Latest / The ACL Athlete Podcast / 298 | Why “Keep Working On It” Might Not Be Enough in ACL Rehab

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298 | Why “Keep Working On It” Might Not Be Enough in ACL Rehab · The ACL Athlete Podcast

• 0:18
  SPEAKER_00: Welcome everyone to the ACL Athlete Podcast.
• 0:22
  SPEAKER_00: This is the podcast where we talk about everything related to the ACL, whether that's the injury itself, the rehab process, return to sport, and more.
• 0:31
  SPEAKER_00: I'm your host, Dr.
• 0:32
  SPEAKER_00: Ravi Patel, performance physical therapist and coach.
• 0:36
  SPEAKER_00: Between myself and fellow guests and experts, you'll learn through the lens of the patient, the healthcare professional, and the coach.
• 0:43
  SPEAKER_00: The goal of this podcast is to equip you, the athlete, with the education to make the best informed decision about your care and your ACL journey.
• 0:54
  SPEAKER_00: Thanks for joining.
• 0:55
  SPEAKER_00: Now let's dive into today's episode.
• 1:01
  SPEAKER_00: What is up, team, and welcome back to another episode on the ACL Athlete Podcast.
• 1:07
  SPEAKER_00: First, I just want to say I hope that you guys are doing well.
• 1:11
  SPEAKER_00: I want to also say thank you for the ongoing support, the messages, the comments.
• 1:17
  SPEAKER_00: I continue to read those every single week, and I'm so thankful for those and y'all's support.
• 1:24
  SPEAKER_00: And it's the thing that keeps me going.
• 1:27
  SPEAKER_00: And it's the thing that really brings me a lot of joy whenever someone's like, I listened to this episode and I took action on this.
• 1:36
  SPEAKER_00: And it might not just be one episode, it might be multiple ones, and it's something that is the goal of this podcast is for you to feel equipped to be able to move forward, be an advocate for yourself, and be able to get back to the things that you want to do.
• 1:53
  SPEAKER_00: So I just want to say thank you.
• 1:55
  SPEAKER_00: And in a world where things can feel heavy, I just hope that this can allow it to feel a little bit lighter and also for you to not necessarily feel like you are at a loss.
• 2:08
  SPEAKER_00: So I want to dive into this today because I feel like I have been having a lot of conversations with ACLers regarding cases where they think that they've just kind of exhausted things and they've taken things on their own, or they feel like physical therapy has been exhausted itself and they have not fully evaluated it from the perspective of like, is this truly something that they just need to keep consistently working on and get there?
• 2:40
  SPEAKER_00: Or is this something that there's an actual roadblock or problem, whether it is what they're doing, or whether it is maybe biologically that is within the joint itself or the surgery, right?
• 2:51
  SPEAKER_00: And the thing that you'll often hear in this process, especially when you raise a concern or a question, I feel like most of the time, especially if you're in the first three months, let's say even the first six months, it's like keep working on it.
• 3:08
  SPEAKER_00: And you've heard that, right?
• 3:10
  SPEAKER_00: So maybe it's from your surgeon at a follow-up, maybe it's from your PT when you asked why your knee still won't straighten all the way, why you're walking with a limp, why it might swell every time you are standing for a while.
• 3:25
  SPEAKER_00: Keep working on it, it'll come with time.
• 3:27
  SPEAKER_00: This is something, the same thing with quad strength or flexion, like the the especially the foundational pieces.
• 3:35
  SPEAKER_00: It's something that it's it can be hard sometimes to audit, and sometimes it does take some more time, right?
• 3:41
  SPEAKER_00: So we don't necessarily want to fault that phrase in and of itself.
• 3:45
  SPEAKER_00: But today I'm not talking about necessarily the first time that you hear that, right?
• 3:50
  SPEAKER_00: The first time usually it makes sense.
• 3:52
  SPEAKER_00: I'm talking about, you know, the third, fourth, fifth time.
• 3:56
  SPEAKER_00: You might even hear it the tenth time.
• 3:58
  SPEAKER_00: And we're talking about weeks and months out, especially with your physical therapist.
• 4:02
  SPEAKER_00: The 10th time might not be, you know, that far out.
• 4:05
  SPEAKER_00: You might hear that maybe within the first three months, right?
• 4:09
  SPEAKER_00: So that's something because of that frequency of contact and what you're seeing them, that that might not be too far-fetched, right?
• 4:17
  SPEAKER_00: But it's something that as you're moving along, when you're looking at these things, that you start to continue to ask, like, when will this come along?
• 4:26
  SPEAKER_00: And keep working on it, or it'll get better with time.
• 4:30
  SPEAKER_00: I just feel like is not a very good response.
• 4:33
  SPEAKER_00: And I think there needs to be more clarity around this, especially when you have been working on it, really working on it, and nothing is changing.
• 4:41
  SPEAKER_00: And that sentence still tends to be the answer, it still tends to be keep working on it, or it'll get better with time.
• 4:49
  SPEAKER_00: So let's get into it because today is all about that keep working on it, because I want to talk through this a bit more because what it actually means when it's legit and when is the moment that you need to stop and actually get this thing looked at and stop kind of just writing this of it'll get better with time, or keep working on it.
• 5:12
  SPEAKER_00: So, some quick context, so we're not repeating ourselves here, is if you've been listening for a while, I did an episode on the whole graduating PT thing, and another on the illusion that your knee will get better with time.
• 5:23
  SPEAKER_00: And I know I've already referenced that in this episode.
• 5:25
  SPEAKER_00: So go listen to those if you haven't.
• 5:28
  SPEAKER_00: Those two were about the end of care and the belief that time fixes everything.
• 5:34
  SPEAKER_00: This one is really more so referencing the middle part.
• 5:38
  SPEAKER_00: You're in the process, you've raised your hand like you're in class, and you say, you know, something's off, something doesn't feel right, and you get handed a dismissive type of response.
• 5:51
  SPEAKER_00: And this is very common a dismissive or let's just say kick the can down the road type of response.
• 6:00
  SPEAKER_00: And I find this to be easier of a response to give to somebody because it's just easier.
