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290 | The Fear Of Damaging Your New Graft After ACL Surgery · 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: Robbie 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: I'm gonna start off this episode by saying your graft is super strong when it gets put in there.
• 1:07
  SPEAKER_00: Don't feel like you need to walk on eggshells, but also don't be dumb.
• 1:12
  SPEAKER_00: But you don't need to feel fragile or scared you're gonna mess it up.
• 1:18
  SPEAKER_00: It's locked in there after that surgery.
• 1:20
  SPEAKER_00: And I feel like you guys need to hear this.
• 1:22
  SPEAKER_00: And I'm gonna elaborate more on this and really prove my point.
• 1:26
  SPEAKER_00: I dug into some research on this.
• 1:29
  SPEAKER_00: It's something that I have been wanting to share with you guys for some time.
• 1:33
  SPEAKER_00: And then I got this message from a listener that I'm gonna share here in a second that just prompted me to just be like, all right, it's time to do this, because I think it's really important because this is something that crosses every single ACLer's mind, no matter who you are, and I feel like you need to hear this.
• 1:51
  SPEAKER_00: And so I'm gonna share what this listener had said, and then we're gonna build off of this.
• 1:59
  SPEAKER_00: I'm near the one-year post op, and it's been a long, hard road to preach.
• 2:05
  SPEAKER_00: I thought of something that I wish someone had said to me early on that may help someone else starting this journey.
• 2:14
  SPEAKER_00: I was really scared of re-injury, and I wish my PT would have reassured me that my graft was strong enough to handle the exercises and weight bearing.
• 2:24
  SPEAKER_00: I wasn't given good direction on either of these, among many other inadequate things, and that has prolonged my recovery.
• 2:32
  SPEAKER_00: If you feel your PT is directionless and confusing, I'd recommend seeking a different PT.
• 2:38
  SPEAKER_00: I wholeheartedly agree.
• 2:40
  SPEAKER_00: This is from a listener who has kind of shared this, which I really appreciate getting this, because it's something that I feel like so many people resonate.
• 2:49
  SPEAKER_00: And I can't believe I haven't done an episode on this, honestly, because I personally resonate with it so much with my two ACL surgeries.
• 2:57
  SPEAKER_00: And I know so many people feel that.
• 2:59
  SPEAKER_00: Many of you listening.
• 3:01
  SPEAKER_00: And if you're a physical therapist or someone who supports an ACLer, this is real.
• 3:07
  SPEAKER_00: And it's something I also want to say, even if you're told this, it doesn't immediately mean that it's gone.
• 3:13
  SPEAKER_00: It's like, okay, cool, I could do everything, no worries, right?
• 3:17
  SPEAKER_00: It's still there, right?
• 3:18
  SPEAKER_00: It's such a physical, emotional, mental experience.
• 3:23
  SPEAKER_00: The injury, the trauma, and then going into having a major reconstructive surgery, or maybe multiple, and it's usually your first one, many people's first true medical experience.
• 3:36
  SPEAKER_00: I know it was mine.
• 3:37
  SPEAKER_00: And so it's something that's really daunting, right?
• 3:40
  SPEAKER_00: And it's upended your world, it has changed things dramatically.
• 3:45
  SPEAKER_00: And so, yeah, you have this new thing put into there, and the last thing you want to do is mess it up.
• 3:51
  SPEAKER_00: You feel fragile, and that is fair.
• 3:53
  SPEAKER_00: And so I don't want to just completely disregard it, even if I've said this in the past or you've heard other people say this.
• 4:00
  SPEAKER_00: Well, oh, it's fine, it's locked in there.
• 4:02
  SPEAKER_00: Today I want to really showcase this.
• 4:05
  SPEAKER_00: And this feeling is very real immediately, especially post-injury, and especially, especially post op.
• 4:13
  SPEAKER_00: And it can be a very pervasive thought well into weeks and months after ACL surgery.
• 4:20
  SPEAKER_00: It's not just like it's the first week or two.
• 4:22
  SPEAKER_00: Yeah, it's probably a bit more fresh and you're a bit more anxious and worried you're gonna do something wrong because you're fresh and you feel all the things, and you kind of feel like this kind of change of a chapter.
• 4:33
  SPEAKER_00: So you're like, let's not mess it up on the road to recovery.
• 4:36
  SPEAKER_00: And that first two to four week period, especially, though, that's where it really is in the back of your head a little bit.
• 4:43
  SPEAKER_00: It's a small little voice, even though you might feel like, okay, I'm fine, it's a small little voice there.
• 4:48
  SPEAKER_00: And it can still persist throughout the process.
• 4:51
  SPEAKER_00: Every time you may take a step, you move the leg, there's times where you feel some pain or some sort of zing, some sensation that you feel in your knee, then ensues, you know, depending on personalities and your experiences, you might freak out.
• 5:06
  SPEAKER_00: You might spiral a little bit of damaging the graft because you felt that thing.
• 5:10
  SPEAKER_00: And you may have been told the graft is fine again, but I guess still having that cross your mind often.
• 5:17
  SPEAKER_00: And what I will say is that most of the time people are not prepared for this surgery or process.
• 5:22
  SPEAKER_00: When I am talking with ACLers who go through this, you know, they have typically the surgical consultation.
• 5:30
  SPEAKER_00: There's no preparation on this, y'all.
• 5:32
  SPEAKER_00: There's not really much to expect.
• 5:34
  SPEAKER_00: They're like, okay, here's the medicine, here's the surgery, here's the graft, here's where you're gonna go to PT or go find a PT.
• 5:40
  SPEAKER_00: And a lot of times people don't find PT until after.
• 5:43
  SPEAKER_00: Now, if you're lucky prior to and find a really good PT, then they will prep you for all this.
