Episode 59 | When Can You Drive after ACLR?

What is up ACL athletes, and welcome back to another episode on the ACL Athlete Podcast. Today is episode number 59, and we are talking about when can you drive after ACLR or reconstruction or surgery, or this even applies to after injury. This is the thing where you could take principles from this episode and apply it to when can you drive. Last week, we talked about when can you return to work, and that’s going to be different for each person. Same thing about when can you drive. It’s going to be different and we are going to dive into that. But before we get there, this is one of those things that is really important that this is educational and it’s not to be confused with medical advice. If you really need a specific answer for your case, you need to talk to your surgeon, talk to your PT, and make sure that you have the guidance for your specific case because it is so individualized. 

Now, with that said, no one wants to be a burden, or have mom and dad driving you around after ACL reconstruction. You just kind of want to be free. You want to be independent. You don’t want to depend on other people. When can you drive? What you will typically hear is anywhere from two to three to six weeks; that’s typically the range that you will hear. And today, I’m going to break down some important factors to consider, as well as some research that helps us in making this decision. And you’re like research, come on. This is something that we need in order to make sure we are making good decisions and that we have data to support what we’re doing. And we take some of the anecdotes, we take the research, we take the actual function of the person in front of us, and we make sure that we are moving in the right direction. 

As I mentioned in the last episode, this cannot be a blanket answer across the board. And we know this because each person is different, each case is different. The context of which you are in is different. So that’s why we got to make sure we understand these principles that we talk about today in order to make a better decision for yourself. This is also why we do not necessarily use time alone. But I do understand this is something that we anchor ourselves to. It helps to provide an estimate, and we use an average of what we typically see. I understand that point, which is why I will talk about some times, and these studies will reference them. But just know that it serves as a proxy, allowing time to develop the things that you need in order to complete the task. Time itself will not dictate what it is that you can do, it just provides an opportunity to get to that point – the healing, the function, the ability to kind of decrease pain and swelling, all of these things. And that’s what time allows us. And that’s where we get that estimate. But there’s nothing magical about two weeks itself, besides it provides opportunity. 

At the end of the day, you want to make sure you are safe and you can function appropriately since you are operating heavy machinery. Also, isn’t it pretty bizarre that we can get into this machine and drive it around, and it can get up to 150 miles per hour, and it can brake pretty quickly and we can spin it and turn it and all these things? It’s pretty crazy when you actually think about it. But anyways, let’s get back to the topic here. 

Some factors that we want to consider when you are trying to return to driving. First, which leg is operated, and a side note here is that I had to research in European countries, is the pedal opposite or not, realize it’s still the same as in the U.S. They just sit on the other side of the car. The right leg is actually a very important leg here. If your right leg is operated, that is going to dictate a lot of how quickly you can return back to driving, since we use that for our gas and our braking especially. If you had surgery on the left side, then you can get away with being able to drive sooner because it might not need to be used at all while you’re driving. The only caveat here is if you have a manual, a manual transmission car, then that could be something that will be dictated no matter which leg is operated.

The other thing that this leads us into is the type of car that you have. Is it automatic? Is it manual? If it’s automatic, then obviously, there’s less moving pieces. So then we just really need to focus on our right leg. If it is a manual car, then we need to make sure that both legs are fully functional and able to be used to be able to be reactive in any type of situation. 

Now, let’s talk about pain. Pain is really important here, post-op. Everyone feels it. It sucks. It feels like you get hit by a sniper sometimes. Totally, I get it. I remember those days I had a hamstring graft on both of mine and it felt like literally someone shot me in the back of my hamstring in the corner and it was the worst. And sometimes depending on movements, it would jar pretty crazy. You guys know what I’m talking about. If you had an autograft or had ACL surgery, it’s just one of those things where they can come out of nowhere. And it makes you feel like you kind of want to die – but being very dramatic here. But pain is something that is very, very prevalent and happens in this process.

