Latest / The ACL Athlete Podcast / 162 | Should You Push Through Pain in ACL Rehab?

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162 | Should You Push Through Pain in ACL Rehab? · 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, guys, and welcome back to another episode on the ACL Athlete Podcast.
• 1:10
  SPEAKER_00: We are on episode 162, 162 weeks straight rolling.
• 1:17
  SPEAKER_00: Should you push through pain in ACL rehab?
• 1:20
  SPEAKER_00: This is a question I get all the time from ACLers.
• 1:24
  SPEAKER_00: I think there's this typical work hard stigma of no pain, no gain.
• 1:30
  SPEAKER_00: I remember hearing this in high school and thinking, yeah, push harder, you know, but it's all within context.
• 1:36
  SPEAKER_00: Sure, as humans, you have to embrace some discomfort to grow, whether that's mentally, physically, etc., right?
• 1:43
  SPEAKER_00: I'd say this is better suited for people who aren't going through an actual physical injury because the lines can get blurred here.
• 1:51
  SPEAKER_00: Now, I want to provide some context here to help kind of set the stage for this episode.
• 1:56
  SPEAKER_00: So I got an email from an ACLer saying they're eight weeks post-op, still dealing with pain, and feel like they just need to bear down and accept the pain and push through it.
• 2:07
  SPEAKER_00: And this can be especially true from what I see and hear from people who are further out in their ACL reconstructive process or post-surgery because they feel they should be further along.
• 2:18
  SPEAKER_00: So then they start resorting to more aggressive options while it might not be the best for their situation.
• 2:25
  SPEAKER_00: And then the other thing I want to mention here is that I got tagged in a bunch of Neymar's videos, the one where he's like just crying and cussing and screaming, and it's a video of his team working on his range of motion.
• 2:38
  SPEAKER_00: I'm sure some of you listening have probably seen this.
• 2:41
  SPEAKER_00: And the thing that sucks about this is it's just a terrible example of how this process should look.
• 2:46
  SPEAKER_00: And especially from one of the best soccer players in the world.
• 2:50
  SPEAKER_00: Now, I don't know his situation or case.
• 2:53
  SPEAKER_00: No athlete should ever be held down and pushed through something like that for their rehab.
• 2:58
  SPEAKER_00: It shares also the wrong message, especially when you think about our youth athletes, you know, our teenagers and people going through this who are super young who are like, man, this is the best player in the world.
• 3:09
  SPEAKER_00: And maybe they really love him.
• 3:11
  SPEAKER_00: And this is what they're doing.
• 3:12
  SPEAKER_00: I have an ACL surgery, so maybe this is what I should be doing.
• 3:16
  SPEAKER_00: So then they start bearing down and pushing through pain, or having, you know, their friends or whoever rehab professionals really pushing down on them and gritting through it when this is something that is not honestly healthy and could actually be counterintuitive to being able to progress in this process.
• 3:36
  SPEAKER_00: And so that's where I want to answer this question should you push through pain in ACL rehab?
• 3:42
  SPEAKER_00: Now, this is not an easy question to answer because pain operates in the gray area.
• 3:49
  SPEAKER_00: So there's no black and white answer of should you push through pain?
• 3:52
  SPEAKER_00: Yes.
• 3:52
  SPEAKER_00: Should you push through pain?
• 3:53
  SPEAKER_00: No.
• 3:54
  SPEAKER_00: It's actually just kind of like a it depends, and we're gonna try and answer that as best as we can.
• 3:59
  SPEAKER_00: But first thing is first, we don't need to demonize pain as bad.
• 4:04
  SPEAKER_00: Just know it's a normal response from our body giving it to you for some reason, right?
• 4:09
  SPEAKER_00: Some people refer to it as an alarm.
• 4:12
  SPEAKER_00: And the thing that I want to kind of press on you is could you imagine if we didn't feel pain at all?
• 4:18
  SPEAKER_00: On initial thought, that sounds awesome.
• 4:20
  SPEAKER_00: Don't feel any discomfort, and especially as I'm getting older, I'm starting to feel things here or there.
• 4:25
  SPEAKER_00: And so I'm like, oh, that sounds great.
• 4:27
  SPEAKER_00: But what if you stepped on a nail?
• 4:29
  SPEAKER_00: You'd never know, and then it'd probably get infected, and then you probably have to lose your foot or something.
• 4:34
  SPEAKER_00: So pain is actually good because it lets us know it's kind of this like alarm that lets us know something is going on.
• 4:42
  SPEAKER_00: And so then we need to tend to it in some degree.
• 4:44
  SPEAKER_00: Plus, with ACL injury and surgery, you just had some major changes to the knee.
