Latest / The ACL Athlete Podcast / 249 | The Sweet Spot Debate: Can You Return to Sport in Less than 9 Months in ACL Rehab?

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249 | The Sweet Spot Debate: Can You Return to Sport in Less than 9 Months 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.
• 1:07
  SPEAKER_00: So if you've been following the news for the NFL et al.
• 1:12
  SPEAKER_00: Packers tight end Tucker Kraft just towards ACL, which means his season is sadly over.
• 1:19
  SPEAKER_00: And if you follow these stories long enough, especially with professional sports, you'll notice a pattern.
• 1:26
  SPEAKER_00: Even at the highest level, with full-time medical teams, daily access to rehab, this is their job to rehab, and all the best recovery tools possible, these athletes typically take around nine months or longer to return back to full competition.
• 1:45
  SPEAKER_00: And that's a really important perspective here for everyone listening to this, because if professional athletes with round-the-clock support are all taking that long, then I think it's super, super important for 99.9% of us, the ones who are having to juggle, work, school, family, or limited access to rehab care, right?
• 2:11
  SPEAKER_00: To safely do it in less time.
• 2:14
  SPEAKER_00: And people are always wanting to get back faster or accelerate this process.
• 2:18
  SPEAKER_00: And so today I do want to touch on this article because this is how this came up, actually, is I had an ACL article that just popped up because everything around my life revolves around ACL.
• 2:31
  SPEAKER_00: And the article was titled, What's a typical recovery time for Tucker Kraft's Torn ACL injury?
• 2:38
  SPEAKER_00: This is by Packersnews.com.
• 2:40
  SPEAKER_00: Tom Silverstein is the journalist who wrote this article.
• 2:45
  SPEAKER_00: And the thing that it leads with is the Green Bay Packers generally don't allow players back on the field for at least nine months from the time of their injury if the damage is a torn ACL ligament.
• 2:59
  SPEAKER_00: And so they goes on to say basically that holds true for Tucker Kraft, who tore his ACL on November 3rd, which was two days ago, as the time of this recording.
• 3:10
  SPEAKER_00: So this is fresh, y'all, giving y'all as fresh as possible.
• 3:13
  SPEAKER_00: And then it just says that Kraft could be ready for the 2026 season if everything goes smoothly.
• 3:18
  SPEAKER_00: And then it references three other ACL injuries to Green Bay Packers in recent years, and the approximate nine-month time frame was the same.
• 3:28
  SPEAKER_00: Wide receiver Christian Watson tore his ACL on January 5th and was held out of training camp and practiced until October 6th.
• 3:36
  SPEAKER_00: So he didn't start back until October 6th with his practicing.
• 3:39
  SPEAKER_00: And so he practiced three weeks before activated for a game.
• 3:42
  SPEAKER_00: So obviously he was doing a lot leading up to that.
• 3:45
  SPEAKER_00: It wasn't like he just jumped straight into it.
• 3:48
  SPEAKER_00: Defensive end, Rashawn Gary tore his right ACL against Detroit November 6th of 2022, returned nine months later, practicing for the first time August 7th.
• 3:58
  SPEAKER_00: And then Center Elton Jenkins tore his ACL in his left knee against Minnesota in 2021.
• 4:05
  SPEAKER_00: He returned nine months later, practicing for the first time in August 14th.
• 4:09
  SPEAKER_00: So slightly less than nine months after the injury.
• 4:12
  SPEAKER_00: And so these are just situations that I wanted to share in terms of this because I think it helps set up the podcast episode itself because I want to dig into this nine-month time frame and really what this looks like in terms of ACL rehab and the perception of it.
• 4:32
  SPEAKER_00: And I think that there are some things that also do push against this, which I want to talk about, which is one particular article from heavy hitters from Aspetar that I think is important to touch on.
• 4:44
  SPEAKER_00: But I think it makes the case known that if we reference a lot of professional sports and athletes who tear their ACL, we are typically seeing that nine to 12 month time frame.
• 4:56
  SPEAKER_00: Yes, some are early.
