This is the second installment of our timeline of ACL rehabilitation. In the first post we discussed “prehab” and how full range of motion, proper quadriceps strength, and absence of swelling can improve post-operative outcomes. Prehabilitation takes us to the day of surgery and the beginning of recovery. This post will discuss the day of surgery through the first month of recovery.
Under the Knife
The day of your ACL surgery will be filled with some understandable anxiety and trepidation. Much of the fear; however, is due to the unknown and worries of what might go wrong. Hopefully I can dispel some fears so your surgery day is as calm and routine. It is estimated that 100,000 ACL reconstruction surgeries are performed each year. Likely, the surgeon you are seeing has done many ACL procedures and therefore you have little to worry about in relation to mishaps or issues.
To prepare for your day of surgery be sure to read the instructions given to you by your doctor at your pre-operative appointment. There will be instructions to avoid eating for a certain period of time before the surgery (12 hours or more) so as not to interfere with the anesthesia. Be sure to have a good meal before the time deadline! On the day of surgery, you will check in with the medical team and they will prepare you for surgery. Once you are in your robe you will be asked the same series of questions MANY times. These questions include your name, date of birth, and the side/location of your surgery. This is standard protocol to be sure they have the correct knee for the surgery. The team will ask for your John Hancock on the knee you will be having surgery on.
After this preparation you will briefly speak with your surgeon who will describe the procedure and ask if you have any questions. You will then be wheeled into the operating room and be given anesthesia which will put you to sleep soon after entering the room. Before you know it you are having sweet dreams of scoring the game winning touchdown at homecoming.
Immediately After Surgery
When you wake up after surgery you will be groggy and likely a bit nauseous from the anesthesia. Your knee will be covered with lots of gauze and ace bandages. A nurse will visit with you at this point to discuss your level of pain and be sure the fuzziness from the medication is wearing off. Your doctor may have given you a nerve block which will make your whole leg feel numb. This will also make it so moving your leg, feet, and toes is difficult or impossible at first. Do not worry, this will pass in a few hours. The nursing staff will check on you regularly in the first few hours after surgery to be sure you can move your toes and feel pressure in your feet.
Your doctor will again meet with you to discuss the outcome of the surgery. They will explain how your ACL ligament, cartilage, and overall knee health looked and what they did to fix your ACL. After this meeting you will be wheeled into a patient room where you will be for a few hours. The medical team will be sure to teach you how to use crutches. They will also be sure you can use the bathroom and that your pain is under control.
Likely, on the same day you have surgery you will be discharged from the hospital. You will be wheeled out on a wheelchair and brought to your car. If you know someone with a larger car have them pick you up since you will not be able to bend your knee at that time. Sitting in the back seat is often a good choice. Keep the windows down and maybe bring a mint of the ride home since you will likely still feel the effects of the anesthesia.
The First Week After ACL Surgery
It is not until you are home for a few days that you realize how surgery affects your daily function. By day 3 the nerve block in your leg has worn off and the pain of surgery sets in. Most will feel a throbbing ache around the whole knee. Your doctor will prescribe pain medication to help with your comfort. You will be given a large brace with multiple straps to protect your knee in the initial phases of rehabilitation. The brace should be worn at all times when standing and using your crutches. If you are home watching TV the brace can be taken off. Be sure to follow the instructions given to you by your doctor regarding your wound. It will remind you to avoid things like taking a bath and to call you doctor if you have a swollen, red, and painful calf as this may indicate a blood clot. All the post-operative details will be provided to you.
Adjusting Mentally to ACL Rehabilitation
I remember after my ACL surgery feeling isolated and actually quite bored. I was 16 when I had my ACL surgery and I thought that some time at home to watch movies and play video games would be sweet. The reality was; however, that those feelings lasted about 2 hours and then I wanted to be out with my friends or playing sports. I had my surgery in the early summer so everyone was going to the beach and I was at home. It was a tough time mentally and physically during my first month of recovery.
The mental changes and struggles that take place after ACL surgery are not talked about as much as the physical changes although they are equally debilitating. In your head you feel like you are capable of playing sports at a high level but physically you have difficulty just using your crutches to get the bathroom. Be sure you have a good network of family and friends around who have positive energy and who will keep you motivated. The worst things to do at this point in your rehabilitation is to be isolated and alone. Do your best to get out of the house, get some fresh air, listen to great music, and potentially even journal about the experience.
