It’s been almost two years since I had reconstructive ACL surgery. Between personal experience, those I’ve worked with, the emails and comments I’ve received, a few patterns have emerged as to what mistakes I see people making.
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Lack of mental preparation
Far and away the most common thing I get from people, post surgery, is “Oh my god! This is so bad! Is this normal? I’m so miserable. I can’t do anything. The pain is unbearable. I can’t bend my knee, my muscles are disappearing; I’m so depressed.”
I don’t expect everyone to do the amount of research I did for this. I spent over 3 months reading everything I could, talking to people and writing about things. However, if you do even a modicum of research on this topic, you should learn pretty damn quickly it’s normal to:
- Not just be down, but to be incredibly depressed after this surgery
- Not be able to do anything
- Need someone around you for a while after the surgery. I don’t mean a few hours, I mean like a couple weeks.
- Be in extraordinary pain
- Be on so many drugs you can’t see or think
- Be crying
Part of this is definitely the surgeons fault. I don’t know if it’s because the surgeons don’t want people to know how bad things are, or because they become jaded after doing so many surgeries, either way, they do a horrible job preparing people for what this surgery entails. One of the surgeons I saw sent me to his receptionist to schedule surgery without even discussing what the surgery was. I mean nothing was discussed. Not what’s an ACL, why I might need it, the length of rehab, invasiveness of surgery, time off work, NOTHING. Yes, I knew all these things already, but he didn’t know I knew them.
He didn’t even bring up the option of not having surgery. Or the fact I’d be denied health insurance in the future because of having it. If not for the law changes coming in 2014, for the rest of my life I would have severe health insurance issues because of this injury. The insurance companies take this incredibly seriously, so should you.
Part of me gets the lack of understanding; part of me doesn’t comprehend how people don’t understand a power drill will be put through their bones. Look at your leg, imagine a power drill being put through it. Is it really that hard to understand how you’re going to feel after this? “Waa, I can’t bend my leg, waa, this hurts.” No shit, a POWER DRILL was just put through it.
I’m not sure how else to get this across. My only other way is all the people I know who’ve had this done have another big theme to them. Their ACL experience is one of, if not the, worst experience of their lives. Since people love to look to athletes with this stuff, Derek Rose has said his ACL experience is the closest to death he’s ever been, and Wes Welker said he wouldn’t wish his experience even on his worst enemy. Keep in mind these are guys who are, for the most part, ACL success stories! They’re the outliers, and they still had awful times.
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Unrealistic expectations
This goes right with lack of mental preparation. If you even only briefly look around you’ll quickly find how many people are never the same again after this injury. Too many expect to have this surgery and be good as new. The fact of the matter is your leg will never be “normal” again. To reiterate, multiple holes will be drilled through your body, more than likely one of your tendons will be cut apart, it will then be either sewed back together or you’ll hope it grows back, the part of the tendon which was cut off will be screwed into your bones, one or two screws will likely be left in your body, and that tendon will hopefully turn into a ligament with time. Your leg will never feel normal again because it will never be normal again. It has been forever changed.
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That doesn’t mean you’re forever resigned to pain. You can not be in pain but have a leg that just feels weird at times. If you haven’t had surgery, this probably doesn’t resonate. For those who have though, they know exactly what I’m saying. Whether it’s their knee feels weird, it makes odd sounds, the screw moves around, whatever, there is almost always something odd remaining long after the surgery.
“But I’ll be different.”
In Thinking, Fast and Slow, Daniel Kahneman references a time in his younger days when he and some colleagues were writing a textbook. They were projecting how long the book would take and their chances of actually completing it. They pretty much all thought it would be completed, and in about two years.
Kahneman then asks the one colleague who has worked with others who’ve made a textbook, “How many of them actually finished?” The colleague was a bit embarrassed. “Maybe 40%” “And how long did it take those who finished to complete their work?” The colleague was now even more embarrassed. “I’d say the average was about 7 years.”
Kahneman refers to this as the inside and outside view. When you’re on the inside -you’re the person getting the surgery- you think the odds don’t matter for you, or that you’ll beat them. You don’t want to hear that 65% of ACL patients never return to their previous activity level. And even if you do hear it, you’re not listening, or you think you know something they all didn’t. Rather than consider the endless list of NFL players who never made it back after tearing their ACL, you instead focus on Adrian Peterson.
