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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Suchita
February 11, 2017
Hi, thank you so much for this article. I just had my first ACL surgery day before yesterday, and I am beginning to go through the flow of emotions that you mention in your article, and that I read in some of the comments. It is a hard, painful and demanding process. I am also at a point that I keep regretting how it happened in the first place. I am a novice at skiing, and I tore my ligament in the worst way possible, just walking through fresh snow, even before I began skiing! I am also now regretting the poor choices I made later that day (continued skiing the whole day, didnt use an ice pack, didnt compress the knee, etc.) and in the days that followed (thinking that it was something minor that I can do on my own, travelling with heavy luggage, etc.). I am also a type 1 diabetic, and with my sugar levels going crazy since the surgery, I feel like its all coming together in the worst manner possible right now and making it all pretty unbearable. Also, knowing that I might never regain my levels of physical activity is positively upsetting, given that it could all have been easily avoided. My hope is that I am able to undergo physiotherapy seriously enough, and come out of this to at least regain some level of activity, because right now, it all seems really bleak.
reddyb
February 12, 2017
Hey Suchita,
Sorry to hear about the tough time you’re having. I can relate to some of the “I wish I did this differently” emotions. I still go through that some all these years (5+) later. And I’m healthy!
Where I think how it was so silly how I got hurt too. Playing flag football of all things. Getting me back on a flag football field again is unlikely to ever happen again. When somebody asks me about doing something of that nature, while I can do it physically, the risk isn’t worth it to me anymore. (I’ll instead go play tennis. I know the court is flat while the field might have holes.) Here and there then I’ll think “if I didn’t play flag football that day…”
So that’s natural to go through. The best way I’ve found to go through where you’re at is thinking about the rehab in stages. Thinking “ok, time to get to this stage.” This another reason for not sitting around for two weeks post-op, but instead getting moving on the small things you can do. Quad activation, moving the patella, knee extension, controlling swelling, eating a certain way. (All in the ACL guide if you’re looking for help: https://b-reddy.org/2014/04/02/the-most-important-phase-of-acl-rehab-copy/ )
36 hours post-op is when pain peaks. It should get better from here on out!
Suchita
February 12, 2017
Thank you Brian, that is good to know.
I can completely understand your reluctance to play flag football again, even if you are now physically fit enough to do it. I am not sure that I will ski again either. I can also appreciate the importance of going through the recovery in stages as you suggested, because it takes your mind off what is now beyond your control (even if it doesn’t go away completely, as I ascertain from your experience!), and gives you concrete things to do which can help you get back, at least in the early days. I completely agree with your opinion on starting PT as soon as possible to enable quicker recovery.
One step that I would like to take is to not ignore my unoperated knee. I have been putting a lot of pressure on it in these early days so that I don’t put too much weight on the operated knee, and I feel like it is already getting a bit sore. It would be great to know what you did to strengthen your “other” knee. I use support while walking, but I find myself unconsciously putting my entire weight on that knee. I don’t want to be in a situation where my operated knee improves tremendously (hopefully, potentially, maybe?), but I develop some kind of chronic pain in the other knee. Can I ask if you did anything for the other knee?
reddyb
February 14, 2017
Good question.
This is where the importance of getting into rehab as quickly as possible shines even brighter. The sooner the operated leg has full walking range of motion (full extension), the sooner one can use the leg walking, the less stress on the other leg. This doesn’t have to be full walking either. Just placing 50% of the weight on the operated leg can help tremendously. (A progression for walking is in the ACL manual.)
In terms of strengthening, the leg unlikely needs any extra work. It’s similar to the upper body. Anybody who has crutched around for a week or more can tell you the last thing their upper body will feel like it needs is a strength training session. The crutching ends up being the workout.
Now before surgery, that’s where having everything be in better shape can help considerably (as well as not being overweight). But once the crutching begins, then adding more work to areas which are likely already way more worked than they’ve ever been is not only unnecessary, but probably counterproductive. Regardless, no matter how hard one workouts out pre-surgery, nothing can simulate not having one leg available for thousands of steps a day. It’s a gigantic increase in workload. It’s more a matter of how miserable crutching is, not whether it’s miserable :).
