Latest / The ACL Athlete Podcast / 261 | The ACL Is a Seatbelt: You Don’t Know You Need It Until You Do

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261 | The ACL Is a Seatbelt: You Don’t Know You Need It Until You Do · 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.
• 1:00
  SPEAKER_00: What is up, team, and welcome back to another episode on the ACL Athlete Podcast.
• 1:07
  SPEAKER_00: So I hope you guys are doing well.
• 1:08
  SPEAKER_00: I hope that your week is going well.
• 1:11
  SPEAKER_00: I know that this crazy snow Arctic freeze blast across the US has been a little crazy for folks, especially for those who are not so prepared for ice and snow and cold weather.
• 1:26
  SPEAKER_00: Um so hope everyone is doing well out there.
• 1:29
  SPEAKER_00: If you don't know what I'm talking about, it's probably way past that time of you listening, or it's just not relevant to you.
• 1:35
  SPEAKER_00: But for those of you who are listening, I hope that you are doing well.
• 1:39
  SPEAKER_00: So diving into today's topic.
• 1:43
  SPEAKER_00: So what if I told you that most athletes don't actually know when they need their ACL?
• 1:50
  SPEAKER_00: I mean, who does?
• 1:51
  SPEAKER_00: There's a bunch of different ligaments in the knee.
• 1:54
  SPEAKER_00: There are a bunch of different supportive structures, which are the muscle groups, right?
• 1:58
  SPEAKER_00: Those are active and then there's passive structures, which are typically your tendons and your ligaments, especially your ligaments.
• 2:07
  SPEAKER_00: And so there are different things that essentially make up the knee joint itself and the thing that supports the stability of it.
• 2:14
  SPEAKER_00: And so athletes when they need their ACL and don't need their ACL, right?
• 2:21
  SPEAKER_00: You're not really gonna notice it, not when they're walking, not when they're lifting, not even when they're jogging or potentially even cutting lightly or doing more rehab-specific drills, especially because it's all sub-maximal, right?
• 2:36
  SPEAKER_00: Now, don't get me wrong, there are situations where you step off of a curb if you don't have an ACL and that knee gives out.
• 2:42
  SPEAKER_00: And I went a good long period of time because of insurance issues for my first ACL.
• 2:48
  SPEAKER_00: So I basically walked around for a few months without an ACL.
• 2:53
  SPEAKER_00: And so I got pretty familiar with how the knee felt and trying to do things, and I was able to get back to doing a lot of daily stuff, moving stuff, lifting stuff, and then I tried to test it out for a run one time and I hit uh a hard cut because I was also in high school and didn't know any any different, honestly.
• 3:14
  SPEAKER_00: And my knee kind of shifted, and so then I was like, Oh, that's why I need my ACL, right?
• 3:21
  SPEAKER_00: But the thing is, is that because the ACL doesn't just really announce itself, that's the thing about this process and the knee itself.
• 3:28
  SPEAKER_00: It's more what I like to say is it's more like a seat belt, you don't feel it doing anything until the exact moment you desperately need it, right?
• 3:37
  SPEAKER_00: And so today I want to talk about why feeling good, especially in ACL rehab late in the process, can actually be one of the most dangerous phases.
• 3:47
  SPEAKER_00: So take that for what it's worth.
• 3:49
  SPEAKER_00: But I do think that there is some merit to this because of just working through this process and this process taking a long time, and so I want to dive into that.
• 3:59
  SPEAKER_00: Also, why clinical exams and timelines can give false confidence and why objective testing is the only way to really know where the knee stands, especially as time goes on?
• 4:11
  SPEAKER_00: So, in terms of the seatbelt analogy itself, let's just kind of pause for a second and address this head on.
• 4:19
  SPEAKER_00: So, does the seatbelt analogy actually make sense for the ACL?
• 4:23
  SPEAKER_00: Right?
• 4:24
  SPEAKER_00: Absolutely.
• 4:25
  SPEAKER_00: And from like a biomechanics and a real world risk standpoint, it's actually a very strong analogy in this because the ACL itself is a largely passive structure until a high-risk event.