It’s not only a physical game; it’s a mental one too. This is what a lot of people miss when trying to come back from this. It’s not just the being able to come back physically, it’s the mental aspect. You very well could get your leg back to its former strength, have no pain, no setbacks, etc. But, you may end up thinking, “I don’t care. I don’t want to go through that again.” Honestly, that’s where I am. I was cleared at 9 months -exactly on time, had no setbacks, went out and played some sports, proved to myself I could do the entire process, then said “I’m done with this shit.” I don’t want to go through all that again. If I (or you) was a million dollar athlete I’m sure my mentality could change, but I’m not. I don’t want to do anything which could increase my chances of going through that whole process again. Physically, I’m able to go back to my previous activity level. Mentally, I’m not.
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Focusing too much on former patient’s experience
Asking those who’ve also had an ACL reconstruction can be productive, but you don’t want to rely on other people’s recounts as you’re only information.
1) Every case is different.
It’s unlikely you’re going to be able to run into someone who is having the exact same surgery as you. Here was my full surgery: Reconstructive ACL surgery with a hamstring autograft, medial meniscal repair, partial lateral menisectomy. Every word of that affects the rehab. Unless you’re talking to a person with the same procedure as you, you’re likely going to have different experiences.
2) Your sample size is too small
ACL surgery isn’t that common. So, you may only have one or two people you know who’ve also had this done. Even if you go online and read 20 different accounts, it’s still a small sample size.
That can greatly skew your perception of what this all entails. Using me as another example: I had basically no pain after my surgery. I have a couple ideas as to why, but regardless, pretty much no pain. This is an aberration. To illustrate how much pain is expected post-op my surgeon prescribed me 80 pills of percocet, all at double dosage (because I’m very tall). He told my dad, “Call me if he needs more.” That’s an insane amount of pills. How many did I take? One, which was the night of the surgery. I only took that because I was afraid a huge flow of pain was about to set in, and I didn’t want to wake up in the middle of the night when it happened.
If you’re someone using me as your reference point for pain after ACL reconstruction, you’re in for a rude awakening when you come out from your anesthesia and realize I was an outlier.
3) You don’t want to put all your faith in people’s memories
Since I brought up Daniel Kahneman, I’ll keep that theme. Kahneman has done some research on our perceptions of how painful an experience was. What’s been found is we remember pain by 1) How intense it was and 2) How it ended. Number 2 is what’s important here.
Tying this to ACL stuff: The worst part of ACL surgery is the beginning. As the process goes on, it normally gets better. You’re more likely to ask fellow ACL patients their experience not right after their surgery, but fairly far out from it. Said another way: You’re more likely to get someone’s recount a year, two, or three years after their surgery, rather than 2 weeks post-op.
Their answer is not only going to reflect things in the early stages, but also how they’ve felt recently. Plus, their recent memories are more available than their older ones. Since people tend to feel better a year, two, or three years after their surgery rather than at two weeks, they tend to mix how they currently feel with how they felt immediately post-up.
Say your friend Jon had ACL surgery. He was a mess immediately post-op, but now at 3 years post op he’s pretty good. He’s not amazing, but he can’t complain too much. You run into Jon, tell him about your current ACL issues, how you’re contemplating surgery, and what’s his advice. How did things go for him? Would he recommend it?
Because Jon feels pretty good now his first response is, “You know, it wasn’t that bad. Not the best time, but I’m pretty good now.” However, if you were next to Jon the day after he woke up and ask him how he was feeling, his response would be, “MAKE IT STOP!”
I have a client Dan who has had upwards of 10 leg surgeries, one of which was an ACL. Dan recently decided to have another leg operation. He came in about a week afterwards. “You know, every time I do this I swear I’m never getting another one. It’s like I forget how bad things are after these things. Then, once I get it done again, it all comes roaring back.”
Me: “It’s like a really bad hangover. You swear you’ll never drink again, but next thing you know it’s Saturday night.”
A much better way of learning what ACL surgery is like is not only to ask former patients, but ask those who were around them right afterwards. If Jon’s dad was his primary caretaker, ask dad what the experience was like. They’ll almost assuredly give you a more accurate description.
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Postponing physical therapy
Many years ago it was common practice after surgery to put the person on bed rest. With leg stuff you’d often be casted up for at least a month and pretty much couldn’t use the leg. Scientifically, those days are gone. We now know this is a terrible way of approaching the post-op period. The longer you don’t use the muscles the quicker and more they atrophy. You increase the person’s risk of blood clots. You also make the physical therapy phase harder as the person is starting from further behind.