We have two implications when we think about pain. Increased pain levels in patients who undergo ACL reconstruction have been shown to be associated with strength and proprioceptive deficits in the first postoperative year. So that came from a study that showed essentially because of pain, we have some limitations potentially in strength. We know our quads are impacted significantly. And proprioceptive deficits essentially mean we are not necessarily aware of where our limb is in space. We actually get some of those mechanical receptors that are cut out because of the reconstruction and the trauma of the surgery and the injury. And our ACL helps us to be able to close our eyes and determine, well, where is our knee at in space. When we don’t have that, that proprioceptive ability decreases and so pain can impact that significantly. 

And the second piece of this of why pain can have an implication is because patients who experience more pain will probably take more narcotic pain medication. And so then we know that there are studies that have connected prescription opioid use as a risk factor for motor vehicle collisions and accidents. So that’s just something we need to be aware of and that is going to lead me into the next point of pain and medication itself. 

Pain medication is going to make you feel groggy, delay your reaction time, and this is going to be dependent on the surgeon, what they give you, did you get a nerve block, and what type of pain meds are you taking. Is it just like an over-the-counter NSAID or is it actually a narcotic and opioid? All of these things will really factor into your driving. Because if you are taking pain medication that could impact your cognition or your reaction time, that’s not going to work. And there was actually a study by Obermeier, where they saw a discontinuation of narcotic pain medication that occurred around a median of nine days but it can go up to 44 days postoperatively when they surveyed patients. And it’s important to ensure that patients are no longer using narcotic pain medication before they start driving. And we know the obvious answer here is that we just want to be safe and we want to make sure that when we’re operating, we are fully aware of it, that we can have good reaction time, just in case. And you got to play worst-case scenarios anytime you get into a car and you got to be aware of your surroundings. And pain medication can really impact that. 

I remember when I was taking some pain meds immediately post-op. My goal was to try and get off those as quickly as possible, which should be the goal. But not at the detriment of not being able to sleep or just so miserably in pain. But at the same time, I also wanted to get back to driving, especially whenever I was in college. Because I didn’t really have any assistance for driving and trying to get to rehab and all of those things. I kind of tried to get off them really quickly. But I do remember that they did impact my cognition. And I know any of you who are listening, you’re very familiar with this too, where you’re just trying to take the edge off in order to sleep and just kind of function, especially in those early days. Keep that in mind in terms of pain medication. 

The next thing we’ll talk about is the graft type, which actually does play a pretty big role here because if it’s an allograft versus an autograft, that’s going to dictate the pain, as well as it could be impacting the function or range of motion. This study looked at allograft regaining normal braking times by three weeks postoperative. And in contrast, those treated with a patellar tendon or a hamstring autograft, they ended up having a significantly delayed braking time at three weeks. But that normal braking ability came back by six weeks. And that is something that we need to make sure we understand with this is that the braking time is going to be really important and they compared that to controls braking time. When we’re thinking about graft type, if we have a patellar tendon, it kind of makes sense because there can be that anterior knee pain. You may not want to activate your quad as much. Then that can impact your ability to react to a brake, in case you are driving, as opposed to maybe a hamstring tendon. It’s not necessarily impacting directly the quad, but it will impact pain behind the knee. So that is something that you won’t need as much as, let’s say, the quad in terms of breaking. But again, that is going to be graft type and the pain and the strength coming along, all those things factor in.

Next up is our weight-bearing status. And something to just think about if you’re non-weight-bearing, let’s say you had a meniscus repair, and you have to be non-weight-bearing for four weeks or six weeks, and it’s on the right foot, then that’s going to be something where you could pretty much say you’re not going to be able to really drive for four to six weeks. Because if you can’t put weight on it, you’re obviously not going to be able to use that leg until after that time when you can start to put weight on it and full weight on it.