• 4:49
  SPEAKER_00: That's normal to feel the pain, and it's normal for that to be a bit heightened too.
• 4:54
  SPEAKER_00: Now, I'm going to bring this back around to saying that there is a sweet spot on pushing through this pain.
• 5:00
  SPEAKER_00: Can't wait for pain to be completely gone because you might be waiting a really, really long time.
• 5:06
  SPEAKER_00: You think about it, you had a ACL injury, and then you had a ACL reconstruction.
• 5:12
  SPEAKER_00: If you fall into this category, so you had two major knee traumas.
• 5:17
  SPEAKER_00: And for you to wait until the pain is completely gone, you would wait for a long time because when we think about just the healing process of our biology and how that works, it can range anywhere from you know two to four weeks to something major like this.
• 5:32
  SPEAKER_00: You are looking at weeks and weeks and months.
• 5:34
  SPEAKER_00: And if we talk about even the ligament or the ACL graft itself, man, that thing is continuing to turn into a ligament after a year, up until two years, based on what we see through the ligamentization process.
• 5:47
  SPEAKER_00: Um, when we look at the research.
• 5:49
  SPEAKER_00: And so, with that said, though, when we're thinking about pain, we're also thinking about that kind of initial acuteness of the surgery itself or the injury, right?
• 5:59
  SPEAKER_00: And so this is something that's really normal, and we obviously want this to come down, but here's where we're gonna kind of talk about the pushing through pain and making sure that we kind of find this sweet spot, if you will.
• 6:12
  SPEAKER_00: And so this is where we just want to make sure we just don't go ham immediately after a post op.
• 6:19
  SPEAKER_00: So I know for my aggressive athletes or who want to get on the move with it, um, they're doing all the things nonstop, right?
• 6:25
  SPEAKER_00: And you might be a no pain, no gain type person.
• 6:28
  SPEAKER_00: The thing that can happen though is if you try to push through it, there can be this like negative feedback loop that can be created, right?
• 6:36
  SPEAKER_00: You're feeling pain, and maybe you're like, all right, I'm sick of this, I'm just gonna bear down and and and push through it.
• 6:42
  SPEAKER_00: And so when you do that, the knee can react negatively by sending more pain and swelling.
• 6:48
  SPEAKER_00: And then as a chain reaction to that, you have to back off because of the increase in that pain and swelling.
• 6:54
  SPEAKER_00: You're kind of back in that same spot, and you have to decide to send it again, and then you repeat the cycle again, right?
• 7:03
  SPEAKER_00: And so this is something that we commonly hear about, and it's not good.
• 7:07
  SPEAKER_00: And I know many Asailers we talk to find themselves in this kind of negative feedback loop where they do push through that pain because they don't feel like they're moving as quickly as they should be, or they just want to be aggressive and push through it.
• 7:20
  SPEAKER_00: Then yeah, they have that increase in swelling and pain, or the knee reacts negatively.
• 7:25
  SPEAKER_00: You have to almost like take a step back because the knee has reacted and you're in pain and swelling.
• 7:32
  SPEAKER_00: So then, therefore, you have no choice but to reduce what you were doing, and then you're back to that kind of like that same baseline.
• 7:39
  SPEAKER_00: So you're almost like, you know, one step forward, one step back, or sometimes it's almost like one step forward, two steps back is probably what it feels like most of the time.
• 7:47
  SPEAKER_00: And so it's this kind of negative feedback loop that people can get stuck in in this like cycle.
• 7:52
  SPEAKER_00: And so this is where we want to make sure we can find the sweet spot.
• 7:56
  SPEAKER_00: And this can be a little bit of a moving target, but think about it just like Goldilocks principle, right?
• 8:03
  SPEAKER_00: So, Goldilocks, they went to the house and tried to find the porridge that was not too hot, not too cold, and it was just right.
• 8:11
  SPEAKER_00: And this does take a little bit of trial and error.
• 8:14
  SPEAKER_00: And the thing that I always encourage my athletes and our athletes within the team to do is think about this.
• 8:21
  SPEAKER_00: And I've I've used this before, but I think it's so helpful in this process, is that thinking about the steak analogy.
• 8:28
  SPEAKER_00: So you got a steak.
• 8:29
  SPEAKER_00: I'm sorry if you're vegetarian, but you probably know this regardless, is that when you cook a steak, there's a certain temperature people like, right?
• 8:36
  SPEAKER_00: There's rare, medium, rare, medium, all the way to well done, right?
• 8:41
  SPEAKER_00: And so the thing is, is that it can be tricky sometimes to figure out when a steak is done.
