A Physical Therapist’s Reflections on Knee Surgery

Having been an orthopedic PT for 15 years and treating many, many patients with knee injuries, I knew exactly what had happened when my leg buckled during a soccer game last November. Indeed, an MRI confirmed that I had torn my ACL. Not only that, but I’d also torn my MCL, my LCL, and my lateral meniscus, and chipped some of the surface cartilage on the back of my kneecap. I told the surgeon that I thought I’d now get to find out really just exactly how my patients feel when they come in for therapy. And now in reflection, 8 months later, it turns out that an ‘up’ side of undergoing knee surgery personally is that it really did lend me additional professional insight that will be useful in my continued PT practice. Here are some of the things that I found:

  1. It doesn’t matter how good your condition is going in – there WILL be significant muscular atrophy. – I’ve explained to my patients for years that the more they optimize their muscle tone pre-operatively, the better they’ll be able to efficiently regain strength and function after surgery. The way timing worked out best for me, I had 2 full months between my injury and surgery to work on pre-operative rehabilitation. I was determined to be in great shape going in. I rode a bike, I did a variety of strength & balance training, and I built up my quads as much as I possibly could. The night before surgery my thigh muscles measured equally in circumference & I could comfortably do 50 forward lunges (deep!) without pain in my injured leg. I almost felt ‘normal’, except that there was still an occasional sickening ‘giving-way’ of my leg when I’d turn corners or try to decelerate (like walking down a steep incline). I felt as ready as I could possibly be.

    Surgery went smoothly. After several days on the couch, I eagerly unwrapped my bandages to see what lay below. And what I found was that even though I had good muscle contractions and solid control of my leg, I’d lost a full inch of circumference around my thigh. Wow! This reinforced for me that it’s important for patients (and therapists) to realize that our bodies have specific physiological responses to injury or ‘insult’ (eg: surgery), and that because of this, the timelines for healing and recovery of function are the way that they are. Recovery takes time, and this is true no matter what. So we control what we can by creating as optimal an environment for healing as possible. But the bottom line is that we still need to allow our bodies the opportunity to heal on their own time.

  1. Following the Physician’s immediate post-op instructions specifically is a GREAT idea! – My surgeon made a particular effort to make sure that I realized that I should not skimp on ice and elevation (along with the rest & compression that make up the rehab mnemonic ‘RICE’ ) after surgery. Several physician friends also made sure that I planned to keep up with pain medication for 48 hours after surgery ‘No Matter What’. I certainly had no illusions that I needed to be a hero. And I had a great cast of family and friends that stepped in to make sure that I really didn’t need to do anything during those first post-operative days. So I lay on the couch, icing my leg with my foot up, completely nonstop for a full 2 days. By the end of this time I was dying to move my leg – an act that was being restricted by the tons of post-op gauze and wrapping that had been packed on. It felt great to remove all of that and to clean off some of the iodine and markings left on my leg from the surgery. Once this was accomplished, I realized that my leg really looked almost normal – apart from the stitches at the incision sites, of course. I really had only the slightest tint of bruising and swelling was also very minimal. I was also able to bend my knee almost a 90 degree angle of flexion before I felt any resistance. Let me tell you that this made all sorts of things easier – from sitting up at the table to changing clothing to riding in the car. People (including me) have a tendency to want to get up and around as fast as possible and to minimize the ‘down-time’ after an injury or surgery. However, this experience reinforced for me that it really is wise to go easy during the acute stages of recovery. For me, 2 days of solid rest made the subsequent phases of recovery go significantly smoother!
  2. Motion is Lotion – A couple of commonly-used physical therapist phrases are ‘Use it or Lose it’ and ‘The more you move, the better you move’. As I worked through the first several weeks of post-surgical recovery, I experienced firsthand that these things are, indeed, correct. I was lucky in that I did not have a lot of pain and that I did not struggle with significant stiffness. My knee movement returned readily and steadily. However, after any period of relative inactivity – eating lunch, driving to work, or even sitting on the couch after exercise to elevate my leg – my knee would enter a state of what I would describe as ‘sluggishness’. Things just felt congested. I’ve told patients over the years that doing lots of little bits of activity is often as good as or better than saving up to spend a large block of time exercising – only to then return to relative inactivity for the whole rest of a day. Indeed, in my experience after surgery, the more I would repeat even very simple little movements (ankle pumps or quad sets sound familiar, anyone?), the better that my knee would feel. Bending and straightening was freer. Muscle tone felt more coordinated. Swelling, if it had occurred, was reduced. Let me tell you, I found that it was a real benefit to work in a PT clinic, where I could get on the stationary bike for a few minutes several times during the course of the day. Motion, I found, really IS lotion.