• 4:57
  SPEAKER_00: Yes, there are some who put things on the line and get out there at six, seven months, but that's their own risk.
• 5:03
  SPEAKER_00: And there are other things that go along with that that they are weighing that we obviously are not going to see, especially from the professional sports setting.
• 5:10
  SPEAKER_00: We're not going to hear any of these details.
• 5:12
  SPEAKER_00: They try to keep this close knit.
• 5:14
  SPEAKER_00: Players don't want this stuff released.
• 5:16
  SPEAKER_00: They have millions of dollars at play, their careers at play.
• 5:20
  SPEAKER_00: And sometimes they don't even disclose this stuff to teams themselves because they are trying to protect contracts.
• 5:26
  SPEAKER_00: So we have to understand context, the number of people who are involved, and there's a lot that is writing on essentially these returns of these athletes, right?
• 5:36
  SPEAKER_00: So they're wanting to get back, but we're not going to always hear the details of it.
• 5:40
  SPEAKER_00: But we will hear a lot of how long it takes people to get back.
• 5:44
  SPEAKER_00: And I feel like in recent years, I've appreciated that there's been less of Adrian Peterson type scenarios where this athlete got back in six months or four months.
• 5:54
  SPEAKER_00: Yeah, it's still consistently something that we hear.
• 5:57
  SPEAKER_00: We're hearing the narrative change a little bit better towards at least the nine-month and beyond process for a lot of things, but there are still some stipulations around testing's not really done much.
• 6:08
  SPEAKER_00: Great rehab is still a challenge and access to good care, but it's just something that we typically see.
• 6:14
  SPEAKER_00: And so it's nice to get away from some of those earlier timelines, if you will, and seeing more of the nine-month.
• 6:21
  SPEAKER_00: And the thing that I do want to share is that in professional sports, that's the gold standard that a lot of people uphold to.
• 6:27
  SPEAKER_00: Well, if this pro athlete did this, then this is what I must do as well, right?
• 6:31
  SPEAKER_00: If they have this particular coach or this type of equipment or this type of rehab, I should do that too, right?
• 6:39
  SPEAKER_00: And I will say there are a lot of things good in the pro setting.
• 6:43
  SPEAKER_00: I think that sometimes it's disguised as good, but I've met amazing clinicians who are not in the pro setting, and I've had very many clinicians that I've met who are not awesome, but they're in the pro setting.
• 6:55
  SPEAKER_00: So I'm just gonna leave that there.
• 6:57
  SPEAKER_00: Uh relationships and connections really help a lot with getting jobs.
• 7:01
  SPEAKER_00: So I think that it's just important though.
• 7:03
  SPEAKER_00: A lot of times people will reference, well, my surgeon is the pro team surgeon, right?
• 7:08
  SPEAKER_00: So if you want to lean into that, then I would say also let's lean into like what the pro athletes are doing in terms of timeline, right?
• 7:15
  SPEAKER_00: So it's taking them at least nine months with all things perfect in their daily calendar, resources, money, everything, right?
• 7:25
  SPEAKER_00: Full-time job again.
• 7:27
  SPEAKER_00: Now, let's dive into this article because I think it's super important to lay this out.
• 7:33
  SPEAKER_00: I want to share the details of this article because it is new and it is something that really pushes against this nine-month timeline.
• 7:44
  SPEAKER_00: And so for me, this is something that when it comes out and something pushing against my bias, I'm like, whoa, whoa, whoa, wait.
• 7:51
  SPEAKER_00: But at the same time, I fully agree.
• 7:53
  SPEAKER_00: And these researchers are some of the best researchers in the world when it comes to ACL rehab, when they have dialed in their own process.
• 8:00
  SPEAKER_00: And I think that's why we also have to consider this article in context.
• 8:05
  SPEAKER_00: And so this article is by Katsufaki, who has done such an amazing work.
• 8:10
  SPEAKER_00: I have so much respect for her and Aspetar and all the researchers and people who are doing amazing work there.
• 8:18
  SPEAKER_00: But the article is in the British Journal of Sports Medicine.
