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226 | The #1 Mistake After ACL Surgery That Keeps Swelling Around · 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's up, y'all?
• 1:01
  SPEAKER_00: Welcome back to another episode on the ACL Athlete Podcast.
• 1:06
  SPEAKER_00: So today we are talking about sneaky ways that swelling can stick around or really interrupt the ACL rehab process.
• 1:16
  SPEAKER_00: And I've been a little bit more on a swelling kick because of just conversations we've been having, talking with ACLers, talking with the team, and just different ways that we're seeing this show up.
• 1:28
  SPEAKER_00: And swelling is always something that we are tackling ASAP and ACL rehab, like as soon as possible.
• 1:36
  SPEAKER_00: We are trying to get this thing out.
• 1:38
  SPEAKER_00: A lot of times people will say, Oh, well, we want swelling there and the inflammation there for the healing process.
• 1:43
  SPEAKER_00: I promise you, as far as what we know now from the research and from the way that just the natural way that the knee moves, and for the sake of our quads, for range of motion, we want to get the swelling out as quick as possible.
• 1:59
  SPEAKER_00: And that is one of the biggest dreams and biggest goals for not only ACLR, but especially for your physical therapist or rehab provider.
• 2:07
  SPEAKER_00: If we can get that knocked out and get your extension going, get your quads awake, you are on the road to some solid success early on.
• 2:17
  SPEAKER_00: But the big thing is that it's a challenge because, of course, as the surgery happens, as the injury happens, and all the other factors that play into it, the injury and the time between injury to surgery, how bad the injury was, are there any other issues in there like bone bruising, other concaminant type issues that also arise during the injury, any additional procedures that need to happen, like meniscus or MCL, maybe there's a tibio plateau fracture, in addition to harvesting a ACL graft from one of the sites or an allograft, and then of course putting that thing in there, right?
• 2:54
  SPEAKER_00: So getting the bone tunnels, putting the screws in there, all the things, right?
• 2:58
  SPEAKER_00: So then, therefore, we understand why the knee is mad and angry after a surgery like this.
• 3:03
  SPEAKER_00: It is healing and it's our natural healing process.
• 3:07
  SPEAKER_00: But with that said, people have different reactions to swelling.
• 3:10
  SPEAKER_00: We've had some people where their knee doesn't really swell up, and you're one of the lucky few.
• 3:15
  SPEAKER_00: While most other people have a normal response to swelling to maybe a very extreme response to swelling.
• 3:22
  SPEAKER_00: And then, of course, there are other live factors that play into this.
• 3:25
  SPEAKER_00: And so what I want to talk about today are just thinking about what our daily lives and rehab and things of that nature will play into how maybe swelling can stick around, especially in the knee joint and what we can do about it.
• 3:43
  SPEAKER_00: And I've seen many situations where people are trying to improve all the things, and it's something we do especially early on, right?
• 3:49
  SPEAKER_00: We're trying to work on flexion, extension, pain.
• 3:52
  SPEAKER_00: People are also limping with their gait, their quad activation, trying to also exercise outside of this, right?
• 4:00
  SPEAKER_00: And when they prioritize getting their swelling down, we typically see that the rest of these different buckets or different pieces tend to improve and improve a lot.
• 4:13
  SPEAKER_00: So if we bring swelling down, their extension improves, their flexion improves, their pain improves, their limping improves, and guess what?
• 4:21
  SPEAKER_00: Their quad also starts to improve with waking up and getting activated.
• 4:27
  SPEAKER_00: That doesn't necessarily mean it's a one-to-one of okay, if swelling's gone, then therefore these things will automatically just improve and get better.
• 4:35
  SPEAKER_00: It just gives you a better opportunity and a better stimulus, if you will, to be able to work on these things because swelling does kind of butt heads with these areas because when you have more fluid in the joint, it's going to limit all these things because it is just naturally impacting the way that that joint moves, the pressure, and also the way that muscle activation is around the joint.
• 5:00
  SPEAKER_00: And that doesn't necessarily mean that we just forget about everything and just work on swelling.
• 5:06
  SPEAKER_00: We work on all the things, right?
• 5:08
  SPEAKER_00: But then we are going to heavily prioritize swelling management, especially early on.
• 5:13
  SPEAKER_00: So we have to plan and manage these things, and that's where a good program individualized to you going through this process, but then also good guidance to adapt it as we go because guess what?
• 5:24
  SPEAKER_00: Life's gonna happen, things are gonna change, and so then therefore, we need to make sure it's an adaptable plan that is guided.
• 5:30
  SPEAKER_00: And if you're looking for swelling management strategies, I did a two-part series on this, episodes 216 and 217, where I dig into some of the research as well as practical swelling management strategies.