The next thing I want to talk about is a brace. And that is something depending on the surgeon and who you’re working with. They might lock you in a brace. They might only allow you a 90-degree bend in a brace. And some surgeons here will not even brace anyone after surgery. It really depends. But the brace that you’re in is going to be important because you need to be able to make sure you can bend your knee and that it’s comfortable. I know a lot of people who don’t like their brace and it makes sense. It’s putting pressure on there. You feel kind of rigid and fixed. It just kind of depends. But you want to make sure that that brace is allowing you to do what you need to do for breaking and pushing the gas. 

And so that’s going to lead me into more functional things which are your range of motion, quad strength. Your range of motion, you just need to be able to get to extension, especially when you imagine pushing down on the brake and then being able to flex in order to make sure you have enough range of motion to switch from gas to brake. So that’s going to be really important here, is to have that prerequisite range of motion. And then you want to make sure you have really good solid quad activation and strength. Because the thing that can happen is if you think about whenever you sometimes take stairs or walk, I know that this happened for me and I’ve seen this with athletes, is that the quads still kind of waking up, still trying to get active. And there can be some steps where you kinda almost feel like the knee kind of gives, whether that’s taking a stair or even just in normal walking. You got to think about this situation even when you are driving a car. Has there been more frequency of the knee giving out because maybe the quads aren’t awake enough yet? They’re not active, they’re not strong enough. So that is something to consider in this, is making sure that you have adequate quad strength. If you’re hitting really solid quad sets, straight-leg raises, being able to hit some long arc quads, things like that, and you’re seeing your quad wake up and you feel like your knee doesn’t really give much and you’re starting to do some squats and split squats, all of these types of movements, hopefully, you’re able to start noticing that you have the strength and that prerequisite along with the range of motion to get there. 

The other thing you need to think about is just the injury and surgery itself, as we had just talked about. Was there a meniscus repair? Maybe there was something where you had some bone bruising or some pretty solid trauma to the knee. And then pair that up with how quickly you had the surgery after the injury because that’s going to play a big role, too. And maybe that’s impacting your swelling and your pain, maybe it’s impacting your range of motion and your strength which therefore is going to impact your ability to use that leg to drive. These are all the things I want you guys to just be kind of considering as you’re thinking about returning to driving. 

Now, I did want to dive into this systematic review by Salem in 2021. It’s return to driving after anterior cruciate ligament reconstruction. And what they did was they looked at five total studies. And in those studies, a big emphasis that they looked at was breaking reaction time. They timed how quickly someone can react to breaking, and that was a big component of return to normal values and driving. And they compared that to just normal controls and what that normal braking reaction time is. And so what they typically saw was that for these values to return to normal was typically four to six weeks after a right-sided ACL reconstruction and approximately two to three after left-sided ACL reconstruction. And there was one study in this review where they looked at manual transmission. And it was one of those things where it was a little difficult to determine. But usually around four to six-week time period because they need to be able to reach that same level of the healthy controls that they compared to, and that’s what they found. But graft choice was something that was important. Autograft versus allograft, they noticed that people with allograft were able to get back to things a little bit quicker compared to the autograft [?] just because of the pain and potentially the muscle inhibition that can come afterwards. But that is something where the allograft was somewhere around three weeks and then for the autograft, you typically saw somewhere between four to six weeks, on average. 

This study also talked about a study done by Wenn where they looked at some stepping test and a standing test. Some clinical surrogates to see driving ability and they were able to see correlations between these tests, as well as the breaking reaction time preoperatively. These are something that can be used potentially in the clinic, an assessment to see how are things in terms of the breaking reaction time. And the reason why we continue to harp on this breaking reaction time, one, because the studies are looking at this. And because we want to play a worst-case scenario with this. Sure, we need the function and the reaction time for the gas, but typically when we’re being really reactive is whenever we’re breaking. That’s whenever we need to like suddenly hit the gas. And when we talk about a worst-case scenario, you can think about anything, whether it’s like a car not paying attention, maybe a kid runs out in the street, whatever that could happen, you just wanna make sure that you are aware and you have that reaction time, which can be impacted by so many things.

