The Weekly - ACL Post-Op Recovery

This week I started rehab and recovery from my second ACL surgery of the past three years. After the first surgery, I focused so much of my energy on rehab that I neglected to document the process but having landed myself back in this mess through sheer bloody foolishness it seems appropriate to take a minute to reflect for the benefit of whatever poor idiot comes down the pike next.

The Choice

Originally I wrote a longer section talking about the different treatment options and the quality of the research on longterm outcomes and so on and et cetera, but I’m not a doctor and and this isn’t the time for a rant about the American medical system. The quick summary is that, one way or another, your longterm risk of osteoarthritis has Gone Up and the only real questions left to answer are:

• Are you a professional athlete? Most of the outcomes data is based on the results for high-level athletes so if you’re not one—and I’m certainly not—good luck deciding how relevant it is to you.
• Do you want to return to intense physical activity involving sheer forces on your knees (e.g. climbing, wrestling, soccer)?I’ve encountered so many stories and people who tore ACLs multiple times while playing soccer that I’m surprised it doesn’t get more attention. I suppose it’s overshadowed by the rate of football concussions but that just raises the question of why in the hell we keep pushing children into so many different arenas where they risk seriously injuring themselves.
• Will you do your PT at least twice a day every day for three plus months? A lot of people sign up for sessions with a physical therapist and then blow off the homework like it’s a middle school class on good citizenship. Unfortunately, as with most things in life, the only grade is your end result and nobody cares enough to say anything if you decide to screw yourself over with laziness. Whatever work you do in session with your therapist needs to be repeated at home daily if not more often.

The Run Up

It’s surprisingly easy to get a bunch of people to cut you open and rearrange things. Let me amend that: It’s surprisingly easy if you have a good insurance plan. The conversation tends to go:

“So your ACL is torn. Do you want us to fix it?”

“How safe is it?”

“More or less enough. It usually works.”

“I guess ‘usually’ is pretty good…”

And before you know it you are signing consent forms, talking to an anesthesiologist, and a no-nonsense nurse is shaving patches in your chest hair without so much as a ‘by your leave’. From the perspective of the medical staff your engagement here is largely ceremonial. They have a task to perform and you have nothing to contribute aside from making sure your body is in the right place at the right time.

Since you won’t be doing anything useful in the surgical theater, the most useful thing you can do leading up to the surgery is make sure that your home is set up to make the first month after surgery as easy as possible. Pre-cook two to three weeks worth of freezer-friendly meals. Schedule friends to walk your dog, feed your cat, and change your ice pack. Enjoy a few more days of being able to bend your leg without discomfort.

I assumed that it couldn’t be that bad since I would still have one good leg and a fully functional upper body, but it turns out that a C average isn’t a great score for a body and absolutely everything is harder when you have to avoid using a sore, swollen leg. I ended up throwing away pretty much anything that couldn’t be made in the microwave.

The Come Down

There’s a tendency to want to view the surgery as a climactic event with fireworks and cake and maybe a Dad (whether your own, store-bought or otherwise) there to call you ‘Champ’ and tell you how well you did, but the whole thing is strangely anticlimactic. The surgical team gases you, everything goes black, and you wake up with the surgery done, a prescription for hydrocodone and 6-12 months of rehab ahead. You’ll have a lot of time over the next few months to reflect on how you got here and where you’re going.

For my first surgery, I’d just broken up with my partner of many years, I was living alone in a too-large two-story house, and several of my closest friends had moved across the country. I remain deeply grateful for the friends that banded together to get me to physical therapy, but the intense isolation left a huge space to fill and it was too easy to project a temporary enfeeblement into a life sentence.

This second surgery has been markedly different. The home is smaller and more full of people. Friends on all sides have offered to walk my dog or make me food or keep me company. It’s still challenging to struggle to get into the bath (again) and relearn how to walk (again) and overwhelm yourself with the effort of bending your knee more than a few degrees (again), but having care and support helps keep that effort in context as a temporary challenge to be addressed rather than letting it balloon into an existential threat.

Whatever your support network looks like, you have to be prepared for physical therapy to occupy most of your time and attention for the next several months. It’s an interesting process to engage with because you’re simultaneously training your tendon graft to understand its new job as a knee ligament, rebuilding diminished muscle in the donor site—and thank god I have some pretty solid quads to begin with—and letting your body and your self know that the worst of the trauma is past and it’s okay to do leg stuff again.

One of the exercises you do to restore range of motion in the knee is a heel slide and, sure, swelling and effusion in the leg work to limit range of motion but one of the biggest obstacles is that your central nervous system never signed a surgical consent, it has no idea what’s going on except that there was a scene missing and suddenly a whole bunch of trauma signals started flooding in from the knee, and so it basically decides to send in a traffic cop to slow things down and keep you from fucking yourself up even more. As when dealing with a normal cop, the heel slide is a slow careful movement that lets you reassure your body that everything is fine and nothing is fucked.

Likewise when I take a step right now there’s a caution subroutine that wants to trigger and shift weight away to the sides because trauma. It’s an understandable response but if you let it stick it’ll create horrific gait problems long term and it takes a strong effort of Will to force a normal footfall pattern with proper knee extension and force distribution throughout.

The first weeks will be the most psychologically difficult because there’s such a large gap between what you can do and what you think you should be able to do and you’ll discover for yourself the frustration of having to learn how to walk again, but all the effort you pour into rehab will pay off in increased joint functionality down the line.