Latest / The ACL Athlete Podcast / 279 | Bone Bruise After an ACL Injury: What It Means for Your Rehab and Recovery

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279 | Bone Bruise After an ACL Injury: What It Means for Your Rehab and Recovery · The ACL Athlete Podcast

• 0:18
  SPEAKER_00: Welcome everyone to the ACL Athlete Podcast.
• 0:22
  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.
• 0:31
  SPEAKER_00: I'm your host, Dr.
• 0:32
  SPEAKER_00: Robbie Patel, performance physical therapist and coach.
• 0:36
  SPEAKER_00: Between myself and fellow guests and experts, you'll learn through the lens of the patient, the healthcare professional, and the coach.
• 0:43
  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.
• 0:54
  SPEAKER_00: Thanks for joining.
• 0:55
  SPEAKER_00: Now let's dive into today's episode.
• 1:00
  SPEAKER_00: What is up, y'all?
• 1:01
  SPEAKER_00: And welcome back to another episode on the ACL Athlete Podcast.
• 1:06
  SPEAKER_00: So I've got my coffee, it's in the morning.
• 1:10
  SPEAKER_00: I am excited to talk about you guessed it, bone bruising in ACL rehab.
• 1:17
  SPEAKER_00: After ACL injuries specifically.
• 1:20
  SPEAKER_00: So here's a scenario I hear about often.
• 1:23
  SPEAKER_00: So you tear your ACL, you get your MRI, your surgeon, or maybe your physical therapist looks at the report and they mention a bone bruise in there.
• 1:34
  SPEAKER_00: Maybe say something like, That's pretty common with ACL tears.
• 1:37
  SPEAKER_00: And then they move on to the conversation about surgery timing and graph choice and when you'll get back to sport and all those things.
• 1:45
  SPEAKER_00: The bone bruise gets maybe 10-15 seconds of air time.
• 1:51
  SPEAKER_00: And then for the next several weeks, you're grinding through this prehab process, you're feeling you know more swollen than you expected, there's more pain, the quads aren't firing the way it should, walking still hurts more than you thought it would.
• 2:08
  SPEAKER_00: And nobody connects those dots back to the bone bruising.
• 2:13
  SPEAKER_00: And that's what this episode is about.
• 2:15
  SPEAKER_00: It's the bone bruise, it's not just like a footnote in this process, it's a part of the journey, it's a part of the injury, and its size and location should be directly shaping how your rehab is actually being planned and the progress of it.
• 2:31
  SPEAKER_00: And when we look at this, I'm not saying the bone bruise is impacting all those things, and that's why it's all being impacted in a negative way.
• 2:40
  SPEAKER_00: It's just a part of the pie or the piece of the puzzle that we're trying to put together.
• 2:44
  SPEAKER_00: And it's something that you'll see in this episode that happens to the majority of ACL injuries, and it's just something that doesn't really get talked about very much, but I see it influence so much rehab and so much of people's expectations and progress or lack thereof because it has a kind of healing process in and of itself and is really a very important factor as to why we also think rushing into surgery is not necessarily the best idea.
• 3:15
  SPEAKER_00: So you'll hear me unpack a lot of this in this episode, but I want to just kind of share this openly because it is something that you'll see and it just kind of gets overlooked.
• 3:26
  SPEAKER_00: But let's get into what a bone bruise is.
• 3:29
  SPEAKER_00: So when you tear your ACL, your knee doesn't just, you know, tear that ligament.
• 3:34
  SPEAKER_00: There's other things that happen.
• 3:36
  SPEAKER_00: The same force that tore the ligament drives two bones into each other.
• 3:41
  SPEAKER_00: Your thigh bone, your femur, and your shin bone, your tibia, they bump into each other usually whenever the ACL injury happens.
• 3:49
  SPEAKER_00: It's at a high speed under high forces, usually, and the surface of those bones take on that impact.
• 3:56
  SPEAKER_00: Now the outer shell of the bone usually holds.
• 4:00
  SPEAKER_00: It's not something that usually fractures.
• 4:02
  SPEAKER_00: Sometimes there could be a fracture depending on if the ACL breaks off of its end, but that's a kind of a different story here.
• 4:11
  SPEAKER_00: Usually there can sometimes be fractures of the bone, but it's not very common in ACL injuries.
• 4:18
  SPEAKER_00: But the outer shell of the bone holds, and that's why on a standard X-ray, everything can look normal after an ACL tear, because there's no fractures you can see on the film.
• 4:29
  SPEAKER_00: But underneath the surface, if we go deeper than the outer shell of the bone, the internal bone structure takes a hit.
• 4:36
  SPEAKER_00: Think of it like a sponge being crushed inside that bone.
• 4:40
  SPEAKER_00: The tiny scaffolding inside the bone buckles and there's fractures in small little clusters.
• 4:47
  SPEAKER_00: The marrow space fills with blood and swelling.
• 4:52
  SPEAKER_00: Cells die inside.
• 4:54
  SPEAKER_00: I know that sounds aggressive.
• 4:55
  SPEAKER_00: That damage does show up on the MRI as what we call a bone bruise.
• 5:00
  SPEAKER_00: So, as you can imagine on the skin, the skin, if you get bruised, right, you get hit.
• 5:05
  SPEAKER_00: The skin doesn't necessarily tear, but you get bruising underneath it, and there's some bleeding underneath it.
• 5:09
  SPEAKER_00: You can kind of think of this as the same thing of what happens whenever there's a bone bruise.