• 5:48
  SPEAKER_00: Like we do this for all of our athletes who are getting ready for surgery, but there's so many people who get blindsided by thinking, oh, I'll just have surgery, and they come out of this and they're like, oh crap, like this, this is hard.
• 5:59
  SPEAKER_00: Like I feel pain and I feel worried and I'm worried about this knee.
• 6:04
  SPEAKER_00: And so it's real.
• 6:05
  SPEAKER_00: But the thing is that most people are not prepped for this.
• 6:08
  SPEAKER_00: So there's no way there was a conversation of like, oh, that knee is strong, that graft is in there.
• 6:12
  SPEAKER_00: Usually it's a very just kind of step-by-step process, and there's not a ton of expectation or education around these specific things, but it's the things that go on inside our heads.
• 6:23
  SPEAKER_00: Us as ACLers, we are thinking about these things, right?
• 6:28
  SPEAKER_00: And so you're scared, you will have to go through this process all over again if you mess this thing up.
• 6:33
  SPEAKER_00: So I get it, and I want to say this just flat out to you guys that the feeling of that graph being fragile, being scared you're gonna mess it up or damage it, it's super real.
• 6:46
  SPEAKER_00: And I get it, and it's especially something that I relate to because of having two of them.
• 6:55
  SPEAKER_00: You want to protect a major and expensive, don't let me forget to say this, an expensive surgery in most cases, and look at expense different ways.
• 7:04
  SPEAKER_00: Financial, it could be very time expensive, it could be very emotionally expensive, it could be physically expensive.
• 7:12
  SPEAKER_00: There are a lot of expenses that happen through this, and it's exhausting, and you hope to never relive it again.
• 7:20
  SPEAKER_00: And there are many people I get on calls with where they're like, I don't really care to do X, Y, and Z.
• 7:26
  SPEAKER_00: I just never want this to happen again to me, especially if you have had a really hard process, or maybe you're not as like very, very goal-driven towards this one thing.
• 7:37
  SPEAKER_00: There's so many people who have this happen where they're just like, please not let it happen to me again.
• 7:42
  SPEAKER_00: That's really it.
• 7:43
  SPEAKER_00: And so that's something that's really important in this.
• 7:48
  SPEAKER_00: And so I want to share about how I felt that I felt scared of doing something wrong, even after my second ACL reconstruction.
• 7:56
  SPEAKER_00: You'd think, oh, first ACL, you kind of got through it, so you got some experience, you understand how it feels.
• 8:02
  SPEAKER_00: If anything, I would say I was more anxious with my second ACL, and I was more protective of that one.
• 8:09
  SPEAKER_00: And I knew what the year in front of me looked like.
• 8:12
  SPEAKER_00: So every little zing, every weird sensation in that knee got louder, then it really deserved in my head space.
• 8:20
  SPEAKER_00: And also didn't have as much support for my second one as my first one.
• 8:24
  SPEAKER_00: So there were a lot of challenges with it.
• 8:27
  SPEAKER_00: But here are some of the scary situations we've had ACLers experience where they think something has gone wrong.
• 8:34
  SPEAKER_00: And it spans across so much, y'all.
• 8:36
  SPEAKER_00: So much.
• 8:37
  SPEAKER_00: Imagine that person is post-op ACL or your post-op ACL within the first days, the first, like let's say two weeks of it.
• 8:45
  SPEAKER_00: You know, it could be lifting their leg awkwardly, stepping weird, you know, their dog runs into their propped up leg.
• 8:54
  SPEAKER_00: It could be into the crutch while they're walking or gets tangled up.
• 8:58
  SPEAKER_00: And then it could be also losing balance, slipping, catching yourself, could be in the shower, could be getting into your car, out in public, or maybe it's like wet and icy.
• 9:08
  SPEAKER_00: So especially in the winter times, people need to be especially careful.
• 9:12
  SPEAKER_00: But that could be very common.
• 9:14
  SPEAKER_00: Reacting to a situation, just life happening, you know, you drop something, like you drop a glass or something and you react naturally, you know, helping your little kid, if you are a parent and your kid is about to, you know, fall off the edge of their couch or like hit their head.
• 9:31
  SPEAKER_00: Like I relate to that, having now a two and a half year old, where you're trying to save them from breaking their neck half the time.
• 9:37
  SPEAKER_00: So the thing is, like you have to react to things.
• 9:40
  SPEAKER_00: And if one of those has happened to you, and there's so many more as I shared, and your stomach dropped, you know, it's not necessarily you don't need to fault yourself for being dramatic.
• 9:50
  SPEAKER_00: That's exactly what this fear can do to people.
• 9:53
  SPEAKER_00: And it's fair to have the space to feel that.
• 9:56
  SPEAKER_00: And I'll never forget one of my first ACLers remotely never worked with her, got to see it through the whole process from prehab all the way to return to performance.
• 10:06
  SPEAKER_00: And when she was in her first week, her dog ran straight into the side of her knee.
• 10:12
  SPEAKER_00: And she had a big dog, big heavy dog.
• 10:15
  SPEAKER_00: And she freaked out, and for fair, fair reason, right?
• 10:20
  SPEAKER_00: And so we can we connected, she messaged me, and you know, she told me what had happened, and we talked through it, and we kind of talked through, you know, what is she is feeling, what does she feel in the moment, the mechanism of it, what was the thing after that.
• 10:35
  SPEAKER_00: And I was able to share with her, like, I think you're fine.
• 10:38
  SPEAKER_00: I know that it was scary, but I think you are fine.
• 10:41
  SPEAKER_00: And of course, we can't 100% predict that, but let's go ahead and see how exercises progress, how your knee responds, and then let's see how the coming days look.
• 10:51
  SPEAKER_00: And if there's anything that's concerning, you know, you alert me, and then we can also connect with your surgeon and see if that's worth checking out further.
