Episode 65 | Essential Feedback Loops for Your Grumpy Knee – Part 2

What is up guys, and welcome back to another episode on the ACL Athlete Podcast. Today, we are continuing this series talking about the grumpy knee. This is part two, Essential Feedback Loops For Your Grumpy Knee in ACL rehab. If you have not had the chance to listen to the previous episode, which is episode 64, How To Navigate Your Grumpy Knee in ACL rehab, go and check that out first as it’ll lay the foundation here for this episode, and so you can get a full picture of what this is looking like. I would also encourage you guys to go and listen to episodes 13 through 15, where we talked specifically about pain and swelling. And some of the things that you’ll even hear today, as we circle back to a lot of questions that I’m getting from athletes. And some things that I want to share with you guys, essentially what I share with my own athletes and some guiding principles and feedback loops that we use. 

The grumpy knee is one of those things that can get really frustrating. I remember in my own ACL rehabs, I had so many different times where my knee got ” grumpy,” where it either swelled up or I did a little too much and I had a lot of pain. I remember my second one, I actually aggravated my other knee because I was trying to do too much. And you think I would learn from the first one, but guess what? I did not, I tried to overdo it. My right knee actually started getting patellofemoral pain, which is just kneecap pain because I was just trying to do too, too much. And these are all the things that we learned in this process. 

My goal is always to share with you guys things that can help you from making the same mistakes I did in my own journeys, but also what I see literally day in and day out with my remote athletes as well as the people I see in person. And that way you can have the most smooth journey. And if something does come up, then guess what? You have a plan in place to tackle it. And make sure that you make the most of your ACL rehab. So I’m going to repeat this because I think everyone needs to hear this. If you are struggling with something and you need actual medical help, then this is something where you need to go and talk to your physician or you need to talk with your physical therapist and game plan it out. When in doubt, check it out. That all rhymed. I’m so sorry. Again, I did not plan for that, but here we are. But seriously, go and get it checked out. It’ll give you peace of mind to be able to make sure that you’re moving forward. We need these assurances in life, and that’s something that can be really helpful to get from someone that you trust who is an expert or who is guiding you in this process.

And if you do not get that from that person, then you need to find someone who does provide that for you. At the end of the day, your provider, your physical therapist, your surgeon, the people who are supposed to be in your corner are the people who are supposed to be helping you and assuring you when you are having issues in your process, in your rehab. And now this doesn’t mean you go and talk to them about every single little bitty thing and write them paragraphs of emails. It’s just let’s try to gather information and make this easier on them. And so that’s where the previous episode was hopefully helpful, create that story, know what it looks like, it’s something that’s impeding your process.

And then today, the goal is to cover these feedback loops, but also if you’re working with somebody, make sure that they’re in, they know about it. And that way you guys can tackle this as a team, as opposed to sometimes trying to just figure it out on your own, which can be really, really hard given how complex the human body is.

Now, let’s talk about essential feedback loops and some guiding principles for your grumpy knee. One thing that I talked about before was the protect and expose continuum. And this is something that is still relevant and true. And I want you to just kind of think about this continuum that goes left to right with two arrows. And one side is protected and one is exposed. And sometimes whenever we are, let’s say post-injury, or post-surgery, we need to protect the joint a little bit and not push it too hard. Because at the end of the day, the body is healing just like a paper cut. We need to allow it to do its thing and not just go and be rough with it or do a bunch of exercises.

Now, there are things that you want to be doing, but at the end of the day, the goal of that phase is to protect it. And then the same thing happens with things where maybe there’s some swelling or some pain, but then the goal is to slowly expose it to certain stressors, and to use that dimmer switch in this process as opposed to that on-and-off switch. So we could slowly ramp up and slowly expose, as opposed to staying in this protection mode for so long or exposing it too much. We don’t want to be on one end or the other too much. We just want to slowly be moving along this continuum. 

One of the things I tell my athletes is that if you wait for the pain to completely disappear and not feel a darn thing in the knee, then you’re going to be waiting a long, long, long time because we have to work with pain and it’s kind how life is a little bit. We just have to deal with the pain. But how and where and what, and the details of it is what’s going to really matter. This is not me saying no pain, no gain. It’s us figuring out, okay, what exactly are the details of this? And then that way we could have some principles in place to make sure we navigate it well. If that’s continuing to get in the way of getting to the next-phase goals or to return to sport or performance, then that’s something we got to take a step back from and figure out, okay, what is it that we can work with and what is it that we can’t? I’m hoping today these feedback loops that I give my own athletes will help you guys to be able to better navigate this yourself. We discuss protect and expose continuum. 

