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151 | Why Offloading is Important for Post-Op ACL · The ACL Athlete Podcast

• 0:19
  SPEAKER_00: Welcome everyone to the ACL Athlete Podcast.
• 0:23
  SPEAKER_00: This is the podcast where we talk about everything related to the ACL, whether that's the injury itself, the rehab process, return to sport, and more.
• 0:33
  SPEAKER_00: I'm your host, Dr.
• 0:34
  SPEAKER_00: Ravi Patel, performance physical therapist and coach.
• 0:38
  SPEAKER_00: Between myself and fellow guests and experts, you'll learn through the lens of the patient, the healthcare professional, and the coach.
• 0:46
  SPEAKER_00: The goal of this podcast is to equip you, the athlete, with the education to make the best informed decision about your care and your ACL journey.
• 0:57
  SPEAKER_00: Thanks for joining.
• 0:58
  SPEAKER_00: Now let's dive into today's episode.
• 1:04
  SPEAKER_00: What is up, team, and welcome back to another episode on the ACL Athlete Podcast.
• 1:09
  SPEAKER_00: So today we are discussing why offloading is important for post-op ACL.
• 1:15
  SPEAKER_00: And so this is something that will actually apply to post-op ACL surgery or to even post-injury.
• 1:23
  SPEAKER_00: So this is something that you know will have a little bit more application for the surgical process because there have been two essential injuries to the joint, but this applies to both.
• 1:34
  SPEAKER_00: So you can kind of take this if you are someone who's post-injury or for post-op.
• 1:39
  SPEAKER_00: So offloading is something where you can essentially assume we are taking weight off the injured or that surgical leg.
• 1:47
  SPEAKER_00: This is where we are trying to just essentially offload that leg to be able to allow for many things that we will discuss.
• 1:54
  SPEAKER_00: So if you're standing normal on your feet with no injury or surgery, for example, you're likely putting 50% of your weight into each leg to equal 50% of your body weight into the ground.
• 2:07
  SPEAKER_00: So why is offloading important for post op ACL or post injury?
• 2:13
  SPEAKER_00: And so, well, usually after both the injury and surgery, you're given some type of weight-bearing guideline.
• 2:20
  SPEAKER_00: Usually after surgery, it's very specific.
• 2:23
  SPEAKER_00: So this might be something where it's weight bearing is tolerated, or you might it see it written as WBAT.
• 2:30
  SPEAKER_00: That's weight bearing is tolerated.
• 2:32
  SPEAKER_00: So basically, weight bearing as you can tolerate, or it's maybe partial or toe touch weight bearing, or the other one you'll see is non-weight bearing.
• 2:41
  SPEAKER_00: So NWB.
• 2:42
  SPEAKER_00: And that is something where you're putting no weight on the leg.
• 2:45
  SPEAKER_00: And these are our three buckets that people will fall into, especially post-surgery, as their guidance for putting weight on their leg.
• 2:54
  SPEAKER_00: With most people probably falling into weight bearing is tolerated.
• 2:59
  SPEAKER_00: There used to be a lot more of non-weight bearing guidelines after surgery.
• 3:04
  SPEAKER_00: But as time has gone on, surgeons are starting to adopt allowing athletes to put more weight on it as soon as the surgery happens, which is great.
• 3:12
  SPEAKER_00: I think that that is the thing that we need to move towards more.
• 3:15
  SPEAKER_00: The only caveat here is if it's a complex surgery or injury, or if it's something where potentially you had a meniscus, then surgeons will often create some sort of non-weight bearing restriction for a certain amount of time.
• 3:30
  SPEAKER_00: We usually see this between two to six weeks.
• 3:34
  SPEAKER_00: It could be weight bearing is tolerated, but a lot of times we will see on average something like four weeks where someone is non-weight bearing, or maybe those first two weeks they're non-weight bearing and then gradually are able to put weight on their foot.
• 3:46
  SPEAKER_00: So essentially, this will vary based on what the restrictions you are given after your surgery.
• 3:55
  SPEAKER_00: But what we will often see majority of the time, athletes will be weight bearing is tolerated.
• 4:01
  SPEAKER_00: And the thing that will happen with this is that, you know, you might have your physical therapy early, and then therefore you have some guidelines around that of like what that truly means.
