acl

My ACL Journey - Late Rehab (Part 6)

This is Part 6 of a series outlining my recovery. There’s an impressive set of information online about how best to recover from an ACL tear, but I wanted to share my own story for a few reasons. There are a few critical resources online that made an outsized difference to me that I’d like to share. I also wanted to actualize the story I wanted to tell when I got to the other side. Finally, for me it was comforting to read the journeys of others going through the same process. I hope you find this helpful and do reach out with any questions you have.

Part 1 - The Injury

Part 2 - The Prehab

Part 3 - The Surgery

Part 4 - The Early Rehab (weeks 2-7)

Part 5 - The Middle of Rehab (months 2-6)

Part 6 - Late Rehab (months 7-10) [this page]


This section of “late rehab” covers the beginning of month 7 until the beginning of month 10 post-op. There was a ramp-up in the intensity of my training, and a gradual reintroduction of my normal activities. I ultimately was cleared from physical therapy and now feel stronger than I would have been at this time had I not torn my ACL!

At the start of month 7, I didn’t get a lot of time with my PT because of urgent travel to the east coast. I wasn’t thinking at all about my knee, and instead focusing on family. I often lacked the motivation and energy to do even a single cycle of lunges and squats. After a few weeks, I returned home.

At the start of month 8, I was still ahead of the rehab curve, but I had an itch to “make up for lost time” and increased my PT visits from 2x a week to 3-4x a week. Given how intense the plyometric sessions were at that stage, my PT didn’t think it was a good idea but I did it anyway. In addition to cranking up the PT visits, I also was also running 3x a week, supplementing that with 2-3x a week on the spin bike, and mountain biking whenever I liked. I was having a lot of fun, but I was also starting to feel weakness in ways that I wasn’t expecting. My uninjured leg developed plantar fasciitis pain that stubbornly lingered for months. My operated knee also started to feel more sore than normal from patellar tendinopathy.

At the start of month 9, I stopped running and at PT we focused two weeks almost exclusively on eccentric loading on my knee. These were the slow and boring workouts that were a contrast to the cutting and jumping training I was starting to get used to. The effort paid off and I was able to do my third and final return to sport testing at the 9 month mark. The RTS testing was never something I focused on, since I had already gone skiing, mountain biking, and climbing, but it was always fulfilling to see progress.

Concluding thoughts & looking ahead

Tearing my ACL and preparing myself mentally for surgery were traumatic for me. However, pnce I had committed to taking the journey, I began to think of this process as an opportunity to grow into something more. I wanted to look back on this period of my life and have more than just purely negative memories about what I couldn’t do. Rehab pushed me to better myself in ways that I have no doubt will shape the rest of my life.

If you tore your ACL, I that hope reading everything I’ve documented gives you some hope. It’s a dark place to be when you find out the news. Focus on what you can control. Rehabbing like a pro athlete may be out of reach, but there is a “best version of yourself” that is attainable. Have a a vision of who you want to be on the other side of this experience. This is going to suck, but with the right mindset it doesn’t have to be all bad.

My ACL Journey - The Middle of Rehab (Part 5)

This is Part 5 of a series outlining my recovery. There’s an impressive set of information online about how best to recover from an ACL tear, but I wanted to share my own story for a few reasons. There are a few critical resources online that made an outsized difference to me that I’d like to share. I also wanted to actualize the story I wanted to tell when I got to the other side. Finally, for me it was comforting to read the journeys of others going through the same process. I hope you find this helpful and do reach out with any questions you have.

Part 1 - The Injury

Part 2 - The Prehab

Part 3 - The Surgery

Part 4 - The Early Rehab (weeks 2-7)

Part 5 - The Middle of Rehab (months 2-6) [this page]

Part 6 - Late Rehab (months 7-10)


This section of “middle rehab” covers the beginning of month 3 until the end of month 6 post-op. Initially, there was a slowdown in the rapid progress I’d been experiencing from early rehab. I was still progressing, but no longer in big leaps. I needed to mentally shift how I thought about my rehab as a result. As the summer turned to fall, colder/rainy weather, family obligations, Covid, and travel impacted my rehab and morale by limiting how active I could be.

Mental state

It was easy to motivate myself in the first eight weeks of rehab. I was seeing improvements every other day, which deepened my commitment to stick to the prescribed plan. In month three, the PT visits began to feel the same: I was doing the same exercises with the same effort as before and the monotony set in. At the three month mark, it felt like five or six months had gone by. Of course, I knew that if I compared myself to a few weeks ago, there was a clear improvement in my movement quality and confidence. Still, I could no longer rely on the instant gratification to excite me.

I thought back to my earlier promise to myself, that I needed to come back stronger. I knew that this meant more than just bigger, stronger, and more capable leg muscles. It also meant identifying what I wasn’t doing pre-injury that I should have been doing. The first thing that came to mind was meditation. I’m a fairly intense person, so I’ve been reluctant to try sitting down and quieting my mind for, even a few seconds. I decided to make a real effort at it and was convinced after a few sessions. I’ve been at it for months and have made it an essential part of my mornings. In addition to having better quality sleep, I also find myself less quick to become frustrated at throughout the day.

My friends also told me about the legendary comeback of Adrian Peterson (AP), one of the greatest running backs in American football history, after he tore his ACL. I found the story inspiring and also went down a rabbit hole of looking for other pro athletes who recovered from ACL reconstruction like Tom Brady, Lindsey Vonn, and Zlatan Ibrahimović. Everyone online focuses on the size of their quads and hamstrings, but few people talk at length about how a strong mind is what separates normal or weak recoveries from the incredible recoveries. Everyone heals differently of course, but everyone also has the ability to push themselves to their own (safe) limit and I believed most people don’t even get close. I started to believe that this is what made elite athletes special. It wasn’t the million-dollar team or infrared sauna sessions. It was the power of will to follow through on a vision.

Regardless of how true that statement actually is, I believed it. I also believed that I likely would have healed faster if I was younger, but I wouldn’t have had the knowledge base about how different factors (e.g., hydration, sleep, nutrition, stress, consistency, etc) influence that recovery. There are dozens of pro athletes (e.g., Megan Rapinoe, Héctor Bellerín) who have said that the ACL rehab is the best thing that’s ever happened to them; they describe it as a gift. That initially seems absurd. Losing a year just to gain back muscle you spent a lifetime building? It seemed genuine and not something they said for the cameras. They all mentioned growing from the experience: refocusing their priorities, diet, resilience, and perspective. I recognized that I could either come out of this rehab regretful about what happened to me or I could see it as a wake-up call, a major pivot point in my life that I look back on decades later with pride. I’m going to live through this rehab anyway, so I might as well make the most of it.

During this phase of rehab, I was interviewed by Greg Louie, DPT (known on Instagram as @the_ski _pt). In that chat, I shared more about my mindset towards rehab. Find it here: https://open.spotify.com/episode/2EkLKYW1lcZQxS51DOyg0r?si=8493a3c566d74bf0

Diet

I already had a healthy, balanced diet, but I probed to see if there was room to push further. This wasn’t directly aimed at improving my ACL recovery; it was more around the vision of coming out of this setback on a higher level. I started to learn about glycemic index and glycemic load of different foods. It was a term I was vaguely familiar with, but never bothered to really learn about. I gave up on white rice, something I grew up eating multiple times a day in a South Asian home, and swapped over to brown rice. It definitely isn’t as tasty, but it makes me feel better and now I prefer it.

I also addressed my afternoon snacking by swapping to eating only one-ingredient snacks (nuts, blueberries, apples, etc). After a long bike ride where I’ve burned 3,000 calories, I throw down a protein shake I made myself rather than pig out at a restaurant on the drive back. It sounds like my life became a lot less fun, and from one perspective it has, but it’s a worthwhile tradeoff. My friend Greg likes to say, “Once your body has experienced what feeling really good is like, it’s hard to go back.”

Exercise

The exercises I did at physical therapy were focused on hypertrophy, stability, agility, deceleration, max speed, and eventually pivoting. Here’s a set of video clips that shows what the progression looked like:

I loved the balance exercises, which were initially a weakness for me even on my good leg. I bought a bosu ball just to practice more at home. Rehab was always top of mind for me: during breakfast, while waiting until my pancakes were ready to flip, I’d do bodyweight squats and lunges. I got so used to doing them that I’d need to do dozens before I’d feel a burn.

On strength exercises at PT, I’d always choose the harder weight when given the option. If there was an exercise wanted to quit on, my mind would flash to a scene of me on skis about to make a turn, imagining that it could go one of two ways: I’d either injure myself or make the move. That visual helped push me to complete all of my sets.

You never want to fail because you didn't work hard enough.

- Arnold

My PT began return-to-sport testing at 5 months and 2 weeks, just to get a baseline to compare against when we would test again the next month. I was surprised at how much I was able to do, but there was definitely a gap in confidence with my operated leg.

All of this was really enjoyable for me, in large part to the efforts of my physical therapists at SPT, providing variation and making it fun. I also finally accepted that resistance training had something to offer me and began to learn about concentric vs eccentric movements, how to train for power vs strength vs hypertrophy, and how I might balance that with my endurance goals. I even started to daydream about the workout splits I’d have in a year. I was fully invested into my training.

