Pain, the Brain and ACL Recovery


A few weeks ago I had a very interesting experience regarding my ACL rehabilitation. It’s very similar to an experience I had with Achilles tendon and heel pain. Here it is.

A perceived setback

I had ACL reconstruction on May 1, 2014. I have been very aggressive with my rehabilitation and I felt it was going very well. My PT and I agreed on a strategy and he approved of the process in general. I knew that sitting and resting was not the right way to go if I wanted to regain full function. For people like me, laziness wasn’t a problem; an overly aggressive approach might be though.

I knew that I could be in trouble if I did too much work too fast and stressed the knee too much. I worried that I’d drifted into this territory when at almost nine months I experienced more pain than I expected. I had a final appointment with my surgeon and she expressed some concern at my symptoms. We agreed that I should back off my activity and rest a bit. Seems perhaps I had reached the point of “too much of a good thing.”

I backed off lifting, running a cycling. I didn’t stop my activity completely but I cut it back significantly. After a couple of weeks I realized the knee wasn’t feeling much better. I continued to experience frequent pain; not debilitating but somewhat worrisome. I decided a visit to the PT was in order. I wanted to get some guidance and make sure I hadn’t damaged the graft.

The long and the short of the visit was this: The graft and my knee were fine. I needed more strength in the leg and around the knee. I needed to do more work, not less! Eureka! (My previous PT had moved on to another position and I had to meet with a new one. Unfortunately, the “bedside manner” of this PT left much to be desired. Right off the bat she was rude, dismissive and she interrupted my answers to her questions. I became very frustrated and it was work to keep my yapper shut and listen to what I needed to. Fortunately I got the information I needed.)

From here, I was ready to rock ‘n’ roll.

Goodbye fear. Hello confidence!

My experience was a very clear experience of what modern pain science has been finding recently. Here are some important points:

1) Pain doesn’t equal injury: In Reconceptualising Pain According to Modern Pain Science, neuroscience researcher Dr. Lorimer Moseley has made several points about pain. Two are pertinent here:

  • pain does not provide a measure of the state of the tissues
  • The relationship between pain and the state of the tissues becomes weaker as pain persists.

Yes I had an injured knee and yes I had surgery in which part of my patellar tendon was cut out in order to make a new ACL. This was all very disruptive to parts of the knee and was clearly part of the pain I was feeling. It takes about six weeks for the graft to heal. The reconstructed ACL is pretty much healed at six months which would’ve been October for me. In other words, my knee was/is healed and any pain wasn’t from tissue damage.

2) Fear is a significant obstacle that must be addressed: Fear is a powerful part of our pain. Overcoming that fear is major part of a successful rehab and return to activity. The pain in my knee caused me to worry that I’d re-injured it and it led me to avoid a lot of activity that I enjoyed. This condition is known as fear-avoidance. The International Association for the Study of Pain (IASP) describes fear-avoidance this way:

Psychological factors play a key role in the development of chronic musculoskeletal pain, in particular dysfunctional beliefs about pain and fear of pain. Fear of pain leads to avoidance of activities (physical, social, and professional) that patients associate with the occurrence or exacerbation of pain, even after they may have physically recovered. Whereas this response is adaptive in the acute phase—rest promotes recovery—it leads to disability and distress when avoidance behavior is continued after the injury has healed.

"Fear-avoidance model" by LittleT889 - Own work. Licensed under CC BY-SA 3.0 via Wikimedia Commons -

“Fear-avoidance model” by LittleT889 – Own work. Licensed under CC BY-SA 3.0 via Wikimedia Commons –

When I learned that my parts were solid and strong and that I wasn’t broken, I felt the fear drain away like water down a toilet. I was a happy dude!

Another of Moseley’s points is important here: that pain can be conceptualised as a conscious correlate of the implicit perception that tissue is in danger.

Big words. What does that statement mean? I’ll let Moseley explain (emphasis is mine):

First, there are other central nervous system outputs that occur when tissue is perceived to be under threat, and second, that it is the implicit perception of threat that determines the outputs, not the state of the tissues, nor the actual threat to the tissues.

In even simpler terms, we may feel pain absent any damage but we feel pain when our brain perceives a threat–even when there is no threat. I compare this to a car alarm that is set off by the wind. There’s no break-in occurring yet the alarm signal is going off due to the alarm sensing a threat.

3) Patient education is vital: Very interestingly, an effective strategy in treating chronic pain is patient education. This strategy of patient education is supported in several studies that are discussed in a review in the Archives of Physical Medicine and Rehabilitation, and it’s further discussed in an article titled Can Pain Neuroscience Education Improve Endogenous Pain Inhibition? Literally, knowledge of pain processes can reduce pain. (Pain is weird!) I believe that my experience supports this phenomena.