Scientifically, those days are gone; realistically, too many still lay around for weeks before doing anything. If there is anything to be learned from athletes in this realm it is that physical therapy after reconstructive ACL surgery does not start a week or two weeks after the surgery, it starts the day of surgery.
There is no reason to wait. You can’t do much right after surgery, but that doesn’t mean you can’t do anything. You can mobilize the patella, wrap the leg, squeeze the quad to make sure it stays awake, as well as work on your range of motion.
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Obsessing over flexion instead of extension
If you read the comments of this post: Reconstructive ACL and meniscus repair surgery: Physical therapy days 2-11, which is about my experience, you’ll see over and over people fresh out of surgery going nuts about their lack of ability to bend their knee.
Again and again I respond, “Stop worrying about bending your knee, start worrying more about straightening it!”
I think why this happens is after surgery you may lose 10-20 degrees of extension, but 100-120 degrees of flexion. So, to the person, in their mind it’s like, “Holy fuck! I can’t bend my leg at all!” This is normal. The flexion will come with time, and there’s really no need to rush it. In fact, you need to be careful not to push it too much too soon as that can stretch the graft out. Mechanically, especially in the beginning, you will only be able to flex your knee so much anyways, due to the swelling. It’s going to take some time for all the fluid to get out of there.
Extension on the other hand, you need worry about immediately. First, there is no reason to not get all the extension back right away. By this I mean the day of surgery. You don’t have to worry about stretching the graft out with extension. Second, extension is much easier to lose in the long run. Personally, I needed to check my extension multiple times per day. And for about 6 weeks, everyday, I’d gain it back only to lose it again a couple hours later. Third, the longer you go without getting it and keeping it, the more likely you are to never get it back again. All the time I see people with a knee surgery history who years later still can’t fully straighten / hyperextend their knee.
The other thing here is returning to walking. It’s ok if you can’t bend your knee to 120 degrees, or hell even 90 degrees, that’s not going to affect walking. However, if you can’t fully straighten your knee, that’s a really bad knee to be walking on. You end up walking on a bent knee all the time, which beats the hell out of your joint. So, working on full extension helps get you back to healthier walking while obsessing over bending your knee does not. There is a progression here, and the ability to walk again is very high on the hierarchy. Certainly much higher than bending your leg.
Full, complete flexion will take months and months, and that’s ok. Stop worrying so much about it.
Which brings us full circle: If you only do even a bit of preparation, you should know not to bend your leg too soon, that you won’t be able to bend your leg, that you should be extending it, that you’re going to have a lot of pain and discomfort, etc. Just a couple questions to the surgeon will let you know this.
This often ends up being a $50,000 surgery, with power drills, screws, knives, hours of anesthesia, high level pain killers, a significant degree of short term disability, minimum 6-9 months of physical therapy, you get the idea.
For Christ’s sake do your homework.
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For more information on what to do coming out of ACL surgery, or if you’re someone who needs to take a step back and reboot the process, check out my manual The most important phase of ACL rehab. Click link for more info, or click below to purchase
For those looking to get things really dialed in, check out An underappreciated aspect of ACL rehab and prevention. Click link for more info, or click below to purchase
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-Update 9/3/15- Posted the following comment:
Hey Everyone,
I wanted to let you know I put together a manual specifically for regaining knee extension.
You can see more about it and get it here: http://b-reddy.org/2015/09/03/help-i-cant-straighten-my-knee/
I also wrote something detailing why regaining extension range of motion quickly is so important: http://b-reddy.org/2015/09/03/why-you-dont-want-to-wait-to-regain-knee-extension-range-of-motion/
I cover extension ROM fairly thoroughly in the ACL manual, but this is more extensive than before. Also, some have asked me, “I’m more than a month out, will your ACL manual still apply?” While the answer to that is usually yes, now I have the extension manual for those are only specifically looking at that.
Hope this helps!
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-Update 11/16/15
Another post on the importance of regaining knee extension range of motion, and why you don’t want to wait to do it: http://b-reddy.org/2015/11/16/how-weak-calves-can-cause-knee-issues/
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Post-script (Update 7/1/15)
After receiving many comments on this post, I left this comment:
Dear All,
Understand this coming from a place of wanting to see people do this process better. It is not meant to be judgment, or beratement.