• 11:00
  SPEAKER_00: Within a few days, it resolved.
• 11:01
  SPEAKER_00: Like the issue was not there.
• 11:03
  SPEAKER_00: It was more of the moment where it kind of panicked her, but then after that, it settled down.
• 11:08
  SPEAKER_00: But that was what was so helpful about having, you know, someone to be able to talk her through that.
• 11:13
  SPEAKER_00: Otherwise, she could have navigated the next days, weeks with anxiety, walking on eggshells, worried about doing exercises, further delaying her progress, and also just being worried about her knee.
• 11:25
  SPEAKER_00: And so these are things that really happen all the time to ACLers, and they may not even share it.
• 11:31
  SPEAKER_00: They're like, oh, it's a fluke, it's whatever, it's fine.
• 11:34
  SPEAKER_00: And so I think it's important to work with a provider to be able to share these things if they come up and to be able to talk through that and to be able to put your anxiety at bay.
• 11:46
  SPEAKER_00: That's what I think a good rehab provider and good team in your corner does.
• 11:50
  SPEAKER_00: So let's talk about what would actually be a concern, signs to look out for, because I think that's really important.
• 11:57
  SPEAKER_00: I'm not gonna just like dance around this and be like, ah, it's fine, like sunshine and rainbows.
• 12:02
  SPEAKER_00: Like, let's talk through what could possibly be signs of something being a red flag or a yellow flag.
• 12:08
  SPEAKER_00: A clear audible pop.
• 12:10
  SPEAKER_00: Everyone's familiar with this for the most part, but yeah, you feel a very big shift and a pop, right?
• 12:17
  SPEAKER_00: And so that's something that noticeably can be something to note.
• 12:22
  SPEAKER_00: And then, yeah, a true shift in the knee where you feel that joint kind of like come out of place a little bit and then go back.
• 12:28
  SPEAKER_00: I'll never forget that feeling on my first ACL tear where I felt that joint literally feel like it kind of slid to the side and dislocated when it popped and then went right back.
• 12:38
  SPEAKER_00: I'll never forget that sensation and that feeling.
• 12:41
  SPEAKER_00: And so you know what that's like.
• 12:43
  SPEAKER_00: And so that's something to be able to look out for.
• 12:46
  SPEAKER_00: A big spike in swelling.
• 12:48
  SPEAKER_00: You're gonna be dealing with swelling post op anyway, so you got to see if it's out of the abnormal, of course, accounting for anything else that could contribute to that, but a big spike in swelling and a big, big spike in pain.
• 13:01
  SPEAKER_00: Range of motion regresses, your extension gets worse, your flexion gets worse, or you kind of get stuck in a spot after it happens and it doesn't improve.
• 13:12
  SPEAKER_00: But in general, I would just say think about a massive just like regression to where you are.
• 13:17
  SPEAKER_00: And of course, you have a very specific moment where you notice something happened.
• 13:22
  SPEAKER_00: But the thing is, is that if it just doesn't improve after that, then yeah, it's worth getting looked at and talking with your team about.
• 13:31
  SPEAKER_00: But it's usually a true mechanism, and that's the thing that you have to kind of keep in mind here like a something to actually like put force on it to tear it, a sudden hard force, something like an aggressive slip or a fall with an aggressive like shift in that knee where that knee really bends in and you're like really dramatically fall, not just like a slip where you kind of lose balance and you catch yourself.
• 13:57
  SPEAKER_00: That's something really important here.
• 13:59
  SPEAKER_00: And it honestly looks very familiar to what a normal like ACL mechanism is, like the way you injure it in the first place.
• 14:08
  SPEAKER_00: Of course, you might not be on the field playing something or you know, on your skis, whatever it might be, but it will feel more like that than not, versus like just like a slight shift.
• 14:21
  SPEAKER_00: And so just for us to normalize this, it's gonna feel normal to feel zings, sharp pains, pops and crackles, noises, especially when you're close to surgery.
• 14:31
  SPEAKER_00: Everyone's gonna feel this.
• 14:33
  SPEAKER_00: I felt it all over the place, and I thought things were going wrong left and right.
• 14:37
  SPEAKER_00: But guess what?
• 14:38
  SPEAKER_00: You just went through a major reconstructive surgery, a second trauma that doesn't even include the injury, and also if those were close together, that even layers into what you feel in the pain and discomfort.
• 14:50
  SPEAKER_00: But then you have a second trauma via this surgery.
• 14:53
  SPEAKER_00: That pain that you're feeling post op should eventually fade into less of sharpness and more of dull pain and aches over the course of weeks, versus this consistent sharpness or breathtaking type pain.
• 15:07
  SPEAKER_00: To me, that shouldn't persist for a very long time.
• 15:10
  SPEAKER_00: It's very much noticeable in those first three to five days, that first week.
• 15:15
  SPEAKER_00: I'm not saying it can't go beyond that, but eventually you should see a shift from that heightened pain, that sharp post-op, and it should shift over the weeks towards a more dull achiness and less of those zings and sharpness.
• 15:32
  SPEAKER_00: Now, that's not across everyone, but that is a general trend you will find with the post-op process.
• 15:38
  SPEAKER_00: But I'm not gonna sit here and say it can't happen because you know, such is life and ACL rehab for that matter.
• 15:45
  SPEAKER_00: But in 99% of cases, you likely just stress that joint beyond its normal limits.
• 15:52
  SPEAKER_00: And let's remember post op any type of just added stress to it, like you slip and the knee kind of just jerks a little bit.
• 15:59
  SPEAKER_00: It's just not gonna like that.
• 16:01
  SPEAKER_00: It's just not.
• 16:02
  SPEAKER_00: It's like I'm not used to this, and right now, like I have the capacity of a snail, and so therefore, it's gonna react a little bit and say, like, I didn't like that.