(To be clear, it’s not that I received education on how pain works. I received the message that my knee was solid, not injured and that it could be worked very hard.)

Keep this in mind.

Dr. Moseley discusses pain education in Pain really is in the mind, but not in the way that you think. I like what he says here:

“The idea that an inaccurate understanding of chronic pain increases chronic pain begs the question – what happens if we correct that inaccurate piece of knowledge?

We’ve been researching the answer to this for over a decade, and here’s some of what we’ve found:

(i) Pain and disability reduce, not by much and not very quickly but they do;

(ii) Activity-based treatments have better effects;

(iii) Flare-ups reduce in their frequency and magnitude;

(iv) Long-term outcomes of activity-based treatments are vast improvements.”

Most of us outside the medical community probably still equate pain to damage. Many inside the medical community still think that way too. (Blame Rene Descartes.) We now know better. Rather than address pain from a strictly biomechanical approach, therapists would be well advised to study and adopt what’s known as the biopsychosocial model for pain. This model is explained very well here and discussed in-depth here. We patients will be well armed in a fight against pain if we understand this model too.


Relatively Good ACL News & 4/3/14 Workout


ACL News

I saw a non-surgical orthopedist yesterday and he walked me through my MRI. It wasn’t the worst news in the world. There were no bad surprises. I do have a grade III sprain aka a fully torn ACL. I have a grade II sprain of my MCL. No surprises there. The good news is my minisci are intact and undamaged. That’s great news! There’s also no bone damage. I’m really happy about both of these things. Surgery will be required but this injury could’ve been quite a bit worse.

I told him about my activities (staying as active and mobile as possible so long as I’m not in pain) and he approved. He said most people who get this type of injury sit down, prop up their leg, and move as little as possible. The muscles whither and their movement suffers. They go into surgery in bad shape and they come out worse. Recovery takes much longer under these circumstances.

This is no good. I’ll meet both meet with a surgeon and start physical therapy in two weeks. Some people have expressed exasperation and frustration at the pace of this process. I’m not one of them. I’m not the only guy wandering around Denver with an injury and this isn’t life threatening. I’m grateful that I have insurance, I don’t have some awful, exotic injury or illness and I’ve got people around me who can help. Anyway, the doc said surgeons typically wait on the surgery for two reasons: 1) We want to reduce swelling as much as possible and 2) We want to restore as much range of motion as possible. This stuff takes time and there’s no way around it.

4/4/14 Workout

  • Good morning: 135 lbs x 6 reps – 145 lbs x 6 reps – 155 lbs. x 6 reps x 3 sets
  • Super set 1
    • pull-ups x 4 reps
    • push-ups x 4 reps
    • goblet squat x 4 reps: I worked up from 16 kg to 20 kg to 24 kg
    • I accumulated 74 reps on pull-ups/push-ups but I didn’t time it.
    • My squat depth is getting better and I’m very happy about that. My knee is tolerating the movement well.
  • Super set 2
    • windmill: 16 kg x 5 x 2 sets – 20 kg x 5 – 14 kg x 5; What’s the windmill? Watch the video.
    • stability ball leg curl: 13 reps x 4 sets

    All’s well. Might get in a bike ride today.

What Goes Into A Successful ACL Reconstruction? An Interview With Kurt Spindler, MD


“I really want to know what predicts ACL reconstruction failure or success so that we can improve our outcomes.” – Dr. Kurt Spindler, MD – Cleveland Clinc

In the course of scouring the Internet for any and all information on ACL injuries and rehabilitation, I came across a research summary titled Predictors of successful ACL reconstruction found. The research comes from the Multicenter Orthopaedics Outcomes Network (MOON), led by Cleveland Clinic’s Kurt Spindler, M.D.  Dr. Spindler is the Vice Chairman of Research in the Orthopaedic & Rheumatologic Institute, the Director of Orthopaedic Clinical Outcomes, and the Academic Director of Cleveland Clinic Sports Health. MOON consists of 17 surgeons from seven institutions. The researchers wanted to establish a “gold standard” for ACL reconstruction and rehabilitation. A related project is the Multi-center ACL Revision Study (MARS). I got to speak with Dr. Spindler recently. He gave me a lot of good information on several topics. After speaking with him I feel very well informed on what to know and what to ask as I start to navigate my way to a new ACL.

What are the big takeaways from the research?

