Latest / The ACL Athlete Podcast / 274 | Structure Outside of PT Is Not Optional in ACL Rehab

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274 | Structure Outside of PT Is Not Optional 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.
• 1:00
  SPEAKER_00: What is up, team, and welcome back to another episode on the ACL Athlete Podcast.
• 1:05
  SPEAKER_00: Today's episode is one that I've been circling for quite a while now.
• 1:12
  SPEAKER_00: I've written it down as a topic four times in the last week alone, which for me means it's past due.
• 1:20
  SPEAKER_00: And we're talking about structure outside of your physical therapy sessions.
• 1:28
  SPEAKER_00: Not the structure you get during your PT sessions, you know, the exercises you might be doing, the stuff you do on the table.
• 1:35
  SPEAKER_00: It's the other hours.
• 1:36
  SPEAKER_00: The hours that, if I'm being honest, determine a huge part of how your ACL rehab actually goes.
• 1:44
  SPEAKER_00: And I want to start with some simple math first.
• 1:48
  SPEAKER_00: There are how many hours in a week?
• 1:51
  SPEAKER_00: 168 specifically.
• 1:55
  SPEAKER_00: If you're going to physical therapy three times a week, let's just say that is just what you start off with.
• 2:02
  SPEAKER_00: It's very common for people to be going three times a week as they start off post op.
• 2:07
  SPEAKER_00: And then yeah, it could go down to two times a week, one times a week.
• 2:12
  SPEAKER_00: Um, it could be every other week or every two weeks.
• 2:15
  SPEAKER_00: The frequency can change.
• 2:17
  SPEAKER_00: Now, a lot of times this is a little bit more determined based on your physical therapist.
• 2:23
  SPEAKER_00: They may say three times a week, they may say two times a week.
• 2:27
  SPEAKER_00: The interesting components to this is that there is also a productivity level that also can influence potentially outcomes for them.
• 2:35
  SPEAKER_00: And so I think that there is some math that needs to be figured out, especially if you have a certain cap on visits.
• 2:45
  SPEAKER_00: Let's say you have 20 visits or 30 visits for the year.
• 2:49
  SPEAKER_00: Maybe you have 60 or 120, or maybe unlimited.
• 2:53
  SPEAKER_00: Amazing.
• 2:54
  SPEAKER_00: That's very rarely most insurances.
• 2:57
  SPEAKER_00: And so this is something that needs to be factored in.
• 3:00
  SPEAKER_00: But coming back to you know the 168 hours in a week, if you're going three times a week, let's say each session is an hour, that's three hours of your week.
• 3:10
  SPEAKER_00: That's three of the 168 hours in the week.
• 3:14
  SPEAKER_00: If you're going twice a week, that drops to two hours.
• 3:17
  SPEAKER_00: Once a week, one hour a week.
• 3:19
  SPEAKER_00: And for a lot of athletes, especially internationally or in the mid to late stages of rehab, it might be once every two to four weeks.
• 3:29
  SPEAKER_00: You're essentially on your own the vast majority of the time.
• 3:33
  SPEAKER_00: And the other thing that's really important here is that it's not that there is a ton of communication in between those sessions.
• 3:41
  SPEAKER_00: A lot of time, by nature, the way physical therapy is and the way it's designed is that you know communicate in those sessions.
• 3:48
  SPEAKER_00: You get maybe something to take home, an HEP or home exercise program, just some things that you're doing, possibly.
• 3:56
  SPEAKER_00: Now, there are situations where people are not given anything or just kind of told, do what we're doing here.
• 4:01
  SPEAKER_00: It's crazy how much that is used.
• 4:03
  SPEAKER_00: And I think that is more so because, in reality, physical therapists, it's a very high volume-based structure of a model.
• 4:13
  SPEAKER_00: So there's not a lot of time to individualize things.
• 4:16
  SPEAKER_00: It's just the way that healthcare is, it is the same in the US, and it is also in other systems where it's socialized medicine.
• 4:25
  SPEAKER_00: So there's no perfect system, it's just not designed very well for individualization.
