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167 | DVTs - A Red Flag Often Missed After ACL Surgery · The ACL Athlete Podcast

• 0:19
  SPEAKER_00: Welcome everyone to the ACL Athlete Podcast.
• 0:23
  SPEAKER_00: This is the podcast where we talk about everything related to the ACL, whether that's the injury itself, the rehab process, return to sport, and more.
• 0:33
  SPEAKER_00: I'm your host, Dr.
• 0:34
  SPEAKER_00: Ravi Patel, performance physical therapist and coach.
• 0:38
  SPEAKER_00: Between myself and fellow guests and experts, you'll learn through the lens of the patient, the healthcare professional, and the coach.
• 0:46
  SPEAKER_00: The goal of this podcast is to equip you, the athlete, with the education to make the best informed decision about your care and your ACL journey.
• 0:57
  SPEAKER_00: Thanks for joining.
• 0:58
  SPEAKER_00: Now let's dive into today's episode.
• 1:04
  SPEAKER_00: What is up, team, and welcome back to another episode on the ACL Athlete Podcast.
• 1:10
  SPEAKER_00: So to kick this thing off, we're going to start with a disclaimer because this is something that people can take quite too literally as medical advice.
• 1:18
  SPEAKER_00: So this is purely educational purposes only.
• 1:22
  SPEAKER_00: So take the information, inform yourself, and then when in doubt, ask your healthcare provider because some of you are going to listen to this episode today.
• 1:30
  SPEAKER_00: You might be post op, you might be feeling pain, and associate it with what we're going to talk about today, which is DVTs.
• 1:37
  SPEAKER_00: So don't freak out.
• 1:38
  SPEAKER_00: Listen to the episode.
• 1:40
  SPEAKER_00: Inform yourself, educate yourself.
• 1:42
  SPEAKER_00: If you're still concerned, then ask your healthcare provider.
• 1:45
  SPEAKER_00: And much of what I'm going to reference today from the educational components are going to be from the CDC.
• 1:52
  SPEAKER_00: That way we know where the resources are coming from.
• 1:55
  SPEAKER_00: I'll be referencing a research study particular to DBTs in ACL rehab.
• 2:00
  SPEAKER_00: So that way we know where these are referenced from.
• 2:04
  SPEAKER_00: So let's go ahead and dive in.
• 2:06
  SPEAKER_00: So DBT, a deep vein thrombosis, aka a blood clot.
• 2:12
  SPEAKER_00: Now, this can seem pretty alarming or triggering for some people, you know, create some worry as I had mentioned.
• 2:18
  SPEAKER_00: Don't freak out yet.
• 2:19
  SPEAKER_00: Make it through the episode and let's just kind of talk about it.
• 2:23
  SPEAKER_00: So why am I doing this episode?
• 2:25
  SPEAKER_00: And the title of this is DBTs, a red flag often missed after ACL surgery.
• 2:31
  SPEAKER_00: At this point, I've had a lot of reps talking with ACLers through consultations, working together.
• 2:37
  SPEAKER_00: And I think it is my own goal to make sure I share the information that I receive from the number of people that I talk to, the volume, the things that I see consistently, things that are myths and things that are basically helping you as the ACLer, especially, or potentially clinician and coach, to equip you with the information to make better decisions.
• 3:00
  SPEAKER_00: And so I think I need to do my due diligence here to make sure that you guys are aware of this topic because I think it's something that does get missed.
• 3:08
  SPEAKER_00: So my goal is to make sure I share this education so you can get in front of these problems, most importantly, so you can have a smooth process.
• 3:16
  SPEAKER_00: So one roadblock I often hear about is DVTs immediately post op.
• 3:22
  SPEAKER_00: It's something that gets overlooked.
• 3:24
  SPEAKER_00: People are not educated on it.
• 3:26
  SPEAKER_00: They assume that it's like very rare to happen, if you will.
• 3:30
  SPEAKER_00: And it can honestly turn into something that is a big deal if it's not managed and delay your ACL rehab as a whole.
• 3:38
  SPEAKER_00: So what often happens in this situation is people have their ACL surgery.
