Timing of ACL surgery- is waiting beneficial?

Posted on August 7, 2015

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This started as a comment exchange from my post on mistakes ACL patients make.

“Hey Brian, I’m a few weeks from ACL reconstruction. Everyone’s told me the PT is the most important part of the recovery back to active sports (basketball for me), and I plan on following your manual and the physical therapist’s protocol to be in the best position for successful recovery.

I ruptured my ACL and had a complex tear of my meniscus during a non-contact incident on July 11th. I have spoken with a surgeon, reviewed my MRI results, and elected to get ACL reconstruction as I mentioned. One thing the surgeon brought up that didn’t come up during my research (and reading your site) was delaying surgery to allow the swelling to subside and to allow some of the injuries in my knee to heal. My surgeon said that doing the surgery too soon after the injury could result in a the leg becoming stiff preventing proper rehabilitation.

My surgeon suggested 6 weeks from the date of the injury to conduct the operation. My surgeon brought up the anecdote that many surgeons who live near ski resorts will operate right after the patient has injured their knee on the slopes just because they know the patient is emotionally unstable and wants the operation done quickly. The surgeon said her colleagues who are smart and understand the “science” will tell the patients to go home, wait 6 weeks, and then have the surgery.

What are your thoughts about the timeline for surgery with regards to the stiff leg that could result from getting surgery too soon?”

Beyond specific cases, I’m unaware of anything where waiting is beneficial. This excludes those who wait, who may decide to never bother with surgery at all. Where they may achieve “good enough” without bothering with surgery. This is where you can make an argument everyday people should always wait. (Some research looking at this- http://www.bmj.com/content/346/bmj.f232.) What we’re aiming more at here is surgery is happening, should you wait to help the outcome of surgery?

James Andrews is about as good as I know of when it comes to this world. If he’s operating on Adrian Peterson five days after he tore his ACL, I doubt there is any benefit in waiting.

While elite athletes and those around them aren’t always doing what’s best, at times seemingly adhering to advice from the Jane Austen era (see herehere and here), I find it highly unlikely they know waiting ~six weeks is better for their multimillion dollar athletes, yet they aren’t doing it. Or that they don’t know this.

Yes, they want to get people back on the field / court as quickly as possible, but they also want to get them back as good as possible. With ACL surgery, you’re already acknowledging waiting at least nine months, with an understanding most will never be the same. An extra six weeks isn’t that big of a deal. The Chicago Bulls were willing to wait like 18 months for Derek Rose. Part of me believes this was so he could suffocate the internet with Powerade and Adidas ads, but it’s probably because they wanted him back, but they didn’t want a lesser version of him back.

  1. Get the athlete back at nine months, but performance will be better if we
  2. Get the athlete back at 10.5 months

Other than if the Super Bowl happens between 9 and 10.5 months, most will gladly wait. If it’s baseball, you’ll wait nearly forever, since their season goes on even longer than that.

There is this notion the better you go into surgery, the better you tend to come out, and it’s a true one. If you’re an athletic person though, and most who tear their ACL are, you’re probably already going into surgery well. You probably already have strong musculature, good range of motion, good proprioception, etc. (Baseball players excluded, as they often tear their ACL from their biggest hazard of a sprinkler.)

HUGE CAVEAT: I know there is research such as this, which has found waiting to be beneficial. (There’s also this review which didn’t find the same thing.)

What I believe happens here is you have those who get injured, who don’t do anything for a week or two, then get surgery, then don’t do anything for another week or two, then start rehab. Basically, they’re starting rehab a month post-injury. Not only that, they’ve barely moved their leg in a month. That’s a very bad start to this process.

Contrasted with those who get injured, don’t do anything for a week or two, spend a week or two prehabbing for surgery, get surgery, already have a good sense of what to do, so they start their rehab on a better note. Or this group gets injured, spends a week or two not doing much, then they feel better so naturally they move around more for a week or two, then they get surgery.

Either way, the second group doesn’t have as extensive a period of minimal motion. By a couple weeks, they’re moving a good amount again. Whereas the first group, after a couple weeks, they just had surgery, so they still aren’t moving for another couple weeks.

-> Said another way, it’s better to not move for ~two weeks, then move for two weeks, then not move for two weeks (six weeks total), then it is to not move for six weeks, then move again. (None of this is ideal though.)

Where the conclusion ends up being those who wait do better, but that’s only due to the context. It doesn’t technically mean waiting is better.

Hence, even in the abstract of the study I linked (bolding mine)-

“However, only a small number of cases (approximately 4%) of Group II patients who followed an accelerated postoperative rehabilitation program had any arthrofibrosis—an observation we also made in the Group III patients. The evidence suggests that delaying reconstructive surgery at least 3 weeks from time of acute ACL injury will result in earlier return of strength and, more importantly, a significantly decreased incidence of arthrofibrosis.”