• 8:47
  SPEAKER_00: And this can go for a lot of just kind of general food, baking, whatever it is.
• 8:52
  SPEAKER_00: But the thing is, is that as you're cooking the steak, if you had to lean one way or another, would you rather overcook the steak or undercook it?
• 9:00
  SPEAKER_00: I'll let you kind of think about that for a second.
• 9:04
  SPEAKER_00: Likely you want to lean towards undercooking it.
• 9:08
  SPEAKER_00: Why?
• 9:09
  SPEAKER_00: Because if you overcook it, you've already sent it, you've overcooked it, there's no going back.
• 9:14
  SPEAKER_00: There's nothing you can do about it.
• 9:16
  SPEAKER_00: You've overdone it, the steak is well done, well well done, and that's just where you're at.
• 9:22
  SPEAKER_00: You gotta either go get a new steak or just eat the steak, right?
• 9:25
  SPEAKER_00: But if you have an undercooked steak, guess what?
• 9:28
  SPEAKER_00: You get to check it, you can kind of check in and see how the temp looks, what does the outside look, just to make sure.
• 9:34
  SPEAKER_00: And if you're like, I don't think uh it's to the right point yet, you're just gonna throw it back on the grill in the oven, on the cast iron, whatever you're cooking it on, and you're just gonna get it up to the right temperature.
• 9:46
  SPEAKER_00: So the beauty is that you can adjust based on undercooking it, versus if you overcook it, you've already full sent it and you just don't really have any choice.
• 9:56
  SPEAKER_00: And so the same thing here that I encourage my athletes to do is that you know, find a certain sweet spot that typically is guided by your physical therapist or performance coach, whoever you're working with at the time.
• 10:07
  SPEAKER_00: And any good one is gonna tell you this, but it's to find that sweet spot.
• 10:11
  SPEAKER_00: But you got to kind of find a certain dosage that is gonna be helpful to move the needle forward, what we call minimum effective dose.
• 10:19
  SPEAKER_00: So that's just the minimum amount needed to be able to make changes for the right dosage that you're given for a particular exercise or adaptation we're looking for.
• 10:30
  SPEAKER_00: And so, with that said, you know, if we're doing a certain set of exercises or movements, I would rather lean towards underdoing it or undercooking it, because then if I listen to my body, I'm like, okay, let me see how it feels.
• 10:43
  SPEAKER_00: Well, if it responds positively, well, cool.
• 10:46
  SPEAKER_00: Like we at least know we're in a good area.
• 10:49
  SPEAKER_00: But if you go full send on knee flexion, trying to walk around a ton, thinking that's going to be better, trying to extend your knee all the time, and thinking that that's also gonna be really beneficial.
• 11:00
  SPEAKER_00: There's a certain threshold where the knee is like, hey, I'm I'm not good with this.
• 11:04
  SPEAKER_00: And so then therefore, once you do send it, you don't really have a choice but to wait.
• 11:10
  SPEAKER_00: You have to let biology do its thing, let the knee calm back down.
• 11:13
  SPEAKER_00: And it could have been time that you could have dedicated towards allowing the knee to improve slowly and chipping away at it brick by brick, versus like going hardcore all in and then having to take that step back because the knee is flared up.
• 11:27
  SPEAKER_00: And everyone who is in this ACL react process usually experiences some sort of flare-up of some degree, and take that as a data point to learn about your body and understanding where is that sweet spot and while factoring in the other big things as well.
• 11:42
  SPEAKER_00: How is your sleep going?
• 11:43
  SPEAKER_00: How's your nutrition?
• 11:44
  SPEAKER_00: How is your stress management?
• 11:46
  SPEAKER_00: How is your overall movement doing, right?
• 11:49
  SPEAKER_00: So those are the big bucket items that we're looking at just to make sure that we're not leaving uh any bucket unchecked or unfilled, if you will.
• 11:58
  SPEAKER_00: And so this is where it's important.
• 12:00
  SPEAKER_00: So the rule of thumb here is to undercook it versus overcook it because you can always add more.
• 12:05
  SPEAKER_00: You could always put it back on the grill, you could always add more volume to it and intensity to be able to see if you did need more.
• 12:12
  SPEAKER_00: But if you start with too much, you just gotta wait.
• 12:15
  SPEAKER_00: And that's what sucks.
• 12:17
  SPEAKER_00: But this is not gonna be you because if you're been listening to this podcast for a minute, we're gonna make sure that you have some of the information you need to make sure that you can at least be prepared about answering this question.
• 12:32
  SPEAKER_00: Should you push through pain?
