Episode 41 | Preparing for ACL Surgery – Part 2

Welcome back ACL Athletes! Today, we are diving into part two of this three-part podcast series for preparing you for ACL surgery.

In part one, we talked about my own experience of my two own ACL reconstructions and setting the expectations for the surgical and rehab process. It’s a long journey and sometimes people think that they’re done in three to six months, or even just what they might feel right after surgery. Some of these expectations versus reality can really impact the process. What I want to do is make sure that you guys have as much of a comprehensive understanding of what this process is like, preparing for it, going through it, and even the immediate days after so you have a game plan in order to make sure you hit this road to recovery as best as possible. And I’m pulling from my own ACL experiences, as well as working with other athletes who are going through this process themselves. 

Today, in part two, we are going into more detail about, more so what that process looks like right after surgery. A lot of these different buckets that are going to be important to make sure you check off what you are focusing on in that way, you can maximize this recovery as best as possible but also be prepared. Because we know this, if you’re going through it, if you’ve been through it, this can get really overwhelming very quickly, especially with not knowing what to expect. If it’s the first time having surgery, what to do, what’s okay, what’s not okay, all of these different pieces. And sure, you may get a sheet of paper that gives you some guidance, but it’s still a little vague sometimes in terms of what you need. And all these other variables to account for in life that aren’t just on the sheet of paper, that I kind of want to walk you guys through. And that way you have a very comprehensive look at getting prepared for surgery. 

Before that, if you have not listened to part one, go back and listen to that because that will be super important in this series as it’ll create the foundation as we build towards today’s episode and episode three as well. And before we specifically dive in, if you are listening and you know of someone who is going through this process, maybe they’re getting ready to have surgery, please share this with them. Because hopefully, this can help them, even if there’s a small little bit of this podcast series that can help them—that would be huge. And these are a lot of things that, I either made the mistake, or I’ve talked to other athletes going through the process, asking them, “Okay, what is it that you wish you would’ve known and what would’ve helped make the process as smooth as possible?” So that’s the goal today. Share this with whoever you know so that way they can have a smoother process and can hit the ground running and get back to the things that they want to do.

All right, guys, I hope you’re ready for this episode because it’s loaded with a lot of good information. We’re going to go through this process and hopefully, there is a lot that you can take away. Remembering for the purposes of this series, we are assuming a date for surgery has been set, you’re doing prehab, which is rehab before you’re having surgery. If not, and you have the time and resources, then try and go to at least one physical therapy session, in some shape or form, before you have the surgery. So you can get used to the process and know what you need to do coming right out of surgery and that can really help people as they’re going through this process.

Next is the surgery itself. And then you have the surgery, you’re done, you’re hanging out in the recovery room, and it’s time to go home. You go home and you’re just hanging out, sitting on the couch. And here is where this moves into this specific episode. The way that I want you guys to think about this is going to be in terms of buckets/categories. Because I want to be able to tease this out so you know what’s important, what are some of the things that follow into that, and then being able to make sure you’re hitting these important buckets of health and wellness and recovery to make sure that you are doing as best as possible for your own ACL rehab process. We’re going to break this down into these different buckets: movement, nutrition, sleep/recovery, stress, support, and then there’s going to be another bucket. And that’s where it’s going to be really helpful for us to be able to delineate these different focuses on these different buckets. And what I’m actually going to do is combine this with some potential products or some items for each category that might be helpful for you.

The one thing that I want you to think about in regard to products is that we can easily just see a list of things and be like, “Okay, I need to get all of this stuff.” I see this in groups, or I’ll get these questions all the time, or I’ll see people comment. And there’s just this huge laundry list of things that people “need to get.” And again, these are just products. Sometimes we can get super excited to just get all these new gadgets and toys. When in reality, it’s us spending money on some things that we potentially don’t need. So that’s why I want you to evaluate these different products from your own framework of what you need versus what you don’t. And here’s the way to look at it. 