Body

My un-operated leg continued to grow stronger and grow in size. We weren’t isolating my operated leg, which was of course notably smaller. I knew it could take a year at least for them to be symmetrical again, but it wouldn’t take a year to match the strength.

I made sure to keep working on my upper body and core, which I had no excuse to skip out on. I looked and felt strong because of this. I’d often be shocked when I’d realize how little time had passed since the surgery. Fortunately, I had a shift in perspective: I had been thinking "Damn, I'm only 3 months into this rehab. It's taking forever" and getting quietly impatient. Instead, as I daydreamed about skiing, I began to think "Damn, 3 months have already passed. I only have 6-9 months* left to get strong before my return to skiing."

*This was of course assuming 9mo-12mo return to sport clearance, which may not be the case.

At week 14, my PT told me to stop wearing the Incrediwear knee sleeve during our sessions. He said it was a crutch, and indeed everything felt 5-10% harder without it. After just a few days I preferred not wearing it for training and only relied on the Incrediwear for long flights or car rides when I’d be idle.

Activity

My rehab took place over the summer, and I was hoping to get some adventuring in without introducing too much risk. Mostly, I biked on road and eventually on gravel. I knew gravel carried greater risk, but I tried to control my speed on descents to a reasonable level. My PT would have preferred I stay off the bike altogether, in case I needed to make a sudden stop and landed on my leg, but I felt confident in my bike handling.

I did do a 7mi (1,800ft ele) hike at week 11, but only because a friend was visiting. I moved at a normal-slow pace and the descents were the most challenging mentally. I wasn’t yet cleared to run or jump, but I did go to a swimming pool a few times to practice those movements in a safe manner.

Someone asked if I’d sign up for a race or an event as a milestone to look forward to. I personally thought that was a bad idea, since I couldn’t be sure of my condition at that date and may pressure myself into doing something simply because I signed up for it. Even if I was ready, the competitive environment would likley lead me to do something I shouldn’t. Instead, I made adventure plans for the weekend just days before based how fatigued I felt. One of my favorite rides was a scenic 62mi (5,500ft ele gain) loop near Mt Rainier that I did on week 14. I felt like I could’ve biked to the summit that day (if that was possible), but left some gas in the tank because I still needed to do my at-home PT the next day.

I delayed in clearing myself for mountain biking, since the speed at which I’d have to limit my riding would be far too slow to have any fun. By month six, my PT (off the record) told me I could start mountain biking, but crashing could be a major setback. I’m planning on sticking to the greens and blues, and avoiding wet, slippery days.

I’ll also be heading back to the climbing gym for some top-rope action and potentially even lead climbing. I’ll avoid hard bouldering for at least a full year, given the constant impact of jumping down.

Rest days

I didn’t plan for any rest days on my legs since the surgery, except for days when I was in flight to the east coast or internationally. I could only get away with this by modulating my load to ensure I had enough of a gap between ‘heavy’ days (i.e., days that I went to PT or the big mileage bike rides).

All of this was possible with very good hydration, proper sleep, and foam rolling twice a day. I wanted to ensure that my fun days on the bike did not need to be shortened, so I needed to make sure I was on top of everything else.

Rest days were limited to circumstances beyond my control, like when I caught Covid or I had severe jetlag from traveling to Bangladesh. If I needed to ease up on the legs, I still worked on stretching, light spin bike and went more intensely on the upper body and core workouts.

Concluding thoughts & looking ahead

I’ve had a very strong recovery so far and my nightmares of re-tearing my ACL during rehab have quieted down after trying out some advanced movements. My PT tells me he suspects I’ll be back to skiing in February (9 months post-op). This aligns with what I expected; I’ll have a very measured approach to returning to skis, which I can outline in my next writeup.

In the meantime, I’ll be working on (1) advanced pivot exercises at PT, (2) sprinting to build fast-twitch muscle fibers, (3) picking up activities I put on hold like boxing, climbing, and mountain biking, and (4) continuing all the good things I’ve been doing on diet, mental health, training, and time management.

My ACL Journey - The Early Rehab (Part 4)

This is Part 4 of a series outlining my recovery. There’s an impressive set of information online about how best to recover from an ACL tear, but I wanted to share my own story for a few reasons. There are a few critical resources online that made an outsized difference to me that I’d like to share. I also wanted to actualize the story I wanted to tell when I got to the other side. Finally, for me it was comforting to read the journeys of others going through the same process. I hope you find this helpful and do reach out with any questions you have.

Part 1 - The Injury

Part 2 - The Prehab

Part 3 - The Surgery

Part 4 - The Early Rehab (weeks 2-7) [this page]

Part 5 - The Middle of Rehab (months 2-6)

Part 6 - Late Rehab (months 7-10)


This section of “early rehab” covers the beginning of week 2 til the end of week 7. During this phase, I saw rapid progression in my flexion, balance, walking gait, and strength.

Sleep and pain levels

For the first week after surgery (outlined in Part 3 - The Surgery) I was on 4,000mg of Tylenol and 440mg of Aleve per day, and hadn’t touched the Oxycodone. My doctor suggested I begin to taper off the painkillers. In week 2, I took only half of the Tylenol/Aleve and only used them before bed. Apparently waking up at 4am when the Tylenol runs out is common. By week 3, I was pretty much entirely off of the pain meds. Although there were nights I’d wake up, I was happier to be off the drugs.

The pain levels at night were low, and would be best described as mild discomfort. After waking up I’d do heel slides to “break up the stiffness” for ten minutes. My sleep was generally good (just shy of seven or eight hours of actual sleep), but later on I started to struggle; I’d wake up far too early at 4am with a headache. When it became dire, I did reluctantly rely on fragments of Doxylamine Succinate, the non-habit forming sleeping pill from Costco. I did also add magnesium glycinate to my evening supplements. I can’t say whether it made a difference to my sleep. Ultimately, the only thing that helped was the single critical enhancement to my life that I’ve resisted for years: meditation. Within a day or two of having a mental visualization that resonated with me, I instantly had no issues falling back asleep.

I slept with my brace on every night as directed by my surgeon. I noticed that other folks were never asked to sleep with the brace (some weren’t given a brace at all). I was quite surprised by the variation in protocols, however I stuck to the guidance of my surgeon. I’m a pretty still sleeper, so it was very unlikely I’d twist my knee involuntarily while sleeping. However, I got used to the feeling of it and didn’t mind. If I didn’t have the discipline to follow my surgeon’s directions on this for a mere 7 weeks, how could I possibly have the discipline to rehab daily for years?

Showering

I took my first shower 9 days after surgery. Until that point I had done a great job of using wet wipes. Until week 4, I showered sitting on a 9-inch step stool that we already had. I didn’t want to buy a dedicated shower seat since it would become trash. At week 4, I carefully switched to standing up and showering.

For the entirety of this time period, I covered my wound with a knee protector. I considered using duct tape and a garbage bag to keep my incision dry, but in hindsight I’m extremely grateful I didn’t since this was so much easier.

Mobility

On week 2, I mostly stopped using crutches. I realized that the crutches became more of a liability indoors at that point, especially on stairs. I carried them with me outdoors as a signal to others so they’d be patient with me, but then by week 4 I left them at home for good.

On Day 10, my PT approved of me to walk with my brace unlocked (to 70 degrees) without crutches. It was scary at first, but I became more comfortable with each step. That first day of walking, only about 5% of my total steps were done with an unlocked brace. A few days later, I bumped it up to about 10%. I continued progressing, mostly walking in circles at home. Initially, I thought a lot about the mechanics of each step but soon I was moving more fluidly. Finally on Day 16, 100% of my steps were done with an unlocked brace without crutches.

On week 4, I was walking around the house without an immobilizer brace with my PT’s approval. I also started moving up stairs normally (rather than one step at time).

In the middle of week 5, for a moment I forgot about my injury and rushed down a set of stairs. I heard a pop in my knee and didn’t realize something dramatic had happened until I was halfway down the steps. There wasn’t any pain, and I actually felt great. I figured it was scar tissue that I broke. Until that moment, it felt as if there was a block preventing me from doing a weighted knee bend. From then onward, I gradually increased my downstairs walking until it was just a part of my normal routine. For the next few days I’d hear more satisfying cracks and pops as I walked down the stairs.

Flexion and Extension

I never lost extension in my injured leg. Even right after surgery, I was more or less equal to my good leg. I did hear that it was possible to lose full extension during the first six weeks, so I made sure not to slack off on continuing those exercises. Here’s a simple timeline of my unaided flexion.

  • Day 8 - 110 degrees

  • Day 15 - 120 degrees

  • Day 22 - 134 degrees

After that, I stopped measuring since it was just a few degrees short of my good leg. Stretching my quads felt great while standing, even though I didn’t have that full range of motion to get my heel to my butt. At the 7 week mark (on Day 49), my PT asked me to try and sit on my heels from a kneeling position. It felt scary at first, but I was able to do it.

Mental state

Seattle was hit with a mild heatwave on my second week, which massively sapped my motivation for a few days. Most Seattle homes, including the one I live in, don’t have air conditioning. I reluctantly got through my exercises, since laying in bed seemed less appealing.

I did feel better having my mobility increase each day. I felt more independent and by Day 9, I was making my own meals, cleaning up after myself, refilling my ice machine, and getting myself to PT with the bus.

