Episode 64 | How to Navigate Your Grumpy Knee in ACL Rehab – Part 1

What is up my fellow ACL athletes? It is a beautiful morning here in Atlanta, Georgia. I’ve got my coffee. We are in the ACL Athlete Podcast recording studio (aka our kitchen and our kitchen island) where we have our setup. One of these days we are going to have the official podcast studio set up. But for right now, this kitchen table, this island is going to have to do. And honestly, it’s a great space. It feels very good to collect the thoughts and to be able to be in the moment and record a podcast for all of you ACL athletes.

Let’s dive into this episode — how to navigate your grumpy knee in ACL rehab? Man, the good old grumpy knee. We all know what this is. Whether you have heard this term or not, this is something that we just kind of relate to, essentially, the knee is not happy. You guys know what I’m talking about. If you’ve been through this process, you just wake up and it feels puffy, or stiff, or it just doesn’t feel like it’s normal self, which after ACL surgery and this process, that’s one of these things that we’re always trying to work through, is getting back to a “normal” knee where we don’t notice it. But a lot of times, especially early in this process, we are trying to navigate this grumpy knee and honestly just trying to survive at times and trying to just get to that endpoint and that end goal that we are always trying to strive for.

And the grumpy knee can always get in the way because sometimes we are just dealing with the human body and we are dealing with something that we can’t always control. And then there are other factors like surgery or things that happen during the injury that we have to also work to navigate around. And this is something that I have this conversation with every single one of my athletes because inevitably you’re going to be dealing with pain, you’re going to be dealing with swelling. It’s more important to know how can we have rules and understanding in place in order to best navigate it, as opposed to getting to a place of “pain-free” or “swelling-free” or “normal knee” that is going to take time just because of the status and the nature of the knee. 

How can we best navigate it when the knee does get grumpy? And before we dive into this specific episode, go and listen to episodes 13 through 15 where we talk about pain and we talk about swelling, the essential components of a quiet knee, and how we can help with those areas. And some of this stuff we talk about today is going to overlap. But I feel that this has been something that I’ve had a lot of questions about. And inevitably people are going to be dealing with pain and swelling and “this grumpy knee.” And I want to help give some specific parameters and feedback loops and those principles in order for us to make sure we are continuing to work towards our goals, as opposed to, oh, I feel this pain, or my knee feels like this. And it becomes a big barrier, or it stops you from progressing.

Now, one thing I do want to say. During this process, your knee will get grumpy. If you’re early on, maybe you just had surgery, and you’re just dealing with the aftereffects of that. At some point, your knee will not be happy. It might be because you did too much the day before. It might just be because like I said earlier, the human body is weird at times and it reacts to when we go in there and we do some sort of surgical process. There are a lot of things to factor in with this, and it might be difficult to figure out why. But hopefully today, we can at least get the full story around what you are dealing with. And then hopefully, the goal is to provide a framework and to provide some feedback loops in order to help you best navigate it. And I’ll share exactly what I give to my own athletes. And this is something that we’ll actually cover in part two. Today is part one where we are going to dive into the full story of the grumpy knee itself, and what you are specifically dealing with. That way we have these feedback loops in place to best navigate.

One additional point I want to make is that it is going to feel normal to feel all kinds of weirdness and craziness in the knee. You need to figure out what is actually worth paying attention to or not. And I will say the closer you are to your injury or to your surgery, you’re probably going to be feeling all kinds of aches and pains and sharpness because you got to think about the trauma that it actually creates.

With that said, I want you to think about if there’s nothing that has been traumatic outside of, let’s say those surgeries or the injury, then you’re probably okay. Then we just got to dive into the details of what’s going on. And so when I think about trauma, we’re thinking about a fall, a slip, something that shifts the knee dramatically. Maybe your dog ran into it and your knee reacted to it afterwards, significantly swollen up or it shifted. Let’s hope none of that happens, but it is a true story. It’s happened to one of my athletes before. But with that said, let’s say anything traumatic, including the surgery or the injury, has not happened. And that probably means you are okay. But what I always say when in doubt, go and get it checked out. That actually rhymes, I’m sorry. But really to get some assurance, especially if there’s something that is really concerning. You go and get it checked out by a healthcare professional, your physical therapist, athletic trainer, your physician, or someone who is well-versed and educated with a degree in this. And don’t go to Facebook or Reddit to figure it out.

I’m going to be serious here because this is something that is so variable from person to person. And when you think about the human body and the complexities of it. For us, it just be like, hey, I have front knee pain. That’s not going to be enough, because we need to be able to know the full story around it, and there might need to be some testing around it if it’s something that is actually serious.

 While it is normal to feel some clicking, popping, maybe some achiness. Remember the timing is gonna be important here. But the other piece to this too is that let’s say something has been sticking around for a while, and if it is stopping you from progressing or doing movements in your rehab, effectively, then it is time to pay closer attention and find out more details.