• 4:31
  SPEAKER_00: That makes it hard.
• 4:32
  SPEAKER_00: And so, like I'm saying, you're on your own a vast majority of the time, especially if the frequency is less than even two times a week, right?
• 4:43
  SPEAKER_00: That's still two hours in the week.
• 4:45
  SPEAKER_00: And now I've touched on pieces of this in other episodes, and I've talked about the gap that exists when PT frequency drops, about falling through the cracks, about why the healthcare system isn't built to support long-term ACL rehab.
• 5:00
  SPEAKER_00: So this isn't me trying to just bring that stuff back.
• 5:04
  SPEAKER_00: Of course, this plays into it, but today what I want to do is zoom in on some things that are more specific and more actionable.
• 5:13
  SPEAKER_00: Because the real issue isn't just the PT frequency is low or that the system is broken.
• 5:19
  SPEAKER_00: The real issue is that nobody is telling you what to do with the time you actually have.
• 5:26
  SPEAKER_00: That's what we're trying to fix today.
• 5:28
  SPEAKER_00: So let's get into it.
• 5:30
  SPEAKER_00: Here's the assumption I constantly see across all stages of ASO rehab, at all levels, athletes treat physical therapy as the full plan.
• 5:40
  SPEAKER_00: Everything that happens inside those sessions is rehab.
• 5:44
  SPEAKER_00: Everything outside of it is kind of like extra credit or optional.
• 5:48
  SPEAKER_00: Do it if you feel like it to some degree.
• 5:50
  SPEAKER_00: But they feel like the weight of things that are done are actually the things that are at PT.
• 5:56
  SPEAKER_00: And maybe the PT gave you a home exercise program, maybe they didn't.
• 6:01
  SPEAKER_00: Either way, the implicit message becomes show up to your sessions, do what we tell you, and the rest of the week will take care of itself.
• 6:09
  SPEAKER_00: That is just a general underlying assumption and feeling.
• 6:13
  SPEAKER_00: The thing is, is that this assumption is wrong, and it is costing so many ACLers, so many of you.
• 6:23
  SPEAKER_00: And I want to be clear here this isn't a knock on every PT out there.
• 6:28
  SPEAKER_00: I'm a physical therapist, I trained in this system, I know what we were and weren't taught, and I know what is happening currently.
• 6:36
  SPEAKER_00: I promise I am very well aware of that.
• 6:38
  SPEAKER_00: There's a structural gap in how rehab is typically framed, and it goes like this the PT session is the intervention.
• 6:46
  SPEAKER_00: You do the exercises and rehab there.
• 6:48
  SPEAKER_00: Everything outside of it is, you know, you're doing your exercises, but it's maintenance at best.
• 6:54
  SPEAKER_00: A lot of athletes assume that, like, okay, we'll do some of the exercises there, and then, you know, outside of your sessions, you know, you'll work on some things, but you move the needle in the PT sessions.
• 7:05
  SPEAKER_00: Now, don't get me wrong, if this is like truly structured two to three times a week, you're getting really intentional work in.
• 7:13
  SPEAKER_00: That is awesome.
• 7:15
  SPEAKER_00: But what I'm arguing today is the opposite of this is that the work you do outside of your physical therapy sessions when programmed well is where the majority of your adaptations can actually happen.
• 7:27
  SPEAKER_00: Your PT sessions should be informing, guiding, and adjusting that work.
• 7:31
  SPEAKER_00: But the volume, the intention, and the structure of your week that can live outside the clinic walls.
• 7:38
  SPEAKER_00: Let me just kind of paint you guys a little bit of a picture of what most athletes are actually doing between sessions, because I've had enough of these conversations to know these patterns.
• 7:48
  SPEAKER_00: The first group does basically nothing between sessions.
• 7:53
  SPEAKER_00: And the other thing I want to consider here is that in different phases, this might vary.
• 7:58
  SPEAKER_00: So if you are maybe prehab versus post op versus, let's just say in the mid-stages into the late stages, there could be some variation in this.
