Dr. Mike Smith (Host): Welcome to Everyday Well, a Health and Wellness podcast, brought to you by Memorial Hermann Health System. Tune in for the latest healthcare tips and information that matter most to you. I'm your host, Dr. Mike. So, you've had the surgery, now the real work begins. Today, we're diving deep into the ACL rehab timeline with Cassie Casatelli, a physical therapist with Memorial Herman.

We're covering everything from your first appointment to full-speed sport or activity clearance. Cassie

Host: is

Dr. Mike Smith (Host): sharing the cheat sheet for patient success, your job as a patient, how your physical therapist guides your progression, and how to safely get back into the activities you love. Welcome to the show.

Cassie Casatelli: Hi. Thank you. Yes, I'm so excited to be here today. The ACL is a hot topic. And so, I know it's always kind of in our realm in the rehab world. I'm excited to kind of tell you all about it today.

Host: Yeah. And I think that's a great place to start. How about giving us a nice little review of the ACL, you know, where it is, what it does for us, and if somebody does injure it, what are the common treatments?

Cassie Casatelli: Absolutely. So, the ACL is a ligament located in your knee. It helps with providing stability for your knee. So whenever you're pivoting, you're cutting, you're accelerating and slowing down, this ligament is really important for those sort of activities. You can injure it a couple different ways. We most often see it in sports. It's actually most often injured in non-contact sports. So, you know, you plant your foot and then you pivot on it. You come down from a jump weird, and you land differently and you can hear a pop.

And then, the treatment for it, some people can live without an ACL, but we do recommend getting it fixed if you are an active person. So, you're going to go back to those sports that require jumping, cutting, pivoting, and high levels of activity.

Host: And that's who we're talking about today, are people, you know, who are going through the surgery. And it's after the surgery that you come in and really help them. So, let's start with this question: how soon after surgery should a patient expect to start physical therapy?

Cassie Casatelli: Yeah. So, this is kind of surgeon-dependent. But typically, we like to see you one to two days after surgery. The sooner we see you, the sooner we can start on range of motion, normalizing that. We can work on your gait mechanics, so your walking mechanics, make sure everything looks good there and you can walk out normally, or as close to normal as we can get you. And then, we got to start working on that quad strength. The quad unfortunately takes a big hit after surgery. And so, it's really important that we start getting that going because it takes a long time for us to get it back to where it needs to be.

Host: And so, following surgery, like, what can a patient expect during that first day of physical therapy? Because just like you said, they may not be conditioned ready to really get going, but you know a couple days later, they got to, right? So, what's it like for them?

Cassie Casatelli: Absolutely. So, everyone kind of responds differently to pain medicine and, you know, their pain tolerance after surgery. But we like to see you into therapy, because I know it sounds a little counterintuitive. Like if it hurts to move, why would I move? But it's really good for us to start moving. Again, your PT is going to do that in a controlled and safe way so we know how to get you back to where we need to get you safely.

And so, that first visit is going to be a lot of talking, right? We want to see how this happened, what led up to the surgery, what your goals are, because that's going to dictate kind of the stuff that I do in therapy with you. So, the activities or exercises that I get you back to.

Host: Yeah. And, you know, it's interesting you mentioned it may be hard, you know, it's counterintuitive. "I hurt. Why would I want to move?" Right? But that's key, getting people moving early and quickly is really critical in all this, and I bet probably ends up with better outcomes.

Cassie Casatelli: Absolutely, it does. Again, the brain is protecting the injury that happened or the surgery that happened, so we have to kind of calm that nervous system down. And let your body know, "Hey, it's safe to move in this manner," because your body wants to heal you quickly. But we know if that happens, you're going to probably get pretty stiff. And then, things are going to get weaker. And so, we need to come in and make sure that you are normalizing that range of motion. And then, you're kind of getting that strength back.

So, first day too, we're going to get to work. We're going to start working on your range of motion. We need your quad activated. And then, we're going to work and make sure that you are using your crutches or whatever assistive advice that you've been using correctly and safely.