  3. Patience is a Virtue – Typically in an outpatient orthopedic PT clinic, we see patients consistently after ACL reconstruction for 6-8 weeks. After that, we’ll sometimes continue to see them on some sort of intermittent basis for up to 12 or sometimes 16 weeks, which is about the time that patients get to return to running and some semblance of recreational activity rehearsal. It’s pretty infrequent that a patient remains in formal therapy all the way through the 6 to 8 month period of post-surgical recovery. I have developed a bit of a pep talk over the years to give to my patients as they stop being regulars in my clinic around that 8 week mark. It involves telling them that even though they are feeling a lot better, they need to remember that there is still healing going on unseen inside the body. They need to continue to stimulate their tissues to repair and rebuild – keeping up with their exercise programs and not losing focus before they’ve really had a chance to fully recover. I don’t necessarily get to hear how patients feel 4 or 6 or 7 months after surgery, or about how well they have or have not been able to follow my advice. So following my own progress through the middle and later stages of post-surgical recovery was interesting. I fully planned and expected myself to follow all of the advice that I had ever given to my patients. I set treatment goals for myself and was quite formal about my own rehabilitation program. I worked hard – determined to set a good example for my patients, all of whom were extremely supportive and interested in following my recovery as they were able to track it while they were in my clinic. What I found, as recovery went on, was that it was really HARD to stay focused at week 9, and week 12, and week 15! It was easy to tell if I slacked off. I’d note some mild stiffness, or feel a little less solid coming down stairs. But boy, was I tired of doing squats and lunges and miles upon miles on the stationary bike! So to all of my patients who have struggled to stay mentally engaged during the latter portions of rehab – I now know exactly how you feel. And good for you for being persistent and staying the course. If I did not get to see you through until your full return to your desired activity – I sincerely applaud all of your efforts and diligence! Because I know recognize even better than before that it certainly couldn’t have been easy.

  4. It’s Great to be Back! – So the big question in my mind as I neared readiness for return to activity was, ‘how would I feel mentally’ as I stepped back out onto the running trail and the soccer pitch? Would I be tentative? Anxious? What would the odds be that now that I’ve had an injury, I might have another? When I was officially cleared to return to sports, I had no question that I was physically ready. My motion and strength were good, and my surgical knee certainly felt more stable than the other one when my surgeon performed all of his tests. I will say that I had a little nagging feeling as I strapped on my brace at soccer for the first time. Would I want to put myself in a situation that might involve contact? Would I be OK playing when the field was a little damp? I am pleased to report that – just as at other stages in my rehab after this surgery – I’m finding that the more I do, the better I feel. I can still feel that my body is relearning muscle patterns and movements that it has not had the opportunity to practice much lately. But each repetition of each pattern feels more solid than the previous one. I am looking forward to the day a few more months down the road where I won’t need to wear the athletic brace if I don’t want to. But I am completely content to be working my way back into the activities that I love. I appreciate all of the expertise that my surgeon and his team provided to enable a good post-surgical outcome, as well as all of the rehab support from my PT colleagues, friends, and family! However, I am hoping that I don’t need to further expand my knowledge of physical therapy from a patient’s perspective again for quite a while!