If you start the rehab solidly, *right* out of the gate, then that benefit goes away. Which ties into the ACL mistakes article. I mentioned a huge mistake is postponing physical therapy. That rehab starts the moment you wake up from surgery.

Actually, it starts the moment you get injured.

Which is why you see people like the Andrews group not wait. They’re notorious for starting rehab immediately.

(As a random tangent, we’re finding he same types of things with other injuries, like the lower back. The worst thing to do is go lay down a few days, or a couple weeks. The best thing to do may be counterintuitive to some: You hurt your back, you get moving as much as reasonable immediately.)

“Thanks for the detailed response, Brian. I understand your logic behind Adrian Peterson, and this is one of the cases where I questioned my surgeon on the delay to get surgery to optimize results. At the same time, Peterson’s body and musculature is drastically different from mine and most average athletes which could impact healing and recovery time (I’m just hypothesizing here).

Regarding the study you referenced, it sounds like there is not enough information about what the individuals in the study did in between their injury date and their surgery date. I didn’t read the full study but perhaps the activity of the specimens prior to surgery in the two groups was not controlled thus impacting the conclusion. Sounds like there needs to be a follow up study on how much motion and activity before surgery (and the first week or two following surgery) impacts results.

In terms of prehab, what general exercises would you recommend? I’ve been doing a stationary bike to maintain muscle and for basic cardio, but curious as to which exercises are good and which ones to avoid. I tried doing some air squats and found that really irritated my knee so I’ve avoided that exercise for strengthening my quads/glutes.”

Adrian Peterson, and athletes of his kind, having some enhanced healing ability is a myth. I cover that, and him extensively, here. I understand the caution against using high level athletes as a comparison, but healing wise, biologically, the comparison is ok. (The resources they have at their disposal is a different argument.)

Also, it’s not like any of us are going to approach Adrian Peterson’s fitness by waiting six weeks, or six years. The idea is if a person is athletically inclined (I’m talking intense sports here, not the weekly beer league), however they were before surgery is probably as good as they’re going to be before surgery; not as good as a human can be. That a week later versus six weeks later, not much is likely to change. You’re probably not much stronger, have much more muscle, have much more range of motion, or need to lose much weight. If you’re the rarer case of a person who hasn’t exercised in two decades, who stepped awkwardly one day and blew their knee out, then six weeks of solid exercise may be quite appropriate. This is the person who should highly question if surgery is even worth it though.

As an athlete, if you wait six weeks, your athleticism is going to fall off. You can’t maintain the same level of training intensity immediately post injury that you had pre injury. Lesser training intensity likely means lesser performance. e.g. Lift less weight -> have less strength. Meaning you now have to overcome this in the rehabilitation phase. e.g. It’s better to start serious strength training again in three months, rather than three months + the 6 weeks you prehabbed.

By the same token, what benefit would there be in waiting? Say you just tore your ACL-

  • You’re going to have some swelling and pain for perhaps a few days
  • That bottle of liquor you’ve been saving for a special occasion is getting opened. If it’s whiskey you’ll feel better; if it’s tequila you’re sinning.
  • Because of the swelling, some quadricep activation is probably a good idea, to make sure it doesn’t become too inhibited. You can restore that within hours of the injury. Or, never lose it to begin with.

  • Some loss of ROM may happen as well. The extension loss can be restored the day of injury. The flexion ROM can take some time, depending on the swelling. You have to have a “my knee is pregnant” type of swelling to not be able to hit 90 degrees though.

Regarding the flexion ROM. Here are likely options-

  • Say it takes maybe a month or so to restore it fully. Then you get surgery, only to lose it again, and have it take months to restore it again.
  • You have the surgery immediately, with less than full ROM, and then you restore it fully months after surgery.

There’s no benefit in the first option above. Restoring full flexion ROM with the subsequent endeavor of losing it again, doesn’t benefit anything. In totality, with the first option, you’d actually end up with more weeks of less than full ROM than if you had surgery immediately. For example,

1) ~3.9 weeks without full ROM -> have surgery -> ~months without full ROM = ~3.9 weeks +~months

2) ~1 week without full ROM -> have surgery -> ~months without full ROM = ~1 week + ~months

-> I know I said above not moving, then moving, then not moving, is better than not moving for a longer period, then moving again. With the above though, we are moving in week 1. So flexion is going to be restored to a significant degree by week 1. It’s just that getting full flexion may not happen. Where then that extra few weeks or so to get a few extra degrees of flexion isn’t going to be beneficial longterm. (The reason post-OP you can’t as easily restore flexion ROM is due to fear of stretching out the graft. Which is why it can take months and months.)

The other way to view this is if you’re a person who, before you tore your ACL, knows you are going to get ACL surgery regardless. This is the high level athlete again, who knows if they tear their ACL, surgery is happening. (If you’re in college or a professional, you may not even really have a choice.) In that case, there is no point in waiting beyond a few days. You’re only delaying the inevitable.