• 6:10
  SPEAKER_00: It's just one of those that, especially if you're busy in a high-volume clinic where you don't have the time to be able to take the attention, to be able to assess, to be able to individualize things, or in a surgeon's office where you only get five or 10 minutes and you've got tons of patients back to back to back that you're seeing and working with, you don't necessarily have the time to zoom out and take the full detail of what's going on, right?
• 6:37
  SPEAKER_00: And I'm not saying this is across the board, but this is a very common trend that we see is that it's easy to just get kind of snippets of this, especially from the surgeon's experience, or it's easy to just have the high volume pressure to be like, okay, well, just keep working on it, especially if we are early in this process.
• 6:57
  SPEAKER_00: And again, not trying to fault this phrase, but I think it's important when you are starting to raise more and more concerns because it's not getting better if you keep working on it, and it's not improving, and you're knowing in your gut is feeling a little different with you that you are wanting to get a little bit more out of that response versus just saying, keep working on it, do exercises, and it'll get better with time.
• 7:23
  SPEAKER_00: And this is someone speaking from experience from a number of different injuries and surgeries that I've had, but especially through my ACL process, I had hiccups in the process, and I would just kind of get this response of it'll get better with time.
• 7:39
  SPEAKER_00: And it's something that I think there needs to be more depth to it.
• 7:44
  SPEAKER_00: And especially for my analytical ACLers, the ones who need a little bit more with that, I think there needs to be a little bit more intention behind, hey, you know, let's assess this, let's back this up with some legit testing and some evidence, what the research shows, put this all together with some data, and then be able to say, like, these are our action steps.
• 8:07
  SPEAKER_00: And if this does not improve within X, Y, and Z, and any good physical therapist should have an idea of like, okay, this is how much this should improve in the next two to four weeks, the next six to eight weeks, right?
• 8:20
  SPEAKER_00: We have certain references for different qualities or things we're trying to develop in this process, symptoms, range of motion, strength, power, reactivity, dynamic things.
• 8:31
  SPEAKER_00: Like, we have this ability to understand the physiological process and how that develops, that we should have a good idea of what that should look like.
• 8:40
  SPEAKER_00: And then there should be some checkpoints to know, like, okay, once we hit this, we need to look at this further, especially as we look at the trend of data points.
• 8:49
  SPEAKER_00: And let me be just fair here, too, because I don't want this to sound like everyone is just brushing you off, right?
• 8:55
  SPEAKER_00: Your surgeon sees you at these set time points, they're not with you week to week.
• 9:00
  SPEAKER_00: So we have to understand that context.
• 9:02
  SPEAKER_00: And so I'm not trying to necessarily bash that, but I also am trying to say, like, understand that context.
• 9:08
  SPEAKER_00: PTs are working inside of a system that is just volume-driven, that is really hard to look at the nuances of this.
• 9:15
  SPEAKER_00: And a lot of the time, keep working on it.
• 9:18
  SPEAKER_00: You know, it can't be the right call.
• 9:19
  SPEAKER_00: Like, you just need to kind of continue to put in reps and trust the process, especially early on.
• 9:25
  SPEAKER_00: And this is where I think it's really important is early on, when you're dealing with this, like it is fair to have a little bit more of that repetition of, yeah, let's keep working on the frequency and the dosage, get the swelling in check, the range of motion, responding to that consistency.
• 9:40
  SPEAKER_00: But keep working on it only counts as a plan when there are three things that are attached to it: a number, what are we measuring, and where are you today?
• 9:50
  SPEAKER_00: A plan, what exactly am I doing?
• 9:53
  SPEAKER_00: How often and how hard?
• 9:55
  SPEAKER_00: A date.
• 9:56
  SPEAKER_00: When do we retest?
• 9:58
  SPEAKER_00: When are we assessing this again?
• 10:01
  SPEAKER_00: For us, it's looking every single week, but every four to six weeks, we are taking some set of assessments.
• 10:08
  SPEAKER_00: Whether it is built into your programming with the results that you provide, whether it's direct testing, there are different ways that we are assessing this, but we are looking at this very often.
• 10:19
  SPEAKER_00: And every single week tells us a story.
• 10:21
  SPEAKER_00: Every session, every data point, and we are trending this across time to see from these different buckets and criteria we're looking at and what you report, how is this progressing or a lack thereof?
• 10:33
  SPEAKER_00: So if you've got a number, you've got a plan in place, you've got a date also associated, and the number moves, that's awesome.
• 10:41
  SPEAKER_00: Keep it going.
• 10:42
  SPEAKER_00: It sounds like something where, yeah, keep working on it.
• 10:45
  SPEAKER_00: This is applicable.
• 10:46
  SPEAKER_00: If you got none of these, that's not really a plan.
• 10:50
  SPEAKER_00: And it is kind of like a kicking the can down the road and it's a shrug.
• 10:53
  SPEAKER_00: Especially if you're just having exercises thrown at you, I think it needs to be audited and I think there needs to be detail around this.
• 11:01
  SPEAKER_00: So, this is for my ACLers who are just having challenges when they are just continuing to be told, here are exercises, here's the protocol, and they're not necessarily having this looked further into, especially after you can kind of tell things are not improving the way that you would expect.
• 11:20
  SPEAKER_00: And you again, not some sort of far-fetched like expectation or high expectation.
• 11:25
  SPEAKER_00: It's what you would assume that you have learned of this process, and even your providers have communicated, and it doesn't necessarily align, and there's still a problem that you are dealing with.
• 11:38
  SPEAKER_00: Could be extension range of motion, it could be flexion range of motion, it could be pain and swelling in the joint, it could be limping, it can be your quad strength development, going downstairs, all these kind of basic things that a lot of people post op are kind of dealing with, but then it's also things later in the process of like, okay, well, why don't I feel like I have enough power in this leg?
• 12:01
  SPEAKER_00: Why do I feel like I cannot get my knee over my toe?
• 12:04
  SPEAKER_00: Why can I not jump on a single leg?
• 12:06
  SPEAKER_00: There are always different parts of this process that we are looking at, but especially these early ones, especially if you're dealing with the range of motion deficits or symptoms, that is something that as you get further out from this process, you need to start looking at deeper.
• 12:24
  SPEAKER_00: It's typically not just going to get better with time.
• 12:27
  SPEAKER_00: Keep working on it.