• 5:15
  SPEAKER_00: The outside bone doesn't get necessarily broken, but internally there's a bruise where there is some fracturing, nothing that's going to make the bone unstable necessarily, but it is going to be something that the bone has taken some trauma.
• 5:29
  SPEAKER_00: And so then, therefore, there is a little bit of bleeding, which causes that bruising in the internal spongy kind of area, if you will, of the bone.
• 5:36
  SPEAKER_00: And here's something that's really important that's a part of this.
• 5:40
  SPEAKER_00: The cartilage sitting on top of that bone absorbs some of that impact too, even when it looks completely normal to the naked eye during surgery.
• 5:50
  SPEAKER_00: So there is something that can impact this, and it's something when we say, you know, when you have a bone bruise, it's not just like bumping your shin on a coffee table.
• 6:01
  SPEAKER_00: There's that internal bone damage that can happen, and sometimes cartilage involvement too, that can happen when you have that ACL tear as well.
• 6:12
  SPEAKER_00: And so there are actually three types of bone bruises that we will talk through.
• 6:16
  SPEAKER_00: The one most relevant after an ACL injury is what we call an intra-osseous bruise.
• 6:22
  SPEAKER_00: And I'll break that down here soon.
• 6:24
  SPEAKER_00: That's the damage that is deep in the marrow from the compressive impact.
• 6:30
  SPEAKER_00: But in more severe cases, it becomes subchondral, meaning the damage is right at the bone cartilage interface.
• 6:38
  SPEAKER_00: That's the type with the highest risk for the cartilage above it.
• 6:42
  SPEAKER_00: Now let's talk about location because this is actually one of the cooler parts of the you know ACL bone bruising process here, because I think it's just unique with the just kind of injury mechanism and what shows up.
• 6:54
  SPEAKER_00: So roughly 85% of acute ACL tears have bone bruises visible on MRI.
• 7:01
  SPEAKER_00: So majority of you are gonna have a bone bruise.
• 7:03
  SPEAKER_00: That's most 85% is a pretty strong amount, high probability.
• 7:08
  SPEAKER_00: That is not a small number with this, so we need to make sure, you know, in terms of ACL injuries and talking about this rehab, it's important to bring this up.
• 7:18
  SPEAKER_00: The most common pattern is on the lateral or the outside of the knee.
• 7:23
  SPEAKER_00: This is where that lateral tibia plateau, which is the top surface of the shin bone on the outer side and the lateral femoral condyle, the bottom of the outer thigh bone.
• 7:39
  SPEAKER_00: And so when both show up together, it's called a kissing contusion.
• 7:44
  SPEAKER_00: So if you imagine if you took your right fist and your left fist and you just brought your hands together and you're looking down at it, and let's say that we are looking at your right knee, right?
• 7:56
  SPEAKER_00: If you're looking down and you bring them both together.
• 7:59
  SPEAKER_00: If you're looking at your right knee, then what you're facing where your thumbs come together is the inside, and on the outside is where your pinkies are, right?
• 8:08
  SPEAKER_00: So when an ACL injury happens, let's just say it's happening and we're kind of recreating this moment here.
• 8:15
  SPEAKER_00: What happens is that the force, think about almost like separating your your index fingers, right?
• 8:22
  SPEAKER_00: And so then more force is going into your pinkies.
• 8:24
  SPEAKER_00: So that's kind of what happens, and so the inside actually gets less stress, and the outside, the lateral aspects of the tibia and the lateral aspects of the femur, the both those bones together, when that ACL tears, and you can kind of think about the knee kind of coming in or caving in a little bit, then the outside bones are what kind of hit together on impact.
• 8:44
  SPEAKER_00: And that's where this bone bruising can happen from that force, especially depending on how aggressive that injury is.
• 8:53
  SPEAKER_00: So this is called that kissing contusion.
• 8:56
  SPEAKER_00: And the reason this happens is directly tied to how I was sharing the ACL can tear, especially in a classic non-contact ACL injury.
• 9:06
  SPEAKER_00: You have the D cell, and then you have a valgus collapse or the knee kind of caves in a little bit, and then you have the classic pivot shift mechanism.
• 9:15
  SPEAKER_00: This is also similar to that kind of test that a lot of orthopedic surgeons will do to test if the ACL is torn, but it's a typical mechanism that puts the ACL in that vulnerable position.
• 9:26
  SPEAKER_00: The tibia shoots forward as the ligament tears, and the outer edge of your thigh bone slams into the back of the outer tibule plateau.
• 9:36
  SPEAKER_00: So basically, that thigh bone is hitting that tibia, and the bruises are going to be essentially creating that imprint of how that collision happened.
• 9:45
  SPEAKER_00: And so the degree of knee flexion at that moment of injury, so how much your knee is bent, is actually going to influence exactly where that bone bruise is landing, especially on the lateral femoral condyle.
• 10:00
  SPEAKER_00: If the knee was more extended, the bruise might sit more towards the front, more flexed, and it might sit a little bit further back.
• 10:07
  SPEAKER_00: But that's how these bruises can kind of tell, okay, how much knee flexion was the knee in when the injury happened.
• 10:14
  SPEAKER_00: And when you see bruising on the medial side of the knee, then that is something that we probably want to pay a bit more attention to, if you will, especially like a posterior medial tibial bruise, um, if that shows up, because it can basically tell us that the injury was a bit more complex.
• 10:30
  SPEAKER_00: There was more force involved.
• 10:32
  SPEAKER_00: And so we need to make sure we screen for other potential damages inside the knee, especially to tissue.
• 10:38
  SPEAKER_00: Maybe it's like a meniscus ramp lesion, maybe it's an MCL involvement.
