Swelling and quadriceps muscle weakness are not uncommon after ACL reconstruction, and can even persist for several months.
Athletes want to get back to running and eventually their sport as fast as they can. But sometimes using time-based criteria is not optimal.
In this episode, we answer a question about whether an athlete should start running 5 months after an ACL reconstruction, even though they have persistent swelling and very low quad strength compared to the other limb.
To view more episodes, subscribe, and ask your questions, go to mikereinold.com/askmikereinold.
#AskMikeReinold Episode 365: How to Manage Persistent Swelling After ACL Reconstruction
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Show Notes
• Evaluation and Treatment of the Knee Masterclass
Transcript
Mike Reinold:
All right, so for today’s question, this is a good question I thought. This is from David from Glasgow, Scotland: “I’m seeking advice on managing persistent swelling following ACL reconstruction. I have a client that’s now approaching five months post-op, still has a grade one on a sweep test, but is eager to begin running.”
Okay, so that’s one point of the question. So he has persistent swelling, grade one sweep, wants to keep running. The other issue that he talks about in his question here is that he says “his LSI is around 60%, so he is wondering if he should start running with a little bit of swelling, 60% LSI, and it’s five months.”
So I think that’s a good question, but then he brings up a good secondary one. I wanted to get to here, his clarification on LSI, because he says “he’s 60% when compared to his preoperative testing, but because his unaffected leg is so much stronger now, his current LSI is actually 35% compared to the other side.” Those are low numbers. I think you’d argue the 60 is low numbers too. So let’s talk about this. What do you guys think? We got persistent swelling, we have low LSI. I’d love to hear your thoughts. Is this person ready to run? What do you think, Dave?
Dave Tilley:
Yeah, the first thing that came to my mind when I heard the question is I think it sounds like this person is chronically having some issues with regaining strength because of the swelling and the pain, and like AMI maybe. So it sounds like… We’ve been talking a lot about intermission and stuff like that that has maybe some neural pieces, maybe some pain-related pieces. But my gut is that his strength testing is not accurate because it’s still a little swollen. It’s still a little painful, and the quad is not really working as well as it should be. And so that was what came to my mind first, was maybe those numbers are really low because there’s some, I don’t know, baseline level things that haven’t been addressed first, and it’s like you’re not getting accurate data on his strength because maybe he can’t load or because the quad inhibited a bit.
So that’s my first thought, and the second thought was running is just hopping on one leg. That’s what Kevin has always told us. So the forces of hopping on one leg, if you have a couple of things in the background that are not maybe smoothed out first, I don’t think you’re going to tear something or hurt something, but you’re just setting yourself up for a sore knee, in my opinion. So that’s what I just thought off the top of my head, but…
Mike Reinold:
Yeah, and I’d add too, I’m always amazed that when you have a crazy deficit in strength, but there’s obvious things like swelling going on that if you give it a couple of weeks, you quiet it down and you retest their strength and you see such a large jump. They don’t go up 20% in strength in a couple of weeks. It’s just that you take away whatever’s perhaps inhibiting it, which is cool. So yeah, no, I couldn’t agree more, Dave. So that sounds good. Kev, what do you think?
Kevin Coughlin:
Yeah, I think to your point about quieting the knee down, I would just wonder: has this patient had persistent swelling since the surgery, or was there a time when the knee was quiet? And then as they’re introducing new exercises, the patient’s not responding well because that definitely happens where you’re in those transition points where you’re going from mostly in the clinic on the table to in the gym.
Sometimes exercises don’t sit so well off the bat, or that transition from gym-based exercises to adding in plyometrics and agility. So I wonder if there was an inciting event where a new addition of an exercise was aggravating the person’s knee, and then you just would backtrack, I think, to that previous phase and try to calm it down, and then continue to progress appropriately.
So I definitely want to figure that out and try to, like you said, definitely quiet the knee down first before pushing through. And then I think in terms of LSI, it’s obviously great to have those pre-op numbers, but I think with 60% and those symptoms, were probably still not running. But when you look at a 35% symmetry, that’s really bad, and I think if you start running with that, you’re going to definitely… The knee’s going to feel terrible, or something else isn’t going to go right. So I wouldn’t rush into it. I think not to get suckered into the time-based progressions and just try to get back to looking at the function and hitting that criteria.