My ACL surgery was a defining moment in my life when I realized I wanted to help people in the same situation I was. Use your surgery to help yourself grow and to bring out your passions. Athletes who have never been injured do not understand or appreciate the gift they have. An athlete who have gone through ACL surgery will come back driven, motivated, and ready for whatever challenges they face because they know what it is like to not be able to play the game they love.
Starting Physical Therapy ACL Rehabilitation
Your doctor will have provided you a referral for physical therapy either before or at your day of surgery. As soon as you have the referral you should contact your local sports physical therapist to schedule a series of appointments. Most referrals will have a frequency of about 2-3 times per week and will starts between weeks 2-4 after surgery.
Before attending physical therapy you will begin some exercises at home. These exercises will be given to you by your doctor or your physical therapist during “prehab”. These goals of these exercises are to wake up your muscles, improve your range of motion, and increase circulation.
Waking up the muscles
After surgery, the inflammation around your knee will cause your quadriceps muscle to have a difficult time contracting. Swelling impedes the nerve signal from getting to your muscles. Also, the surgical procedure itself will decrease blood flow to your quadriceps causing some atrophy or muscle loss. It is necessary to wake this muscle up by doing simple squeezes. It may be helpful to have a small rolled towel under your knee to press your knee into. The best cues to get your quadriceps muscle to squeeze is to imagine you are pulling your knee cap up your thigh towards your hip. Your quadriceps muscle, when contracting, tugs on the patella and draws it upwards. This exercise should be done as often as possible.
You can also begin to do calf squeezes, buttocks squeezes, and abdominal work while on your back. Be sure to remember that just because you had knee surgery does not mean you have to hold off on working the rest of your body. I remember having 30 pound weights in my bedroom to do curls, and skull crushers, and presses while I was recovering. Range of motion
It is important to begin to move your knee to prevent joint stiffness and the development of scar tissue. Be sure to follow any instructions given to you by your surgeon on range of motion limitations (sometimes bending to only 90 degrees for the first 4-6 weeks, especially if you have a meniscus repair).
Bending your knee for the first time can be scary. You will feel pain and the swelling will make movement challenging. The pain will feel like an ache and it will be sharp from the sutures or staples used to close your surgical wound. Be sure to keep the bandages on until you have a post-op appointment with your doctor or see your physical therapist.
It is easier to bend your knee at first if you place it on a physioball and roll the ball back and forth. This is also a great way to keep your knee bending for an extended period of time as you watch your 3rd hour of SportsCenter.
You will be using crutches for the first 1-4 weeks after having ACL surgery. Each surgeon has a slightly different protocol for how much weight to place on your leg. Some tips to remember from my own experience messing up with using crutches.
- If you have stairs at your house be sure to place the crutches down a step first before you step down. (I had to drop my crutches, grab my banister, and swing to the stairs wall when I did this wrong after my surgery)
- Use padding under the armpits if you begin to feel pain or have numbness in your arms
- Be very careful placing the crutches on wet slippery surfaces
- Keep your room clean so your crutch doesn’t catch on a pair of jeans making you fall over (yep, did this one too, luckily without any injury)
Goals of ACL Rehabilitation: Month 1
The goals of this first phase of rehabilitation are straightforward but not simple. The majority of long term impairments after surgery come from not starting your recovery well. If you listen to your doctor and physical therapist and remain motivated you will do very well.
- Decrease edema and swelling with the use of an ice machine or ice packs, elevation, and compression
- Improve range of motion for knee flexion and extension using exercises prescribed by your doctor and physical therapist (range of motion goal 0-90 or 0-120 degrees)
- Activate your quadriceps and gluteal muscles to prevent atrophy and help with walking gait
- Prevent circulation issues with regular leg and body movement
- Begin physical therapy to help restore walking gait, strength, range of motion, and overall function
- Stay motivated and positive
Onward to Month 2
The first month of ACL rehabilitation can be daunting. Hopefully this post has eased some of your fears and given you a road map of expectations and goals. I tried to keep things general as this is a phase of great change. Your family and medical team will help you every step of the way. I will continue the ACL timeline next month. If you have questions about ACL rehabilitation and live in San Jose California then stop by Competitive EDGE Physical Therapy. Work hard!