• 12:28
  SPEAKER_00: If it hasn't worked for the first probably three months, maybe six months, it's not likely going to improve unless there is some more intervention from a testing standpoint and from an actual game plan of what you're doing standpoint.
• 12:41
  SPEAKER_00: But again, you need numbers around this, you need a plan, and you need a date that is going to be very, very important.
• 12:47
  SPEAKER_00: And if that sounds familiar, it's the same thing I said in the time episode: time plus testing plus a plan plus guidance.
• 12:56
  SPEAKER_00: Time by itself is not the recipe.
• 12:58
  SPEAKER_00: Keep working on it without no number, no plan, no date.
• 13:02
  SPEAKER_00: And it's just, you know, someone who's just saying, like, all right, yeah, let's keep progressing along, and you know, we'll keep working on it.
• 13:10
  SPEAKER_00: But here's the part that matters: say you've done all that, you've been working on extension for months, or swelling that just won't settle.
• 13:18
  SPEAKER_00: Maybe it's this pain that is persisting along in this process.
• 13:22
  SPEAKER_00: You're showing up, you're putting in the work that you are told to do.
• 13:26
  SPEAKER_00: You might find yourself also on Reddit or Facebook groups, researching someone who has similar experiences or sharing yours, looking for exercises to try and move the needle forward, and you still just kind of keep hearing, keep working on it.
• 13:44
  SPEAKER_00: That's the thing that you continue to keep hearing.
• 15:51
  SPEAKER_00: That is the moment it needs to be audited.
• 15:54
  SPEAKER_00: And the audit comes down to one question: Is this a dose or kind of program planning problem, or is it more of a biological problem, a surgical problem?
• 16:04
  SPEAKER_00: Right.
• 16:05
  SPEAKER_00: We're gonna kind of bucket those together.
• 16:07
  SPEAKER_00: A dose problem or exercise problem plan is on the rehab side, wrong frequency, wrong intensity, load being mismanaged, or not enough, exercises that don't necessarily match the stimulus of what we're trying to get after.
• 16:24
  SPEAKER_00: We've seen people who are like, I'm doing range of motion work eight hours a day, and they're doing none of the right stuff, none of the stuff that is going to necessarily move the needle, but they're like, I'm doing all this stuff that I saw on YouTube or my PT or combination of things, and then it's the kind of whole DIY conglomeration of things.
• 16:45
  SPEAKER_00: And we're like, wait, we need to back off.
• 16:48
  SPEAKER_00: We need to cut this down to 25%, and we need to tackle the dosage and frequency a little differently.
• 16:55
  SPEAKER_00: And people are so surprised by one subtracting things and then also being able to change the structuring of it and also the way that we are using feedback loops and the way to work on it, and they're able to move things along, right?
• 17:11
  SPEAKER_00: And this is coming back to like the dose or exercise planning problem, the rehab side of things.
• 17:17
  SPEAKER_00: That's more the controllable pieces as well as the load management of the stress you're putting on your knee.
• 17:22
  SPEAKER_00: Then there's the biological problem or the side where we can't control as much.
• 17:27
  SPEAKER_00: Yes, you can control the movement side, the nutrition, the stress, the sleep, the recovery, the amount of stress you're putting on your knee.
• 17:36
  SPEAKER_00: But at the end of the day, the body is going to have its own healing process on a number of factors from history, age, genetics, the surgical process, the hardware used, the graft used, material used.
• 17:49
  SPEAKER_00: All these things are going to play into this.
• 17:52
  SPEAKER_00: And so there is a biological component of this I've talked about before.
• 17:56
  SPEAKER_00: And this is what's going on in the joint itself: how the body is healing, how the surgery side of things went, scar tissue, something mechanically getting in the way.
• 18:06
  SPEAKER_00: And no amount of effort necessarily fixes these issues in most cases.
• 18:12
  SPEAKER_00: And sometimes it just irritates it more whenever you're trying to exercise your way out of it.
• 18:18
  SPEAKER_00: And this one is one that needs a little bit more further detective work and really a second set of eyes, something that could mean another surgical consult, or just at least more imaging and then getting more detail around this.
• 18:33
  SPEAKER_00: But here is the thing with this: you can't tell which one it is by just saying, yo, let's keep working on it.
• 18:40
  SPEAKER_00: You only find that out by looking, by truly playing detective here, by testing, measuring, having objective data around this, asking better questions around the ACLers' experience of like, okay, what are you feeling when you do this?
• 18:55
  SPEAKER_00: Walk me through your day, walk me through your week.
• 18:58
  SPEAKER_00: Whenever it is flared up, what are you feeling?
• 19:01
  SPEAKER_00: What are you doing to make it feel better?
• 19:03
  SPEAKER_00: What are things that, you know, make it feel worse?
• 19:06
  SPEAKER_00: And then we are tracking this along the weeks and days.
• 19:09
  SPEAKER_00: So if it's range of motion and extension is a problem, we are tracking this.
• 19:13
  SPEAKER_00: We're assessing weekly on your heel pop and what is that looking like?
• 19:18
  SPEAKER_00: What does that feel like?
• 19:19
  SPEAKER_00: How does your exercises feel with what you're doing?
• 19:22
  SPEAKER_00: And working harder on the wrong thing can be very frustrating.
• 19:25
  SPEAKER_00: So that's why we have to assess this first and know what is going on versus saying, here's a new exercise.
• 19:31
  SPEAKER_00: Let's hope this helps.
• 19:33
  SPEAKER_00: And I said this before on the time episode as well, but range of motion deficits like extension are just the perfect example.
• 19:42
  SPEAKER_00: They do not work themselves out.
• 19:44
  SPEAKER_00: I've seen people carry them for months and years thinking it would just kind of get back on its own.
• 19:49
  SPEAKER_00: We've seen people who are years out who still have a slight limp, slight bent knee.
• 19:53
  SPEAKER_00: So if your extension has been stuck and the answer has been just, okay, hopefully we'll get better with time, keep working on it.
• 20:02
  SPEAKER_00: That's an audit trigger right there.
• 20:04
  SPEAKER_00: Especially if you're beyond the three to six month window.
• 20:07
  SPEAKER_00: Or let's say you got it and then it regressed back, and now your extension is not comparable to the other side.
