How To Optimize Recovery From ACL Surgery: First 2 Weeks
Undergoing surgery can be scary, and sometimes the recovery process can be even scarier. Your surgeon – if you’re lucky – gives you a protocol for what you can and can’t do, but often times the protocol is vague or contains a lot of medical terminology that is difficult to understand. This will be the first in a series of posts that aims to demystify how to optimize your recovery from ACL surgery. I will write about it in stages, with this post focusing on the main goals of recovery during the first 2 weeks post-surgery.
What is Occurring Physiologically During the First 2 Weeks After Surgery?
An ACL reconstruction is a traumatic event, and as a result, a lot of inflammation is produced. This results in pain and swelling around the knee, with one of the unfortunate side effects being inhibition of the quadriceps muscle (and the other muscles around the knee to a certain extent). This results in disuse of the quadriceps, which leads to atrophy (loss of muscle mass) almost immediately. As a result, the primary goals of rehab during the first 2 weeks are to prevent these things from happening as much as possible.
Main Goals and Optimization Strategies
1. Minimize Swelling
Swelling is the unfortunate byproduct of an evolutionary system that had to find a way to heal injuries while minimizing the risk of short-term re-injury. If you were on the savannah a million years ago and tore your ACL, the only way you were going to recover any function of that knee was through your body’s inflammatory process, which results in an increased delivery of blood and nutrients to the knee. Unfortunately, since your body is sending more fluid to the knee, there is an imbalance in terms of the delivery of fluid compared to the removal of fluid, which results in swelling. Typically, your body removes swelling through a series of vessels called the lymphatic system, which is stimulated by muscle contraction. However, due to pain around the knee, we contract the muscles less to minimize the pain, and when we do contract the muscle, the contraction is weaker because of the swelling and pain. However, thanks to technological, societal, and surgical advances, we have tools and strategies to protect the knee during healing (plus we don’t have to run away from tigers very much anymore) and swelling is now more of a hindrance than an unfortunate by-product of a life-saving inflammatory process. In my opinion, minimizing swelling around the knee is the single greatest priority following ACL surgery, and the best way to facilitate the removal of swelling from around the knee is through non-painful, non-fatiguing muscle contraction. These movements stimulate the lymphatic system, which is the primary system the body uses to bring fluid back towards the heart. These contractions can be done with active exercises, such as ankle pumps and isometric contractions of the hamstrings and quadriceps, but they can also be done artificially with an electrical stimulation machine. I personally believe this is the better option, since you don’t have to think about it and the contraction it creates will be less painful than if you actively contracted the muscle. Compression and elevation are also helpful for reducing swelling. Your doctor may have given you a compression sock when you went home, but it’s best to ask well before surgery so you can have a compression sock or an ACE wrap on hand if your surgeon doesn’t provide one.
2. Minimize Pain
Pain can occur for multiple reasons following ACL surgery, with the primary causes being pain from the surgical incisions and graft introduction sites, as well as increased pressure on the nerves from the swelling (another reason that minimizing swelling is important). Controlling pain is very important, because as pain is reduced, you will be more willing to move your leg, and this movement produces muscle contractions that reduce swelling and muscle atrophy. The easiest way to minimize pain is through the medications your surgeon prescribed for you, which typically include a combination of NSAIDs, acetaminophen, and opioids. Another effective way to manage pain is with ice. While you can apply ice directly to the skin, using a machine like a GameReady will give you the benefits of ice and compression together, which will be more effective.