I’m not sure what’s going on the last week or two, but some themes that keep coming up:
1) There seems to be an overall lack of acknowledgment about how long a process this is. Many of you have probably heard “6-9 months,” which is one reason I didn’t hit on this in the article. I assumed it’d be rare to to complain about progress at 2-3 months, as it ignores the fact you have, at least, *double* that amount of time to go. But I’m seeing this more than I thought.
Plus, in reality, this is an 18-24 month process. The 6-9 month mark is more, “Yeah, I’m running again, have full ROM, no issues with walking…but it’s not like I’m playing sports without worrying about it.” FULL recovery is upwards of two years, *IF EVER.*
2) There is either a lack of reading before commenting, or a degree of denial. Because either people aren’t reading the section on “Obsessing over flexion over extension,” or they want to ignore it. So many comments here are about lack of ability to bend the knee. At 2-3 months of all things!
Part of me thinks I need to write a sequel to this post. The other part of me thinks people need to read the following paragraph from the post until it really sinks in:
“Full, complete flexion will take months and months, and that’s ok. Stop worrying so much about it.”
I made two sentences its own paragraph specifically so it would stand out. “Months and months” is not one, two, or three months. It’s MONTH*S* and MONTH*S*.
I understand this is a traumatic time for many who come across this article. But I, nor anyone, can propel your physiology into a different state. It sucks an injury from perhaps out of nowhere, can jack your mind and life up so much, but it is reality.
And if you’ve chosen the path of surgery, you’ve chosen a very, very brutal, long, tedious, depressing, handicapped, lonely, path. One in which there are no guarantees you come out better for having it. You very well could come out worse.
Much like we all degenerate with age, and need to accept it at some point or live in delusion, there are realities to tearing your ACL we all need to accept. The first step to getting over any problem is full acknowledgment of the reality of the problem. I promise many of you, if you get to this point sooner, a sense of relief will come over you.
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Laura
November 10, 2016
I’ve read this article every single day before my surgery and post-op. I want to thank you for your insight and brutal honesty with this. I’ve sent this all that have taken care of me during these past few post-op weeks, to help them gain insight into why I have been hitting rock bottom days. I have a single stitch in my medial meniscus which set me back from walking and/or range of motion for 6 weeks. The day I found that out was fucking miserable, and my family, boyfriend, and friends all tried to be positive, “it’s only temporary! You’ll have great triceps, you’ll be walking before you know it” which was appreciated, but this article nails it. Some of my darkest days have been because of my left knee. That bastard. Every day is a new day to loosen up the stiffness that settled in overnight, and isn’t guaranteed to go away even with hours of patella mobilization, quad sets, passive ROM. It’s an absurdly ridiculous journey to be forced on, but I am very grateful I found this article as my research guide. Thank you from one ACL to the other.
reddyb
November 11, 2016
You’re welcome, and thank you for sharing.
This is how I felt. It does get better if you keep at it. Around 8 weeks I noticed I didn’t have to be as tedious with it all. That finally the leg said “Ok, we’ll stop being a bitch. Somewhat.” Then gradually it was like I wore it down. “Ok, ok, fine. We’ll really stop this time.”
Keep going!
Laura
February 20, 2017
I am about 4 months post op and having to go under again on March 6 for manipulation 😐 1-8% of all ACL patients hit this obstacle, but hopefully after the procedure I’m able to start gaining full ROM easier!!! It sure has been a BITCH in PT trying to bend.
reddyb
February 21, 2017
Sorry to hear that Laura. Hope the manipulation does the trick for you. Some people do just stiffen up like crazy, as you hit on.
Good luck!
Joe
November 15, 2016
Hi Laura,
I also had complete ACL and meniscus tear. I’m 4 weeks out now and still on crutches. ROM is only a bit past 90 but its a STIFF 90. I’m not sure how far along you are but was wondering what your ROM was and how it went. Early on they forced my ROM to about 80 degrees and it was hell. As in I was screaming begging them to stop and cursing a bit. It’s been better since then but that was by far the most pain I’ve felt. Worried going from 90 to 140 will feel like that and not looking forward to it.
Hope your recovery is going well! At times I feel like asking for a stump and calling it a day.. That may be exaggerating but sadly its not as much of one as it should be.
Thanks for your time
Joe
Joe
November 15, 2016
I had a complete ACL tear and meniscus tear 6 weeks ago. I had surgery a little over 4 weeks ago. ROM has been a pain. I can barely get it past 90 degrees (although I was told not to go much past 90 until I clear 6 weeks and get the ok from surgeon concerning meniscus). When I do get it past 90 its basically forced and when it’s bent for a while it takes a little while to get it flat. Just seems very stiff. I feel like going from 90 to 140ish range of motion is going to be torture if its even able to bend much past 90.