• 4:12
  SPEAKER_00: And usually people are a little bit apprehensive to do that post-surgery because they're worried about the knee.
• 4:19
  SPEAKER_00: Is there going to be anything wrong with it?
• 4:21
  SPEAKER_00: Just know that that surgical process is locked in and it is not going on anywhere unless you do something really dumb.
• 4:28
  SPEAKER_00: So weight bearing is tolerated is usually fine, but that's why it says as tolerated, because you need to be able to build up tolerance to it and can't go hot out of the gate.
• 4:38
  SPEAKER_00: One, you are maybe locked in a brace.
• 4:40
  SPEAKER_00: Two is that your range of motion is not necessarily there immediately post op.
• 4:46
  SPEAKER_00: You know, you're starting to get your muscles a little bit more active.
• 4:49
  SPEAKER_00: And then obviously going through and putting weight through that leg.
• 4:52
  SPEAKER_00: That's creating compression at that joint.
• 4:55
  SPEAKER_00: Nothing bad, but it's something that is going to create, you know, stress on different structures.
• 5:00
  SPEAKER_00: And so then, therefore, we got to make sure that we are progressing appropriately.
• 5:05
  SPEAKER_00: What we will see with this typical guidance or restriction with weight bearing is tolerated post-surgery, is that people will progress too quickly and they want to get off the crutches.
• 5:16
  SPEAKER_00: And I know I've talked about this before, but it's something that we commonly see, and I want to touch on this and the importance of why offloading or why the crutches are given to you.
• 5:26
  SPEAKER_00: And what happens is if people rush off of this, is that it leads to the joint and the knee getting really grumpy, and it'll have some increased swelling and pain in many cases when it is rushed.
• 5:39
  SPEAKER_00: And usually this is accompanied with some limping or skipping some range of motion through the gait cycle, especially something like extension.
• 5:48
  SPEAKER_00: And so now we're not saying here, in terms of this, you know, to offload and to just completely not let the leg come down, or being able to go full weight bearing as immediately and as quickly as possible.
• 6:03
  SPEAKER_00: We're not saying do one end or the other on the spectrum.
• 6:07
  SPEAKER_00: What we're saying here is that we want to make sure that we appropriately and progressively offload.
• 6:13
  SPEAKER_00: And why is it helpful?
• 6:15
  SPEAKER_00: Well, you've just had a joint that's had a fairly traumatic injury, especially if it's recently, and then you have a surgery.
• 6:23
  SPEAKER_00: There's another traumatic injury in a sense.
• 6:25
  SPEAKER_00: And so it is a lot for the knee.
• 6:28
  SPEAKER_00: It is something that is putting it through stress.
• 6:31
  SPEAKER_00: Our body is going through this natural healing process post-injury, and then even post-surgery, right?
• 6:38
  SPEAKER_00: And so this is something that it does with any type of injury.
• 6:41
  SPEAKER_00: But especially when you have something like an ACL tear, maybe there's a meniscus, maybe there's bone bruising, maybe there's a fracture, maybe there's an MCL sprain.
• 6:50
  SPEAKER_00: You know, there are a lot of things that can play into the injury itself.
• 6:53
  SPEAKER_00: And then we got to go in and we got to do surgery.
• 6:56
  SPEAKER_00: And when you add more to it with that, like incisions, cleaning up scar tissue, or just like tissue that doesn't need to be there anymore, the residual ACL that's there, the stumps, taking a graph potentially from somewhere on your body, like your quad hamstring, or your patellar tendon, drilling some tunnels, anchoring some screws, repairing potentially some other areas such as ligaments, meniscus.
• 7:24
  SPEAKER_00: The knee might be a little pissed and it might freak out a little bit, and that's normal.
• 7:29
  SPEAKER_00: You know, this is just the name of the game with an injury like this, and especially with having surgery.
• 7:35
  SPEAKER_00: You know, it's it's that kind of two-step process which most people will go through.
• 7:39
  SPEAKER_00: You'll have the injury, and then eventually you'll have the surgery.
• 7:42
  SPEAKER_00: If you do, then that's what you're looking at.
• 7:45
  SPEAKER_00: So you just gotta kind of view it this way.
• 7:47
  SPEAKER_00: It's not just this like brand new knee that you can magically just kind of do as much as you want on it.
• 7:52
  SPEAKER_00: You got to respect the healing process.