Your number one rule is what is my goal I’m trying to accomplish; whether that is helping with your pain, maybe it’s to reduce swelling, to increase your quadriceps contraction, or maybe it’s to increase your range of motion in flexion. And then if you’re talking about specifically a product or something you want to purchase, then you need to ask, is there something that can help assist to achieve this goal? And whether that’s the pain, you can think about ice with the swelling; you can think about a compression sleeve with the increasing in quadriceps contraction. Maybe that’s an NMES device that will send electrical current to it for the range of motion, and inflection. Maybe it’s a strap to be able to maneuver better based on your position. This is no different than the goal of getting stronger and using something like ankle weights, dumbbells, kettlebells, and barbells. Our goal is to get stronger in a certain way. And then we’re using these tools to be able to help us get stronger. Here’s the same thing. We have a goal with certain objectives, whether it’s pain or strength or you name it. And then we have tools to potentially assist us. And so I’m saying you just don’t go buy a laundry list of things someone said to and ask yourself why. And then use this podcast series to even think through maybe some things that you would need, based on your specific position and circumstance. 

Rule two is you don’t need very much of anything. I might list some things and sure they could be helpful and you can get 100% of these things. But just know that you don’t really need 99% of the things that I’ll talk about today, in terms of products. And I’ll give you this as an example. When I went through my ACL recovery, I didn’t really have anything that is on this list and my outcomes turned out just fine. I’m going to talk about important goals and concepts that you need to know. I’ll talk about products that can be helped to assist the process, but just know that there is nothing that you have to get and you can do just as easily with just a towel, a simple band, and maybe just something to prop up your heel with. It’s going to be dependent on you, based on your situation, maybe financially, maybe just like the setup of your home, maybe it’s the surgery. There are so many factors that play into it, but don’t feel any pressure like you need to get all of this stuff and that you won’t have a good recovery without it.

And sometimes on social media, you’ll see all these shiny gadgets, whether it’s BFR or NMES or whatever it is. I’ve even talked about these things before. But just know you can still have a really great recovery without any type of gadget or electronics—you name it. And finally, just know that I don’t have any financial affiliations with any of these. So these are just from my own experience and suggestions with working with other ACL athletes as well as my own experiences.

All right, let’s get into it. Let’s set the stage. You’ve had ACL surgery. You are home. It is day zero, the day of surgery. As I mentioned in part one, walking through this process and getting home, you’ll kind of be out of it, you’ll feel a little groggy that day, you’ll feel the pains and aches, you’ll feel a bit sleepy, you’ll be slow. All of these things are going to be really normal and that’ll slowly start to wear off, in terms of the anesthesia getting that out of your system. You have a nerve block, which we’ll talk about in a second. Those things will play into how you’re feeling. And then you’re just hanging out, you’re chilling, and you’re on the road to recovery. Now, let’s get after it. All right, for bucket one, this is going to be movement. And this is going to encompass all movement. And obviously, the primary focus of your rehab and of your ACL surgery that that doesn’t mean these other areas and buckets that we talk about aren’t just as important. But obviously, the physical component is a big piece to this. 

Precautions & Restrictions

We’re going to start off with precautions and restrictions after surgery. This will often be based on what was done in the procedure itself. The surgeon will let you know. Maybe it might be your non-weight-bearing, so you can’t put any weight on your foot. We’ll talk about this as well later. But that might be one thing, or maybe you’ll put a little bit of weight on it, or you can fully put all your weight on it. But that might be something you can only maybe bend your knee to 90 degrees in the first four weeks. This can really vary.

My point here is to make sure you know what these are. And this is typically something the surgeon themselves and the assistants that are working with them will let you know exactly what that is right after the surgery because they’ve done the procedure. Maybe they had to do something differently than was pre-planned.

And then now, they’re letting you know and whoever is with you, here are your guidelines of weight-bearing or bending your knee, things of that nature. And so make sure you know that. And then if we’re moving into the next point of this, you need to start PT as soon as possible. And PT means physical therapy. There are some situations where I will see some athletes, or I will hear of some athletes where they didn’t start physical therapy, you name it. It could be anywhere from a week to, I’ve heard some athletes not doing it for six to eight weeks until after surgery. They’ve been either immobilized or they were just like, I don’t know what to do, and they never got guided by our professional of like, “Okay, this is what the next steps are, and how soon to do it.”