Next is the Goldilocks principle. The Goldilocks principle is similar to the Goldilocks and the Three Bears. We want to make sure we find the sweet spot with this. And sometimes it’s going to be testing out and figuring out what is not too hot and not too cold. And this can be thought of as not too little or not too much. You want to make sure that you can find the sweet spot with this. And sometimes this is something that you have to learn a little bit, especially as we get more experience in this process and get more data points to know how your body is actually going to be responding.

Let me give you a very simple example here. The Goldilocks principle in action is, let’s say you start running and you are trying to run three miles and your knee starts to swell up. But if you run a mile and a half, your knee does not swell up. Well, we found a sweet spot and then now we got to figure out, okay, how do we stay consistent at this point? And then let’s, instead of jumping to three miles, maybe let’s just do 1.75 miles, maybe it’s two miles, maybe increase the intensity a little bit. Although my general guidance on that is to increase volume, so the distance before you start running super, super fast. And maybe it’s just adding an extra day of rest in between. There are a lot of things to figure out. But this Goldilocks principle is finding the sweet spot where essentially that grumpy need does not kick in. That’s where we might need data points and understanding to know where it is that truly sits. 

Another example might be you’re doing seated knee extensions, or maybe it’s a back squat. And you are trying to do a weight that is causing your form to shift and is potentially also driving a lot of anterior knee pain. So that is with, let’s just say maybe 95 pounds on your back, maybe you’re on a Smith machine, maybe you’re on a barbell, maybe you’re on a dumbbell, whatever the weight is. But when you drop it down, let’s say from 95 pounds to -we are now aiming for 75, and you could do the position correctly, you don’t feel the pain as much, and it stays pretty low. It doesn’t ramp up. Then, hey, guess what? You’re still getting a really good effect and training effect from what we’re trying to get, and guess what? The pain is staying low as opposed to ramping up. And you’re shifting your body all around as well. These are the Goldilocks principles to think about so you can find a sweet spot to continue to move forward in your rehab.

The next one is going to be the traffic light and pain activity. This one I love so much because we are so difficult at describing pain. I myself can’t describe it that well. But if we can bucket it into these three different buckets, it will help dramatically with knowing, do we move forward. Do we stop or do we regress a little bit? When we think about the traffic lights, we have the green, yellow, and red lights. I want you to think about the zones of those. If we talk about a zero to 10 scale and you’re like, “Oh gosh, the 0 to 10 scale.” I know it’s so hard to describe, but let’s think about this in terms of the traffic light. We’ve got zero to three as green, you got four to five as yellow, and then you’ve got six, and above is red. The green light or zero to three is the safe zone, and that’s okay for us to keep moving forward. The four to five is the yellow, that’s acceptable and it’s okay to keep going. But you want to be careful to not push past just like a yellow light in real life. Now, depending on who you are, you’re probably like, let me speed forward, which is probably most of us. But really in yellow light, it typically means caution because it’s about to turn red. This is something that you also want to essentially take the same analogy and apply it to your own movements and rehab that you’re doing. And then if we talk about the red light, the six to 10 or six and above is excessive. We do not want to go into this territory as it will not be worth it, and you’ll probably pay for it later, more than likely. Now, instead of thinking about it in these numbers, I like to think about it instead of the green, yellow, and red lights.

And the other things that you can associate with are low, medium, or high pain or discomfort. Green is low, the yellow is medium, the red is high. And these are feedback loops for you to be able to use in order to know, can I do this activity? Can I do this exercise? Is this movement beneficial to me? And if we’re starting to get into the yellow light or above, then you have to be careful because it might end up not being worth it in the long run. At the moment, it could maybe feel okay, and that’s where you just got to be able to have those data points to understand and gain more experience to know if is it worth it or not.

The other thing that I want to add to this is if it’s a sharp pain, then you’re probably going to need to modify it, as opposed to more of a dullish pain which is what we typically feel in this process. This can be reduced by changing maybe the range of motion, the position, the weight, the tempo, or even the type of movement itself. Maybe a split squat hurts for you. But when you go to do a box squat, it feels much better. Guess what? We’re still getting quad work, we’re still getting a knee-dominant movement. And that can be really beneficial as opposed to hanging it all up, going riding the bike. Let’s still try to attack what we need to. And that’s where working with an experienced coach and communicating and having these feedback loops can be so vital. Instead of taking that big step or two steps back instead, it’s more of a pivot or a lateral move. And then that way you can continue to move forward while you’re navigating the grumpy knee.

