Latest / The ACL Athlete Podcast / 103 | Managing Your ACL Graft Donor Site after ACLR

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103 | Managing Your ACL Graft Donor Site after ACLR · 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.
• 1:03
  SPEAKER_00: What is up, team, and welcome back to another episode.
• 1:07
  SPEAKER_00: Today we are talking about ACL graft donor sites.
• 1:12
  SPEAKER_00: So how to manage them right after you have an ACL reconstruction, surgery, so we can make sure that we set you out on a good path.
• 1:21
  SPEAKER_00: So ACL graphs are a very common topic in this space.
• 1:25
  SPEAKER_00: Autograph versus allograph, what are they?
• 1:28
  SPEAKER_00: Autograph, consider that as taking that from your own body.
• 1:32
  SPEAKER_00: Allograft is from a cadaver, typically, so not of your body.
• 1:38
  SPEAKER_00: Autographs are what is usually associated with donor sites because the autograft is taken from your own body.
• 1:45
  SPEAKER_00: So there is a piece that is taken from a specific donor site.
• 1:49
  SPEAKER_00: That is where they typically take a tendon.
• 1:52
  SPEAKER_00: Tendons connect muscle to bone.
• 1:55
  SPEAKER_00: And so they take a tendon or piece of the tendon, and they will eventually turn that into your new ACL ligament.
• 2:04
  SPEAKER_00: So ligament connects bone to bone, tendon, muscle to bone.
• 2:09
  SPEAKER_00: And there's a big difference here, and it's important to understand this to understand the donor sites and where it's taken and how we can manage that.
• 2:17
  SPEAKER_00: So the three big autographs that we'll see, the sites, are the big three: hamstring, quadriceps, or patella.
• 2:27
  SPEAKER_00: So quadriceps tendon is usually taken at the top of the kneecap towards your quad.
• 2:32
  SPEAKER_00: The patellar tendon is taken below your kneecap, where that little patellar tendon is, and then you have your hamstring, usually on the inner side.
• 2:42
  SPEAKER_00: It's usually a combination of one of your hamstring muscles called the semitendinosis and potentially combined with your gracilis.
• 2:50
  SPEAKER_00: For example, for both of my ACL surgeries, my surgeon did an hamstring graft, and so he took my semitendinosis on both sides in order to make my ACL graft.
• 3:02
  SPEAKER_00: And what I will see quite often are people coming in later to work with us having issues with their donor site.
• 3:09
  SPEAKER_00: It might be discomfort, it might be pain, it might be some weird sensory issues.
• 3:14
  SPEAKER_00: Now, there's a number of reasons why that could be.
• 3:17
  SPEAKER_00: It could be impacting that sensory nerve, like the saphenus nerve, that can impact that.
• 3:21
  SPEAKER_00: It could be because there was a preexisting kind of injury or underlying thing going on.
• 3:27
  SPEAKER_00: But really, most people have issues with it because, well, you had a trauma to that area that the donor site was impacted and the graft was taken, and maybe it hasn't been loaded, and so it's basically gotten weak or lost its ability to kind of really do its job.
• 3:45
  SPEAKER_00: And so that's what typically happens in most cases.
• 3:49
  SPEAKER_00: I'll tell you an example.
• 3:51
  SPEAKER_00: One of the guys I saw recently who had a hamstring graft multiple weeks out, he could barely bend his knee.
• 3:57
  SPEAKER_00: Now we had passive knee flexion to about roughly 90, 100 degrees, but he could barely bend his knees actively to do that because he got a hamstring graft.
• 4:09
  SPEAKER_00: Uh, his hamstring was weaker, and I think he had some hesitation loading it.
• 4:14
  SPEAKER_00: And also there was a protocol in place that was basically telling him not to load his hamstring at all.
• 4:21
  SPEAKER_00: Now, there's a give or take in this process of loading your hamstring early in the process with let's say a hamstring graft, which we can kind of talk about here in a little bit more detail.
• 4:31
  SPEAKER_00: But the thing to think about here is when you have an ACL surgery, you have two kind of trauma points, if you will, if we're gonna keep this super simple.