• 12:33
  SPEAKER_00: And I've touched on this subject many of a times, and here are some podcast episodes to specifically check out to help you, especially if you're new listening to the podcast.
• 12:43
  SPEAKER_00: So episode 13, why is your knee swelling?
• 12:46
  SPEAKER_00: And then we are looking at four ways to improve your knee swelling.
• 12:50
  SPEAKER_00: So that's a follow-up to make sure that you have some strategies to improve that effusion in your knee, that swelling.
• 12:56
  SPEAKER_00: Episode 14 and 15, dealing with pain and acle rehab, part one, dealing with pain and acale rehab part two, which is episode 15.
• 13:05
  SPEAKER_00: There are other ones where we talk about pain.
• 13:09
  SPEAKER_00: And so I want you to just kind of roll through the podcast, but these are good starting points for you to figure out what are some guiding kind of lights around this.
• 13:19
  SPEAKER_00: And the other thing we talk about is the phases that you're in, right?
• 13:23
  SPEAKER_00: And so looking at early versus mid and late stages, if you're in early, you're probably doing a little bit more of this kind of protection type mode versus like as you get further into the early phases and into mid and late stages, it's exposing you.
• 13:38
  SPEAKER_00: So we call this the protect expose continuum that I learned from Greg Lehman.
• 13:42
  SPEAKER_00: And this is essentially, you know, when you're post-op or post-injury, there's a little bit of protection going on.
• 13:47
  SPEAKER_00: You don't want to exacerbate and stress the knee, you want to allow that healing process to take place, but slowly kind of dose in the things that you need for that time being to make sure you're not just fully just letting it go and that it's just quote unquote in this healing process.
• 14:03
  SPEAKER_00: So there's a way to integrate some things that you need without trying to red light this thing or being able to push high into pain, and then you have to just kind of wait for things to kind of settle back down.
• 14:16
  SPEAKER_00: The Goldilocks principle, as I talked about earlier, finding that sweet spot, and that's a little bit of trial and error.
• 14:21
  SPEAKER_00: If you take that undercooking kind of framework and uh principle, then you can essentially find that sweet spot as you go and then just kind of slowly add to it over time.
• 14:33
  SPEAKER_00: And look, this is a nine to 12 month process.
• 14:36
  SPEAKER_00: You don't have to go ham in month one.
• 14:37
  SPEAKER_00: Like you're gonna lose this battle if you try to just go crazy in month one because you got a long, long time to go.
• 14:45
  SPEAKER_00: So find that sweet spot, continue to readjust and audit this process, especially with a provider you're working with, that is gonna be so key.
• 14:54
  SPEAKER_00: The traffic light feedback loop is so important.
• 14:57
  SPEAKER_00: That's where we do the red, yellow, green based on kind of like your pain levels and what you're feeling, the type of pain you're feeling, especially avoiding any sharp type pains.
• 15:07
  SPEAKER_00: You have the 24-hour feedback loop, which is just checking in to see how your symptoms and that profile is doing within the 24-hour period.
• 15:16
  SPEAKER_00: It might be 36 to 48 hours for you, depending on your knee.
• 15:19
  SPEAKER_00: But we use just that 24-hour feedback loop, load management.
• 15:23
  SPEAKER_00: So managing all of your essentially stressors that you're putting through your body, especially physically.
• 15:29
  SPEAKER_00: So think about your exercises and physical therapy you're doing.
• 15:33
  SPEAKER_00: Think about the steps you're taking in a day.
• 15:35
  SPEAKER_00: Think about your just kind of daily activities that can potentially add up.
• 15:39
  SPEAKER_00: Maybe it's work-related, right?
• 15:40
  SPEAKER_00: You're a teacher, you're a nurse, maybe you are a construction worker, and this is something that you have to deal with with steps, especially think about school, right?
• 15:49
  SPEAKER_00: High school, college, you gotta take steps to get to class.
• 15:52
  SPEAKER_00: So these are things to factor into the overall stressors and overall load management of your system.
• 15:59
  SPEAKER_00: And there's so much more that we dive into into these episodes, but this is the thing where I want to make sure I just provide you essentially with the answer to this podcast.
• 16:10
  SPEAKER_00: So should you push through pain?
• 16:12
  SPEAKER_00: I am gonna kind of give you a black and white answer, but with uh, you know, kind of stipulations with that.
• 16:19
  SPEAKER_00: And the short answer is no.
• 16:21
  SPEAKER_00: There is a sweet spot though, and I'd rather you not push through pain than push through pain because pushing through pain is probably gonna lead to that negative feedback loop as I talked about, versus like if you don't push through pain, then you're probably gonna be in a relatively better spot.