• 10:42
  SPEAKER_00: So these are things that we need to kind of factor in that tell a bit of a story.
• 10:47
  SPEAKER_00: And the grading of these bone bruisings is important because um it can just kind of tell us like, okay, to what degree are we dealing with?
• 10:57
  SPEAKER_00: And so there's a classification system called the Costa Paz classification that breaks them into three different types of grading, if you will.
• 11:06
  SPEAKER_00: And it's simple, but it's just something that I'm just gonna share with you because we are covering all things bone bruising in this.
• 11:12
  SPEAKER_00: So, type one, the signal on the MRI is deeper in the bone, away from the joint surface.
• 11:18
  SPEAKER_00: It's a low severity, the majority of these resolve.
• 11:22
  SPEAKER_00: And this is probably most cases, I would say, with bone bruising, more of a type one.
• 11:27
  SPEAKER_00: Type two, the signal is right up against the bone cartilage interface, moderate severity, most resolve, but not all.
• 11:35
  SPEAKER_00: And then type three, the surface of the bone is actually disrupted.
• 11:38
  SPEAKER_00: It's either depressed or collapsed.
• 11:41
  SPEAKER_00: This is the most severe type.
• 11:43
  SPEAKER_00: In the Costa PAS follow-up study, every single type three lesion they tracked had developed some cartilage thinning and depression at the two-year mark.
• 11:52
  SPEAKER_00: Not some of them, but all of them.
• 11:54
  SPEAKER_00: So that's important to factor in if you have a grade three bruise.
• 11:58
  SPEAKER_00: On X-ray, a type three on the lateral femoral condyle can sometimes be visible as what's called the deep lateral femoral notch sign.
• 14:12
  SPEAKER_00: That's a depression in the bone surface that's measurable.
• 14:15
  SPEAKER_00: So something that we can look at.
• 14:17
  SPEAKER_00: When that notch is deeper than two millimeters, it's a strong secondary sign to feel that you've had a significant impact injury.
• 14:26
  SPEAKER_00: So this is just telling us more to the story of your injury itself.
• 14:30
  SPEAKER_00: So if you're an athlete listening to this, you know, if you're looking at your MRI report or talking to a provider, you can ask the surgeon or the ortho and ask what type of bone bruise this is, you know, and to just kind of talk through that a little bit.
• 14:45
  SPEAKER_00: A lot of times it gets overlooked, but then these grading systems can be helpful.
• 14:49
  SPEAKER_00: Is everyone following these?
• 14:51
  SPEAKER_00: Not necessarily, but it is something that can help us with the severity of it and just understand the full kind of picture of this versus, you know, just being like, okay, it's a bone bruise, let's move on.
• 15:02
  SPEAKER_00: When in reality it can have some implications, especially from a rehab and just like an overall expectation process.
• 15:10
  SPEAKER_00: So the other thing that I would love to spend some time on is what the ACLR is actually going to feel in this, because it's what a lot of ACLers are not told.
• 15:20
  SPEAKER_00: They're not educated on what this is, and it is something that can have implications of you know what you feel, the recovery.
• 15:29
  SPEAKER_00: And I think that's so massive in this process.
• 15:32
  SPEAKER_00: And so a bone bruise doesn't feel like a bruise you get bumping into something.
• 15:36
  SPEAKER_00: So I think that's important.
• 15:37
  SPEAKER_00: While I described that earlier, it's not necessarily going to feel exactly that way.
• 15:41
  SPEAKER_00: It's going to feel like that bone hurts.
• 15:44
  SPEAKER_00: It's kind of like a deep, achy sensation.
• 15:47
  SPEAKER_00: It can get worse when you're kind of loading the leg and putting kind of compression on it, like being upright, walking, especially with heel strike when you're in extension, going down the stairs, anything impact related.
• 15:59
  SPEAKER_00: The swelling tends to stick around longer than you'd expect, and the joint stays reactive and a bit more irritable, even when things seem like they should be calming down.
• 16:10
  SPEAKER_00: And this gets muddied because the injury itself is so complicated because you already have a response from just an isolated ACL tear.
• 16:21
  SPEAKER_00: As I had mentioned, there's usually bone bruising in majority of ACL injuries, but then you have meniscus potential, you have maybe cartilage that has been also impacted, you know, other ligaments like the MCL could be sprained.
• 16:34
  SPEAKER_00: There could be other areas that are influenced in this.
• 16:37
  SPEAKER_00: So it starts to really muddy up the waters of what's contributing to everything.
• 16:42
  SPEAKER_00: And so you're not going to be able to fully know what percentage is allocated to all the swelling and pain you're dealing with.
• 16:50
  SPEAKER_00: But it is something that I think is important to factor in because there are a lot of people who are told, oh, well, within you know, a few weeks you'll be back to walking, X, Y, and Z.
• 17:01
  SPEAKER_00: And I think it is so important to understand that if you have this, the recovery can slow down, especially if you are someone who is just not improving, the swelling sticking around, maybe like there's just like this achiness that is deep and within.
• 17:19
  SPEAKER_00: Like that is something that can have layers to it, but this bone bruising can play into that.
• 17:25
  SPEAKER_00: And it's something that I think a big reason why prehab before surgery is harder for some athletes than others.
• 17:33
  SPEAKER_00: Getting that full extension back, getting the swelling down, getting the quads back up and firing, all that can be slower when there's that significant bone bruise that's involved.
• 17:42
  SPEAKER_00: The bone and the cartilage above it are essentially in a little bit of a compromised state, even though imaging may not fully show it.