• 8:21
  SPEAKER_00: And the title is Is Nine Months the Sweet Spot for Male Athletes to Return to Sport after ACL Reconstruction?
• 8:29
  SPEAKER_00: And so I want to just talk about some details of this article because I think it's helpful to break it down.
• 8:37
  SPEAKER_00: And so when we look at what they were trying to basically their objectives, they were looking at how rehab adherence and completion impacted return to pivoting sports like soccer, basketball, handball, and whether returning before or after nine months post-surgery change the risk of re-injury.
• 8:56
  SPEAKER_00: And now leading up to this point, there has been a lot of research that shows if you return less than nine months, your re-injury risk increases for ACL.
• 9:05
  SPEAKER_00: And after nine months, it increases the probability of returning the sport and decreases the risk of re-injury.
• 9:13
  SPEAKER_00: If we just took the collective data and that is out there, nine months and beyond.
• 9:18
  SPEAKER_00: That's why we also lean on that through this process.
• 9:20
  SPEAKER_00: And you'll probably hear anyone who's in ACL world probably use that number and probably say nine to 12 months, give or take, right?
• 9:27
  SPEAKER_00: And so the other piece that they're looking at is the risk of re-injury if an athlete meets objective discharge criteria.
• 9:36
  SPEAKER_00: So what they looked at were 530 male athletes around the age of 27 was the average who participated in pivoting sports pre-injury.
• 9:46
  SPEAKER_00: It included competitive recreational athletes.
• 9:49
  SPEAKER_00: About 40% were pro-amate competitive, and then it excluded female athletes.
• 9:55
  SPEAKER_00: All ACL reconstructions were either done with hamstrings, patellar tendons, or quad graphs.
• 10:01
  SPEAKER_00: And then when we look at the in-person pieces, they were at Aspetar under a very standardized criteria-based progression system with basically mandatory testing every six weeks.
• 10:15
  SPEAKER_00: So this is a key player here, y'all.
• 10:17
  SPEAKER_00: Aspotar has their process dialed in.
• 10:20
  SPEAKER_00: They have tons of clinicians there, tons of testing resources.
• 10:24
  SPEAKER_00: They're a big research hub.
• 10:26
  SPEAKER_00: And so it's amazing to get this data, but we also want to understand like the setting that this is in, right?
• 10:32
  SPEAKER_00: So that's going to be an important thing is that if we have testing within a clinic at the gold standard access to equipment, amazing, every six weeks, and they have their own process dialed in for their particular surgeons, graph types, et cetera.
• 10:46
  SPEAKER_00: And so these athletes went through three rehab phases essentially.
• 10:50
  SPEAKER_00: You think about the early, intermediate, and advanced stages.
• 10:53
  SPEAKER_00: So you've got the early post-op stuff, you've got the intermediate where you're building more strength, and then you're getting into more advanced, like plyos, reactor strength, like sports-specific stuff.
• 11:03
  SPEAKER_00: And so progression wasn't necessarily based on time, it was based more on objective test results.
• 11:09
  SPEAKER_00: So they had to meet strict discharge criteria to be cleared for sport.
• 11:14
  SPEAKER_00: That meant pain-free testing, 90% strength and jump symmetry, completed a sports-specific progression, educated on prevention and maintenance.
• 11:23
  SPEAKER_00: And then they were followed two years post-surgery to basically track their return rates and the re-injury.
• 11:29
  SPEAKER_00: And so the key findings here the return to sport rates, well, 72% of all athletes returned to pivoting sports within two years.
• 11:37
  SPEAKER_00: Those who finished rehab and met criteria were six times more likely to return to sport.
• 11:45
  SPEAKER_00: Return to sport rates by rehab completion.
• 11:48
  SPEAKER_00: So if you stopped early, you had a 50% chance of returning to sport.
• 11:52
  SPEAKER_00: Stopped mid-phase, 70% chance of returning to sport.
• 11:56
  SPEAKER_00: And then if you completed the full process with them, you had a 90% chance of returning to sport.
• 12:02
  SPEAKER_00: Big, big key factor here.
• 12:04
  SPEAKER_00: Rehab adherence was one of the strongest predictors of successful return.