• 5:44
  SPEAKER_00: And that's something that I want to make sure is out there for you to be able to look at and be able to utilize.
• 5:50
  SPEAKER_00: And maybe there are some things that you're not tapping into that you weren't educated on, or maybe something that you're like, oh, I didn't know that this was an option, and something that is just an easy, low-hanging fruit for you to implement, especially if you're dealing with some fluid and with some swelling in the joint.
• 6:07
  SPEAKER_00: And the thing is that this doesn't just apply in terms of the swelling pieces early on to post op ACLers or post-injury ACLers.
• 6:17
  SPEAKER_00: This can also go for the ACLer who might be out of these earlier stages and months in, but still dealing with some swelling.
• 6:27
  SPEAKER_00: It's typically lingering from the earlier stages more often than not.
• 6:31
  SPEAKER_00: And so this is always an important point if an ACLer we are consulting with or working with brings up dealing with swelling.
• 6:41
  SPEAKER_00: We will have people say that they are quote unquote following the plan, right?
• 6:45
  SPEAKER_00: They are following all the details of the plan, all the guidance that's been given, whether they are, you know, working with someone else or maybe they're working with us, right?
• 6:55
  SPEAKER_00: And they're saying, like, yeah, I'm listening to everything, I'm doing all the stuff.
• 6:58
  SPEAKER_00: And then their knee is still feeling tight and swollen and symptomatic.
• 7:03
  SPEAKER_00: And this typically leads to a delay in the progress during the A cell rehab process.
• 7:09
  SPEAKER_00: We can't necessarily move forward if the knee is not responding well to what it's already been given.
• 7:16
  SPEAKER_00: And the word we're looking for is tolerance, it is not tolerating the stress that is being placed on it, the knee joint itself.
• 7:24
  SPEAKER_00: That leads to symptoms, typically pain and or swelling.
• 7:29
  SPEAKER_00: There are people who are dealing with pain who don't have swelling, and there are people who don't really have pain and they're dealing with swelling.
• 7:35
  SPEAKER_00: Often can kind of go together, especially the earlier you are in this process.
• 7:40
  SPEAKER_00: But with that said, the symptoms are manifesting themselves, especially the swelling piece, because the knee joint is not tolerating what is being placed on it.
• 7:52
  SPEAKER_00: So then we are exceeding the capacity and the tolerance of that knee joint.
• 7:57
  SPEAKER_00: So, us as rehab professionals and coaches, we have to play detective.
• 8:02
  SPEAKER_00: And while it could be a super tricky and symptomatic knee, those do exist while following the plan.
• 8:09
  SPEAKER_00: More often than not, it might be what the ACLR is, or in parentheses, if you will, or is not doing outside of their ACL rehab.
• 8:20
  SPEAKER_00: And so this is an important point here.
• 8:22
  SPEAKER_00: So we have to start asking questions.
• 8:25
  SPEAKER_00: When did it start?
• 8:27
  SPEAKER_00: When did it start to potentially spike, if you will, um, in terms of this symptoms and specifically talking about swelling here or fluid in the knee joint?
• 8:36
  SPEAKER_00: And it could be just a little bit or it could be a lot, right?
• 8:39
  SPEAKER_00: And so there's a range of how much that could be.
• 8:42
  SPEAKER_00: What variables have changed since this has started?
• 8:46
  SPEAKER_00: Did you go too hard in a session?
• 8:48
  SPEAKER_00: Did you go too hard in multiple sessions back to back?
• 8:50
  SPEAKER_00: Did you take a rest day?
• 8:52
  SPEAKER_00: Was there any other factors contributing?
• 8:55
  SPEAKER_00: And what we often see is that people think that there was no change and it just kind of happens out of nowhere.
• 9:02
  SPEAKER_00: Or sometimes it's something that they connect the dots with, but it ends up not being that thing, right?
• 9:10
  SPEAKER_00: It ends up being, okay, well, let's say for example, someone gets sick with a cold.
• 9:15
  SPEAKER_00: And if we had no understanding of like what cold medicine does, right?
• 9:20
  SPEAKER_00: Usually a cold is a virus, and therefore cold medicine that we buy over the counter, you're like, oh, well, the cold medicine made it go away.
• 9:27
  SPEAKER_00: And really it just dampened your symptoms.
• 9:30
  SPEAKER_00: The cold medicine is not healing your virus or taking the virus out, it is actually something that is just helping to dampen the symptoms that way, as your body is fighting this virus, that it is essentially going to take the time it needs to be able to fight this thing off and heal.
• 9:47
  SPEAKER_00: But that's where it's really important here, where sometimes people will say, like, well, this was the reason why.