• 7:54
  SPEAKER_00: And so what will happen is especially early after that surgery or after the injury, you're gonna have an inflammatory process that is really spiked up.
• 8:06
  SPEAKER_00: The knee's like, what's going on?
• 8:07
  SPEAKER_00: It's starting to do that healing process.
• 8:10
  SPEAKER_00: And that inflammatory process is usually where you are at that point, and that's gonna be accompanied by swelling and pain.
• 8:18
  SPEAKER_00: Pain is there because you had an insult to the joint and different structures.
• 8:22
  SPEAKER_00: It's also there to kind of create a little bit of a warning, like a yellow and red light, to be like, hey, like don't move this because we are trying to heal this thing up and you might injure it further.
• 8:33
  SPEAKER_00: So it's always a dance between that of figuring out what pain you want to work through and not.
• 8:39
  SPEAKER_00: We have our feedback loops, and if you want to look into that, we have episodes around navigating pain that you can look at our traffic light system and our 24-hour feedback loop to help with this.
• 8:52
  SPEAKER_00: The biggest thing here is that we want to bring down our sharpness and our pain, and then it should move towards kind of dullish pain and then becomes a little bit more predictable the further away from surgery and injury you get.
• 9:04
  SPEAKER_00: Swelling, this is also one of the things that is the bane of our existence because it can play against us a lot.
• 9:11
  SPEAKER_00: The knee feels full, it can impact range of motion, it can impact the quad activating.
• 9:18
  SPEAKER_00: So when we are post-op, this inflammatory process is kicking in, swelling and pain is there, all this stuff is normal, right?
• 9:27
  SPEAKER_00: Offloading the joint via crutches can help to facilitate this inflammatory process, and it can allow us to protect the joint and allow us to start this healing process and this healing phase.
• 9:40
  SPEAKER_00: This doesn't mean that you just don't do anything, and this doesn't mean you do everything, right?
• 9:45
  SPEAKER_00: You don't want the pendulum on one side or the other.
• 9:47
  SPEAKER_00: You want to find the sweet spot, and this is where your physical therapist plays a big role.
• 9:52
  SPEAKER_00: You want to make sure you can find that sweet spot.
• 9:55
  SPEAKER_00: And the way we do that to some degree is being able to make sure that we have certain goals we're working through and having those feedback loops, especially with knowing what is a green light for you to do, what is a yellow light for you to do, and what is maybe a red light.
• 10:09
  SPEAKER_00: Let's not step into that just yet, right?
• 10:12
  SPEAKER_00: So, this is something that will be really key.
• 10:15
  SPEAKER_00: And this immediate offloading that we do in terms of the post-surgical process that is going to help with protection and healing, it's gonna allow us to make sure the joint is minimally stressed.
• 10:28
  SPEAKER_00: That's why we're offloading it.
• 10:30
  SPEAKER_00: We're allowing it to do its job in that acute phase to be able to make sure that, especially in those first one to two weeks, we are giving it its space and its time.
• 10:40
  SPEAKER_00: When we rush to get off crutches and are loading that joint too much without the appropriate progression, this can flare that knee up and can cause some swelling and pain to stick around for longer than it should.
• 10:52
  SPEAKER_00: And I'm sure some of you listening here are maybe past this point.
• 10:56
  SPEAKER_00: And it's something where maybe you did have some swelling and pain stick around and you rush off the crutches and you're dealing with potentially some limping, or maybe just the knee is like really stiff, and you're dealing with kind of some of these issues, right?
• 11:12
  SPEAKER_00: And I would be curious to hear whether you actually, you know, got off the crutches appropriately, or you just kind of ditched them, and then you're like, I'm good enough.
• 11:20
  SPEAKER_00: And in this case, we want to make sure that we just don't get off of them too quickly.
• 11:27
  SPEAKER_00: And this can cause that pain and swelling to really stick around, and we don't want that.
• 11:32
  SPEAKER_00: That's gonna play against our quad activation, especially.
• 11:35
  SPEAKER_00: Arthrogenic muscle inhibition is a big connection with swelling being present.
• 11:40
  SPEAKER_00: And then we want to make sure that we can also develop strength.
• 11:43
  SPEAKER_00: Again, swelling and pain playing against that.
• 11:46
  SPEAKER_00: So the same concept applies to something like step count, right?
