Episode 36 | Top 5 Priorities Right After ACL Injury or Surgery

What’s up guys, and welcome back to another episode on the ACL Athlete Podcast. Today, we are talking about a topic that I’ve been getting a lot of questions about. We’re going to dive into it today. But before that, I just want to remind you all that there is a free ACL athlete self-assessment download. You can go to the link in the show notes. This is something for you to reflect on and evaluate your journey and where you’re at. This will be only available until next Monday. And if you didn’t get a chance to catch that episode, that was episode 35, where we talked about it and broke it down. Go and do that if you haven’t, and let me know your thoughts.

For this episode, we are diving into the top 5 rehab priorities after ACL injury or surgery. These are going to be your main buckets that you’re focusing on right after you have that injury or after you have an ACL reconstruction surgery. This can get really overwhelming for a lot of people, and even for physical therapists,  there are just so many different parts to juggle. And a lot of times they’re following a protocol which is fine, but we need to make sure that we have a good framework and understand what we’re working towards.

Let’s keep this simple guys and that’s the main focus I want you to have for this. Phase one is keeping it simple. We’re going to reverse engineer from the goals you want to achieve of phase one, and the way that we use it with the ACL athlete is your restore phase and then building into your foundations. This kind of goes hand in hand, so restore is like let’s get that knee back to its normal function, and then we are rebuilding these foundations. And to tag along with that, I want to use the idea of a house. In order to build your house, you need a very strong and solid foundation. I know people have heard this from other places. But ACL rehab, I cannot stress enough how much of these foundations and these important goals that we’re about to talk about, are going to really dictate the rest of your ACL journey. And if you do not get the foundations right and restore these, then it’s going to be very difficult for you to progress into the more demanding phases, and to strengthen and to get into jumping and plyometrics and agility and all of the things that we all want to get back to. But you have to do the initial boring stuff right in order for you to get there. 

When we talk about phase one goals, one of the things that’s driving this is the healing aspect; whether you have the injury or the surgery, you have to respect the healing. The body has to do its job. It just had trauma to it, whether it’s either the injury or the surgery. Each one is going to be very different, but we have to respect what the body is doing. Just like when you’re sick or you have a cut or anything like that, sure, you can help remedy it to some degree. But you can’t speed anything up. This is where you need to kind of let go of time in terms of how long this is going to take and what this looks like. I will tell you that a lot of people will skip over this really quickly. Or, maybe PTs are following a protocol and they’re like, okay, two weeks or four weeks, you should be into the next thing. But we need to look at what is happening with the person in front of us and be able to recognize, okay, what is the most important for this person right now? Because what you will also know is that with these injuries it can be a lot of different complications, whether it is a meniscus issue and that’s the difference between cutting away the meniscus or stitching it down. Is there a fracture? Is there another ligament injury? Are there other things that are going on that could impact this phase one?

If you help yourself set the expectation and know that this initial phase is going to be a little bit more repetitive and can get a little monotonous just because you are working on these foundations. But we need to work on these and work on these consistently over time, in order for you to get to stage two where you’re working towards more of the strength and introducing other dynamic things. But right now a surgery or an injury is constraining you to what you can do, which is great. Let’s dive into these main goals.

And you guys have heard me talk about this before. But the main things that we try to accomplish these top five rehab priorities are going to be—four of those are going to be the quiet knee. And then the other is going to be your gait and walking pattern. When we talk about the quiet knee, the first part is a full active range of motion. And breaking that down, even more, we need to prioritize as much as possible full terminal knee extension range. And that means the passive where you’re almost stretching into that. If I were to lift your leg up, you can get there. And then actively, being able to contract that, and we’ll go into the quadriceps next, but being able to actively get there. And this needs to be matching the other side or your other knee, and being able to match that up is going to be really important. Typically, it’s around negative 5 to negative 10 degrees of hyperextension. There’s a PT out there or a rehab professional telling you that zero is okay, unless that is what your baseline is just at rest on your other knee and where you were before. Odds are it’s not. You need to get that extra 5 to 10 degrees because that’s going to make the difference of you being able to recruit your entire quadriceps.

As we’ve talked about in the past, it will also distribute forces differently at your knee if you cannot get that full terminal knee extension. Inflection is also important, but this can be something that will come with time. And this is where you just kind of, as you’re progressing week to week, you’re slowly trying to build this up. No one gets a full knee bend after week one. It just doesn’t happen, and that’s not the goal anyway. But just look at this as a progressive process. But as soon as you can get that early terminal knee extension, you will be in such a good place to be moving forward. Full range of motion, especially extension with knee flexion coming along over time.