• 3:44
  SPEAKER_00: They get discharged to go home with sheets of paper, right?
• 3:46
  SPEAKER_00: Everyone is probably nodding their head if you're in this process or I've gone through it.
• 3:50
  SPEAKER_00: It's just information, instructions around some of the things that happened in your surgery, some things to look out for.
• 3:58
  SPEAKER_00: Maybe it is a DBT, maybe it's not.
• 4:01
  SPEAKER_00: Um, it's usually stuffed in there with all the papers along with maybe some of those post-op exercises.
• 4:06
  SPEAKER_00: So then you're off on your own, really.
• 4:09
  SPEAKER_00: You may have a follow-up with your surgeon's office or PT immediately after the surgery, or it might be days or weeks or even months.
• 4:18
  SPEAKER_00: You guys think I'm kidding, but this literally happens.
• 4:21
  SPEAKER_00: Talk to people who it's been a month, two months since they last saw their surgeon, or the healthcare provider because they said you need to be in locked in an embrace for X period of time.
• 4:30
  SPEAKER_00: And we're talking about like different parts of the earth, like different countries, there's different operating procedures.
• 4:36
  SPEAKER_00: It's wild, y'all.
• 4:38
  SPEAKER_00: It is the wild, wild west.
• 4:39
  SPEAKER_00: That's what I say about healthcare, especially with ACL rehab, because there's so many different ways of going about doing it, and most of them are a little bizarre.
• 4:49
  SPEAKER_00: But with that said, what is often missed is looking out for red flags, especially immediately after post op.
• 4:55
  SPEAKER_00: They might tell you about managing the wounds, as I had mentioned, and looking for infection given the surgery and the incision sites.
• 5:03
  SPEAKER_00: That's something that is very apparent.
• 5:05
  SPEAKER_00: You look down and you see those incisions, you want to protect those incisions, you don't want to get them underwater, you want to make sure that you're not bleeding, not any like weird signs and symptoms of infection.
• 5:15
  SPEAKER_00: So those are things that are a little bit more obvious and maybe a little bit more stressed.
• 5:20
  SPEAKER_00: One red flag that often gets overlooked, though, is signs of a DVT.
• 5:26
  SPEAKER_00: So let's talk about what a DBT is.
• 5:29
  SPEAKER_00: And so, as I had mentioned, a DBT is a deep vein thrombosis, aka a blood clot, in your vein, typically deep below the skin.
• 5:38
  SPEAKER_00: That's where the DBT comes from.
• 5:40
  SPEAKER_00: And one thing I want to share first is this study to help understand the rates of DBTs and also what are PEs or called pulmonary embolisms.
• 5:50
  SPEAKER_00: So the name of this study is rates of deep venous thrombosis or DBT and pulmonary embolus or PE after ACL reconstruction or anterior cruciate ligament reconstruction.
• 6:04
  SPEAKER_00: It's by Erickson and company in 2015.
• 6:08
  SPEAKER_00: So what they did is they took six studies, a total of 692 patients, 488 of those people were men.
• 6:16
  SPEAKER_00: And then uh the other difference is women.
• 6:20
  SPEAKER_00: And then when we look at these people, they all underwent ACL reconstruction.
• 6:25
  SPEAKER_00: No patient received postoperative pharmacological anticoagulation, so basically things to thin the blood or to help with preventing a DVT or PE.
• 6:36
  SPEAKER_00: And to back this up for a second, DVT is something where it's in the lower body typically in this situation.
• 6:44
  SPEAKER_00: And when we talk about pulmonary embolism, that is something where the clot can break free and then move towards your lungs.
• 6:51
  SPEAKER_00: And so in this study, it was just kind of looking at a multitude of studies, and basically it said that out of the 692 patients, 58 patients or 8.4% had a DBT, 81% of them below the knee, and 19% above the knee, which is pretty common when you get a DBT, it's usually, I would say, in the calf area, but not always, as even this study shows.
• 7:19
  SPEAKER_00: One patient or 0.2% had a symptomatic pulmonary embolism.
• 7:25
  SPEAKER_00: And then when reported, 27% of the DVT episodes were symptomatic.