• 8:08
  SPEAKER_00: And that's where I think it's also really important to consider this because on the front end of this process, when you're first injured or post-op, you're gonna be reduced and constrained to what you can do.
• 8:22
  SPEAKER_00: It's not gonna be this full-fledged strength and conditioning program because obviously the priority is to get the knee in a good place, get it quiet, get it happy, get it calmed down while also working on strength and mobility, range of motion.
• 8:35
  SPEAKER_00: Those are things that are gonna be important here.
• 10:43
  SPEAKER_00: But that's going to be more frequent because you're working on range of motion pieces mostly every day, right?
• 10:49
  SPEAKER_00: When you're early post-op or post-injury.
• 10:53
  SPEAKER_00: That tends to change a little bit as time goes on, and you start to see this embedding of true exercise-based sessions where you're working on true strength and conditioning, weightlifting, you know, pushing the muscles, pushing positions, you know, later stages of pushing power and dynamic things.
• 11:11
  SPEAKER_00: But the thing is, is that early on it's a bit more limited because of just the way the post-op process is.
• 11:17
  SPEAKER_00: So you're having more frequency every day.
• 11:19
  SPEAKER_00: And then as time goes on, it might be two to four times a week of true training sessions, and then you're doing maybe some mobility stuff in between if you're still trying to close the gap on that.
• 11:31
  SPEAKER_00: Right.
• 11:31
  SPEAKER_00: Now, this is where it is really, really important because in this group that I mentioned, the first group, they're not doing anything between the sessions.
• 11:41
  SPEAKER_00: They show up to that PT, they do the work, and then they go home and they wait for the next appointment.
• 11:45
  SPEAKER_00: They're not skipping on purpose.
• 11:47
  SPEAKER_00: Nobody told them it was supposed to be otherwise.
• 11:50
  SPEAKER_00: The PT didn't give them much.
• 11:52
  SPEAKER_00: The surgeon said to take it easy.
• 11:55
  SPEAKER_00: Um, so they do.
• 11:56
  SPEAKER_00: Weeks go by, they feel like they're progressing because they're going to PT, but outside of that one or two hours a week, let's three say three hours max, their body isn't really being challenged at all, right?
• 12:09
  SPEAKER_00: And I think this is really important because you guys would be shocked at the number of people that I hear who are told do some of this stuff at home.
• 12:21
  SPEAKER_00: Or maybe don't do anything, just focus on the sessions that are here, and then you could just kind of rest in between that, right?
• 12:30
  SPEAKER_00: And that happens a lot, and it's crazy the amount of conversations I've had with ACLers who are just kind of told not to really do too much, especially in those early post-op phases.
• 12:40
  SPEAKER_00: And I find this a lot also in the mid-stages, where you know, maybe someone's going two times a week to PT and they're just doing stuff at PT, and then on the other days, they're not doing anything.
• 12:51
  SPEAKER_00: Anything outside of those two hours they spend there, they don't do anything at all in the week.
• 12:56
  SPEAKER_00: And this happens a lot more than we think.
• 12:58
  SPEAKER_00: So this is the first group.
• 13:00
  SPEAKER_00: Second group has an exercise program that is sent home with them.
• 13:04
  SPEAKER_00: It's a list of exercises their PT gave them.
• 13:07
  SPEAKER_00: It might be a list on a sheet of paper, it might be something through an app, if you will.
• 13:13
  SPEAKER_00: Again, not structured.
• 13:15
  SPEAKER_00: It's just more so of like 10, 15, sometimes even 20 exercises on a printed sheet of paper or on that app, right?
• 13:23
  SPEAKER_00: And this is where we see a lot of times people will share, they're like, this is all that I'm doing.
• 13:29
  SPEAKER_00: And sometimes I'll see that people are doing almost, you know, two to three hours of work two to three times a day.
• 13:36
  SPEAKER_00: And this is almost the opposite side of things, too.
• 13:39
  SPEAKER_00: They're doing their best work to do this and get through it, but that list hasn't also changed in six weeks and it's almost compounded.