And the way that I want you to look at these details is essentially like we’re trying to figure out the full story of what’s going on. Not to be hyper-focused here, but to get the details. So if you do need to go in somewhere or talk to your physical therapist about what’s going on, then you have an understanding of what they’re going to ask, as well as information for yourself.

And maybe you might be able to figure out the answer to actually what is causing the issue. Let’s figure out the full story of the grumpy knee that you’re dealing with. And what we’re going to answer is the: what, where, when, why. And then part two is going to answer the how. How are we going to best navigate it, specifically based on some essential feedback loops and principles? When we dive into the what of the grumpy knee, it’s the what and the where. So what and where does it hurt? What’s making the knee grumpy? Well, Is there swelling? Is there pain? Is it stiffness? Is the pain specifically somewhere? So these are things that we need to figure out the details for. And with any patient that I see or any client that I have, we’re going to talk about what is it that they are specifically feeling, especially if it’s pain that might be stopping them from moving forward.

And then if we’re talking about swelling. Generally, the knee itself will feel puffy or tight or just kind of uncomfortable, especially when you bend it all the way. Let’s say trying to get your heel to your butt, you’ll notice that tightness at the top of the knee. So that is something to kind of keep in mind.

Pain, is it sharp? Is it dull? Is it nervy? We need to kind of figure out what that pattern looks like and need to figure out what the specific area is, especially if it’s pain. Swelling is a bit more of a general feel when you’re talking about pain itself. It’s so multifactorial and it can come in many different shapes and forms and specific areas, and that’s why we need to be able to get a decent description of it, so we can know how to best tackle the problem. 

Next up is the why. And this one can be difficult to establish because we do not operate in silos, unfortunately, in our lives. And so there are a lot of things that happen in our daily lives that we’re not necessarily sure about. As I had mentioned before, if there’s a certain traumatic incident or an accident that is brought on, then that is probably likely the issue. Otherwise, we have to dive a little deeper. What I mean by that is if you are immediately post-injury pain because of the tear or the trauma, if you are immediately post-surgery, then again pain because they literally just did reconstructive surgery on your knee and it’s essentially a second trauma.

These things make sense. It’s also going to depend on the degree of the injury and what they have to do potentially in the surgery that you need to keep in mind. Someone who just had a solo ACL reconstruction, so the ligament was the only thing that was repaired versus someone who had some cartilage damage, had a meniscus repair, had a bony contusion, maybe a fracture in there, maybe there’s an MCL injury. The feeling of that knee is going to be very different and possibly the reconstructive process that they’re going to have to take is going to be different. So guess what? The person with the more traumatic knee and the results are probably going to feel a little bit more in the knee versus someone who just had an ACL mid-tear and they had to just get that replaced. It’s going to be a little different. Each person, at the end of the day, is just going to be different because of their own pain experiences and how their body is going to handle it. This is just something to think about when we’re talking about the why.

And then the other piece is also, is it during the rehab process? When we’re talking about a certain accident or incident that happened, maybe you did a jump really weird and you landed straight on your knee. You didn’t bend your knee. And so then the front of the knee is kind of aggravated. Is there something that you did? Maybe you did a bunch of running, maybe you did an excessive amount of squats and that’s why it’s happening. Or it could be something that is going to be really difficult to track down, and that’s what we’re trying to figure out is the why. Was there an exercise you were doing where you remembered that specific moment and has been around since then? Or, was it something where you’re not really sure, it just kind of came on and it gradually started to build up and now it’s starting to become a problem. And now you’re waking up with a grumpy knee, whether that’s more swelling or whether that’s the pain that’s just not going away and keeping you from moving forward. Was it something that you ramped up really quickly in your ACL rehab or training? 

A lot of times, I see this with people who are potentially trying to run. They’ll reach out to me and they’ll be like, “Hey, I started running. And my knee is bothering me, it’s swelling.” And I feel like I can’t really go that far. And usually what I’ll see is two pieces. One is that they were never tested to get cleared to run. They just hit the three-month mark. And then the other piece is that they typically ramped up their running too fast. And this is based on maybe previous ways that they ran. And they’re like, “Well, I know I’m fit and I can do this.” But you also just had a reconstructed knee. Or, one where you’re trying to manage without the ACL. And so that’s going to be a little different from a ramp-up process. And so that’s where we got to know those details and we got to make sure that we ramp up slowly with some of this stuff. And this term we call load management. How is the load being progressed? 

And I’ve used this analogy a lot recently because I think it’s just such a good idea for ACL rehab. But instead of hitting that on-and-off switch for the three-month mark or the six-month mark, or you magically cross some sort of threshold, instead it should always be this dimmer switch during this process. It should never feel like this extreme shock or you feel so unfamiliar with something just because, especially we’re basing it off of protocol and time. This is just something to factor in for the why. Why are we feeling this? Can we deduce this down to something that we can target a little bit better? And then that’s going to help us paint a better picture. Maybe it’ll tell you, okay, well, maybe I was doing something during this time and I started to realize, “Wow, I ramped this up really quickly and that’s what’s causing this issue or this discomfort.” 