• 16:12
  SPEAKER_00: There's a little bit of a zing, a sharpness, and a pain, but just know like it needs to be a bit more extreme.
• 16:17
  SPEAKER_00: You just kind of push it beyond its current like capacity and limits, and so then it's gonna talk to you a little bit because it's like I didn't like that quick movement.
• 18:30
  SPEAKER_00: And usually, in most cases, it settles down pretty quick in a few days.
• 18:35
  SPEAKER_00: But when in doubt, contact your surgeon and your physical therapist, give them a heads up, they can help you work through it.
• 18:42
  SPEAKER_00: I promise.
• 18:43
  SPEAKER_00: We have done this with so, so, so many of our ACLers over the years, especially remotely, and in 99% of situations, I can confidently say the graft is fine.
• 18:55
  SPEAKER_00: The biggest thing here is to be smart about what you're doing and set yourself up for success.
• 19:01
  SPEAKER_00: If you have to navigate a crowd or be on crutches in challenging conditions, plan for it, y'all.
• 19:08
  SPEAKER_00: Don't react to it, plan for it.
• 19:09
  SPEAKER_00: Be smart.
• 19:10
  SPEAKER_00: Shit happens.
• 19:11
  SPEAKER_00: Sorry if kids are listening.
• 19:13
  SPEAKER_00: But if we can plan around things, then most of these scenarios are avoidable.
• 19:19
  SPEAKER_00: Outside of it just being life.
• 19:20
  SPEAKER_00: Look, I get it if it's wet outside and you're walking outside.
• 19:23
  SPEAKER_00: If it's the shower and you kind of slip because the bathroom's wet, you know, that happens.
• 19:29
  SPEAKER_00: You know, you can't control your dog in 24-7 situations.
• 19:33
  SPEAKER_00: So that's the live things that happen that we can't always control.
• 19:36
  SPEAKER_00: But if you know that there's a situation you could put yourself at risk for, then just try to control it.
• 19:42
  SPEAKER_00: Like if you know you got a really slippery bath or shower and you're gonna attempt to stand up, let's think about that a little bit, right?
• 19:49
  SPEAKER_00: And just be safe.
• 19:51
  SPEAKER_00: I think that that's the biggest thing in plan for it.
• 19:54
  SPEAKER_00: Now, here's the main point of today's episode, and just knowing that your graft is super strong when it gets put in there.
• 20:01
  SPEAKER_00: And let me elaborate on this because your knee is gonna feel fragile, you just had that major surgery as we talked about.
• 20:09
  SPEAKER_00: But what I don't think is explained enough in this space is that that graft that the surgeon put into the knee, the moment it went into the knee, it was the strongest, or it'll be stronger than the ACL that you tore.
• 20:27
  SPEAKER_00: Yeah, so that new graft you're getting.
• 20:30
  SPEAKER_00: Now, if we're talking about a ACL repair where they try to repair the native ACL or the bear procedure, the different newer procedures that are not the most traditional ones, I'm not gonna talk about that today because we don't have the tensile strength of what the bear is.
• 20:46
  SPEAKER_00: These are repairs of the native ACL, and that is a different story.
• 20:51
  SPEAKER_00: Now, it doesn't mean that you still need to walk on eggshells, but with that said, that is something that we can't necessarily put numbers to just yet.
• 21:00
  SPEAKER_00: But with that said, with most of you listening, people who are gonna have reconstruction, people who are gonna get a new graft as an ACL, this is going to apply to you, especially to be able to say that the native ACL that you had is going to be technically weaker than what the new graph is that you're gonna get immediately.
• 21:23
  SPEAKER_00: So let me talk through this more.
• 21:25
  SPEAKER_00: And the thing that's gonna help this is I want to connect it to numbers.
• 21:29
  SPEAKER_00: Like you guys need to know what the data show is, and this is me geeking out on this, and I'll keep it super simple so that way you guys can be able to look at this, listen to this, and be able to say, okay, this makes sense, and there's data and biomechanics behind it.
• 21:44
  SPEAKER_00: So, in terms of looking at the numbers, Noise and colleagues back in 1984 tested the native human ACL and found it fails around 1700 to 2200 newtons of force.
• 21:59
  SPEAKER_00: So that's our current benchmark.
• 22:02
  SPEAKER_00: 1700 to about around 2200 newtons of force.
• 22:05
  SPEAKER_00: So that's the tensile strength of it.
• 22:08
  SPEAKER_00: So whenever that ACL is torn, you can imagine that basically the force on that particular ACL overrides, let's just say 1700 to 2200 newtons, and that's what tears it.
• 22:19
  SPEAKER_00: That's your benchmark.
• 22:21
  SPEAKER_00: Now here's your graft, the new graft that is getting put into there.
• 22:25
  SPEAKER_00: And remember, it's gonna be either an allograft or an autograft.
• 22:29
  SPEAKER_00: Allograft is taken from a cadaver, an autograph is taken from yourself, and what is typically most common, especially autograft, is going to be the hamstring, the quadricep tendon, or the patellar tendon.
• 22:42
  SPEAKER_00: And in most cases, the patellar tendon will have bone on both sides, and then the quad tendon could have a bone on one side, but I would say most of the time it's just soft tissue.
• 22:53
  SPEAKER_00: There's no bone, but it's very surgeon dependent.
• 22:56
  SPEAKER_00: Now, those are the two categories: autograph, allograft, and then you have the big three under the autographs.
• 23:02
  SPEAKER_00: Now, what I want to do is look at the ranges around these, and there's no clean one number across because the research can really vary.
• 23:12
  SPEAKER_00: There's a lot of kind of specificity around the graph setup, the way that they harvest it, the thickness, all these things.
• 23:20
  SPEAKER_00: But let's just kind of go through some of these.
