Latest / The ACL Athlete Podcast / 240 | A Hidden Factor in ACL Strength Testing – Familiarization

Transcript

240 | A Hidden Factor in ACL Strength Testing – Familiarization · 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 today we are talking about strength testing, specifically familiarization.
• 1:13
  SPEAKER_00: That's a long word.
• 1:15
  SPEAKER_00: Familiarization of strength testing.
• 1:18
  SPEAKER_00: I think this is an important topic to touch on.
• 1:21
  SPEAKER_00: And this is something that came up recently as I was talking with the team.
• 1:26
  SPEAKER_00: We were working through some different athletes and their test results and just comparing from one test to another test and trying to align that with also what we're seeing with what they're doing in the gym dynamically, to just correlate all the information and see, okay, does this all make sense?
• 1:44
  SPEAKER_00: And one thing that was interesting and that we see very consistently is that athletes, when they go to get a strength test done.
• 1:54
  SPEAKER_00: Now, let's say, for example, that they're actually getting tested legitimately, whether that is through a dynamometer or through an isokinetic machine, being able to actually get isolated quad strength testing or hamstring strength testing.
• 2:10
  SPEAKER_00: That is what we are talking about specifically here.
• 2:13
  SPEAKER_00: This concept will apply honestly to anything that is being tested or any performance-based measure for the athlete.
• 2:23
  SPEAKER_00: But specifically, I want to talk about strength testing because one, that's important.
• 2:27
  SPEAKER_00: Number two is that there's so much that matters with the process of testing, right?
• 2:34
  SPEAKER_00: So we're just gonna assume that the athlete is being tested appropriately, right?
• 2:40
  SPEAKER_00: The one thing that is interesting is that there is a familiarization process with getting tested.
• 2:49
  SPEAKER_00: And I just want you to kind of think about this for a second.
• 2:52
  SPEAKER_00: You've had an ACL injury and likely an ACL reconstruction, maybe not, or maybe a different type of procedure.
• 3:00
  SPEAKER_00: But with that said, majority are going to have an ACL reconstruction.
• 3:04
  SPEAKER_00: So you have either an allograph or an autograph.
• 3:07
  SPEAKER_00: And then comes a time where you're going to get strength tested.
• 3:11
  SPEAKER_00: Now, let's just use, for example, the three-month mark, a very common time frame.
• 3:16
  SPEAKER_00: You're far enough out from the surgery that you will get strength tested.
• 3:20
  SPEAKER_00: It's not too early where you might flare things up by kicking too hard.
• 3:24
  SPEAKER_00: And let's just take, for example, the quad strength test where you're just kicking into an immovable object, isometric testing to be able to see how much force can your quad produce or how much torque can it produce, right?
• 3:38
  SPEAKER_00: And we get an objective number, we get a data point, something that gives us a value for what that force stands for.
• 3:47
  SPEAKER_00: And so when athletes first get tested, and I see this all the time with athletes, I'm testing here, uh, whether it's athletes we see are getting tested by other people we know, we refer them to other places for our remote athletes.
• 4:00
  SPEAKER_00: This is something that is very common.
• 4:02
  SPEAKER_00: And what happens is that when this athlete is getting tested, one leading up to the testing, it's important to communicate about this and understand that this is not a make or break or a pass-fail type situation, especially at the three-month mark, y'all.
• 4:19
  SPEAKER_00: We know that the quad's gonna be weaker than the other side.
• 4:22
  SPEAKER_00: So then, therefore, this is not something that we're gonna surprise ourselves and be like, oh, 90% symmetry, and you're where you should be at nine months now.
• 4:31
  SPEAKER_00: No, we know it's gonna be weak.
• 4:33
  SPEAKER_00: We just want to assess and see how weak we are compared to the other side or what is the difference.
• 4:39
  SPEAKER_00: And so, therefore, communicating about this test, also not making it such a big deal of this test as a pass fail, but more so of saying it's a data point, right?
