Think Beyond the Initial Injury: How to be a Helpful Practitioner
I’ve had two anterior cruciate ligament reconstructions (ACLR) in my life.
As a practitioner, the surgeries have taught me different things and, given one occurred as a teenager whereas the other as an adult, helped me better view the impact of surgeries during different stages of life.
This article walks through why we need to think of surgeries beyond the initial injury and what we can learn from others within the medical team to optimize recovery and a return to training and activities of daily living.
Before we begin, know that the ACL runs through the middle of the knee and "prevents the shin bone from sliding out in front of the thigh bone" (Mount Sinai, 2024).
Surgery No. 1: An Outside Hitter in Volleyball Chasing an Errant Set
My first ACLR occurred when I was 16 years old playing volleyball. After the surgery, I didn’t think much about healing beyond the progress I was making with my physio (physical therapist) and how my body weight and composition were changing. The latter was a tough pill to swallow as a teenager and one that my care team neither warned me nor spoke much about.
During the recovery process, I don’t recall intentionally fueling with anything that would optimize my recovery (granted, my teenager job at the time was working at a fast food joint). I didn’t think about how calories were necessary for healing and reducing surgery-related infections. Rather, I thought about how they may have been leading to my weight gain. I didn’t think about the role of protein in retaining as much muscle as possible during my inactivity. I remember watching Oprah, popping pain killers, crutching around high school, attending physio, and eating what my family prepared for me. I’m pretty sure my favorite foods at the time were apples and Lay’s Salt & Vinegar chips.
Surgery No. 2: Skiing Down a Mogul-filled Slope I Shouldn’t Have Been On (the fall was tame)
The second incident was 15 years later. This time around, I was working as a sports dietitian with more knowledge compared to my teenage self. During that experience, I had the ability to learn from my surgeon about what the surgery was going to entail, which was eye opening and a turning point in how I approached not only my own recovery, but how I could better relate to and help the athletes I work with.
What the surgeon described to me were the steps he was about to take in the operating room. It was graphic. He described the multiple wound sites I would have, including the cuts into and around my knee to allow entry points for the surgeon’s tools; the cutting of and cleaning out the torn ligament (I assumed it stayed in there?); the graft being resected from another area of my body (i.e., an entirely new wound site; a harmless bystander!); the drilling, stapling, and screwing into the femoral and tibial bones; and the stitches on the skin’s surface that I could see. And with any surgery, all of these wounds and the presence of hospital tools and surgeons in and around them were all opportunities for infections.
And all I used to think I had was a ligament issue.
Surgery No. 1: What is Considered within a Nutrition Plan?
With all my past injuries and time spent with physios, when they’re evaluating an injury I’ve noticed they evaluate well beyond the area I’m telling them is a concern. Sixteen-year old Ally heard “ACL tear” and had tunnel vision on the ligament as being the sole issue.
Had I taken that nearsighted approach to injury management as a dietitian, I would have thought about (1) ligament health, so maybe collagen, glycine, vitamin C, zinc, and copper; (2) body composition management post-surgery, working to focus on muscle tissue rehabilitation; and (3) hydration to manage constipation common with laying on the couch, consuming pain medications, and avoiding drinking because you can't be bothered to head to the bathroom (standing hurts post-ACLR).
Although not wrong, it’s an incomplete view of all that is happening during the post-surgical phase. You have to think like a physio (or athletic trainer) and think bigger.
Surgery No. 2: What Else Must be Considered in a Nutrition Plan?
By learning more about the surgery, my awareness expanded to:
Bone health: Calcium, vitamin D, and another reason to be mindful of collagen and protein intake.
Skin and muscle health and integrity: Consider all the layers that are cut through, whether you can see them post-surgery or not.
The inflammation and swelling caused by surgery: Tie in fruits, vegetables, and other whole plant sources, not simply for fiber and weight management, but for their antioxidants.
Strengthening the immune system: With all that inflammation, risk of infection, and likelihood of underfueling—whether it’s intentionally trying to avoid weight gain or being in pain, sitting on the couch, and not wanting to crutch over to the kitchen—underfueling will suppress the immune system and its ability to support recovery.
And then there’s the non-surgical factors that need to be considered:
Crutches need both hands to function: I used to eat snacks walking in between meetings at work. Using crutches made this impossible. I was constantly hungry throughout the day and had to adjust the size and caloric density of breakfast and lunch.
Laying on the couch at home with my ankle elevated to alleviate the swelling. I was hungry, but in too much discomfort to grab a snack from the kitchen. I created a snack cart next to the couch filled with fresh fruit, shelf-stable protein shakes, and protein bars.
Standing to prep and cook food was uncomfortable. I purchased healthier versions of frozen meals to speed up the cooking process and time spent standing in the kitchen.
I could go on, but the more people you can talk to who have lived experiences with an injury, the better you can help others in the same situation.
Key Messages: Injuries and Surgeries are an Opportunity to Learn from Non-Dietitians
The second ACLR I had used the patellar tendon as the graft from the same knee (a.k.a., an autograft). I asked my surgeon what the patellar tendon was. It’s a ligament that runs over the middle of the kneecap, with the graft being the tendon’s middle. It’s like taking the cream out of an Oreo cookie. I didn't realize that could be done and wouldn't have thought its own name would be deceptive.
So, ask questions. Lots of them. To be a thorough and effective practitioner, you have to be willing to learn and ask questions throughout the medical team.
Then there’s the athlete: What are they worried about that you can assist as the dietitian? Will they have family around to support them with their nutrition or will they be alone in a dorm room? Are they willing to cook or will they be relying on Uber Eats?
Don't assume coworkers or athletes will think less of you for asking. The ultimate goal is to help the athlete.