PT guy said its not usual for it to be so stiff getting to 90 at this point and that it’ll be a long road ahead.
I was curious if 4 weeks post surgery if significant stiffness is normal or is it a realistic possibility I wont be able to walk normally or jog/run. I injured it playing basketball and am 36 so I’m just calling it a day playing basketball. Unfortunately I was in the worst shape of my life when it happened and it took a while to get the quad to start coming back. I’m still on crutches although Im putting more pressure on my right knee when walking with them and the brace.
Also after surgery (first 2 weeks) I was told to bend knee until i felt resistance and hold for 10 seconds. Went to therapy and the range was awful so they forced it to bend to around 80 degrees and that was brutal. I didnt think my knee could feel that much pain, it felt like my leg was going to jump out of my skin. Hoping to avoid that type of feeling getting from 90 to 140 ROM. Currently I sit on edge of table and use other leg to help knee bend to just a bit past 90.
Any advice heading forward? I know I’m a little behind schedule I’m just worried about ROM and if I’ll ever be able to return to normal/at least jog from time to time.
Sorry for the rambling and poor sentences, frustrated from PT earlier today. It takes everything I have not to start beating on my knee out of frustration.
reddyb
November 18, 2016
Hey Joe,
Walking should be going well by four weeks. Might not feel completely normal, but it should look normal, not be painful (barring being on the legs for hours and hours), and ROM should easily be good enough to do it. (Extension ROM is crucial here, not flexion.) If you’re having issues walking, this would be my first concern.
There are a lot of comments here about regaining flexion range of motion (can search the page for flexion), as well as even more details in the ACL manual (https://b-reddy.org/2014/04/02/the-most-important-phase-of-acl-rehab-copy/) , and you can look at my ACL diary (scroll down https://b-reddy.org/category/anterior-cruciate-ligament-acl/rehab/ ). Things such as forcing ROM are addressed- you don’t want to force tissue to relax. You want to relax your way into getting it to relax.
Kim
November 27, 2016
I passed a year post surgery on Oct 29th and I am finally feeling pretty normal. I have a clicking in my knee when I walk sometimes, it recently stopped but then came back Thursday when Thanksgiving night black friday shopping. I stopped PT for my knee early ( after a few months) because I had a car accident two months after my surgery and had so much back and neck pain that my knee became secondary. I am sure it set me back on my progress but shit happens. lol I have since had two back epidurals, trying to handle the back pain, but my knee feels good. I am, just now, able to squat down and kneel. Those were probably the biggest challenges after walking down the stairs. I do not run, but I didn’t run before. I am definitely taking it easier exercise wise since my surgery because I am afraid to go through that again. It was a big deal. I did it so I would be able to return to normal activities but now I am scared to do things lol. I used to ski, I may never again because I don’t want to go through a year healing again. I am happy to report that I feel like it was successful 🙂
Shelly
November 28, 2016
I totally agree.. I did the surgery to be able to ski again but don’t think I’d want to risk going thru this again. I’m 1 year & 9 mo post surgery & now all of a sudden my knee will lock extended, won’t bend, & it won’t fully extend. It’s like I’m going backwards.. maybe scar tissue build up (?)
I’m so over this!
reddyb
November 29, 2016
Hey Kim,
Thanks for sharing your update. That’s tough mixing the car accident into things, but like you said, shit does happen!
That fear you have is normal. Pretty much everybody experiences it to some degree. Personally, I was good at about 9 months, returned to some activity, then actually had more fear years 2-4, to where then it really subsided and is now an afterthought. But still a thought :).
Kim
November 27, 2016
Oh btw, Mine was my own hamstring graft ACL Reconstruction.
gboller2014
November 28, 2016
At 26 weeks post-op, sporting my newly fitted, custom ACL brace, I was working “progressives” (sprints, laterals, and reverses) during PT, and felt the dread pop in my hamstring during a reverse. Yep, proximal hamstring tear. Damn! This will set me back a bit on the rehab (probably 4 weeks). Wanted to share this event because I think it’s important to caution against pushing too hard, even at six months out. And I was pushing too hard; this one is on me, not my PT program. I have been over-anxious and over-ambitious throughout the rehab process. And at 56 years of age, I definitely need to re-scale my expectations. “Patience grasshopper.” An apt line I remember from a 70s show I used to watch.
reddyb
November 29, 2016
Sorry to hear about the hamstring, but appreciate you sharing.
