What to know in the 1–2 weeks following arthroscopic knee surgery (eg: ACL Reconstruction)
Reconstruction of the Knee ACL (Anterior Cruciate Ligament) is one of the most common operations in Australia. The first week your operation is one of the most challenging, especially as you may not have had the chance to visit a Physio/Physical therapist before the operation and get a ‘heads-up’ on what’s normal during that first week.
There are many things that can cause you concern you after the operation and this blog/post aims to cover many of those things, however, if you have any burning questions you should get in touch with your post-op Physio/Physical Therapist, it’s their job to help you out during this period (even though it’s technically free).
Pre-op condition determines post-op success
…most of the time
Get into your prehab as soon as you can (before your operation)
If you have excellent strength around your knee joint before the operation you are much more likely to have a very successful rehabilitation after the operation. We can pretty much have you feeling as ‘good as gold’ before your operation, you’ll be doing everything except playing sport. Also, you will be familiar with the rehab exercises that are provided after your operation, as they will (initially) be very similar to the ones provided after your injury (pre-op).
At the very least, have one pre-op appointment with your Physio for post-op program.
If you cannot afford or don’t have the time for Physio appointments before your operation (approximately 4–6 +/- 2), at the very least make an appointment before your operation so your Physio can meet you, find out your goals and provide advice on what you should be doing between the operation and your first appointment. This appointment is very valuable and you will be grateful you did it in that first chaotic week post-op. It will also make you more comfortable to contact them if you have any issues during the first week post-op.
Crutches
You will be on two crutches until you can walk normally (zero-minimal limp) with one crutch. Then you’ll be on one crutch until you can walk normally without a crutch.
If you are provided crutches by your hospital, do not leave until you are satisfied that they are sized correctly. The handle should be lined up with your hip bone (greater trochanter, poke the side of your hip below the belt-line/waist until you find something bony), top of the crutch or arm guard fits 2 fingers below your elbow (for forearm/Canadian crutches) or armpit (for axillary crutches).
The staff at the hospital should also instruct you on how to use your crutches with stairs, however we have a saying: GOOD FOOT to HEAVEN, BAD FOOT to HELL. When going UP things, lead with your GOOD foot, then your crutch(es) and “bad” leg go together. When going DOWN things, lead with your “BAD” foot and crutch(es), then your good foot.
Self-Monitor for Red Flags
You do have a role to play in your operation (apart from getting cut open and sewn up, and paying bills), you need to monitor your knee (and yourself) for “red flags”. These are signs and symptoms of some post-op complications that are rare but important that you identify and get help for asap.
These include:
· Infection — monitor surgical wounds for spreading, warm redness +/- extra pain, night pain, sometimes with some pus or ‘exudate’, some leaking of fluids out of wounds.
· DVTs — deep vein thrombosis, which is a blood clot in a vein, usually deep. It feels like a calf strain/muscle strain, but it’s very localised when you search for it, it’s the size of a 10–20c piece (2–3cm), the local area or the whole leg can be red, swollen and warm. You need to present to your nearest emergency department if you suspect this, but call and let your Surgeon’s office know about it. You can also get a superficial vein thrombosis, closer to the surface of the skin. This is why you are supplied with tubigrip/compression for your knee and calf post-op by your Surgeon, if you weren’t, get some off your Physio/Physical therapist. Compression helps reduce DVTS from happening, alongside your anti-swelling post-op exercises.
· Wounds opening — it’s common to have some dried blood in your dressings (dark, not expanding in size), however if you notice any fresh blood spreading after 2–3days, contact your Surgeons office for an urgent review.
WBAT — Weight Bear As “Tolerated”
Your Surgeon may have advised you that you can weight bear as much as you tolerate it, but I like to tell patients to weight-bear as much as your KNEE can tolerate it.
Push into discomfort, but not through pain in the first week post-op. Your biggest aim is the manage the post-op swelling and if you are on your feet too much, you will increase the swelling. Your knee has just had an operation, which is pretty much a ‘controlled injury’.
Surgery is a controlled injury
“But the Surgery fixed me, the Surgeon high-fived me post-op and said “you’re good to go””.
Nope, sorry, it doesn’t work that way. Surgery is an injury. Someone (albeit a very well qualified and experienced Doctor) took a knife and cut through many layers of your tissues, harvested a hamstring tendon, drilled holes into your bone (a tubular ?fracture?) and then sutured you up again. They were also not very nice to you during the op, there’s a fair bit of manipulating of the knee during the operation to check the ACL graft.