• 7:31
  SPEAKER_00: The rate of DBT after A cell reconstruction in patients who did not receive postoperative pharmacological anticoagulation, no medicine to help the DVTs or with the PEs is 8.4%, as I mentioned.
• 7:45
  SPEAKER_00: The rate of symptomatic pulmonary embolism, 0.2%.
• 7:49
  SPEAKER_00: And DBT episodes that did occur, 73 were asymptomatic.
• 7:53
  SPEAKER_00: So the DBTs that people had, most people did not feel symptoms with that, right?
• 7:58
  SPEAKER_00: So 58 out of the 692 patients that were pulled from these studies is how many had a DVT.
• 8:07
  SPEAKER_00: So what I want to kind of point out here is that that's just not a nothing number, right?
• 8:11
  SPEAKER_00: It's not like it's like just two people.
• 8:13
  SPEAKER_00: It's a decent amount for us to understand that it does happen, right?
• 8:17
  SPEAKER_00: So it's good to be on the lookout.
• 8:19
  SPEAKER_00: And DVTs, as I mentioned, can be common in the lower body.
• 8:23
  SPEAKER_00: And when we talk about how it happens, basically blood isn't flowing properly and can slow down, especially post op.
• 8:31
  SPEAKER_00: You can get a clot, you just had a major surgery, there's swelling, there's immobility, lack of movement.
• 8:36
  SPEAKER_00: And this can lead to blood to just pull and decrease the speed of the return back up our venous system, since our muscles help act as a pump.
• 8:46
  SPEAKER_00: And so if we're not using those muscles as we are, you know, walking and doing our normal day-to-day stuff, then blood can just kind of hang out a little bit and it can pull, and that's where clots can form.
• 8:59
  SPEAKER_00: And so what's important here is to understand when the clot forms, it can partially or completely block the blood flow, whether that is within the calf itself, depending on that clot forming.
• 9:13
  SPEAKER_00: And the reason why it's a big deal and why do we care, as I had mentioned, this can break loose and travel to the heart and the lungs.
• 9:21
  SPEAKER_00: When it blocks the blood flow to the lungs, it can lead to a pulmonary embolism, which is probably the most common route, which can be a big issue.
• 9:29
  SPEAKER_00: But again, don't freak out.
• 9:31
  SPEAKER_00: You just want to keep this on the radar if you're approaching surgery or in that fresh one to roughly 10 to 14 day window, typically.
• 9:40
  SPEAKER_00: So, what I want to point out are some signs of a DBT and a PE.
• 9:44
  SPEAKER_00: So then that way you could have that on the radar just in your arsenal to understand, all right, what are you feeling?
• 9:50
  SPEAKER_00: Should you worry about it?
• 9:52
  SPEAKER_00: Should you not?
• 9:52
  SPEAKER_00: So, signs of a DBT, pain in your leg, often the lower leg, common spot is the calf.
• 9:58
  SPEAKER_00: A lot of times people will complain of kind of pain behind the knee, but mostly in that calf area.
• 10:04
  SPEAKER_00: And then they will have swelling outside of just the knee joint itself.
• 10:08
  SPEAKER_00: Common spot is that lower leg.
• 10:10
  SPEAKER_00: They will have tenderness in that calf area, and there will be some redness of the skin.
• 10:15
  SPEAKER_00: For a pulmonary embolism, some signs and symptoms are difficulty breathing, faster than normal or a regular heartbeat, chest pain, or discomfort, which usually worsens with a deep breath or coughing, coughing up blood, very low blood pressure, lightheadedness, or fainting.
• 10:33
  SPEAKER_00: And this is something that I know it all seems like alarming stuff.
• 10:37
  SPEAKER_00: It probably seems like, you know, you hear those random prescription drugs on TV, and you're like, you know, nausea and digestion, all these things like that seem very life-threatening, right?
• 10:47
  SPEAKER_00: And so this is something that I think is just important to share.
• 10:51
  SPEAKER_00: And it's something that we could do a better job of as a medical system as a whole.
• 10:56
  SPEAKER_00: Um, one of my best friends, his dad had a procedure, and he was never really communicated about the signs of a DVT, right?