• 13:47
  SPEAKER_00: It started with five, it started to get to 10, 15, 20.
• 13:51
  SPEAKER_00: Half the exercises are from the first month of post op.
• 13:55
  SPEAKER_00: Nobody explained the purpose behind any of them or when to progress, what to take away.
• 13:59
  SPEAKER_00: So they're being compliant, putting in the time, but the quality and the intent of that work is all over the place.
• 14:06
  SPEAKER_00: I call a lot of this junk volume.
• 14:08
  SPEAKER_00: People could reduce this by 50 to 75%, have five to eight exercises that they are hitting hard, the right intensity, the right intention, the right recovery, the right movements, repetitions, and they will move the needle versus doing 20 exercises because more is not always better in this process.
• 14:30
  SPEAKER_00: And I promise you this.
• 14:31
  SPEAKER_00: The third group is doing their own thing, they're doing the DIY process, YouTube ACL rehab videos, right at threads, Instagram, tons of posts.
• 14:41
  SPEAKER_00: They have an ACL little folder on their Instagram that they just save exercises to and they're like, let me try this.
• 14:46
  SPEAKER_00: This looks cool.
• 14:47
  SPEAKER_00: They're piecing something together, and honestly, I give them credit for the effort.
• 14:52
  SPEAKER_00: You know, they're trying to fill in the gaps.
• 14:53
  SPEAKER_00: But what they've built is kind of like a Frankenstein program from 12 different resources.
• 15:00
  SPEAKER_00: Uh, and I won't even call them resources, it's just 12 different places that they saw something with no coherent thread running through it.
• 15:07
  SPEAKER_00: There's no principles underlying it.
• 15:10
  SPEAKER_00: It's just, you know, this person said this exercise was good, and it's just piecing things together.
• 15:15
  SPEAKER_00: No rooted framework, principles, no criteria.
• 15:18
  SPEAKER_00: It's just the DIY process of it.
• 15:22
  SPEAKER_00: All three of these groups are working with the same core problem.
• 15:26
  SPEAKER_00: There's no structure, not real intention behind their days, and structure is what converts time spent into the progress made.
• 15:36
  SPEAKER_00: I cannot stress this enough.
• 15:39
  SPEAKER_00: Now I want to make an argument that I think is important, especially for where most of you are in this process.
• 15:46
  SPEAKER_00: You might be in the early post-op, or you might be kind of moving towards like the mid and late stages of ACL rehab.
• 15:54
  SPEAKER_00: This is where the details matter a lot.
• 15:57
  SPEAKER_00: And I'm going to say that every single phase is important in and of itself.
• 16:01
  SPEAKER_00: Every single detail, the guidance, the structure, everything that is built around it.
• 16:07
  SPEAKER_00: It's not just good enough when it's like generic or you know, 70% there, 80% there.
• 16:12
  SPEAKER_00: It needs to match you and meet you where you are, especially with your life dynamics.
• 16:17
  SPEAKER_00: Work, school, kids, family, all the other things you're involved with, different stressors, you know, things can change.
• 16:25
  SPEAKER_00: We're adjusting things every single week for our athletes because of just what life is throwing at them and because this process is dynamic, because we are dealing with the human body and the knee, right?
• 16:35
  SPEAKER_00: But the thing is that they have structure each and every week to know what they need to do, what that looks like, and also having it be adaptable.
• 16:42
  SPEAKER_00: It's not set in stone.
• 16:43
  SPEAKER_00: We can adjust as we need to.
• 16:45
  SPEAKER_00: The thing is, is that those mid and late stages, this is where details are going to be really important.
• 16:52
  SPEAKER_00: Again, not trying to take away from the early post op.
• 16:55
  SPEAKER_00: There's just a little bit more restriction.
• 16:57
  SPEAKER_00: And I will say if physical therapy can help us get by anywhere, it can be in maybe those early phases.
• 17:04
  SPEAKER_00: And I'm not saying this because it's just magically because our skill set is amazing in this.