• 23:22
  SPEAKER_00: So the patellar tendon, the actual prepared construct that goes in your knee tests at around 17, 1800 to up to 2,900 newtons.
• 23:33
  SPEAKER_00: And that's per Wilson research in 1999, noise in 1984, and Meheran review from 2020.
• 23:41
  SPEAKER_00: There's plenty of other studies as well, but these are really well cited studies.
• 23:46
  SPEAKER_00: And you know, that's something where you could see right around the native ACL, but then also above it.
• 23:51
  SPEAKER_00: And again, there could be some give or take between being a bit under and being over, but just know that it's gonna get in there and be pretty strong.
• 23:59
  SPEAKER_00: The native patellar tendon itself, crazy strong, like when it's actually.
• 24:04
  SPEAKER_00: Actually, there, like going from your patella to your tubotuberosity, that thing is super strong.
• 24:10
  SPEAKER_00: So taking that thing out and putting it as an ACL, you're in a really good spot.
• 24:14
  SPEAKER_00: Plus, you are getting bone on both sides, which has a little bit of, in my personal opinion, a cheat code because it's gonna embed into that bone a little bit faster than just the soft tissue grafts that are like the quad tendon or the hamstring or the allograft.
• 24:29
  SPEAKER_00: The hamstring swings kind of the widest, so there's different ways people will take that hamstring tendon or gracillus with it, which is an adductor tendon as well, and they'll either double bundle it or triple bundle it.
• 24:43
  SPEAKER_00: Again, this can kind of range from 2,400 newtons all the way up to 4,000 newtons.
• 24:49
  SPEAKER_00: And so this is the Wilson study again.
• 24:51
  SPEAKER_00: There's also a Hamner paper in 1999.
• 24:54
  SPEAKER_00: So the range can be 2400 to even 4,000, depending on how many strands your surgeon uses.
• 25:01
  SPEAKER_00: And strands means they literally bundle that thing.
• 25:04
  SPEAKER_00: So if they have it's a longer tendon, so they actually bundle it together.
• 25:08
  SPEAKER_00: So the thing about taking a piece of string and folding it into double or triple and quadruple and being able to harvest and use it that way.
• 25:18
  SPEAKER_00: And that's how they use that as a tendon, which is also what I have for both my ACLs.
• 25:24
  SPEAKER_00: Fun fact.
• 25:25
  SPEAKER_00: And so for the quad tendon, it sits at 2100 to 2300.
• 25:29
  SPEAKER_00: That's Meron in 2020, and allograft, which is the donor tissue, cadaver, can span really at the widest range.
• 25:37
  SPEAKER_00: It could be anywhere from like 1200 newtons on the low end up to 4600 newtons on the high end.
• 25:43
  SPEAKER_00: It depends on the donor tissue, patellar tendon, hamstring, tibialis, Achilles, quad tendon.
• 25:50
  SPEAKER_00: And that range comes from Banavets and colleagues in 2023.
• 25:54
  SPEAKER_00: And Banovets and colleagues also has similar numbers across these autograph tendons as well, usually in the 2000s, like uh the early 2000s, if you will, like 2000s being in newtons, so like 2200 newtons, for example.
• 26:11
  SPEAKER_00: But that's another study to reference.
• 26:13
  SPEAKER_00: But just know that there's real variance across the board.
• 26:16
  SPEAKER_00: But what doesn't change is that every single one of these ranges either matches or it really beats the native ACL when it goes in there.
• 26:25
  SPEAKER_00: And nobody in reality is walking around with a weaker ACL than what they failed with in the first place.
• 26:32
  SPEAKER_00: So just know that.
• 26:33
  SPEAKER_00: And the other thing that's really important with this is that you'll hear these tensile strength ranges in Newtons, but just know that that's just one part of it.
• 26:45
  SPEAKER_00: There's variance in these, and it doesn't necessarily tell the whole story of tensile strength.
• 26:50
  SPEAKER_00: And so I want to just kind of share this a little bit because everyone wants to argue across what's the best graft.
• 26:57
  SPEAKER_00: And you could look at these numbers and be like, oh, well, yeah, it's I mean, it could be allograph.
• 27:03
  SPEAKER_00: You look at just tensile strength, but there's so much that you have to look at within this of factors across graft types.
• 27:11
  SPEAKER_00: So when you're looking at cross-sectional area, think of how thick the graft is.
• 27:15
  SPEAKER_00: The bigger cross-section area generally means more raw material that can share across the load, right?
• 27:22
  SPEAKER_00: You have a thin rope versus a thicker rope, a thicker rope is going to be able to handle stress a little bit better.
• 27:28
  SPEAKER_00: And so that's the argument a lot of people will make against the quad tendon.
• 27:31
  SPEAKER_00: But again, too thick could be a problem too, because it could also create issues, especially in that femoral notch.
• 27:37
  SPEAKER_00: So just a note there.
• 27:39
  SPEAKER_00: Young's modulus, I remember learning this in PT school and talking through this in biomechanics and even in undergrad.
• 27:45
  SPEAKER_00: And this is always such a cool concept, but it's the material's natural toughness, it's how resistant the tissue itself is to stretching, independent of the size itself.
• 27:57
  SPEAKER_00: So the material it's made of is going to influence that.
• 28:01
  SPEAKER_00: And just know that the quad tendon versus patellar tendon versus hamstring tendon, those tendons aren't consistently the same of their material.
• 28:08
  SPEAKER_00: The makeup of those are a little different across.
• 28:11
  SPEAKER_00: And then you have stiffness.
• 28:13
  SPEAKER_00: That's how much the actual prepared graft can resist from stretching once it's built and it's sized.
• 28:20
  SPEAKER_00: So this one blends that material quality and that thickness together.