• 9:53
  SPEAKER_00: Or sometimes when people are doing certain things during their ACL rehab, they will often like say that they were doing, you know, X movement, and they're like, Oh, it's because of X movement, that's why this happened.
• 10:07
  SPEAKER_00: In reality, it's not always just this one-off.
• 10:10
  SPEAKER_00: Well, it can happen like this, but especially with swelling, a lot of times there can be these things that can kind of play into it, and it's just not something that just happened out of nowhere, right?
• 10:22
  SPEAKER_00: Sometimes that does happen, of course, but like I said, it is rarely that, and it's usually something that is maybe non-exercise-based activities or live things that can sneak in.
• 10:34
  SPEAKER_00: And I see this all of the time, and we as a team talk about this all the time, where someone is still dealing with swelling and they're like, we're following things and you know, tackling it to a T.
• 10:47
  SPEAKER_00: And then I just want to share like a couple examples of recently here of just some things that we've talked through with some ACLers to help hammer this home, and this might connect for a lot of you.
• 10:57
  SPEAKER_00: So we had an ACLer that was crushing it after two years of lots of issues, right?
• 11:02
  SPEAKER_00: Two years of a lot of stuff going on, a lot of poor guidance here.
• 11:07
  SPEAKER_00: And then they came to us, started working with us, and he was doing really well.
• 11:11
  SPEAKER_00: And then his knee randomly started to get puffy and had some pain.
• 11:15
  SPEAKER_00: And I was really thrown off by this because the athlete was doing so well.
• 11:21
  SPEAKER_00: And so then, therefore, you know, things like this can happen where maybe their knee kind of flares up, they do some sort of awkward movement, and the knee just kind of twinges, if you will.
• 11:30
  SPEAKER_00: But oftentimes, whenever something like this happens, we're like, okay, is there anything that happened that you noticed of?
• 11:36
  SPEAKER_00: And they're like, no, not really.
• 11:38
  SPEAKER_00: And then I started to dig deeper.
• 11:41
  SPEAKER_00: And this athlete in particular said he was trying to focus on losing weight, he had it on his mind, he had gained a little bit of weight since he had torn his ACL and not been able to like exercise like he wanted to.
• 11:54
  SPEAKER_00: And so he decided on his own to start incline treadmill every morning for a week for an hour at 15 degrees of incline.
• 12:04
  SPEAKER_00: And then his knee flared up.
• 12:07
  SPEAKER_00: And he never mentioned adding this in.
• 12:09
  SPEAKER_00: And I think in his mind, he's like, Oh, it's not a big deal, or it's not too intense, it's just walking, right?
• 12:15
  SPEAKER_00: It'll help me lose weight and probably help the rehab itself get my knee stronger.
• 12:19
  SPEAKER_00: But in reality, in combination with his workouts plus this specific input, it was just too much.
• 12:26
  SPEAKER_00: It flared things up, and you know, that wasn't something that was communicated because a lot of times what happens is that ACLers, you just kind of want to move, you want to do your own stuff.
• 12:37
  SPEAKER_00: You don't feel like you need to say every single detail, which I understand that, but it can make things a little challenging because this stuff isn't just a one-off, it's usually an accumulation that ends up adding into this.
• 12:51
  SPEAKER_00: Plus, you got to think about all the other variables in life and also your rehab itself, right?
• 12:57
  SPEAKER_00: And so this is something that he wanted to throw the towel in all of a sudden because of this and his long stent prior to working with us, and two years of just going through this process, and he was doing well, but then this knee kind of flared up, and we had to redirect it back.
• 13:14
  SPEAKER_00: We had to educate and we had to be like, hey, look, like this was a spike in your training load.
• 13:19
  SPEAKER_00: 15 degrees incline for an hour is a lot on anybody, especially whenever it's back to back-to-back days, in addition to your rehab, in addition to just your daily life, right?
• 13:30
  SPEAKER_00: So there was a spike in training and step count and volume that we had to play detective and figure out that he was just like, oh, it's not a big deal.
• 13:38
  SPEAKER_00: And so, anyways, redirecting this helped us to understand why it happened, and then for us to game plan and adapt things as we go.
• 13:47
  SPEAKER_00: Another example of this is that this is an ACL who is older, she had a cadaver graft early on post-op.
• 13:54
  SPEAKER_00: She said things were going over overall really well, but she can notice the knee feeling tight, right?
• 14:01
  SPEAKER_00: And so I'm sure some of you can probably relate to this where the knee feels tight, but it doesn't feel like swollen.
• 14:07
  SPEAKER_00: You wouldn't necessarily say, Yeah, my knee is swollen.