• 20:14
  SPEAKER_00: You don't have a heel pop, you feel like you look in the mirror and your knee looks a little bent, you can kind of tell that.
• 20:20
  SPEAKER_00: Then that is something that needs an audit, a further look at this, looking at the passive extension, the active extension, doing some tests to see what's going on, and then also tracking your history and being able to see what you've been doing.
• 20:34
  SPEAKER_00: And so the thing that we see a lot in talking with some of these ACLers, especially as they're further out, and it's the part that I find can be a little dangerous in this process is around, let's say that six to 12 month mark, especially as you get closer to 12, something shifts for people.
• 20:55
  SPEAKER_00: People stop asking, you know, is this right?
• 20:58
  SPEAKER_00: Unless it's like grossly wrong.
• 21:00
  SPEAKER_00: Like if they have a knee extension deficit of 15 degrees, you're likely going to get that addressed.
• 21:07
  SPEAKER_00: And I would hope you would get that addressed.
• 21:08
  SPEAKER_00: But it's in this gray area where you're like, my knee isn't matching the other side, but I can't necessarily get a heel pop.
• 21:16
  SPEAKER_00: I can kind of feel my quad.
• 21:17
  SPEAKER_00: I'm able to do some exercises, but I still feel some discomfort in my knee.
• 21:22
  SPEAKER_00: I still feel like there's just some sort of block or restriction.
• 21:26
  SPEAKER_00: The same thing can be said about flexion, or maybe someone is living with not this huge blown-up knee, but you just have this slight puffiness that continues to persist.
• 21:37
  SPEAKER_00: Or maybe it's just this sharpness with these certain movements whenever you get into extension.
• 21:42
  SPEAKER_00: Or maybe it is your quad is just not wanting to respond to any type of loading, right?
• 21:49
  SPEAKER_00: Maybe it's a donor site that is just not wanting to give.
• 21:52
  SPEAKER_00: And it's been this way since surgery.
• 21:55
  SPEAKER_00: You feel it in that quad tendon harvest area, you feel it in the patellar tendon, maybe you feel it in the inside of your knee.
• 22:01
  SPEAKER_00: And it's just something that has not really given, right?
• 22:05
  SPEAKER_00: But it's not enough to where you're just like, it is completely created a brick wall in my process.
• 22:11
  SPEAKER_00: Like you're still able to do most of the, you know, rehabby type things.
• 22:16
  SPEAKER_00: You might not be able to do it to the full extent you want to, but you modify around it, and you've been someone who has just been kind of carrying this for a while.
• 22:25
  SPEAKER_00: And again, it's not so grossly obvious where you're stuck in flexion or your knee is blown up or your extension is, you know, plus 15.
• 22:33
  SPEAKER_00: It might be something that is just, you know, in that it's 70% of the way there.
• 22:39
  SPEAKER_00: It's 80% of the way there, but you know it's not fully there and how it should be.
• 22:44
  SPEAKER_00: People as time passes stop asking, you know, is this right?
• 22:49
  SPEAKER_00: And start asking, is this just me?
• 22:52
  SPEAKER_00: And I'm gonna pause there for a second, and I want you to think about this.
• 22:56
  SPEAKER_00: Is this right or is it just me?
• 22:58
  SPEAKER_00: And this is something I see this shift as time progresses.
• 23:01
  SPEAKER_00: They start telling themselves, this is my new normal knee, maybe this is what everyone is experiencing, and I get it.
• 23:08
  SPEAKER_00: When you've heard keep working on it for months, your brain does the math on this, maybe this is as good as it gets, right?
• 23:14
  SPEAKER_00: And everyone maybe hears, oh well, you've had an injury and a reconstruction, so why would you expect it to feel the same as the other side?
• 23:23
  SPEAKER_00: And I always say, you should never expect it to feel the same.
• 23:28
  SPEAKER_00: You can expect it to feel different, but it doesn't mean lesser than that is very important, y'all.
• 23:38
  SPEAKER_00: With good rehab, a good surgical process, and getting this dialed in, it can feel different because yes, it has been reconstructed and it has a major injury to it, but with that said, it should not feel functionally less.
• 23:51
  SPEAKER_00: And that is the goal.
• 23:52
  SPEAKER_00: The standard should still be the same from a performance standpoint to get that knee back to where it was prior to the injury and still being comparable to the other side.
• 24:03
  SPEAKER_00: That is so.
• 24:04
  SPEAKER_00: Massive here.
• 24:04
  SPEAKER_00: So don't lower the bar just because you feel like you've had some sort of injury or surgical process and allow it to be like good enough.
• 24:13
  SPEAKER_00: And like I said last time, what was the quote?
• 24:15
  SPEAKER_00: Good enough only works in horseshoes and hand grenades.
• 24:18
  SPEAKER_00: I'm going to start saying that more.
• 24:19
  SPEAKER_00: It's just one of those things that good enough doesn't work in ACL rehab.
• 24:23
  SPEAKER_00: And it's the reason why we have such high reinjury rates because people allow good enough to be the bar that they allow, and our rehab and our healthcare process is the problem and not testing.
• 24:34
  SPEAKER_00: But with that said, that is the bar that is set.
• 24:37
  SPEAKER_00: And so people are like, oh, well, I guess this is just kind of it.
• 24:41
  SPEAKER_00: And then they go out and then some other issues happen or it happens again.
• 24:45
  SPEAKER_00: And this is not what I want to normalize.
• 24:49
  SPEAKER_00: It's not as good as it gets.
• 24:51
  SPEAKER_00: And then the clinic or the PT, it might hit its limit.
• 24:56
  SPEAKER_00: The insurance visits are gone.
• 24:58
  SPEAKER_00: Or it's a smaller clinic without the space or the equipment to really load you or do anything dynamic.
• 25:04
  SPEAKER_00: Or the PT has given what their skill set allows.
• 25:07
  SPEAKER_00: Again, I'm going to repeat, we barely spent any time on ACL in my PT school.
• 25:15
  SPEAKER_00: Barely.
• 25:16
  SPEAKER_00: We covered the whole knee in a module.
• 25:18
  SPEAKER_00: And the thing is, is that we have to cover every single diagnosis you can think of.