• 28:24
  SPEAKER_00: And the patellar tendon is a really good example here.
• 28:27
  SPEAKER_00: It has incredible stiffness.
• 28:29
  SPEAKER_00: You think about how much force that patellar tendon needs to transfer in the front of the knee in order to jump, run, sprint, all the things, decelerate.
• 28:38
  SPEAKER_00: And that patellar tendon has such a huge, huge component of that.
• 28:42
  SPEAKER_00: And so that beats the quad tendon, for example.
• 28:44
  SPEAKER_00: Although the quad tendon beats the thickness piece, so there's variance across these things.
• 28:50
  SPEAKER_00: So it's not just that, you know, tensile strength that's one thing, there's all these different categories that really influence the quality of the graph you get, but then also how long they can hold up for and what they can resist and what they can deal with.
• 29:08
  SPEAKER_00: So I think that those are really important.
• 29:11
  SPEAKER_00: And the last thing I want to kind of talk about here that I think is the most important from a post-op perspective is the fixation strength.
• 29:19
  SPEAKER_00: How well the graft is anchored into your bone tunnels.
• 29:23
  SPEAKER_00: So when they do the surgery, they're gonna be able to show where those bone tunnels are and they're gonna drill those holes where they're going to funnel it through the femur part and the tibia part.
• 29:34
  SPEAKER_00: That's your upper thigh bone and also your shin bone.
• 29:38
  SPEAKER_00: And they're going to be able to look at those and say, okay, well, early on, the weak point usually isn't the tissue, the graft itself that they harvested, it's the anchor points actually that it is still kind of settling in.
• 29:54
  SPEAKER_00: And that's where you have to see the buttons, or maybe someone has a screw.
• 29:57
  SPEAKER_00: And in some cases, there could be this tightrope that comes in, which is like this kind of fiber tape that they call it that people are using, like an internal brace is typically the term.
• 30:09
  SPEAKER_00: And that is something that they do along the ACL.
• 30:11
  SPEAKER_00: And I think there's value in that.
• 30:13
  SPEAKER_00: Um, the jury's still out, but I think that we're gonna see promising research on it, where that tightrope or that fiber internal brace is along the ACL, and so it helps to also create that tension and doesn't allow it to, you know, kind of stretch or allow it to kind of expand further than it needs to.
• 30:34
  SPEAKER_00: So just know it's locked in there with the screws, with the buttons, it's in there.
• 30:39
  SPEAKER_00: You don't really need to memorize any of this, and that was probably way longer than it needed to be.
• 30:44
  SPEAKER_00: But just know this that several properties are working together to hold your knee stable right after that surgery, but it's not just one single number.
• 30:53
  SPEAKER_00: And across every version of that combination, whether it's allographed, autographed, double, quadrupled, if we're talking about hamstring, you're starting from a good spot in terms of the graft itself, the strength of the graft.
• 31:09
  SPEAKER_00: It is going to be mind-boggling to me if you are early post-op and you do something and you tear right through the middle of that graft.
• 31:17
  SPEAKER_00: I would be absolutely shocked.
• 31:20
  SPEAKER_00: I would be more inclined to say like a fixation point is the thing that doesn't set as much.
• 31:25
  SPEAKER_00: But with that said, just know it's a screw and it is a button, and they lock that thing in there, they lock it in there.
• 31:33
  SPEAKER_00: They're going to keep that thing tight.
• 31:36
  SPEAKER_00: And so the graft is strong, that fixation point is strong, it is not fragile.
• 31:42
  SPEAKER_00: And here's one more thing that I think puts a lot of people at ease right away.
• 31:48
  SPEAKER_00: This fear that can start from day one.
• 31:51
  SPEAKER_00: You know, you have your knee that is straight post op, you come out of surgery, you wake up, and it's usually straight.
• 31:57
  SPEAKER_00: You might have a brace on it or an immobilizer.
• 32:00
  SPEAKER_00: You may not have any brace on it.
• 32:02
  SPEAKER_00: You might have an ace wrap, you might have kind of like some ice on it, whatever it might be, but it's straight.
• 32:08
  SPEAKER_00: And bending it has that just kind of logical feeling of doing something bad to the graft.
• 32:13
  SPEAKER_00: Because it's straight, when you try to bend that knee immediately, you're gonna feel hesitant because you're like, oh, I'm gonna do something wrong.
• 32:21
  SPEAKER_00: And I remember feeling this with both my surgeries.
• 32:24
  SPEAKER_00: You just, you know, just it's just the rested, fixed position.
• 32:27
  SPEAKER_00: So when you bend it, you're like, oh no, I'm gonna actually tear and stretch that graft.
• 32:31
  SPEAKER_00: And just know the more you go into knee flexion, you're actually decreasing the tension on the graft, on the ACL.
• 32:37
  SPEAKER_00: You are doing less to that ACL than when it is coming out of that surgery straight.
• 32:41
  SPEAKER_00: Whenever you are in the last 30 to zero degrees of extension, that's when the ACL is more taut.
• 32:47
  SPEAKER_00: When you bend that knee beyond that, and you know the foot is not fixated to the ground, you're actually taking tension off of that ACL.
• 32:54
  SPEAKER_00: It's getting slackened.
• 32:56
  SPEAKER_00: I don't know if that's the proper word, but it's there's more slack in the ACL as you bend it.
• 32:59
  SPEAKER_00: And so I think that's something to just share with you guys because you're decreasing the tension on it.
• 33:05
  SPEAKER_00: So going from straight to bending for range of motion, you're decreasing tension, not adding to it.
• 33:11
  SPEAKER_00: So the thing you're most scared of doing to bend that knee, you're feeling the pressure of the fluid and the swelling, you're feeling the pain sensation, of course, especially if you had a graph taken.