• 14:09
  SPEAKER_00: Um, and then when you look at both knees, maybe it's just a little different around the kneecap on the ACL operated side.
• 14:17
  SPEAKER_00: But you wouldn't categorize it as like, yeah, my knee is really swollen.
• 14:20
  SPEAKER_00: And so the thing that is usually communicated, especially when it's visually not able to see it as much, is that the knee feels tight.
• 14:29
  SPEAKER_00: And usually when you go to bend it or flex it, that's when it's even more noticeable because it approximates that joint and puts more pressure into the joint.
• 14:37
  SPEAKER_00: So if you have any extra fluid in there, guess what?
• 14:39
  SPEAKER_00: It is going to talk to you whenever your knee goes in that deep flexion.
• 14:43
  SPEAKER_00: And so, anyway, she noticed the knee was feeling tight.
• 14:47
  SPEAKER_00: She said she had been walking a mile every day.
• 14:50
  SPEAKER_00: She was early, early post-op.
• 14:53
  SPEAKER_00: And she was wired as a mover, never was sedentary, and she was itching to move.
• 14:58
  SPEAKER_00: So she thought she was in a good enough place in her reap to start walking, right?
• 15:03
  SPEAKER_00: And this was just like consulting with her.
• 15:06
  SPEAKER_00: And so she just set just kind of this arbitrary goal to walk a mile, right?
• 15:11
  SPEAKER_00: And there's nothing wrong with that.
• 15:13
  SPEAKER_00: We just always want to make sure that it aligns with where the person is and meeting them where they're at without the detriment of their progress.
• 15:21
  SPEAKER_00: And so the challenge was that she was also rehabbing.
• 15:25
  SPEAKER_00: So she just thought it was normal when in fact she had spiked her step count post op.
• 15:31
  SPEAKER_00: And so we had to back off things and improve it a lot, right?
• 15:36
  SPEAKER_00: And so that was the big goal here.
• 15:38
  SPEAKER_00: And when she did back off of it, man, the swelling really settled down.
• 15:43
  SPEAKER_00: And then it happened again where the knee swelling kind of came back.
• 15:47
  SPEAKER_00: She started feeling some tightness.
• 15:49
  SPEAKER_00: She mentioned no changes and the plan was being operated as had been discussed.
• 15:56
  SPEAKER_00: Then she mentioned she started standing at work more, adding more walking back into the mix here and there.
• 16:02
  SPEAKER_00: And instead of the five-minute reverse treadmill that might be in her warmup, she went for 30 minutes every day.
• 18:14
  SPEAKER_00: Y'all people who love to walk, I know you can relate here.
• 18:17
  SPEAKER_00: And this is something that makes it a little bit challenging for us and challenging for your knees.
• 18:23
  SPEAKER_00: Again, not following the plan and creating spikes in their overall load or stress to the body and the knee.
• 18:29
  SPEAKER_00: And I see this a lot with people who go and travel.
• 18:32
  SPEAKER_00: Um, just did a recent episode on this about traveling and setbacks and just understanding what that looks like in terms of training and your rehab, but we see this a lot with people who are traveling because you're on your feet more.
• 18:45
  SPEAKER_00: Athletes with potential school or going to college and walking around, and maybe they get the two weeks off for a certain break, but then they got to get back to school, right?
• 18:54
  SPEAKER_00: You may get some assistance there, but in general, you go from not walking a lot post op to potentially a big spike, and it might not be, you know, even close to what you were doing.
• 19:06
  SPEAKER_00: Maybe you were hitting 10,000 steps a day, maybe you're hitting 15,000, maybe even 20,000 for some of you guys.
• 19:12
  SPEAKER_00: And that's the thing, especially if you're a runner, um, if you're on your feet a lot, then that is nothing out of the ordinary for you.
• 19:20
  SPEAKER_00: So then when you're early post-op, you're like, well, what's 2,000 steps?
• 19:24
  SPEAKER_00: I used to could do like 10 or 15,000 on average.
• 19:27
  SPEAKER_00: The thing is, is that the body is going to just do what it does.
• 19:32
  SPEAKER_00: And so then, therefore, we have to understand that when you're putting yourself vertical, one gravity is working, but then two is that there's just being load and stress on the knee in the body after such a major injury and especially a major surgery where there was a lot done.
• 19:51
  SPEAKER_00: And so this can be challenging, especially for those folks who do go travel or people going back to school or college, or people who have jobs where they have to be on their feet.
• 20:01
  SPEAKER_00: Talking about nurses, talking about, you know, ER physicians, thinking about long shifts, 12-hour shifts, 24-hour shifts.
• 20:08
  SPEAKER_00: Maybe you're a teacher.
