Episode 58 | When Can You Return to Work after ACLR?

What is up ACL athletes, I hope you guys are having a good week so far. Today, we are talking about when can you return to work after your ACL rehab. And what you can do is actually input any specific, like let’s say, daily activity or goal, typically it’s either school or work. What was actually funny is my wife and I were having a conversation, and she works with kids with special needs. And one just very simple realization we had that she was talking to one of her kids about, is that people either go to school or they work. There’s no real in between… maybe you could try vacation or travel. But anyway, it’s just kind of the realization of life; you’re either in school or you work. And then I guess you retire, but you’re working a good part of your life. Anyway, that’s what this is talking about mainly, is how do we get back to more so work whenever you are a post-op ACL. This is a question I get often from my own athletes, as well as I’ve had this come up a lot recently from athletes who are just reaching out. I just wanted to tackle an episode on this, so then that way you guys have an idea and you have the principles behind it, and you can apply it to your own situation.

Now, what you will typically hear when the question is asked, or maybe you’re asking your surgeon or physical therapist, usually it’s coming from the surgeon first because they are basing it off of the surgery they did, timelines, X, Y, and Z. What you’ll typically hear is anywhere from four to eight weeks. Now, what is really tough is that there cannot be a blanket answer across the board to this question. And let me tell you why. Everyone’s work is different and jobs are different. And then you got to factor in all the things, the biological healing of the body, your age, your genetics, the surgery itself. Was there a meniscus repair? Was there not? Any type of restrictions you may have? And then obviously, you got to think about the job itself. What are the demands of the job? And so in this episode, I want to talk about reverse engineering some of this stuff in order for you to be able to make a better decision, in terms of being ready for work and making sure that you have a game plan leading up to it.

First, let’s look at some examples of work. And obviously, there are so many different occupations and jobs out there. Come to think about in terms of the demands of the job itself is a nurse in the ICU, a middle school teacher, an IT technician, maybe a stay-at-home mom, maybe it’s a collegiate athlete, maybe it is a physical therapist. All of these jobs are going to have very, very different demands because of just the physical nature of it. Maybe one is more sedentary or maybe the desk job versus one that is going to be very physically demanding. Let’s take someone who’s a construction worker versus someone who does IT. Those two things are very, very, very different. You’re not going to really need to physically use your body as much for an IT job versus someone who is a construction worker, which is obviously very physically taxing. Those are some examples. 

And now the thing is I want to break down some of the factors that you truly do need to consider in order to know when can you return to work. And this is also something I want students and people in school to be able to utilize as well. You just insert that same thing, depending on your specific context, Maybe you’re in high school and you need to go back to school itself and move around in the halls and in classrooms, and maybe you want to get back to being part with your team at practices, navigating that and understanding what you need there. And then if you’re in college, I remember there was a lot to navigate, whether it was buses or stairs, or just the huge crowds of people whenever people are shifting classes. These are all things you have to figure out. And one is to make sure that you are safe and don’t risk something just because you’re trying to get back to it so quickly. Regardless, if we’re talking about high school, college, or more specifically in this episode – work, it all kind of applies across the spectrum. 

Now, let’s look at the factors that we need to consider to know. Are we ready to take that on? And the lens that I want you to look at this is through the same thing as we’re getting back to any other activities. If you think about the general progression post-op or post-injury is to be able to start walking normally again, to be able to do your daily tasks to be able to drive, and to be able to just generally move around. And then we move to the next level, what is the next level of demand, which is typically working or maybe just kind of being outside and moving around a little bit. And then it’s moving more towards what most people want to get back to, which is their sports. So that is all going to vary, and that’s usually towards the end of the ACL rehab spectrum where we’re trying to put a lot of stress on the body, get ready for the sport that you are trying to do, or the activity. Obviously, we’re able to handle a lot at the end, hopefully.

If we look at work, we’re going to look at it the same way. What are the needs of work in order to make sure our bodies can meet the demands of it? Because if we have a very low capacity, which is the amount of work that we can handle or do. In this instance, maybe it is walking, then it’s going to kind of blow our knee up a little bit because that threshold is so low. We need to make sure that threshold is much above whatever we’re trying to do. And then that way it’s still facilitating our recovery and our rehab, and we don’t set ourselves back. Let’s dive into some of these factors that need to be considered in order to know if are you ready to go back to work or not.