And everybody should be up moving around. The alternate of lay around and barely move to avoid crutching is not a good route. Example: https://b-reddy.org/2014/01/24/should-you-immobilize-your-leg-after-tearing-your-acl/
The other aspect here is the body has limited resources in terms in healing ability. While I can’t quote research on this, my feeling is, and how I approached my rehab was, to not strength train non-surgery pertinent areas until the surgery inflammation died down a good amount. (About two months in.)
An example would be powerlifters. They only compete in three lifts, yet even within that world there are specialists. One reason is that if all somebody does is train the bench press, then they have more resources available to do that than somebody trying to push their squat and bench.
If one is trying to get the upper body / other leg stronger, and get one leg to recover from surgery, it’s a fair argument to say the operated leg may recover faster if it doesn’t have to compete for resources with those other body parts.
That doesn’t mean to not use the non-operated leg. A good rule is whatever the operated leg does, do with the other side too. Besides giving the non-operated leg some exercise, exercise which is unlikely to cause a necessity for adaptation (it’s going to be low intensity for that leg), it helps provide a consistent benchmark. “Ok, my good leg can do this, but my operated leg can only do this.”
Pick Yin
February 14, 2017
Hi Brian,
Thank you for this blog. Your contribution provided me some comfort.
I was lucky enough to have access to good (and immediate) rehab after my concurrent ACL recon and meniscus repair surgery. However I was (and still am) overweight and was probably 1 year in after my injury before the surgery – also didn’t have pre-surgery physiotherapy.
Now 4 months into rehab I’m dealing with constant tightness around the graft and the urgent necessity increase weight loss rate (down 11 pounds about 6 weeks post op but obviously this has slowed down).
I have 2 questions:
1. Regarding hyper-extension of -10 degrees, I am not there yet. I was told 0 is good after 4 weeks and the hyper-extension will come back gradually. Should I be concerned and is this the reason why I still feel discomfort (sometimes pain) when weight bearing at 0 degrees while walking?
2. I have looked around the topics and manuals you have posted – is there anything on the later phases (POP 3 to 5) of ACL/meniscus rehab? I am aware of the long road to recovery and would like to see if you have something not the typical therapist would let me know.
reddyb
February 17, 2017
Hey Pick,
Good for you for getting the weight-loss train going. That helps everything.
1) *If* your normal ROM is -10 degrees, you can get a feel for this by using your good leg as the barometer (provided it hasn’t been injured in the past), then at four months I would be concerned about not having full hyperextension.
Not everyone’s normal extension will be -10. Some will be -5. But whatever that normal is, for it to not be there at four months is not ideal. It’s not highly concerning, but you’re on the road to that, and there’s really no reason it shouldn’t be there by now. Barring something going on with the surgery.
I’m not a fan of the “It will come with time” approach for extension ROM. There are some out there who it practically never goes away. I’ve had people come into the gym within days post-op, and they have full extension ROM. For whatever reason, they never stiffened up. These tend to be congenitally lax people. For others though this does not come back unless it is worked on.
Tough to say this is the reason you have pain sometimes while walking. But my experience has been you have someone do a long duration hold to work their extension -might be five minutes or more- then (slowly) have them get up and walk around, and they often feel a sense of “Oh man. That feels better.”
It’s admittedly a strange thing. That having more ROM needed while walking will make one feel better walking. Going to write about this in the future.
Around four months is when other things tend to crop up as well, like patellofemoral pain. So that could be an issue too. Have an article about this coming as well.
2) You can see a progression regarding the later months by scrolling down here- https://b-reddy.org/category/anterior-cruciate-ligament-acl/rehab/
My suggestion would be to consider the running progression. That’s not something most are exposed to.
Suchita
February 16, 2017
Thank you for the advice Brian, I will try to use the unoperated leg optimally as the recovery progresses. I want to congratulate you on all the resources you are providing here, such as the ACL guide, it is all very informative, especially for those who are not full-time sportsmen, or physical trainers. It is really good to have the information before you begin the healing process, just to know what to expect.
reddyb
February 17, 2017
You’re welcome, and thank you for the nice words. Always helpful to hear things of this nature.