• 4:39
  SPEAKER_00: It's not heavily stressed in low speeds, controlled tasks.
• 4:43
  SPEAKER_00: Its true value shows up in unexpected, chaotic, high load moments, those high stress moments because you don't feel it, it's protecting until it really fails, honestly.
• 4:54
  SPEAKER_00: It's either tearing or it's not there, right?
• 4:57
  SPEAKER_00: And most importantly, the absence of symptoms does not equal the absence of risk.
• 5:02
  SPEAKER_00: Let me repeat that again.
• 5:03
  SPEAKER_00: The absence of symptoms does not equal absence of risk.
• 5:08
  SPEAKER_00: And I think that is something that can be really challenging.
• 5:11
  SPEAKER_00: And this is exactly how a seatbelt works.
• 5:13
  SPEAKER_00: So I was trying to kind of work this out in my head in terms of like, okay, does this actually make sense?
• 5:17
  SPEAKER_00: I've just been kind of thinking about it more in terms of the seatbelt that's there.
• 5:21
  SPEAKER_00: And so you can really drive for years, right?
• 5:25
  SPEAKER_00: Feel totally fine, never think about having your seatbelt on until there's one moment where it suddenly matters more than anything else.
• 5:32
  SPEAKER_00: And that's the way the ACL essentially functions the same way.
• 5:37
  SPEAKER_00: And so most of what we do in rehab, even some of the advanced rehab, if you will, doesn't fully stress the ACL.
• 5:44
  SPEAKER_00: You got to think about, you know, when you're straight line walking, controlled lifting, right?
• 5:49
  SPEAKER_00: The predictable single leg work, especially gym-based work, you're not gonna really be testing that ACL out as much.
• 5:55
  SPEAKER_00: Now it can kind of feel like that ACL is super fragile, it's healing in there.
• 5:59
  SPEAKER_00: If I do any sort of movement, it's gonna give.
• 6:02
  SPEAKER_00: And there are different phases of this where this matters depending on the healing of the ACL, but most importantly, the stability and the structures around the knee, most importantly, the muscle groups.
• 6:13
  SPEAKER_00: So whenever the quad is not turning on, then yeah, we might actually have to resort to other passive structures in the knee because when you go to do something and that muscle group isn't helping do its job, then we do rely on the passive structures, right?
• 6:28
  SPEAKER_00: Because those things are gonna work if the other muscle groups are not strong enough or they're not kicking on enough to be able to provide that additional active stability, which is the primary focus of what's gonna protect the joint.
• 6:42
  SPEAKER_00: And so with predictable single leg work, you're not gonna really notice it.
• 6:45
  SPEAKER_00: Even pre-planned, like change of direction stuff.
• 6:48
  SPEAKER_00: You know, those are things that you're probably not gonna nearly notice that knee giving way as much as like in your brain, you might think so.
• 6:56
  SPEAKER_00: These are very low, chaotic environments and probably sub-maximal.
• 7:00
  SPEAKER_00: And what I mean by this is not 100% intensity.
• 7:03
  SPEAKER_00: And so athletes start saying, I don't even notice my knee anymore.
• 7:07
  SPEAKER_00: It feels normal.
• 7:08
  SPEAKER_00: I feel strong, right?
• 7:10
  SPEAKER_00: And that makes sense, right?
• 7:11
  SPEAKER_00: Because you're going through this rehab process, and most of especially rehab, you're not necessarily testing the car at 100% speed.
• 7:20
  SPEAKER_00: So then, therefore, you're not really gonna notice like the seatbelt effect of it, right?
• 7:26
  SPEAKER_00: Now, there can be those episodes where it gives out when people don't have their ACL, but that's the thing that can always be challenging in this process because the ACL's job isn't to protect you in just like these clean, predictable situations.
• 7:40
  SPEAKER_00: Its job is to protect you when you know you decelerate late to react instead of you know the planned situation.
• 7:47
  SPEAKER_00: Maybe you land awkwardly, you're tired, and fatigue plays into this.