I think what you’re getting at is more a relative instance. Where the above is not the typical person. The typical person may not even realize they’ve torn their ACL until a few months have gone by. That’s a different case, and really a different question. “Is waiting beneficial?” versus “Should I wait?” In absolute terms, the answer is Caribbean clear. In relative terms, it’s New Jersey murky.

That said, once one discovers the ACL is torn and have made the decision to have surgery, it really doesn’t take long to acquire solid range of motion (minimize fluid accumulation) and decent quad strength, unless you’re someone who has really been doing something detrimental post-injury.

If you have your act together, within a week you can be mentally prepped as well. Although, having a good team around you is very helpful here. Those who will take the time to really delineate what’s going on, what’s about to happen, what rehab consists of, expectations, etc. (Random note- there is some evidence the more prepared people are for a surgery, the less pain they have afterwards.) For the everyday person, it’s probably going to take a few weeks at least to garner all this information.

The other factor here is if you’re obese. If you have a significant amount of weight to lose, then you may have other priorities to begin with. Post-op, like getting around on crutches, when obese, is hell.

-> If you’re athletically inclined and have weight to lose, and you know you’re going to get the surgery, then waiting is still unlikely worth it. Using athletes again, you don’t see defensive lineman wait a year to lose weight, then get surgery. They need to be Big Poppa’s -they need to weigh what they do- and they can’t spend multiple years recovering. (Most will be cut if they took that route.) Plus, despite their obesity, they have the strength where crutching and such won’t be too bad.

But there’s no single answer with the everyday person. I discuss this when having to confront ACL surgery in conjunction with an upcoming wedding. For many, they are going to need to have their life in order before they can undertake this process. This is where we again start realizing recovery from ACL injury is more like a two year process.

As far as the research, I wasn’t linking that to delineate what’s best. We know what’s best, at least we know what’s worked best so far, and it’s an aggressive approach. (I give an example of what’s aggressive below.) One in which rehab starts immediately. There are few things which are black and white when it comes to human health, this is one of them.

-> Most things with the body can be reversed. It’s rare a few weeks, or something of that sort, can have such a lasting impact. Eat crappy for a few weeks and it’s no big deal. A few weeks the opposite way, if that, and you’re back on track. Don’t exercise a few weeks and no big deal. Exercise a few weeks, if that, and you’re right back to where you were. Why is something like this ACL business different? Where it’s more like you didn’t see the sun while in Vegas for a few days; you get home and realize piecing your life back together may take some time, if ever.

This is more a theoretical discussion, but I like to think of it this as there are events which happen to the body which more readily stick with the body. These events tend to be highly traumatic, where hormonal responses run wild. Near death experiences stay with people, even if they only lasted a second. You may have been perfectly safe for 25 years, or ~788 million seconds, but one second of hell can overwhelm that. You may have driven for decades without issues, but that one single car accident may forever terrify you of driving. It can take months to years to grow significant amounts of bone from a particular activity, like weight-training. But you can grow bone, and keep it forever, after dislocating your finger (very brief, yet traumatic, activity), like has happened to me:

Formerly dislocated on right.

Formerly dislocated on right.

Tearing your ACL, and reconstructive ACL surgery, can be a highly traumatic event for people. For some, it will, bar none, be the worst experience of their lives. That type of shit sticks with you, and when you’re in the midst of it, the adaptations occurring can subsequently stick with you too.

If right after surgery you are terrified, and decide to be as safe as possible and do nothing for a few weeks, that might stick with you for a very long time, and or be very hard to reverse. If after the injury and the surgery you play it this way, that’s an even stronger message to the body, “this was bad. From here on out, we will be very cautious ambulating.”

You all of a sudden week four, or week eight, post-op, realize you want to move your leg like you used to. But your body says “fuck you, the last time we really moved our leg the entire thing went numb, we cried, we screamed from the incomparable rushing of pain to our leg, we decided God doesn’t exist as he would never do this to someone, we went to the hospital, we had to lay in that crazy claustrophobic tunnel-like machine, we were hit hard financially, multiple knives and power drills were put through our body, we were put on so may drugs we actually saw God, we were handicapped, didn’t shower for weeks, acquired a small addiction to pain killers, decided God does exist and we’ll pray to him to help…No, let’s keep that leg right where it is. Having a stiff leg right now isn’t great, but it’s better than risking that god damn tornado of hell reoccurring. kthanksbye.”

(This is again where things like throwing out your lower back are similar. What do many people do after hurting their back? Not move for a period of time. We’re finding more and more this can be a factor in the transition from acute to chronic pain. The BodyInMind group has a lot on this, and I’ve seen it with clients. The recovery differences between those who throw their back out, yet are in the gym the next day doing what they can, versus those who take a couple weeks off, is very different. The first group recovers much quicker.)

In terms of what I recommend pre-op, it’s the same as what I recommend immediately post-op. I cover that thoroughly in my ACL manual. If you’re wondering “What’s an aggressive approach?” this is an example of one.

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