• 17:10
  SPEAKER_00: It's more so that the early post-op is constrained, you're going to make the most progress.
• 17:17
  SPEAKER_00: And it's harder to mess up, if you will.
• 17:19
  SPEAKER_00: It is harder to mess up.
• 17:21
  SPEAKER_00: Don't get me wrong, there's still a lot of pieces that can be layered into it that could go wrong.
• 17:25
  SPEAKER_00: And we see it all the time, like people not getting extension, swollen knees, a lot of issues that people can get from these early phases, but it is harder to mess up.
• 17:36
  SPEAKER_00: And I would say PTs are maybe a little bit more familiar with compared to mid and late stages, which is where performance, strength, and conditioning is really going to be tapped into and that skill set, which is not something we learned in school.
• 17:51
  SPEAKER_00: And so these details matter a lot in mid and late stages because this is where the strength needs to reach real thresholds as well.
• 18:01
  SPEAKER_00: You can't necessarily always keep protecting things.
• 18:04
  SPEAKER_00: We got to start pushing things.
• 18:06
  SPEAKER_00: And this is where the power development kicks in, where plyometric capacity is continuing to be built, where more of the sport-specific movements start getting layered in.
• 18:14
  SPEAKER_00: And the demands of this phase are genuinely more complex and higher than the early post-op phases.
• 18:21
  SPEAKER_00: Early post-op, as I shared, you're constrained to that surgery.
• 18:24
  SPEAKER_00: There's a little bit more of a limited menu you can order from.
• 18:28
  SPEAKER_00: The variables are manageable, even for that general SPT.
• 18:33
  SPEAKER_00: But the further you get from surgery, the more this process starts to look like performance training.
• 18:38
  SPEAKER_00: And it should.
• 18:39
  SPEAKER_00: And that's a very different skill set entirely.
• 18:43
  SPEAKER_00: And I just want to share this.
• 18:45
  SPEAKER_00: Maybe you're new to this podcast, or maybe you've listened to all of my tangents before on other podcasts.
• 18:52
  SPEAKER_00: But we're taught in physical therapy school just very basics about the knee.
• 18:58
  SPEAKER_00: We're not taught how to rehab an ACL from start to finish.
• 19:02
  SPEAKER_00: We didn't even talk about testing an ACL rehab.
• 19:04
  SPEAKER_00: We talked about none of that.
• 19:06
  SPEAKER_00: We're trained to be generalists coming out of school, and that is not a criticism.
• 19:10
  SPEAKER_00: It's just the accuracy of what happens.
• 19:13
  SPEAKER_00: We're like primary care medicine.
• 19:15
  SPEAKER_00: You don't want to see a primary care medicine for a heart-related issue or neurological condition or some sort of autoimmune issue.
• 19:24
  SPEAKER_00: They're going to refer out to a specialist.
• 19:27
  SPEAKER_00: And that's truly how I feel the physical therapy world should be for particular cases and injuries.
• 19:33
  SPEAKER_00: Yes, a general ankle sprain, back pain, go to a generalist, right?
• 19:38
  SPEAKER_00: For something that has such a high reinjury risk, I wish that there was a little bit more of a specific avenue we could take that is specialized.
• 19:46
  SPEAKER_00: The thing is, is that because we come out as basically the primary care of PT, we are able to treat everything, but we're not good at anything.
• 19:54
  SPEAKER_00: It prepares us to evaluate and treat a ride range of conditions across the body.
• 20:00
  SPEAKER_00: ACL rehab gets some time, but we talk about the knee.
• 20:03
  SPEAKER_00: I think back to PT school, we talked about ACL for about two days.
• 20:08
  SPEAKER_00: That's about it.
• 20:10
  SPEAKER_00: And the thing is, is that we just talked about the ACL itself.
• 20:14
  SPEAKER_00: We talked about other ligaments that were also going on with it.
• 20:18
  SPEAKER_00: We didn't talk about progressions of different phases or exercises and things to do.
• 20:23
  SPEAKER_00: That was just not something that we covered.