Then, you want a strong voluntary quadriceps contraction. You want that quad firing as hard as it can and as much as it can. This will be something that will coincide with getting that terminal knee extension. If you’re getting there, then your quad should be getting there with you. This is where I like to do neuromuscular electrical stimulation (NMES). If you’re not doing it, it’s something that I highly suggest and that’ll be another podcast by itself. But, it is something that is supported by the research because we have such a difficult time with the pain and the swelling. We know there are a lot of neural processes going on that shut down your quads, that this NMES can help to kickstart it and get us firing better so we can build up our quads again. Getting that contraction is very vital. And the point of this podcast today is not to go through different ways to do that—is to establish these top five rehab priorities. We’ve got full active range, especially extension; we’ve got strong voluntary quadriceps contraction. Then the other two pieces of the quiet knee minimize swelling and pain.

Well, guess what? This is something that’s going to come with time and you’re just going to have to allow your body to heal. And it’s going to be one of those things where it’s going to be a dance, between looking at the activities that you’re doing and how your body is responding to it, especially your knee. So that’s where the whole swelling piece comes in and the pain piece comes in. As you get further away from your injury or your surgery, that’s going to really dictate how your knee can progress with different loading strategies, which is your overall rehab. And then we dive into your normalizing gait or walking pattern.

Gait is just another word for walking. And so the thing that can be tough here, is that sometimes athletes can get restricted with weight-bearing. Let’s say that there’s a fracture or a meniscus repair, and depending on the surgeon they will offload you or do non-weight-bearing so you can’t put that foot down from anywhere to two to sometimes six to eight weeks. It really depends. On average, you probably see four weeks with the meniscus repair, especially. But it’s really hard to say, and those are some of the things that you just have to respect with the surgeon. Just because they went into the knee, they saw what they needed to do. They’ve seen the history of working with their athletes and the strategies that they use, that this is a good time to start introducing load.

But as soon as you can start impacting and distributing load into that foot, let’s say, you go from non-weight-bearing to partial weight-bearing or weight-bearing as tolerated, you need to do it. And as long as the pain and the swelling coincide with that, then that’s going to be really helpful to be able to progress with your walking pattern. This is going to help start putting load and stress through the joint, which we need. Guys, if we offloaded our weight, think about astronauts, they waste away. Because there’s no gravity, astronauts have to train a ridiculous amount in space. We have gravity which helps us, but whenever we offload joints, we start seeing muscle wasting. I know all of you guys have seen this if you’ve had to kind of offload your knee. You start to see your quads shrink up, especially post-injury and surgery. And it’s one of those things that are not fun to see, but it’s one of the things that you got to build back up. And part of that starts with being able to activate the quad in the range, but then also loading it through the ground by creating force back into your leg. And that’s good. And you want to take this nice and slow in that way we can also minimize how deconditioned that leg gets. 

Taking a gait pattern nice and slow with a heel-to-toe type drill is really good and using hurdles and things like that. And if you are non-weight-bearing, then there are other drills that you can work on and certain postures and positions that you can add into the legs until you can start to put weight through that leg. But this is an important piece of this and can get skipped over. What I will see is that people will have still a slight limp or they may compensate at their hip, which we’ve seen with research. And a lot of this comes down to, they didn’t get their range back, especially the terminal knee extension, their quads were weak and they skipped over working on their gait pattern. And then now, they’re trying to get into all the strength training and even running, and their knees swelling up and they’re having a lot of issues. Because we did not get the foundations set, we did not restore the knee, we did not build those strong foundations, and now people are having trouble further down the road. I see this every single day. I have athletes who reach out to me about this. It’s harder to get the further away you get from surgery or from the injury. Restore this as quickly as possible. 

And then some bonus that I’m going to add is donor graft site loading. If you had the surgery and let’s say, you have gotten a patellar tendon graft, or a hamstring, or a quad graft or whatever it is, you need to be strategic. But loading this early will be very helpful to make sure that you don’t have this donor site pain later. And this is why we’re working with a very skilled ACL-specific physical therapist who will really help you because they’ve seen this, they know it. You want to make sure that you are taking care of this donor graft site. 

The other two pieces are going to be minimizing deconditioning. And so what happened is people have surgery. And look, I’ve been through it twice, I get it. You don’t want to do anything else. But as quickly as you can start to train or condition yourself, because when we’re just kind of laid up, we start to lose these athletic qualities, whether it’s speed or strength, or just general aerobic fitness. And it’s a tough pill to swallow, but it’s the reality of having the surgery or the injury, and then having to offset some of that just to allow it to heal. But you can kind of get back to things pretty quickly because you have three other limbs, guys. I have an athlete right now. She is three weeks post-op, but she picked up doing her upper body stuff a week after the surgery. We don’t see each other. She’s completely remote. But she’s crushing it and she’s been consistent with her workouts, and then she builds in her ACL rehab in between that. We’ve kind of structured a program that way. But she is not minimizing her conditioning because she wants to stay conditioned upper body as well as aerobically. Those are one of the things to consider is making sure that this deconditioning process does not extend and that you have other abilities to work on it. Just strategize this with the physio or the rehab professional you’re working with, to make sure you keep that conditioning level up. And you’ll probably also see that your recovery is going to also help and be more beneficial for your ACL rehab.