Sharing my video clips (see day 14, day 21, day 44) of my progress on the r/ACL subreddit felt great, especially getting encouraging and positive comments from strangers. I also benefitted greatly from the group chat I made with fellow ACL-rehabbers. Sharing kind and supportive messages to them when they were down made me feel just as good as when they’d do the same for me.

As the weather got nicer, thoughts about what I was missing out on began to creep in. Although I loved being on my spin bike, I was really looking forward to being back on my road and gravel bike. In addition to wanting to be cleared by my PT, I needed to personally feel confident enough to blitz through hills. I didn’t want Leah to miss out on mountain biking, so I encouraged her to ride with friends and meet with new people.

I had a lot of time on my own to think about my situation. Every day I became more determined that I didn’t want to let this challenge I was in go to waste. I wasn’t satisfied with returning to a slightly better version of my pre-injury self. I had a vision of a version of myself with bulletproof knees. I knew this meant keeping a laser focus not just for a few months, but for years ahead. I would have a new obsession, which conveniently would support my passion in the outdoors and give me longevity in the sports I cared about. There was also a strong positive feedback loop: the more often I exceed expectations in physical therapy, the more confidence I had that what I was doing worked.

Doubts

The biggest concern I had was that I was either progressing too fast or not fast enough. My flexion, extension, and quad activation came back quickly, so I was cleared to do exercises and movements at PT and at home that normally wouldn’t begin until weeks later. When I looked at Dr. Khalfayan’s rehab protocol for the Seahawks, I was always about a week ahead. This all sounds like great news, but I was concerned since my PT hadn’t treated anyone progressing so quickly. Would Nelson (my PT) become too eager and put me on exercises that I wasn’t ready for yet? Or is it possible he wouldn’t take advantage of my fast recovery and I’d be dragged down into a more conventional rehab timeline? Both of these concerns weren’t valid, as Nelson did a great job finding the sweet spot for the first four weeks.

Another big concern I had was whether all this flexion so early was good. I saw several comments where patients were told to avoid flexion beyond certain amounts to ensure the graft didn’t get too loose. My PT dismissed this concern by noting that while under anesthesia, the surgeon manipulates your flexion quite a bit. Pushing your flexion early is only a problem if you’re forcing it. Mine came back naturally. At my week 7 follow-up with my surgeon, he did caution me about aggressively pushing the flexion with quad stretches and butt-to-heel sits.

It was tough seeing my calf, quad, hamstring, and glute muscles get smaller, especially because I figured I’d have less atrophy since I was progressing quickly. It’s obviously possible I did have less atrophy than what’s normal, but the smaller muscles were still demoralizing to look at.

Finally, I also needed to ask myself whether my ego was potentially going to put me in danger. By writing about my recovery, I was putting a spotlight on myself. Would it be possible for me to irresponsibly push myself too hard because I had an audience? Absolutely. However, I also knew that I didn’t want to tell a story about re-tearing my ACL. Forcing myself to write about the recovery absolutely impacted my rehab; every day I thought about the story I wanted to tell.

Driving

I had surgery on my right leg, which meant that I’d have a longer return to driving. I didn’t want to rush back into it given the harm I could cause to others or myself if I was wrong. Leah and I did a two-minute test drive in an empty lot on Day 20 and I had no issues. This was a big milestone for me; it brought more independence and severed the short tether to home. On Day 21, I drove myself to PT (30 min each way). I was mildly uncomfortable but never felt unsafe.

By week 6, I was doing two-hour one-way drives without much issue, however sitting in traffic became even more dreadful and frustrating.

Diet

I largely stuck to the same diet as my first week (outlined in Part 3 - The Surgery). Between Day 8 and 20, I was assembling refrigerated items or frozen meals from Costco or Trader Joe’s. By Day 21, I was back to cooking meals from scratch. I did need to be mindful about not being on my feet for too long. If I wasn’t, I’d feel pressure in my knee from the blood pooling up. Propping my foot up on the counter while I cooked required some flexibility but helped a lot. I continued to avoid booze and the only sweets I indulged in were small bits of really good dark chocolate.

I added creatine to my supplements, even though the benefits to athletes recovering from ACL reconstruction wasn’t definitive. I was concerned about gaining several pounds of water weight, but that never happened. I lost four or five pounds from my “active healthy weight,” which I attributed to some quad muscle loss but primarily trimming down on my belly fat from the core exercises and eating salads for lunch every day (something I never did before).

Physical Therapy

I was scheduled to visit my PT twice a week starting on Day 8. Generally we’d start with measurements of flexion, quad size, and some light massage before exercise. For every visit with Nelson (my PT), I’d exceed his expectations and he’d question out loud whether he thought I should get some advanced exercises.

Ultimately, I made the decision to entirely switch to a different physical therapist on week 6 for a few reasons.

  • Scheduling - It was clear there was more demand for my PT than they had capacity for. I even overheard them referring new patients to other providers. For me, this meant booking time slots at inconvenient hours.

  • Personal attention - Although I liked my PT, he’d only spend 30 min with me before passing me off to an aide who would swing by occasionally to point me to the next exercise. For the most part, a PT session didn’t feel any different from being at home.

  • Familiarity with athletes - Most of the patients seen by my PT’s office were older folks or generally not athletic. Their recovery timeframes would be vastly different from mine, and so would their goals. My PT hadn’t seen anyone recover at my speed, and seemed less confident whenever I nudged him to progress me.

  • Bigger facility - Most of my ACL rehab inspiration came from watching athletes running around on astroturf, throwing medicine balls at walls, and dragging weighted sleds for yards. I didn’t see how any of this would be possible in the small facility I was currently in, so I sought out a larger one.

I wouldn’t have had the confidence to make the drastic shift to if not for the earlier advice of my friend Zander about baseline expectations I should have. Fortunately, I found Sports Physical Therapy Factoria which rehabbed professional athletes (e.g., Seahawks, Marlins). Within the first day, RJ (my new PT) tested me my asking me to go through a range of motions I hadn’t tried since surgery, like lunges and deep squats. He agreed I was ahead of the curve, but didn’t seem overly impressed (which I took as a good sign). He then set me on a battery of exercises where I was soaking in sweat within just the warmup. I was a bit incredulous at what he had me doing, but it felt amazing to get a proper workout in. I also loved that he said that we’d exercise both legs rather than focus on rehabbing only the injured leg.

After that first session, I felt great until I got home. As RJ noted, there’d be swelling and we’d need to use that as an indicator of whether we’d pushed too far. My knee felt stiff and tight for the first time in weeks, and I reluctantly reached for an Aleve. When I told him this at our next visit, he didn’t flinch and we did another intense battery of exercises which would’ve challenged me even without a recent surgery. I shook off my skepticism when I realized he was right. The swelling wasn’t as bad the next time, and my body began to adapt to the new load.

By the end of week 7, I was doing exercises at PT that would have been physically demanding even without the ACL reconstruction (e.g., single leg box squats, goblet squats, dynamic side lunges with a medicine ball, weighted sled pushes, reverse nordic curls, squats on an inverted bosu ball etc). Since everything felt hard and I’d be out of breath, I wasn’t sure anymore if I was falling behind. RJ (new physical therapist) repeatedly gave me the confirmation that I was still doing well.

Exercises at home

Each round of PT exercise at home would take about 1 hour. Between Day 8 and 16, I’d do the following exercises three times a day. If my reps weren’t perfect, I didn’t count them. I found that buying a tally clicker helped me focus on the movement instead of trying to remember the count.

  • Knee extensions, firmly pressing down for 10sec on the quad (while sitting up with a towel underneath the ankle) x10

  • Calf stretch with a strap for 10 seconds (while sitting up with a towel underneath the ankle) x10

  • Hamstring stretch with a strap for 10 seconds (while laying down) x5

  • Heel slides without a strap for 10 seconds (including a 2 second hold) x15

  • Quad sets with a towel roll under the knee for 10 seconds (while sitting up and looking at the quad to establish a mental connection) x20

  • Straight leg raise holding a quad set (while laying down) x20

  • Prone terminal knee extension for 10 seconds (while laying on my belly) x10

  • Prone knee flexion, lifting and slowly lowering (with a 1-2lb ankle weight) x15

  • Side lying hip adduction, lifting and holding the leg up for 2-4 seconds (with a 1-2lb ankle weight) x15

  • Side lying hip abduction, lifting and holding the leg up for 2 seconds (with a 1-2lb ankle weight) x15

  • Heel raise, placing toes on a staircase step for a full range of motion x20

  • Standing terminal knee extension, flexing the quad to straighten fully (while wearing unlocked brace) x15

  • Step throughs, where I practice slowly taking a step forward and backward with an unlocked brace, slowly breaking each movement down into careful steps (not looking down at my feet to practice having the motion feel intuitive) x15

  • Sit to stand, doing a half squat down to a bed with unlocked brace (while flexing quad and glutes when standing) x15

On Day 17, I added the following exercises. I reduced my exercise sets to twice a day instead of three times a day since the exercises were taking longer, I was feeling more of a workout because of the spin bike, and work and normal life was getting in the way.