• 4:50
  SPEAKER_00: It's for us to collect information for us to continue to be more and more targeted with our exercise prescription, our program design to make this more tailored to you.
• 4:59
  SPEAKER_00: Because otherwise, we're just kind of flying blind, right?
• 5:02
  SPEAKER_00: If you don't test, you are guessing in this process.
• 5:05
  SPEAKER_00: And so this is something that we want to make sure we can get an objective measure on.
• 5:10
  SPEAKER_00: And so with testing, the narrative leading up to it is really important, not to make it a big deal, but then also to let them know hey, we're gonna look at some numbers with some of my athletes.
• 5:22
  SPEAKER_00: I don't even tell them, right?
• 5:23
  SPEAKER_00: They're used to maybe using the device in an endurance way or strength building way, but we are not quote unquote testing.
• 5:31
  SPEAKER_00: And that might be to just remove the anxiety and just kind of see as time goes on, leading up to the three-month mark.
• 5:38
  SPEAKER_00: But let's say we are doing the thing, we are gonna strength test, and that's what's gonna happen, right?
• 5:44
  SPEAKER_00: So then they get put into the position, right?
• 5:48
  SPEAKER_00: The setup typically they have an ankle strap on, and I'm thinking more of an isometric strength test with a dynamometer here.
• 5:56
  SPEAKER_00: They're sitting on some type of box, or maybe it's a knee extension machine with a device hooked up to it to be able to measure the load or the force being pulled out, just like basically what a weight scale does or a crane scale does.
• 6:11
  SPEAKER_00: That's essentially the same thing.
• 6:12
  SPEAKER_00: That's what a dynamometer is.
• 6:14
  SPEAKER_00: And so this athlete is getting set up and we are wanting to get this value, right?
• 6:21
  SPEAKER_00: So then there's this whole process of setup, educating, being able to let them warm up, understanding them, their status coming into it.
• 6:30
  SPEAKER_00: Are they dealing with pain?
• 6:31
  SPEAKER_00: Are they dealing with swelling?
• 6:32
  SPEAKER_00: Are they dealing with any soreness from sessions before?
• 6:36
  SPEAKER_00: Did they move a lot in that day?
• 6:38
  SPEAKER_00: We want to collect information to understand the context of what this testing is going to take place.
• 6:44
  SPEAKER_00: The other thing that is really key with this is that the setup is going to be really important to be consistent and the cueing.
• 6:52
  SPEAKER_00: You know, this is gonna be something that if I say kick out as hard as you can versus kick out as fast as you can, surprisingly, you're actually gonna kick out a little different because you're gonna jerk that machine or the setup if you go as fast, but if you kick out as hard, it might be a little different.
• 7:10
  SPEAKER_00: So the cueing matters a lot, the buildup to it matters a lot.
• 7:14
  SPEAKER_00: And so there's a familiarization with this process.
• 7:19
  SPEAKER_00: And I think this is something that really flies under the radar, but massively impacts your testing results during ACL rehab.
• 7:28
  SPEAKER_00: And so, here, for example, if there are athletes here in Atlanta, there's a hospital system that will do strength testing on an isokinetic machine at three, six, and nine months, which is awesome.
• 7:38
  SPEAKER_00: And so then, therefore, they will get their results at the three-month mark.
• 7:42
  SPEAKER_00: And the thing that is not often communicated to them is just basically the results of what we're seeing and also how to interpret that.
• 7:51
  SPEAKER_00: But then also, you know, for us to just kind of take this as a data point, it's helpful.
• 7:57
  SPEAKER_00: But also the familiarization of these tests matters so much more than we give it credit.
• 8:03
  SPEAKER_00: And the example I want to use here is imagine stepping into a gym for the first time, and someone tells you to test your max strength on a new machine you have never used before.
• 8:14
  SPEAKER_00: Never.
• 8:15
  SPEAKER_00: We could say it's a leg press, we could say it's a hack squat machine, it could be a knee extension machine.
• 8:20
  SPEAKER_00: And some of these are maybe a little bit more straightforward, but it's your first time stepping into the gym, right?