• 20:10
  SPEAKER_00: You know, there are so many different occupations that we work with where people have to be on their feet.
• 20:15
  SPEAKER_00: And guess what?
• 20:16
  SPEAKER_00: You're just at a general disadvantage early post-op compared to the folks who are remote or able to sit down and just prop their legs up, right?
• 20:24
  SPEAKER_00: And that just comes with the territory of just what you do, right?
• 20:27
  SPEAKER_00: Or what you have to do.
• 20:28
  SPEAKER_00: And so these all make a massive difference, especially with a knee that is post-op, that is sensitive, and especially that is dealing with swelling.
• 20:38
  SPEAKER_00: I know sometimes that can't always be changed.
• 20:41
  SPEAKER_00: Like you have to go back to work at some point, right?
• 20:43
  SPEAKER_00: So then, therefore, we can't necessarily change that in your situation in most of the times.
• 20:49
  SPEAKER_00: And I think it's a matter of controlling what you can, especially early on.
• 20:53
  SPEAKER_00: And that's what I want to really drive home here.
• 20:55
  SPEAKER_00: And it's also not about trying to smart the system thinking it won't hurt or this little bit won't hurt, right?
• 21:01
  SPEAKER_00: And oftentimes I do get that some people don't know that it's a big contributing factor.
• 21:06
  SPEAKER_00: And it's rarely ever just one time, it's usually the accumulative effect of it repeated over time.
• 21:14
  SPEAKER_00: Like, yeah, one mile walk might not be that bad.
• 21:17
  SPEAKER_00: And then if you don't do it at all after that for a period of time.
• 21:20
  SPEAKER_00: But then when you do that more consistently day after day after day, with a you know, symptomatic knee that's still early on, that's getting used to load bearing again, being able to be stressed, and also you're stressing it with rehab and kind of pushing the joint, that maybe that that all together is going to be the thing that might kind of push it over the edge and keep the swelling and the symptoms continuing to stick around, right?
• 21:46
  SPEAKER_00: So, what I want to do is be able to provide a helpful framework to understand how swelling might sneak in based on human movement in general.
• 21:56
  SPEAKER_00: We want to think about movement as a total load, sometimes referred to as like an allostatic load.
• 22:02
  SPEAKER_00: But this concept is important because if this load is too much over a period of time, chronically, especially, it can create problems.
• 22:11
  SPEAKER_00: In this case, swelling, where there may be some sneaky factors playing into this total load we're not considering.
• 22:18
  SPEAKER_00: So let's walk through this very briefly in terms of what this looks like.
• 22:22
  SPEAKER_00: So, number one, there is structured physical activity that is typically exercise based, and we're going to throw our rehab into this.
• 22:32
  SPEAKER_00: Number two is going to be non-exercise physical activity.
• 22:35
  SPEAKER_00: It can be seen as N E P A, NEPA.
• 22:39
  SPEAKER_00: And then there is activities of daily living, or otherwise called ADLs.
• 22:43
  SPEAKER_00: And then number four is just sedentary behavior.
• 22:46
  SPEAKER_00: That's just us sitting, not moving very much, doing things stationary.
• 22:51
  SPEAKER_00: Now I want to dive into each of these very briefly.
• 22:53
  SPEAKER_00: So when we talk about number one, structured physical activity, of course, that is very obvious here, but this is typically exercise-based, rehab-based, is intentional, it's planned, it is very goal-directed movement aimed at improving your fitness or rehab or function, right?
• 23:10
  SPEAKER_00: This could be aerobic exercises, this could be resistance training, it could be mobility, flexibility work, could be rehab-based work, it could be sports and rec-based stuff.
• 23:20
  SPEAKER_00: But this is stuff that is going to be your structured physical activity, usually to help someone from that rehab standpoint or to help improve physical fitness, right?
• 23:30
  SPEAKER_00: And then there is the non-exercised physical activity, the NEPA.
• 23:37
  SPEAKER_00: This is the sneaky one.
• 23:38
  SPEAKER_00: Unstructured movement, not intended as exercise, but still contributing to energy expenditure and physical function.
• 23:47
  SPEAKER_00: Daily movement, walking to the stores, taking the stairs, household chores, occupation related activity, physical jobs, especially, construction, standing at work, as I had mentioned, maybe it's a teacher who has to be on their feet a lot, a nurse, uh ER physician.
• 24:03
  SPEAKER_00: There's so many occupations out there that people have to be on their feet, or especially physical labor where they're doing some hard work, right?
• 24:12
  SPEAKER_00: And then there's leisure activities, gardening, light yard work, playing with your children, right?
• 24:17
  SPEAKER_00: Not classified technically as like a formal exercise, but you're on your feet and you're moving.