• 25:23
  SPEAKER_00: And we didn't really cover the rehab or progressions or return to sport or testing.
• 25:28
  SPEAKER_00: A dynamometer was never mentioned ever in our rehab class.
• 25:34
  SPEAKER_00: Never.
• 25:35
  SPEAKER_00: And so this is something that is really important.
• 25:37
  SPEAKER_00: It's not tested on our board exam and our licensure.
• 25:42
  SPEAKER_00: This is not a requirement.
• 25:44
  SPEAKER_00: And so this is something that I think is important to understand.
• 25:47
  SPEAKER_00: It's like asking medical doctors nutrition advice.
• 25:51
  SPEAKER_00: At the end of the day, they barely spend any time on nutrition, yet they're still passing out nutrition advice.
• 25:58
  SPEAKER_00: And I get if it's anything to be able to provide some information about these things.
• 26:03
  SPEAKER_00: But again, it's just not the scope of practice that is their skill set.
• 26:09
  SPEAKER_00: And so for us in physical therapy, we don't get a ton of exposure to this.
• 26:13
  SPEAKER_00: So when you are assessing most PTs, they do not have as much exposure to the depth of ACL expertise that you would hope.
• 26:22
  SPEAKER_00: And so I think that this is really important in terms of the skill set from a physical therapy standpoint, because most of us, as we come out of school, are trained to be generalists.
• 26:33
  SPEAKER_00: We are able to work with a lot of different things, but we are not good at one single thing unless you specifically go down this path to get specialized and take the extra educated time and training to be able to do that.
• 26:49
  SPEAKER_00: Otherwise, we are able to keep you alive and be able to rehab most of the basic things.
• 26:56
  SPEAKER_00: And then, yeah, as time goes on, we may get more exposure to some of this stuff, but it is on us to get more ACL-specific experience and especially expertise.
• 27:06
  SPEAKER_00: That is where it brings me to the skill set.
• 27:09
  SPEAKER_00: Because I think sometimes people equate physical therapy across the board as like, oh, as a physical therapist, they know how to get me there.
• 27:16
  SPEAKER_00: They have a doctorate, they have a license.
• 27:19
  SPEAKER_00: And how many professions do we know that exist in this world where they are not created all the same?
• 27:26
  SPEAKER_00: Every single one.
• 27:28
  SPEAKER_00: Teacher, a professor, a doctor, engineer.
• 27:33
  SPEAKER_00: Any one of these professions, you can name it across the board.
• 27:37
  SPEAKER_00: It's not all created the same.
• 27:39
  SPEAKER_00: Now there is a certain basic level of expectation.
• 27:42
  SPEAKER_00: Yes, you can help me rehab something, right?
• 27:45
  SPEAKER_00: You can help me build something, right?
• 27:47
  SPEAKER_00: A contractor.
• 27:48
  SPEAKER_00: You can help me design something or be able to do what engineers do.
• 27:52
  SPEAKER_00: A teacher, you are able to teach someone to be able to communicate, right?
• 27:56
  SPEAKER_00: There is a basic level of understanding, but at the same time, they're not all created the same.
• 28:01
  SPEAKER_00: And I think that this is so important.
• 28:02
  SPEAKER_00: I know I'm going on a tangent here, but I think this is so important for you to hear because I think people think that it is all created the same, or they're nice, they mean well, and that they are, you know, seem smart.
• 28:15
  SPEAKER_00: And I'm like, yeah, we're not idiots going to PT school.
• 28:18
  SPEAKER_00: Like, don't get me wrong.
• 28:20
  SPEAKER_00: But like the thing is, is like we can sound smart, especially to someone who knows nothing about this or is educated in orthopedics or musculoskeletal care.
• 28:30
  SPEAKER_00: Like, this is something that is easy to portray a kind of white coat-like syndrome, if you will, where we can come in as the person who is very knowledgeable to someone who is not knowledgeable in this process.
• 28:43
  SPEAKER_00: And ACLs are a specific injury, and not every PT sees a lot of them.
• 28:50
  SPEAKER_00: So this is where it's so important, as I had shared, to make sure that there's the volume that is easily able to be assessed, but then also the testimonials and reviews to show that.
• 29:03
  SPEAKER_00: And any of the friends that I know who are in this space, who are in the ACL space, who work with the volume and have the high outputs, you can look them all up and they all have the reviews to show it.
• 29:15
  SPEAKER_00: And so that is gonna be the most important thing for you to be able to assess, just like any other big investment or purchase.
• 29:23
  SPEAKER_00: You're gonna do your research on the reviews, what people say, and make sure, you know, if you're gonna test drive this car, you're gonna see what other people have said about this car.
• 29:31
  SPEAKER_00: What's the speed?
• 29:32
  SPEAKER_00: How does it maneuver?
• 29:34
  SPEAKER_00: How is the safety of it?
• 29:36
  SPEAKER_00: All these things, and you're gonna see this across a number of reviews, not just what Bertha said on their test run of the car, right?
• 29:44
  SPEAKER_00: So, this is something that you take that totality that is gonna be so important for this.
• 29:49
  SPEAKER_00: I'm gonna really try to pivot here because I really went down on this fiery hole here of this fiery tangent of what ACL and physical therapy and the specialty of this.
• 30:03
  SPEAKER_00: So I'm gonna try and keep rolling here.
• 30:05
  SPEAKER_00: But the message becomes is we've done what we can.
• 30:09
  SPEAKER_00: Now it's on you, right?
• 30:11
  SPEAKER_00: The skill set has exhausted, or insurance, the clinic has exhausted what it can do.
• 30:17
  SPEAKER_00: It's on you.
• 30:18
  SPEAKER_00: Now time for you to take the reins and go.
• 30:20
  SPEAKER_00: Or you get told you've graduated.
• 30:22
  SPEAKER_00: And we've already talked about that word and what it does to people.
• 30:25
  SPEAKER_00: It makes you feel done when you're probably only a third of the way through.
• 30:30
  SPEAKER_00: And I want to be careful here because this is again not about blaming PTs or surgeons.
• 30:36
  SPEAKER_00: Most of them are trying hard inside a system that was not built to take you all the way back to full return to sport, return to activity, to get you back to this high criteria of what you need.