RJ
February 17, 2017
Wow…lighten the fuck up. It’s one thing to try to be a realist but you are skewed in a direction nobody cares to hear about. People get thrown into things every day and prepare the best they can. Most (all) ACL surgeries are due to accidents and people need to walk. I went over a year with a nonfunctional ACL and know all the options / risks. I prepared for replacement and hit it head on. Not everyone is a planner like me though.
reddyb
February 19, 2017
I don’t know about nobody, but I know about a certain somebody…
YJ
February 23, 2017
Thanks alot for the blog ,
Unfortunately my rehab isn’t going too well. I am now 5 months post op and I only getfull passive extension after 2 minutes of stretching. Left to itself I’m at 10 degrees.
And I haven’t achieved active extension.
My PT thinks the graft could be too tight but I spoke with my doctor yesterday and he said its impossible that he would have done that, he’s supposedly one of the best in Switzerland and does 80 acl surgeries a year. He said it could be a build up of scar tissue.
I’m now afraid that I didn’t push as hard in the beginning. I had physio twice a week for 2.5 months and was going gym regularly but I didn’t aggressively push for full extension as my PT was happy with getting full extension passively after stretching and told me not to worry. What do you think Brian? Should I just keep pushing?
Many thanks
reddyb
February 24, 2017
Hey YJ,
Sorry to hear about the tough time. Are you saying that if you do a couple minutes of stretching, you’re able to hit full extension ROM?
YJ
February 26, 2017
Passively yes, I can get zero degrees extension and full flexion.
I lose the extension though quite quickly after the stretch.
I do not get it actively even after stretching, though I’ve been told there’s slight progress.
Thanks for the response!
reddyb
February 28, 2017
If you get it passively, that’s a great sign. Just need to do it more often. Common to do it, then lose it within 30-60 minutes. In which case, do it every 30-60 minutes, or whatever the timeline is. Eventually it should stick.
YJ
March 18, 2017
Hi again Brian,
I kept doing stretching diligently and now I’m reaching full extension passively and its sticking!
However there hasn’t been much progress with the walking, I still walk with a few degrees off, my swing is better after a stretch but there is still something holding my leg back.
Is this something that will ultimately come with time? I’m not sure what it is
Thanks for the help
reddyb
March 19, 2017
Good to hear!
Would be looking at ankle push-off: https://b-reddy.org/2015/11/16/how-weak-calves-can-cause-knee-issues/
https://b-reddy.org/2016/07/01/acl-prevention-and-rehab-the-other-23-hours/
YJ
March 19, 2017
thanks for the response Brian, I read the link you gave and tried the heel push exercise, I managed to do it with a straight knee no problem, any other idea what might be the issue?
reddyb
March 21, 2017
Doing the exercise and doing it while walking aren’t the same thing. Would give that link another read. The exercise isn’t the point. It’s how you walk.
There is more in the other 23 hours link I provided in the last comment.
YJ
March 27, 2017
Hi Brian, I purchased the link, excellent general points but for the walk, I believe what I am still suffering from is a lagging extension when walking and I have actually been implementing the advice you’ve suggested without significant improvements. It’s 6 months now so I’m puzzled why I’m still walking with a stiff gait.
I am seeing my doctor in two days, any suggestions for questions I should ask?
Many thanks for all the help
reddyb
March 28, 2017
Thanks for purchasing!
-If the extension lags while walking, then we’re back to getting the extension ROM to stick more passively.
-If you have the range of motion, then it’s a matter of using it while walking i.e. not walking on a bent knee.
-In terms of what you feel / believe, that’s a whole different ballgame. You could feel stiff because you are. However, you may feel stiff because the knee has some fluid in it. Or because you have arthritis. (Not trying to scare you, but it’s a reality). Or you might feel stiff because the knee just feels weird now. This is where another pair of eyes helps give objectivity.
I’ve had many times where I feel like I have fluid in my knee, but I don’t. Proprioception gets disturbed after a surgery. The more involved the surgery, the more disruption. Many after ACL surgery will tell you all types of weird things they felt. The first two months I was walking, I would be walking in a straight line yet felt like my surgery knee was two feet to my right. It was crazy. Just three days ago I asked my girlfriend how my knees looked. The surgery leg felt bigger than the other. It’d been a very active day so I thought perhaps I did too much. But it wasn’t bigger, and two hours later it felt 100% normal. (Which wouldn’t happen if it had swelled.)
This is more physical therapist / whomever is helping you with your exercise territory than surgeon, as they’re more the ones helping with range of motion and how you walk. Hell, it’s often hard for a surgeon to even watch a patient walk. Patient room, and even most hallways they work out of, are too small to do so.