  • Standing kickback, where I’d balance on a leg and kick back the other leg at a 30 degree angle (switching sides after each set) x15

  • Hurdle step over, where I’d step over an imaginary hurdle (forwards and backwards, alternating legs) x80 steps total

  • Spin bike, where I’d primarily pedal with my injured leg

For the spin bike, I was cleared to bike for 5 minutes at low resistance on the first day, and I could increase by 2 minutes each day. I made a rule that if I were to increase resistance, I would have to dramatically decrease the length of time I was pedaling. Only after completing a short duration at higher resistance could I begin to increase the duration again. I always finished each session feeling like I could have pedaled for a lot longer.

On Day 21, my PT (Nelson) had me try some new exercises, including a double and single leg press. Below are the other exercises I added to my routine (without removing any of the earlier ones). I finally reduced my at-home PT to a more manageable once daily. After a few days of adjusting to the new load, I increased the reps of all the exercises by 50% and added more resistance where possible (e.g., 1lb-2lb ankle weights, tougher resistance bands, resistance on spin bike).

  • Standing kickback, same as the exercise above, except I’d have a resistance band (switching sides after each set)

  • Balanced leg, standing with a injured foot on a soft cushion while the other foot’s toes touch behind you on ground for balance (as if in a short lunge with 90% of the weight on the balanced leg). Eventually I’d make it harder by tossing a ball to the wall and catching it to add some random stimulus.

  • Balanced leg blinded, same as the exercise above except balance the foot on solid ground and keep your eyes closed for 45 seconds. Eventually I did this with my foot off the ground.

  • Step ups, stepping up on a staircase, eventually standing straight solely on the injured leg poised to take a big step with the other leg.

  • Hamstring curl ball rolls, while laying down I pressed my foot down on a 6-inch ball that I’d roll in towards me while flexing my hamstring.

The only rest day I took was after my first intense session with my new PT. RJ and I both agreed that my body could recover from the load within 24hrs. However if I got poor sleep, I’d first cut out my non-rehab exercises (i.e., upper body and core). If I was really in need of a rest day, I would reduce the reps and resistance rather than sit around doing nothing. Light motion was better than no motion. RJ added the following at-home exercises (which I just tacked on to the earlier exercises from Nelson):

  • Monster walks w/ band at the ankles, walking sideways for 10 yards and then walking reversing direction.

  • Banded railroad track walk, shuffling forward for 10 yards and then doing it backwards

  • Skaters w/ band, sweeping a foot forwards in an arc for 10 yards and then doing it backwards

  • Standing Banded Fire Hydrant, for three sets of 10 reps on each leg with a band above the knees

  • Banded air squats, for three sets of 10 reps on each leg with a band above the knees

Massage

On Day 11, I got a new toy: the Normatec 3 Legs System. I was initially worried about damage to my incision because of the pressure, but then remembered that advanced cold therapy machines like the Game Ready are built with compression in addition to cold therapy. I also tried the device on my good leg first to feel what it’d be like.

After using it, I had absolutely no clicking, popping, or tightness in the knee between flexion and extension. My knee felt almost identical to my normal leg and it actually freaked me out. I thought I might have done something wrong and introduced too much laxity in the knee. I was relieved the next morning when the familiar tightness and stiffness came back (but to a lesser degree). Overall, I felt great with the Normatec, but I did get some light bruising in my inner thigh (and I don’t bruise easily). I decided to lay off using it until Day 14, when it became an essential part of my daily routine after icing.

I really wanted to say that the Normatec was a waste of money, but I was very noticeably less tight in the knee after using it for 30-45 minutes. I got a pro deal on it, and figured it may be valuable for recovering from big days in the mountains in the future.

Icing

I stopped icing my knee at my new PT’s recommendation on week 5. He called out that it would shunt out fresh blood to heal my knee after a workout. I went cold turkey on this and didn’t miss it at all.

In hindsight I would not have purchased an ice machine, even if it cost a third of what I paid. I found myself reaching for the ice packs in the freezer more often out of convenience and preferred the mobility it gave me.

Incision site

By day 14, all of my bruising was nearly gone. On Day 16, my PT removed the steri strips from my incision site and rubbed some lotion on the area. The patellar incision was nearly invisible and instead my eyes were drawn to the varied scars I already had that followed the many mountain biking falls over the years. I was told to begin mobilizing my patella and patellar tendon laterally to help break up any scar tissue. This would help me prevent patellofemoral pain syndrome from developing in the future.

By week 4, the patellar incision was more noticeable, with a shiny sheen on it. My PT advised me that we needed to begin mobilizing the scar itself to help break up the scar tissue and make that skin loose again. I bought a Gua Sha tool after deciding the blunt side of a butterknife wasn’t appropriate. I also went to an acupuncturist, which my insurance covered for 12 visits a year. I can’t say whether it made a difference, but I sure felt great during it.

While awake, I regularly wore an Incrediwear knee sleeve, which was far more expensive than I would have liked. Everyone on ACL forums loved them and they’re very well-built. I slept with a cheap cloth knee sleeve that my PT gave me. The compression sleeves felt nice but also protected my incision from the sun, which apparently would deeply tan or burn the incision line. I had seen photos of others with the scar — some looked better than others. I had read on a random comment that keeping it protected for a year was important for avoiding the deep tan, so I decided that’s what I’d do. Even if it wasn’t necessary for my recovery, it all fed into the question of testing my discipline.

On week 6, I noticed a tiny opening in my incision. Given how well the scar had healed, I just assumed it was a very superficial layer of skin peeling. Three days later I pushed on it and noticed a pinprick of creamy pus come out. I called my surgeon’s office and was advised to head to the ER. I spent nearly four miserable hours there and was released at 2am. Fortunately I caught the infection early and it was only superficial. I wouldn’t need to change my physical therapy at all. I decided to aid the closure of the wound by using some steri-strips to close the wound. Even though my surgeon said it wasn’t at all a setback, I’ll admit I was annoyed with myself for getting this close to having one.

My routine

For the first week after surgery (outlined in Part 3 - The Surgery), I outlined my routine in a lot of detail. I won’t be doing that for this six-week period. Here’s what didn’t change: my morning full-body stretches, hydrating very well, protein shake, salads for lunch, sleeping at a consistent time, screens-off an hour before bed. The only notable item I added was several minutes of guided meditation which became invaluable for setting my mind for sleep.

In my idle time, I continued to do Duolingo for at least 30 min/day, work on my writing, and edit photos. I did my best to avoid doom-scrolling on social media but it became harder as I spent less of my day doing at-home PT.

I had a concept of idle-time rehab as well for each week. For week 1, it was doing ankle pumps while elevating. For week 2, it was doing unassisted heel slides. For week 3, it was patellar mobilization. For week 4, it was breaking up scar tissue in my patellar tendon. If I had a free moment and nothing to do, I’d do my idle exercises hundreds of times.

Concluding thoughts & looking ahead

In the last few weeks, I’ve learned a lot about my body and started to get the sense that this ACL tear has been a wake-up call. I wasn’t actually invincible, and I was actually quite weaker than I was willing to accept. If I wanted to keep playing outdoors in the mountains for a long time, I needed to build resiliency in my body.

In the next part, I’ll outline what months 3-6 were like (unless I have a good reason to break it up into a smaller intervals).

My ACL Journey - The Surgery (Part 3)

This is Part 3 of a series outlining my recovery. There’s an impressive set of information online about how best to recover from an ACL tear, but I wanted to share my own story for a few reasons. There are a few critical resources online that made an outsized difference to me that I’d like to share. I also wanted to actualize the story I wanted to tell when I got to the other side. Finally, for me it was comforting to read the journeys of others going through the same process. I hope you find this helpful and do reach out with any questions you have.

Part 1 - The Injury

Part 2 - The Prehab

Part 3 - The Surgery [this page]

Part 4 - The Early Rehab (weeks 2-7)

Part 5 - The Middle of Rehab (months 2-6)

Part 6 - Late Rehab (months 7-10)


Surgery

On May 2nd, Leah drove me to be checked in for surgery at 11:30am. I hadn’t eaten since dinner the night before, and my last sips of water were just minutes before 7am. In anticipation of being constipated from anesthesia, I ate high fiber and vegetable meals the previous day; in anticipation of being thirsty, I put down nearly a liter of water that morning. I had to pee a bit more than usual that morning, but I was never thirsty leading up to surgery.

I was quickly changed into a gown. It all started to feel very real when I put on the hair net though.

I was given a small sip of water with preemptive Tylenol. My resting pulse came in at 45, even lower than I would have guessed. I was mostly relaxed, and knew I had nothing to worry about. Having Leah by my side put me at ease. The nurses were sweet and both Dr. Fuchs (my surgeon) and the anesthesiologist came separately to have a chat with us. Dr. Fuchs had a magical way of relaxing me even more. Despite having done nearly a thousand of ACL surgeries (and nearly 5,000 surgeries overall), his presence was so warm and caring. He explained the procedure one more time: a patellar autograft and he’d see if anything needed to be done to the meniscus. Before he left, he wrote his initials on my right leg confirming that’s the one they’d cut open. The anesthesiologist asked if I’d be interested in an adductor canal nerve block, which apparently 10% of patients turn down. I happily accepted.