• 24:23
  SPEAKER_00: And so this can also be something that is referred to in the research as neat non-exercise activity thermogenesis, but this is essentially all physical activity that is not deliberate exercise.
• 24:36
  SPEAKER_00: So that's going to be something that's important here because this NEPA is going to be the sneakiest one of them all.
• 24:41
  SPEAKER_00: And then you have number three, which is activities of daily living.
• 24:45
  SPEAKER_00: So this is basically like your self-care stuff you need to do every day for independent living.
• 24:49
  SPEAKER_00: You have your basic ADLs, so like getting, you know, a shower, bathing, dressing, grooming, toileting, feeding.
• 24:57
  SPEAKER_00: And then you have instrumental ADLs.
• 24:59
  SPEAKER_00: So that's like cooking, cleaning, shopping, using transportation, right?
• 25:04
  SPEAKER_00: Like, so these are things that, in a sense, are just like activities of daily living for us to just kind of thrive as humans, right?
• 25:11
  SPEAKER_00: And then the last piece is sedentary behavior.
• 25:13
  SPEAKER_00: So this is usually when you're awake, right?
• 25:16
  SPEAKER_00: And then therefore it's low energy expenditure.
• 25:20
  SPEAKER_00: And typically you're seated, maybe you're reclined, whatever that might be, maybe you're laying down.
• 25:26
  SPEAKER_00: But with that said, it might be sitting at a desk, you know, remote work from this standpoint, watching TV, driving, being on a computer, playing video games.
• 25:36
  SPEAKER_00: So this is essentially very different from physical activity being basically physical inactivity, right?
• 25:43
  SPEAKER_00: And so this is something where, you know, people can still meet their exercise guidelines or physical activity guidelines, but they can still have like high sedentary time, if you will.
• 25:55
  SPEAKER_00: You might go exercise for 30 minutes to an hour, and then therefore the rest of that time is spent seated for the most part.
• 26:03
  SPEAKER_00: So nothing bad with that.
• 26:05
  SPEAKER_00: It's just more of a terminology that is utilized, right?
• 26:08
  SPEAKER_00: And so with that said, these are the four components that are going to be important structured physical activity, exercise base, that makes sense.
• 26:15
  SPEAKER_00: And that's what the rehab process is, and where we assume you are stressing the knee, right?
• 26:21
  SPEAKER_00: Non-exercise physical activity, the the NEPA, this is the one that, if you want to say you quote unquote the silent killer, if you will.
• 26:29
  SPEAKER_00: And so this is the one that most people overlook as nothing, but I promise you it adds up and could be playing into why your knee stays swollen.
• 26:40
  SPEAKER_00: And then in terms of activities of daily living, this one can also be a part of a kind of like a sneaky secondary silent killer where you might just be on your feet a lot doing stuff, especially if you have kids.
• 26:54
  SPEAKER_00: I know that that's something that you can't just get rid of your kids, right?
• 26:57
  SPEAKER_00: Like you have to take care of your kids.
• 27:00
  SPEAKER_00: You know, we have people who have six months olds, we have people who have, you know, a two-year-old, four-year-old, six-year-old, multiple kids, twins.
• 27:08
  SPEAKER_00: And so then therefore, it makes it challenging because you can't just sit down, right?
• 27:13
  SPEAKER_00: You have to make sure that you're taking care of your children as well.
• 27:17
  SPEAKER_00: So these types of things can add up.
• 27:19
  SPEAKER_00: And then, of course, the sedentary behavior piece we're not too worried about, unless you're just not moving at all in your day, then of course, that's also not good as well.
• 27:27
  SPEAKER_00: And so when we are looking at this, there's always a sweet spot with this.
• 27:32
  SPEAKER_00: And I think the best way to manage this is through knowing what your rehab programming and then also knowing your step count as an easy proxy.
• 27:42
  SPEAKER_00: That's easy starting point with this.
• 27:45
  SPEAKER_00: If you do not have like an Apple Watch or some sort of way to track your step count, typically most phones do this.
• 27:51
  SPEAKER_00: Now, it is not as accurate, but with that said, like most people have their phones on them and you're able to track your step count roughly, right?
• 28:00
  SPEAKER_00: Now, give or take, depending on how often you have it, maybe you set it down somewhere, but at least it gives you some sort of frame of reference of movement depending on how much you have it on you.
• 28:10
  SPEAKER_00: But yeah, your rehab programming and your step count are going to be such easy proxies for us to measure and be able to look at.
• 28:17
  SPEAKER_00: Now, as I mentioned, not perfect, but it is helpful to keep it objective and also adjust the dose response.
• 28:23
  SPEAKER_00: Maybe it's 5K steps, your knee doesn't feel great.