Host: Oh, so day one, you're getting them out of bed.

Cassie Casatelli: They're coming to our clinic. So, they'll go home the same-day. It's an outpatient procedure, so they'll go home usually that same day. And then, one to two days after their surgery, they'll come to our outpatient facility in physical therapy, and we'll get rolling.

Host: Speaking of crutches, like how does that work? Are patients—do they leave the hospital after the surgery with the crutches or a brace? Or is that something you decide if they need?

Cassie Casatelli: Yes. So in surgery, they will put the brace on after they're done. And then, after you go to recovery, usually a PT comes in, that's with the hospital, associated with the hospital. And they'll show you how to use the crutches, how to use the brace, and then you'll show up to therapy with me in an outpatient setting, first day of therapy with the crutches and the brace already, or the assistive device that you choose or they choose for you.

Host: Now, I'm sure you see all kinds of patients, probably some patients that just want to get going and get back to their normal routine and exercise regimen, right? And there's probably some that maybe want to go a little slower. How do you manage those very different desires or expectations?

Cassie Casatelli: Absolutely. So, some people, , they need to be motivated. We need the motivators for them. They might be a little scared, which is fine. It's intuitive. You just had a surgery, right? Your body's trying to protect everything. You want to protect everything. But that is what we're designed to do, is to help you move safely. So, we know the proper exercises that you're allowed to do after this surgery. And so, we can help those people kind of motivate them. "Hey, we need to make sure your range of motion is getting where it needs to be because this is going to be for good outcomes. This is going to be for your overall health."

Those other people on the other side, they may need to be slowed down because we have to, again, abide by these precautions for the surgery. So, there are different phases to ACL rehab. And we just have to make sure that we are keeping the patient within those phases at that time point, because this is a continuum of a very long healing process. And so, we have to make sure that they're safe in those so you don't, unfortunately, retear, right? We don't want to see that happen and you have to go through another surgery.

Host: Speaking of phases, you know, as you mentioned for this kind of therapy, what are some of the exercises that you don't want patients doing right away? You know, is there any jogging, jumping jacks, any kind of, you know, squats—is there anything you just are like, "Hey, let's build up the strength first. Let's get more healing done." What are some of those exercises?

Cassie Casatelli: Absolutely. So, you know, our go-getters, they're going to want to try to run as soon as possible. But unfortunately, jogging usually happens at or after the 12-week mark. and that's just because we need that quad strength to build up, I know it's quite a while. And I tell everyone the first part of rehab is pretty boring. I'm just very blunt with everyone. And you have to know that. You have to be prepared for that. But it's on purpose, right? Your body is still healing naturally. And we want to make sure that you are setting a good foundation for all the other activities that you want to do. If we don't have a good foundation, things are going to get messy as we get into the other phases.

Host: Well, how long is this then? So, you've mentioned several phases now, 12 weeks before people can really start jogging again. What kind of time period are we talking about?

Cassie Casatelli: Yeah. So, this isn't the fun part to tell people, but it is a minimum of a nine-month process. It can be up to a year.

Host: That's a lot longer than I thought you were going to say.

Cassie Casatelli: Yes. It's a long process and, again, that's kind of designed on purpose because the ligament that they have reconstructed, right, it needs to mature and it takes that long for the ligament to truly mature. And then, your strength, it just takes so long for that quad strength, that thigh muscle strength to get back to where it needs to be to help support you to prevent another injury or anything else that could happen while you're trying to get back to your sport.

Host: And if you have a patient that does this, they're patient with you, and they're going through the phases the way you want them to go through, what kind of outcomes do you see? Are we reducing the chance of re-injury? If they go through this with you or are they pretty much cleared now for life? I mean, what kind of outcomes are we dealing with?