All right, team, make sure you listen to this: Start doing rehab as early as you can. If I can see my athletes the day after surgery, that is my ideal situation. And that is because I want to see them after surgery, I want to get them set up, and just hit the ground running, if you will, in terms of this recovery process. And making sure that they’re set up and that the first week goes as smoothly as possible. We are initially and immediately sending the foundation for what’s to come with the ACL rehab process. What I love is that, if you do prehab, you could be familiar with a lot of these movements prior to surgery, and that’s why it’s so great. So that way you’re not left trying to figure out, okay, what do I need to do while you’re also fresh out dealing with pain, swelling, immobilized, just life, in general, moving around. So that’s why I like to kind of do this beforehand, to make sure that as soon as you get out of surgery you know some of the basic things that you need to do.

And sometimes the surgeon’s office and after surgery will give you this paper of some of the things that you can start doing, which is a good guide to kickoff. But you typically can do this the day of or the day after. And there are not very many cases that I’ve seen where you can’t start doing some of that stuff, especially anything from quad sets to even some assisted heel slides. But you don’t need 200 to 300 different exercises. Your surgery is going to limit you and be your constraints so just focus on the basics. 

Let’s get the quad going so quad sets. Make sure that you are contracting a lot with that. Assisted heel slides, ankle pumps, to keep the blood flowing, glute sets.Maybe there’s some hamstring isometrics in there unless you had a hamstring graph yourself, then that might be of caution. But something along these lines, something really simple, maybe a list of five different movements that you’re just kind of working on throughout the day. And sometimes you’ll hear a protocol that is given, and sometimes that’s given to the patient. Maybe you won’t see that until you see the PT, but remember what I mentioned earlier. It’s a guide but don’t get too caught up with the timelines.

Sure, you want to be active and you’re making the most of your time. But do not get too caught up in that because that can really push you up against a wall and you just don’t want that. And you want to make sure that you are progressing how Sally should or how Jim’s doing. You compare yourself to you and don’t let the protocol dictate your success or failure, if you will. 

Goals After Surgery

Now, let’s talk about goals immediately after surgery and I’ve talked about this before. If you guys haven’t gone through the quiet knee series, I highly suggest going through it because it could be really helpful for you to get a better grasp of what is important after surgery to get the knee restored and the foundations in placed. These goals are going to be the quiet knee, gait retraining, and preventing deconditioning. These are your foundations, and I cannot stress this enough. Toss out all of the other stuff. These are what you need to be focusing on primarily 95% of the time. These are going to be your range of motion and try to get your extension as quickly as possible so you want to get that to match the other side. And while you’re also working on your flexion to progressively improve that over time, you want to make sure you can get a voluntary quad contraction. Can we squeeze that quadricep and activate it? And this can be super hard after surgery with the pain, with the swelling, with all the things that have happened, and the nerve block. 

Getting a good quad contraction, getting your gait normalized, managing your swelling and pain to make sure that that is improving over time, and then preventing deconditioning. And this is keeping other areas moving and other ways to train aerobically. Now, don’t go too crazy with this. A lot of times people will just be like, “Oh, I gotta do all the things like my knee plus train my other leg and my arms.” You still want to have that as a big priority. But, in that first week, give yourself a little bit of grace. You’re dealing with the knee and a lot of discomfort there. And you know you’ll hear a lot of clinicians say, “Oh, minimize as much deconditioning, get them on the bike and the ropes and all of this stuff. If you’ve gone through the surgery, that first week is a bit of a doozy. The last thing you want to be doing is all this crazy aerobic work. 

With that said, you still want that to be important. But even in that first week, give yourself a little bit of grace and don’t create another problem. I’ve had one person who just went ham on single-leg squat to a chair. They ended up developing patellofemoral pain and discomfort (kneecap discomfort) on the non-operated side. And then we were dealing with two limbs that were just having trouble with pain. Don’t do that. All right, so getting into the goals here, range of motion. One statistic I want to share with you is about atrophy that I think is important to emphasize how much atrophy can happen. And research has shown you can lose up to 350 grams of muscle tissue and a reduction of 30% of muscle protein synthesis for every two weeks you’re immobilized after surgery. Now, this is a general statistic. And if you take the 350 grams, it could be somewhere around the average size of your heart. Don’t freak out, it’s totally fine. And guess what? Your quads are going to get smaller. There’s not any single person I’ve worked with or talked to who hasn’t experienced some atrophy to their quads. 

