Bad Signs After ACL Surgery: What You Need To Know
It’s no secret that Physical Therapy is essential after ACL surgery. The wrong rehab program (or no rehab at all) sets you up for delayed progress at best and failure at worst. Not every PT has the knowledge to guide you through ACL rehab properly. This blog will help you identify some common bad signs to watch out for after your ACL surgery. If you catch these early, it can be much easier to correct course. We’ll talk about general bad signs as well as signs that your rehab program can be improved.
Red Flags After ACL Surgery
Let’s start with the stuff that is a bit more straightforward. The following signs are things we call “red flags” in the Physical Therapy world. If I see these in the clinic with post-op ACL patients, I am concerned that something is going wrong, and I will refer back to the Surgeon and/or contact them.
These are not things to mess around with. Your Surgeon and physical therapist should check for these things, especially immediately after your ACL reconstruction. This is not necessarily a comprehensive list. Use your common sense and make sure your Surgeon is accessible to you if you have questions.
Some red flags to look out for after ACL surgery:
Significant and/or worsening redness or warmth
Increased swelling or bruising
Fever
Significant instability
Redness, tenderness in the calf
Tingling in the leg or foot
These are all signs of things like infection, graft failure, blood clots, or nerve injury. If you notice any of these things after your surgery, get help as soon as possible.
Bad Signs In ACL Rehab
Once you are past the immediate post-op phase, you should pay more attention to exactly how your Physical Therapist is approaching your ACL rehab program. Nobody is perfect, and adjustments are always made, but if a physical therapist is inexperienced in ACL rehab and/or doesn’t include the right things, it can set you back.
Here’s a list of things I DON’T want to see in early ACL rehab:
No manual work on your knee. This is usually necessary to decrease swelling, improve range of motion, and decrease pain.
Not enough quad strengthening. Quad strengthening should be a focus of your ACL rehab throughout, especially in the early stages. If you don’t regain fundamental quad strength and control, everything is harder.
No training of your unaffected (non-surgical) side. Good rehab programs train your whole body. You don’t want to let your other leg get weak and lazy while you are working so hard on the surgical side. You also want to have a good comparison of what your baseline is. This won’t happen if you don’t train both legs.
No conditioning training or advice on how to stay generally active. Most people who have ACL surgery are used to being highly active. It can be physically and mentally destabilizing if you don’t do what you can to keep moving. There are creative ways to continue conditioning and engaging in general movement after surgery. Your PT should help you with this.
No home exercise program. Even if you are seeing your PT 2-3x/week, you need to do a home exercise program to keep progressing. If your Physical Therapist doesn’t give you a good home program (or never progresses it), this is a problem.
Lack of focus on weight-bearing and gait training. This is similar to the point about quad strength above. The earlier you can walk normally, the better ACL rehab tends to go. This should be a heavy focus early in your rehab program.
Bad Signs in Return To Sport ACL Programs
As your ACL rehabilitation progresses, the focus needs to shift from basic training to more sport-specific work and mental preparation. Early and late-stage ACL rehab are very different, and even if someone does a great job helping you in the early stages, they may not have the strength and conditioning and coaching skills to help you get back to sports and high-level activities safely.
ACL return to sport training DONT’s:
No structure to the return-to-running program. Returning to running is a milestone in ACL rehab that marks the shift to higher-level activity. If the only advice you get is something like “just take it slow,” you need a better program. For example, there should be some guidelines for progressing walk/jog intervals to build your endurance.
No formal testing. Your physical therapist should conduct periodic tests of your strength, jumping, landing, and other movements during your program. This needs to be done with actual measurement devices, such as a dynamometer for strength testing, not just “eyeball tests.” If you don’t measure something, you can’t manage it.
Leaving out open- or closed-chain lower-body training. Some physical therapists are not up to date on evidence and avoid certain types of exercises in their ACL rehabilitation programs. Open-chain exercises (such as leg extensions) are safe and important to include in your program. On the flip side, your PT needs to be comfortable programming more challenging closed-chain exercises such as squats, deadlifts, and lunges. Here’s a great article from my colleagues at E3 rehab discussing why leg extensions are safe and effective after ACL surgery.
Not enough isolated quad strengthening. I’ve already mentioned this multiple times, but quad strengthening is imperative after ACL surgery. You should always have some form of isolated quad training in your program. Research shows that this can be a problem months (and even years) after ACL reconstruction if not appropriately trained.
No progression of your program. Your ACL rehab program needs to be consistently progressed. This includes mobility, strength, conditioning, sport-specific training, and more.
No sport-specific training. Your physical therapist needs to have at least a basic understanding of the sport or activity you are trying to get back into. Each sport requires specific things of your knee, and these need to be taken into consideration to ensure you are prepared.
No dual task and/or open environment training. This goes along with the point above about sport-specific training. You need to be able to maintain movement quality and focus in more complicated situations. This will help ensure you are ready to get back to sports safely.
No coordination with the Surgeon, parents, and coaches. Especially as you prepare to return to sports, the communication on your care team needs to be excellent. Each case is nuanced, and everyone needs to be on the same page.
No discussion of mental readiness. This is a BIG one. Even if your PT does an excellent job with all the physical aspects of your training, you can feel unprepared to return to sports. The mental and emotional hurdles of return to sport after ACL surgery are very real and need to be taken into account. Check out this podcast from my friend Dr. Steph Allen for more on Returning to sport after an ACL injury.
ACL Rehab and Return To Sport Programs in Lakeville, MA
This is not a comprehensive list, and if your PT program avoids most of the above, you should do just fine. But if you read through this blog and realize that many of these points describe your rehab experience, you may want to discuss them with your physical therapist and Surgeon and/or find a new provider.
If you’re just starting your ACL rehab research, hopefully, this blog has gotten you thinking about what you need to look for and ask about in your rehab program. ACL rehab is a long and challenging process. Please do your research before you pick a PT to work with. A PT with the right experience and communication skills will save you a lot of time and energy and will help ensure you get the best possible results.
At Wagner PT & Performance, we offer specialty programs for ACL return-to-sport training. Even if your rehab has been less than ideal to this point, it’s never too late to get back on track. Let us help you get back to sports safely and confidently.