• 33:21
  SPEAKER_00: And then also you're feeling the incision, you're feeling the stretch of the stairy strips or the glue in the front of the knee, and it doesn't feel great when you're trying to bend it, but just know the ACL is fine.
• 33:32
  SPEAKER_00: The thing that is important is being able to, yes, move that knee, but just know that you're putting the least stress on it as you bend it.
• 33:39
  SPEAKER_00: So don't be scared to bend it.
• 33:41
  SPEAKER_00: That is something that's helpful, and people will be hesitant, but it will really help in the recovery to especially get that range of motion back, as you know.
• 33:50
  SPEAKER_00: And some of you might be like, Well, why am I talking so much about this?
• 33:54
  SPEAKER_00: And why is this so important?
• 33:57
  SPEAKER_00: Because one, almost every ACL there feels this.
• 34:00
  SPEAKER_00: Number two is that it's so important, and here's what happens when people are scared to move or to load because they don't want to mess up the graft.
• 34:10
  SPEAKER_00: There's this domino effect, and I've observed this so many times, and sadly, I've seen it on the end where people are stuck, they are not making progress, they're having issues, and it could be this one thing that was never discussed, and it's the thing that really triggers the first domino.
• 34:31
  SPEAKER_00: It could be a good or bad thing, but in this case, it's not great.
• 34:35
  SPEAKER_00: And that domino effect is it makes people afraid to do their exercises, to move their knee, afraid to progress and putting weight on their leg, afraid to load their leg, afraid to load heavier earlier, and to challenge themselves, which therefore leads to not regaining range of motion, not regaining their normal everyday function and things they need to be able to do for their activities of daily living, and then not be able to progress in strength, which leads to delays in the process.
• 35:06
  SPEAKER_00: And yes, I'm gonna say delays and that feeling of being behind, right?
• 35:12
  SPEAKER_00: And a prolonged recovery.
• 35:14
  SPEAKER_00: Especially if, like, let's say this drags out further than it needs to, if you're hesitant in the first weeks, then all this kind of kicks the can down the road, you don't push it as much, and then you do feel behind.
• 35:26
  SPEAKER_00: And then guess what?
• 35:27
  SPEAKER_00: If you only have 20 visits, 30 visits, let's say even 60 visits, and those get all occupied in the first three, four months, and then you don't have any insurance.
• 35:37
  SPEAKER_00: Guess what?
• 35:38
  SPEAKER_00: People aren't necessarily getting tested, they're not at that place where they can kind of push things yet.
• 35:43
  SPEAKER_00: They kind of do the DIY process of trying to figure it out on their own.
• 35:47
  SPEAKER_00: And inevitably, I think that sometimes this can also lead to injuries because people are not being educated on this, they feel scared to push things sometimes, and therefore there is a domino or a compounding effect that just kind of inevitably unfolds with this situation.
• 36:06
  SPEAKER_00: And the fear itself costs you more than the movement, like actually moving and doing and loading it ever would.
• 36:13
  SPEAKER_00: And I will stand by this until some sort of major research paper comes out to prove this wrong.
• 36:19
  SPEAKER_00: And the biggest thing that I find people that is still demonized that I am prepping a podcast episode on is doing knee extensions post op and doing open kinetic chain, and it's still so demonized in the space that surgeons scared it it's gonna stretch the graft.
• 36:36
  SPEAKER_00: PTs are still saying these things, and we see it all the time, y'all.
• 36:40
  SPEAKER_00: I had calls this week where people are like, My PT says let's not do this, it's gonna stretch your graft.
• 36:46
  SPEAKER_00: As much as we think it is an old saying, it is not, it is still very present, and you're leaving the biggest needle mover and movement on the table that you could possibly be doing.
• 36:57
  SPEAKER_00: And so this is one of those where the fear itself costs more than the movement ever would.
• 37:02
  SPEAKER_00: And I really feel that about seated knee extensions.
• 37:05
  SPEAKER_00: We need to load that, it targets the quad in isolation, and it's going to move the needle more than any single exercise that you do in ACL rehab.
• 37:14
  SPEAKER_00: And I will stand by that.
• 37:15
  SPEAKER_00: If there is one we needed to pick, that would be it.
• 37:18
  SPEAKER_00: Now you gotta do it in a progressive way, you gotta be smart about it, don't go hot out of the gate.
• 37:22
  SPEAKER_00: But it's the thing that will save most ACL rehabs, is if we can get the quad strong again.
• 37:29
  SPEAKER_00: And so this is why who you're working with is so freaking important, y'all.
• 37:36
  SPEAKER_00: And I will stand by this.
• 37:38
  SPEAKER_00: You probably feel like I'm a broken record at this point.
• 37:41
  SPEAKER_00: But the rehab professional and the provider, the PT, the coach that you decide to work with will be the person that is the most influencing decision that you will ever make in this ACL rehab process.
• 37:52
  SPEAKER_00: Ever.
• 37:53
  SPEAKER_00: It's not the surgeon, it's not Joe Schmoe, who's the trainer.
• 37:57
  SPEAKER_00: Like your rehab provider to get you through this long, hard process will be the thing that makes or breaks this process.
• 38:03
  SPEAKER_00: Now, biology aside, we can't control all those things.
• 38:07
  SPEAKER_00: But if you're saying biology is working with you and you need the proper guidance and the proper structure and the planning, this is where it's going to be a game changer.
• 38:16
  SPEAKER_00: Because the right PT would have told you this prior to the surgery, and you would have had this consistently communicated.
• 38:23
  SPEAKER_00: So that way it's built into your programming, your communication.
• 38:27
  SPEAKER_00: You talk through these things.
• 38:29
  SPEAKER_00: There's not a single athlete we don't talk through with this.