• 11:04
  SPEAKER_00: And he kind of lives in an isolated area.
• 11:07
  SPEAKER_00: His wife wasn't home.
• 11:08
  SPEAKER_00: And so he just kind of carried on because he just thought it was just like some normal like discomfort in his calf, and it just kind of picked up over time.
• 11:17
  SPEAKER_00: And then eventually he did start to have these symptoms of difficulty breathing and irregular heartbeat, chest pain, things of that nature.
• 11:25
  SPEAKER_00: And what happened is he had a DBT and it broke off and it moved its way towards his lungs.
• 11:30
  SPEAKER_00: And this is something that's alarming, right?
• 11:33
  SPEAKER_00: It's something that, you know, in your gut, you're like, this doesn't add up right.
• 11:37
  SPEAKER_00: And when I talked to my friend's dad, when I talked to the wife, they were never really communicated about looking out for these things.
• 11:46
  SPEAKER_00: And while this can happen with post-op ACL, it can happen with anything post-op, especially when you're immobile or you're not moving around as much.
• 11:54
  SPEAKER_00: It's something that we want to look out for.
• 11:58
  SPEAKER_00: And I think because there is so much information to maybe share with the patient, maybe the patients out of it, maybe the caregivers and paying attention, those things can happen too.
• 12:09
  SPEAKER_00: A lot of times, what I do see is that it's just a sheet of paper that goes into there because the odds are lower of it happening, it might not get discussed.
• 12:17
  SPEAKER_00: But this could be truly something that really makes a huge difference, whether it's your ACL rehab or even more seriously, your life, right?
• 12:26
  SPEAKER_00: And I don't like to go to super big extremes here.
• 12:29
  SPEAKER_00: And while this is still a small percentage, as you guys saw, even with that study, it's something that I do see quite commonly with ACLers that I talk to with consultations.
• 12:42
  SPEAKER_00: And this is something that I think is important enough to record a podcast episode over.
• 12:47
  SPEAKER_00: So I just want to go through some common treatments, what you could do to set yourself up for success to prevent one of these.
• 12:54
  SPEAKER_00: If you are someone who is approaching surgery, or maybe you are listening to this immediately after surgery or in that sweet 10 to 14 day window, right?
• 13:04
  SPEAKER_00: So, most common treatment is blood thinners, thin your blood, so then that way the clock can wear off.
• 13:08
  SPEAKER_00: Um, nothing is getting stuck there, compression stockings to help compress the fluid and move that back up.
• 13:15
  SPEAKER_00: What can you do to best set yourself up to prevent one of these post op?
• 13:20
  SPEAKER_00: Movement.
• 13:21
  SPEAKER_00: Movement is key.
• 13:23
  SPEAKER_00: Being still embedridden in a sense is what makes DVTs want to form.
• 13:28
  SPEAKER_00: So you want to integrate as much movement as possible without, of course, overdoing it.
• 13:32
  SPEAKER_00: Exercises are key here.
• 13:34
  SPEAKER_00: Big reason why everyone gets those ankle pump exercises.
• 13:37
  SPEAKER_00: People are probably always wondering why am I doing these ankle pumps all day?
• 13:41
  SPEAKER_00: So that helps with blood flow and muscle activity to help blood flow and to return back our venous system.
• 13:49
  SPEAKER_00: And so that's something that is super common.
• 13:51
  SPEAKER_00: We give people in the hospital, post op ACL, just things to help people continue to keep moving, get that calf muscle working to help pump fluid right back up our system, because that's the way that our venous system works, especially in the lower body.
• 14:05
  SPEAKER_00: And so this is something that you want to make sure you're working on.
• 14:09
  SPEAKER_00: I mean, we have athletes do this like every single hour, and you're doing like, you know, 50 reps, 100 reps.
• 14:16
  SPEAKER_00: It's just something that you could do just kind of passively as you are sitting or as you're laying down, whatever it is, postop to be able to keep that muscle pump going.