• 7:51
  SPEAKER_00: And then, of course, the environment is chaotic.
• 7:53
  SPEAKER_00: So you're really testing out that knee and you're having to react to a lot of different things.
• 8:00
  SPEAKER_00: You don't know if the system is ready for that by quote unquote feeling good, and that's the thing that's really important here.
• 8:07
  SPEAKER_00: And so feeling good to me can be a big disguise and it can be challenging in ACL rehab because this is where things can get really hard and even potentially a little dangerous, if you will, because as time passes in this ACL process and after surgery, the pain starts to typically get better, the swelling decreases, movement feels easier, and typically people's confidence also increases.
• 8:33
  SPEAKER_00: And so then eventually the athlete will assume I must be good to go at a certain point in the process.
• 8:39
  SPEAKER_00: But the symptoms disappearing does not necessarily mean that capacity has been returned.
• 8:44
  SPEAKER_00: And that's super important here.
• 8:46
  SPEAKER_00: And I think sometimes because things feel good doesn't necessarily mean that their strength, their power, their ability, that all the muscle groups and surrounding tendons need to do to be able to perform, doesn't mean that it's been met yet.
• 8:59
  SPEAKER_00: And so under the surface, you could still have those quad strength deficits, you could have the poor rate of force development.
• 9:06
  SPEAKER_00: So if you're thinking about strength, we're talking about how high of a ceiling you can produce, the force, and then rate of force is essentially how quickly you can get there, right?
• 9:15
  SPEAKER_00: Especially in sport and activities, we want to be able to access that strength very quickly.
• 9:19
  SPEAKER_00: If we're super strong, but we can't access it quick, especially when we have only milliseconds to react, it's not really helpful.
• 9:26
  SPEAKER_00: So that's why we also have to work on the power rate of force part of this process.
• 9:32
  SPEAKER_00: The other thing, too, is that asymmetries mass by compensations that has really played a big role in this process because you think about how long you go with the injury and then also the post-op process.
• 9:44
  SPEAKER_00: If you go that route, your body has learned ways to work around this to be able to get the job done, to take the stairs, to walk, to be able to even sit down to a chair.
• 9:54
  SPEAKER_00: And even with lifting, asymmetries are all over the board with any type of injury because our body finds a way to get it done, right?
• 10:01
  SPEAKER_00: And so poor tolerance to fatigue is also something that we will see based on this, inadequate deceleration capacity, so being able to break and slow yourself down, and then reactivity that there can be some gaps in this that never really show up in the typical strand standard rehab.
• 10:18
  SPEAKER_00: And especially if rehab for you was too conservative, avoided uncomfortable loading, didn't necessarily progress speed, chaos, or fatigue, and then focus on completion instead of you know, like the stress exposure of this process.
• 10:33
  SPEAKER_00: And it's challenging because when you think about most physical therapy clinics, they're not equipped to be able to take on this full process.
• 10:42
  SPEAKER_00: But again, when we're looking at certain healthcare models, insurance models, people are typically going to these clinics for months and months on end and hoping that it can get them there.
• 10:52
  SPEAKER_00: Now, don't get me wrong, there can be limitations to so many clinics because not everyone has just this turf and open free weight room to be able to do everything.
• 11:00
  SPEAKER_00: But I think we need to know the limitations of that.
• 11:03
  SPEAKER_00: So you're going to be limited by the environment you're in.
• 11:08
  SPEAKER_00: For example, if you have a sports car and you're driving in a neighborhood, you are never going to test the limits of that sports car.
• 11:17
  SPEAKER_00: And just know that you're never going to get it up to 100% of its capacity because the neighborhood is, you know, the roads in a neighborhood are built a certain way.
• 11:27
  SPEAKER_00: You have turns, you have cul-de-sacs, you have roundabouts, you have tons of stop signs, speed bumps.
• 11:32
  SPEAKER_00: Like you're never going to hit full speed in a neighborhood.
• 11:35
  SPEAKER_00: And that's kind of the same thing with certain rehab environments, if I'm honest, most, or we can't necessarily open it up and be able to test how you're doing on a field or on a court, or to be able to cut, jump, express yourself with high velocities.