  • Choose the correct type of graft. (An allograft comes from a cadaver. An autograft comes from you, either as part of the patellar tendon or hamstring.) There are advantages and disadvantages to both. Age and activity level are important factors. For teenagers and twenty-somethings, the autograft is best. I told him that I’m highly active and I intend to return full-bore to my activities. He said the autograft (either hamstring or patellar tendon) is right for me.
  • First-time ACL reconstructions perform much better than second reconstructions. Be patient. Do the rehab correctly and don’t rupture the repair!
  • Pick a skilled surgeon, one who does a lot of reconstructions and does them frequently.
  • Do the rehab! (I intend to make my rehab a religion.)

To what degree should I stay off my feet and avoid activity? Is it safe to do any type of activity? If so, what?

  • Pain should be my guide. If it hurts then stop.
  • I can exercise to whatever degree I’m able, so long as it’s gentle work and pain free.
  • I can use an exercise bike, paddle around in a pool, do squats (unweighted obviously) and any other sort of work that I can tolerate.
  • Avoid fast movements and twisting.

In speaking with surgeons, what questions should I ask?

  • How many repairs have you done?
  • How many repairs per year do you do?
  • On whom have you done them? Athletes? Kids? Sedentary people?
  • How involved are you in the rehab program? Will I just receive a handout of exercises to do or will you monitor my progress and adjust the program as necessary?

Is there an ideal rehab protocol?

Dr. Spindler said there wasn’t a strict protocol that’s best. Every injury and every individual will progress differently and rehab must be adjusted accordingly. He directed me to the evidence-based MOON rehab guidelines.

How soon should surgery follow an ACL tear? 

  • The knee should have good ROM.
  • Swelling should be down.
  • Good muscle function should be present.
  • The patient should be able to walk.
  • A long wait increases risk of further injury.

What should I know about miniscus damage? In the case of a damaged miniscus, how much can be salvaged?

  • Tissue with good blood flow can be salvaged.
  • Overly damaged tissue without blood flow should be excised.

What should I know about ACL repair using a bioenhananced scaffold technique?

At this time, there doesn’t appear to be any advantage to using this experimental technique.

He told me I had several favorable factors on my side:

  • I’m athletic.
  • I don’t smoke.
  • I have a good BMI.

One variable that I can’t control is the amount of damage to the knee. My MRI said I have a partial tear and some damage to the MCL. I’ll learn more on Thursday when I meet with an orthopedist. Thank you to Dr. Spindler and the Cleveland Clinic for the interview. This has been a huge help to me and I hope it helps someone else with a bad knee.

ACL News & the 3/31/14 Workout


ACL information & Dr. Howard Luks’s excellent blog:

Got a call from Kaiser and apparently the MRI indicates I don’t have a fully torn ACL. There’s evidence of a big sprain (which is a type of tear) and some damage to the MCL. I don’t know about any damage to the minisci.

On the surface, this sounds good. I’m not certain though that a partial tear is much better than a full tear. Of course I got online and started looking up partial tears and such. I found the site of Dr. Howard J. Luks, MD of New York. His blog is incredibly informative and I got a lot of useful information on all things ACL-related. There’s this post on partial ACL tears which discusses the difference between an ACL reconstruction and an ACL augmentation:

“The difference between an ACL reconstruction and an ACL augmentation is fairly simple. During the process of an ACL reconstruction we will reconstruct or replace the entire ruptured ligament. Anatomically, the ACL is composed of two separate bundles and a complete reconstruction will compensate for both of those bundles. In an ACL augmentation, you have only sustained a partial tear. That means that a portion of your ACL remains intact and might be normal. Many high volume ACL sports medicine orthopedic surgeons are capable of reconstructing only the torn portion of the partial ACL tear. This leaves the normal portion of the ACL alone. There are many advantages to an ACL partial tear augmentation over a full ACL reconstruction. While the discomfort, and the nature of the surgery is virtually identical – – – it is far more likely that someone who undergoes an augmentation will have a much more natural feeling knee when all is said and done. The reason for that is because the normal ACL has certain nerves within it. Those nerves give the brain certain feedback as to the position of the knee joint. It turns out that those nerve fibers are quite important. If we preserve the intact portion of your ACL, then we are preserving those nerve fibers and hopefully preserving the integrity of your knee in the long run.”

Perhaps an augmentation is in my future? I’ll have to ask about that on Thursday when I meet with an orthopedist.