And in this study by Wenn, they reported that people who underwent left-sided autograft ACL reconstruction, specifically to your left side, were able to demonstrate braking reaction time, and similar controls within two weeks. But whenever they looked at people who had that done on the right side, so the one that is actually doing the braking and the gas pedal, there was a significantly slower response time until the sixth postoperative week. And when they look at the reaction times. It does seem like it could be very minor, but when you actually put this in more physics terms or realistic terms, the reaction time difference was 913 milliseconds at two weeks versus 215 milliseconds at four weeks. And that’s the difference in a car traveling at 60 miles per hour, and that’s going to travel 80 feet in 913 milliseconds. It would be going 19 feet in 215 milliseconds. So that’s the difference between the reaction time, 80 feet versus 19 feet between the reaction time. So that when you actually put that to scale, that is actually a pretty big difference. 

Now, we’re getting caught up in some of the data and the details, but it’s something important to know and we have data to show it and back it up. So that’s why I want you guys to be equipped and be well aware of this. As we round out this episode, one of the things that I always ask you guys to think about is just think about the demands of driving, and we’ve talked about this today. But when you think about what you need, your range of motion is going to be really important. You need to make sure that your pain is under control. You need to make sure that you have good adequate quad strength, as well as other strength around the knee and the hips to move the leg. And you want to make sure that your reaction time and your cognition are there. And so when we think about some of the big takeaways here. One, I know time is an important factor, I want you guys to have like a relative range or an estimate based on these studies and what we typically see, and these reaction times, typically get back to normal if you have a right-sided ACL, around four to six weeks; and then it’s approximately two to three weeks after a left-sided ACL. So that’s the thing that you want to think about whenever you are timing this out. 

And some other practical takeaways or questions to ask yourself, did you have a right or left ACL reconstruction? If it’s a right, it’s going to take longer. If you had an autograft or an allograft, if you had an autograft, it’s going to take a little longer. If you have a manual versus an automatic car, if you have a manual, it’s going to take longer. Are you taking medications that could impact your thinking or reaction time? These need to completely stop before you step foot in a car. And then this is something that you need to think about planning before surgery. It’s something you need to have a game plan post-op to make sure you understand what is the worst-case scenario if you can’t drive for six weeks. And I do this with all of my athletes where I’m like, okay, if you have surgery now, let’s just make sure we are equipped and planned for six weeks, maybe eight weeks out, just in case. And this goes for work, for walking, for driving, or anything where you might need assistance. And just know that that’s something you want to plan for. The perk is, is that if it’s less than that, then awesome. That’s just a benefit to you getting to things sooner. And hopefully, it will be. But you just want to make sure that that is in place and that is something that you think about and maybe you need to line up Ubers to get to your orthopedic appointments or to physical therapy, or is having family or friends to help you along the way.

The other thing that I want you to take away from this is practicing in your driveway. This seems silly but seriously practicing in your driveway. Imagine a worst-case scenario if you did have to hit the brakes because something ran out in front of you or someone took a weird turn. Crazy drivers in this world, they’re all over Atlanta. You just want to think about these situations and can you react to them. And you don’t want to be the cause of anything like that. Not to sound morbid here. But you just want to be smart. 

And then the other thing is to make sure you are cleared by a professional. Don’t just start to make assumptions on your own. Be guided by someone who is familiar with the process, who understands, your surgeon, your PT. Just make sure you’re not risking it and just be safe. You want to make sure you are safe for your own health, for other people’s health. And in that way, you don’t have to depend on mom and dad to get you around or on Ubers, and that way you could be independent. Make sure you think through this, think through your own personal situation. If you have any questions, please feel free to reach out. That will do it for today, team.

When can you return to driving and normalcy in life, hopefully, pretty soon. This is your host, Ravi Patel, signing off.