Mike Reinold:
I love it, and I think that’s a great lesson for a lot of people. Time-based protocols are real and very important, but you could argue they’re almost like “this is the earliest you can begin something.” It doesn’t mean you have to begin something at that date. It’s more of a pace car of, “okay, the biological healing process may allow you to start running and jumping right now, but that doesn’t mean your knee is ready for it.” So that’s some things that people sometimes don’t quite understand. So I think that’s good. What else? Dan, what do you think? I’d love to hear your thoughts, and then maybe Anthony and Lenny, I’d love to, and Lisa, everybody’s on here. I get to see all the squares on here. I want to get people’s thoughts on what they would do with this person.
Dan Pope:
I think these are tough patients, and I think that we probably see them more often than we’d like. I can’t tell you the amount of patients I’ve had year out, even sometimes two years out. They still get swelling, just pops up here and there. It’s unfortunate, and obviously we want to get this down as much as we can, but I think it’s maybe just part of the game sometimes. I think the more concerning part, which everyone’s saying is the strength is incredibly low… Obviously want to see that a little bit higher. I wouldn’t get this person running until you see them a little bit, maybe closer to 70 or 80%. But in terms of the swelling, I would ask some questions about what the rest of the day is like. Is this individual spending a ton of time on their feet? Are they doing a lot of walking?
What’s their step count throughout the course of the day? Are they doing anything to manage the swelling? Do they have anything over top of the knee? Are they trying their best to get the swelling out? Are they just kind of at this point gave up on those things just because they’re five months out? I would look at their program. I think sometimes when we’re doing our strengthening, we think about strengthening as safe, and then plyometrics is not safe until we have a quiet knee. But you can certainly make a knee swollen by doing too much from a strength perspective. So I’ll just take a look at the strengthening program and say, “Hey, do you think anything in here is aggravating? Do we need to cut back on some of the more aggressive strengthening? Can we get some of that strength to be, let’s say, blood flow restriction training at this point?”
I know that eventually we’d like to move away from blood flow restriction training, but maybe that’s a good option for now to keep building some strength without aggravating that. I think those were my main ones without giving too much information, stealing other people’s thunder.
Mike Reinold:
I love it. Anthony, what do you got?
Anthony Videtto:
Yeah, I was kind of going to say exactly what Dan was saying. If we’re in the gym all the time and we keep aggravating the knee, well maybe we need to take away some of the aggravating factors. So maybe BFR, NMES might be a scale back that we can utilize to help reduce some of the swelling in the knee, quiet it down, and then we can progress from there. I also think if we start doing plyometrics or any type of running, I think we’re just going to continue to make this matter worse. Quad strength is so low, I think that’s just going to increase swelling overall. So I don’t think that’s the right way to go. I think we might have to scale back, like Dan was saying, and then reassess from there.
Mike Reinold:
And I kinda feel bad because I feel like this patient was probably told at X month they can do X, so they have maybe unrealistic… “Expectations” is maybe the wrong word, but you know what I mean? They had their heart set on this, and if it doesn’t happen at five months, they think they’re going to be behind, when they don’t understand that this quad and that swelling is probably their rate limiting factor. So you got to put all that together. So Len, question for you, although I just muted you, but question for you: what’s the statistical probability that this person’s meniscus and articular cartilage look amazing after this ACL? Do you think that maybe this person was just a little beat up, maybe? Is there a chance? Why does somebody swell for five months, assuming that we’re not pushing things, that sort of thing? I don’t know. What do you think? I feel like you see this a lot.
Lenny Macrina:
I do. Excuse the B-I-N-G-O in the background if you’re hearing music. My son has decided to follow me around. Anyway. Yeah, I think it’s more than we think. I see this a lot. The swelling doesn’t worry me as much. I just see persistent swelling. Maybe my people I work with swell a lot. I don’t know. But the swelling, I think, is just a product of probably a bone bruise, or if there’s some cartilage issue going on. So not concerned with that as much. I mean I am, if it was like a two plus, definitely one plus questionable, one plus or trace… I’d want to know if they’re doing plyometrics and had they been doing plyometrics leading up to this, to some pogo, some basic stuff, some box jumps, and then other stuff to see how the knee responded versus just jumping into a running program.