• 30:47
  SPEAKER_00: But I do need, but I do need you to hear this distinction.
• 30:50
  SPEAKER_00: The clinic hitting its ceiling is not a ceiling for your knee.
• 30:55
  SPEAKER_00: That is just a constraint of the system.
• 30:59
  SPEAKER_00: Those get blurred all the time with this process.
• 31:03
  SPEAKER_00: Your PT visits run out, the tools or answers.
• 31:07
  SPEAKER_00: That tells you nothing about what your knee can still do.
• 31:12
  SPEAKER_00: It's just telling you about the constraints of the system or that specific PT clinic or what they have access to.
• 31:20
  SPEAKER_00: And this is why I don't want you going at this alone.
• 31:23
  SPEAKER_00: You can't necessarily outrun a week quad if you've been left on your own at month four or five, or maybe it's month nine, and you just start testing it, running, jumping, hoping you're guessing, right?
• 31:38
  SPEAKER_00: And guessing is how people have a lot of trouble in this process.
• 31:43
  SPEAKER_00: We need to make sure we are measuring and assessing properly because that is going to dictate the path.
• 31:48
  SPEAKER_00: So, what do you do out of all this?
• 31:51
  SPEAKER_00: Three things.
• 31:52
  SPEAKER_00: One, get your numbers, range of motion compared to the other side, quad and hamstring strength, measured by what the research shows, not guessing, isokinetic dynamometry, using isometric dynamometry, or using a five repetition maximum at minimum of an isolated test.
• 32:09
  SPEAKER_00: And then being able to assess how you can run, jump, cut objectively, looking at it qualitatively, subjectively.
• 32:18
  SPEAKER_00: If nobody has ever given you a number, that is step one.
• 32:21
  SPEAKER_00: This is where we have to make sure we audit and have it measured.
• 32:25
  SPEAKER_00: And then we get to step two, get a second set of eyes.
• 32:29
  SPEAKER_00: Ask directly what is this based on?
• 32:31
  SPEAKER_00: What's the plan if it hasn't changed in four to six weeks?
• 32:34
  SPEAKER_00: If you don't get a clear answer, get an outside opinion.
• 32:37
  SPEAKER_00: Y'all, second opinions, third opinions, fourth opinions, get an opinion.
• 32:41
  SPEAKER_00: Sometimes that's a different rehab provider.
• 32:44
  SPEAKER_00: Sometimes it's another surgical consult, especially when something isn't responding the way it should.
• 32:49
  SPEAKER_00: It's not being disloyal.
• 32:51
  SPEAKER_00: People feel like they're cheating on their spouse for some reason or they're betraying their best friend.
• 32:57
  SPEAKER_00: And at the end of the day, you will one day finish your physical therapy and you will never see your physical therapist again, no matter how lovely of a relationship you had.
• 33:07
  SPEAKER_00: And it will be something that they will maybe remember you if you had a significant impact or they did on you.
• 33:13
  SPEAKER_00: But at the same time, it is not something that you feel like you need to keep in good relation because you're gonna see them at the family reunion in a year, right?
• 33:25
  SPEAKER_00: Like, guys, like this is your health, this is your knee, like take control of it.
• 33:29
  SPEAKER_00: We who cares if you hurt feelings, if it's a good medical professional, then they should have the respect to understand that.
• 33:37
  SPEAKER_00: If someone came to me and said that, I'm not gonna sit here and be upset about it.
• 33:41
  SPEAKER_00: I'm gonna say, I respect that, and I think additional eyes are helpful, especially with challenging cases when people are not progressing as they should.
• 33:50
  SPEAKER_00: So it's not being disloyal, it is due diligence on your own knee.
• 33:55
  SPEAKER_00: So seek that out if you can, and you should be able to, no matter what system you're in, where you are.
• 34:01
  SPEAKER_00: Number three, I'm gonna be direct.
• 34:04
  SPEAKER_00: Do not do it yourself.
• 34:07
  SPEAKER_00: I know the instinct is there.
• 34:09
  SPEAKER_00: You're tired of it, you maybe have lost the trust of what it is that you're working with, or you've maybe seen a few surgeons and a few PTs, and you're just like, I just don't know who to trust.
• 34:23
  SPEAKER_00: Maybe this is just it, and you are someone who is just like, I'm just gonna try and figure this out.
• 34:29
  SPEAKER_00: I don't blame you, but I would say don't do it yourself.
• 34:35
  SPEAKER_00: I know what that instinct is, you're tired, you've already spent the time and money, finances.
• 34:41
  SPEAKER_00: I know weigh a lot in this too.
• 34:42
  SPEAKER_00: And you think, I'll just figure it out, or you know what, I'll just kind of stop doing those things that risk it and I'll work around it.
• 34:49
  SPEAKER_00: But the mid and late stages are the hardest part to navigate alone.
• 34:54
  SPEAKER_00: And doing more of what already did and work is not a new plan.
• 34:58
  SPEAKER_00: Not just doing some of the things online, some of the things that your PT gave you, and hoping that it gets better.
• 35:04
  SPEAKER_00: So, who do you look for in this?
• 35:07
  SPEAKER_00: Someone who works with ACLs all the time, not once in a while, not you know, a few ACLs a week, someone who tests objectively and actually shows you your numbers, someone with a real proof, the reviews, the testimonials, people who look like you, and someone who's comfortable with complex, messy cases, or maybe you're someone who's had a more linear case and you're just like, I don't necessarily need the complex cases, but you do need it if you are someone who has not been improving and you need someone to be able to really look at the nuances of this and play detective.
• 35:44
  SPEAKER_00: I just got off a call with someone who has been at this for well over a year.
• 35:49
  SPEAKER_00: She thinks that this process has been relatively, you know, just something that she's questioning herself of like maybe she's overthinking it.
• 35:59
  SPEAKER_00: And as soon as we talked, I just knew that there were certain things that were just not looked at.
• 36:06
  SPEAKER_00: And there's certain things that I was like, if we could just assess and put some pieces in play, let's see if this improves a little bit.
• 36:14
  SPEAKER_00: But I have a pretty strong gut feeling of this is something that we can look at and get you in the right place and get you on the track to recovery.