• 11:50
  SPEAKER_00: And so we need to know the limitations of that.
• 11:52
  SPEAKER_00: And so then, therefore, if we can't necessarily test it, then therefore we're not necessarily going to get that ACL up to a certain point.
• 12:00
  SPEAKER_00: Now, again, we're not trying to test it to failure, we're just trying to make sure the exposure is there.
• 12:05
  SPEAKER_00: And that way you're not mistaken by whatever you did in the small clinic is going to necessarily keep you fully protected because you are limited by the constraints of the clinic.
• 12:18
  SPEAKER_00: And so the thing is you just don't find these gaps by accident.
• 12:23
  SPEAKER_00: You only find them if you actually look for them.
• 12:25
  SPEAKER_00: And that's the biggest thing here.
• 12:27
  SPEAKER_00: And so one of the other things I do want to discuss here that aligns with this is essentially the clinical exam is a challenge, it's a problem.
• 12:35
  SPEAKER_00: And so I don't think this gets said enough, but you know, when a surgeon examines your knee in a quiet clinic, it's in this small little room that you sit on the table, you know, you lay back, they'll do the Lockman test, they may do the pivot shift test, you'll sit up, and then they'll kind of put their hand on your ankle and kick out into it.
• 12:55
  SPEAKER_00: They'll look at it and they say, Yeah, that ACL is in there.
• 12:58
  SPEAKER_00: It's strong.
• 12:59
  SPEAKER_00: The ligament's there.
• 13:01
  SPEAKER_00: It just means the ligament's there.
• 13:03
  SPEAKER_00: You they can't tell how strong the ligament is, they don't know its capacity of it.
• 13:08
  SPEAKER_00: You know, the graft is intact, the ligament is there.
• 13:11
  SPEAKER_00: That is really all that they can tell you based on that, especially in that five to ten minute time period they take with you.
• 13:18
  SPEAKER_00: And so the thing is that this is not sufficient for a clearance, and it's not sufficient to just let us know, like, okay, now you can move forward with X, Y, and Z.
• 13:26
  SPEAKER_00: It's usually based on timelines that they use and also just that five, 10-minute test or time with you, if you will.
• 13:34
  SPEAKER_00: And so the exam itself doesn't tell us how you absorb force, it doesn't tell us how quickly you can produce the force, how your knee behaves under fatigue, whether you rely on the compensations that you can't necessarily feel.
• 13:48
  SPEAKER_00: And as much as everyone says, like, I don't compensate, or I feel like I'm doing it equally.
• 13:53
  SPEAKER_00: If you check out Susan Sigward's work, she has an incredible study talking about being able to look with the naked eye months out post-op ACL, and you can't see any differences.
• 14:05
  SPEAKER_00: But when you look at actually the muscle activity, there's a shift early on.
• 14:09
  SPEAKER_00: You you shift to the uninvolved side, and then as time goes on, you start to shift to the involved side, but you start to move your focus from the quads to the hamstrings and the calves.
• 14:22
  SPEAKER_00: The body is an incredible master compensator, and I've seen people look so pristine in terms of their movements, and the thing is that sometimes they'll be like, Yeah, I don't really feel it there though.
• 14:34
  SPEAKER_00: And so our job in rehab is to constrain things so they have no choice.
• 14:37
  SPEAKER_00: That's why we love the knee extension machine, because you have no choice but to use your quads.
• 14:42
  SPEAKER_00: But with that said, like the the visual or the the qualitative assessment with a movement is important, but it's not the only thing.
• 14:51
  SPEAKER_00: We have to make sure it matches up to a objective component, right?
• 14:56
  SPEAKER_00: And so the main thing I want to point out here is why this matters more the further out you are.
• 15:03
  SPEAKER_00: Now, early on, you know, the first three to six months or so, people are like, I'm still in it, right?
• 15:08
  SPEAKER_00: Like, I know I'm not there, they're still still healing.
• 15:10
  SPEAKER_00: Once people start getting into that eight, nine month process, especially year mark, they start to think about things a little differently, especially because you've been in it for a while.