• 12:08
  SPEAKER_00: I'm gonna repeat that.
• 12:10
  SPEAKER_00: Rehab adherence was one of the strongest predictors of successful return.
• 12:16
  SPEAKER_00: Timing.
• 12:18
  SPEAKER_00: So less than nine months versus greater than nine months.
• 12:21
  SPEAKER_00: So this is key here.
• 12:22
  SPEAKER_00: Among those who met discharge criteria, 71 athletes returned before nine months, 97 returned after nine months.
• 12:31
  SPEAKER_00: Key, key information there.
• 12:34
  SPEAKER_00: No difference in new ACL or knee injury rates between the two groups.
• 12:39
  SPEAKER_00: So that's super key there.
• 12:40
  SPEAKER_00: The average return time, competitive athletes took around 9.9 months, and recreational athletes took about 11.6 months.
• 12:49
  SPEAKER_00: Now, what does this mean?
• 12:51
  SPEAKER_00: Returning before nine months didn't increase risk if the athlete passed all objective tests.
• 12:58
  SPEAKER_00: But again, this is in a world-class setup with strict testing, full rehab adherence.
• 13:04
  SPEAKER_00: So there are some contextual factors that influence some of these athletes returning before nine months.
• 13:11
  SPEAKER_00: The new injury rates were 9% had new ACL injuries, 5.7% on the same knee, 3.4% on the other knee.
• 13:19
  SPEAKER_00: And so athletes who met discharge criteria had half the reinjury rates compared to older aspetar data that they showed, largely attributed probably to mandatory testing and just how they monitor progress.
• 13:31
  SPEAKER_00: So these are some key players that I want to share.
• 13:35
  SPEAKER_00: And so the last piece that I think is important is to emphasize the limitations and just the context of this study.
• 13:42
  SPEAKER_00: It's a male-only study.
• 13:44
  SPEAKER_00: Females were not represented, so we can't necessarily generalize these results to female athletes.
• 13:50
  SPEAKER_00: Different risk profiles, different return to sport timelines.
• 13:53
  SPEAKER_00: It's a single elite rehab setting conducted at Aspetar, world-class, supervised, in person, very dialed in.
• 14:03
  SPEAKER_00: And the thing is, most ACLers do not have access to this level of care, right?
• 14:09
  SPEAKER_00: And this is something that is super detailed, and then the testing is very dialed in.
• 14:14
  SPEAKER_00: If you look at their process, it's awesome.
• 14:17
  SPEAKER_00: I love it.
• 14:18
  SPEAKER_00: We even base some of our stuff off of using Aspetar and their research.
• 14:22
  SPEAKER_00: They've created so much research, they have the numbers to show these things, but we have to understand the context of it.
• 14:29
  SPEAKER_00: High structure and compliance was a big player, had testing objectively every six weeks.
• 14:35
  SPEAKER_00: The athletes had a lot of supervised sessions, so they had guidance through this process.
• 14:40
  SPEAKER_00: Again, with legitimate clinicians through this process, so it's very different than most physio-based or PT-based models, where you know you may go two to three times a week initially for insurance-based here in the States.
• 14:54
  SPEAKER_00: And then it just ends up tapering down typically.
• 14:57
  SPEAKER_00: Of course, unless you have amazing benefits, unlimited PT visits, and you have good PT, then yeah, that's awesome.
• 15:04
  SPEAKER_00: But that's far and few between, especially with where we're at with healthcare and the amount of visits we're allotted.
• 15:10
  SPEAKER_00: And so the same thing also with other countries, like we have athletes who see their PT once a month, every two weeks.
• 15:17
  SPEAKER_00: We have ones that might go once a week.
• 15:20
  SPEAKER_00: So we're trying to fill in the gaps here, especially depending on is the process dialed in.
• 15:26
  SPEAKER_00: And I don't think that necessarily the insurance model is fully the worst thing in the world.
• 15:33
  SPEAKER_00: I think there's a lot of things bad with it.
• 15:35
  SPEAKER_00: But I think the challenges is one, as I've shared before, is that we just do not have consistent testing that is the gold standard yet.