As I was wheeled towards the operating room and said goodbye to Leah, the nurse gave me a heads up on what to expect within the next minute. I’d soon be mobbed by a team of medical professionals all working on me as if I was a Formula 1 car. The doors flung open and I was greeted by Dr. Locknane, the Ortho specialist who first broke the news to me that I had a torn ACL. He’d be assisting Dr. Fuchs during the surgery. Even though I had only interacted with him briefly, I was so happy to see him. He had done a lot for me emotionally by breaking the news with the right level of tenderness, but also giving me the confidence that I could bounce back. During the minute before I was put to sleep, they were asking about my recent bike trip. Dr. Locknane did a double take and asked me to repeat the stats of my bike trip (480mi, 42,000ft). He enjoyed the occasional triathlon and looked like a strong athlete, so I had a smile falling asleep knowing that he was impressed with my prehab.

Discharge

The procedure lasted 90 minutes and I had been asleep for another 90 minutes. When I woke up, I assumed the nurse was my wife because I had been dreaming of the bike trip. Within a minute, I realized where I was and had a huge grin on my face. I was on the other side! I happily accepted the nurse’s offer of ginger ale and apple juice. I also ate a cup of vanilla pudding and fig newton bars. I was fully expecting to have no appetite based on what everyone told me, but that wasn’t the case at all.

When Leah arrived a few minutes later, I was smiling even more. She might have assumed it was the drugs I was on, but I really was just happy to be eating and doing so without pain. The nurse gave us some instructions and photos from the surgeon, informing us that I could be weight bearing since there was only a 5% meniscus trim. I was incredibly relieved at this news.

The car ride

Getting into the car was quite easy because we had planned for this. Leah brought a very low-friction blanket for me to slide over in the backseat, where I buckled in. It was quite comfortable and I continued to eat lots more (cranberry walnut bread, chocolate, sparkling water) during the 30-minute drive.

I hadn’t practiced on crutches before, and promptly forgot what I had learned on Youtube about how to get up and down stairs using them. Instead of trying, I decided to butt-scoot my way up our townhouse to the third floor bedroom, where I’d be settling in. Reflexively, I was avoiding putting weight on the foot even though I was cleared to do so. Once in bed, I ate some more (fruits, salad, vegetable curry with rice) and removed the post-op brace that had me locked in at 10 degrees. I felt incredibly lucky: no meniscus repair, big appetite, zero pain.

I only needed to keep the brace on while walking and sleeping. That first day, I only had time to do 20 minutes of in-bed exercises and an hour of the CPM at 50 degrees. My wound dressings were so thick that the cold therapy machine couldn’t get through, which was a bit annoying. I think my surgeon wasn’t a fan of putting the ice machine bladder on beneath the wrap because of the pressure it would cause with the knee brace. I ended up having a decent night of sleep and my pain levels continued to be at zero so I stayed off the Oxycodone.

Pain levels

Before I went to bed every night that first week, I made sure to keep the Oxycodone pills close by. I knew I needed to stay ahead of the pain. Fortunately, every morning I woke up I was still numb from the nerve block. I became quite anxious for when the hammer would drop and I’d find myself in a world of hurt, but it never happened. By Friday (three days after surgery), I was starting to wonder whether this was a problem. I coincidentally got a call from the anesthesiologist who said I was quite lucky. The first three days are considered the most painful because of the swelling, and I skipped over all of that. He said the timing of the nerve block is variable and can fade after a day or last up to a week. The drug I got was Bupivacaine (brand name: Exparel), which has been around only a few years. It releases from these fat-based particles in bursts, sometimes more at a time and sometimes less, which explains the variability in how long the relief lasts for.

My nerve block lasted til five days after surgery, but I wasn’t sure if it had actually worn off because I expected a lot more pain. I confirmed it had worn off when I could finally feel touch but the pain in my knee was simply a dull ache that maxed out at 1 or 2 out of 10, and only when I bent my knee after being straight for an extended period of time. Since my pain levels were close to zero, I stuck to 1000mg of Tylenol every 6 hours and 220mg of Aleve every 12 hours (staggered). On day 8, I decided to halve my Tylenol and Aleve intake, and would quickly taper off entirely. Dr Fuchs also had me taking a small dose (81mg) of aspirin every 12 hours to prevent blood clots for two weeks.

I used an Oura ring to keep track of my sleep. Since I wasn’t in pain early on, I never got a bad night of sleep. In fact, I got better sleep the week of surgery than the prior two months. In the first night, my resting heart rate shot up to an average of 54 bpm (low of 49), and then quickly returned to normal in the following nights.

Average HR for sleep the night after surgery

Range of motion

My surgeon insisted that I rent a CPM machine which they helped arrange. My insurance stopped covering it last year, so I’d be paying out of pocket (~$24 per day). Someone came by to drop it off the day before the procedure and gave me instructions on how to use it. My surgeon wanted me at 120 degrees of flexion by the time he saw me for the post-op appointment 8 days later. The plan was to start at 45 degrees the day of surgery and use it in 1-hour sessions three times a day, increasing by 5 degrees each time. I could always do more if I wanted. I started at 50 degrees and ended up using the machine at least four hours a day, never increasing by more than 15 degrees in a given day. By Sunday, five days after surgery, I was at 120 degrees on the CPM and I was told to keep that level of flexion til my post-op meeting on day 8.

I was cleared to return the CPM, but thought about holding on to it. I loved how it loosened me up (in a good way) and gave me something “productive” to do when I wasn’t grinding out PT exercises. On day 9 though, I realized that I really didn’t need it at all. Between my full extension and the 110+ degrees I was getting, my knee was feeling normal.

Exercise

I’m glad I met with my PT before surgery because he gave me a set of exercises to work on while being idle. I never lost quad activation nor did I lose the ability to do a single leg raise with a flexed quad. I noticed my quad muscles begin to slim down on day 3, which wasn’t fun to see. I also never lost the ability to fully extend my leg either. Here’s what my exercise regimen looked like in the first week with the goals of reducing swelling, increasing flexion/extension, and minimizing quad muscle atrophy. Three times a day I would do the following:

  • Knee extensions, firmly pressing down for 10sec on the quad (while sitting up with a towel underneath the ankle) x10

  • Calf stretch with a strap for 10 seconds (while sitting up with a towel underneath the ankle) x10

  • Hamstring stretch with a strap for 10 seconds (while laying down) x10

  • Heel slides with a strap for 15 seconds (including a 5 second hold) x10

  • Quad sets with a towel roll under the knee for 10 seconds (while sitting up and looking at the quad to establish a mental connection) x25

  • Straight leg raise holding a quad set (while laying down) x25

This routine took 45 minutes and I took special care to execute the the last two exercises perfectly since these would be the ones to help me resist atrophy the most. I finished each set with 27 minutes of strong NMES while my leg was elevated and I did ankle pumps. The quad sets and straight leg raise were the most mentally taxing. They never caused pain, just mental fatigue.

Besides the exercises the PT had me doing, I wanted to ensure the rest of my body was getting some movement in. I adapted my elaborate daily morning stretching to my new limitations and needs. Every morning I’d roll my shoulders, stretch my torso, neck, and deeply stretch my uninjured leg, hips, and groin as best I could. After a four days, I was feeling confident in doing some pullups, so long as I landed carefully on my good foot. I also did standing pushups with my hands on a dresser and messed around with 5lb dumbells for light shoulder work.

I eagerly wanted to move on to the more fun exercises that would have me hopping around but I knew I needed to unlock those levels by ensuring I had range of motion, extension, and reduced swelling.

Icing

My ice machine (DonJoy Iceman Clear) was pretty useless for the first two days when my incision dressings were so thick that the cold wouldn’t penetrate. I relied on ice packs instead, and wasn’t too mindful about when to use them. However, once I removed the cotton padding on the wound (leaving gauze and ace wrap), I had a more regular routine with the ice machine. I had to be aware of how long I kept the ice machine on, and planned to use an Alexa smart plug to set a schedule. It ended up being a lot more convenient to just plug the unit in and set timers with Siri.

I had read that frozen water bottles were easier to use than ice cubes, and I was prepared to go that route, but we found that just adding ice cubes two or three times a day cooled the water a lot more. I am curious whether a more expensive ice machine like the Bregg Polar Care Wave (which I bought for my mother a few weeks earlier) or even renting a GameReady that has compression would be worth it. My surgeon didn’t think much of the compression so I didn’t bother. I did plan to use a Normatec 3 Legs system on the leg once there wouldn’t be any concern with the incision site.

Injury site

I first got a look at the incision site when we had to change the gauze under the ace wrap, 48 hours after surgery. Fortunately, the nurses provided us with plenty of extra material. It looked like there was some significant bruising on the inside of my knee, but far less than what I had seen others post photos of online. Apparently it would look worse before it got better, so I took photos to track progress. I won’t show those photos since they’re a bit graphic. By day 8, my bruising was minimal.

I did use a massage gun on my calf and quad, being sure to avoid the knee, hoping it would help with the bruising by moving the blood along. I also bought arnica gel that I planned to use later to help with swelling. Just like the supplements I was taking, I couldn’t tell if it would make any difference but I figured it wouldn’t hurt.

