Episode 62 | Wound Management and Healing after ACLR

What’s up team, and welcome back to another episode on the ACL Athlete Podcast. Today is episode number 62, and we are talking all about wound management and healing after your ACL reconstruction or surgery. We want to make sure you are taking care of your wounds and your incision sites. We want to make sure that you have a really solid environment to make sure that this gets taken care of, and so you can be steady and focused on your ACL rehab. Some of this may seem a bit obvious, but this episode will talk you through some insight, and some advice on things to look out for, especially as I either notice trends or questions or specifically things that have come up that can possibly derail this process. So that’s why this podcast really exists, is to help educate you on this and for things to look out for in your own journey.

I just want to put a disclaimer on this episode because this is purely educational and should not be taken as medical advice, especially if we’re talking about wound healing and wound management. But I just want you guys to feel very informed with this and to understand your own journey on how to do that. I’m going to take from my own experience of my two ACL reconstructions and surgeries, as well as other ACL athletes that I’m working with on a daily basis, and the things that I am seeing. 

Here are some of our main goals with wound management. Let’s keep it clean. And a good role with this is don’t get them wet until you are 100% confident, they’re closed and healed. And usually, the surgeon or the physical therapist you’ll work with, we’ll give you the go-ahead on this. Don’t assume and make sure that they are healed and you’re a hundred percent good to go. Better to be cautious in this process. Make sure to avoid infection. And this is not something that anyone is just welcoming with open arms. Obviously, no one wants an infection. But just to give you guys some insight on this. I have two different stories that I want to share. One is about someone who had an ACL reconstruction and she had this very long process and the site and the wound got infected. It actually got up in the screw and into her graft and they had to go through and they had to take all that out and clean it. And now it’s been a process of, essentially you’re feeling the effects of an ACL reconstruction, but the graft is not there. It’s something where she’s having to delay the process. They had to go in and they had to irrigate and clean out the area. She’s on antibiotics, so it’s created a lot of complications.

On the flip side, there’s another athlete who I’ve talked to who got his wound infected and this created a problem as well. It created a lot of pain and a lot of issues. And so the screw itself got infected, not the graft. They had to go in and they actually had to remove the screw because that was starting to stick around longer than they wanted. It’s been a process for him to be able to go on his ACL journey and progress because that has limited him a little bit. And he’s not able to kneel on the knee because you got to protect the area. You don’t want to remove the scab and it’s been having to heal and it’s taking much longer because of that process.

Do I have you convinced to avoid the affection and to make sure that you protect your knee? I’m not trying to instill fear or fearmonger you, it’s just the reality. People can get infections and this is something that I have seen athletes get and it’s not cool. Protect your wounds, and that’s why we’re talking about this episode today. You want to create a proper healing environment to make sure that you can move forward in your ACL rehab. At the end of the day, we just want to get done with this process. As soon as we can move through the initial stages, the more that we can get towards a more normal life, as well as the fun stuff that we want to get towards.

First, let’s kick this off with some simple phases of wound healing. There are three main phases that any wound goes through. It’s inflammatory, so that’s where the body sends all the defenses to the site. If you think about the white blood cells, just everything that goes into that inflammatory initial process, and then it moves into a proliferative process where it starts to rebuild the site or the wound area, and then it goes into remodeling. This is what you could think about solidifying the site, creating the armor of the skin creating that tensile strength, and getting it close to back to normal.

Let’s talk materials post-surgery. Usually, to close the wounds you’ll get stitches, staples, or glue. Sure, there are other options out there, but this is what you’ll typically see. Staples are very much less used at this point, still happens, but less often. Stitches or glue are typically what you see for those incision sites. This is where stitches might be dissolvable or they might have to be cut out, depending on your surgery, depending on the surgeon. The glue usually is dissolvable. It’ll start to flake off as the skin starts to heal. This could be something where it might go two, or three weeks of that dissolvable glue. And then, it’ll start to wear off over time. If you do not have something that’s dissolvable, then typically somewhere around 7 to 14 days, is when they’ll go in and they’ll cut out the stitches or remove the stitches to make sure that you can continue to facilitate the healing. The purpose of those is to approximate the edges, to make sure that the healing and the scabbing and all of that takes place well. 