• 15:45
  SPEAKER_00: And physical therapists and settings are not equipped well enough with strength and conditioning and the ability to do very individualized approaches or even having the facilities and the equipment to do so.
• 16:01
  SPEAKER_00: And so the the programs are very generic and a lot of times it's guided by time-based protocols and the exercises.
• 16:09
  SPEAKER_00: To be honest, y'all, a lot of times PTs will follow just what the surgeon has on a piece of paper.
• 16:14
  SPEAKER_00: Surgeons don't train for exercise prescription or ACL rehab, they know how to do the surgery.
• 16:19
  SPEAKER_00: And I don't want to go on a tangent here, but this is just the way it is.
• 16:23
  SPEAKER_00: And so sometimes PTs, especially new grads, we are thrown into it.
• 16:28
  SPEAKER_00: We don't get a lot of training on this.
• 16:30
  SPEAKER_00: And then we're like, okay, what's the protocol say?
• 16:32
  SPEAKER_00: So then we have at least a guide.
• 16:34
  SPEAKER_00: But when the guide is not necessarily the best and it's been dated to you know early 2000 or the 90s, and it's been built by somebody who probably doesn't understand exercise very well, they do know the surgery, it's very challenging.
• 16:48
  SPEAKER_00: And so it's kind of been this progression of this is what we've been doing, right?
• 16:54
  SPEAKER_00: And so, as we know, what we've been doing has not been working very well because re-injury rates are one out of three, one out of four athletes go on to re-injure again.
• 17:02
  SPEAKER_00: It's not great.
• 17:02
  SPEAKER_00: 20-30% chance of reinjury is not a great statistic.
• 17:06
  SPEAKER_00: So, with that said, that's where the model can be challenging.
• 17:10
  SPEAKER_00: But if we have a dialed-in process and framework that is up to date, testing standards, I think we could get away with being able to, you know, give people a little bit more consistent things.
• 17:22
  SPEAKER_00: Of course, individualized as needed, but with that said, like that's where it's super key is like making sure this is up to date and meeting the athlete where they are, and we are testing well, equipment access is good, and being able to monitor that more frequently.
• 17:36
  SPEAKER_00: The other thing with this paper, there's no randomization with this stuff.
• 17:40
  SPEAKER_00: So people weren't just thrown into the early versus late returns, for example, to see how they did.
• 17:45
  SPEAKER_00: It again like excluded females, which I think is a big player here for this particular study because we can't necessarily extrapolate that to a pretty high injury specific population, right?
• 18:00
  SPEAKER_00: We know, especially for young female athletes, ACL risk is much higher.
• 18:06
  SPEAKER_00: And so then, therefore, we can't necessarily say they can return to sport before nine months because this was done on athletes in their 20s, males, and so therefore, it can make it a little more challenging.
• 18:18
  SPEAKER_00: Um, even though we want to do that, we can't do that because that's just the way that we need to take data and make sure that we have very consistent proof of it to show us, like, okay, now we can basically approve this hypothesis or we can disprove this hypothesis, right?
• 18:35
  SPEAKER_00: And in reality, what research is doing is making things less wrong versus this is the perfect, this is right, you know, and this is the way we have to do it.
• 18:45
  SPEAKER_00: So this study reinforces something we see all the time that it's just not about a clock, it is about the criteria, right?
• 18:54
  SPEAKER_00: So time matters for biological healing, how you progress, how you test, how you prepare matters way more.
• 19:00
  SPEAKER_00: So even at a world-class center like this, the average return was still somewhere around the nine-month time frame.
• 19:09
  SPEAKER_00: But there were athletes who did it earlier.
• 19:11
  SPEAKER_00: But basically, this showed that there was no difference in the re-injury risk on time return as long as they met the objective criteria.
• 19:19
  SPEAKER_00: That's the thing that I really want to stress here that I think it's important.
• 19:24
  SPEAKER_00: And the authors themselves said it best time is necessary but not sufficient.
• 19:29
  SPEAKER_00: So that just means that we can't skip the process and expect the same results.
