In the Patient’s Shoes: My ACL Reconstruction Journey as a Physical Therapist
Erik Kust, PT, DPT, OCS
My name is Erik Kust, and I am a board-certified clinical specialist in orthopaedic physical therapy at Orthopaedic Hospital of Wisconsin. While I’m usually on the other side of the ACL reconstruction surgery journey, I experienced it firsthand as a patient last year.
I wanted to detail my journey after ACL reconstruction and meniscus repair surgery to describe for patients what it feels like, as well as outlining the recovery and rehabilitation process from this significant and common knee surgery.
It’s important to note that everyone’s experience is different. You should follow the instructions from your doctor and rehabilitation team. This was my personal experience, and I thought it would provide some insight and comfort to others who are going through ACL reconstruction surgery.
So please, join me on an informative (and maybe even fun) insider’s perspective on ACL reconstruction surgery. If you have further questions about ACL rehab or anything else mentioned in this post, reach out at firstname.lastname@example.org.
MY ACL RECONSTRUCTION SURGERY PART 1: HOW I TORE MY ACL
My journey to eventual ACL-R and meniscus repair started like many ACL injuries—with sports. I originally tore my ACL playing sand volleyball in October of 2017. I experienced a complete ACL tear with a partial medial meniscus tear. This painful injury was confirmed via MRI.
When I tore my ACL and meniscus, I had a crucial decision to make about the path my ACL reconstruction would take. Being a stubborn rehab professional, I wanted to try my hand at being a “coper,” rather than opting for ACL reconstruction surgery right away. A coper is someone who “copes with the injury,” returning to previous levels of activity despite an ACL deficient knee (in my case, a knee with a completely torn ACL).
Admittedly, my decision was ill-advised due to the presence of an original meniscus injury. Typically, successful copers (and yes, some copers overcome ACL tears without surgery) have isolated ACL tears with no concomitant injuries, among other criteria (1). Regardless, they should work with a physical therapy professional to advise them on the best approach to activity.
I made my decision and committed to PT for my injured knee. Eventually, after about four grueling months of strengthening, balance, and jump training, I was back to playing soccer, basketball, and volleyball regularly and felt positive about my rehab cycle.
The more level 1 sport activities (level 1 covers athletics including jumping, hard pivoting, and cutting) one does with an ACL-deficient knee, the higher the chances are of further potential injury. This is primarily due to the adoption of altered movement kinematics, which essentially means you move differently to compensate for your injury, putting stress on other areas of your body that can’t support the movement.
Unfortunately, as I continued participating in aforementioned level 1 sports activities, I suffered further ACL injury. On April 11, 2019, in the championship of a meaningless co-ed indoor soccer game, I cut, planted, and suffered a bucket-handle meniscus tear. This painful injury was unfortunately not one I could manage conservatively through PT. The meniscus tear was displaced into the intercondylar notch of the femur, thus wholly blocking my range of motion.
I began the two-week pre-surgery process. During this time, I underwent several consultations and prehab to help me prepare for the meniscus and ACL reconstruction surgery on April 30, 2019.
MY MENISCUS AND ACL RECONSTRUCTION SURGERY DAY
The day of my meniscus and ACL reconstruction surgery is mostly a blur. Different medical personnel came in and out of the pre-operative room, going through all the necessary preparations for orthopedic surgery. Everyone was polite and concise in their work. I felt I was in great hands, and I was comfortable as I walked into the operating room.
After feeling a little prick in my arm, I was completely out. The next thing I knew, I was waking up following my ACL reconstruction surgery. The first few hours after waking, my initial discomfort was from nausea (a common effect from the anesthetic).
The most difficult post-surgical task was transferring myself from a wheelchair to the car. The newness of managing a knee brace locked in full extension took some getting used to. In my first few hours home, I knew I should attempt to get my knee as close to straightened as possible, for as long as possible. This was quite challenging due to post-surgical pain, which is different than other types of pain I’ve experienced. After surgery, there is typically a great deal of swelling, which makes resting the knee in full extension painful. I knew I had to persist, though, because extension is a must.
The first day post-op, I made initial attempts at quadricep sets along with gentle ankle pumps. I kept my knee wrapped and elevated with intermittent ice. I was glad to have the use of an ice machine, thanks to my dad. Ice was used every hour on the hour and throughout the night, as well. The use of ice in the initial days after ACL reconstruction and meniscus repair surgery helped keep the swelling and pain to a minimum, but still, sleep didn’t come easy!
ACL RECONSTRUCTION SURGERY POST-OP DAY 1
The first day after ACL reconstruction surgery meant the first day of my rehab journey began. I focused on extension range of motion (ROM) and quadriceps activation activities, as I mentioned before. Extension ROM entailed keeping the knee as straight as possible for as long as possible. Typically, spending long periods of time (at least two minutes) in extension is how the knee best recovers to full extension due to a material property called “creep.”
During my rehabilitation, I learned to listen to my knee, which would tell me when it had enough. It’s essential to maintain a careful balance between pushing yourself to recover while still listening to your body’s signals. This is where a great physical therapist is key to your post ACL reconstruction surgery recovery.
To understand knee surgery and recovery, it helps to understand the different components of the knee. In my case, I had my ACL (anterior cruciate ligament) reconstructed along with a meniscus repair. The meniscus is a load-bearing portion of the knee and must be individually protected and loaded at a different rate than the ACL.