And the first factor is going to be your job. You need to analyze your job. What we do and what I do for all of my athletes is a performance needs analysis. And this is done in any good strength and conditioning program where we are trying to figure out, okay, here’s the athlete sport, and here’s where they’re at, and here is what we need to do in order to program and build them up towards those end goals. We are breaking it down into different components of psychology and physical, tactical and technical. There’s a lot of different things that go into it. But for you, when you’re looking at your job and you’re evaluating it, you need to figure out, okay, one, you would know if it’s physical or not. How physically demanding is it? And then figuring out what types of ways are you physically exerting yourself.

A construction worker is going to need to take a lot of steps, and lift the heavy weight; a nurse in the ICU is going to have to take a lot of steps, and that might be something where they have to transfer a patient.A middle school teacher might need to take a lot of steps and maybe react to something where there’s a fight in school, or maybe there is something where they need to react quickly because someone got hurt. Or maybe there’s a lot of times when you’re not really doing anything besides just having to take on a lot of steps and deal with a lot of punks. This is something that is going to be very different compared to the IT technician or someone who has a desk job where they could just prop their leg up, chill, not have to really take too many steps, and a lot of their job is more so just stationary in front of them. That’s going to be so, so different from a physically demanding standpoint.

One of the things I recommend is figuring out how many steps you’re going to take in the day. I think this is so important and something that can get missed that is very simple, that you can record. And so I will give you an example. I have some teachers I’m working with post-ACL. And one of the things that they had mentioned is that they need to get up to roughly around 10,000 to 15,000 steps in a given day. And that’s a lot of steps. But you got to think about how much they’re shifting and, and transitioning and things of that nature and trying to keep up. If you have a teacher who wants to go back to work, then that is something where we need to make sure that the phases initially are built up to get them back to that. And that is going to dictate the timing as well. If you are three weeks post-op, and let’s say you had a meniscus repair, you’re not even putting that foot down. So then now you have to decide, okay, well, how much time do I have off? Let’s say you have up until eight weeks off in order to go back to work. Well, you have eight weeks to try and build up to a volume you think you can tolerate. So that’s getting off the crutches, and being able to walk appropriately.

And then if you’re thinking about achieving 10,000 to 15,000 steps, that’s a lot. We need to make sure that we are tackling this and knowing how many steps you’re going to average in a day. And whatever the job demand is, and if you have to take those steps, we need to make sure that we are building a plan to build you up towards that step count. It’s no different than someone training for a marathon, if you will, or a half marathon or even a 5k. We need a week-by-week progression of step count in order to make sure that we are acclimated to that. Otherwise, what I will see is that when the step count skyrockets, people’s knees will get grumpy, they will get painful, and they will swell. It’ll happen because the capacity of the knee is not used to those steps, and it’s a lot of stress to it, and it’s freaking out. Don’t let it freak out. And that’s where the plan in place is so important.

But the plan itself has to be based on something objective to help you get there. Four to eight weeks is so arbitrary for anybody. I understand that time is a very good anchor point for all of us because we use it so much. But, because every person varies so much we need to be able to have something else that we anchor to that’s a bit more objective in the day-to-day, that can help bridge back to something that they’re trying to do. Let’s say, take the 10,000-step example, if we try to even get halfway to that, that’s 5,000, we need to get, let’s say someone’s trying to get 10,000 steps at eight weeks. Ideally, if we can get somewhere towards 5,000 at week four or five, that’s good. We’re halfway there. And it’s always not going to be this clean and easy because it depends on when someone gets off their crutches, do they have any restrictions from a weight-bearing standpoint. Those are the things that need to be considered whenever you’re building back up. 

Going back to the job, is it physical? Are you taking a lot of steps during the day? Are you lifting a lot of things? Maybe you’re moving side to side, transferring patients a lot, or is it more stationary or a desk job style? That is going to be a very big factor in this. Then you have to factor in the injury itself. What was the injury? Was there bone bruising or fracture? Were there other ligament damage? Were there any meniscus issues? What was done in the surgery? This is a very, very big one because if you have a meniscus repair versus meniscectomy, your knee is going to respond very differently and your restrictions are probably going to be if you had a repair. A lot of surgeons will put you at non-weight-bearing at least pretty early for two weeks to four weeks, and even up to six to eight weeks. So that’s going to be important to know from your surgery, well, what is your weight-bearing status? And that will actually impact a lot of you being able to get back to a job where you might have a lot of steps. Otherwise, you’re going to be crutching along a lot, and that can be really tough too, especially from a recovery and stress standpoint. 