Cassie Casatelli: Yes, this is a great question. So even though this is a nine to 12-month process to return to sport. You are going to be doing things prior to that. So, I will release you to the gym so you can do some gym workouts, again, as you can safely. I'll give you guidelines throughout this entire process. And it's not like you're not going to be better until nine to 12 months, right? You're going to feel much better before then. And that's why we talked about we might have to slow people down in that beginning phase, because they start feeling really good, which is great. We love that. But staying on the timeline is really beneficial. Unfortunately, because of this surgery, right? You've had a surgery, you've had some things done to your knee, it's really important to keep this strength up. So, that's why it takes a long time to get that strength. And then, you do have to maintain it after this surgery. You don't have to be as religious as we were in your rehab, but maintenance program, I would consider two to three times a week of strengthening after this year, especially if you're going to continue into sports.

I will mention another thing, as we age, every year after about 30 years old, we start to decline in our muscle mass and our muscle strength. So, we are kind of fighting this reduce in strength throughout our years of life. And so, it's really important to get a strength regimen down to kind of combat that decline.

Host: What if somebody isn't a big athlete or basically, for their exercise, they walk their dog, you know, every day. And somehow they injured their ACL in that. Are you still also recommending for them that strength training?

Cassie Casatelli: Absolutely. I think that that would be really beneficial. You know, a hot topic is arthritis, right? We all are scared of arthritis. It's this big kind of thing that we can get when we age. But the thing that helps arthritis is strengthening. If we offload that joint where the arthritis is, or the pain is, we get stronger and the muscles take the force from those joints and it's overall better for your longevity. You know, you're able to do the activities that you want to every day. Even something simple like going up and down stairs or picking something off the floor, squatting down to get that, strength becomes really important as we age.

Host: Yeah, no matter what, right? Whether you have ACL injury or not.

Cassie Casatelli: Absolutely.

Host: I want to go back and discuss with you kind of the post-surgery time period. We're talking maybe a few days, weeks, you know, a few weeks after surgery. Because you mentioned they go home, right? This is an outpatient type surgery. So, they go in the morning, they're home in the evening. What are some of the things that they need to avoid when they get home? Because you're not with them, you're counting on them to be taking care of themselves, doing the right things. So, what are some of those things that you're like, "Don't do this"?

Cassie Casatelli: Yes. Thankfully with this surgery, there's not a whole lot of precautions, but of course we don't want to do the higher level activities. And right after surgery, I'm hoping you're probably not going to feel too up to running or jumping, so we probably don't have to worry about that. But some things that I would void is trying to put something directly under your knee. We're trying to get the knee straight. That's really important for walking mechanics and to activate your quad. If you have a bent knee and you start walking on a bent knee, that is going to aggravate that knee further. And we need to try to control for that swelling and that pain in the first portion of your rehab process, because that's going to be better outcomes later on.

Host: So, the bent knee though, people want to do that because it feels better.

Cassie Casatelli: Yes. There's a lot of swelling that happens. And so, it tends to kind of build in the knee and, and behind the knee especially. So if I'm stretching the back of your knee, you're not going to like that. Unfortunately, we do have to build up your tolerance to it. I promise it gets better as you do it. I know it sounds, again, counterintuitive because it hurts. But it really is the best for your outcomes to normalize your walking, and to get that quad activated. Because the quad's job is to straighten the knee. So if it can't get straight, it can't truly work in the way that it's supposed to.

Host: You're so right. Long, long, long time ago, I was taught by a physician once early in my training and he said something along the lines, patients are going to tell you they can't exercise because they hurt. And he always flips it on them and says, "Well, you hurt because you don't exercise."

Cassie Casatelli: Absolutely. We need that strength.

Dr. Mike Smith (Host): Yeah, for sure. A hundred percent. So, I totally get what you're saying there. Sticking with that, the post-surgery time period, now they're at home, hopefully they're not bending the knee. You know, they're not doing jumping jacks or whatever, I don't know, whatever. They're avoiding all that kind of stuff. What are some of the barriers though they face? Like, what are some of the real tough things for them? I mean, I can imagine you have some patients that just don't want to get out of bed. So, what are some of those kind of barriers you have to deal with?