• 11:50
  SPEAKER_00: Anything that creates stress on the joint itself, a slow, gradual progression is essentially us going from offloaded towards loading progressively week over week, day over day, to make sure that the knee and the body is tolerating the stress that is being placed on it, versus really trying to ramp back up with a high step count.
• 12:12
  SPEAKER_00: This can be something that plays against you as well because you're almost overloading that joint too much by creating too many steps.
• 12:20
  SPEAKER_00: Next thing you know, you get an unhappy knee.
• 12:22
  SPEAKER_00: And then that is gonna make swelling probably stick around and maybe the knee swell up a little bit more.
• 12:27
  SPEAKER_00: And we see this a lot with either our people who have to get back to work, which we understand, and then you know, let's say they're on their feet a lot, like a teacher.
• 12:38
  SPEAKER_00: We've seen this where it can just be hard for that swelling to get out because they are vertical so much.
• 12:44
  SPEAKER_00: Versus our remote athletes, they're just chilling, they might be able to prop up their leg, not as many step counts.
• 12:50
  SPEAKER_00: And while we don't want you to just kind of decondition or be a couch potato, we also don't want you to be using quote unquote steps as your conditioning with early post-op.
• 13:01
  SPEAKER_00: That can play against you because, again, we want to manage the stress and the load in the knee.
• 13:06
  SPEAKER_00: And walking and step count is not your best friend on the early post-op phases because that knee is trying to settle down and heal.
• 13:15
  SPEAKER_00: And so that's why I'm I'm emphasizing so much why offloading can be valuable or why it can be helpful to progressively build that up during this process, because it's going to really help with making sure that the knee is happy, it's able to comply with what you're stressing it with, and making sure that it is all gradual, like a dimmer switch, never an on and off process.
• 13:39
  SPEAKER_00: I use the dimmer switch so much.
• 13:41
  SPEAKER_00: And this is something that applies so well, especially with going from a weight bearing as tolerated.
• 13:47
  SPEAKER_00: And this is where it kind of plays into our process of making sure we practically apply this.
• 13:54
  SPEAKER_00: But before we talk about this, I want to talk about you know, protocols and the guidelines given for this.
• 13:59
  SPEAKER_00: So, usually you'll be given a certain timeline.
• 14:02
  SPEAKER_00: You know, in a week, you should start doing X, in two weeks, you should start doing this.
• 14:07
  SPEAKER_00: There's so much variability.
• 14:09
  SPEAKER_00: I've seen it within a week, I've seen it within four weeks.
• 14:13
  SPEAKER_00: There's no clear indication.
• 14:14
  SPEAKER_00: It's just more so have you met the requisites of being able to walk without your crutches?
• 14:19
  SPEAKER_00: That's the main thing.
• 14:20
  SPEAKER_00: Do we have an adequate amount of extension, flexion?
• 14:24
  SPEAKER_00: Is the knee settling down from a swelling and pain standpoint?
• 14:28
  SPEAKER_00: Are your quads active?
• 14:29
  SPEAKER_00: Can you do other movements that utilize controlling the quad to be able to showcase you can swing that leg through a gait cycle, like a straight leg raise, even without a quad lag?
• 14:41
  SPEAKER_00: Can you be able to roll into extension in a loaded position?
• 14:45
  SPEAKER_00: Are you dealing with a lot of pain because that's going to play against you?
• 14:49
  SPEAKER_00: There are a lot of things that we want to make sure that we meet the criteria-wise before we just, you know, let you get off to just walking without crutches.
• 15:00
  SPEAKER_00: So there's no clear indication of this, and it will be a specific case to case, which is why your provider is going to be so key to help with this.
• 15:07
  SPEAKER_00: Practically, how can this apply to you as you're listening to this?
• 15:11
  SPEAKER_00: If you're post-injury or post-op, this will be dependent on your weight bearing restrictions initially.
• 15:16
  SPEAKER_00: Let's say your weight bearing is tolerated and no other restrictions.
• 15:20
  SPEAKER_00: You go from two crutch to one crutch to no crutch.
• 15:25
  SPEAKER_00: If you have a brace, my opinion is to ditch that first before your crutches.
• 15:30
  SPEAKER_00: But of course, making sure your medical professionals have guided you with this and are okay with that.
• 15:35
  SPEAKER_00: But a lot of times people will keep the brace and dish the crutches.