I’d give any tear longer than four weeks!
gboller2014
November 30, 2016
Shout out to my doc for prescribing the Diclofenac Sodium gel — that stuff is the bomb! Knocks out the pain in the hamstring almost immediately!
reddyb
December 2, 2016
Thanks for sharing. Always nice to know alternatives to opiates!
John
November 28, 2016
What are your thoughts on stem cell therapy for knee?
Joshua Schoenberger
December 16, 2016
I’ve had this surgery and am playing college soccer sooo there’s hope for those of you that lost it reading the first couple paragraphs lol. I now have to get the other acl done, but as long as you work your as off as, I plan to do and listen to the physical therapist you will be fine! Don’t give upeople on what you love, it’s just a minor set back. A year or two out of your life is small, stay confident, focused and get through it! Goodluck to everyone going through this. I feel your pain.
Murad
January 5, 2017
I’m one month post surgery. Patellar autograft because I have had recurrent tears/weakness/scarring with my hamstrings in the injured leg.
Hx: 46 yr old male.
Nov 1989 Tore MCL (40%) when I was 18 playing soccer. Walked to the train station, up two flights of steps then from station 1km home. Leg put in cast for 8 weeks, back playing after ten.
Oct 2010 had arthroscopy to have meniscus cleaned up because it was so ragged. Was able to go back to work within a week and back running/playing soccer/cycling within two months.
April 2016, guy kicked me in the same knee this time full ACL tear, partial MCl tear, no meniscus left. Leg was unstable (like it was a bag of marbles). Went to work the next day, was sent home and told I could not work. Descended into full blown depression/anxiety. I work as a psych nurse and often have to grapple with patients, some of whom have been using ice/meth etc. Have not been allowed to work on the ward since.
Dec 2016 Successful surgery.
Recovery has been slower than I’d hoped. My calf muscle and ankle looked and felt like I had been attacked by some vicious Oompa-Loompahs. The pain was oxycodone worthy for the first month. Sleeping was impossible. Persisted though and have managed 0 degrees extension and 110 flexion on a good day after warm ups. Walking is tricky still. (One crutch at home/ two out in the world). My quads have disappeared.
As for the mental aspects, I have realised that our brains are prediction machines and that proprioception is very much tied into our recovery. The expectation I have had that my knee is unstable is based on the actual instability of the knee. Going downstairs and having my knee buckle has made my leg tell my brain that it is worried about its ability to support me. Not being confident in trusting my knee is a very frightening prospect. Add to that the nightmares and dissociation I experienced post the injury. The guy who kicked me, had been aggressive towards me the whole match and basically blindsided me when he smashed my knee. For months, I was terrified of being in public spaces where there were people around me. I have not felt this vulnerable since I was a kid. I had nightmares for months, my startle response wa heightened, I avoided social situations, I spaced out a lot, I was easily confused, I couldn’t concentrate. The list was endless-it felt like my persona had changed.
So, back to how our brains are prediction machines: Have been reading a lot of research into embodied cognition, basically the theory that our nervous system(and all its sensors) is as much a part of our brain as our hippocampus and our amygdala or our hypothalamus and that it is all attempting to keep the world around us and within us as predictable as possible. This means, essentially, that the constant flow of information between our efferent/afferent nerves affects our mindmap of not only our immediate surroundings but also our internal structures; in this case our knees. This, I think, is one factor in why such injuries are as much about neural consequences as they are about muscle and tendon and ligament. The data processing that occurs during and immediately after the tear affects how we see ourselves. Unfortunately, our amygdalae(fight/flight/freeze response centre) can often misinterpret signals as being threatening when they are not and vice versa. Which is why we react emotionally. Which is why the tears. Which is why the fears. Our brains are scared of these things re-occurring and that is understandable. We are wounded animals and we need to keep ourselves safe.
So leg says to brain, “OMG, that hurt, let’s not do that again.” And brain says, “You’re right, if anything looks similar to that situation comes up, avoid it at all costs!” And we struggle with our recovery in overcoming our own well meaning brain. I mean, at times, now, I will flinch when people even come close to my leg, and this is seven months later. The sensory input from such an injury lights up our brains like tracer fire, compared to the normal every day mundane signalling we’re used to, so it’s no wonder we are so wary and also, may go a long way to explaining why it is normal to become obsessed by the leg.
