27 May Swelling – The Enemy Within Rehab Of The Knee!
Whether you’re recovering from ACL surgery or pursuing non-operative treatment, managing swelling is crucial to a successful and timely progression through the rehab process. In this blog, we’ll explore why monitoring and managing swelling are essential for your recovery and why swelling is the enemy within ACL Rehab.
The Importance of Swelling Management
Swelling is a common occurrence following an ACL injury, whether it’s treated surgically or non-operatively. It’s your body’s natural response to tissue damage and inflammation. While some swelling is normal, excessive swelling can impede your progress in physiotherapy and delay your return to normal activities.
So If Swelling Is Somewhat Normal, Why Do We Care About It So Much?
“Swelling can significantly affect your ACL rehabilitation journey in several ways”
- Arthrogenic Inhibition of the quadricep muscles:
Swelling within the knee joint can lead to a process known as arthrogenic inhibition, where the quadriceps muscles reflexively shut down due to pain and/or swelling. Essentially, swelling leads to a huge disturbance between the brain and the quadriceps, making it incredibly difficult to activate and engage the quadriceps.
The critical part to this is knowing that quadricep muscle function is king during ACL rehab and the stronger the quadriceps are, the happier the knee will be, equating to more progress during rehab and greater function.
However, with worse quadricep function comes more pressure and load on the knee joint during daily tasks, potentially leading to more swelling. With more swelling, comes worse quadriceps performance, leading to a vicious cycle and a plateau in progress during Rehab.
- Pain and Discomfort:
Along with the changes in the neuromuscular system as outlined above, swelling can exacerbate pain and discomfort within the knee, further hindering rehab progress. This is due to increased pressure within the knee and the formation of the ‘inflammatory soup’ within the knee. This soup leads to greater mechanical and chemical irritation of the nerve endings around the knee, triggering greater pain responses from the brain. Managing swelling can help alleviate pain and improve your overall comfort level during rehabilitation. Pro-tip: Don’t be a martyr – take your pain meds regularly in the first phase of rehab!
- Range of Motion (ROM) Limitations:
Swelling can restrict the knee’s range of motion, preventing you from achieving full extension and flexion. This limitation can impede your progress in rehabilitation exercises aimed at restoring normal knee function and mobility.
Another way to tell that the knee is happy, is whether it can achieve full range of motion or not and to be cleared to run, one of the bare minimum criteria is to achieve both full knee extension and flexion.
- Walking/Gait disturbances
Achieving a normal walking pattern after ACL injury is critical to success and is generally something that we want to achieve in the first 6-12 weeks. As you can imagine, as swelling has huge implications on the aforementioned areas, it also hugely influences our walking patterns, leading to adverse loading on the knee and even more swelling, more pain, worse quadricep function and so on…
Pro tip – don’t rush off crutches until your quadriceps function is impeccable, swelling is minimal and your walking feels and looks normal to ensure the cycle doesn’t occur or worsen.
Okay, But How Do I Best Manage It?
To effectively manage swelling during your ACL rehabilitation, particularly in the early post-operative period or early after the injury, it is absolutely imperative to do the following diligently:
- Protect – realise that you’ve essentially just undergone another trauma to the knee and the body will need time to heal. Take it easy, find a good show to stream, a good book to read and watch all of those movies on your list. Mandatory couch potatoing (for a brief time)!
- Elevate the leg – for at least 30 minutes, 3 times each day, it is recommended to elevate the WHOLE leg above the level of the heart. This will allow gravity to do its thing and help the circulatory system flush out the fluid from the knee. Pro tip: add some active foot and ankle movements to engage the muscle pump to give some additional fluid drainage from the knee (see below).
- Control your pain as best as possible – don’t be a martyr! Ensure you’re taking your pain medication regularly – there are no heroes in this game! Ensure you take your pain meds an appropriate amount of time before rehab exercises to get the most out of them!
- Regular Icing – ensuring you are regularly icing throughout the day for 20-30 minutes at a time is hugely important. Pro tip: it’s an awesome idea to ice for 15-20 minutes before commencing your rehab exercises to ‘cool the knee down’. This ensures you get the most out of your exercises. It may then be a good idea to ice after exercises as well.
- Compression – During the day, ensure your compress the knee with tubigrip or something similar. This will be very effective at reducing swelling. However, make sure to take it off at night time!
- Do your exercises (!!) – it might seem like a bit of torture whilst you’re doing them, but doing your exercises 3 times per day or as prescribed by your physio is so, so, soooo important and only in your best interest. Making sure you get the quads firing, get the knee moving (get it straight) and practise your walking proficiency works as a fantastic interplay with all of the aforementioned modalities to achieve the best results, setting you up for a successful progression through the rehab plan.
If you’re doing the above diligently, you’ll be on the right track. But just like anything in rehab, if you aren’t assessing, you’re guessing! So, you need to monitor your swelling to make sure it’s tracking in the right direction.
The simplest way to do this, is to measure the circumference of the knee with a tape measure twice per day; once in the morning and once at the end of the day. It is normal as you’re recovering that your swelling increases during the day but you’re trying to make sure that it doesn’t increase by >2cm throughout the day. If it does, you may be doing too much throughout the day, OR, you’re not paying attention to the above well enough!
Here’s a demonstration (below):
So, do your absolute best to combat this tricky enemy within ACL Rehab – it may just be what holds you back, or what keeps you progressing along the pathway nice and smoothly. Remember, “you can’t win ACL rehab in the first 6 weeks, but you can lose it!”
Todd Grbac
Physiotherapist
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