• 28:26
  SPEAKER_00: Then stay there as you continue to build your load and your capacity.
• 28:29
  SPEAKER_00: Maybe it's at the 4K, you're like, I feel good in the day.
• 28:33
  SPEAKER_00: And then slow cook this thing.
• 28:35
  SPEAKER_00: Do not rush trying to build up your step count, because I promise you, from a swelling and symptom standpoint, your knee will be like, I'm good, and it's gonna slow your rehab down.
• 28:45
  SPEAKER_00: And being in this kind of rush mode or trying to force it is definitely not going to feel very great.
• 28:52
  SPEAKER_00: So don't rush it because I promise you, as long as swelling is there, even the littlest bit in that joint you may not even notice, that is going to impact potentially your range of motion, your quad strength gains, your pain, and more importantly, moving along in this process as a whole.
• 29:09
  SPEAKER_00: I kind of compare it similar to putting the E-brake on while you are trying to drive.
• 29:15
  SPEAKER_00: You may be moving along, but you know it's not moving like it should, and it could be better.
• 29:20
  SPEAKER_00: So imagine getting in your car, you kind of throw that brake on where you kind of press in with your foot, or maybe it's a handbrake, and you're trying to drive with it, right?
• 29:29
  SPEAKER_00: And your car will be moving.
• 29:30
  SPEAKER_00: The thing is, is that you just kind of know it doesn't feel right.
• 29:34
  SPEAKER_00: And that's kind of how this happens, especially when you're dealing with pain, but especially swelling, because that is going to really influence the joint.
• 29:42
  SPEAKER_00: And I know I'm like really being a dead horse here, but like the thing is, is like this is so important and something that really does impact people's overall process, and it can make a massive difference in how the rest of it goes.
• 29:58
  SPEAKER_00: So, my encouragement to you here is to evaluate these things in your own ACL rehab.
• 30:04
  SPEAKER_00: Of course, there might be things you can't control, like our athlete that has to get back to school, as I had mentioned, and walk the halls in the day, or the teacher that has a kindergarten classroom, or the ER doc who has a 24-hour shift.
• 30:16
  SPEAKER_00: But when you can make adjustments, do it.
• 30:20
  SPEAKER_00: And for those who love to walk or loves to move and are itching to do so early and thinking they are fine, I would recommend making sure to follow the plan and don't add too much too soon.
• 30:35
  SPEAKER_00: Talk with your rehab provider, ask them if it makes sense to do this, even if it's just like a half mile walk for you, and you're like, I'm used to walking five miles a day.
• 30:46
  SPEAKER_00: It can add up and it can accumulate.
• 30:49
  SPEAKER_00: My goal here isn't to scare you from moving.
• 30:51
  SPEAKER_00: That's the last thing I want to do.
• 30:53
  SPEAKER_00: And our goal is always to have people hit their physical activity guidelines, do this rehab really well, and get them moving as soon as possible up to a certain threshold and sweet spot, but not at the detriment of your rehab.
• 31:06
  SPEAKER_00: Instead, what I would say is like see if you can scratch that itch by doing off-feet conditioning.
• 31:11
  SPEAKER_00: Bike is a good option here once range of motion is good for flexion, or using the fan or assault bikes here, where you can have your leg off and use the arms.
• 31:21
  SPEAKER_00: Same with like a rower where you could put that ACL leg on a slider, a ski erg where you're sitting down, maybe med ball circuits, and so many other implements we can use to create a circuit, create a cardiovascular effect, feel like you're working, and to scratch that itch to be able to hit those physical activity guidelines without compromising the knee joint.
• 31:43
  SPEAKER_00: It is off-feet conditioning or off-feet loading that you are able to do that isn't going to impact the knee joint as much, like being vertical and especially increasing your step count, especially early on, or for people dealing with lingering swelling issues.
• 31:58
  SPEAKER_00: And we've had people start stuff like this week one.
• 32:02
  SPEAKER_00: You don't need to be a couch potato for the first two weeks or four weeks, or quote unquote rest, as maybe some surgeons might say in the first four weeks.
• 32:11
  SPEAKER_00: We need to move.
• 32:12
  SPEAKER_00: We need to move in a very strategic way, but we also don't want to do it too much and we don't want to do it too little.
• 32:18
  SPEAKER_00: And so this is where it comes back to having a good rehab provider who knows this stuff and has a plan, and not only just a plan that is like, all right, this is what it looks like, but it's adaptable.
• 32:29
  SPEAKER_00: Because I promise you, whatever plan that you start with will not be the plan that is going to be the same at month two, three, four, and five, six, seven, eight, nine, ten, or however long you are in this process, it needs to be adaptable because life doesn't happen in a vacuum or rehab doesn't happen in a vacuum.