• 17:49
  SPEAKER_00: And this brings me to a point I really want you to hear, whether you are an athlete or a clinician listening about bone bruises, the same diagnosis does not mean that we are going to follow the same timeline.
• 18:03
  SPEAKER_00: And as you guys know, I am not the one for timelines in this.
• 18:07
  SPEAKER_00: Yes, we say a nine to 12 month process, and that's after ACL reconstruction, but people vary so much across the spectrum, especially with their lives existing also while they're recovering from this.
• 18:20
  SPEAKER_00: And we can line up 10, 20 different ACLers right in front of us, and they're all gonna have different paths back.
• 18:27
  SPEAKER_00: Their recoveries are gonna look different.
• 18:29
  SPEAKER_00: They could have early stages that go super fast and mid and late stages that can go slower.
• 18:34
  SPEAKER_00: One can deal with a ton of flare-ups, and one could have barely any.
• 18:38
  SPEAKER_00: There's just gonna be so many different variables that influence the recovery of this, including a bone bruise.
• 18:44
  SPEAKER_00: How hard was the impact of your injury?
• 18:47
  SPEAKER_00: Did you just have a weird little plant and step and then it popped?
• 18:51
  SPEAKER_00: Or was it like, oh, someone landed and collided with you and that's how you tore your ACL?
• 18:57
  SPEAKER_00: Or you landed from you know a big height and you impacted the knee, and that's how you tore your ACL, right?
• 19:03
  SPEAKER_00: There's gonna be a lot of implications of the actual injury itself and how that knee is going to essentially respond, especially after the injury and the recovery itself.
• 19:15
  SPEAKER_00: So the same diagnosis is not gonna mean the same timeline.
• 19:19
  SPEAKER_00: Two athletes can both show up with that ACL tear on paper, right?
• 19:23
  SPEAKER_00: Everything could be the exact same thing in terms of the diagnosis.
• 19:28
  SPEAKER_00: Both are doing their prehab, both are putting in the same amount of work, but one of them has a large bone bruise covering most of that lateral femoral condyle, and the other doesn't.
• 19:40
  SPEAKER_00: Those two athletes are not going through the same process.
• 19:45
  SPEAKER_00: The one with a larger bone bruise is going to have more pain, more irritability, it's gonna be sensitive, it's gonna probably have a little bit more swelling, a slower return back to normal walking, and a longer prehab window before surgery.
• 19:58
  SPEAKER_00: That's if you get it.
• 19:59
  SPEAKER_00: And this is my number one reason why I think people should not rush into surgery.
• 20:04
  SPEAKER_00: Majority of people listening to this, and I would say 95% of people do not need to head into surgery really quick.
• 20:10
  SPEAKER_00: I've seen so, so many ACLers at this point that we have worked with who have come in from kind of you know later from other, you know, surgical process and other PT, and people who have just reached out and they were like, I rushed into surgery, you know, my surgeon said they had a slot open in two weeks.
• 20:31
  SPEAKER_00: I just wanted to get it over with.
• 20:33
  SPEAKER_00: Maybe it was something insurance related, which I totally get.
• 20:36
  SPEAKER_00: I don't blame anyone.
• 20:37
  SPEAKER_00: But the thing is, is that it can really influence how your outcomes are, especially post op.
• 20:44
  SPEAKER_00: And we have people who don't get their range of motion back, don't have the kneecal again.
• 20:49
  SPEAKER_00: And then you talk about this bone bruising.
• 20:51
  SPEAKER_00: If you had the ACL injury, and let's say you had surgery within two weeks, that bone bruise is not healed yet.
• 20:57
  SPEAKER_00: And so that is an important factor in this because a lot of times people who are struggling post-op, they did not take the time prehab to be able to get things in a good spot.
• 21:07
  SPEAKER_00: I'm not saying everyone, but we see this pretty consistently that people who rush into surgery and don't do prehab and they struggle with things after surgery, it's because the knee has gone through two massive traumas in too much of a short period of time.
• 21:22
  SPEAKER_00: And as much as we want to get it over with, unless there is something very time-sensitive, like you are a professional athlete and your contract's on the line, the Olympics is coming up, you are maybe a high school athlete who has this massive scholarship and there's a lot of things hanging in the balance, there has to be a very high, high stake situation for you to have to rush into this procedure.
• 21:48
  SPEAKER_00: And this is something that I'm consistently seeing more and more is that majority of people just need to wait a little bit longer.
• 21:56
  SPEAKER_00: And when I say a little bit longer, if we can wait at least a minimum of four weeks, ideally six to eight weeks, y'all, that will at least give enough time for this body to settle down a little bit.
• 22:08
  SPEAKER_00: And then you're able to go into this surgery in a much better spot versus rushing into it.
• 22:13
  SPEAKER_00: Now, if your knee is awesome, great, not having any issues, and you feel like you're regaining the strength and you're at a good baseline, then yeah, you can nudge that timeline up earlier.
• 22:25
  SPEAKER_00: But I think for most people, they're gonna just need a bit more time to let the knee settle and normalize a little bit before another major kind of injury and impact to the joint through a surgery.
• 22:38
  SPEAKER_00: And so if you are in the early weeks and things feel harder than you expected right now, if the swelling isn't going down the way it should, maybe your extension is kind of lagging a bit, you know, if walking is hurting a bit more than you had thought, that may not mean that you're feeling your rehab, especially if you're doing everything the right way.
• 22:59
  SPEAKER_00: And again, there's a lot of variables here, but it could also be, you know, the bone bruising that is potentially influencing some of this recovery.
• 23:06
  SPEAKER_00: And that just needs to be factored into your plan and especially into the symptoms that you're feeling.
