April 28, 2023
Inside the Stephanie Talbot journey back to basketball: Part 2
Nearly two months down, many more to go
(Note: This is Part 2 of a series about the Stephanie Talbot recovery from ACL Reconstruction (ACLR). Catch up, if you missed it, on Part 1 here.)
Youth sports participation
When Stephanie Talbot was a kid in Australia, she participated in Little Athletics, where she learned movement basics like running, jumping and throwing a ball. The activities started young, as did incorporating physical activity into her lifestyle. The American equivalents to Little Athletics might be YMCA or Parks and Recreation Departments, which provide families with local opportunities to participate in exercise and sport.
At eight years old, Talbot started playing basketball and netball. Where she grew up “in the country,” similar to an American town, girls played netball while boys played footy (Australian Rules Football). Talbot said, “We played basketball in the summer and netball in the winter, because you can’t dribble in the puddles.” Netball is similar to basketball in that athletes shoot a ball into a ring, but there isn’t dribbling, and each players’ position indicates which specific zones on the court they’re restricted to play in.
The Women’s Australian Rules Footy League (AFLW) launched in 2017. Talbot previously had interest in playing footy, but it would have interfered with her basketball career. She’s unsure if we’ll ever see her transition sports. Former WNBA champion and Olympian basketballer Erin Phillips, also in the ACLR Club, set the precedent of swapping sports. She currently plays footy in Adelaide.
Now, at age 28, Talbot has played basketball for 20 years, but since surgery on March 1, she hasn’t touched a ball. She’s in no rush to get back to the court. Instead, she’s rehabbing. If she was eager to get back onto the hardwood, she’d be permitted to participate in dribbling, passing and set shots, like free throws. Her options are limited, not yet allowed to run or jump. Staying away from sport early on doesn’t impact rehab, so for some, the time away is welcomed. For others, being away from their sport negatively impacts their mental health. They feel a sense of lost identity. To be on the court brings them joy and that’s where they want to be.
As Talbot works her way down her rehab path, she’s sharing parts of her experience. This post will look at the rehab priorities from about two weeks until two months after ACLR: common early rehabilitation exercises, arthrogenic muscle inhibition and restoring normal gait.
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Early rehabilitation exercises
The early rehab following knee surgery can be dreadfully boring. Exercises that physical therapists prescribe seem simple compared to the things the athlete was doing only a few weeks earlier. These exercises, though mundane, are essential.
Talbot started off her rehab with maneuvers that any athlete — at any level — would also be performing following knee surgery. Middle schoolers post-ACLR get the same ones as the professionals. Soccer players match up with basketballers. She started with ankle pumps, moving her foot up and down, shortly after surgery. This exercise is blood clot prophylaxis. Blood clots are normally prevented by your calf muscles contracting with every step while walking. If the athlete is resting in their initial painful post-op period, that normal muscle pumping isn’t occurring.
Now that Talbot is walking on a daily basis, standing heel raises replace ankle pumps. She stands and elevates onto her toes and comes back down as many times as possible until her calf muscles get tired. Eventually, the exercise is progressed — standing on a step so the calf muscles go through a greater range of motion — or by working one leg at a time. The purpose of each exercise evolves as the stage of rehab progresses. Calf muscle work is important for the mobility of the knee because the gastrocnemius muscle crosses the knee joint and can impact how straight your knee can go. Calf muscles are also important for leg strength while running, later in the process.
Talbot also works on tightening her quadriceps muscles to get them back to their regular level of function. This goes in conjunction with working on the calf muscles while trying to get her knee as straight as possible. For many athletes, especially females, the knee joint can move straighter than straight (hyperextension). It’s important to have both knees matching in hyperextension as early as possible after surgery. Many people have difficulty keeping their knee hyperextended while lifting their leg following knee surgery. This exercise is called a straight leg raise. If the knee can’t stay straight, the athlete has a quadriceps lag, where the muscles are “lagging” in their ability to keep the knee from bending. Talbot can now lift her leg with only a slight bend, which is important for getting her normal walking pattern back and usually indicates that swelling has improved.
