Episode 8 | 8 Questions You Should Ask Your Surgeon Before ACL Surgery – Part 2

What’s up team, and welcome back to the ACL Athlete Podcast. So today we are talking about part two of the eight question series, what to ask your surgeon before ACL surgery. Now, the first part of this, I want to quickly sum up the first four questions that we covered last week, and then we’ll dive into the second half.

But before that, I just wanted to talk about a news highlight from this week. So there was a wrestler from Iowa. He’s in college wrestling, and Iowa’s a very big top school for wrestling and his name is Spencer Lee and he competed in the 125 weight class. And this kid won the national championship with no ACL and that is pretty mind blowing because you think about the sport of wrestling and how much pivoting and turning and moving around. But the craziest part is that he tore his ACL eight days before the final tournament, in the final match. He tore his previous ACL, I believe it was in high school, and then he had another injury in 2019.

But this guy was wrestling with no ACLs in his final match, and he won the national championship. Which is just insane, but it’s also really cool. And it goes to show now, he had a very unique situation. He was in the top tier. He was very time sensitive about where he was. And you know, in that situation you just kind of make a decision: do I do this or do I not?

And for him, you know, the risk was worth it and it paid. And in some other situations it might not have been. But all this to say, it can be done without an ACL. That’s the biggest take home here. And if it’s more time sensitive, then that’s something to consider. But even if it’s not, not having an ACL sometimes can be fine.

It just depends on the goals. Now he may end up having surgery. Just because of, you know, what he wants to do outside of just wrestling and then also for his life. So just something to consider, which will actually lead me into the first question we talked about last week, which was, do I need surgery?

And this again, is based on your goals. But it’s going to be very different for each person. The main thing that I want you to think about with this is there is a non-operative option that should be presented and that jumping to surgery, if there’s no time sensitivity and if you’re not trying to get back to something within a certain timeframe or you need it for the sport specifically, then that’s just something to.

Number two was what are my ACL graft options? And we broke those down into an autograft, which is taken from you, an allograft, which is taken from another person. And those can be quad, patella, hamstring. If it’s an allograft, it might end up being something of another tendon. And then moving into what graft do you do the most and how many per year?

So you want to know what’s in their wheelhouse. What do they like performing? And that’s most important because you want someone who has gotten reps with that. So when you ask how many have you done per year or you know, in this year or recently, that is something that can be of very good value because.

No one ever wants to be the first person. So if you can get that information, it’ll also give you more peace of mind. Number four, do I need physical therapy before surgery? And that’s something that we call prehab. And the answer should be, yes. Now, not everyone recommends it, and it depends on the timeframe and the process, but if there is the opportunity to do that, I would highly, highly, highly recommend it.

The research supports having prehab and helping restore knee function prior to surgery. It is very beneficial and I honestly think it should be required. So that is an important part of it. It helps you get acclimated to the process, and allows you to meet the physical therapist. You’ll work with some exercises to get that knee going.

You can hit the ground running as soon, okay well not literally, but you get started very quickly right after surgery because you’re familiar with the process. And I find with a lot of patients of mine that it really creates an ease of mind because they are familiar with everything rather than everything being so brand new after a surgery.

So those are the four questions. Now we’re gonna move into the second part of this where we’ll dive deeper into the second half of the questions. So number five, technically how long will I be in physical therapy after surgery? And it’s also important to maybe get an idea of what they recommend in terms of the number of times per week.

So some will say one time per week, some will say three times per week. Now a lot of this is going to be dictated by insurance, but you just want to get a general idea of what’s in their mind – Okay, maybe you’ll do physical therapy for three months, six months. Maybe they’ll say 12 months. Who knows?

And again, insurance will dictate that. But it’s something to, more than anything, get the expectation and understanding where the surgeon is coming from in terms of the value of physical therapy, which obviously I’m very biased, but a good surgeon will really value physical therapy, so it is a good way to get that frame of reference and understanding that point of view.And when you’re doing this, think about the prehab that will go into it. So maybe visits before the surgery, and then leading into the surgery and after. 

That leads into the next question, which is, what is my recovery timeline, return to sport? I think that this is the question that people ask the most.

I get that the most for sure, and the number that I want you to have in your head is nine, nine months. And if we look across the research right now, nine months is a very strong timeline and a criteria that is used to be able to clear people for sport. That does not necessarily mean that as soon as you hit nine months, you’re good to go.

It’s just what the research and data has supported to this point. Anything before that increases the risk of re-injury. So oftentimes what you will hear is six months and I don’t know where six months came from. I think it might be a mix of the research not evolving enough as well as it seems like a reasonable time from an injury to be able to kind of bounce back.