• 32:48
  SPEAKER_00: This is something where there are so many moving pieces, so we need to adapt with these things.
• 32:54
  SPEAKER_00: Most importantly, getting guidance on getting this knee in a really solid spot in the first four to six weeks is going to be so, so key.
• 33:04
  SPEAKER_00: I promise this will make for a much smoother mid and late stages of ACL rehab if you're able to follow the plan really well and to be able to stick to this and be able to kind of build this up progressively.
• 33:17
  SPEAKER_00: I always use the dimmer switch.
• 33:19
  SPEAKER_00: It's not an on and off switch.
• 33:20
  SPEAKER_00: All of a sudden you hit week four and you can go walk a mile, right?
• 33:24
  SPEAKER_00: Or you hit you know month four and you're supposed to be returning to run, and all of a sudden you just start with a half mile run, right?
• 33:32
  SPEAKER_00: It's a dimmer switch.
• 33:33
  SPEAKER_00: And so we need to make sure we have a good entry point to start, see the dose response of this, and see how it accumulates over time and manage our symptoms and our different KPIs.
• 33:44
  SPEAKER_00: That's gonna be pain, that's gonna be swelling, range of motion, different strength components, also subjectively how you're feeling with how things are going.
• 33:52
  SPEAKER_00: There are gonna be so many areas for us to continue to evaluate as you go, and that's gonna allow us to know do we need to stay in the same spot?
• 34:00
  SPEAKER_00: Do we need to progress, or do we need to regress some things in order to make sure we keep this knee in a really, really solid spot?
• 34:09
  SPEAKER_00: And that's where working with an ACL expert and someone who knows this stuff is gonna be so, so key.
• 34:15
  SPEAKER_00: So if you feel like you're someone dealing with this, then this is something that I would encourage you to seek out, right?
• 34:21
  SPEAKER_00: And there are plenty of people out there, we do this and we work with people remotely.
• 34:25
  SPEAKER_00: We're happy to help here.
• 34:27
  SPEAKER_00: But we're just saying, like, find someone to support you and guide you in this.
• 34:30
  SPEAKER_00: You are not the person that needs to make all these decisions.
• 34:33
  SPEAKER_00: It should be your rehab provider and coach being able to help you with this.
• 34:37
  SPEAKER_00: And the biggest thing to watch out for is that sneaky NEPA, the non-exercise based physical activity.
• 34:44
  SPEAKER_00: That's where it gets most folks who are dealing with swelling for longer than we want, especially if they're following the plan.
• 34:51
  SPEAKER_00: And if someone's dealing with swelling and they're following everything to a T very consistently, then that's where we need additional medical assistance, right?
• 35:00
  SPEAKER_00: But in most cases, I would say we need to target this really well and do all of our swelling management options before we start going down more medical-based interventions.
• 35:11
  SPEAKER_00: And there are a time and place for that, and we have athletes who need to go that route based on just the way their knee responds.
• 35:17
  SPEAKER_00: But with that said, I would say it's not the majority, that is for sure.
• 35:21
  SPEAKER_00: So look out for this, the sneaky ways that swelling can stick around, because I promise you it can make a massive difference in your ACL rehab.
• 35:31
  SPEAKER_00: But especially if you are in these early phases or you're someone who's just having this kind of linger, evaluate these areas and see if you can't dial it back just a little bit.
• 35:41
  SPEAKER_00: It's always this one step back for two steps forward.
• 35:44
  SPEAKER_00: That's the way that we look at it.
• 35:46
  SPEAKER_00: And it is going to allow you to speed up the rest of the process if you are able to get past especially these initial barriers.
• 35:55
  SPEAKER_00: And that's going to help you the most as you go through this ACL process.
• 35:59
  SPEAKER_00: And if you can focus on getting that knee quiet, get it calm early, you will win this process.
• 36:06
  SPEAKER_00: I promise you this, because it is going to be a massive game changer, and you will be so thankful as you get into the mid and late stages of ACL rehab that you focused on the basics, you followed a game plan, you adjusted as you needed to, and your knee is responding really well to the load and tolerating it really well.
• 36:26
  SPEAKER_00: So I hope this is helpful, y'all.
• 36:27
  SPEAKER_00: If you have any questions, you can always reach out to us via Instagram, via email, via our website.
• 36:34
  SPEAKER_00: We are always here to help.
• 36:36
  SPEAKER_00: Um, whether you are someone who is looking for some support through the ACL process, or whether you're just looking for some questions and some clarity around some things based on your specific case.
• 36:47
  SPEAKER_00: Until next time, team, this is your host, Robbie Patel, signing off.