And if you guys look up Saquon Barkley, he’s the New York Giants running back. He tore his ACL last year. And this guy is known for his quads. He’s got tree-trunk quads. And if you look at his ACL side, he has less muscle mass than the side where he did not have his ACL injury. And this is not uncommon to see, and it will tell you also that atrophy is a real thing. And also, if it happens to the 0.001% of the athletes who has all the resources possible and it’s their full-time job, if it happens to you, just know that it’s normal.

Atrophy does happen and a lot of times this is because you are immobilized and it can lead to just the muscle decreasing in size. With that said, as long as you start moving, in terms of doing some of the exercises like quad sets and getting the muscles going, and starting your PT earlier, you’re going to be in totally fine shape. You got plenty of time to build your quads back up the way that you want to. You literally have to be a vegetable or a couch potato for a very long time. Just don’t do that. Plus, you’re going to start exercises on day one. We’re good to go. 

Range of Motion Goals & Continuous Passive Motion Devices

Now, that leads me to my next point: CPM devices. These are called continuous passive motion devices. I’m not a really big fan, guys. And the research doesn’t support it at all of its use. Some surgeons will recommend it or even require it potentially. But to me, it’s not backed up by research. I’m also someone who has had anecdotal experience, one ACL surgery without, one with it. And with my first one, I did it without, had a great recovery, full range of motion. My second one, I did it with it. I felt like I relied on the CPM a little too much. And it’s a passive device, it moves your knee. For those of you who don’t know, you kind of sit in this machine, you put your leg into it, and it essentially bends and extends for you. But it’s all kind of passive and you can kind of change the degrees. It can be good, but with that said, it’s all passive. The way that we move our legs and things like that are active so you get muscle involvement with it, which can be a huge benefit. 

In my opinion, if you’re working on a range of motion, try to work more toward the active piece. Maybe save that cost for something else that you might want to invest in through this process. The bracing question can come up a lot in terms of locking the range of motion. This will really vary based on the surgeon that you have. Some surgeons love a locked brace where they’ll lock you into an extension for a bit. Some of this will also depend on the procedure itself in terms of a meniscus repair. Maybe they’ll limit you to only a certain degree or maybe they’ll limit you and unlock the brace after a certain period of time. This can all really vary. They’ve done studies on this as well, for postop and there hasn’t been much conclusion in terms of whether there is a benefit versus not. I do think for some people it can feel very protective, which I totally understand that. I had braces in both of mine. But I see tons of athletes now who do not get a brace post-op and they do just fine. You just have to be smart with it. This can vary really based on the surgeon and even the procedure that you have. 

And then the range of motion itself, it’s self-directed. You’ll go into this active-assisted range of motion where you might use a belt loop to help assist you. We see that as more of like a passive type movement. And then knee extensions, usually it’s a heel prop—low load, long duration stretch, or something that I love to build into when the athletes can tolerate it. Knee flexion, the assisted belt or strap, pulling towards you. Heel slides, being able to make sure you work into that new flexion range and progressively improve that as your pain and swelling gets better. These are the range of motion goals and buckets that we’re aiming for. 

Quadriceps

Now, let’s talk about your quadriceps. These are the absolute prize possession of your ACL rehab. There’s not a single muscle that is more important than your quadriceps. They will shrink, as we talked about earlier, it’s going to happen. The first day, it’s going to be very difficult to even feel like you can contract it because of the pain and the swelling, and you’re just fresh out of surgery. That’s totally fine. Keep working on that. And there’s something about a mind-muscle connection. You know how you flex your bicep. But then if you think about flexing that muscle, there’s actually a better neural connection and activation when you kind of think about it. The same thing here. We’re going to try and get that mind-muscle connection back to our quadriceps. Because we know not only a local thing with the pain and the swelling, but it’s also the neural connection that we’re trying to reestablish and retrain. Try to get that working and getting going as soon as possible.

One of my big things is quad sets right after surgery. I give all my athletes this 10 by 10 rule. Every single hour I want them to do at least 10 quad sets with 5 to 10 seconds hold—that is the goal, every day, all day. If you can do more, then do more. And then they have certain concentrated times where they do end up doing more work specifically. But I have never heard of someone doing too many quad sets. And because of the importance of the quads, I can’t stress enough how much that activation piece is going to help. And then that comes into place where you have the NMES, which is the neuromuscular electrical stimulation. I did a podcast episode on this in the past. But this can be of incredible benefit, and the research shows us that there can be huge benefits post-op to get the quads going.