• 15:19
  SPEAKER_00: And again, there are so many people across the spectrum.
• 15:22
  SPEAKER_00: We have athletes who are way over this, who have come to us much later in the process, and they have a humble understanding of this.
• 15:30
  SPEAKER_00: And there are some people who honestly just don't know any better, or it's just really challenging because it's a little bit of a paradox, right?
• 15:37
  SPEAKER_00: The later you are in post-op, the harder it is to tell if something is missing, unless it's super obvious, right?
• 15:45
  SPEAKER_00: Early on, pain gives you that feedback, the swelling limits some of the behavior, and then of course there's guarding.
• 15:51
  SPEAKER_00: Later on, it's probably more common to say as people get months out that their, you know, pain is better, their swelling is typically better, they're guarding less, they're gotten used to things, they've gotten stronger, so their movement feels free.
• 16:05
  SPEAKER_00: You're trusting the knee a bit more, and you stop questioning it as much, right?
• 16:10
  SPEAKER_00: And so the thing is that your sport really doesn't care how long it's been since you've been post-op, right?
• 16:17
  SPEAKER_00: It cares whether your system, your knee, your body as a whole can handle force, speed, timing, fatigue, the chaos of it.
• 16:27
  SPEAKER_00: And that's why so many reinjuries happen when athletes say, I felt totally fine, right?
• 16:32
  SPEAKER_00: But they didn't know they needed the seatbelt until it crashed, right?
• 16:38
  SPEAKER_00: And so that's something that kind of leads me to this objective testing is essentially us checking that seatbelt.
• 16:46
  SPEAKER_00: And so objective testing isn't about fear, right?
• 16:49
  SPEAKER_00: It's about making sure we can verify, validate where this knee is based on the current research and knowing from a performance standpoint what we need.
• 16:57
  SPEAKER_00: We are trying to meet the demands of the activities in sport, not only from just daily life for longevity, but also being able to handle those things when you get out there, right?
• 17:08
  SPEAKER_00: It could be skiing, it could be playing soccer, it could be playing handball, it could be playing ultimate, it could be any of the sports that you can think of, MMA, climbing, all the things.
• 17:19
  SPEAKER_00: Like we need to make sure that the body is prepared for all those things in the knee itself.
• 17:23
  SPEAKER_00: And the thing is, is that testing answers questions your body can't feel, right?
• 17:29
  SPEAKER_00: Can you actually produce enough force?
• 17:32
  SPEAKER_00: Can you actually absorb it fast enough?
• 17:34
  SPEAKER_00: Do asymmetries still show up under load?
• 17:37
  SPEAKER_00: What happens when fatigue is introduced?
• 17:39
  SPEAKER_00: Does performance match the demands of your sport?
• 17:42
  SPEAKER_00: So testing doesn't mean something is wrong, it means you're just checking this system before real life checks it for you.
• 17:50
  SPEAKER_00: Okay, and that's one thing that we want to be really careful of.
• 17:53
  SPEAKER_00: I don't want real life to check it for you.
• 17:55
  SPEAKER_00: We want to make sure we check this system and test it appropriately, just like the seatbelt itself.
• 18:00
  SPEAKER_00: And so if you're listening to this as an athlete, maybe a parent, maybe a coach, maybe a PT, right?
• 18:06
  SPEAKER_00: Feeling good is important and we want that confidence because it matters, the time matters, but none of those replace the evidence, and that is so key.
• 18:15
  SPEAKER_00: So the real question isn't does my knee feel okay?
• 18:19
  SPEAKER_00: It's is my knee ready for the worst case scenario?
• 18:22
  SPEAKER_00: Is it prepared for the demands of my sport or my activity?
• 18:26
  SPEAKER_00: Because sport is not going to ask y'all's permission.
• 18:29
  SPEAKER_00: Okay.
• 18:30
  SPEAKER_00: And so I think that this is really, really important here because the ACL itself doesn't actually fail in rehab, it fails in the real life.
• 18:38
  SPEAKER_00: Now, there have been accidents that have happened in rehab that I have heard of.