Now, last but not least, is the 24-hour feedback loop. And realistically, this is looking within to the window of the 24-hour feedback loop or the 24-hour window of what happens afterward. After 24 hours or the next day of the set activity that you’ve done. Maybe it’s a gym session, maybe it’s you go and do an on-field rehab day, maybe it’s specifically you go out for a two-mile run, whatever that is that you did the day before, you need to check in. And you need to see the next day and see how the pain or the swelling is feeling aka whatever you define as your grumpy knee and what you’re feeling with it. And so if it has increased in pain, it might have been too much. 

And the other things that you have to factor in, again, we don’t operate in silos in our lives, are variables such as being in the gym. Let’s take the set activity that you did the day before. You’re trying to analyze to see if is it better the next day. The other variable is that you need to, let’s use running as an example just to make this simple. You ran the day before. And now you’re trying to see how it feels the next day, in terms of grumpiness and pain and swelling. The other factors you’re going to have to factor in is, well, did you go to the gym as well? Did you do some daily ACL-type of work? Did you have to go to the actual work? And you have a labor job or you’re a teacher and you’re walking around, as opposed to someone who is a desk worker or remote where you didn’t have to move around as much. And then did you have to run some errands? Did you have to do some yard work? Did you have to go chase your kid down and make sure that they don’t fall off the edge of a bed or something?

These are all the things that you have to factor in day to day. And it’s going to be something that will impact essentially how you feel that next day. I know that there are plenty of athletes I work with where they’re feeling fine and good. But if they are up on their feet all day on a certain day, and they have been dealing with this grumpy knee, then the next day is probably puffy and swollen. And you guys know what I’m talking about, where it feels like it’s tight, and this is something that we just kind of factor in. They were at their kids’ basketball game, or maybe they’re at the soccer fields all day standing up. So that’s going to impact essentially the grumpy knee, the pain, the swelling, all the things that you might be feeling, and that is important to factor into your 24-hour feedback loop. So that was a long tangent of essentially talking about additional variables that are important.

But when we talk about this 24-hour feedback loop, you are taking set activity, which we use as an example of running the day before. And then now you’re checking in to see, okay, how does it feel the next day? If it stays the same or better after 24 hours, we’re on the right track; ideally, it’s better. If it stays the same as it felt the day before, then we’re okay. But if the pain gets worse, if you’re dramatically worse the next day, then something needs to change, whether that’s an extra day, whether that is the amount you ran, whether that’s completely stopping running for a short time to work on some issues that you’re dealing with. That’s where the other part of the story is going to be important. But this 24-hour feedback loop is going to give you information to know, do I continue on this road or not. 

You have three paths. If you either have it’s feeling better, then that’s great. Keep going. You have, it feels the same again. Be cautious to make sure it doesn’t head in the worst direction. But at least it’s staying where it is and your activity is continuing to persist, or maybe you’re increasing slowly, or it’s getting worse. And that’s where we need to kind of hit the red light and we need to stop and we need to figure out, okay, well, what do we need to do to get it to stop getting worse? 

The other thing that I would like to add to this is that when you talk about the set activity and then you are trying to monitor the next 24 hours, the thing that we’re trying to look at is: did your knee tolerate what it is that was done? And there can be times where it doesn’t kick in necessarily until a little bit later. But it can also work on the opposite side of before. It might be only four hours or eight hours after you did a set activity, let’s say running where the knee starts to respond negatively. It could also be 36 hours after. Each person is going to be different. The 24 hours is just a good idea because that is going to typically dictate the next set of exercises or activities that we’re going to do. So that’s going to help you get a good litmus, if you will, on what it is that we need to do next. Is it better, is it the same or is it getting worse? These are the three things you need to factor in, and that’s going to play into essentially how you take your next steps and how you navigate what is going to be the approach to take care of this grumpy knee. 

If it continues to get grumpy, one, you need help. Two is that you need to modify something. You need to change something because essentially this is our body and our knee telling us we are not tolerating what is going on. Something needs to shift or change, and that’s where working with a coach or someone who is very familiar with this process is very, very important.

The last thing that I want to mention with this is going to be other variables that impact your pain, your swelling, and just overall how your body feels. And that’s going to be, of course, the movement piece. Nutrition plays a massive role here, so do not forget that. Make sure you’re getting adequate protein and hydration. Sleep is a big bucket. If you’re not sleeping, then your body is not able to heal very well and that’s most of our recovery and rebuilding. You could be crushing your ACL rehab. But if you’re only getting three or four hours of sleep, guess what? It’s not going to reap its benefits because you’re not recovering. And there’s so much associated with our sleep and our cognition, but especially with our pain and our ability to recover and get stronger. There’s tons of research out there on it.