• 20:25
  SPEAKER_00: Um it was just the knee in general that were included in those two days.
• 20:29
  SPEAKER_00: Return to sport gets basically no phase time.
• 20:33
  SPEAKER_00: And the programming, loading, the performance training that you know really drives, especially those mid and late stages of ACL rehab.
• 20:40
  SPEAKER_00: That stuff is rooted in strength and conditioning.
• 20:44
  SPEAKER_00: And that's something that PTs in general we just never formally studied.
• 20:49
  SPEAKER_00: And so this is something that is really hard in this space because I think there's this assumption that someone's a sports PT or someone says they're a sports medicine clinic, or we work with ACLs, and it's like, yes, you may be due, but a lot of times it's more of a marketing thing or something that they're like, yeah, I've seen an ACL or two, versus there being this true foundation of performance, strength and conditioning, and understanding those mid and late stages, especially.
• 21:20
  SPEAKER_00: And I came into physical therapy after being a strength and conditioning coach at the university level.
• 21:25
  SPEAKER_00: That background is what gave me the foundation to actually program mid and late stage ACL rehab.
• 21:30
  SPEAKER_00: Well, I wouldn't say my physical therapy brain really taps in very much.
• 21:34
  SPEAKER_00: It's all from the foundational SNC performance world where we get our athletes back, which is the most important pieces in this process, performance-based rehab.
• 21:44
  SPEAKER_00: And having torn my ACL twice, I also know firsthand what it feels like to be on the other side of a plan that doesn't account for what you need in those later months.
• 21:54
  SPEAKER_00: The irony is that the phase where the programming requirements are highest is also the phase where PT frequency tends to drop.
• 22:03
  SPEAKER_00: You're seeing your PT less, just as the prescription needs to get more sophisticated, if you will.
• 22:11
  SPEAKER_00: There's more things to balance, more moving pieces.
• 22:14
  SPEAKER_00: That mismatch is where a lot of athletes get stuck.
• 22:17
  SPEAKER_00: So when PT frequency is low and the programming demands are high, especially balancing everything, what fills that gap matters enormously.
• 22:27
  SPEAKER_00: It's so big, y'all.
• 22:28
  SPEAKER_00: And right now, for the most part, most people, the gap is being filled with nothing or a static home exercise program, a list of exercises, no structure to it, or random content from the internet.
• 22:43
  SPEAKER_00: And so usually people go through phases of this, and we see this all of the time.
• 22:50
  SPEAKER_00: Now, let me give you a different frame for thinking about your week.
• 22:53
  SPEAKER_00: Think of your week as a training week, not a PT attendance schedule, two times a week or three times a week.
• 23:00
  SPEAKER_00: Those two are very different things: a training week versus a PT attendance schedule.
• 23:06
  SPEAKER_00: A training week has structure, it has loading days and it has intentional recovery days, it has purpose built with each session, it has progressions built in from one week to the next.
• 23:20
  SPEAKER_00: The session you do on Tuesday connects to what your PT worked on Monday.
• 23:25
  SPEAKER_00: The session you do on Thursday is building on what you did Tuesday.
• 23:30
  SPEAKER_00: Nothing is random, nothing is just killing time.
• 23:34
  SPEAKER_00: Now, let's give you a real example of how this should actually look at different stages.
• 23:39
  SPEAKER_00: Early post op.
• 23:40
  SPEAKER_00: Let's say you're going to PT two to three times a week.
• 23:43
  SPEAKER_00: That's two to three hours of guided work if you're being guided, right?
• 23:47
  SPEAKER_00: It might be with PT some, it might be with a tech sum.
• 23:50
  SPEAKER_00: Hopefully you're with the PT the whole time.
• 23:52
  SPEAKER_00: But usually they are working with multiple people, especially if it's in network insurance based.
• 23:57
  SPEAKER_00: The remaining four to five days should have some intention behind them.
• 24:01
  SPEAKER_00: Doesn't mean you're going all out.