• 4:39
  SPEAKER_00: You have the bone drilling and the new ACL reconstruction, you know, they're they're putting the screws in or whatever material they need to to anchor the ACL itself, and they have to get the ACL.
• 4:50
  SPEAKER_00: And the way they do that is by going into that donor site area, the quad, the hamstring, or the patellar tendon, and they're gonna get that little piece of tendon, and they're gonna try and get that graft in order to turn it into your new ACL.
• 5:05
  SPEAKER_00: Then you have to think about that donor site that is left behind after that.
• 5:08
  SPEAKER_00: That's kind of that second trauma, if you will.
• 5:11
  SPEAKER_00: And so that's where that patellar tendon, quad, or hamstring is impacted.
• 5:15
  SPEAKER_00: For patellar or quad, you have a form of what we call like a tendinopathy.
• 5:20
  SPEAKER_00: So people will typically hear like a tendinitis or a tendinosis, but tendinopathy is this big umbrella term where it's basically saying there's a pathology of that tendon.
• 5:30
  SPEAKER_00: And so that's what we're kind of dealing with when you think about when that graft is taken.
• 5:34
  SPEAKER_00: The hamstring tendon is a very interesting place because you're actually impacting the muscle.
• 5:41
  SPEAKER_00: So for some semi-tendinosis, they've done research on where sometimes that muscle will shrivel up, it'll kind of dissipate, it might connect to other connecting muscles.
• 5:52
  SPEAKER_00: So there might be a connection to the semimembranosis.
• 5:56
  SPEAKER_00: These are just different parts of your hamstring muscle as a group.
• 6:00
  SPEAKER_00: So it's a very interesting tendon and graph that is taken, and that is something that could be considered maybe like a grade three muscle strain combined with maybe a tendinopathy, where that tendon is impacted, and especially if they take the whole thing, then yeah, that's losing that specific part of your hamstring.
• 6:19
  SPEAKER_00: And so grade three basically means if you imagine like that bruising that you see, and people, you know, like tear a complete tendon and a muscle, that's kind of what a hamstring graft is, basically.
• 6:31
  SPEAKER_00: That's what we're looking at.
• 6:32
  SPEAKER_00: So you gotta think of it as like, okay, you have the ACL reconstruction, if you get an autograft, there's another form of something going on that we have to manage.
• 6:41
  SPEAKER_00: And so, how do we do that?
• 6:42
  SPEAKER_00: So, often in most protocols and most surgeons, we'll often recommend actually to avoid loading the area for a while, which is fair, but this has kind of changed over the recent years, but still see a lot of protection around it.
• 6:57
  SPEAKER_00: Like this recent athlete I saw, there was no loading for the hamstring for six weeks.
• 7:03
  SPEAKER_00: That's a very long time to just shut your hamstrings down.
• 7:06
  SPEAKER_00: If any of you know, as soon as you have ACL injury, or especially after surgery, your leg turns into a hot dog and you lose all your muscle mass.
• 7:16
  SPEAKER_00: So, our goal is basically how can we reduce that from happening and how can we regain our strength as quickly as possible?
• 7:23
  SPEAKER_00: Part of that is trying to introduce some load, but we have to be very strategic about it.
• 7:28
  SPEAKER_00: So this means that we kind of view this almost like a tendinopathy or a muscle type strain to a certain degree.
• 7:36
  SPEAKER_00: Then we need to manage it like so.
• 7:38
  SPEAKER_00: Doesn't mean that we got to go hot out of the gate with heavy strength work, loading it as hard as we can, pushing to the max.
• 7:45
  SPEAKER_00: We're just gonna kind of build up very slowly with a general framework of isometrics, eccentrics, concentric, and then we're gonna kind of work into some rate and speed of loading type work.
• 7:58
  SPEAKER_00: But really, the main focus initially post op is we're gonna get in some level of isometrics in as soon as possible.
• 8:05
  SPEAKER_00: And for those of you listening trying to figure out what isometrics are, imagine that you bend your elbow to 90 degrees, and so you kind of have your elbow flexed, and you put your hand on top of your wrist, and then you try to flex your elbow, trying to pull your wrist up, but pushing down with the opposite arm.