And lastly, I want to talk about timing or the when, when is going to be really important. The timing is going to be really important for us to understand a little bit more of the story of what you’re dealing with with your grumpy knee. Did you just have an injury or surgery? Guess what? It’s going to hurt. It’s going to be probably swollen and we talked about this earlier. And so this is just something to think about. And especially if you’re still close to that timing, think about how long it takes the human body to heal, whether it’s a cut or a broken bone. And then you start talking about other soft tissue-related issues which is a lot of what ACL is dealing with. You’re talking about a ligament. We don’t have a full ligamentization process which is going from a tendon to a ligament. What research says is typically around two years. So that thing is still transferring over time from tendon to ligament, and that’s where it’s something to factor in a meniscus healing, a bony contusion. And then you’re starting to try to stress the joint, which is also going to throw it for a whirl as well. Knowing that you are close to injury or surgery will also help to know maybe the joint is still healing, as well as maybe you lost some strength so then the joint is having to pick up a lot of the stress. Because you’re not able to activate the muscles or you don’t have the strength to do some movements yet. 

There are a lot of things that play into this, especially with close proximity to the injury or the surgery. One of the things to ask yourself is how long has it been since this specific grumpiness, pain or swelling or both has started? And if it’s ever since the surgery, then it might be something where you’re just doing too much and we need to kind of take a step back and we got to figure out what is it that your knee can handle with the loading. Or, is it something where you are thinking about, okay, you’re three months or six months out, you are three years out, maybe? All of this is going to matter in telling your history and your story of what’s going on, and that way you can get to the roots of the problem that you’re dealing with. And I say roots because when you look at an underground at tree or a plant or anything that is planted, typically there are roots that go in many different directions, not just a single root. 

A lot of times in rehab we can say, “Oh, we’ll get to the root of the problem.” Sure, you can look at that as plural, but roots are typically how you want to look at this. Because when we were talking about pain when we’re talking about this knee and life in general, it’s typically multifactorial. There could be multiple routes that are playing into this we need to make sure we have a strategy and some principles and feedback loops in place to tackle. When we’re talking about the grumpy knee is probably due to several roots of why it’s happening. Sure, sometimes it can be one specific thing. But life usually doesn’t happen in those silos or in isolation so that’s why we got to make sure we tackle it this type of way. 

A good example here is you’re getting front knee pain because you ramp up your running too fast. But you’re also doing things in the gym that might be exacerbating the pain. Oh, and you don’t have full knee extension or good quad strength -multiple roots here. Now, can we try to isolate some of this stuff? Yes. But at the end of the day, there are multiple things that are contributing to this, so we need to make sure we have a plan in place to tackle it. Or, is the timing of this only when you do a certain activity or a movement? And I keep coming back to running because that’s one of the things that I often have athletes reach out about. It’s a big milestone in this process. And a lot of times what I will see is that people will start having pain and they’ll start having a lot of swelling in the joint. A lot of times because again, going back to those points of not adequately tested, or they do not have the proper progressions to get there. And then all of a sudden we start repetitively compressing and expanding the joint through running, and the joint itself is not happy and it’s grumpy. So that’s where we can deduce back, “Okay, well, it’s running. Well, maybe this is something where we need to tweak the plan for running. Or, is it something where we got to take a step back and start building up some parts of it in order to see if the knee will tolerate it?” And that’s where we just have to kind of play detective.

The first place where we start and any detective starts is gathering the details in order to do this. This is where we get the full story. In part two, we’re going to cover the how. How can we tackle this? What are the essential feedback loops for your grumpy knee so that way you can keep moving forward? And even if it’s something where you got to take a step back to take two steps forward, that’s going to be really important. And you need some of this stuff with you in your back pocket so that way you can navigate it, and you don’t have to necessarily rely on going to your physical therapist in person, whether that’s two or three times a week, or maybe you’re not doing physio or PT at all. Then you need to know how to navigate this. And that’s my goal today, is to be able to get the full story and that way we can make sure we have a good plan in place in these feedback loops to tackle it. 

This is part one, looking out for part two where it will be the essential feedback loops for your grumpy knee. And while you are here, if you have literally a minute, please leave us a review. It means the world to me. Thank you so much in advance. But if you don’t, then you’re basically just dead to me -I’m just kidding. Still love you all. But seriously, go and leave a review, if you’ve got some time. It will help all kinds of ACL athletes out there who are looking for some sort of direction and some education in order to be on their own journey. And that’s exactly why this exists. That’s going to wrap it up for today, guys.

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