• 38:32
  SPEAKER_00: And we sometimes have to have these conversations when people are, you know, finishing their other PT and they're four months out, six months out, 12 months out, and they're still scared to move their knee because they're scared they're going to tear their ACL.
• 38:43
  SPEAKER_00: And we're like, this is actually costing you more than being able to push it and get your knee in a better place.
• 38:49
  SPEAKER_00: And so this is why it's so important.
• 38:51
  SPEAKER_00: This is why I care about it so much because someone reached out and shared this to me.
• 38:55
  SPEAKER_00: That's 12 months of this person who could have been spared within a week or two, and maybe the first month of just communicated by her PT that, hey, like this is where it's at.
• 39:08
  SPEAKER_00: Understand to normalize this feeling, but also know, like, I'm promise I'm gonna give you things that are gonna be within your threshold that we're not going to do any damage to it.
• 39:17
  SPEAKER_00: And that's a good provider, right?
• 39:19
  SPEAKER_00: And so nobody reassured her, nobody gave her direction, and it prolonged her recovery.
• 39:26
  SPEAKER_00: And so, my goal of this episode is I'm gonna put your guard down.
• 39:30
  SPEAKER_00: I want you to know you're not going to damage or tear the graft.
• 39:34
  SPEAKER_00: You don't need to walk on eggshells in this process or feel like it's gonna tear on some quick bend step or stepping off a curb or something, like you're fine.
• 39:44
  SPEAKER_00: Now, look, don't be stupid and think it's an invincible thing.
• 39:48
  SPEAKER_00: Yeah, there is a sensitive period of the three to nine month mark, especially three to six months, where that graft is going ligamentization.
• 39:55
  SPEAKER_00: So it doesn't mean, hey, go all out at three months and go cut, pivot, do all the things.
• 40:01
  SPEAKER_00: And that's where we just have to be smart about this process.
• 40:05
  SPEAKER_00: And most of the time, though, most of you who are worried about it already are already so careful that honestly, you have literally nothing to worry about.
• 40:15
  SPEAKER_00: The people who are thinking about this all the time, you literally have zero concerns about there ever really being an issue, if I'm being honest, because you're already thinking about it.
• 40:23
  SPEAKER_00: So then, therefore, you're being a bit more cautious, and therefore you're not gonna be that person who goes out there and does something stupid at, you know, month four or five, right?
• 40:32
  SPEAKER_00: But that's something that I think is so important.
• 40:36
  SPEAKER_00: I know these episodes have gotten so long, but I really hope that you are able to listen to this and get value from this and see numbers and understand this and understand this from someone who's gone through it twice, who has felt this.
• 40:49
  SPEAKER_00: And so I'm gonna finish this the way that I started it.
• 40:53
  SPEAKER_00: Your graft is super strong when it gets put in there.
• 40:56
  SPEAKER_00: Do not walk on eggshells in this process, it will it will do more harm than good.
• 41:02
  SPEAKER_00: Don't be dumb.
• 41:04
  SPEAKER_00: You don't need to feel fragile ever in this process, and I know it can feel that way, but you don't need to feel that way.
• 41:10
  SPEAKER_00: You're resilient, you're strong, you can do this thing, and you don't need to feel scared.
• 41:16
  SPEAKER_00: You're going to mess it up.
• 41:18
  SPEAKER_00: You know, this is something that as long as you're being intentional and you're working with somebody who knows what they're talking about, then you're gonna be fine.
• 41:27
  SPEAKER_00: If you're not working with someone who doesn't know what they're talking about, change it.
• 41:31
  SPEAKER_00: Do something different.
• 41:33
  SPEAKER_00: And it's something where you got to think about what is the cost of that?
• 41:37
  SPEAKER_00: What is the cost of an action?
• 41:39
  SPEAKER_00: What is the cost of six months from now if you're still in the same place thinking about where you are because you just didn't change anything?
• 41:46
  SPEAKER_00: So if you had one single thing to change is to work with someone who knows this process, do not do it yourself.
• 41:53
  SPEAKER_00: We have physical therapists on our roster.
• 41:56
  SPEAKER_00: I tell people this because not just because, oh, like we work with PTs, it's because we don't get trained in this in school.
• 42:03
  SPEAKER_00: This is such a hard recovery.
• 42:06
  SPEAKER_00: And it's something that even PTs who we mentor, and this is PTs who have gone through our mentorship who are still choosing to work with us.
• 42:15
  SPEAKER_00: It is by choice because they don't feel comfortable enough or they also just don't want to handle it themselves.
• 42:21
  SPEAKER_00: So we are working with physical therapists who could guide themselves, but they're choosing not to.
• 42:27
  SPEAKER_00: And that's one thing to kind of put in perspective for you guys is that they spent hundreds of thousands of dollars going through school and they're still choosing to find help, even though they have been educated on this a bit more than most.
• 42:40
  SPEAKER_00: So that's really important here.
• 42:42
  SPEAKER_00: So make a good decision here on that because I promise it can make the difference in where you are in a week, in the way that you feel in a week, and especially where you're at in three months, six months, and especially what you care about most in your life.
• 42:54
  SPEAKER_00: If you need help, we're here.
• 42:56
  SPEAKER_00: We're here to help.
• 42:57
  SPEAKER_00: We would love to help you.
• 42:58
  SPEAKER_00: You can look at the show notes.
• 43:00
  SPEAKER_00: If you are looking for help from anywhere in the world, we are here.
• 43:04
  SPEAKER_00: If you need help to find someone local to you, we're also here to be able to be a resource to point you in that direction.
• 43:10
  SPEAKER_00: All that I care is find an ACL specialist to work with and just know that that graft is locked in there.
• 43:18
  SPEAKER_00: Go do the freaking thing.
• 43:19
  SPEAKER_00: Until next time, y'all.
• 43:21
  SPEAKER_00: This is your host, Robbie Patel, signing off.