• 8:24
  SPEAKER_00: So you feel your bicep engaged, but it's not moving.
• 8:27
  SPEAKER_00: So that is an isometric where we're kicking on the muscle, but we are not changing in length, or the position is not changing.
• 8:35
  SPEAKER_00: And this is one of my favorite ways to load, especially post op, or whenever people are dealing with some high sensitivity, because it allows us a good entry point without irritating the joint or the area too much.
• 8:48
  SPEAKER_00: And we can always adjust the intensity and how long we do it, the angle.
• 8:52
  SPEAKER_00: So there's a lot of ways to enter without really, really provoking the area.
• 8:57
  SPEAKER_00: And so the only caveat I'm gonna give here is that if there's a certain type of meniscus repair or some sort of other addition to the surgery, maybe it's with a restriction for the hamstring graph because of its insertion into the medial meniscus or a meniscus repair.
• 9:15
  SPEAKER_00: These are just things that we might have to just kind of depend on the surgeon and the surgery and some of the restrictions there.
• 9:21
  SPEAKER_00: But in most cases, we are able to add some load of some degree immediately post-op, even if it's just a little.
• 9:29
  SPEAKER_00: So our goal is to work into the pain, but not through it.
• 9:34
  SPEAKER_00: That's what's really important here is to find your tissue tolerance, basically the level it can handle and recover from.
• 9:41
  SPEAKER_00: So feeling productive in the loading, but not provoking the knee or making it angry.
• 9:46
  SPEAKER_00: And I've done previous podcast episodes on pain and ACL rehab and how we use feedback loops to help control this and give us data in order to adjust the next day.
• 9:57
  SPEAKER_00: Check them out if you haven't listened to that.
• 10:00
  SPEAKER_00: But this is kind of some of the framework that we start to use when we start to load some of these donor sites post op.
• 10:06
  SPEAKER_00: Now you might be thinking I'm a couple days out or a week out, and I still can't really get engagement in the area.
• 10:14
  SPEAKER_00: That's still okay.
• 10:15
  SPEAKER_00: Like everyone's gonna kind of vary on this spectrum, but you might be coming out of surgery and you're feeling okay to add a little bit of like kind of engagement in that certain muscle and that donor site, and that's gonna be okay.
• 10:28
  SPEAKER_00: That is actually gonna set us up for success as long as we manage it very well.
• 10:33
  SPEAKER_00: And so, for a simple approach to post op for our athletes, that I want to kind of show you and give you kind of the tactical framework is to start with a lower level intensity and discomfort.
• 10:45
  SPEAKER_00: Don't try to push it, just start with some sort of easy entry point, hold the position for 15 seconds, the isometric, building up maybe to 30 to 45 seconds over multiple sets.
• 10:58
  SPEAKER_00: So, for example, if you have a quad graft, we might get you in a prone knee extension type position, so on your stomach, and have your knee bent to a position that's tolerable, and you might be kicking into a box, or maybe you have a strap and around the foot, and then we bend it to a certain angle, like a knee extension, flat on your stomach, and you'll lightly kick into it.
• 11:22
  SPEAKER_00: That'll help load your quad tendon a little bit.
• 11:24
  SPEAKER_00: Patellar tendon graft, we might be seating you at 90 degrees or 60 degrees, like a seated knee extension, and you might be kicking into just one of those pads or the wall, and you might be doing it at like a 10% intensity, maybe a 20%, just to get some load into the quad, into the patellar tendon.
• 11:42
  SPEAKER_00: If you're doing a hamstring graft, maybe it's just heel digs on your couch or your bed.
• 11:47
  SPEAKER_00: Um, maybe it's on like a box at varying angles, or maybe we'll move towards like a hamstring bridge where we can actually engage your hamstrings isometrically and bridge up.
• 11:58
  SPEAKER_00: And as time goes on, you can be more and more specific with your loading.
• 12:02
  SPEAKER_00: For example, hamstring grafts can be really tricky.
• 12:06
  SPEAKER_00: I remember for the longest time I would have hamstring strains, my strength wouldn't get up to where it needed to be, especially when I was trying to do like higher end sprinting or uh loading my hamstrings, or especially this inner range type flexion.