• 23:13
  SPEAKER_00: Now, what does the research actually say about bone bruising?
• 23:17
  SPEAKER_00: And so I want to give you three research findings here and try to keep these super practical.
• 23:23
  SPEAKER_00: So the first one is healing takes longer than most people assume.
• 23:27
  SPEAKER_00: The median time for a bone bruise to resolve on MRI is around 10 months.
• 23:34
  SPEAKER_00: Yep.
• 23:35
  SPEAKER_00: That's the median, the range goes from a few weeks all the way up to even two years or longer, depending on the type and the size of the bruise.
• 23:44
  SPEAKER_00: Especially type three lesions often never fully resolve on imaging.
• 23:48
  SPEAKER_00: So that's just one thing to note.
• 23:51
  SPEAKER_00: The important nuance here is that your symptoms will get better well before the MRI clears.
• 23:56
  SPEAKER_00: So that's something to just kind of factor in.
• 23:58
  SPEAKER_00: The imaging might be a little bit more delayed.
• 24:01
  SPEAKER_00: So that's more so something that provides.
• 24:04
  SPEAKER_00: Hope, and also most people aren't going to get a ton of follow-up imaging, but with a situation like this, just know the symptoms typically will improve before the MRI.
• 24:12
  SPEAKER_00: So feeling better and being fully healed are not always the same thing, though.
• 24:18
  SPEAKER_00: This is one of the kind of core arguments for criteria based, especially with symptom guided progressions, over just calendar-based timelines.
• 24:27
  SPEAKER_00: Just because the knee feels okay doesn't mean the tissue has finished doing what it needs to do, meaning there is still healing taking place.
• 24:35
  SPEAKER_00: Finding number two is that the bruise size predicts cartilage risk.
• 24:41
  SPEAKER_00: This is the one that I really want you to pay attention to.
• 24:44
  SPEAKER_00: A 2020 study in the Orthopedic Journal of Sports Medicine, OJSM, by Kia and colleagues looked at what happened to cartilage five years after ACL reconstruction.
• 24:56
  SPEAKER_00: They measured bone bruise area on initial MRI and then graded the cartilage on follow-up imaging years later.
• 25:04
  SPEAKER_00: When the bone bruise covered the entire lateral femoral compartment on the MRI, there was a 74% chance of significant cartilage damage at the five-year mark.
• 25:15
  SPEAKER_00: 74%.
• 25:16
  SPEAKER_00: On the flip side, when there was no bone bruise on the initial MRI, that was the single strongest predictor of intact cartilage at five years.
• 25:23
  SPEAKER_00: That all makes sense, right?
• 25:25
  SPEAKER_00: If you have like a massive bone bruise, then that cartilage is impacted.
• 25:29
  SPEAKER_00: If you don't, then you know you're probably not going to have as much of a cartilage issue because the bone hasn't been impacted.
• 25:35
  SPEAKER_00: So the size of the bruise on your very first MRI is telling you something meaningful about the long-term trajectory of your joint health.
• 25:42
  SPEAKER_00: It doesn't mean bad outcomes are guaranteed, though.
• 25:45
  SPEAKER_00: So just make sure your takeaway is not if I have a bone bruise, my cartilage is screwed.
• 25:51
  SPEAKER_00: That is not my take home here.
• 25:52
  SPEAKER_00: It's just a matter of understanding what the research shows is that there can be implications of cartilage down the road.
• 25:59
  SPEAKER_00: But most people, I would say again, don't have these aggressive type three bruises.
• 26:04
  SPEAKER_00: So then, therefore, most people are going to resolve and heal.
• 26:08
  SPEAKER_00: It's just a matter of understanding, okay, was your injury a massive impact?
• 26:12
  SPEAKER_00: Was it not?
• 26:13
  SPEAKER_00: What does the bone bruising say?
• 26:15
  SPEAKER_00: But these are just some things that we need to just understand the implications of the injury and also what bone bruising could do.
• 26:24
  SPEAKER_00: The finding for number three is it's the combination that creates the highest risk.
• 26:30
  SPEAKER_00: So Ladderman and colleagues took their study and looked at outcomes two and six years after ACL reconstruction.
• 26:38
  SPEAKER_00: Bone bruise alone did not predict worse functional scores.
• 26:41
  SPEAKER_00: Big here.
• 26:43
  SPEAKER_00: But athletes who had a bone bruise and cartilage damage at the time of injury were 3.4 times more likely to have symptomatic outcomes at six years.
• 26:53
  SPEAKER_00: So bone bruising in isolation, that's not something to be as worried about.
• 26:59
  SPEAKER_00: The risk can elevate when the cartilage above it was also involved.
• 27:03
  SPEAKER_00: And that's more likely with larger bruises, which brings us back to the size mattering.
• 27:09
  SPEAKER_00: The takeaway from all three of these findings is the same.
• 27:14
  SPEAKER_00: Know what you're working with, account for it in your plan, and don't treat the bone bruise as something to acknowledge and move past.
• 27:22
  SPEAKER_00: Now, most orthos are not going to spend much time here, nor are most PTs.
• 27:28
  SPEAKER_00: And I'm not saying, hey, we need to make this the focus of the rehab.
• 27:31
  SPEAKER_00: Again, it's the ACL, get the knee in a good place.
• 27:34
  SPEAKER_00: But with that said, it's just something that's important to factor into the conversation, especially more so just setting expectations.
• 27:43
  SPEAKER_00: And especially if you are someone who is just working hard and you're just not having the pain and deep aches kind of resolve, then this can be factored in, especially if it's closer to the injury date, then it's further away.