One other additional piece I want to highlight here is that when people are offloaded and non-weight-bearing for, let’s say four weeks when they go to do partial weight-bearing or toe touch, or weight-bearing as tolerated. Essentially, you go from not putting any weight on the foot to gradually loading the leg and starting to get back your normal walking gait. The knee can swell up and it’s because it has not been loaded from an impact standpoint or a compression standpoint. And that’s essentially what we do whenever we put our limbs on the ground, whenever we go through the gait cycle, we are compressing that knee joint up and through. And that’s what happens whenever you go from non-weight-bearing to weight-bearing. And so that could be a different stress to the joint. And depending on the knee and the healing and how things are going, it can react by swelling a little bit. This is not uncommon, and I actually see this a very, very good bit with athletes. And they get surprised because things are going well. All of a sudden, their weight-bearing as tolerated; they start putting some load on the knee and it kind of swells up a little bit. That is something to be on the lookout for if you are someone who is non-weight-bearing for a bit and then has to go to weight-bearing.

The other piece to this is, was there a lot of swelling to begin with? And this is a big factor in my opinion. And I think that swelling can really be the bane of existence for anyone who’s dealing with a knee issue, ACL. I’ve dealt with it so much and I’ve had a lot of athletes who have dealt with it. And it’s one of those things where there’s only so much you can do. And it’s usually the things that we don’t want to do which is just offload the knee, decrease the amount that you are putting stress on the knee. Is this a vicious cycle? There’s swelling, you go back to work. Let’s say it’s a physical job, there’s pain and swelling, but you got to keep going back to work. It’s this ongoing cycle. The only true way to fix this naturally is to truly offload it, to balance that stress initially, in order to make sure that we’re navigating it the right way. And then what we need to think about is how is the knee recovering in the early phases. Are you getting that quiet knee? Are you getting that full knee extension? Are you getting your range for flexion coming along pretty well? Is the swelling coming down? Is the pain coming down? Are you normalizing your gait pattern? Those initial phases where you’re kind of protecting the knee, but getting that foundation built is going to dictate a lot of how you can return back to work as well. These are all things that I want you to think about. 

Now, we’re going to dive into some more practical strategies and things that you can incorporate in order to know, okay, am I going to be ready or not? And so what I want to do is reverse engineer the demands of your work requirements. In that way, you know, okay, here’s the things that I need to look for, and then how can I create a plan to get there? And maybe this is something that you talk more so with your physical therapist in order to game plan this out, to make sure this doesn’t create a big bump in your recovery. Because I can see this oftentimes where people will return back to work and then rehab takes a back seat, and then it ends up aggravating the knee, and then it becomes an issue. So we want to make sure we have a plan in place to attack it. As I’ve mentioned before, treat work the same thing as any activity or sport you’re trying to build back to. And especially if it’s something that is more physical, then we need to account for that. Do you need to be able to walk? How many steps are being taken? Are you lifting things? Do you need to potentially react really quickly? Maybe you work in a nursery or kids are super young and you need to keep them from killing themselves, who knows? With babies, we’re trying to make sure that they’re alive. And I know in nurseries we’re trying to make sure they do not fall or run into anything, so maybe you need to react. 

I’ve worked with a mom who literally tore her ACL because her daughter was about to fall off a ledge, and she had a choice of either making this weird kind of movement to catch her daughter or her daughter fell off and who knows what would’ve happened. And she risked her ACL, which was worth it, I think. But it’s one of those things where you have to know like, okay, what is the worst case scenario? Maybe you need to be lifting people out of a bed and you work in a hospital and you’re doing transfers. Is there pivoting or twisting related to your work that you need to account for? Some general buckets that I want you to think about are the number of steps you need to take in a given day; the strength that is actually needed for the job; are you doing lifting; and what type of direction? Is there reactivity involved? Do you need to be able to pivot on a spot in order to, maybe something happens like the kid at the nursery? You need to know if these types of things are necessary. And then what we need to do is make sure we build up to each of these, and that this is not just a straight shock to the system.

As we talked about before steps. If we require work at 10,000 steps and you’ve only been hitting 2000, that is going to be a huge wake-up call to you and to the knee. We needed to build this up and only after the knee calms down some. So, unfortunately, you can’t force this. If your knee is swelled up and you’re trying to increase your step rate, that’s not necessarily going to be the best way to tackle this. Because you need to make sure your knee is calm and we need to slowly build it up just like the whole running sequence. If you’re trying to run a 5K or a 10 K, you need to think about this as kind of like a plan in order to build up to that volume. Same thing with the step count. If you’re trying to acquire 10,000 steps on average to make sure your knee is comfortable with it and responds well. Well, maybe that starts acclimating early in this process and it goes from 2,000 in a few days. Knee tolerates that, well, then maybe we bump it up to 3,000, then we bump it up to 4,000, and it’s an intentional plan to build up.