For example, during rehabilitation for an isolated ACL reconstruction, there’s no need to limit weight bearing like you do for a meniscus repair. However, in the early phase of post-ACL reconstruction surgery as well as meniscus repair surgery, the rehabilitation principles remain the same. The rehabilitation process requires respect for tissue healing times. The therapist will help the patient use exercises that adequately stress healing tissues while mitigating muscle loss. The goal is always to help the patient return to functional activities as soon as possible.
NEUROMUSCULAR ELECTRICAL STIMULATION DURING ACL REHAB
During any knee surgery rehab, it was crucial to have quadriceps activation. I was lucky enough to have access to an electric stimulation machine that uses neuromuscular electrical stimulation (NMES). NMES can and should be part of rehabilitation post ACL surgery because it further activates the quadriceps muscle better than the patient could do without assistance (2). I also employed the use of blood flow restriction (BFR) with NMES for each session. Again, it’s important to follow your physical therapist’s instructions, but these are a few of the tools and techniques they may use during your ACL rehabilitation. Most of these therapies are relatively painless when used properly.
BLOOD FLOW RESTRICTION IN ACL REHABILITATION
Blood Flow Restriction (BFR) is a novel technique I utilized throughout my rehabilitation, but particularly in the early stages of recovery. In the broadest sense, BFR is a technique that uses external compression (similar to a blood pressure cuff) to restrict blood flow to an exercising muscle group.
ACL rehabilitation exercises with BFR create a more challenging environment for the recovering muscle. We do activities with minimal-to-no resistance. Still, when adding an external tourniquet, these movements are very beneficial in the early stages after ACL-R (contact me to learn more about this exciting, evidence-based tool, available to our rehabilitation patients).
For my ACL recovery, I primarily utilized BFR to decrease muscle loss in my quadriceps and hamstrings in the first 4-6 weeks after my surgery. I knew that during those early stages of rehabilitation, it was unsafe to complete higher-level exercises because it is imperative to respect tissue healing. Besides, anything more strenuous would probably hurt!
CONTINUING MY ACL REHABILITATION: WEEK ONE
During the first week of ACL rehabilitation, I continued to combine NMES and BFR to prevent as much muscle loss as possible while in the acute phase of rehab. I added straight leg raises—a staple in early-stage rehab—to my exercise regimen.
Early on in the recovery process, I was unable to keep the knee completely straight when lifting from the ground—otherwise known as an extensor or quad lag. Until my quadricep was strong enough and my swelling decreased substantially, I used a strap to assist with maintaining full extension throughout my movement.
Other ACL rehabilitation exercises include low-load long-duration stretching into extension—a position that isn’t fun, as noted before. After six days of rehabilitation, I was able to achieve full extension. After that, I focused on my ACL rehabilitation goal of actively pushing into full extension with a variety of quadriceps setting exercises. I did the exercise in supine, prone, and standing positions to retrain my knee that it was safe and healthy to extend straight fully.
The first week of ACL rehabilitation also included logistical activities, like a follow-up call with my surgeon and an initial physical therapy visit. The surgeon’s call was to check-in and make sure I had no lingering questions or concerns. The physical therapy visit was when the real progress toward a full recovery was made (I may be a little biased).
During the initial physical therapy visit, your practitioner will help you eliminate any guesswork about your rehabilitation. It’s essential to arrive with questions and be ready to work. During my initial visit, the physical therapist inspected my surgical wounds before changing the dressing. The therapist also gave me a tube grip sleeve to help control swelling.
The therapist will often engage you in a passive range of motion (ROM) activities, as well. Expect to hear a lot of “relax” commands. During our first session, we achieved 90 degrees of flexion—a solid start. Physical therapy also measured swelling and muscle circumference to help me track progress throughout my time in ACL rehabilitation.
You may wonder what it’s like to be a physical therapist getting physical therapy. I assume it’s similar to how a plumber would feel if they hired a plumber to fix an extravagant problem with his or her toilet—pretty humbled and a little awkward. Frankly, I felt low about being unable to navigate the post-op hurdles myself. I had to remind myself that ACL reconstruction surgery is a beast, and recovery is a big hurdle. Help was appreciated and needed!
The experience opened my eyes to the patient side of the therapist-patient relationship. I believe it gave me insight into the intricacies of working with a patient so early postoperatively. As a patient, I realized it’s scary to have a stranger move your body part that just underwent surgery! My biggest lessons were to carefully explain what you will be doing when moving the injured body part and communicate why the movement is essential.
My ACL reconstruction surgery was a life-changing experience. Those first critical weeks of recovery were vital to my eventual outcome. In the future, I’ll explain a little more about my rehab process and what the next stages were like (hint—it was definitely more fun)!
(1) Kaplan Y. Identifying individuals with an anterior cruciate ligament-deficient knee as copers and noncopers: a narrative literature review. The Journal of orthopaedic and sports physical therapy. 2011; 41(10):758-66. [pubmed]
(2) Kim KM, Croy T, Hertel J, Saliba S. Effects of neuromuscular electrical stimulation after anterior cruciate ligament reconstruction on quadriceps strength, function, and patient-oriented outcomes: a systematic review. The Journal of orthopaedic and sports physical therapy. 2010; 40(7):383-91. [pubmed]