• 14:26
  SPEAKER_00: The other thing you can do is compression, as I had mentioned, to help prevent fluid from building up and to allow that to kind of flow back or return to where it needs to go through to the heart and to the lungs, right?
• 14:39
  SPEAKER_00: The most important point of this episode for you to take away is basically the preventative measures ahead of time and knowing those things and to know the signs and symptoms and be educated on them.
• 14:52
  SPEAKER_00: As I had mentioned, I've had a number of ACLers who I've consulted and they said, well, my first one, two months got derailed because I had a DVT, something they weren't warned about, and they had to slow things down and typically avoid any higher intensities and strenuous activities while also probably being on blood thinners.
• 15:12
  SPEAKER_00: And this is something that it's not just like one in every, you know, few hundred ACLs.
• 15:18
  SPEAKER_00: It happens more than we think.
• 15:20
  SPEAKER_00: So this is just something that is important to put on the radar for our ACLers, for the people who are working with them.
• 15:28
  SPEAKER_00: And that way you can get in front of it, especially if it's a DVT, because a DVT progresses into a PE.
• 15:34
  SPEAKER_00: So if we can get in front of it with a DVT happening, well, cool, we can prevent this cascade of events that could lead to a more serious problem, right?
• 15:43
  SPEAKER_00: Now, here's your reminder as we near the end of this episode.
• 15:47
  SPEAKER_00: I know this is a little bit different for everyone who's listening, but this is one that I wanted to put out there because I think it is something that could make or break a difference, even if it's one of you listening and you're like, this really helps me to make sure it didn't turn into something big.
• 16:03
  SPEAKER_00: It didn't make me freak out, or I was able to impact my recovery by getting in front of it, and therefore I didn't have a one to two month delay of getting back to doing certain activities you wanted to.
• 16:14
  SPEAKER_00: To me, that's a home run.
• 16:16
  SPEAKER_00: So, this is my reminder and disclaimer for this episode that this is not medical advice, it is just for educational purposes.
• 16:24
  SPEAKER_00: If you feel concerned, give your healthcare provider a call.
• 16:28
  SPEAKER_00: Worst case, they say you're fine.
• 16:30
  SPEAKER_00: Best case, you get in front of this and don't let it turn into something like a PE, needing to go to the ER, which is just a whole mess in and of itself.
• 16:38
  SPEAKER_00: And the last thing you want to do is slow down your ACL rehab any more than it needs to because of how long this process is.
• 16:46
  SPEAKER_00: So I hope that this was informative team.
• 16:49
  SPEAKER_00: It is something that can get missed, but something to just be aware of post op, along with the other things that you need to keep up with.
• 16:57
  SPEAKER_00: And ideally, you are seeing your surgeon's office, you are seeing your physical therapist that you can check in with to make sure.
• 17:05
  SPEAKER_00: We've had remote athletes where we have had this come up and it's using every preventative measure in the book, but that doesn't necessarily mean that you will not get it.
• 17:16
  SPEAKER_00: There's not a hundred percent prevention of this.
• 17:18
  SPEAKER_00: Some people are just a little bit more prone to this, and so we want to make sure we can get on front of this as much as possible because maybe there's genetics tied to this, there's a history of this, and it can be something that can be left unattended to, like my friend's dad or some of the ACLers we have worked with or have consulted with, and it's something that can impact things in the long run, especially because you want to just kind of get out of this post-op phase and you want to kind of get back to your normal life.
• 17:49
  SPEAKER_00: Well, this is one additional thing you can equip yourself with to make sure that you minimize your risk of it.
• 17:55
  SPEAKER_00: But then also, if, for example, this does happen to you, you can prevent it from turning into something more major like a PE.
• 18:04
  SPEAKER_00: So if you have any questions here, reach out to us.
• 18:08
  SPEAKER_00: If it's something that you're concerned with, definitely consult your medical provider you are working with.
• 18:14
  SPEAKER_00: And worst case, they just say you're good and you can keep carrying on.
• 18:19
  SPEAKER_00: But it's good to be informed about things, be your own advocate, as I always say, in this ACL rehab process.
• 18:27
  SPEAKER_00: Until next time, team, this is your host, Robbie Patel, signing off.