• 27:58
  SPEAKER_00: If you're months and months and months out from your injury date, there's a strong chance that that bone bruising is probably on its way healed already and not really that big of an issue.
• 28:07
  SPEAKER_00: But if you're early and closer to that injury date, then that is something to just be able to factor in, knowing going into the surgery, but then also especially your rehab process.
• 28:20
  SPEAKER_00: So, how does this shape rehab, especially before and after the surgery?
• 28:25
  SPEAKER_00: So let's focus on making this practical.
• 28:28
  SPEAKER_00: What is this actually going to mean?
• 28:31
  SPEAKER_00: So before surgery, full extension is needed to come back before you go into the operating room.
• 28:37
  SPEAKER_00: That is ideal.
• 28:38
  SPEAKER_00: And to us, this is not really an optional thing, it's something that you should get back.
• 28:43
  SPEAKER_00: Now, some people might just be like, okay, the surgery's here, I need to get it done.
• 28:46
  SPEAKER_00: Of course, assuming nothing's blocking it from getting there, but we need to get that back.
• 28:50
  SPEAKER_00: A bone bruise contributes to the swelling and irritability that can potentially slow down getting extension.
• 28:56
  SPEAKER_00: And research shows the average time to restore full extension with a bone bruise is around roughly 18 days.
• 29:04
  SPEAKER_00: And in some cases, it can push almost to a month or so.
• 29:08
  SPEAKER_00: Operating before extension is back significantly increases the risk of post-surgical stiffness.
• 29:15
  SPEAKER_00: I just I think this is so massive here, and I think it gets missed a lot.
• 29:20
  SPEAKER_00: So the calendar should not fully decide on when surgery happens.
• 29:26
  SPEAKER_00: The state of the knee is so important.
• 29:29
  SPEAKER_00: Extension, swelling is controlled, quad activation, you've got your flexion in a good spot.
• 29:34
  SPEAKER_00: Basically, a good quiet knee, when those are restored, it feels like that is the time point that you are ready to go into surgery.
• 29:43
  SPEAKER_00: And we have seen this consistently with athletes who worked on prehab really hard and got the knee quiet and in a good spot before surgery, they come out of surgery doing much better.
• 29:53
  SPEAKER_00: It's the people who don't get their knee quiet prior to surgery rush into it.
• 29:57
  SPEAKER_00: And again, I'm not faulting any ACLer in doing this.
• 30:00
  SPEAKER_00: It's more so of the healthcare professionals doing their due diligence.
• 30:06
  SPEAKER_00: And I absolutely love it whenever a surgeon does a consultant evaluation with a new ACLer and they say, We need to get this extension better, we need to get the swelling down, we need to get this knee in a much better place and do some prehab, and then we'll do the surgery.
• 30:22
  SPEAKER_00: They have criteria to have the surgery.
• 30:25
  SPEAKER_00: Not because there's an available spot, not because it makes revenue, not because, oh, let's just fill up the caseload.
• 30:32
  SPEAKER_00: Let's do what's in your best interest to make sure that you have the best outcome and recovery possible.
• 30:40
  SPEAKER_00: And I love this, and I always get so happy when I hear ACL or say that their surgeon has required this.
• 30:47
  SPEAKER_00: After the surgery, the early phases, weight bearing is generally appropriate, especially if there's no meniscus repair or any other reason to limit weight bearing.
• 30:57
  SPEAKER_00: So you don't need to baby the leg off the ground, right?
• 31:01
  SPEAKER_00: We need to just restore normal walking, weight bearing, but you can expect that the swelling, maybe the pain response, the quad activation may be slower to normalize than a typical ACL tear without any bone bruising.
• 31:15
  SPEAKER_00: So you want to build your targets around what the knee is actually doing, not just what week you're in post op, not on the calendar.
• 31:22
  SPEAKER_00: We need to do this based on criteria and what are these very important quiet knee goals to be able to get that knee in a good spot and build up tolerance and capacity to that knee.
• 31:33
  SPEAKER_00: And then as we come into the impact loading question after surgery, this is where a lot of programs, in my opinion, kind of move too fast.
• 31:45
  SPEAKER_00: And usually it's because they're using a calendar, but sometimes, you know, they are just like, okay, we're at week 12, or you know, we're three and a half months in, maybe even four months in.
• 31:57
  SPEAKER_00: And like, let's just start running, jumping, doing all the things.
• 32:00
  SPEAKER_00: And I think we just need to make sure that we're using criteria to progress things appropriately, especially with checking symptom profiles of stiffness, pain, swelling, and just seeing how people are responding and start to grade things appropriately.
• 32:16
  SPEAKER_00: And especially when there is a bone bruise present and is something that is closer to surgery, maybe someone is a bit more sensitive in the knee, their symptoms are a little bit higher, maybe they're having issues with range of motion restoration, the swelling is sticking around.
• 32:33
  SPEAKER_00: I truly think that delaying running and plyos can be valuable in this and for us to keep building more strength and focus on the quiet knee areas.
• 32:45
  SPEAKER_00: If the knee is quiet and it is responding well to things and the symptoms are really great, then yeah, let's kind of nudge things along based on the criteria and not slow people down just for the sake of it.
• 32:56
  SPEAKER_00: But often I'll see people around four, even sometimes five months, especially with people with significant bone bruising.
• 33:03
  SPEAKER_00: We might delay them from running.
• 33:05
  SPEAKER_00: And if running is not a goal, we might even delay it longer, to be honest.