YJ
March 31, 2017
Thanks for the lengthy responses Brian!
I just had my MRI and saw my doctor, there seems to be quite a bit of inflammation and build up of scar tissue. At first the Doctor said lets do nothing and wait but after testing my knee, he said it was too stiff and immediately recommended an arthroscopic surgery to remove scar tissue.
I sent my MRI to another doctor who recommended me to wait a couple of months but he will see me personally on Monday.
What do you think? Is this surgery completely safe, I have read some horror stories online. I am very confident with my Doctor’s abilities, he’s done some 1600 aclr in his career and he’s pushing to get it done.
reddyb
April 2, 2017
My general response to any possible surgery is “only when necessary.” For each person, the definition of necessary will change.
When it comes to range of motion, by far people aren’t doing what’s necessary to get results. That said, some people *didn’t* do what was necessary, and end up at a point where even if they now have been, they may need surgical intervention due to getting a late start.
As far as the specific surgery you could have, that’s tough to know. While others may have had a bad experience, they probably didn’t have the exact surgery you’d be having. I’ve only had one person who went through something along these lines, and no, it didn’t go well. The issue for some with scar tissue removal is they’re hypersensitive to making scar tissue. So they end up having a surgery for an issue that surgery makes them very likely to have.
In other words- scar tissue can grow back and scar tissue will occur any time a surgery happens. For some, more than others. A surgery of this kind doesn’t typically involve anywhere near the trauma of ACL reconstruction. So one thought process is the scar tissue, if it does come back, doesn’t come back as much.
But there is no way around it- cut the body open, scar tissue happens. It is by no means a given that it’s cut away and is a done deal. If someone e.g. gets the surgery then does the same crummy physical therapy they did after the initial surgery, they could be back to square one.
Long story short one needs to be confident they are doing the surgery for the right reasons. Not as a way to circumvent reality e.g. having to do a lot of work themselves.
By no means trying to put you in this light. Detailing what I’ve, again, by far, seen.
Jim
March 1, 2017
Brian,
I wrote several months ago. I am now 7.5 months post ACL reconstruction surgery. The cadaver-supplied ACL is doing well but (there always seems to be a “but”) I learned today that I have complex tearing of my medial meniscus. I guess this is the setback that I have to deal with. Since this Blog is titled the “biggest mistakes . . .” I thought I’d add – failing to make sure the orthopedic surgeon addresses the non-ACL issues that exist in the knee following a traumatic injury. I have now gone back and reviewed the radiologist’s report from the MRI taken at the time of my original injury and see that there were slight non-displaced tears in my meniscus that the radiologist described as being the type that could develop into bucket handle tears. The surgical notes indicate the surgeon observed these tears at the red/white location (which I understand is where tears may or may not heal) and decided not to stitch the tear. This has now developed into the complex tear 18mm in size. I am experiencing grinding/clicking when walking with stability issues. My understanding is that the meniscus will have to be cut out – no chance of repair given the size, location (and my age – 50 years old). Interesting is that I had/have no pain at the joint and my PT (who has helped with recover) was convinced I had no meniscus problem. Not the type of setback I wanted since I now see another surgery with more recovery time and now I will have less meniscus with arthritis as a potential outcome. Sheesh. Any thoughts on whether PT can counter the instability/clicking that is experienced with a complex meniscus tear? Any thoughts on whether the use of a knee brace post meniscus surgery is at all helpful?
I really appreciate the opportunity to throw these thoughts out into the electronic world and to have your considerate thoughts on the issues.
gboller2014
March 1, 2017
Jim…sorry to hear about your meniscus problem. But that surgery should be a breeze compared to your ACL surgery/recovery. I had a double meniscectomy at the time of my ACL surgery. My first meniscectomy (medial) was 36 years ago — open surgery. Did your surgeon say how much of the meniscus has to come out? My surgeon was careful to trim only the damaged portions, so I still have plenty left. Re. a brace — did you get fitted for an ACL brace yet? I got a DonJoy custom-fitted brace at 6 months, and use it now (I’m now 9 months post-ACL) to play tennis. Very much recommend getting a brace!!