But we’re seeing that change, which is good, but we need more of it. But if you hear six months, the question needs to be, okay, if I’m cleared at six months and I’m looking at nine months as my return to full sport, being back on the field competing, how do I bridge that gap? What do I do there? And so one of the things you might say is, I have  X amount of visits for insurance, and it might be gone at that point.

So is there a program that you guys offer or recommend that I can follow to make sure that I am doing the right things. To make sure I recover appropriately. And you know, if that’s not available, then maybe they can connect you with a coach, maybe connect you with someone who can fulfill that gap to be able to get you to that point.

And I think that that’s really important with this. And probably what gets missed the most is that the normal process will end up being someone does physical therapy for three to four months, their insurance runs out and they do not get more and then they’re told, okay, now you can just go and be fine and merry and expect that, like the knee’s gonna recover.

But there’s not really much of a plan. I actually just talked to an athlete yesterday and she was cleared at four months and she was just given a pamphlet and was like, here you go. And has not been checked in on, and now she is nine, 10 months out and nowhere close to feeling confident, strong, or anything like.

So figuring out what that process looks like. So there is a plan, there is a roadmap for you to know, okay, I’m gonna do physical therapy for three to four months. My insurance visits might run out. Or maybe you spread it out to six months and then now you have this three month program that you get lined up with a coach, a performance coach, to be able to help you get to that final spot of sport.

So that is something that I would recommend if there’s nothing recommended by the surgeon or physical therapist, is to seek it out on your own Google search people nearby. You could always reach out to me. I can always see if there’s someone local to your area, if you wanna work with someone in person, but I think that this is a very big piece to this whole process.

So it’s, it’s definitely one of the things that I would recommend asking your surgeon. Next up is question number seven, which is what are my parameters for being cleared? And you want to know these answers because this is actually going to guide some of the things for your clearance. So a lot of times you’ll see your range of motion, your strength, the time, confidence. There are these different parameters that they’re looking at, and depending on the surgeon and how much testing that is available, they may end up doing a lot of return to sport testing, which is really cool, but you just don’t see that as often. And it just depends on the region you’re in and maybe even the belief in the surgeon and whether they think that these things are necessary.

What I will often hear from clients and patients in the past is, their strength will be tested with a hand, so whether that’s seated and kicking out into a hand, we call that an MMT, which is stands for a manual muscle test, and I wish that is another thing that could just kind of go away, but it’s something that is used to be able to know, okay, is a muscle even active?

But that’s pretty much it. Other than that, it doesn’t really tell you anything about strength or what level the person is. So if that’s the way that you’re getting cleared, then there needs to be something else attached to this, which will lead me into the final question. Is, do you do any objective strength testing now?

With everything with ACL and return to sport, if you’re talking about big buckets, strength is one of those that we see that just does not get attacked, and when the testing’s applied, you start to notice that there is a deficit on the injured side versus the non-injured side. Sometimes those numbers can even become even where both limbs end up being detrained, and that’s another situation where we can’t necessarily use the uninjured limb as a reference.

The biggest thing that you want to focus on with this is the goal of 90% side to side. And when you ask the surgeon about objective strength testing, typically that refers to utilizing a biodex or an isokinetic dynamometer, which is the gold standard to be able to figure out certain speeds and ranges and peak force, which gives you accurate output for strength and where you are at. So that would be one of my biggest pieces in terms of asking the objective strength testing and seeing if they have a Biodex or Isokinetic machine at the surgeon’s clinic. And if not asking them well, Is there a physical therapy clinic I can go to to test this? Is there a university? And a lot of times what you’ll find is that if there’s a nearby university and they have a kinesiology department, that you’ll often find an isokinetic machine there. So this is one of those things that you might have to seek out, especially depending on the geography that you’re in. 

There needs to be some type of objective measure, a number associated with your strength, your quad strength, your hamstring strength, because that is going to give you such a good outcome. If you’re talking about return to sport, using those to be able to adjust your training to make sure, you know, if strength is missing on one side, then being able to prioritize, okay, I need to do more quad specific strength work, so maybe leg extensions or some other type of quad strengthening that is going to help increase those numbers.

So that’s it everyone, for the eight questions to ask your surgeon before ACL surgery. Now reminder, being respectful, being genuinely curious to just hear out these answers and just know that. You don’t have to feel pressured that this is the only way to do it. And if your gut is telling you, let’s get a second opinion then get a second opinion. Even if someone were to come to me and say that as a medical professional, we have to be okay with that. And it’s okay to follow your gut on some of this stuff to make sure that you’re making the best choice for your current situation right now. So that’s it everyone for this episode.

As always, thank you all so much for being here and for your support. Have a great day, week, weekend whenever you’re listening to this. This is your host, Ravi Patel, signing off.