• 33:09
  SPEAKER_00: It's something that we can maybe push forward with more strengthening and then eventually kind of titrate that stuff in.
• 33:16
  SPEAKER_00: Again, it's all going to be based on how people progress through this process and also what their goals are.
• 33:21
  SPEAKER_00: But this is not necessarily a rigid rule.
• 33:24
  SPEAKER_00: I'm more of a fan of delaying things.
• 33:26
  SPEAKER_00: Um, I also believe that the typical run-walk intervals that can happen soon after the ACL rehab process, you know, let's say they're at that four or five month mark, that could be valuable.
• 33:40
  SPEAKER_00: But I think there's also a route where you could also go more speed-based.
• 33:45
  SPEAKER_00: So you could do shorter distances, a lower intensity, and that could be valuable too to be able to titrate in some work.
• 33:52
  SPEAKER_00: And especially for our field and court-based athletes, that could be so, so valuable because they're getting speed work in and being able to work up with those types of specific demands versus doing walk-run intervals that aren't specific to their sport.
• 34:07
  SPEAKER_00: That's a side tangent, but I think that there could be a value of almost like two roads where someone gets to a point where they're start showing signs and are ready to run based on criteria, then we could start to introduce maybe a more speed-based approach versus more of like an endurance running based approach, especially if you're a runner and love to run.
• 34:29
  SPEAKER_00: So that's something that will vary based on the time and how this all progresses.
• 34:34
  SPEAKER_00: But there's not, you know, a randomized controlled trial with a specific number saying, like, you know, four or five months is when you wait.
• 34:44
  SPEAKER_00: But when we think about bone healing biology, that's going to be important in terms of giving it the time.
• 34:49
  SPEAKER_00: And I think in terms of like the timeline of resolution, when you really think about the bone bruising, there's not this fully dialed in, like, okay, it'll be healed fully by this time.
• 35:01
  SPEAKER_00: It can sometimes have some implications, especially if we're thinking about loading and that subchondral bone, especially if it's too aggressive.
• 35:12
  SPEAKER_00: So we want to just be mindful allowing that to load and not overload it too much.
• 35:18
  SPEAKER_00: We want to let it heal.
• 35:20
  SPEAKER_00: So, what's the approach here?
• 35:22
  SPEAKER_00: It's to use symptoms and use criteria to guide us.
• 35:28
  SPEAKER_00: Using the knees response to loading as the guide.
• 35:31
  SPEAKER_00: That's huge.
• 35:32
  SPEAKER_00: It could be something where we can use a bunch of different tools.
• 35:36
  SPEAKER_00: Um, it could be BFR, it could be even doing kind of water aquatic type work, anti-gravity stuff, it could be sled work, it could be a variety of things in the early post-operative window for us that we can build some cardiovascular fitness, obviously, building in the quad strength and building in movement quality without feeling like we have to repeatedly like do a lot of impact, especially while things are healing.
• 36:01
  SPEAKER_00: And especially for my ACLers here, do not let anyone rush you through this phase because you just look good or what the protocol says.
• 36:10
  SPEAKER_00: Looking good on a quad set is very different because it's something that is not gonna put impact on that bone.
• 36:18
  SPEAKER_00: So it's just something that we need to factor into this process as we are progressing early in the post op, especially, and especially as we get further and further out from the injury itself.
• 36:30
  SPEAKER_00: And so, what about return to sport regarding bone bruising?
• 36:33
  SPEAKER_00: And there's not really a ton of research that shows, you know, you know, holding, getting back to sport because the MRI doesn't show bone bruise resolution yet.
• 36:42
  SPEAKER_00: As I shared, it could take longer.
• 36:45
  SPEAKER_00: Galloway and colleagues in 2023 looked at 60 athletes with quantified bone bruise volumes.
• 36:50
  SPEAKER_00: Bruise size did not impact or predict time to return to sport, functional scores, or two-year graph failure rates.
• 36:59
  SPEAKER_00: 95% of athletes returned to sport regardless of the bruise size.
• 37:03
  SPEAKER_00: Pinger and colleagues found the same thing the same year.
• 37:06
  SPEAKER_00: Bone bruise grade and volume did not influence strength or functional outcome scores at one year.
• 37:12
  SPEAKER_00: So your standard return to sport criteria still applies.
• 37:15
  SPEAKER_00: You're still looking at at least nine months post op at minimum.
• 37:19
  SPEAKER_00: You're still aiming for 90% limb symmetry for many of your things, ideally 95%, and making sure that the torque to body weight is at an appropriate level of at least 100% body weight or what we're looking for, psychological readiness is there, and then obviously the dynamic pieces of jump testing and change of direction testing, things of that nature.
• 37:42
  SPEAKER_00: Now, what the bone bruise does help with is, you know, maybe it is something that will factor into moving in a more conservative way.
• 37:53
  SPEAKER_00: And when you're on the fence, when an athlete, you know, is you know, they're clearing this criteria, but the knee might still be sensitive, reactive.
• 38:01
  SPEAKER_00: It could be a little swollen after loading, it could still be responding with some soreness, more than you'd expect, right?
• 38:07
  SPEAKER_00: Especially a large, you know, or type three bruise is a reason to give it a bit more time, not rushing into it.
• 38:14
  SPEAKER_00: It doesn't necessarily hold you back from clearing or you know, being ready.
• 38:18
  SPEAKER_00: It just informs a judgment call when things aren't fully clear-cut just yet.
• 38:23
  SPEAKER_00: So that's something that we can factor into this.
• 38:26
  SPEAKER_00: So for the clinicians and coaches who are listening, I want to wrap up with a few direct points.
