Kneehab: Why a healthy brain is just as important for ACL rehab as patience and physical therapy
KneeHab 101 series
Knee injuries are a part of sporting life in the mountains. In the spring of 2017, the Summit Daily sports section printed weekly articles about ACL/MCL injury, surgery, rehab, recovery and prevention, featuring interviews with local doctors, physical therapists and pro athletes. They’re the only knees you’ve got — show them some love.
Read on for all eight installments in the series, including video interviews and first-person columns.
Week 1 — “A club I never wanted to join,” injury column
Week 2 — Anatomy of an ACL/MCL injury
Week 3 — Yoga for ACL/MCL recovery
Week 4 — ACL surgery 101
Week 4 — “Slice, dice, make it nice,” surgery thoughts and fears column
Week 5 — Myth-busting for knee injuries
Week 7 — Man on the street: Summit locals talk knee injuries, video
Week 8 — “Long, hard road,” recovery column
Summer follow-up — Getting back to normal, sports doc Q&A
They say about 12 weeks after surgery is the trickiest period for ACL rehab. Now that I’ve passed the magic mark, I have to agree.
“Despite the graft healing and feeling stable, it doesn’t mean your knee is ready to perform,” said Jonathan Bravman, a sports medicine doctor with the University of Colorado-Denver, when I asked why my new ACL is weaker at 12 weeks than the day the surgeon sewed it into place. “That’s a subtle but very important point.”
In late February, I blew my ACL near the base of Beaver Creek. About a month later, in late March, I had my ACL and meniscus surgically repaired by William Sterett with Vail-Summit Orthopedics. By late June, almost 12 weeks to the day after my operation, I was ready to get back to pre-injury normal.
But patience has never been more of a virtue than it is now, Bravman said. After three months (aka 12 weeks for us math-challenged), most surgeons and physical therapists give their knee patients the go-ahead to start biking, hiking, rafting, running — all the fun stuff we couldn’t do while waiting for our bodies to repair. I didn’t quite track the day on a calendar, but I knew full well when the three-month mark was coming. I could even feel it in the way my knee was suddenly moving and bending and simply acting the way it did when I woke up that painful, obnoxious day in late February.
It might feel ready to drop cliffs, but it’s not even close. Thing is, Bravman said, any sort of tissue repair in the knee needs at least six months of rehab before a patient can get back to high-level activities of all varieties, including cutting sports like skiing or basketball. But the timeframe is flexible, he continued, and depends on two factors: the type of repair and the type of patient. One is purely physical, one is physical and mental, but for me, balancing both of them means the difference between a confident “return to play” in time for the snowboard season or yet another few weeks of cabin fever.
At the 16-week mark, I called Bravman to talk about the tricky weeks between functional activity and full activity, and how new research is showing the brain plays a much bigger role than ever thought.
Summit Daily News: Why should knee patients ease back into activity — in other words, why wait when you feel so much better than you have?
Jonathan Bravman: When I talk to patients about recovery, I talk about phases. That early phase is waiting for surgical healing, then the next phase is working on gait and getting your muscles, particularly the quad, working fairly normally. That’s your early healing period, about the first six weeks. … The surgery itself is another injury. That early period of time is when you’re letting the body respond to and heal from the injury (and) this turns out to be a vulnerable time for people’s knees. The graft feels well, the knee seems stable, but that’s a period of time when the graft is going through a process called “ligamentization,” when it’s becoming a different part of your body. Just as you start feeling normal, don’t be fooled: You’re out on the lawn, friends are a throwing a Frisbee, you think you can do that, and then you pivot wrong to get back to stage one. Your knee is blown again.
SDN: Talk about the mental side of recovery. How does the brain influence recovery?
JB: There’s a small body of research that shows return to play — the “eureka moment” when your body gets back to normal — we think that they’re remodeling their neuro cortex to reform their neurological pathways to the new knee, necause the knee you have now is new, right?
Patients need a longer time for true functional recovery, and part of it is how your brain understands where your leg is in space, called proprioception. Your body is now relearning to protect itself and the new tissue.
SDN: How can a knee patient — or anyone going through rehab — take care of their brain?
JB: Don’t turn into a recluse just because you can’t be on the soccer field or the trail. Go out and be part of that group because it’s a social group. So many of us tie our social identity to the activities we do and it can sometimes be the nucleus of what helps us recover. This can generally help recovery. … If you talk with people in your peer group, you’ll find that other people have dealt with the same thing. They can help you with the mental side of things.
SDN: Now the big question: On average, when can a knee patient get back to everything they love at the level they’re used to?
JB: The conversation comes full circle at this point because the time period might change based on what happened with surgery, including graft choice — what was used to reconstruct the ACL — where something like a cadaver graft might take 10 months to a year. … Some of my pro athletes might be ready the day the calendar hits six months, where your average person might not be ready for 10 months or a year. We put that decision in the hands of the physical therapist, the person who is measuring your strength and looking at you, week in and week out, and we give them the leeway to help patients along.
The field test
Along with the brain, Bravman also told me that quad strength is a major indicator of any current (and future) rehab timelines. In short, spending even 15 minutes daily on quad exercises in the early stages of rehab leads to a smoother recovery, sometimes even years into the future.
So, after 14 weeks of quad pumps, clamshells, assisted squats, leg raises and the like, I was ready to test my leg on some real-live stuff. I’ve got a sprint triathlon coming up in early August, after all, and there’s no better time than now to suffer a little. I joined a group of friends for a leisurely hike along the Quandary Peak superhighway on a jam-packed Saturday. Less than four hours later, we reached the top — and still had enough energy (and knee pep) to wander along the jagged western ridge.
Quandary Peak: done and done. Now I’ve just got to swim, bike and run in the same morning for the first time ever. Brain, let’s make it happen.
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