And then we’re gonna circle around to stress. Your stress will be impacted by your cortisol levels, which will therefore impact your inflammation, which will therefore impact your healing. These are things that you also want to make sure you get control of and understand what stressors you might be dealing with. It might be a school drama, it might be getting into college or getting a scholarship, it might be for you to handle giving birth, maybe you’re having a kid, or maybe you have twins. I just had one of my ACL athletes, she had twins. And that’s a lot of stress to be dealing with. And you can’t just get rid of it. So you got to be able to figure out how to navigate it best, and that’s going to be something that’s going to be really important. And then you factor in work, you factor in other life stuff. I just want to make sure that we also zoom out a little bit, not just focus on the knee or the body, but also focus on the other important variables or the bigger buckets that we need to make sure that we’re tackling in this process as well. 

And I’m going to finish with these questions because I think that they’re really, really solid questions to ask yourself, especially about a grumpy knee. And that will also help you to best navigate the next steps. So one thing to ask is, is the pain the same as the original pain? If yes, then that’s at least good. We don’t want pain constantly shifting on us unless it’s getting better. But at the end of the day, we are talking about, is this pain the same as the original pain? If yes, then good. 

Is it tolerable? If yes, then that’s good. So that’s keeping it low or less than 3 out of 10. Does it interfere with daily function? If yes, then you need to adjust. So that’s where if you can’t literally pick up your kid, or maybe it’s you can’t take the stairs or you can’t drive, or you can’t shower, just daily functional stuff, then we need to make sure we adjust because that’s impeding our everyday life. And we’re having to change it because of that.

Does it keep getting worse day by day? If yes, then we need to adjust. And these come back to those feedback loops again and making sure you’re working with somebody to help you adjust. But we want to make sure it’s not getting worse day by day. So then if yes, then adjust it. 

And then the last thing is, has my nutrition, sleep, and stress been the same or different? If one is different, then adjust. So for example, I’ve had someone where everything has been the same. They’re carrying on with ACL rehab, but they had someone who passed away who was really close to them. And it put such a burden on them, as you would imagine. This is a stressor that can’t be necessarily controlled, but we need to make sure that we adjust for it. So that’s why taking in and looking at the bigger picture sometimes can be really helpful, especially with something that’s been a little bit more chronic or has been dealt with in nature for a longer time. If your nutrition, and stress are the same and it’s not really any different, then that is something where, okay, and you’re still dealing with this knee, then that could almost give you a better focus on, it is based on my movement. And a lot of the time it is going to be based on movement, but these other buckets are going to be important to make sure we tackle as well.

I hope that this was helpful, guys. My goal was to provide these essential feedback loops that I gave my athletes. And that way you have the ability to navigate this on your own. And if you want more details, check out episodes 13 through 15. But in review for today, we talked about the protect and expose continuum, the Goldilocks principle, the pain and traffic light, your 24-hour feedback loop, as well as questions to ask yourself; including the big picture of movement, nutrition, sleep, and stress.

And the last bucket I want to add here is your connection or your community. This is going to be your support system, and this all kind of plays into this. But that can generally lead to potentially the stress bucket or feeling isolated, which can very much happen. In this process, I remember feeling it myself during parts of it. And so that community and that connection is going to be important. Make sure you have your support system in place and that you’re exploring your relationships and making sure that those people that you need are there and that you lean on them. So that’s going to be the last bucket that I wanted to make sure we tackle, that actually plays into these feedback loops and into the bigger picture.

And you might be like, well, how is my relationship with X related to my grumpy knee? Well, if there are stressors in your life that are coming from that, then that could be impacting your motivation or your mindset, as well as maybe even the internal inflammation of your body. And it might be impacting the way that you sleep or the food that you’re taking in. While it might not be directly related to your knee, it could be indirectly. Let’s make sure we take that step out, create that big picture, evaluate, create your story about what grumpy knee you’re dealing with, and then talk to your healthcare professional to tackle this. And use these feedback loops so that way you can take the next steps you need to, instead of having to spin your wheels and try to navigate this on your own.

If you’re having difficulty or if you are feeling like what you’re getting right now with your current rehab is not serving you well, then we have a team of coaches who are dedicated to working with remote athletes. And if you need some help, please reach out. We love working with ACL athletes. We want to make sure that you guys are well taken care of and that there are resources just outside of your geography to help you on your ACL journey. Don’t let what’s down the road limit you from being able to make the most of this process. So that’s going to be it for today, guys. Thank you all so much for listening and also go and leave us a review because you know why. Just leave us a review as that will be so helpful. And please share it with anyone that you know who might be also dealing with a grumpy knee.

As always, I love you guys. Thank you guys. Thank you so much for the support and the ongoing messages. They mean the absolute world to me. And if there’s anything that I can help in supporting you in this journey, please reach out, Email, Instagram, carrier pigeon mail, whatever you want to do, send me a message. Until next time, this is your host, Ravi Patel, signing off.