And then lastly, I’m going to talk on this loosely as future episodes are going to talk about this. I’m a big proponent of blood flow restriction training, and until research proves me wrong, which right now it’s pretty exhaustive in terms of the benefits versus the risks of it. And so that’s another thing that I really enjoy to be able to load muscle groups that can’t get loaded heavy. For example, right after ACL surgery where there’s pain and swelling and all of these limitations.

Retraining of Gait and Walking

All right, next up is getting your gait or your walking retrained. And this is all going to be dependent on your weight-bearing status. There can be typically three different categories. You’ll see non-weight-bearing where you can’t put any weight on the leg. This can be typically after a meniscus repair or maybe some other things that had to get repaired in there, where they stitched it down. But this can vary anywhere from two to six weeks, typically after surgery where you might not be able to put any weight on it. I just had an athlete who had to wait six weeks because of her procedure. But what you’ll typically see is somewhere around four weeks. And then sometimes surgeons will allow athletes to start putting weight on it even earlier.

Then, there’s something called toe-touch weight-bearing. So that means that you can only put a little bit of weight on your toes. This may be a precaution just to limit how much weight you can fully put on that leg. I don’t see this as often. Weight-bearing as tolerated. It’s typically if it’s just an ACL reconstruction alone or maybe you had a meniscectomy, which is what I had. In some meniscus repair cases even, you’re starting to see, maybe they will allow some weight-bearing, but it can really vary. I’d probably say, most of the time, if you have a meniscus repair, most surgeons will limit weight-bearing for a little bit. But this can again vary. This is where going back to those precautions and restrictions that you get are really important to be able to know where you’re at with this.

And then something that gets overlooked—crutches. I would suggest practicing with crutches if you can before. If you can’t, that’s still okay. But it can be helpful with especially different terrain, different surfaces, as well as if you have to use some stairs, which likely you are going to have to use some sort of change in steps or level of a surface. This is where, again, prehab has its pros and wins with it because you can also practice this along with other postop rehab/prehab exercises. 

I’m going to go through this really quickly to make sure your crutches are at the right height. I had an athlete the other day where the doctor’s office gave her the wrong set of crutches. She had to, for a day use too short of crutches, which really did limit her. She had to go get those switched out. If you’re going into this, here are some just good rules of thumb. You want the majority of the weight through your hands, and you don’t want to rest the top of your crutches into your armpits because you have important neurovascular structures in there. You want to make sure there’s at least two inches, or just think about two finger widths between the top of the crutch and the top of your armpit. Your elbow angle, you want to have a slight bend, so you want it to be roughly around 15 degrees bend. Your hand grip of where that falls is, if you were to drop your arms by your side, that hand grip should fall in line with your wrist joint. If that lines up appropriately, that should line you up best for that 15-degree elbow bend.

Here’s some things to think about if you feel like it’s not fitting right. If you’ve set up too tall, the crutches are too tall, typically you’ll see your shoulder shrugged up, digging into your armpits, and then the elbows bend too much and kind of flare out in order to compensate for it. If the crutches are too low underneath your armpits, you’ll typically lean forward way too much, and your elbows and arms will be pretty straight. You want to make sure you have that bend and you’ll typically feel if you go for longer distances, how you know you’re doing it right, is if your triceps start to fatigue a lot. Because that is going to be an important muscle group that’s holding you up. 

Now, what I want to do is talk about one important principle for this early phase that will be really helpful. I can’t stress the importance of frequency in this early phase. I’d rather have my athletes spread out the work that they are doing, the range of motion, the quads, the gait training, anywhere from three to five to even seven times per day than focus on this one concentrated period of time in the day. I tell my athletes to think about it in terms of at least breakfast, lunch, and dinner, or it could be morning, late morning, early afternoon, evening, and night. However, you want to split this up to keep yourself a reminder, but also tell them to set something in their phone to remind them to do things. And that way it can be easy to remember. And that’s how you’re going to make these small little changes over time, as opposed to these concentrated bouts which may not necessarily give you as much as you would hope. This is especially for your range and your quads, and as you build up your gait that’ll be important to get your reps in the day as well. 