But like everybody else has said, I wouldn’t start running. That 2017 paper, I think it was 2017, the Delaware paper that came out, the epic paper that showed the pre-op strengthening. I’m surprised this doesn’t happen more with people because a lot of people come in not as conditioned as we can get them with working out two to three times a week. You get the 16-year-old who’s never trained or the 40-year-old mom or dad who hasn’t trained as much as we just made them train for the past few months, so they get stronger than their pre-op level. So we take pre-op numbers on their uninvolved side and at least use that as a gauge. That’s the minimum, but most people blow through that and get stronger over a quick period of time.
And so I usually have to compare current leg to uninvolved leg most times. And the 60% or the 35%, 60% I am not as worried about as much. 70 would be ideal. That’s the number that I use. But I think we need to maybe give it a little bit more time, get more plyos involved. Maybe re-look at the strengthening program and go from there. It’s a long-winded answer, but definitely probably a bone bruise. I think studies have shown almost a hundred percent of ACL injuries have a bone bruise associated. I think that lingering swelling is from that, I would guess.
Mike Reinold:
Yeah, I was going to make that comment that it’s common to be swollen, and I think that was the point. That’s why I want to get Lenny’s feedback on that. It’s common to be swollen, especially to have a mild persistent one. You’re not talking about the guy that blows up and then takes a few days to come down. I think that’s different. This is a mild persistent swelling. It is a little different when you think of it that way. So I’m glad Lenny mentioned it with LSI because that was the last bit of the question here, is just because their knee was crappy five months ago doesn’t mean that we want to aspire to be as crappy as he was five months ago. That would be my summary of that, is they’re in a much better place now. Their other leg’s probably in a good spot.
That’s what you want to shoot for. So I wouldn’t do LSI from their crappy pre-op numbers. Maybe that’s why they tore their ACL. Because they were so deconditioned. So I’m thinking about that. So the only thing else, Lisa, we got to have you jump in here. So Lisa, what do you think? Would you run this person right now? The person’s begging you. You’re nicer than me with your patients, I feel like. They’re begging you. How do you handle the person that’s begging you to run when they’re not ready? What are some strategies you’ve done?
Lisa Lowe:
I mean, no, I wouldn’t let them run right now. I mean, you guys know, I don’t really see that many ACLs because you guys all see them and I get to play substitute teacher, I always say, whenever one of you guys needs the fill-in, which I’ve had, honestly, the one person that comes to my head that I’ve had to have this battle with was more of a middle schooler with terrible numbers and knee pain that I was bucketing in the really high risk group for getting an ACL tear. And the strategy in talking with her and with her parents was basically like, “Look, until either we can get pain down a little bit or we can get strength up a little bit, or hopefully both, you are risking a year of rehab versus a couple of soccer tournaments and which would you rather?”
And so I tend to just paint the worst picture of what might happen and then let them be the one that makes the decision of like, “Oh yeah, maybe I don’t want to do that.” I guess I personally don’t like people to tell me what to do. So I like to give the scenario: “If you go back at this and we could be back where we started from here.”
Mike Reinold:
It’s not your job to say what they can or can’t do.
Lisa Lowe:
Yeah, I don’t know. I mean, I wouldn’t suggest that somebody runs with those numbers, but let them understand their risk. And depending on the age of the person, if it’s a 40, 50-something-year-old recreational runner and they really just can’t stand it, like, they’re an adult. They make that choice. But I feel like you just got to educate them of what their choice is.
Mike Reinold:
I like that. So give them the thought process on what’s the pros and cons and then it always comes back to this, data, quantify. So here’s your numbers now, here’s our typical criteria to run. You’re not there yet, so we got something to do. It’s not a bad thing. There’s a fluctuation on who’s ready when they start running. But Lenny and I had this conversation yesterday with somebody who was like, “You’re not supposed to feel good five months out of ACL.” It’s almost weird if you do. So I’d almost rather be you that’s going through this process and still working hard than the person that doesn’t have any pain, that sort of thing.
Sometimes they get back too early and they do too much. So just stick to the criteria, stick to the objective stuff, and hopefully that helps. So great question, David. I think that was helpful. I think a lot of good came out of that question for both the swelling and the LSI conversation. So thanks for sending that in. If you have anything like that, just head to mikereinold.com, click on that podcast link, and fill it out. And please subscribe. Apple Podcasts, Spotify, whatever you listen to, subscribe so you get notifications for the next episode. Thanks so much.