The other factor I saw mentioned is the strange ghostly nature of our limb-as if our leg didn’t belong to us. When you first try and move your quad after surgery and it doesn’t respond is such a disconcerting moment. “Move damn you, move!” But it just mocks you with its lack of motion. “Make me move,” it says. It’s as if the leg belongs to someone else. Again, the interlinking of proprioception, pain, memory, hope, structural problems and re-learning is such a complex matter; it’s like movement of our limbs is done by a committee that forgot that you are in charge.
These things take time; my physio watched me hobbling the other day and she said, “It’s like you have to lean to walk again.” How true.
If anyone is interested in embodied cognition, read Andy Clark or watch his videos on YouTube. Fascinating insights into our brains.
reddyb
January 6, 2017
Thanks for the thoughtful comment Murad. Appreciate you delving into the ghostly / foreign sensation the leg can give off. It can be quite a trip when first experiencing it.
One thing I’d add here is I’ve seen a notable -though I’m not sure how reputable ( https://b-reddy.org/2016/04/06/is-there-about-to-be-a-revolution-in-acl-surgery/ )- ACL researcher discuss one issue with reconstruction is the lack of nerve regeneration *within* the new ligament. So while I very much agree with what you’re saying regarding the “top down” effects, and this certainly a trend in thinking, there may be more here. That it’s not just the brain being tentative due to past experience, but the brain being tentative due to current anatomy.
One of the big issues -not saying with you, but the principles- with the top down movement is not appreciating nervous system anatomy. For instance, a lot of the proponents will go something along the lines of “The injury is healed, yet the person still has pain.” Then into some brain based rationale. Yet no examination of whether the nerves have healed / normality has occurred has been done. More details here: https://b-reddy.org/2015/12/16/visiting-the-north-american-spine-societys-annual-conference/#Microscope
As an example, tearing my ACL was nowhere near the most painful injury I’ve had. Nor was the surgery recovery. Dislocating my elbow was indescribably worse. I was immobilized and rushed to the hospital due to the athletic trainer saying I was at risk of death, as they weren’t sure if I also broke my arm and could be near severing an artery (shards of bone can cut the artery). I woke up during anesthesia when they were trying to put the elbow back in, which is not a gentle experience. I was handicapped at school, had to have other people write notes for me, was told numerous times to be careful because I could dislocate it again if coming back too soon. Yada-yada.
The only way an ACL experience was at all comparable in suckiness was how long the recovery took, because within four months of dislocating my elbow I was back on a (small) d-1 practice field, playing linebacker. Made it through the entire season with no issues.
I was nowhere near mentally ready at four months post-op ACL wise. Still wasn’t ready at 9 months, though I was fully cleared. I’m more than five years post ACL surgery. While I can do whatever I want to do, I still think about my knee much, much more than I ever think about my elbow. There are activities I’m still tentative with when it comes to my knee. Not due to trouble performing the activity, but due to accepting the increased risk of tearing the ACL again. (Think skiing.) I’ve never once avoided an activity because of my elbow, or even did a double take.
The experience of the injury is not proportional to my current emotions, at least in my scenario. The nervous system *around the knee*, likely needs to be part of the hypothesis.
Murad
January 6, 2017
That’s a great point about the nerves within the ligament needing to be considered in this equation-I think that gives a much rounder picture of how our cognition is embedded in our bodies; in this case a ligament that has been reproduced physically but not yet neurologically. I began to wonder whether the post op numbness was affecting my feedback from the knee. It’s peculiar that some of the knee is numb and some of it is in agony, all at the same time and in areas that are proximal to each other. How does that extensive numbness affect proprioception?
For some reason, what you said reminded me of patients I’ve had with amputations and phantom limb sensations. The toes on one patient were gone but he would wriggle them and would over-balance when trying to stand on that leg. And he hated how they would itch, even though they no longer existed.
Your point about risk of re-injury is well made. I’m not sure I could bear to go through all this again-especially at my age. It’s a great conversation starter though-have heard the knee stories of so many people on the bus now because of my crutches and brace! Nothing like bonding over injuries.
reddyb
January 8, 2017
Truth!
The idea of looking at “reproduced physically but not yet neurologically” also gives more credence to why it takes so long to come back from this injury, despite the graft being set at ~10 weeks. While there is the muscular strength aspect, such as those who e.g. need to regain hamstring strength after being cut there, this doesn’t happen in allografts, yet they still take as long to heal.