3. Restore Knee Extension, Improve Muscle Activation, and Minimize Muscle Atrophy
These three go together, because if you can’t get your knee straight, it’s hard to activate your quadriceps, which means you will lose muscle faster. Again, one of the best ways to restore knee extension is to reduce swelling. Let’s address knee extension first. One of the easiest ways to restore knee extension is with passive, long-duration stretches. Two of the most common ones we use are the prong hang and the heel prop. In addition, this is an area where seeing a physical therapist is helpful, because they can manually assist with straightening your leg. Another component that contributes to knee extension is the mobility of the patella (kneecap). When your knee moves into extension, the patella is supposed to move superiorly (towards the hip). However, the patella can become stiff following surgery and will not glide effectively in any direction, which can limit knee motion. A physical therapist can help improve the mobility of the patella, or your doctor may tell you it is ok for you to start doing them yourself as well. Once your knee extension is improved to the point that you can begin to contract your quadriceps, it is important to begin improving this activation as much as possible. In the first week after surgery, it is very effective to combine these active contractions – also known as quad sets – with neuromuscular electrical stimulation (NMES). The use of the NMES will activate a larger proportion of the available muscle fibers than performing the quad set alone, which will help decrease the rate of atrophy. Biofeedback is another tool that can be helpful for improving quadriceps contraction once you have the ability to contract the muscle by yourself. Another modality you can begin using with quad sets, as early as 3 days after surgery, is blood flow restriction (BFR) training. BFR temporarily decreases the amount of blood reaching the leg muscles, requiring them to recruit more muscle fibers to perform the same task; this helps with both muscle activation and maintaining muscle mass. In addition, the use of BFR causes a hormonal response that helps with the maintenance of muscle mass. If you want to learn more about BFR, check out our guide to how to incorporate BFR into recovery from ACL surgery.
4. Nutrition Strategies
It is also important to consider the role of nutrition for maintaining muscle mass following an ACL reconstruction. The large amount of trauma from surgery places the body into a hypermetabolic-catabolic state, which means that your metabolism skyrockets in order to meet the demands of healing. When your body enters this state, it stimulates an increase in the release of hormones and signaling molecules that break down glycogen and convert amino acids to glucose to provide energy. Cortisol is especially relevant to this process, because when it is released, it results in a decrease in protein synthesis and an increase in protein breakdown. Since a lot of these proteins reside in the muscles, this means that a lot of the proteins that are broken down will come from your muscles. And which muscles will your body preferentially take proteins from? The muscles you aren’t using, which in this instance happen to be the muscles we are trying to maintain muscle mass in. In healthy individuals, this process begins within 2 days! Thankfully, there are researched protocols that can help to mitigate these effects. Research shows that consuming a 50g carbohydrate drink 2 hours pre-operatively decreased post-operative insulin resistance by up to 50% and consuming 125g of carbs the night before surgery helped maintain whole-body protein balance 24 hours after surgery. Another study found that ingesting 400 ml of a carbohydrate drink the night before and the morning of surgery decreased the loss of quadriceps strength at one week post-surgery and improved quadriceps strength values at both 1- and 2-month follow up. There is also evidence that protein supplementation is helpful for maintaining muscle mass (not surprising). One study examined the effect of essential amino acid (EAA) supplementation in individuals that were exposed to high levels of LPS (an endotoxin that is partially responsible for creating inflammation after surgery) and found that EAA supplementation increased protein synthesis by 40% and reduced protein breakdown by 20%. Another study found that administering 20g of EAAs 2x/day following a total knee replacement reduced quadriceps and hamstring atrophy at 2- and 6-weeks post-surgery. To learn more about EAA supplementation, you can read my blog post here. Summary In my opinion, these are the keys to a successful recovery during the first 2 weeks following an ACL repair. Swelling management is imperative, because if you cannot control your swelling, it will be very difficult to achieve the other goals of decreasing pain, improving knee extension, restoring quad activation, and maintaining muscle mass. I also believe it is very important to use NMES to begin improving quadriceps activation as soon as it is appropriate; this process can be accompanied by BFR, likely with even better results. In addition, proper carbohydrate and protein consumption both pre-operatively and post-operatively will help to reduce inflammation and maintain muscle mass.
Western Slope Rehab and Performance is Here to Help
If you are struggling with injuries or have recently been in a motor vehicle accident, we can help. We are a physical therapy company that provides home-based orthopedic services in the Grand Junction, CO, area, as well as telehealth appointments throughout Colorado. If you would like to schedule a free consultation, you can call us as 970-462-9177, or fill out our contact form here.
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