• 19:34
  SPEAKER_00: Objective criteria, uh, looking at movement, looking at strength testing, sports-specific work, jumping ability, putting numbers to it should guide your return, not just using dates on a calendar or I'm at nine months.
• 21:54
  SPEAKER_00: And so this is something that again, I want to share, you know, was all in a control rehab system.
• 21:59
  SPEAKER_00: They were part of a research study with mandatory testing, oversight.
• 22:05
  SPEAKER_00: So that's gonna be very, very, very different than what we typically see in this space.
• 22:11
  SPEAKER_00: And so I think that this is just a huge thing to highlight here.
• 22:16
  SPEAKER_00: And the other thing that I want to share too, just from the nine-month perspective, it's not just this magical, you get to the nine-month time frame and you're there, right?
• 22:27
  SPEAKER_00: As I've observed this process, working with over hundreds of people at this point, being able to work with and consult with different ACLers all over the world.
• 22:37
  SPEAKER_00: Our team has done this for so many people.
• 22:40
  SPEAKER_00: When we look at this process, because of how much is just regressed down, to be completely honest.
• 22:47
  SPEAKER_00: That is just when you have this injury, this knee goes downhill.
• 22:52
  SPEAKER_00: When you have the surgery, the knee also gets dropped a little level, right?
• 22:56
  SPEAKER_00: And so this is something that we see is we have to rebuild so much.
• 23:03
  SPEAKER_00: We have to rebuild the quads, we have to get all the symptoms down, we have to get the range of motion restored, we have to get your capacity built up, your energy system and conditioning.
• 23:12
  SPEAKER_00: We need to get your power back up, we need to get your elasticity back up, your ability to move in space, your ability to get back to doing the thing, sport-specific stuff.
• 23:23
  SPEAKER_00: There's so much we have to work on from a physical abilities standpoint, your preparedness for your sport and to be just athletic in general.
• 23:32
  SPEAKER_00: That is one thing.
• 23:34
  SPEAKER_00: And the thing is, is that just takes a very long time.
• 23:37
  SPEAKER_00: There are some people who beat this, and there are some people who are just genetically gifted.
• 23:42
  SPEAKER_00: We all know people like that.
• 23:43
  SPEAKER_00: So they might speed along with things, and there's some people who might have it a little bit easier than others for context reasons.
• 23:51
  SPEAKER_00: The person who has the ACL surgery with a patellar tendon who has three kids who are under the age of five, and they are a teacher, is gonna have a very different obstacle in front of them.
• 24:04
  SPEAKER_00: Than the remote worker who has a patellar tendon graph who can throw their feet up and doesn't have any kids, and you know, they have a girlfriend, right?
• 24:13
  SPEAKER_00: So it's very different in terms of context of how this recovery is gonna go.
• 24:17
  SPEAKER_00: And also we can't forget the biological healing.
• 24:20
  SPEAKER_00: So when we think about this process, everyone's body responds differently to surgery.
• 24:25
  SPEAKER_00: Surgery is not a normal thing for us, but it is something that we need just by development of medicine.
• 24:31
  SPEAKER_00: And so then, therefore, these surgeries are beneficial to get these graphs back and fix things.
• 24:35
  SPEAKER_00: The thing is, the biology can do different things.
• 24:38
  SPEAKER_00: Some people they have swelling stick around longer, their pain response is worse.
• 24:43
  SPEAKER_00: And then the complications of the injury or the surgery.
• 24:46
  SPEAKER_00: Some people get DVTs more than others.
• 24:49
  SPEAKER_00: And so there are so many characteristics that are involved with biology.
• 24:53
  SPEAKER_00: And then we talk about the healing.
• 24:55
  SPEAKER_00: Some people lay down more scar tissue, some people just don't have any swelling, some people end up having a harder time waking up their quads, some people have it wake up day one, and then some people have that scar tissue laid down, and then therefore it influences their range of motion, and then therefore they have to get it removed versus ones who just have a smooth process.
• 25:14
  SPEAKER_00: That's biology.
• 25:16
  SPEAKER_00: And then the other thing that's a huge factor is the graft.