• 12:22
  SPEAKER_00: So when you imagine like heel to butt type range of motion, yeah, you could do that if you pull it there or use your hand at your ankle to pull your heel to your butt.
• 12:31
  SPEAKER_00: Hopefully, if you have the flexion.
• 12:33
  SPEAKER_00: But to control that last little bit to get towards that end range flexion, that requires a lot of your hamstring tendon and your hamstring muscle.
• 12:43
  SPEAKER_00: And so that inner range is what we're talking about.
• 12:46
  SPEAKER_00: So think about maybe that 110, 120 to 145 degrees.
• 12:52
  SPEAKER_00: There is a lot responsible for that hamstring graft that was taken to assist with that.
• 12:57
  SPEAKER_00: And a lot of times the athletes with a hamstring graft will have is weakness in that range.
• 13:03
  SPEAKER_00: So what we'll do is maybe later on in the process is we'll work on that inner range strength with liftoffs, maybe with some tibial internal rotation to help bias that hamstring region and that graft area to target that donor site more directly.
• 13:19
  SPEAKER_00: But the goal is to find a tolerance you can handle and don't pay for the next day.
• 13:24
  SPEAKER_00: You want to make sure it returns back to normal baseline ideally.
• 13:28
  SPEAKER_00: And post op, that might be a little tricky because everything feels really sharp and uncomfortable.
• 13:34
  SPEAKER_00: So that's where you just want to be very mindful, find a good entry point, and as long as you kind of wake up the next day and you're not overcooking it and you're not really paying for it, then you can just kind of keep working with it, keep building it in.
• 13:49
  SPEAKER_00: And the one thing that I always tell my athletes, this analogy we always use, is and I hope you guys eat me who are listening.
• 13:56
  SPEAKER_00: If you don't, you can just kind of run with the analogy.
• 13:59
  SPEAKER_00: But if you're cooking a steak, would you rather overcook it or undercook it?
• 14:04
  SPEAKER_00: When you're thinking about preparing it, the situation, what would you rather be dealing with?
• 14:09
  SPEAKER_00: An overcooked steak or an undercooked steak?
• 14:12
  SPEAKER_00: An undercooked steak, because you can always heat it up more to get it to that right temperature.
• 14:18
  SPEAKER_00: If you overcook it, you've just got a well-done steak and that's all you're gonna get.
• 14:22
  SPEAKER_00: You can't go back.
• 14:23
  SPEAKER_00: But if you undercook it, you could always add a little bit more.
• 14:26
  SPEAKER_00: But once you go too far, it's burnt or it's well done, and you just kind of have to deal with it.
• 14:32
  SPEAKER_00: Or in this case, in ACL rehab, if you go too far or do too much, you kind of have to wait and let the kind of knee do its job, the body do its job in order to kind of get back to that baseline.
• 14:44
  SPEAKER_00: But if you undercook it, you could always add more the next day or the next time you attack it.
• 14:49
  SPEAKER_00: So this is always a really good rule of thumb for a lot of our ACLers because knees can be so sensitive, and we want to make sure that we don't, you know, try to push really hard and then have to take a big step back.
• 15:01
  SPEAKER_00: And this is a way to really help navigate that process.
• 15:04
  SPEAKER_00: So take care of your donor site.
• 15:07
  SPEAKER_00: You can think about it like a tendonopathy or like a muscle strain.
• 15:12
  SPEAKER_00: That is something that can be helpful to kind of change our perspective on it and understand that there's multiple moving pieces within this ACL reconstructive process versus just like, all right, they went in and put a new ACL.
• 15:24
  SPEAKER_00: It's like, well, but there's a place that they took it from if it was an autograph.
• 15:28
  SPEAKER_00: So just think about it from that sense so you can think about taking care of that donor site area.
• 15:33
  SPEAKER_00: Find a good entry point to load it, respect the healing process and your body, especially early post op, and follow your specific guidance.
• 15:42
  SPEAKER_00: That'll do it for today.
• 15:44
  SPEAKER_00: Until next time, team.