And then the last piece to this is going to be training the other knee. Now, I want you to be sensitive about this because what people will suggest is that you got to train the crap out of the unoperated side. But you got to understand that you’re having to do a lot more work on that leg because you are offloading the ACL side. A lot of people are like, oh, we’ve got this great training program, keep the other side as trained as possible, and you’re going to do workouts on that. And look the first week, it’s a doozy, so don’t kill yourself with it. But there is this concept of a cross-education effect. And I’m planning to do a podcast on this very soon, actually. But it’s where if you train the unoperated side or the uninjured side, you could still reserve some of the benefits of strength and muscle size on the other side. And we’ve seen this through research. The body is really crazy. But a lot of this works through neural pathways, and there’s something about the eccentric training of it. Think about it if you’re standing and you lower yourself on your unoperated side carefully, but you’re eccentrically lowering and working your quad to a chair, then that can have some benefits to the operated side to help preserve some muscle and strength. So that is just one of the things to think about. But just to know guys, that because the protocol says in two weeks you should be doing this, I’ve always stressed to you, do not worry about time as much in this ACL rehab process. Because it will crush you if you look at three months and you’re supposed to be running and all of a sudden you’re at three months, and you could still barely do normal squats and things like that. So that’s where setting that foundation is important.

And just remember, every protocol is just a guide, and every athlete and you are different. Just know you’re different from me, different from other athletes that I work with. There are a lot of pieces to your own life and even your own injury and surgery that is going to dictate your whole recovery process and that will help to ease this process for you, especially when you kickstart. Because I know a lot of athletes and what you want to do is push as hard as you can. But just listen to your body for this, especially phase one, but through this whole process. And more importantly, you should be working with someone who knows how to guide you with it and to hold you back or let you take the gas and move forward.

With each athlete I’m working with, we progress based on their specific case and not time. Just as you know, sure we have certain constraints on it. But phase one can vary a lot and depending on the athlete. For me, sometimes this phase can really be anywhere from 3 weeks to 12 weeks, depending on the case. Now, if I had to put an average on it, it’s going to be somewhere around the six-week range. Does that mean that we don’t start moving toward other things? Not at all. But that’s where we kind of break down what are the things that they are missing and they need in order to move forward. But we do not move forward with more highly intense stuff or aggressive things until they have these foundations and these top five rehab priorities in place in phase one. We do not. It’s essentially we don’t build level two until level one is built and the foundation is built. So that’s the way that I look at it as we move forward. And that’s where people will be set up for the best success if they stay and adhere to these types of guidelines.

If you guys want to dive in more in terms of the details of these specific areas, I did an episode on the quiet knee, as well as prehab and these different components of knee extension, quad activation, and strength. Episodes 10 through 15, I believe, should get you guys everything you need to look at more details of this. But today, I just want to come on and talk about these five priorities. If we’re going to recap this, it’s going to the quiet knee, which is the full range of motion, prioritizing full terminal knee extension as the flexion comes along, and full quadriceps activation, which is that front thigh muscle. Let’s get that thing nice and contracted and active. Little to no pain and little to no joint effusion and swelling, which can always be a doozy. And then the fifth component of this is going to be normalizing your gait and walking pattern. Those things are going to carry you out in this first phase into the rest of your ACL rehab. 

The other bonuses that I had mentioned were donor graft site loading, and minimizing the deconditioning process by still getting your other three limbs involved. And training the other leg and making sure the cross-education effect can play a role. And making sure that the limb that is operated this should be understood. But you’re also working the other muscle groups. Your glutes, hip abductors, calves, and shins, typically people are doing ankle pumps, all of those other pieces are typically understood with this early ACL injury or post-op. But those are going along with the deconditioning process and making sure that everything else stays conditioned, as you progress along in your ACL rehab. Set the foundations guys. I cannot stress this enough because this will build on top of each other as you move forward. Athletes who typically do this well, have a good rest of the rehab process.

All right guys, so that’s it for today. Don’t forget the free download that’ll be up until Monday. But I hope that this was helpful. If you have any questions, as always, please feel free to reach ravi@aclathlete.com. Until next time guys, this is your host, Ravi Patel, signing off.