Jim
March 2, 2017
Thanks for the comment. I see the orthopedic surgeon tomorrow in the a.m. to find out what she believes the best course of treatment should be. Don’t know how much of the meniscus is to be taken out. I really don’t fear the recovery – what I fear is the long-term knee health and my ability to function normally. I still like to coach soccer and ref youth games. Heck, I was fortunate in my ACL recovery that I was able to participate in U12 soccer practices without feeling any pain or problem. I certainly wasn’t pushing myself but I was comfortable. I’m more than willing to take it easy for however long it takes but I’m concerned that the knee will never feel “right”. I know it won’t be the same but I want it to at least feel “right”. Again, thanks for the comment.
reddyb
March 3, 2017
Hey Jim,
Sorry to hear about the meniscal setback. If it’s any consolation, you can hear about my meniscal setback here if you haven’t already: https://b-reddy.org/2015/09/21/your-knee-just-locked-on-you-what-do-you-do-the-fickleness-of-the-meniscus/
The meniscus, much more than the ACL, is open to interpretation. If a tear has been around for a while, some believe even trying to repair (stitch) it is largely futile. If a person is above a certain age, same deal. Some believe you should always attempt a repair if it’s in a blood supplied zone. And currently there is a trend in thinking many tears are worth leaving alone.
As I hit on in that link, a bucket handle tear, or a tear interfering with joint motion, tends to be much more straightforward- it very likely needs to come out. (Also hit on in that link is how variable symptoms can be with a meniscus.)
Odds of arthritis do go up, but they’re not set in stone. Many people do insane activity after getting their meniscus cut out. Basketball players are perhaps the most common. Dwayne Wade had his cut out at like 20 years old. He’s still starting in the NBA at 35. Kobe went I think at least 10 years missing some of his too.
Don’t let the structure freak you out too much. That can be as bad as the actual missing some of the meniscus.
The surgery should largely smooth out the clicking and instability you’re feeling. You’d have to see whether you even felt a brace was still needed afterwards (and after solid exercising for a while). The last I saw, bracing can help with MCL injuries, but that was about it. That said, I’ve worked with some who simply enjoyed a brace. They felt more comfortable with it, they felt more stable, it gave them peace of mind. Tough to argue with someone feeling those benefits.
Not a fun thing to have to go through, but as someone already hit on, a meniscus surgery is *nothing* like an ACL recovery wise. It’s the longterm management that’s the harder part. Plan to write about this at some point.
Jim
March 7, 2017
Grateful for your reply and optimism – with a good dose of reality of course. I decided to get a second opinion set for 3/20 so I rescheduled the surgery for 3/29. Hopefully, all possibility of a late spring snowstorm here in Minnesota will be gone by April (not always the case) and I can rehab outside. Thanks again
reddyb
March 10, 2017
Being outside tends to help the mind. Good idea when going through a tough period like this.
You’re welcome. Good luck!
Ealana
March 5, 2017
I had acl reconstruction on the 5th of December 2016 using patella tendon graft after 4 months rehab following post lateral corner repair using hamstring graft. I have full ROM both extension and flexion however I still have a great amount of pain and weakness. I was weight baring and walking without crutches 3 weeks post ACL recon. Now I would have fully expected this if it were not the fact I am being told by my PT that I am behind on my rehab and that I shouldn’t be experiencing pain or swelling anymore.
Is what i am experiencing out of the norm or just an unrealistic expectation by the NHS? I had also had a number of moments when the knee has “buckled” inducing hyperextension when under full weight baring, I have often tripped and fallen over or twisted the knee on numerous occasions and really struggle on control coming down stairs.
reddyb
March 7, 2017
Hey Ealana,
Sorry to hear about the struggles you’re having. Pain and weakness being normal depends on when you’re having it. If you’re having it while walking, that shouldn’t be happening. If you’re having it compared to your old activity level, that’s normal.
The knee buckling is *not* normal. If that’s happening on you randomly, just walking around, you want to be checking in with the surgeon ASAP, where they should assess the new ACL and make sure it’s not too lax, along with looking for any other pathology, most notably meniscal.
reddyb
March 8, 2017
Hey Everybody,
One of the biggest questions I’ve received here is “How do I fully bend my knee again?” I put together something to help!
https://b-reddy.org/2017/03/08/cant-bend-your-knee-heres-what-to-do/
Lesley
March 14, 2017
Just tore my ACL last night playing volleyball. This is my first real injury. Looks like I am in for a real challenge. Thanks for all this info. My daughter tore her ACL 2 years ago and is doing really well. I will have to use her as my inspiration!!!! For now – trying not to panic!
reddyb
March 17, 2017
The fact you’re already researching is a good start!