• 24:04
  SPEAKER_00: Loading the knee aggressively, it means mobility work that's actually progressing.
• 24:08
  SPEAKER_00: You're chipping away at it throughout the day.
• 24:11
  SPEAKER_00: It is intentionally structured.
• 24:14
  SPEAKER_00: Upper body and the uninvolved leg is getting training work, so you're not losing fitness across the board.
• 24:20
  SPEAKER_00: Low-level activation work for the quads and the hips and the ankles and the calves, the glutes.
• 24:27
  SPEAKER_00: The point is that even in the early phase, the non-PT days are not just throwaway days.
• 24:33
  SPEAKER_00: They're not the rest days, right?
• 24:34
  SPEAKER_00: They are intentionally programmed and built to make sure you don't lose your fitness, but then also that's where you are stacking the days that are going to be so important in the compound interest.
• 24:45
  SPEAKER_00: It's not just those two or three days, but it's more so making sure there is intentional structure behind each and every single day movement and the whole week, all seven days in a week.
• 24:57
  SPEAKER_00: Now, looking at the mid-stages, you're probably seeing your PT maybe once or twice a week if you're lucky based on your insurance and what this looks like.
• 25:06
  SPEAKER_00: I would say mid-stages, people are probably around the two times a week if you're going to in-person PT.
• 25:12
  SPEAKER_00: This is where strength is supposed to be climbing.
• 25:15
  SPEAKER_00: You're working on max strength, you're working on hypertrophy, maybe some power development.
• 25:19
  SPEAKER_00: Your quad and hamstring need to be getting legitimately challenged.
• 25:24
  SPEAKER_00: Piometric progressions need to start building.
• 25:26
  SPEAKER_00: If your non-PT days have no structure, these qualities don't develop, especially two times a week.
• 25:33
  SPEAKER_00: You can't build meaningful strength, especially in one day or two days a week.
• 25:40
  SPEAKER_00: Now, there are times where two days a week does move the needle, right?
• 25:45
  SPEAKER_00: Like, and I'm not going to say that that is something that we can't work with because we have people who do have you know constrained schedules.
• 25:53
  SPEAKER_00: But when we're looking at this in reality, I would say on average, most people are hitting three times a week, right?
• 25:59
  SPEAKER_00: And we're talking about a minimum effective dose.
• 26:01
  SPEAKER_00: We're talking about intentional time and volume to each muscle groups, especially your quads and hamstrings.
• 26:08
  SPEAKER_00: And usually what you'll see at PT is that it's not just like very intentional like training work for those one to two days or one to two hours in that week.
• 26:17
  SPEAKER_00: Usually you are doing some evaluating, usually you are doing some maybe some soft tissue work with your PT, or maybe there's some other components happening.
• 26:27
  SPEAKER_00: So it's not like in those one to two hours of those sessions, it's consistently intentional hard work.
• 26:32
  SPEAKER_00: And that is very, very important to consider here in cases like this.
• 26:38
  SPEAKER_00: And so when you're doing those one to two hours a week, that is something that we need to make sure we factor in what else is going on outside of that.
• 26:46
  SPEAKER_00: Strength is going to be built on accumulated load over time.
• 26:50
  SPEAKER_00: That accumulation is going to happen outside of the clinic.
• 26:54
  SPEAKER_00: The biggest thing is that with people in these phases, a lot of times they'll go to the PT clinics, they'll do their exercises, and then they'll go home and either do kind of like the filler, easier stuff in between, or they'll just be told, like, do some of the stuff we're doing here on a different gym day.
• 27:11
  SPEAKER_00: But no structure, no progressions, no repetitions, no, like, here's the session, here's how you're gonna follow this from start to finish.
• 27:20
  SPEAKER_00: It is just kind of a little bit more of communicating, like, here's what you should try, if they are given any advice outside of that.
• 27:29
  SPEAKER_00: Now, for the late stage, some of you are seeing a PT once a week, once every two weeks, once three weeks, once a month or less.
• 27:40
  SPEAKER_00: This is very, very common.