The other piece that I want you to look out for here with this specifically that I’ve noticed is that I’ve had some athletes where they might have some allergic reactions or irritation from the glue or something they used in surgery. This is not to go and just run to the surgeon and ask all the questions; it’s just something to look out for. They were totally fine. But if you see this and this persists, then you might need to do something about it. But just something to keep on your radar. It doesn’t happen in most people, but it can happen.

The other things that you will see are Steri-Strips. Those are those little plastic, little kind of butterfly-type strips that will go across the wounds to help close those edges. Gauze is typically that white padded, absorption-type material that will be on top. And then you’ll have an ACE wrap that compresses and protects the knee if you will. And then sometimes you’ll have a brace in certain situations, depending on the surgeon. There could be other things, but this is generally what you’ll see with most post-op situations. And I just wanted you guys to know the material because sometimes you’re like, what the heck is all this? It helps to know what that stuff is, so then that way you can make sure you know what you’re dealing with. If you don’t know the difference between the gauze versus the ACE wrap, you might confuse the two. So just know what those things are. 

You are day one post-op, you have gotten out of surgery. There will typically be all those things that I had just mentioned. There’s going to be that compressive ACE wrap typically on the outside, and then you’ll have that sterile gauze underneath to absorb any of the fluid and protect the site underneath. If you notice some kind of blood staining the night of the surgery, or throughout that day or even the next day, don’t be too worried. This can sometimes be from small incisions where some fluid can come out. Just because you think you just had major surgery so that can be normal. If it starts to be very excessive, almost like excessive draining, then that is going to be something that you probably need to get in touch with your surgeon’s office. 

At the end of the day, when in doubt, make sure that you call and you get an answer, as opposed to just cussing it. And it could have been something that was addressed maybe a little earlier. But some drainage after surgery is completely normal. Post-op day two, you’ll probably not do too much to the wound site, unless it’s just bleeding a lot and you need to change that gauze. Usually that day you will sponge bath, or if you have an ideal shower set up to be safe, you need to prevent the wound from getting wet. 

And then post-op day three, or typically 48 hours after, you will be given permission in most surgeons’ cases and recommendations to be able to shower and just make sure that you do that in a very methodical way. You want to make sure you protect the knee and the wound sites and make sure that your shower or your washing setup is good to make sure you can still get a shower. If you’re going to wash around the knee area just make sure that you can wash it. And then make sure you pat or let it air dry, making sure no direct water gets on the sites. 

And you want to make sure that you create the right healing environment for this. Don’t get the dressing wet, even if it’s waterproof and I mentioned this in the last episode. But I think this can be good to just make sure we readdress is when you’re using this stuff, even though the dressing might be waterproof or water-resistant, I use the analogy of your iPhone getting wet, even though it might be water-resistant. Do you want it to get wet? No. The same thing here is to make sure that you protect the site. It’s just there for just in case. But that’s going to be something that’s very important to allow this wound to heal really well. You’re going to end up removing that ACE wrap on day three and the gauze. And you are going to want to inspect the incision sites. There might be the Steri-Strips or those butterfly bandages that you could see. You’ll leave those alone, usually, those will fall off over time. You want to make sure that that incision and everything around it is good and dry. And you may want to let it air out for a little bit just because of the way it looks. If it’s draining, then obviously you want to make sure that you are able to pick up that draining with the gauze that you are given and make sure that it is clean.

Let’s talk about fluids because I think that that’s going to be really important here. Make sure you delineate because that will tell you some things about the incision site. So it’s normal. When we talk about discharge or fluids, I know this is kind of gross. But just hear me out here. If it’s like clear or yellowish or even bloody drainage from the incision sites, especially in the early post-op days, those are normal. Just make sure that you’re replacing the dressing and you don’t want those to get so drenched to where it’s almost too moist, and then you don’t have a good environment for that wound. You want to make sure that the dressing is nice and dry, and that that is on rotation to absorb anything that it needs to. Usually, once the scabs are there and there’s no discharge and it’s healing well, it’ll tell you to ditch the dressing because it’s no longer doing its job. If it’s not having to absorb anything, it might be protecting some things. But if it’s not having to absorb anything, then it’ll be less likely to be needed. 