• 8:25
  SPEAKER_00: And so then if someone asks you to do a max strength test, odds are you're not going to give it a true reflection of your capabilities.
• 8:34
  SPEAKER_00: And it's not just because you're weak, but because you just don't know how to use the machine yet.
• 8:39
  SPEAKER_00: And that same principle applies to ACEL rehab testing here.
• 8:43
  SPEAKER_00: And that's the thing that's really important is that there is a learning effect with this process.
• 8:49
  SPEAKER_00: And so that's the thing that we need to make sure we understand as we interpret and analyze the results of these different tests.
• 8:58
  SPEAKER_00: And so familiarization is the process of getting used to a test, the movement, the setup, even the environment, the cueing, the communication of it, the duration of it.
• 9:10
  SPEAKER_00: When an athlete does a knee extension strength test, for example, using the isokinetic or handheld dynamometer, their first test is rarely their best.
• 9:20
  SPEAKER_00: And while you might say, Yeah, well, we'll do multiple repetitions, sure, but that doesn't change that specific moment.
• 9:27
  SPEAKER_00: And the thing is, is that that first test is often a reflection of their uncertainty or unfamiliarity rather than their actual quad strength.
• 9:38
  SPEAKER_00: And the thing that's always interesting in this is that sometimes athletes will get strength tested.
• 9:44
  SPEAKER_00: Let's say it's an isometric device and they have access to it regularly, then four weeks later, their numbers really jump up because then they are able to get familiar with it and they're like, oh, I've done this before, right?
• 9:58
  SPEAKER_00: If you've done a machine at the gym before, then you're gonna be like, oh, okay, I know what my parameters are, I know the feel of it.
• 10:07
  SPEAKER_00: And a lot of this is such a feel in this process, but not to mention the apprehension that also gets missed.
• 10:14
  SPEAKER_00: Y'all, like, this is hard.
• 10:16
  SPEAKER_00: You have just had major reconstructive surgery on the knee.
• 10:19
  SPEAKER_00: The last thing you want to do is kick out as hard as you can into something when you've been dealing with pain, swelling, all these limitations over the past few months, and your knee has basically been really challenging to work with, and all of a sudden they're asking you to do a maximum output of as hard as you can kicking out, right?
• 10:40
  SPEAKER_00: And while that might feel okay in reality, mentally, what's going on, even though we know that the knee won't snap, there are people who are thinking my knee might snap, right?
• 10:51
  SPEAKER_00: Kicking out as hard as you can, especially when you think about this ACL that is healing, my knee is still quote unquote fragile.
• 10:59
  SPEAKER_00: It's pretty normal.
• 11:00
  SPEAKER_00: And so then, therefore, you might even hold off on kicking out as hard as you can to feel things out.
• 11:06
  SPEAKER_00: So I think this is something that is really important to share with you guys because sometimes you will get these test results from your physical therapist or whoever's testing this and be like, oh, well, yeah, I'm pretty weak.
• 11:21
  SPEAKER_00: Like, this is really bad.
• 11:22
  SPEAKER_00: Or the interpretation of the results doesn't truly reflect your abilities.
• 11:27
  SPEAKER_00: And what we often find is that it doesn't necessarily align with where the athlete is and what other things they can do, like being able to take the stairs down, being able to single leg squat down, being able to get their knee into a good positive shin angle and knee over toe, right?
• 11:43
  SPEAKER_00: And then we're just like, well, this doesn't add up because this test is showing this, but they're able to do all these things, or vice versa, the test overestimated however much that this athlete could do because that usually the setup was bad.
• 11:59
  SPEAKER_00: And so then therefore, they can't do any of those things, but the strength overestimated it, right?
• 12:05
  SPEAKER_00: But today, really, from a familiarization standpoint, usually what happens here is that it's often underestimated due to that unfamiliarity with the device and with the test itself.
• 12:18
  SPEAKER_00: Think about the same thing with a jump test, right?