Pain & Swelling

All right, let’s talk about pain and swelling. Just remember as I talked in episode one: nothing is linear. You can feel the most random things, guys. Especially in the first week, honestly, two to four weeks, as the body adjusts to the acute changes and this fresh stage of ACL surgery. You’re going to feel a lot of things. It’s inevitable. It’s going to feel funky, but it’s important to kind of just track this over time. And when we’re talking about pain specifically, just know it’s normal to have aches and pains. They literally just did carpentry work to your knee. It’s going to hurt and it’s a part of life. It will really depend on the surgery, the graft, what nerve block they did, how your body responds, lots of factors to play into this. 

Let’s talk briefly about nerve blocks. Most people get them as they’re having ACL surgery. The two different ones that you’ll typically hear are femoral and adductor. Femoral is actually the nerve that innervates your quadriceps. Adductor is the one that is for your groin muscles. Those are the two most common ones you’ll hear. These can really help with the pain anywhere from 8 to 72 hours on average. My experience with my own nerve blocks was around 24 to 48ish hours. I do remember my second day was always much harder than my first day, and that was mostly related to my nerve block. After it wears off, you will 100% know. The pain will be a little bit more obvious and you’ll be able to feel all these specific ones that you might not have been able to feel before. In general, if you have an option in my opinion, go with the adductor block, if you can. That way we can preserve the quadriceps muscle and the femoral nerve. You don’t necessarily always have a choice. I will do a specific podcast in detail about this. But just so you know it’s going to happen. I had actually femoral nerve blocks for both of mine, and I did get my quads back, guys. At the end of the day, it’s totally fine. I’ve even had some athletes who have opted for no nerve block. You just got to know if you don’t get a nerve block those initial few days are going to be more painful. And that’s just up to you and also talking with your team, your surgeon, assistants, your parents, if they’re involved, or whoever else. Just know that they need to be involved in that process.

Pain Medication and NSAIDs

Let’s kind of talk about pain medication and NSAIDs. At the end of the day, I want you guys to make sure you’re going based on your recommendations per your surgeon and doctor. But the goal here is to get off with these. No one ever wants to be taking these for a long time. You don’t want to be reliant on them. But it also depends on how you’re recovering. Don’t give yourself too much of a hard time. Early on, stay on top of the pain meds if you need to. And one kind of personal piece of advice is, especially at night, pain can really disrupt your sleep. And sleep is going to be really tough for you. And we’ll talk about this in the next episode. But sleep is going to be really important for recovery and pain can really disrupt that. You might have to schedule to wake up to take your pain meds. One thing that is the advice here, is don’t wait till the pain hits super hard and then take it. Or, you’ll be in misery for a little bit until that takes the edge off. 

And I personally learned this the hard way, I was trying to be tough. And I remember that I decided not to take it. And then I got to a point where I was in pretty bad pain and then I ended up taking it to help take the edge off. I took some early, I gauged it based on my pain experience and how disruptive it was to my daily life and my sleep. There was a sweet spot somewhere in there. And only you’ll be able to figure that out based on your pain tolerance, your body’s response. But don’t try to sacrifice all of your sleep or recovery just by not trying to take it. Use that as your guidance, as well as making sure you’re following your surgeon’s recommendations with that. And then just know like that is going to be a part of the process.

In addition to pain, ice really does help. I know I enjoyed the feeling of ice to help provide almost a numbing sensation to ease some of that pain that I was feeling. And then TENS unit is another thing that people will use to help block pain. I’m not going to go into the details of it here. But it is something that can be combined, typically the NMES units can have some sort of function to be able to provide a TENS-unit-type setting, to be able to help with the pain and muscle pump. 

Swelling

All right, so now moving into swelling. Just know it’s going to be normal to have the swelling, ebb and flow through this process. Let’s say you might have had a bone bruise, it depends on the type of surgery, the nerve block, how your body responds. Again, all of those factors we talked about this. Your NSAIDs or your ibuprofen or whatever you’ve been given, your anti-inflammatories will also help aid in this. The big thing that you’ll hear is making sure that you elevate, so elevate above your heart level. And then ice will help with the pain. In terms of the swelling, that’s kind of a toss up, I wouldn’t say that the ice is necessarily going to be the thing that’s just going to get rid of the swelling. Your balance and recovery, as well as your body’s response to it, is going to be, at the end of the day, the most helpful. 