• 16:38
  SPEAKER_00: But again, this is gonna be a sweet spot because I don't know anyone who's been able to just kind of move the needle without touching any type of pain early in their process because you're just dealing with a knee that's recovering from a major injury and reconstructive surgery.
• 16:52
  SPEAKER_00: You're gonna deal with some aches, pains, all these weird funky feelings in the knee, popping, swelling, all the stuff.
• 16:58
  SPEAKER_00: And so then, therefore, we need to find a sweet spot within that to be able to move forward.
• 17:03
  SPEAKER_00: And there's so many factors to consider.
• 17:05
  SPEAKER_00: But if you're like Neymar or this person who's messaged us and asked us this, along with all the ACLs who have mentioned, like, hey, like, should I push through this?
• 17:14
  SPEAKER_00: Um, I feel like I'm not making progress, X, Y, and Z, and they're feeling this pressure to do that.
• 17:19
  SPEAKER_00: Don't push through it so aggressively to a point where you're paying for it.
• 17:23
  SPEAKER_00: And at the end of the day, this is where you have to take your medical advice from your surgeon and your PT, especially, to make sure that it's accounting for your context and your case and your situation.
• 17:35
  SPEAKER_00: Um, this is not medical advice.
• 17:36
  SPEAKER_00: These are just kind of guiding educational frameworks and things that you can potentially use in your process.
• 17:42
  SPEAKER_00: Audit the process and what you're doing.
• 17:44
  SPEAKER_00: Make sure that the variables are accounted for, and maybe the ones that you haven't been accounting for that are sneaking in there.
• 17:51
  SPEAKER_00: Walking tends to be a big one.
• 17:53
  SPEAKER_00: Maybe with your work, there are certain things that you're doing that you're not realizing.
• 17:57
  SPEAKER_00: Maybe you have to take a bunch of stairs and you're like, oh, this is fine, and you're just not recovering well, or maybe it's just things your knee's not tolerating really well.
• 18:05
  SPEAKER_00: So look at those kind of like silent little symptom provokers, if you will.
• 18:11
  SPEAKER_00: But then of course, this kind of comes back to also your knee healing, to the rehab you're doing.
• 18:16
  SPEAKER_00: So many moving pieces, so many variables.
• 18:19
  SPEAKER_00: But this is where having a trusted team with you, especially a guide, a physical therapist, um, a coach in your corner to make sure you're not operating this by yourself.
• 18:30
  SPEAKER_00: And you shouldn't be answering this question alone.
• 18:34
  SPEAKER_00: This should be the thing that your provider should be answering for you and creating context around it and being specific about it, not just being like, well, you know, just do this one and this is fine, this exercise is fine.
• 18:46
  SPEAKER_00: Like, no, let's create some guiding principles behind this to help you no matter what situation you're in.
• 18:52
  SPEAKER_00: And the thing that's pretty cool is that our ACLers we work with, giving them these frameworks, these kind of guiding principles and the feedback loops, they will tell us later, you know, they finish with us, they graduate, they might incur another injury, maybe they hurt their shoulder or their back, or something else comes up.
• 19:11
  SPEAKER_00: And it's really, really cool to hear.
• 19:13
  SPEAKER_00: They're like, I just use those feedback loops that we talked about.
• 19:17
  SPEAKER_00: And they're like, I was able to kind of get out of that versus like catastrophize and freak out about it.
• 19:21
  SPEAKER_00: They're like, oh no, it's fine.
• 19:23
  SPEAKER_00: Like, I listened to my body, I undercooked it for a minute, I didn't just completely stop and rest.
• 19:28
  SPEAKER_00: You know, I was able to put these things in play and I was back at it, which is amazing.
• 19:33
  SPEAKER_00: So, my suggestion here is go listen to these episodes I mentioned.
• 19:37
  SPEAKER_00: Huge in helping navigate pain, swelling, symptoms throughout your ACL rehab.
• 19:42
  SPEAKER_00: And it's the exact ones we give our athletes to help navigate this process.
• 19:47
  SPEAKER_00: We give that to you for free.
• 19:49
  SPEAKER_00: Use it as your disposal at the end of the day.
• 19:51
  SPEAKER_00: Consult your rehab team to make sure that it falls within the lines for you.
• 19:56
  SPEAKER_00: But to answer this, should you push through the pain?
• 19:59
  SPEAKER_00: No.
• 20:00
  SPEAKER_00: But there's typically a sweet spot.
• 20:02
  SPEAKER_00: It's not a black and white answer here.
• 20:04
  SPEAKER_00: So I hope this helps, team.
• 20:06
  SPEAKER_00: Until next time, this is your host, Robbie Patel, signing off.