• 12:21
  SPEAKER_00: A lot of athletes, they have never been told to do a counter movement jump with their hands on their hips, or they haven't been told to do a drop vertical jump where they drop down and then they hit the ground as quickly as they can, they jump up and land, right?
• 12:34
  SPEAKER_00: That is not something that we are normally just doing in our everyday lives, and you usually aren't doing that unless you are being tested from a performance standpoint with a gym with a very specific group and setting.
• 12:49
  SPEAKER_00: Otherwise, it would be more so based on a rehab process like ACL rehab if they are testing those things.
• 12:56
  SPEAKER_00: But it's just gonna take time because you have to get used to it like anything else, a new skill, a new movement, and especially after an injury like this.
• 13:05
  SPEAKER_00: The thing that happens with this is that the test retest reliability improves, especially after you have more sessions with it.
• 13:13
  SPEAKER_00: And I see this very, very consistently when I see my athletes, they are so used to being strapped up to the dynamometer because we're not always strength testing.
• 13:22
  SPEAKER_00: I might be indirectly without them knowing it, but I embed these things within the sessions, and we might do endurance sets, for example, where they do long hold repeat isometrics, and we might test the waters a little bit depending on the day, how I'm feeling, how they're feeling, what I'm seeing, and the timing of everything.
• 13:41
  SPEAKER_00: So this is something that if they've done it enough, you're like, okay, they can almost like sit back and not even think about it and just like really push and just making sure that they are so used to this that we cannot fault familiarization as a problem with the results.
• 14:01
  SPEAKER_00: So this is the learning effect that we are looking at.
• 14:04
  SPEAKER_00: People just get better at the test just by doing it more, but it's not just because they're necessarily getting stronger.
• 14:10
  SPEAKER_00: So that's super important here.
• 14:12
  SPEAKER_00: The other thing that I touched on briefly was just setup inconsistencies.
• 14:17
  SPEAKER_00: So this is something that is a challenge because it is not very easy for people to just consistently set this thing up, and it just depends on the clinic, the setting, what this looks like, who is setting it up, their education.
• 14:33
  SPEAKER_00: But we're talking about seat position, the strap tightness, talking about joint angles, is it at the proper angle?
• 14:40
  SPEAKER_00: That's typically one of the things that we see.
• 14:42
  SPEAKER_00: And then is everything stabilized?
• 14:44
  SPEAKER_00: We want to reduce noise, and so this is something that can really skew results, especially if the athlete is tested by just different people with a similar device, if you will, but the setup is a little different or the queuing is different.
• 15:01
  SPEAKER_00: So we're not necessarily comparing apples to apples, is apples to oranges, because the queuing, the setup, the angle is all different, even though we are testing knee extension strength.
• 15:12
  SPEAKER_00: So that is one thing that I do want to add as a caveat here.
• 15:14
  SPEAKER_00: I've had a recent situation like this where one athlete was being tested somewhere else, and they were able to just, you know, lift their entire bodies up off the table.
• 15:24
  SPEAKER_00: And if you guys know, you can't do that with this quad knee extension test because that's basically pulling in your whole body, and of course, you're gonna output more strength.
• 15:35
  SPEAKER_00: The thing is, we gotta keep it rigid, locked down, and it needs to be only isolated to the knee, so then therefore they need to make sure it's only coming from the knee versus their bodies lifting up off the table, the box, whatever it is.
• 15:48
  SPEAKER_00: And so this athlete had a crazy overestimation of the testing results.
• 15:54
  SPEAKER_00: And I was like, this doesn't really add up to how she looks and how she's feeling and performing.
• 16:00
  SPEAKER_00: And then I tested it and there was a 30, 40% difference.
• 16:04
  SPEAKER_00: So we had to have a conversation about this in terms of where the inconsistencies lie.
• 16:11
  SPEAKER_00: But that is something, again, more so can underestimate, but also overestimate.
• 16:17
  SPEAKER_00: So I did want to add that little caveat since we're talking about testing, getting familiar, and analyzing results of this, especially.