Another additional piece that we just talked about was the TENS unit that can help with muscle pump, and muscle pump helps to move fluid up towards your heart. TENS units can help with that and using a compression sleeve. Make sure your wound is healed. Make sure that you have washed it. But a compression sleeve or a compression stocking is super great for this process. Because what it does is that, sure, it can help push some fluid out. But it eliminates fluid from getting in because we’re not letting the skin expands and the joint expands, and allow fluid into the joint. I’m a huge fan of it. I’ve had a lot of athletes who have benefited from it, and it’s pretty simple and easy. It’s a nice little hug to the knee that makes it just feel nice and protected if you will. But that’s one of the things that can really help with swelling. And then some other pieces to this process—bruising is completely normal. You might look like you got beat up and someone went to war with your knee, which is essentially what happened with surgery. They just kind of beat you up, drilled some holes, put a new ligament in, you know nothing, no big deal. But bruising is completely normal. You might feel random temperature changes which can be normal. But it’s important to track if it goes very cold or very hot for a long time.

And one of the things that can get talked about, which we’ll talk about in a second, is something called a DVT, which is a deep vein thrombosis. Actually, let’s just go ahead and talk about it. This is essentially to keep it super simple. People can make this very scary and almost really like fearmonger you. But no, it’s a reality of this process in moving forward. Especially early on when you’re immobilized, blood can pull and when that blood doesn’t flow properly and slows too much, clots can form. Yeah, sure that they can lead to a pulmonary embolism. Let’s not get too caught up in some of these possibilities. The percentages that they’ve tested are incredibly low. But with that said, that brings up the point and the concept of blood flow and making sure that your muscles are helping to pump fluid. So that’s how we keep our blood flow going through our veins is through movement and through muscle pumps. And when you’re mobilized, we don’t get to use that as much. You’ll see ankle pumps prescribed. I have all my athletes do a ton of ankle pumps every single hour, as they’re awake, to be able to keep blood flowing and to keep that muscle pump going. 

And some things to look out for are obviously changes in color that have stayed a long time. And then also a very strong pain or increase in swelling in the lower leg or pain in the back of the knee. Those are the things that you will feel and it’ll be something that you just want to keep a radar on. But don’t take this in the sense of like, okay, I’m feeling this, I’m feeling that. Thinking that that’s what it is. Be safe, be smart, and watch the trends in things. When in doubt, always ask your PT or your surgeon, in this situation. 

Sensation

In terms of sensation, 99% of people will have some sort of random patched skin on their shin area or somewhere around the incisions. That can last anywhere from just literally half a day to maybe even years after your surgery. And this is all just going to depend on the surgery, your sensory nerves, and all of these different areas. But just don’t worry, it is pretty normal. Every single athlete I’ve worked with, there can be some weird sensations on the shin and around that area. And most athletes will have a full recovery from it. It could just be kind of a weird feeling. Make sure that you give it some input so you can scratch it, you could put different textures on it. Just different things like that to see if your body can recognize some of those different sensory inputs, to see if that can just be improved as time goes on, but totally normal. 

As I mentioned in the previous podcast, I still have one area that is a little sensitive and weird. You ask half of my athletes and they’ve got maybe this one little spot that might feel a little funky. The body is not used to being cut in on. When you have surgery, sometimes that can be the response to it. But as long as it’s not your entire lower leg, as long as you don’t lose any motor function, you should be in the clear. But just know that this is completely normal. Again, when in doubt, call your surgeon’s office, and ask your PT, or whoever you’re working with. 

Preventing Deconditioning

And the last part of this movement bucket before we get into products, which will be the start of the next episode. The last thing that I want you to focus on is preventing deconditioning. And I mentioned at the start of this episode that sometimes people can go too hard with this, and then they create another problem in the other knee because they get so stir-crazy. Just find a sweet spot of knowing you are in recovery mode, but then also keep the other areas moving. One of the concepts I want you to think about with this is, since we can’t necessarily do as much with the knee, let’s try and train above and below the joint. We’re talking about the ankle and the hip. One of the things that we talked about with the ankle is the ankle pumps. One thing we talked about is that it can help with the blood flow, as well as getting some activity to your calf muscles. But you’re going to do ankle pumps all day every day, you can even do ankle circles.