Adit Rastogi
March 14, 2017
Hey, your post really makes me feel better after I’ve been struggling to find out if there’s anyone out there going through the same thing as iam. I had surgery on 20th January 2017 and it wasn’t acl reconstruction with meniscus construction using the patellar tendon. The first 4 weeks the surgeon did not refer me to any physio therapist and I was put on a brace locked 10 degrees which didn’t really help. A month later I decided I need to start bending before it’s too late. I had been doing leg raises all this while though. However I’m two weeks into physical therapy and have an active bend of 33 degrees and passive of almost 40 degrees. I take care of massaging the scar tissue and icing my leg. Do you think I can get better with time or am I to late and possibly need MUA in the future or if I work very hard in in physical therapy perhaps I can over come this ? Please let me know your opinion
reddyb
March 17, 2017
Hey Adit,
Sorry to hear about the rough start you’ve had. The only way to know what progress you can make is try, then go from there. The first month you went through is certainly a poor way to start this, but a month isn’t too much in the grand scheme.
At this stage I’d recommend taking a look at the full knee bending manual: https://b-reddy.org/2017/03/08/cant-bend-your-knee-heres-what-to-do/
Hard work is part of this, but doing the right kind of work is crucial. Flexion wise, the passive bending is where your priority should be.
Wounded knee
March 17, 2017
I just had ACL surgery this morning. Also torn PCL, torn meniscus, and they just discovered in surgery this morning my tibia was cracked. I’m a 45 year old male who who got this injury from snow skiing. (Rather snow ski wiping out). and didn’t have plans of running a marathon or playing tennis this summer but I’m a very active person and never indoors. After reading your post I feel like I’m one of those who fall in the category “I’ll beat the odds” and now feel like I’m fooling myself. My nerve block hasn’t even worn off yet. I can point my toes down and to the left (injured right knee) but not up or to the right at all. Did you use a CPM machine? I hear there is a fine line between overdoing it and not being aggressive enough. I agree all injuries are different as are how well people will heel so it maybe difficult to say for sure but it seems with all the research you did you had a reasonable expectation. With a reasonable expectation and a positive attitude I’m hoping that will greatly improve my success rate. I doubt I’ll see you at the Ironman competition in Hawaii but perhaps I’ll lessen my “sports for 20 year olds” and see you on the river fishing. Thank you for your post. I gained a lot of insight from it and think I might start a journal about it so I don’t forget what it was like in the moment.
reddyb
March 19, 2017
Sorry to hear about the other injuries along with your ACL. That’s one thing that gets lost in this- it’s common to have more than just the ACL going on. Tearing an ACL is typically a violent activity to the knee, where it’s likely other structures get banged up too.
The journal can be a nice idea. You’ll likely notice a roller coaster of emotions. You’re riding what is for most the worst time, as this is when one is the most handicapped. The first day you take some steps though and you might be thinking completely different thoughts.
I didn’t use a CPM machine. Compared to nothing (not ideal!), they can be helpful. Compared to working the range of motion yourself, I don’t believe they add any benefit. Can be quite surgeon dependent from what I remember. Haven’t looked into this recently though to see if any views / research has changed.
Thank you for the nice words. Iron Man activities- biking, running in a straight line, swimming, ACL people can do very well in these motions longterm! Things like tennis / skiing are the tough ones ( https://b-reddy.org/2016/10/19/understanding-differences-in-return-to-play-in-different-sports-after-an-acl-tear/ ).
Lesley Carr
April 1, 2017
Hi Brian – this is the person that tore the ACL on 3/13. I had surgery on 3/30. Wowsers – that was painful. I started exercises today. Straight leg lifts, drag the foot toward the butt trying to bend it, and pushing it into a rolled up towel. So far – I can do each thing pretty well. Doing other abs stuff and arm stuff while I am at it. I just jam out to good music and do what I can. Trying to focus on what I can do instead of what I can’t.
reddyb
April 4, 2017
The fact you’re at it this quick is a great start! As is your mindset.
You should be / hopefully are past the worst of the pain. Hope things keep improving :).