If Surgery is an ‘injury’, then healing is required. You had a general anaesthetic as well as a cocktail of other drugs, your body will be in a ‘fight or flight’ mode for quite a while. You will be uncomfortable, you may feel nauseous/ill, you may feel ‘faint’ every time you stand. Your body is in ‘Systemic Chaos’, especially for the first 72 hours post-op. So just sit-back and ride it out, if you have any concerns (which you shouldn’t, after reading this post) contact your Physio/Physical Therapist.
You may have also lost feeling to some areas of your skin around your knee. This isn’t anything to be worried about in the grand scheme of things, it’s quite common, sometimes the sensation comes back, sometimes it doesn’t, it’s a risk of the operation and it won’t bother you to much.
Take your pain-relief/analgesics, don’t be a hero, you aren’t a “bigger man” because you took less pain-relief. Someone just knocked you out, stabbed you, cut you open, stole a tendon from your hamstring, drilled holes into your bones, then sutured you up (and then had the balls to charge you money for it, I may add). If there ever was a time to pop a pain-pill, it’s now.
Rehab Goals
It’s nice to have something to work on during those first 7–10days post-op, you’ll be ‘chomping at the bit’ to do something!
Swelling — make it less
The surgery (being a ‘controlled injury’) will cause swelling/effusion. Your primary job will be to control this swelling. Whilst resting have your knee elevated above the level of your groin. Wear compression (best to have at least 2 layers). Do your anti-swelling exercises (heel pumps, knee push-downs, butt squeezes).
Weight bear only as tolerated (by your knee). If you go too hard to soon, it will swell more. If you swell lots but can’t figure out what you did, don’t stress, some people just swell more than others for no good reason, as long as you don’t make it worse and you the rest of the above.
Ice it? Well it’s mainly for pain-relief but if you think it helps with swelling, go for it, but don’t have it on for too long or you could get an ‘ice-burn’.
Extension — get it straight
At the same time as reducing swelling you will be working hard to restore Extension, which is your ability to full straighten your leg actively (using your quads muscles) and passively (as a stretch). You will have several exercises that target both active and passive extension. However, you won’t achieve either (especially active extension) until your swelling reduces, your quads are inhibited by swelling in the knee (as well as pain).
The key with regaining extension is to do a little bit, but often.
Why is extension so important, more important than knee bend (flexion)? Because it allows you to walk normally! Once you can walk normally (without a limp) you can ditch the crutch(es).
Extension will also help stretch your hamstring muscles which is sometimes where the ACL graft is harvested from.
Move it
Ever heard the saying: motion is lotion, rest is rust, a little bit of movement done often is great for restoring overall range of motion (extension and flexion). To a small extent it also helps reduce swelling. A great early post-op exercise is Knee Rolling ROM, foot on a ball/foam roller/skateboard and just moving it forwards and backwards repetitively.
Scar Management
This is a good point in this blog to recommend: Ask the hospital for extra wound dressings before you leave the hospital just in case you need them.
After a week your wound dressings should come off and you will be surprised by how good it looks. There’s usually only a few portal scars and possibly a longer scar. You will need to learn how to do scar massage on these to help them heal and become more flexible (like the skin around it). Do not start scar massage until advised by your Surgeon, Nurse or Physio/Physical Therapist.
Everyone is different, everyone isn’t perfect
Very few patients have a ‘perfect’ rehab process where they run on time and have no hiccups/speed humps along the way. Every patient gets a bad day or week along the way, whether it be ‘weird nerve things’, extra swelling out of nowhere, random pains around the knee or whatever. We often tell patients post-op “I don’t know WHAT is going to go amiss with you during your rehab, but something will”. Some come out of surgery stiff, which isn’t bad. Some come out of surgery loose, they can move way too far, which often hurts more than being stiff!
It’s all good, whatever is “weird” or “wrong” we’ll be there for you and we’ve seen most of the things that do happen, we also have a hotline directly to your Surgeon and we can hassle them for you if there are any issues of concern.
Return to work
If you are a desk worker, take 2 weeks off. If you are on your feet, take 3 weeks off. When in doubt ask your GP or Surgeon.
Return to driving
When can you drive again post-op?
Basically, it’s when we think you can safely operate a tonne of metal tearing down the road at a high speed and not endanger yourself or those around you. Once you have the right range of motion, the right strength and are confident on your feet. It won’t be when you’re on crutches.
So there you go. I hope you found one or two things that are new and explain why you’re on your butt watching Netflix feeling sore and sorry.
Bottom line: Get a good relationship with a good Physio/Physical Therapist and be in touch if you have any burning questions, queries or concerns.
Did you enjoy this blog or learn something new that will help you with your clinical practise?
Are you a patient and has this helped you in some way?
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