Cassie Casatelli: Yeah, I think it's really tough after a surgery, right? It's kind of you're at your lowest point. You can't do things on your own as you once did. You're not able to play your sport or do the activities that you love, because of the knee surgery. You might be in a lot of pain just from the surgery in general, right? Like, it's a minimally invasive surgery, but they still did work in there. So, it's still okay to feel that pain. You might have a lot of swelling as well. And so, that can be a barrier for you to actually want to do exercise. And that's what I notice. Patients come in, I'm like, "Okay, we're going to start bending your knee back. We need to get that normal range of motion." And they're like, "Man, it just really hurts." So, that's a tough little hump to get over, right? But I try to coach them through it. Make sure, you know, they see the outcome of this, right? It's going to be better when you do these things. Your outcomes are going to get better. You're going to be able to do the things that you love, and kind of hopefully motivate them through that.

I really love watching the postoperative process, because they come in and their confidence is low. And when you watch their confidence just increase throughout the exercise that you give them and the milestones that they meet, it is just amazing to see them at the end of that process and how just far they have come.

Host: Is mental health counseling a part of this at all? Because, you know, I could imagine especially—well, maybe I shouldn't say especially—but that patient of yours who is very independent and is a big athlete and is used to doing and taking care of themselves. And now, all of a sudden, at least in that post-surgery period, they have to rely on other people. They got to accept help. That could be really tough. you know, mentally speaking on people. So, what about counseling? Is that something you look out for, recommend?

Cassie Casatelli: Yes, definitely. We want to make sure that you are taking care of your mental health. So, we do have sports psychologists that we refer to. They're a great help during this process, right? Because there's so much that goes on that you kind of don't expect, unfortunately. And that's also kind of why we wanted to bring this to light for the public, even something like looking down at your thigh and just noticing it just doesn't look like the other one, and your knee just looks different.

So, there are some techniques that we have in therapy that I can help you through. We want to make sure that you're comfortable with your knee, so that's why I try to get my patients to touch their knee right away. And it sounds weird, right? But I want you moving it around. I want you getting used to it. Because if you ignore it, "It's not part of my body," this is going to be really hard for you to accept and to move through.

Host: One last question for you. This has been fantastic, by the way. I've learned a lot. So, thank you so much. With patients, and you and I are patients at times too, so I'm talking about all of us. You know, you want to connect with your surgeon. You want to have that real good connection with a primary care doctor. You want a good connection with the physical therapist, right? So, how does somebody know if they're in that right place for physical therapy?

Cassie Casatelli: if you have a therapist who kind of has your goals in mind, right, because that's really the most important thing. You are the center of our care. You are the reason that we're doing these sort of exercises. Now, I will say at the beginning, like I said, it's kind of boring. Everyone goes through the same exercises because it's for safety.

But once we start getting into these other exercises, if you want to get back to the gym, you want to do a specific sport, we start tailoring it to you. And so, you need to make sure that your physical therapist has that plan for you, and they're focusing on these things that matter most. So again, we're working on these timelines, making sure that you're prepared for these timelines. And we test you every so often throughout this process to check your strengths.

So, you need to make sure that you are going through a battery of tests every so often throughout this nine to 12-month process to make sure that your strength is on track, because I don't like to guess, I don't like to guess where your strength is. Guess what you can do. I need hard objective data to make sure that I'm doing right by you and progressing you in the way that I need. Tailoring the exercises based on that information that I get from that data.

Host: This has been great. You do a great job. I can tell you're very passionate about what you do. And I can tell, it comes from your heart and your dedication. So, thank you so much for coming on today.

To learn more about Memorial Hermann Rocket Sports Medicine Institute or the Advanced Interdisciplinary Knee Program, visit the Memorial Hermann website at memorialhermann.org/aclpodcast. If you found this podcast helpful, please share it on your social channels and check out the entire podcast library for topics that interest you. This is Everyday Well. I'm Dr. Mike. Thanks for listening.