• 16:26
  SPEAKER_00: So, why does this matter?
• 16:28
  SPEAKER_00: Of course, y'all like re-injury rates are at an all-time high.
• 16:32
  SPEAKER_00: We know that return to sport rates are also at an all-time low.
• 16:36
  SPEAKER_00: So we need to make sure that we are making decisions based on good data and information.
• 16:42
  SPEAKER_00: Limb symmetry index is something that we are going to be using, targeting for certain criteria, like 70 to 80 percent for return to running, and then also getting 90, 95% and beyond for returning to performance and sport, right?
• 16:59
  SPEAKER_00: And so we just want to make sure that we are comparing the legs appropriately, making sure that they're not under tested due to that inexperience, and it can be something that maybe we also overestimate their readiness, right?
• 17:14
  SPEAKER_00: So that is something that is gonna be important, especially from a symmetry standpoint, because if they're not used to the test, then they may just have a lower output.
• 17:26
  SPEAKER_00: And then from there, if you're using symmetry alone, you might have two tires that are half flat or half full that you are comparing them to.
• 17:35
  SPEAKER_00: So that's gonna be an important factor within this.
• 17:38
  SPEAKER_00: And so this is something that I have just been putting a lot of thought into in terms of talking with our team, talking with our athletes to just make sure we don't overlook this one concept, and especially for someone myself going through my own rehab and having tested recently.
• 17:59
  SPEAKER_00: And there was one test that I did that was like I wasn't like super familiar with doing personally myself.
• 18:05
  SPEAKER_00: And so I've over time, as I have done these tests, I've gotten more familiar, my output has improved.
• 18:12
  SPEAKER_00: I have also gotten stronger, yes, but it's interesting to see this reference to my other leg as well.
• 18:18
  SPEAKER_00: And the familiarization played a big role in that.
• 18:21
  SPEAKER_00: And so the biggest thing here is let's let the athletes get familiar.
• 18:25
  SPEAKER_00: Let's do serial testing, where this could be every four to six weeks, even more frequent than that, based on time availability.
• 18:34
  SPEAKER_00: It doesn't have to be a full max effort test, it could be just getting the athlete used to doing it, and then also making sure that we have consistent setup protocols and making sure the queuing and everything, all the conditions are replicated as similar as possible.
• 18:51
  SPEAKER_00: And just letting them know that this is not their final test, the first test, especially.
• 18:56
  SPEAKER_00: Usually people improve over time.
• 19:00
  SPEAKER_00: Testing is a skill, it's not just an assessment.
• 19:04
  SPEAKER_00: So, this is something that I hope is helpful for y'all, especially if you're an ACL or listening to this and you're like, all right, I did a test at you know, month three and it just didn't hit where you wanted it to.
• 19:17
  SPEAKER_00: Take that for what it is, okay?
• 19:19
  SPEAKER_00: Like, yeah, that's information for us.
• 19:21
  SPEAKER_00: But then also, if you've never done that before, reference back to the gym example, right?
• 19:27
  SPEAKER_00: If you walked into the gym, never done anything, and someone asked you to do a max bench press, how do you think you're gonna do?
• 19:34
  SPEAKER_00: You're probably not going to exert as hard as you can.
• 19:37
  SPEAKER_00: You might end up, you know, kind of keeping a little bit in the tank to protect yourself because it's new.
• 19:42
  SPEAKER_00: And then you're also going to get better over time.
• 19:46
  SPEAKER_00: But the caveat here is that let's say you also had a chest injury that you're healing from or a shoulder injury, right?
• 19:53
  SPEAKER_00: That's gonna make you a little bit more hesitant if that's your first time.
• 19:57
  SPEAKER_00: So that's something that I hope is helpful for you guys as you're going through this process.
• 20:02
  SPEAKER_00: If you have any questions, let me know.
• 20:04
  SPEAKER_00: Otherwise, I will catch you next week on the next episode.
• 20:08
  SPEAKER_00: This is your host, Robbie Patel, signing off.