• 25:19
  SPEAKER_00: Allographs are typically going to be faster while we still want to give it the time and duration to ligamentize.
• 25:25
  SPEAKER_00: Allographs, you're gonna feel better.
• 25:27
  SPEAKER_00: You didn't have a donor site taken.
• 25:29
  SPEAKER_00: Guess what?
• 25:29
  SPEAKER_00: You're gonna be feeling a little bit better than those who had a donor site and an autograph.
• 25:34
  SPEAKER_00: And then hamstrings are typically gonna feel a little bit better because their knee extensor mechanism, the thing from their quads all the way down to the patellar tendon and the tibial tuberosity, is not impacted.
• 25:45
  SPEAKER_00: And so then, therefore, they regain quad strength much faster than patellar or quads.
• 25:50
  SPEAKER_00: Patellar tendon is the next one that typically progresses a little bit faster than the quad graft, um, just by nature of it not directly influencing the quad as much as the quad graft does.
• 26:00
  SPEAKER_00: And then we see the quad graft take the longest.
• 26:03
  SPEAKER_00: And I think that there will be research to support this.
• 26:07
  SPEAKER_00: I may be coming back to correct this podcast episode one day, but I'm just gonna put it out there that I think that the quad tendon is just going to show very significant deficits of quad strength for longer periods of time.
• 26:21
  SPEAKER_00: We're already seeing some of this, but we see these a lot.
• 26:24
  SPEAKER_00: They're growing in popularity a lot.
• 26:26
  SPEAKER_00: Surgeons love them, and so it is just a more challenging recovery to get your quads back.
• 26:33
  SPEAKER_00: And I'm telling y'all, like, we do the most dialed in process.
• 26:36
  SPEAKER_00: I have friends who see these who are incredible clinicians and coaches who also have hard times with quad graphs, and it's just something that I think, just by nature, for the direct influence of the quad and that tendon, it makes its own challenges.
• 26:51
  SPEAKER_00: So it will take longer.
• 26:53
  SPEAKER_00: So then, therefore, when we look at this from the nine to 12 month perspective, all these people are gonna progress at different rates based on all these factors.
• 27:01
  SPEAKER_00: But I do think that biology plays a huge role, the physical preparedness of this process, that we need nine months to do that, and need nine months to ligamentize that and make sure that ACL turns into an actual ligament.
• 27:16
  SPEAKER_00: And so I think those are factors that are so key in this.
• 27:20
  SPEAKER_00: And so while this paper does show it can happen sooner, and I think that most athletes still need more time to develop these qualities, especially outside of these small percentage of people who might get there faster.
• 27:35
  SPEAKER_00: And so when we're getting to this and looking at this at the end of the day, the question shouldn't be when can I return, but most importantly, and this is what Katsufaki and them stress is not when, but how am I returning, right?
• 27:52
  SPEAKER_00: So I think that's the thing that we need to stress.
• 27:55
  SPEAKER_00: Time gives us that framework, it just gives us a proxy of what we need to accomplish.
• 28:02
  SPEAKER_00: And I think that's why nine months is so helpful compared to six, it's just more time, y'all.
• 28:06
  SPEAKER_00: And so then, therefore, it allows for more time to develop these things, let that knee and that body heal more, the ligament to become a ligament.
• 28:15
  SPEAKER_00: But ultimately, objective criteria is what protects your knee and sets you up for the long-term success.
• 28:22
  SPEAKER_00: And this research study supports it.
• 28:24
  SPEAKER_00: And I do think that just anecdotally, I've had people come back before nine months, like we might communicate about what that looks like from the research and the risk of that, but they have hit criteria, they have something on the line, and guess what?
• 28:37
  SPEAKER_00: We're gonna make it happen as long as they know the risk reward of it.
• 28:41
  SPEAKER_00: We've talked to all stakeholders involved, they understand that.
• 28:44
  SPEAKER_00: And so that's a very key component of this process.
• 28:48
  SPEAKER_00: So whether you're someone who's nine months out, you're 15 months out, you're seven months out, focus less on the number of that month, if you will, and more on that green light through strength testing, making sure your power, your range of motion, your knee symptoms, the sport-specific progressions are all the things that we want to look at, but measure them very objectively.