• 36:23
  SPEAKER_00: The thing that is hard here is that this should have been looked at way before.
• 36:29
  SPEAKER_00: Way before.
• 36:31
  SPEAKER_00: Like 12 months before.
• 36:34
  SPEAKER_00: But the thing is, is that it's hard because sometimes people are like, Well, I'm with my provider, I've seen my surgeon, they're like, keep working on it, you know, you make some changes, but it doesn't improve, or it only improves a little bit, but not to where you would expect or should.
• 36:49
  SPEAKER_00: And that's the thing that is really, really hard with this is you know, being able to look at someone who is comfortable with these cases, whether you are, yeah, three months out, six months out, 12 months, years plus out, people who have already seen a bunch of providers.
• 37:06
  SPEAKER_00: We have athletes on our rosters, as I shared, who went through double-digit healthcare professionals at this point before they got someone who just took the time to listen to them, to create a plan, to assess, and to be able to support them with each step of it.
• 37:21
  SPEAKER_00: And it's a reminder of how common this is.
• 37:25
  SPEAKER_00: Now, is more always possible?
• 37:27
  SPEAKER_00: No.
• 37:27
  SPEAKER_00: And I get this, and I want to just make sure I'm transparent and seeing the side of things: finances, insurance, time, access, these are all real things.
• 37:39
  SPEAKER_00: Seasons of life you're in.
• 37:41
  SPEAKER_00: Like some of our clients, like they sometimes have had previous seasons where you know they're having a kid, right?
• 37:49
  SPEAKER_00: A newborn.
• 37:50
  SPEAKER_00: They are the one birthing the newborn, or they're the one who is supporting, right?
• 37:54
  SPEAKER_00: Like there are certain seasons where they have a family member that's ill.
• 37:58
  SPEAKER_00: You know, there are certain life circumstances that come into play as well that is just not feasible.
• 38:02
  SPEAKER_00: And I get that.
• 38:03
  SPEAKER_00: But in my experience, and I want to be clear, this is my clinical experience and not a stat from a paper.
• 38:09
  SPEAKER_00: The large majority of people who tell me they've hit their ceiling really haven't.
• 38:14
  SPEAKER_00: They've hit the end of what was available to them and what they knew.
• 38:18
  SPEAKER_00: That's a very different thing.
• 38:20
  SPEAKER_00: And just like I said before, this is not something that is your fault.
• 38:24
  SPEAKER_00: If you did the work and nobody gave you a plan around this or assessing this regularly, you did not fail.
• 38:32
  SPEAKER_00: It's the system that has done that.
• 38:36
  SPEAKER_00: But what you do next is on you.
• 38:38
  SPEAKER_00: After you listen to this episode, if you made it through this lengthy episode, and I'm sorry, y'all, but this is something that I just have a lot of things to say about.
• 38:46
  SPEAKER_00: But if you made it through this, what you do next is on you.
• 38:51
  SPEAKER_00: That is your accountability.
• 38:53
  SPEAKER_00: The ball is in your court, and that's the good news.
• 38:56
  SPEAKER_00: Because it means you can do something about it.
• 38:59
  SPEAKER_00: And this might also mean you're still actively with the same surgeon, maybe a different one, or a PT, right?
• 39:05
  SPEAKER_00: It doesn't mean that you have to be done with those things.
• 39:08
  SPEAKER_00: I think it's really important for you to be able to know that you can change at any time, but especially if this resonated to you, then you can do something about it now.
• 39:18
  SPEAKER_00: And not saying you have exhausted everything.
• 39:21
  SPEAKER_00: There's never a point where I have hopped on thousands of calls at this point.
• 39:26
  SPEAKER_00: There has never been a call where I was like, they have done everything possible and they are at a loss.
• 39:31
  SPEAKER_00: And I shared that episode with you guys the other week where I had a call, a vulnerable call, that I just had to take a breath after that call because it just hit me in my core.
• 39:43
  SPEAKER_00: And it makes me emotional to think about it.
• 39:45
  SPEAKER_00: But I was just like, this person was like, tell me if this is it, like this is all I can get.
• 39:50
  SPEAKER_00: And it's crazy.
• 39:51
  SPEAKER_00: I was like, you just haven't been listened to.
• 39:54
  SPEAKER_00: Like, people haven't listened to you.
• 39:55
  SPEAKER_00: And they in the first set of exercises we gave this guy, he he started like it started shifting.
• 40:02
  SPEAKER_00: He was like, I've never seen this laid out this way.
• 40:05
  SPEAKER_00: And it wasn't like it was rocket science, it was just people had never listened to this guy and given him the time of day, the proper planning and assessing and hearing him out of like what are the things that have been challenges for him.
• 40:16
  SPEAKER_00: And that's the thing that's so important with a good provider is that they can hear this and they can really build this out to you.
• 40:23
  SPEAKER_00: And this is what healthcare and the standard of ACL rehab should be.
• 40:27
  SPEAKER_00: And so that is what this is.
• 40:30
  SPEAKER_00: And so I'm not saying that this is your fault, but it is something that now what you do next is so important.
• 40:38
  SPEAKER_00: And it is such good news that you're able to advocate for yourself.
• 40:43
  SPEAKER_00: I understand resources can be slim, and insurance might be gone.
• 40:47
  SPEAKER_00: And you know what?
• 40:47
  SPEAKER_00: Money might be tight.
• 40:49
  SPEAKER_00: As I shared with you guys, I was a college student, tons of debt from student loans, and then I had a$10,000 out-of-pocket max.
• 40:55
  SPEAKER_00: And I had to have the surgery.
• 40:57
  SPEAKER_00: I was like, I can't live my life with my knee kind of shifting, and it was the only option I had.
• 41:02
  SPEAKER_00: So I did it and I made it happen.
• 41:05
  SPEAKER_00: My brother helped me with a credit card payment, and then I started paying monthly payments as a student to make sure it didn't go collections.
• 41:11
  SPEAKER_00: So when people are like, I can't afford it, I can't do this, like I just sometimes question that a little bit because I'm like, most people, if you know your family member was in a very tough spot, you would make it happen.
• 41:24
  SPEAKER_00: And I think the most important thing is that sometimes people think that they know better and they're able to get themselves there.