Diet

I put a lot of thought into my diet. I was fully expecting to be constipated from the anesthesia and the Oxy (which I never took), so I kept a few packets of stool softener on hand. I never ended up needing them and had kept to my regular bathroom routine. I resumed taking my supplements the day after surgery: turmeric, tart cherry, glucosamine, multivitamin, fish oil, Vitamin D, and collagen peptides. I also continued avoiding alcohol to allow my body to heal at full capacity. I wasn’t a coffee or tea drinker; I read THC would help with pain, but I fortunately never had high or even moderate levels of pain. I also wanted to guarantee I had maximum mental capacity to focus on my exercises.

For eating, we had done a Costco and Whole Foods run beforehand. Breakfast would be my usual protein shake (almond milk, honey peanut butter, fat-free greek yogurt, protein powder). Lunch was always a salad kit. Snacks would always be dark chocolate, good bread, apples, pitted prunes, or oranges. For dinner, I’d have rice with my mom’s frozen curries (from a home vegetable garden) brought over a month ago. Leah asked if I wanted her to bake me anything, and I resisted. I wanted to avoid any treats or indulgences. I was treating my body like a machine. Clean fuel only.

We stocked our fridge full of different brands and flavors of sparkling water. It was a nice treat with lunch and dinner and the variety helped keep things interesting. I had great hydration habits before the surgery and kept to them. This of course meant I’d be getting up to pee pretty often. My surgeon wanted me to get up regularly to avoid blood clots and other issues from being idle for too long, and being able to bear weight made things a lot easier. At night I kept a pee bottle near me that I’d use just to avoid having to walk in the dark.

Mobility

I was able to bear weight on my injured leg on the day of surgery, which helped tremendously for getting around. Going up and down stairs was possible since day 1, but I felt more confident about it on day 4. On day 5, when the nerve block wore off, I began to feel the blood rushing down to my leg when I’d stand up. I didn’t like that feeling, so I’d prop my leg up on a table or even a stool when standing for a while (e.g., brushing teeth). I was quite grateful for my flexibility and the aggressive core exercises I did in prehab. All that helped me stay stable when I’d put myself in precarious body positions with the braced foot in the air, sometimes above my head (e.g., to reach for something).

For sitting on the toilet, having a step stool to prop my immobilized leg on was very helpful. I saw someone improvise this by stacking new rolls of toilet paper, but that looked unstable.

It was massively helpful to have a bedside table that you find at hospitals. I was initially skeptical because no one seemed to be recommending it online on ACL groups. It ended up making my life so much easier and I can easily sell it later.

By day 8, I was preferred just one crutch when walking around the house, but generally wouldn’t use any crutches at all for short walks in the same room. Of course, I’d take two with me when I’d go outside.

Skrt-skrt! This was fun to finally try out. Feels like driving a Tesla.

Mental state

I was mostly in a great mood the entire time. I felt like my recovery was going a lot more smoothly than I had expected. I felt particularly great when I figured out what my ideal routine would be. During my exercises, I’d watch Youtube videos of professional athletes recovering from ACL injuries or other major surgeries. I made a commitment before the surgery that despite not having a fully dedicated team, I’d do my best to rehab like a pro. Watching these videos put me in the right mindset. Here are a few that I liked:

  • Billy Kemper (big wave surfer) rehabs after ACL, MCL, meniscus surgery

  • Mark McMorris (snowboarder) returns to win Olympic gold after a devastating injury

  • Connor McDavid (hockey player) rehabs his PCL without surgery

  • Hector Bellerin (soccer player) openly shares his journey with recovering from an ACL tear

  • Andri Ragettli (freeskier) comes back from a devastating knee injury with multiple setbacks and continues to perform at an elite level.

Since I wasn’t on Oxy, I felt comfortable doing some light work. My job never asked me to come back nor did anyone apply pressure. I kept tabs on what was going on and dialed in to some meetings mostly out of boredom. Anything that required real brain power, I deferred to later. Officially, I had taken a full week off, and I planned to be intermittently in for up to the third week of recovery.

Besides writing, it helped to plan the future. Instead of planning mountain adventures, I was planning out where to go eat. Leah was excited to park the car downtown with the handicap placard I’d have for 3 months. I also scheduled a big celebratory dinner with friends to celebrate a month of recovery.

I shared a few updates on my IG story about how things were going, and it always felt wonderful to have my friends acknowledge my recovery in any way. Jason offered to cook or order delivery for us. Other friends and family texted regularly for updates, and some called. I was surprised that others didn’t bother reaching out at all even though they were aware, but I didn’t think any less of them. Instead, what I learned was how I could be a better friend to someone going through a medical procedure in the future.

Having Leah with me was a huge boost to my mood. In addition to making my life easier, I always felt loved every time she looked at me and smiled. Each night I’d share with her what I was grateful for, being sure to highlight even the smallest wins of my day.

Sitting outside in the afternoon felt wonderful. It was Leah’s idea when I was getting a bit bored of being at home.

My routine

This is what my Day 1-8 looked like with 95% accuracy.

  • 6AM - 1000mg Tylenol. I’d wake up naturally to take this without alarm

  • 7:30AM - wake up without an alarm. Chug water to compensate for being dehydrated overnight

    • Morning full body stretch with podcasts, use toilet, clean pee bottle. Wash face, use wet wipes to clean body. I didn’t take a shower until day 9.

  • 8am - Drink protein shake and eat half a bowl of high fiber/low sugar cereal

    • Get on the CPM machine for 1hr with an ice wrap for half the time

    • Check messages from friends/work

  • 8:30am - 220mg Aleve

  • 9am - Morning supplements and 81mg Aspirin

    • Begin leg exercises, set #1. Watch motivational videos while doing this

    • Use NMES and massage gun for 27 min while doing ankle pumps

  • 11am - Light upper and core workout

  • 12pm - 1000mg Tylenol. Salad for lunch

    • Get on the CPM machine for 1hr with an ice wrap for half the time

  • 1pm - Begin leg exercises, set #2. Watch motivational videos while doing this

    • Use NMES and massage gun for 27 min while doing ankle pumps

  • 3pm - Full body stretching, focusing on core (e.g., hanging leg raises), pull-ups, chin-ups

  • 4pm - Get on the CPM machine for 1hr with an ice wrap for half the time

    • Eat fruits as a snack

  • 5pm - Begin leg exercises, set #3. Watch motivational videos while doing this

    • Use NMES and massage gun for 27 min while doing ankle pumps

  • 6pm - 1000mg Tylenol

  • 7pm - eat dinner, CPM + ice machine

    • Watch a 90 min of a show or movie with Leah

  • 8:30pm - 220mg Aleve

  • 9pm - Evening supplements and 81mg Aspirin

    • Read in bed

  • 10pm - lights out

  • 12am (midnight) - 1000mg Tylenol. I’d wake up naturally to take this without alarm

At random moments throughout the day, I’d be doing ankle pumps with an elevated leg or I’d be doing quad sets. I’d keep myself entertained by doing Duolingo, writing, or editing photos from the recent trip. I did my best to limit my movie/show-watching to when I was exercising. I did my best to keep myself fully focused on one task at a time. I also asked myself if there was more I could do each hour to push myself, and usually there wasn’t.

Post-operation appointment

On day 8, I had a morning appointment with my surgeon to follow up on my progress. I was looking forward to this moment because I knew I had been doing well. After seeing my extension and flexion, as well as hearing how my week had gone, he noted that I was “in the top 1% of 1% of patients” that he’s seen. I was flattered and my heart was full hearing that. All the dedicated work had been validated. My incision was also healing really well. His assistant changed my steri-strips and I got some more gauze and ace wrap for the future. We scheduled an appointment for 6 weeks later.

I went to my first post-op physical therapy appointment immediately after. Nelson, my PT, was amazed by my progress. My knee extension was equal to my other leg and my unaided flexion was 110 degrees before I felt tightness or pain. He said he had never seen any patient progress this quickly. I felt like I would burst with joy. He then took a measurement of my quad and to my amazement, the measurement came back exactly the same as the day before surgery: 48cm (compared to 51cm on the good leg). While he massaged my leg and worked on patellar mobilization, he said that I’m far ahead of the standard protocol, so we’d try walking with my brace unlocked using crutches. It was scary to do so at first, but I slowly got the hang of it. I took 10 steps, breaking each movement down thoughtfully and speaking aloud what I was doing. He didn’t want me to try this at home yet, but it was valuable for me to realize that I needed to relearn how to walk. Nelson then had me demo a few more advanced exercises that I could incorporate into my routine. I asked when I could get on a spin bike, since that was more fun. He started to list out the criteria, and then stopped himself by saying “Well, you’re already demonstrating the pre-requisites, but let’s wait another week.”

Day 8

Huge grin on my face after returning home and hearing all the positive feedback from the doctor and PT.

PART 4 - The Rehab

All this validation for the work I put in during the first week has made me even more determined to throw it down harder (without being stupid by going beyond what I’ve been approved to do). In the next part, I’ll cover the rehab that gets me to a point where I have a normal gait!

My ACL Journey - The Prehab (Part 2)

This is Part 2 of a series outlining my recovery. There’s an impressive set of information online about how best to recover from an ACL tear, but I wanted to share my own story for a few reasons. There are a few critical resources online that made an outsized difference to me that I’d like to share. I also wanted to actualize the story I wanted to tell when I got to the other side. Finally, for me it was comforting to read the journeys of others going through the same process. I hope you find this helpful and do reach out with any questions you have.