Another post, 4 Tips to Prepare You for ACL Surgery, included (you may have guessed) these four tips:

  1. The technique for performing an ACL reconstruction has evolved significantly.  Over the last few years nearly all high volume ACL surgeons have gone to an “anatomic” approach.  That means that during ACL surgery we put the new ligament in exactly the same position your native ligament was.  Believe it or not, that’s not how we were originally trained how to do it.  The older technique was easier… which is likely the reason why some surgeons still use it.  Take Home Message:   An “anatomic” reconstruction has become the gold standard.  It is a more technically challenging procedure, so be sure to review with your surgeon what technique they plan on using.
  2. Volume matters !  An ACL surgery is a technically challenging procedure. ACL surgery should be performed by those of us who are experienced ACL surgeons.  Take Home Message:  Be sure to find a surgeon that performs a fair number of ACL reconstructions each month… not a few each year. 

    ACL Surgery

    The Dark Side of the Moon?

  3. When we reconstruct the ACL we need to create a new ligament. We can choose to use your hamstring tendons, a piece from your patella, or a donor graft from cadaver tissue. Different grafts are better suited for different situations.  Women tend to be “quadriceps dominant” so a patella graft might better suit their needs.  A patella tendon graft might be better suited for high level contact athletes.  A hamstring graft is a strong graft well suited for most all activities.  The research shows that a cadaver graft in a young active person should probably be avoided due to a high failure rate. Take Home Message:  One graft does not suit all needs for people considering ACL surgery. Be sure to do your research and talk to your surgeon about your goals so the proper graft can be chosen.
  4. If you have suffered an ACL tear, you are at very high risk for re-tearing the ACL in the same knee — or tearing the ACL in the other knee.  Many people have a predisposition due to a “neuromuscular” impairment.  (I hate big words too) That basically means the way you jump, land, pivot, etc needs to be evaluated to correct your biomechanics to diminish your risk of  requiring another ACL surgery.  Take Home Message: Physical therapy is an absolutely critical part of the overall recovery process.  Finishing up with a formal neuromuscular evaluation may play a role in diminishing your risk of a second ACL tear.

The first point about the anatomical graft was news to me. I’ve read a lot on ACL repairs and that bit was new to me. I’ll definitely have to ask about it when I see the doc. On to other things…

3/31/14 Workout:

  • Deadlift:
    • 155 lbs. x 5 – 205 lbs x 5 – 225 lbs. x 5 – 245 lbs. x 5 – 265 lbs. x 5 x 2 sets
    • Used the sumo stance
    • Knee never buckled.
    • Felt good!
  • Super set 1: 4 sets
    • step-up on plyo box: no weight x 10 reps
    • pull-ups: 20 kg kettlebell x 5 reps
  • Super set 2: 4 sets
  • Ab wheel: 5 reps x 3 sets

Everything felt decent. Went up in weight on the deadlift and felt fine. I tried the sumo stance a while back and the knee wanted to cave in. Today it didn’t. Good.

Major Detour On All Fronts


The good news is I have a radically brand new challenge in front of me. This new wrinkle is going to help me learn new discipline and it will push me to learn all sorts of new things. I’ll be able to relate to a large population of people in a way that I’ve never been able to relate before.


The bad news is I don’t want anything at all to do with this new “wonderful” opportunity. See, on Saturday I tore my right ACL while skiing.   (At the very least I’ve torn the ACL. That’s according to the ER evaluation.) New skis, steep terrain, poor visibility all combined to pinwheel my down the slope and jackhammer my knee into some degree of twisted gristle. (I’ll also admit with some degree of dumb pride that I resumed skiing and made it to the bottom on my own. Probably not a great idea but I’m looking for all the silver to the lining of this cloud.) I’ve been feeling fantastic lately. I’ve been strong in the gym and I’ve been running a lot. Whatever the opposite of that is, this is it.

So all my high falutin’ lofty running goals are going to take a back seat to 1) surgery and 2) a very gradual return to normal human movement. Running, biking, hiking, lifting weights and all that fun stuff is way out there on the horizon. That said, I have every intention to resume all my favorite activities. No way in hell do I intend to give up the active outdoor lifestyle that I love so much.

We shall get to know each other very well.

We shall get to know each other very well.

In less than 24 hrs I’ve learned some useful things about ACL reconstruction. First, there are two basic types of ACL reconstructions. The autograft uses my own tissue either from the patellar tendon or hamstring tendon. The allograft uses a cadaver tendon. There are advantages and disadvantages to all these different strategies. I’ll probably discuss them further in the future.

I hope to get an MRI and further evaluation as soon as possible. I’ll call the doc tomorrow to see when I can get in. I want to get on this thing aggressively and soon. I may learn that there’s more damage than simply a torn ACL. There are other tendons and minisci that could also be damaged.

The full recovery progression on this condition seems to be about a full year, and that’s full-on aggressive multi-dimensional movement. More good news here is that ACL reconstruction has been around for a long while. Lots of high-end powerful athletes go through this process and come back to perform at very high levels. From my understanding, the results can be excellent.