• 41:33
  SPEAKER_00: And I would say in some cases, it's rare, but they can.
• 41:36
  SPEAKER_00: But in these complex situations, you need the guide.
• 41:40
  SPEAKER_00: You need the person.
• 41:41
  SPEAKER_00: And I'm not here to pitch you on like that should be us.
• 41:44
  SPEAKER_00: We're here to help if you want help and you're looking for it.
• 41:47
  SPEAKER_00: But the thing is is to find that person because this is going to be the fork in the road.
• 41:54
  SPEAKER_00: And this is going to be the thing where you're like, I could spend the next 10 years complaining about I never did anything to my fullest to get there, or you decided to draw a line in the sand and you're like, I'm gonna do something about this.
• 42:07
  SPEAKER_00: I'm gonna, even though it is inconvenient from a financial time, stress, all these standpoints that pushes against the resistance and the friction.
• 42:16
  SPEAKER_00: You're like, I'm drawing a line in the sand, and I'm like, I'm gonna do something about this.
• 42:20
  SPEAKER_00: I might have to drive an hour to go see this person, two hours.
• 42:23
  SPEAKER_00: I've had people drive three to five hours just to see or fly in, y'all.
• 42:27
  SPEAKER_00: The thing is, is like people will make it work if it's important to you.
• 42:31
  SPEAKER_00: And if you are have the ability to just kind of have flexibility around that and not be so stuck on this is how it's supposed to be.
• 42:38
  SPEAKER_00: Healthcare was never designed to be perfect to begin with.
• 42:41
  SPEAKER_00: So, whatever system you are in, whatever the structure it is, you have to plan for when it finishes.
• 42:50
  SPEAKER_00: Because there is no system that is ultimately complete, because we should adopt that system if it's the case.
• 42:56
  SPEAKER_00: But we have worked with people all over the world, and there's not a single system that exists yet that I've seen start to finish ACL rehab is 10 out of 10, especially for the coverage that you get and the skill set.
• 43:11
  SPEAKER_00: So this is me getting fired up because I take so many calls where people are like, I don't know, man, like I think I can kind of figure this out or let me think about it, or whatever it is.
• 43:23
  SPEAKER_00: And you know, they come up with all the excuses, and I think sometimes they're just they're nervous, you know?
• 43:29
  SPEAKER_00: And I think more importantly than anything, what you take from this is less about like, hey, we need you to make some decisions about working with us.
• 43:38
  SPEAKER_00: It's more so about I want you to just make a change for the positive for yourself.
• 43:43
  SPEAKER_00: I think that's what's really important in this is don't settle, not at 70% of yourself, 80% of yourself, definitely not at anything less than these.
• 43:53
  SPEAKER_00: This knee is tied to your sport, your activity, your job, your health.
• 43:58
  SPEAKER_00: Um, as I shared, it's a crossroad, and there's a lot of people I have seen on the other side of this who never got the attention they needed, and they are the ones who have chronic pain, they are the ones who gained weight, they are the people who have metabolic disease, they are the people who have more depression, more anxiety, and it's because of this one domino that hit, and it dominoed into these other things.
• 44:25
  SPEAKER_00: And so this is so important for your health, how you show up for your people around you, how you show up for yourself, your gut matters here.
• 44:33
  SPEAKER_00: If it's telling you something is still off and you feel like you're not getting that support, please find it.
• 44:39
  SPEAKER_00: And I'd rather you hear this now than be one of the people who reach out five to ten years later saying, Man, I wish I had done something sooner.
• 44:48
  SPEAKER_00: You don't have to be that person.
• 44:51
  SPEAKER_00: So if you've been told, keep working on it, ask those three questions.
• 44:57
  SPEAKER_00: What's the number?
• 44:58
  SPEAKER_00: What's the plan?
• 44:59
  SPEAKER_00: When do we retest?
• 45:01
  SPEAKER_00: What should I expect?
• 45:02
  SPEAKER_00: I think is also something important to ask.
• 45:04
  SPEAKER_00: And if nobody can answer or lay this out for you, find someone who can.
• 45:09
  SPEAKER_00: Find someone when you talk to them for the first time, and as you go through this process and you just exhale and you just feel a relief, like you're in your car and your GPS got you, that's how you should feel.
• 45:22
  SPEAKER_00: Like you've got a team that is supporting you and guiding you along the way.
• 45:27
  SPEAKER_00: If you have any questions, hit us up.
• 45:30
  SPEAKER_00: We are here to help.
• 45:31
  SPEAKER_00: If this really spoke to you, we have been taking on more cases and more people that we are working with.
• 45:37
  SPEAKER_00: And it has been absolutely incredible to have these messy, complicated cases that our team is welcoming with open arms.
• 45:44
  SPEAKER_00: Like we are here to help, we are here to help you get in the right places, and you will be able to notice a difference.
• 45:52
  SPEAKER_00: And I'm not promising that this is gonna happen in two months, three months, six months, but there will be a dramatic shift in just your overall feel of this process and what you are able to do.
• 46:04
  SPEAKER_00: So we are here to help.
• 46:05
  SPEAKER_00: The information is in the show notes.
• 46:07
  SPEAKER_00: If you need help in getting pointed in a different direction, then please let us know.
• 46:13
  SPEAKER_00: The thing that is ultimately the focus for this episode is if you feel like the can keeps getting kicked down the road, if you feel like you are not feeling like yourself, if you feel like you're not being heard or supported, and you feel like there's no real plan in place, no way to know where you are, then just make a change.
• 46:34
  SPEAKER_00: Find someone who will be that guide for you.
• 46:38
  SPEAKER_00: And I promise you, the rest of this will change, no matter what the time, the investment, whatever that might be.
• 46:44
  SPEAKER_00: And in six to twelve months from now, you could be a completely different person, completely different.
• 46:50
  SPEAKER_00: And if that is not something that is motivating, then I don't know what it is because I know a lot of people would love to be in a different place in the next six to 12 months.
• 46:59
  SPEAKER_00: So if you need anything, we're here.
• 47:02
  SPEAKER_00: Otherwise, I will catch you in the next episode.
• 47:04
  SPEAKER_00: This is your host, Robbie Patel, signing off.