Part 1 - The Injury

Part 2 - The Prehab [this page]

Part 3 - The Surgery

Part 4 - The Early Rehab (weeks 2-7)

Part 5 - The Middle of Rehab (months 2-6)

Part 6 - Late Rehab (months 7-10)


Diagnosing the injury

On March 9th, my entire approach to the injury changed. I scheduled an appointment with an Orthopedic doctor without a referral; I figured the rapid muscle loss and minor instability had to be signs of something worse than a sprain. While the X-ray revealed nothing interesting, the physical exam (the Lachman test) showed I had a soft endpoint to my knee and the doctor could feel there was still fluid buildup within the knee. He had a look of deep regret when he told me that there was likely a “disruption of the ACL” and recommended an MRI. He also referred me to a surgeon colleague. All of this information was going over my head. I didn’t even know what an ACL was, let alone the implications of tearing one. It took several minutes for me to realize the gravity of the situation. As he spoke, I began to physically feel sick and wanted to disappear into the wall.

I called Leah once I was dismissed and gave her the news. The entire drive home, I felt shaken and wanted to pull over and absorb all of this. The MRI a few days later would confirm the tear, though it was unclear whether I had damage to my meniscus.

Leah shared several links to pro skier Caroline Gleich’s Instagram where Caroline shared her journey of tearing her ACL and then summiting Mt Everest about six weeks later, just days before surgery. It seemed absurd that would be possible, but I began to think that maybe the 3-week Nepal honeymoon trek we had in six weeks was still possible.

GOOD THING #1: Getting inspiration from Caroline Gleich’s IG, realizing there’s a lot I could still do with a torn ACL before surgery. Relevant links:

- The injury

- Everest base camp to camp 1

- Video about the Everest climb

- Speed ladder, 1 month post-surgery

- Single-leg assisted squads, 6.5 weeks post-surgery

- Two mile run/hike, 4 months post-surgery

- Cleared for skiing, 5 months post-surgery

- Skiing a long run, 6 months post-surgery

- 100mi bike ride, a year post-surgery

- 30mi, 11,000ft ele trail run, a year post-surgery

Taking action

I began to feel empowered once I focused on what was within my control. The day after learning it was possible I tore my ACL, I began icing regularly. Almost immediately, the tenderness in my IT band (from compensating for my injury) went away. I got into the mindset that I would come out of this experience stronger than if it hadn’t happened. I made a plan for documenting the journey, exercising my core and upper body, and queued up movies to watch while hitting the spin bike 2x a day. I made a note to myself that I shouldn’t feel sorry for myself any longer and I should be mindful to avoid time sinks like getting into video games or doom scrolling.

The new routine was very much like a part-time job and often mentally taxing. Exercising twice a day for 45min-1hr already seemed like a lot, but it became much more demanding when I added in the icing, heating, nutrition, hydration, work schedule etc. Still, this is exactly what I wanted.

While cycling felt great, hiking did not. A three mile hike on a hilly urban trail felt miserable. My kneecap began to feel sore after mile two and I regretted not bringing trekking poles. It was also a lot less fun than being on the bike.

Here’s a photo of me, before it became miserable, with the OTC knee brace I bought.

GOOD THING #2: I relied heavily on the spin bike to reverse some muscle atrophy, and felt quite grateful for having both the equipment and also a strong background in cycling.

I also bought an NMES device to stimulate my muscles while I was idle, in addition to the massage gun I already had. Although pricey, I heard it’d be valuable during physical therapy and my parents loved the one I bought for them years ago. Since I was in the mindset of doing whatever it took to stack the odds in my favor, I bought a bulk supply of supplements: turmeric, tart cherry, glucosamine, multivitamin, fish oil, Vitamin D, and collagen peptides. I wasn’t sure whether these would make any difference, but I knew they wouldn’t hurt. I also started to wear a mask more often while out. I wanted to do everything I could to stack the deck in my favor. I even got a week-long gym membership in Todos Santos, Baja California Sur on vacation to use the crappy spin bike daily.

Finding the right surgeon

I read up on the surgeon that was recommended to me, Dr. Robin Fuchs. I watched videos of him performing the surgery, looked into his background with professional sports teams (Yankees, Knicks, Nets), and also looked into other surgeons that were within my network. I wanted a highly experienced surgeon that specialized in minimally invasive surgery, would provide me an autograft, was part of a big network, and had experience with athletes. Fortunately, living in Seattle provided me with plenty of options and I narrowed my choice down to Dr. Fuchs and Dr. Edward Khalfayan (the surgeon for the Seattle Seahawks).

I had a week-long trip to Baja, then a visit to family in NYC, and after a few days home in Seattle, a long trip to Nepal. This limited my ability to shop around for a surgeon but I knew I’d be in good hands with either of the two I was considering. I met with Dr. Fuchs and prepared a 7-page document of questions for him and even brought my laptop with me to take notes. I could tell he liked me and he said I was doing all the right things. He specialized in bone-patellar tendon-bone (bptb) autografts, which would provide the strongest graft. He also cleared me for Nepal and said he’d do it if he was me, but couldn’t professionally recommend that I go. He insisted that I wear a functional knee brace (Donjoy Fullforce) while hiking to prevent further injury and that I take it easy while I was out there.

GOOD THING #3: Living in Seattle and having access to experienced surgeons who work with athletes. A friend of mine living in Flagstaff unfortunately has had fewer options for choosing a surgeon and physical therapist.

Learning more

Once I knew I was looking at an ACL reconstruction, I threw myself into learning as much as I could and finding a community. Given how common the injury is, there was quite a lot. I skipped any Facebook groups that advocated for healing without surgery. While that’s possible, it’s extremely rare and it seemed like most of the people in those groups were delusional.

The best groups I found were on Facebook (ACL Recovery Club) and Reddit (r/ACL). Both exposed me to stories of people from around the world (although primarily in the US) who were in different stages of recovery. On the /ACL subreddit, sorting by top posts of all time gave me some inspiration for what a strong recovery could look like. Seeing the daily feed of questions helped me absorb how to think about the various setbacks I’d encounter. Reading the comments left on each person’s post helped me feel like I was part of a community.

I wanted to take this a step further and create a cohort of those having surgery in early May, which is when I was scheduled for. I ended up making a group chat where we each shared our stories, fears, and challenges while comforting each other. There were folks from different countries, some getting the BEAR implant surgery, and some having waited years to get a surgery date. Throughout the process, I became immensely grateful for being in a position where I had good private insurance and plenty of choices for surgeons. It seems the UK and Canadian healthcare systems have wait times of months or more. I was also exposed to stories of people who couldn’t afford the operation in the US, or weren’t able to take more than a day off of work for recovery from their physically taxing job.

I struggled to share the news of my torn ACL with friends online, mostly because I didn’t want to relive the day I got injured. I was glad I finally did though. Several folks shared their own ACL reconstruction journey, some having had the surgery two or three decades ago. I learned quite a lot from these friends, many of whom are the type A optimizers like I am. Finally, the best resource I came across for comprehensive information has definitely been the ACL Athlete Podcast hosted by Ravi Patel. Dr. Patel has a great energy and put together some excellent episodes that are pretty timeless, so be sure to dig through his archives. I binged through hours of his content.

GOOD THING #4: Finding a community that understood my journey within my friends and strangers online. I became immensely grateful for what I had.

Travelling

On April 2, I returned from Baja and NYC and noticed that my quad was weaker and before those trips. I hadn’t kept up as diligently with my prehab routine when I was away. Leah and I were questioning whether doing a 3 week hike at high altitude was a great idea. Fortunately, the Nepalese government made a sudden declaration that all foreign hikers will need to hire a guide. We were happy to pay higher tourism fees for visiting Nepal, but we found this rule to be pretty stupid and didn’t want to be guinea pigs. We cancelled our trip and scrambled to think of something else. Leah suggested we go on a bike touring trip and within a day we settled on Corsica.

I can confidently say that I didn’t know much about Corsica and have never done a self-supported bike tour, but I was excited about this new plan. I did a day of biking outdoors on mostly flat ground and a day of questionable mountain biking in Baja. Both times I felt pretty capable even while wearing a functional knee brace. I knew cycling was the best thing I could be doing for my prehab as well, and Corsica has plenty of steep hills to challenge my quads.

The biggest challenge ended up being the flight, which was a long 16hr session each way of standing up every hour and bringing attention to myself doing elaborate stretching exercises. Fortunately, stepping onto the flight with a knee brace signaled to other passengers that I was nursing an injury. I brought a refillable ice pack that I could strap to my knee while sitting, which I’d ask the flight attendants to refill every few hours. This made a massive difference and helped relieved the pressure I’d feel in the knee. My surgeon also recommended I take aspirin to prevent a blood clot.

Overall the trip was a huge success. I felt as strong as ever and had zero discomfort or soreness while biking. We completed 480 miles (42,000ft of climbing) of biking with touring gear strapped onto us. My quads were looking strong and nearly identical in size. I also now had memories to think back on while I’d be laying in bed.

GOOD THING #5: Doing prehab by biking for 5-8 hours a day in hilly terrain for three weeks. Although I have a strong (but recent) background in cycling, I forgot that it would be the best prehab I could do until I saw this reddit post.