• 15:38
  SPEAKER_00: And then they're just swinging their legs around and not able to roll through a normal gait cycle.
• 15:43
  SPEAKER_00: Ditch the brace first if possible.
• 15:45
  SPEAKER_00: Stay on the crutches longer and take way, way more time than you think.
• 15:50
  SPEAKER_00: If you notice your knee is getting grumpy or you're limping, my suggestion is to regress back.
• 15:56
  SPEAKER_00: Nothing sucks more than going from no crutch back to one crutch, but I promise you it'll be so worth the investment of the energy and time.
• 16:05
  SPEAKER_00: And who cares what other people think?
• 16:08
  SPEAKER_00: But you want to make sure you have an assisted version to help offload the knee.
• 16:12
  SPEAKER_00: That's the name of the game here.
• 16:14
  SPEAKER_00: If we kind of look at this from a zoomed out perspective, we're just trying to manage stress at the joint.
• 16:19
  SPEAKER_00: It's been injured.
• 16:21
  SPEAKER_00: There's something that has just happened from a surgical perspective that has injured the knee again.
• 16:26
  SPEAKER_00: So we need to respect that first one to especially four weeks.
• 16:31
  SPEAKER_00: If I could give you a range here to just know, like, all right, I gotta respect this.
• 16:35
  SPEAKER_00: I can't go overdrive and I can't do nothing.
• 16:38
  SPEAKER_00: Let me find the sweet spot with my rehab.
• 16:40
  SPEAKER_00: But especially as I start to load the leg through the ground, especially putting weight into it, we want to gradually progress that like a dimmer switch.
• 16:49
  SPEAKER_00: And my suggestion here is go from two crutch, crush it, absolutely make it feel smooth and good, then go towards one crutch.
• 16:59
  SPEAKER_00: You should be doing gait cycles and gait training and mechanic work to be able to comp accompany all this stuff that you're doing to make sure your gait is normalized.
• 17:09
  SPEAKER_00: And then going eventually down to no crutch.
• 17:12
  SPEAKER_00: But you want to kind of take it progressively because you'll be able to know, all right, is my knee getting grumpy or not?
• 17:19
  SPEAKER_00: The other thing to also consider with this is that how many kind of steps or how often are you vertical in the day, which will impact that.
• 17:27
  SPEAKER_00: You want to say on crutches, probably a little bit longer if maybe you take a lot more steps because you're at school or maybe you're work.
• 17:34
  SPEAKER_00: But if you are maybe someone who's able to be a little bit more stationary for your day and less step count, well, maybe you might be able to kind of progress on this a little bit faster.
• 17:45
  SPEAKER_00: It just kind of depends on your case.
• 17:47
  SPEAKER_00: I've seen the whole spectrum of this, but this is something that we want to factor in, especially with offloading post-op ACL.
• 17:55
  SPEAKER_00: And I promise you this will help you so much as you get towards running and all the other fun stuff.
• 18:03
  SPEAKER_00: But I've seen this play against people where they come in and they're working with us three months post-op and they've been elsewhere and they are still limping or they're still dealing with swelling and pain.
• 18:16
  SPEAKER_00: And, you know, there's something where we asked them their history, and they're like, well, got off the crutches.
• 18:22
  SPEAKER_00: You know, they told us about how they injured the knee, they had surgery right after, and then, you know, it was a complicated knee injury, a complicated surgery, and then they were just off crutches in two weeks.
• 18:35
  SPEAKER_00: And it just didn't make sense because the joint was still healing and they showed no signs of being ready to be off of it.
• 18:44
  SPEAKER_00: So use the dimmer switch here, guys.
• 18:47
  SPEAKER_00: Be able to offload as you need to, and it might be something that you have to revisit more than you think, but take longer on your crutches because I promise it will be such a game changer for you as you approach the kind of early post op phases, and it'll really help to get you towards the next phase versus feeling like you're quote unquote stuck, or you're that person walking around with a limp because you just wanted to dish your crutches.
• 19:15
  SPEAKER_00: Don't be that person.
• 19:16
  SPEAKER_00: Make sure you do it right.
• 19:17
  SPEAKER_00: If you need any help, you know where to find us.
• 19:20
  SPEAKER_00: Until next time, team.
• 19:21
  SPEAKER_00: This is your host, Robbie Patel, signing off.