• 38:32
  SPEAKER_00: Read the MRI for the location, type, and size, not just bone bruise present.
• 38:38
  SPEAKER_00: If they give more detail, then that's awesome.
• 38:41
  SPEAKER_00: The difference between a small type one and a type three will be more of an important detail in this, and it could change your early rehab plan, your surgical timing conversation, and also how you'll help with decision making with your athlete and other stakeholders.
• 38:57
  SPEAKER_00: Use the bruise pattern as a mechanism check.
• 39:00
  SPEAKER_00: Lateral dominant pattern is your classic pivot shift mechanism.
• 39:05
  SPEAKER_00: If there's a posterior medial tibule bruise, then scream for potentially some ramp lesions in there.
• 39:12
  SPEAKER_00: And before we're just kind of looking at just maybe an isolated ACL.
• 39:17
  SPEAKER_00: Explaining the bone bruise is really important to you guys.
• 39:20
  SPEAKER_00: I just want to make sure that you understand this to be able to connect the dots between that being there and then also what is going on in the knee and the progression of how this could look, especially for someone who might not have it.
• 39:33
  SPEAKER_00: And then the timing for surgery will also be potentially influenced of getting the knee quiet, doing good prehab.
• 39:41
  SPEAKER_00: And especially with just the literature in general, it shows that when you do prehab well, that you will have better outcomes in the end.
• 39:51
  SPEAKER_00: So don't worry too much about the timeline of this and more so making sure the knee is ready to take on surgery.
• 39:57
  SPEAKER_00: And for return to sport, um, don't, you know, if there is maybe this aggressive bone bruise and another MRI is taken, it's not going to be fully dependent on that.
• 40:08
  SPEAKER_00: You're going to want to just make sure you listen to the knee, listen to the athlete, making sure that the battery of tests that are done are all showing proper criteria has been hit, and then using our clinical judgment to be able to guide this decision making.
• 40:24
  SPEAKER_00: So I know I packed this episode with a lot of information, and it's something that I wanted to essentially give the bone brews a little bit more air, if you will, um, in terms of this injury.
• 40:39
  SPEAKER_00: A lot of times it does get that, you know, 10, 15 seconds, it's overlooked.
• 40:43
  SPEAKER_00: I know so many conversations I have with athletes where things aren't adding up, and I'll ask, you know, what other things were shown on the MRI?
• 40:51
  SPEAKER_00: Because usually the ACL tear is the highlight, right?
• 40:53
  SPEAKER_00: They may say a meniscus thing, especially if anything that is done in surgery to help with whatever was injured, right?
• 41:02
  SPEAKER_00: A meniscus repair, ACL reconstruction, maybe there's an LET done, maybe it is an MCL repair.
• 41:09
  SPEAKER_00: There are a number of things that can be done in the procedure, but obviously it's going to all be based on the injury itself.
• 41:16
  SPEAKER_00: The bone bruise is not something usually a surgeon addresses.
• 41:19
  SPEAKER_00: And so then therefore we just kind of let time heal, but at the same time, it is going to have some implications of it.
• 41:27
  SPEAKER_00: Now, the main thing here is I don't want you guys running to your surgeon or running to your MRI and being super worried about anything.
• 41:33
  SPEAKER_00: It will heal and it will get better.
• 41:36
  SPEAKER_00: In majority of cases, it is that type one, it's a bone bruise that's there.
• 41:39
  SPEAKER_00: It's nothing super major, but it is something that we want to be aware of because it can influence your expectation of the process in terms of regaining extension, getting swelling down, getting pain down, getting your walking back to normal.
• 41:55
  SPEAKER_00: Even when you start walking, maybe it just doesn't seem to come together as you would expect.
• 42:01
  SPEAKER_00: And that could be the implications from the bone bruising, along with obviously the messiness of everything else that has happened.
• 42:08
  SPEAKER_00: They do resolve.
• 42:09
  SPEAKER_00: Um, of course, there are certain situations where they're more aggressive.
• 42:12
  SPEAKER_00: Most people get back to sport.
• 42:14
  SPEAKER_00: So I want you guys to have hope on this.
• 42:16
  SPEAKER_00: It's not something that is a death sentence, it's just more so being aware that this is a part of the ride and a part of the injury itself.
• 42:25
  SPEAKER_00: So know what you're dealing with, make sure to ask the right questions, make sure your plan is also just kind of having that caveat of knowing that that bone bruise is in there, especially if things are not potentially adding up.
• 42:39
  SPEAKER_00: So don't get too caught up on timelines or like at this point I need to be here.
• 42:43
  SPEAKER_00: It could just be a little bit slower.
• 42:45
  SPEAKER_00: So as long as you're doing your due diligence, testing appropriately, doing the right things day in and day out, then that's what you can lean into.
• 42:52
  SPEAKER_00: And then, yeah, sure, if it doesn't add up, then you can follow up with your providers, your physical therapists, especially your surgeon, to see what else is going on.
• 43:00
  SPEAKER_00: But that's the episode, and I hope that this was helpful for you guys.
• 43:04
  SPEAKER_00: Again, a long one, but this was more of a deep dive into bone bruising.
• 43:08
  SPEAKER_00: Probably should have broken it up into two parts, but I wanted to just kind of get it all out there just to make sure you have all the details here.
• 43:15
  SPEAKER_00: And then if you need any support, any help, or if you have any questions, you can find all of our information in the show notes.
• 43:24
  SPEAKER_00: Otherwise, I will catch you in the next episode.
• 43:26
  SPEAKER_00: This is your host, Robbie Patel, signing off.