Nerves take the longest to regenerate. While someone might have great muscular strength at 6-9 months post-op, most will still not feel their best until 18-24 months. You may be leg pressing great after a few months, but you’re not cutting back and forth great. Proprioception certainly is the reason here, but the exact mechanism doesn’t seem vetted yet. As you hit on (re: numbness around the knee), nerves within the ligament are not the only factor. Potential nerve changes within the meniscus, and anywhere else a person has been touched surgically, have to be considered.
Will have to take another look at the research and see if anything has come about on this.
Simon Laraman
January 18, 2017
Thank you for an exceptionally useful article. Day 7 and my fixation with flexion maybe cured by reading this.
reddyb
January 20, 2017
You’re welcome! Hope your recovery goes well.
aditisingh7
January 22, 2017
Steve,
Thanks for this article! I was crying in pain last night (post op day 8) and came across your article. It made me laugh. A lot.
It’s realistic and need to know info. Thanks for this!
Ps – I’m still hopeful I’ll beat some of your stats. Can’t help it. I’m one of those human beings that’s hopeful by nature (I think there’s a lot of us out there) 🙂 Hope for the best but expect the worst!
reddyb
January 22, 2017
That’s a good mindset to have! I haven’t heard it phrased that way.
You’re welcome for the article. Hope the recovery turns around for you. You should be passing the worst of it soon.
Brian (though I’m sure Steve is a good guy 🙂 )
Abhinav Choudhary
January 26, 2017
Hi,
I am 26yrs old and I have a complete ACL tear along with meniscus tear. This is the fifth time I got my knee injured. In earlier cases it was Partial ACL tear. This time doctors have suggested me ACL reconstruction and Meniscus repair.
Every time I got my knee injured, I waited for about 7-8 months , and after that I was able to start running or playing table tennis.
This time also I want to recover, without going under surgery , by doing exercises. Mainly In future I want to do running and swimming just play with my kids in future. (I am bachelor at present.)
My question are :
1. Is it possible ?
2. If yes, Can you give me some example of persons who have done it ? It will be a huge motivational factor for me.
3. How can I avoid knee injury in future ?
4. Can you suggest me some exercises or link to such pages/blogs ?
Thanks in Advance
Abhinav Choudhary
India
reddyb
January 27, 2017
Hey Abhinav,
I’d check out this post: https://b-reddy.org/2011/11/29/reconstructive-acl-surgery-is-it-beneficial/
You might be interested in this too: https://b-reddy.org/2013/08/07/a-different-explanation-for-adrian-petersons-amazing-acl-recovery/
In terms of exercises I recommend the ACL manual, whether it’s right after injury or surgery: https://b-reddy.org/2014/04/02/the-most-important-phase-of-acl-rehab-copy/
Joe
February 5, 2017
Brian, I enjoyed your article very much and would like to add my own experiences. I held off in my ACL reconstruction for 2 years. But in that time I had many times the knee would buckle and pop, swell for a week or 2 and I’d be utterly useless. I was 27 at the time of injury and at 29 I decided I couldn’t have this happening. In those 2 years and multiple re injuries I ended up tearing lateral and medial meniscus as well as multiple micro fractures. Waiting caused me more issues in the long run. One thing to note is pre op PT is very important and often overlooked. I’m a big guy 6-4 230 lbs. I was 260 before surgery. Dropped 30 lbs in 2 months before surgery. Started doing yoga and stretches to increase flexibility. I can not stress how much the weight loss and flexibility have helped. Now I’m 3 weeks out. Like most people flexion has been the slowest progress due to swelling. The biggest obstacle is overcoming mental challenges. I just started riding a bike after 3 weeks. Some were riding bike after 1st. I’m still using 1 crutch, some people at this point are walking and driving. But don’t pay any mind to that. I’m proud over progressed this far and I’m working hard to get even farther. I take my milestones as they come and don’t try to compare my progress to others because as Brian said “No one had the exact surgery you did” its good reading other people’s accounts of what happened to them. You know you’re not alone, not the only one experiencing set backs or complications. But don’t let yourself get down mentally because “the dr said I need to be at 120 degrees by this date” or “my 45 year old neighbor had his ACL done and was walking 2 days later without crutches” Everyone is different and if you focus on your recovery and put the work in, you’ll progress at your own pace.
reddyb
February 7, 2017
Thank you for sharing Joe. Very good comment. It’s great to have someone chime in regarding how helpful losing weight before / not being heavy during this can be.