Meeting with PT

I arrived back home two days before surgery, which only gave me one day to meet with my physical therapist and ensure he was a good fit. After some great advice from my friend Zander who also had ACL surgery years before, my criteria for a PT was that they be part of a modern facility that was easy to get to, focus on me only during the session, participate in the activities I do (mtb, ski, climbing, etc), push me hard during rehab, and be savvy with blood-flow restriction training. Nelson Thai was all of those and a great communicator. He also had his own ACL reconstructed so he was familiar with what I’d be going through. Although my surgeon didn’t want me in PT until at least a week later, Nelson gave me a set of at-home exercises. Since I already had an NMES device, much of what he would’ve done for me in that first week I’d be able to do on my own.

GOOD THING #6: Meeting with the PT beforehand, even for a day meant that all the check-in paperwork and meet-and-greets would be done. I also went home with a set of exercises to do during the first week, and felt confident that my PT was a good fit for me.

Quad size, just before surgery

My PT measured my quads the day after my bike trip and the day before surgery.

Left leg (uninjured): 51cm

Right leg (injured): 48cm

My flexion on the injured knee was at 135 degrees before I felt some stiff pain and I was able to easily get to 0 degrees of extension. This was the case prior to the bike trip.

Part 3 - The Surgery

In Part 3, I’ll share what it was like preparing my home for surgery, the costs of the procedure, scheduling PT, my pain levels, and time off of work. Link to be pasted here once I finish typing that up.

My ACL Journey - The Injury (Part 1)

This is Part 1 of a series outlining my recovery. There’s an impressive set of information online about how best to recover from an ACL tear, but I wanted to share my own story for a few reasons. There are a few critical resources online that made an outsized difference to me that I’d like to share. I also wanted to actualize the story I wanted to tell when I got to the other side. Finally, for me it was comforting to read the journeys of others going through the same process. I hope you find this helpful and do reach out with any questions you have.

Part 1 - The Injury [this page]

Part 2 - The Prehab

Part 3 - The Surgery

Part 4 - The Early Rehab (weeks 2-7)

Part 5 - The Middle of Rehab (months 2-6)

Part 6 - Late Rehab (months 7-10)


On Feb 24, my wife and I headed to Stevens Pass ahead of a powder weekend. I was feeling strong and grateful for the season so far, and convinced myself I was ready to ride the expert level chutes with more experienced friends. My wife wasn’t too excited on the idea but she knew she wouldn’t have been able to stop me. The next day the crew and I started the day out by bootpacking to the top of a ridgeline before dropping in. I was feeling sloppy, quietly wishing I had warmed up but not willing to say that out loud. I couldn’t bootpack my way down now though. I didn’t see the exact line taken by my buddies dropping in one at a time. I nervously peered over the edge and took a deep breath. Someone said “alright, whenever you’re ready…” and I decided to go in aggressively, tips down, with a plan to turn just where the mouth of the chute opened up to a wider gully on the right.

This wasn’t the right move, at least for me. In a short distance I picked up too much speed, catching what felt like a few small inches of air before landing in the backseat. I screamed, feeling a compression in my right knee. I was doubly surprised. How did I hurt myself this badly on what looked like such straightforward terrain? How am I in such pain to have screamed? Through the burning sensation in my knee, I instantly felt ashamed I had let Leah down. She didn’t want me to be here and made that clear. I stood up and felt weak, and decided to sit back down again. My friends, now split above and below me, all waited quietly. Waves of disappointment crashed over me. I was breathing hard. I was still in shock that I could’ve gotten hurt here.

MISTAKE #1: Not warming up for a ski run, not speaking up, not watching carefully for the right line to ski down

I got up and side slipped my way down. At least ski patrol wouldn’t be needed. I then skied a few turns, one side feeling a lot more responsive and stable than the other. I was cursing myself now because this snow was amazing. I could see why they had invited me up here. Everyone was relieved to see me moving my way down despite the pain. I decided to call it a day and skied all the way back down with a friend. I was entirely fine on the groomers. In hindsight, it was the adrenaline that made me strong and dumb. This is where I could have further injured myself.

MISTAKE #2: Skiing aggressively down groomers after a knee injury

Icing the knee

When I got to the cabin at the base, my knee had swollen up and we used an ace wrap for some stability, assuming it was a sprain. I rested on the couch with some ice to cool me down. I took some Aleve and Tylenol, and the thought in my head now was whether I’d be okay to go trekking in Nepal in 6 weeks. Leah and I had been planning this honeymoon for months and I didn’t want to be the reason we missed out.

Leah drove us home. I was quiet for most of the car ride. I was embarrassed, emotionally devastated, and regretful. I had let her down but she wasn’t calling me out on it at least. When we got home, I took the stairs one step at a time, leading with my good foot. I made the critical mistake that night of wearing my ace wrap to bed. My bedtime HR spiked from a normal average of 46 to 57 because I had essentially put a tourniquet on.

MISTAKE #3: Not elevating the knee, sleeping with an ace wrap

That Sunday I was icing whenever I remembered to and decided to cut off the NSAIDs and Tylenol. I did have a mostly normal gait with a bit of a limp, still walking the stairs in our townhouse one step at a time. There were moments when I’d be walking and feel a sudden “slip” of my upper leg over my knee. It was scary, and I didn’t have an excuse for what it could be.

I realized my mistake from the previous night and slept with just my leg elevated on a wedge pillow; no ace wrap. Like magic, the visible swelling and pain was gone the next morning. On Feb 27 during a virtual appointment with my primary care doctor, he suspected a sprain and maybe minor meniscal damage. His recommendation was to use an OTC knee brace and NSAIDs and to come in for a physical exam if it still hurt in two weeks. This would later turn out to be terrible advice because I didn’t have any pain in two weeks even though I had torn my ACL.

MISTAKE #4: My inexperienced doctor not realizing I showed signs of an ACL disruption, which should’ve prompted him to ask me to come in for a physical exam asap.

I began to treat the injury like a sprain, wearing my OTC knee brace around the house, elevating my knee at rest, icing periodically, and using my massage gun. I even had friends come over on Feb 28 and cooked a three course meal which had me on my feet for several hours. Both legs were fairly sore after that.

On Mar 1, five days after the injury, I decided to get on my spin bike with zero resistance. I felt great and was able to get a few brief minutes of movement. I still had random moments of instability when I’d be walking and happen to fully straighten my leg. I still wasn’t sure what to make of this.

I began to notice the quadriceps on my right side were significantly smaller than the left. The muscle felt more like soft cheese when I pinched it. This concerned me, but I still figured there was a possibility I’d be back in shape to skin up and ski down Mt St Helens later in the month with some exercise. My IT band was tender to the touch, and I’d later find out it was my body compensating for the instability post-injury.

MISTAKE #5: I stopped icing my leg as often, given that I didn’t think it was too serious of an injury. I’d later learn the IT band pain I felt would instantly go away as soon as I iced it.

I also noticed I couldn’t sleep on my side without pain in the MCL area. I went down a YouTube rabbit hole and tried every physical test I could to clue into what might be wrong. I wasn’t able to do a Lachman test on myself though. I was confused more than anything. My symptoms didn’t feel very serious, and my resting HR was back to a normal average of 46. On Mar 5, eight days after the injury, I went out for a walk for 2 miles around a museum. My knee felt aggravated even with the brace but it was progress. By March 8, eleven days after, I was able to walk up and down stairs entirely normally.

In the week since my injury, I’d had read a book on shopping for stem cell therapies and PRP, figuring this was the best shot I’d have at accelerating my recovery for Nepal. Again, I figured I had a strain and maybe some light ligament tearing. I still couldn’t explain the dramatic muscle loss though. I scheduled a consultation with an Ortho for March 9th, a full twelve days after injury. This meeting would end up being the turning point for me, and it would dawn on me that I had an ACL tear which would change everything about how I behaved.

I called out the mistakes I made in these two weeks. Here are some of the great things I did. The Amazon links below are affiliate links, which means I get some change if you purchase. Running this site is an expensive hobby.

  • Skiing down with a friend - I should’ve skied down slowly after the injury, but I didn’t. Still, the one thing I did right was allowing a friend to ski with me. I insisted on going back alone because I didn’t want to separate him from the group. He’s a good guy though and saw right through it. It helped a lot emotionally.

  • Accident insurance - Beyond having health insurance, my wife also convinced me to get Aetna’s supplemental accident insurance. I’m still not entirely sure how it works, but I get paid cash for any medical ‘treatment’ related to an injury or accident. There isn’t any paperwork to file, beyond telling them to look through my billing statements. I got $200 for the video call with my primary care doctor (and many hundreds more for the eventual MRI, Ortho visit, etc).

  • Elevated wedge pillow - We coincidentally ended up with this 12 inch wedge pillow just before my injury. It’s quite large and single-purpose, but it is heaps better than stacking random pillows.

  • Getting ROM - I kept testing for my range of motion every day out of curiousity. Within just a few days I was able to get on a spin bike.

  • Really good OTC brace - I bought a knee brace within hours of the injury, knowing it would come in handy. I ended up buying one of the more premium ones and I’m so glad I did. Don’t settle for less. You only have two knees.

In Part 2, I’ll share my prehab story: diagnosing the ACL tear, exercising with an injury, and traveling for several weeks internationally. Part 2 - The Prehab