After two weeks of these early exercises, Talbot shared that her pain and swelling had improved enough to start ramping up her training. She will continue working on some early rehab exercises, but she can add in more body weight work and even start weight lifting. She shared that she did some squats and hip bridges — where she lies on her back with her knees bent and lifts her hips towards the ceiling — and also started doing deadlifts. “I did RDLs [Romanian Deadlifts] on the first day with a broomstick and it felt kinda stupid with no weight,” Talbot said. “Squats with body weight feel okay, but the RDL with no weight doesn’t. So then the next workout I did them with a 10kg bar and it felt way better.”
Arthrogenic muscle inhibition (AMI)
Arthrogenic means “from the joint.” Inhibition, though not as simple as flipping a light switch, indicates that part of the muscle isn’t working properly due to altered nervous system processes. In many patients who have knee swelling, either from injury or from surgery, the joint swelling inhibits the quadriceps muscles from normal function. Some athletes describe it as if their muscle isn’t turning on. They look at their leg and try to get the muscle to contract, easily done on the opposite side, but they’re unable to achieve the desired motion.
Talbot noticed quickly after surgery that she couldn’t use her muscles to get her knee as straight as it would go when her physio straightened it. She was aware of her quad lag, which is common and will likely resolve soon. Patients with arthrogenic muscle inhibition (AMI) of their quadriceps often have a surgical thigh that looks smaller than the non-surgical leg. The leg is also usually weaker because only part of the muscle is doing the job typically performed by the whole muscle.
“This week’s goal is purely working on trying to get my extension. Like, we initially did a little bit but thought it might come back by itself and it hasn’t, so the physio and rehab this week will do a bit more to get that,” Talbot said. Her knee can hyperextend all the way to where it’s supposed to be when the physio moves it, but her muscles need to be able to achieve that motion, too.
Recent research has examined the underlying mechanisms for why AMI occurs — but even more important is to understand how it’s treated. Grant Norte and his research team wrote, “We now understand that AMI not only impedes recovery of muscle function, but also, in a much broader sense, acts as a limiting factor in rehabilitation if left untreated.” Norte’s research includes descriptions of numerous approaches to target AMI, including focal joint cooling. Talbot has been regularly using a Game Ready Device to circulate ice around her knee in an effort to target her AMI. As she moves through her rehab, she’ll likely incorporate additional treatment options for AMI.
One of the problems associated with AMI is that it impacts normal walking. Nearly all patients following ACLR exhibit swelling and AMI, which impacts quadriceps muscle function. The ACL is stressed by walking. Crutches and a brace are needed to protect the newly reconstructed graft when the quadriceps or hamstrings muscles aren’t working properly.
The surgeon’s preferences and protocol and graft type selection help dictate the need for a brace and crutches. Talbot was advised to use her crutches for just a short time because she didn’t have additional injured structures and her quad function was quickly restored. She’s been cleared to return to driving. If her injury had been to her left leg, she likely could have driven just a few days after surgery once her pain was well controlled.
Now that she’s off crutches, Talbot can focus on taking her new puppy, Ziggy, on longer walks. Having a new puppy around has given her a job to work on: training Ziggy to use a lead (Australian English for leash). Initially, it was challenging for Talbot to walk both of her dogs because she couldn’t walk very far and Ziggy isn’t trained. She noted that her walking speed feels like it’s back to normal, but that she can’t walk for as long as she would before because her knee swells a bit when she does that.
The hardest part, so far, Talbot says, is boredom on the weekends when she’s not training quite as much as she does during the week. Normally she’d be playing basketball and traveling or off on adventures, generally active and outside. Right now, she’s watching “The Last of US” and reading “Lessons in Chemistry.” And maybe next month she’ll want to touch a basketball. Or maybe not. There’s a long way to go still on this road. But, fortunately, it’s not quite so long as it’s been since Little Athletics.
Written by Abby Gordon
Abby Gordon is a Board-Certified Sports Physical Therapist at Seattle Children's Hospital. She was the Team Physical Therapist for the Seattle Storm from 2015 to 2022 and the Travel Coordinator and Equipment Manager for the Connecticut Sun from 2007 to 2010. After four seasons working as a team manager for the UConn Huskies Women's Basketball team, she graduated from the University of Connecticut in 2007 with a Bachelor's in Exercise Science and in 2014 with a Doctorate in Physical Therapy. She writes about WNBA Injuries and Sports Medicine Issues in Women's Basketball for The Next.