There’s something called a band four-way that you can keep the muscles around the ankle still active and going, depending on what you’re up for. At the hip, there’s glute sets. You’re going to be a little bit limited because you can’t move that whole entire leg around on those first few days. You might do glute sets where you’re activating your glute. You might do hamstring sets or isometrics. Then a lot of times people will build into a four-way hip where they’re kind of moving it about.

These are things that you can start working on and doing pretty soon after surgery, especially on the unoperated side. You can definitely hit some of this stuff and be good with continuing to maintain. And then I had said, the other leg is no longer just taking 50% of the weight; it’s taking 100%, especially if you’re non-weight-bearing. Don’t give yourself that additional problem. But just be mindful, find the sweet spot here, and make sure you’re able to keep moving. And that way you don’t decondition, if you will, that’s a term that we use is deconditioning. Essentially, let’s keep your fitness level up, as best as we can while you’re recovering in this early stage.

If we’re talking about the upper body, you got two arms and hopefully you can move those around pretty well. Get you some bands or some dumbbells, keep it super simple, and prop the leg up. You could do some shoulder presses, some rows, some bench pressing, but just keep it simple. Some other options are going to be circuits. 

I have athletes do some aerobic conditioning. Maybe I’ll set them up in a circuit where they’ll do some battle ropes, some slam balls, and maybe just do the bike with just their arms—movements not involving the ACL side. And that way we can get maybe a little bit of a sweat, a little bit of some heart rate and that makes them still continue to feel like they’re moving and doing stuff without feeling like they’re compromising the operated side. These are all the things to consider, especially in this early rehab process. We talked about the quiet knee in very specific detail, and then we talked about preventing deconditioning to make sure that we keep up our fitness during this process.

So just remember, guys, this is a balance of stress and recovery. And there’s a big stress that has been put on your body after surgery. It’s essentially a “trauma,” and your body is recovering and healing. It’s trying to protect the site to make sure that you ultimately can get back to upstate where things feel normalized and healthy and healed. Pain and swelling will be your guides early on. Sure, you might have to push into a little bit of that, especially the pain. But you don’t need to be at 8, 9, 10 out of 10 pain because that’s going to be really tough and it’s also going to make your recovery process even harder. Just know that the first two to four weeks after surgery is definitely more variable. There can be some days where you have some really solid days and then there could all of a sudden be a day where you just have some sharp pain. And generally, you want to see that trend improving, but it can still vary a good bit. And this is based on my own experiences, as well as working with lots of other ACL athletes who have gone through this process.

And generally speaking, pain shouldn’t be significantly higher outside of those first few initial days, and this is in general. It should progressively improve as time goes on. That still doesn’t necessarily mean that you won’t have some of those days. And then generally speaking for the swelling, that should decrease over time, too. But if it does increase the next day, something that you can think about is that’s a good sign that you might have done too much the day before. You might need to adjust and see maybe taking a step back in terms of all the stuff that you did and maybe having to adjust the volume or maybe it was a specific exercise, to make sure that you’re respecting this healing process and the body’s ability to recover from stress.

Again, at the end of the day, it’s stress versus recovery, there’s been a lot of stress, and the focus is on recovery and then finding that feedback system, if you will, or that feedback loop of, okay, how is my pain as time goes on and how is my swelling. And then taking those other metrics of your range of motion and your quadriceps, your gait, all of these things in these early phases, and tracking those as time goes on, as well. But that’s going to be your main guide. And that’s going to be a big part of phase one, which is the movement piece and restoring these foundations.

And again, stressing the importance of these foundations and how it will set the tone for the rest of your recovery. That’s going to be it for part two. And what we will do is dive into part three next episode with the products related to this process. I want to make sure that we cover some of these things that can be helpful. Again, not necessary, but can be helpful. And then we’re going to go into some of these other pieces, some other areas that can be really helpful with this recovery process.

And then we’re going to break down nutrition, sleep, stress, support, all of these things that need to be tied into and thought about as you’re approaching your surgery or maybe your after-surgery and planning the road ahead. So that’s going to be it for today, guys.

Thank you all so much for listening. This is your host, Ravi Patel, signing off.