• 18:42
  SPEAKER_00: I'm not gonna wait, it has never happened to me, but with that said, like you're gonna you're gonna have to test drive it, right?
• 18:48
  SPEAKER_00: And the only way to know if you're ready for real life is to test it like the real life is coming.
• 18:53
  SPEAKER_00: And so we need to make sure that that's where our criteria is set through this process.
• 18:58
  SPEAKER_00: We can't just go based on feel.
• 19:00
  SPEAKER_00: Your ACL is going to be this seatbelt, and the main thing I want to drive home today is don't wait until you need it to find out it wasn't there or that it wasn't properly tested.
• 19:13
  SPEAKER_00: And so that's so important for my ACLers.
• 19:17
  SPEAKER_00: I feel like we just get people who are later in the process who are like, this is good enough, and ACL rehab is not a process where good enough works.
• 19:26
  SPEAKER_00: I wish it was.
• 19:27
  SPEAKER_00: I wish so badly for everyone that it was, but you are playing with some not great odds.
• 19:33
  SPEAKER_00: And so we want to make sure that we test this thing out appropriately, and especially for my late ACLers who feel like they're close to there or almost there, keep going.
• 19:43
  SPEAKER_00: But make sure that, you know, if you're at 70%, you're at 80%, that is not good enough because the research clearly shows that we need to be within a 10% deficit.
• 19:53
  SPEAKER_00: And of course, there is context with each person based on their goals and also what this looks like.
• 19:59
  SPEAKER_00: But with that said, we see so many people get further out who start to just say, okay, well, I feel good.
• 20:07
  SPEAKER_00: And the deceiving part is that they go to a clinical exam with their surgeon and they say it looks good, right?
• 20:13
  SPEAKER_00: And I am excluding any surgeons who, you know, actually do testing, who do strength testing, who actually do other movement analysis, because we have different surgeons where they actually do a thorough panel and they actually look at a comprehensive profile of athletes, and it's amazing.
• 20:30
  SPEAKER_00: So it's not to say all, but it's far and few between.
• 20:33
  SPEAKER_00: And so whenever I hear of people getting cleared, or you know, they had their visit at six months, nine months, twelve months, they get cleared, and then they're just saying, like, ease back into it, right?
• 20:45
  SPEAKER_00: And it literally just happened with one of my youth athletes, one of their reputable surgeons here, he said, ease into it.
• 20:52
  SPEAKER_00: Um, I don't need to see you again.
• 20:53
  SPEAKER_00: But she's still got a deficit in her quads, and she's had a challenging road through this process, but there was no true assessment besides like a little bit of strength.
• 21:02
  SPEAKER_00: There was no field testing, there was no jump testing, nothing like that.
• 21:06
  SPEAKER_00: So to just say, ease into it, even though there's a 30% deficit for a sport that is gonna require a lot of collision, that's not gonna cut it, especially for something like this where the re-injury rates are so high.
• 21:19
  SPEAKER_00: And so I just want to make sure that we as a community, as PTs, as the ACL community as a whole, we just want to make sure that we do this right, make it your last time that this is gonna happen, because it is so, so important to make sure you test this because the ACL itself is just one of those things that you don't really know you need it until you do.
• 21:43
  SPEAKER_00: And I want you guys to know that because a lot of rehab doesn't necessarily fully test it out.
• 21:49
  SPEAKER_00: So, yes, we are going based on feel in this process.
• 21:52
  SPEAKER_00: We're going based on the objective testing components, I hope, that are valid and proven in the research.
• 22:00
  SPEAKER_00: But we just want to make sure that we go by data driving this versus feel because feel will always make us feel a little differently, if you will, especially the further out from ACL rehab you are.
• 22:12
  SPEAKER_00: And that's where people start to make decisions that are a little bit riskier.
• 22:15
  SPEAKER_00: And we do not want you to be one of those people.
• 22:17
  SPEAKER_00: So I hope this helps, y'all.
• 22:19
  SPEAKER_00: Until next time, this is your host, Robbie Patel, signing off.