The thing is, you just don’t wanna spike that from 2,000 to 5,000 or 5,000 to 10,000. And then it’s going to really be important to make sure you have the recovery the day after to know, okay, did my knee tolerate that or not? And that’s going to be very important. The other big piece here is going to be strength. If you need to lift someone out of a bed and transfer them, and you could barely do an air squat without hesitation, then there is a gap here. We need to make sure that the requisites are met in order to transfer over to whatever it is that we need to do with our work. 

Some things I want you guys to look out for. Rehab sometimes takes a backseat. Once work starts up, especially if it’s a physically demanding job, it takes time away and it’s physically exhausting. The last thing you want to do is go to the gym or do your rehab. And then what that can lead to is a grumpy knee, and there’s more swelling and pain, and then it’s this vicious cycle of I need to work and I need to function, but my knee is also pissed. And so that is something that could be that cycle that you want to make sure you break. And that’s where doing this stuff early and building a plan on it is so important. 

Prioritize offloading in the early phases. We get too quick to start to want to walk. Use your crutches appropriately. And I want you guys to think about, instead of it being an on-and-off switch, think about it as a dimmer switch and you’re slowly turning the light on. That’s the same thing in this process. You’re slowly ramping these things up very, very gradually, as opposed to an on-and-off switch of hitting eight weeks or something. And I think that’s one of the things that probably gets missed in most ACL rehab, is that you just don’t automatically cross over this magical threshold. It’s a completely gradual process. That way, you get feedback from your body and able to know if is it handling it or not. Can you create flexibility at work? Can you talk to co-workers or maybe your boss or whoever it is, and work something out where you’re not on your feet as much? And just make sure that your stress is important to the recovery, and just be transparent about how you’re handling it and dealing with it. Just know that if you make these steps appropriately in the beginning and take care of this, then down the road is going to take care of itself. And you won’t have to take a step back or deal with it as much if the early phases are tackled appropriately. Make sure you communicate and see if you have flexibility with work and whatever that is.

I understand that everyone has different financial and work situations, so that’s what can really dictate whether someone needs a return or not. I’ve had some people who are desk workers who returned the day after or three days after the weekend. And that’s something that’s very doable. But it’s always going to be so dependent – I have some people who are in some financial binds, and that means they had to get to work faster and they have a physically demanding job, and I understand that. Here’s going to be my advice to you as a healthcare professional, a coach, and someone who’s gone through this process, is to take care of your knee early and do it really, really well. Don’t rush it. Don’t force things. Listen to your physical therapist or coach you’re working with. Make sure that you do it well, you have progressions and you don’t make big jumps because that is going to make a huge impact in laying that foundation, and as you move forward in the process, especially returning back to work, 

A general rule: The less physically demanding the job is, the quicker you can return back to work. As I mentioned, one of my athletes is a desk worker, so they were back to work pretty quickly. But I have some who are teachers or they work as a nurse and they have to wait because they have to lift, they have to take a lot of steps. And so that is something that they had to delay returning to work because that’s not also something they could just do in front of a computer. And so the more physically demanding your job is, the longer you probably need to wait before you start again. 

My advice to you is don’t rush back to work at the cost of not allowing your knee to heal and normalize in the first phase of ACL rehab. These people typically can have lots of problems throughout the early parts of ACL rehab because the knee never got quiet and never settled down. And it has ongoing pain and swelling because they rushed back to work. Usually, because they’re probably having to take a lot of steps at work and they’re on their feet a lot. This limits them and then there’s swelling and pain, and then it starts that vicious cycle.

Take care of your knee early. Make sure that you are reverse engineering the demands of your work and building up towards that. And there’s a game plan towards that, not just for sport, but each phase of this process. There needs to be a buildup. Take these different objectives and see if you can figure out, okay, here’s where I’m at, here’s where I need to return, and here’s what I need to build up to in order to tolerate that. Bring that to your physical therapist and see if you guys can build a plan in order to get there. And make sure you do not get caught in this vicious cycle, and so that way you can have a very seamless ACL recovery.

All right, team, that’s going to do it for today. Thank you, guys, all so much for listening. This is your host, Ravi Patel, signing off.