Again, we’ll be dependent on your specific situation. Just make sure that you’re changing that out which is keeping it dry and that you are protecting the site with it. If the incisions are draining pus, which is usually opaque, thick, white fluid, or if there is a redness that worsens over days, then that’s just something where you need to call the office. It might be something where you might need to double-check. Don’t go trying to use ointments and creams. People will do this all the time I know our typical thing is, let’s put some antibiotic on it. No, leave it alone. Make sure that unless it’s something that your surgeon or your doctor’s office has given you, don’t go putting random creams and ointments on this that haven’t been recommended as this can delay the wound healing. It can create moisture that can get trapped, and then bacteria love that moisture, and you just don’t want that. You want to increase the risk of infection. So make sure that you follow the protocol with this. And if it does look something similar to those types of fluids, then you communicate to the office and follow their guidance on it.

Some last pieces of advice on changing the dressing. Make sure you wash your hands before you mess with any of the dressings or the wound sites. That’ll be super important for this. So then that way you can keep it sterile and clean. The other thing is that with the dressings, you’ll usually change them daily or maybe every other day depending on the discharge of it. As well as this will be something that’ll probably kick in after day two to three post-op, depending on the wounds again and what it’s looking like. And at some point, you might get the dressing fully removed and you don’t need to use it anymore. Because there’s not any more drainage as I had mentioned earlier, but the stitches might still be in. So that still is not a green light to run water over it. And you want to make sure that those wounds are fully healed before you submerge it in water or run water over it. So that is whenever you get that green light, and that is going to be something again that you’re going to get from your surgeon or your physical therapist that you are working with.

Some last notes here. With your incision, as it starts to heal and time goes on, let’s say it’s three, four weeks out, there’s something that we want to make sure is that, as those heal, you want to make sure you take care of the scar sites. One of the things that I always give my athletes is to make sure that they do some scar mobilization. And this is something that I would highly suggest you talk with your PT and ask them to educate you on this. But this is where you can massage the scar site once it is fully healed and there’s no risk of reopening it. That way you can make sure that the skin is nice mobile and pliable as it’s healing more and more over time.

For my second ACL surgery, my hamstring graft was taken, and where that incision site is near the hamstring distal insertion site. If you can think on the inside of the hamstring of your left leg, there’s an incision right at the knee crease for me. And I remember for the longest time, I had issues with that scarring with that tendon right there. And I would get a lot of pain and a lot of popping. When I worked on that scar incision site, it actually helped so much to be able to free up. I think what happened was that the skin adhered to where kind of some of that graft had been, and I needed to help loosen that up. And the scar tissue mobilization really did help me in order to make that more pliable, so I didn’t get that sensation anymore.

Two additional tips that I want to leave you guys with for creating the best environment for wound management, healing, and taking care of our skin are nutrition and smoking. Nutrition is going to be really important just for the overall recovery, especially after a surgery or injury like this, and making sure that we create the most internal and best healing environment. So that’s going to be making sure that we are very hydrated, making sure that we are getting a variety of foods that are whole and good, from protein and fats and carbs. And making sure that we are taking in the appropriate amount of calories for this. 

And then the other piece that I mentioned is smoking. Smoking will impact oxygen delivery, which will delay healing, and that will be for the incisions as well as for the graft sites itself. And it can even impact the way that the tunneling is so don’t smoke. It’s not good for you anyway, but don’t do it, especially when you’re recovering. Nicotine will really impact this. These are my additional tips for you guys to make sure that you have the best recovery. 

Infection is real. You don’t want it. I’ve had athletes who have gotten it and it delays their process. Take care of your wounds early. Be clean. Be smart. When in doubt, reach out to your surgeon’s office, ask your physical therapist, or whoever you have in your corner to help you and guide you in this process. Use them, use your resources. 

All right, team, that is going to do it for today. If you have any questions, hit me up on Instagram at ravipatel.dpt or send me an email at ravi@theaclathlete.com. That information is also in the show notes, so send anything my way. I just want to help you guys. Make sure that we have the best recovery possible. All right, guys until next time. This is your host, Ravi Patel, signing off.