do I have all the information; have I checked all the boxes of evaluating my options; do I have all the information; do I feel educated about this; going back to what are my goals, what are my values, time with my kids versus playing with friends. These are the things to consider. What are the risks versus rewards of having surgery now. A lot of the time people will debate the whole osteoarthritis. And honestly, this is very complicated and it’s something that needs to be considered for the long-term implications of having the surgery. But what we have seen now is that, if you have surgery versus not, the outcomes are pretty similar for osteoarthritis. The thing that makes things worse is that if you have a meniscectomy where they cut away some of your meniscus, that will increase your rate of having osteoarthritis. Something to consider is the risk versus reward of having surgery now. 

Am I being listened to? I love this a lot because in healthcare and in medicine, you could be really told what to do and not really heard on your end of maybe this is what you want to do, or maybe some thoughts that you have. And you’re just literally being told, “Okay, this is next, this is next, this is next.” It’s good to have the guidance, but you also want to make sure you have peace of mind because this is a pretty major surgery. It can really impact your future and your long-term health so make sure that you are working with people that are listening to you. I like this one a lot. Have I been given enough time to make the decision? Now, this comes back to your own personality as well. Are you someone who takes a lot of time or are you just impulsive and you just decide, okay, they told me this, I decide to do that. I think that’s something to consider about yourself and who’s having the surgery and making sure you have all the information. You recognize your goals, what your values are, the risk/reward of things, have you been heard, and then making sure you have adequate time to make the decision whether to have surgery or not. This is a part of the shared treatment decision. 

For me, in my first surgery, there wasn’t really much choice or being heard. I just remembered this is what you do, this is the graft type, I didn’t even know there were other graft types, which if you’re in high school, why do you care really. But it ends up being really important. Because if I were to pick now, I would have picked a different graft just because of the issues that I had with my hamstrings. Maybe I would’ve picked a patellar tendon or a quad tendon, instead of getting the hamstring graft. So that’s in hindsight. Whenever I had my second ACL surgery, this was something that I was able to make a better decision on because I knew the information, I did my research, I was also learning to be in this area and field. I’ve made sure that I asked for any resources I had and made the best decision because I do take a while to make a decision. I need all the pieces in place to do that. 

This is something that I highly recommend as you’re moving through this process to know, “Okay, have I evaluated all these different areas,” then you could be at really good peace knowing you made the right decision. These are conversations you can have with your team that you create to make sure you have the full 360 and that you know you’re making something that will really give you peace and you have other valuable input during this decision-making process. 

And one of the things that’s really cool on this graphic is, did you know at the bottom, and it says what I had said earlier, actually, without remembering. No evidence suggests that surgery leads to better outcomes compared to high-quality rehab. The rate of osteoarthritis is also not different for those who had surgery versus not.This is essentially saying what we had talked about earlier, that OA, with surgery versus not, doesn’t make a difference. That changes a little bit when you have a meniscus-type issue and you cut away the meniscus. But don’t let osteoarthritis be the decision solely on whether you have surgery or not. It needs to come back to those other questions that you’re asking yourself, starting with the goals you have for your life and for the activities that you want to do. 

All right, guys, this is it for part one of the ACL injury journey. I wanted to go in-depth about this and talk about these individual pieces. And then in part two, we’re going to get into the rehab explained more, which I like the synopsis that they have, the different phases and just some of the things that you can implement and some of the principles that go into this. Stay tuned for part two coming out next week. But for a recap from today, from part one of the ACL injury journey. The ACL injury happens, you have all those feelings, you start to gather your team to start making a game plan, whether that’s your physio, the surgeon, AT, coach, family, teammates, or friends, etc. to help create the best route forward with your ACL injury and whether you have surgery or not. And then your prehab where you’re trying to get your knee back to normal function before you have surgery and if you have surgery, and then the shared treatment decision, the factors that will impact your surgery or not, and then the questions that you must ask and need to ask yourself before you have surgery or if you choose not to. And I think that this will help give you a well-rounded piece to the early process of the ACL injury journey and be able to help guide you along this path.

All right, so that’s a wrap for today, guys. Thank you all so much for listening. This is your host, Ravi Patel, signing off.