• 29:12
  SPEAKER_00: So that's gonna be super, super key here in this.
• 29:16
  SPEAKER_00: I just wanted to share one, we have pro athletes who are taking this long.
• 29:19
  SPEAKER_00: Two is that there's a paper that shows and pushes against the nine-month sweet spot timeline.
• 29:25
  SPEAKER_00: But you'll still see when you look at the details of this paper that nine months is still a very common thing, if not more than that.
• 29:33
  SPEAKER_00: So I want to normalize this for some people who think maybe that they can beat this, or that they think that um it's something that we just tell people, or maybe we need new research, right?
• 29:46
  SPEAKER_00: It really does showcase that objective testing is gonna be so key.
• 29:50
  SPEAKER_00: And I think it's the most important thing in this process, along with just an individualized approach, to be able to make sure that we reduce the risk of re-injury.
• 30:00
  SPEAKER_00: And that's gonna be what's so key.
• 30:02
  SPEAKER_00: We're trying to reduce how many ACL injuries happen, and it's just something that I think until we get better testing, better education around this process of how to rehab them, and then being able to make sure that we can individualize things to athletes and see them through this.
• 30:21
  SPEAKER_00: That's a system-based issue that I think we will be able to see ACL start to turn around.
• 30:27
  SPEAKER_00: I think also if we can get away from sports specialization too early in the process, that I think the ages from 12 to 18, we will see less ACL injuries, personally.
• 30:38
  SPEAKER_00: That's my own personal rec recommendation, my own opinion here.
• 30:42
  SPEAKER_00: But the ability to have athletes strength train more, develop themselves in a variety of ways versus playing one single sport every day all year round for club sports and school sports will be a massive game changer to help this as well.
• 30:57
  SPEAKER_00: But if we're talking about someone who's injured it and we're trying to prevent the next injury, testing, very good individualized programming, and being able to have expert guidance is going to be the thing that prevents that second ACL injury better than anything.
• 31:13
  SPEAKER_00: And I will stand by that.
• 31:15
  SPEAKER_00: And so I hope that this was helpful, y'all.
• 31:17
  SPEAKER_00: I wanted to break this down.
• 31:18
  SPEAKER_00: I feel like this nine-month sweet spot is something that's talked about a lot, but I also wanted to reference like what are the elite of the elite doing?
• 31:26
  SPEAKER_00: And if you look at other sports, they're doing the same thing for the most part.
• 31:30
  SPEAKER_00: And if they come in earlier than that, they probably have something on the line for that.
• 31:35
  SPEAKER_00: Like the Olympics happen, and I read a story about an athlete who basically went through it as quickly as she could so she could do the Olympic event.
• 31:45
  SPEAKER_00: Now, it's an Olympic event, it happens every four years.
• 31:49
  SPEAKER_00: Also, you're not sure if you're gonna make it because four years is a very big turnover in an athlete time frame, especially if you're on the older side of being an athlete, right?
• 31:57
  SPEAKER_00: And I'm talking about you're in your early 20s, right?
• 32:01
  SPEAKER_00: Like it's not like we see a ton of people in their 30s competing in the Olympics.
• 32:06
  SPEAKER_00: So that's something that's at stake.
• 32:09
  SPEAKER_00: So I hope that this shares some perspective for you guys.
• 32:12
  SPEAKER_00: I will link some of this info in the show notes.
• 32:16
  SPEAKER_00: And if you have any feedback or if you have any thoughts on this, I would love to hear this.
• 32:21
  SPEAKER_00: Um, you can send me an Instagram message, you can send me an email, whatever that may be.
• 32:27
  SPEAKER_00: But I hope that you guys have a good rest of your day, night, morning.
• 32:32
  SPEAKER_00: I feel like with daylight savings time, it always feels like night now.
• 32:35
  SPEAKER_00: Um but uh we'll catch you next time on the podcast.
• 32:40
  SPEAKER_00: This is your host, Robbie Patel, signing off.