• 27:42
  SPEAKER_00: Maybe you've even been cleared by your surgeon and you're trying to figure out how to get back to your sport.
• 27:46
  SPEAKER_00: This is the phase where I see a lot of athletes drift.
• 27:51
  SPEAKER_00: They feel like they're done with formal rehab, they almost feel like they should be there, right?
• 27:56
  SPEAKER_00: But they're actually don't feel like they're there and they're not back to full performance, back to their sports and activities.
• 28:02
  SPEAKER_00: This is also an in-between phase where people can get stuck and without structure, especially here, because when they get cleared by the surgeon, there is also a lot of times that people at this point, like later in the process, let's say, you know, it's six months out, seven, eight months out, they've potentially also ran out of PT visits because that got eaten up on the first part of the process, the post op, especially, and maybe into the mid-stages.
• 28:29
  SPEAKER_00: And so a lot of times that's why there's less frequency in PT.
• 28:33
  SPEAKER_00: And the thing is, is that in these phases and without structure, athletes either jump back into things too fast or they kind of just stay stuck a little bit and neutral for a few months.
• 28:45
  SPEAKER_00: The principles across all these are the same.
• 28:47
  SPEAKER_00: Your week should be mapped out very clearly, very structured, not improvised by whatever they recommend from the in-person sessions, not based on how you feel when you wake up, a mapped week with intention behind every training day, every recovery day, every mobility session.
• 29:05
  SPEAKER_00: And so I want to be specific about what structure actually means because I don't want this to be vague.
• 29:11
  SPEAKER_00: Structure means knowing at the start of every week what days you're training and what is this for each session.
• 29:18
  SPEAKER_00: Is it, you know, a quad emphasized strength day?
• 29:23
  SPEAKER_00: Is it more of a mobility type circuit that you're working through?
• 29:26
  SPEAKER_00: Is it a combo of the two?
• 29:28
  SPEAKER_00: Are you spacing one earlier in the AM because you're still working on extension reflection?
• 29:33
  SPEAKER_00: Or maybe you're doing a PM session where there is just more of a training session that's strength focus on the quads, or just lower body in general?
• 29:42
  SPEAKER_00: Are we integrating some dynamic work, some plyometric work?
• 29:46
  SPEAKER_00: Are we progressing you to some on-field work?
• 29:48
  SPEAKER_00: Um, is there conditioning built in on days where you might not necessarily have particular training or even mobility work?
• 29:57
  SPEAKER_00: It might just be active recovery.
• 29:58
  SPEAKER_00: It might be go out for a walk, it might be to ride the bike for 20 minutes for active recovery and also layering in that sport exposure when you're at that stage.
• 30:09
  SPEAKER_00: So we want to make sure we structure things out.
• 30:11
  SPEAKER_00: For example, you know, for someone in maybe mid-stages, maybe we're doing a Monday, Wednesday, Friday, or maybe Monday, Wednesday, Friday, Saturday, right?
• 30:20
  SPEAKER_00: Are we returning to running?
• 30:22
  SPEAKER_00: Are we returning to sprinting?
• 30:23
  SPEAKER_00: Maybe we're embedding those at the end of sessions or on off days where maybe we can kind of balance the variables and the load.
• 30:31
  SPEAKER_00: Each of those days, we're not just saying like, okay, go hit some leg stuff and then go.
• 30:35
  SPEAKER_00: We're like, no, here's your movement prep, which is essentially your warm-up.
• 30:39
  SPEAKER_00: We're intentionally building in mobility stuff, activation stuff, getting the nervous system prepped, getting the tissues warm.
• 30:47
  SPEAKER_00: And then maybe it's building in, depending on the phase, some power dynamic stuff where we are working in different plyometric work, different med ball work, different things that are going to be important from a dynamic movement standpoint and plyometric standpoint.
• 31:04
  SPEAKER_00: And then we would probably be working into some sort of compound lift that's going to be very intentional to constrain maybe quad-based movement, hamstring or hip-based movement.
• 31:14
  SPEAKER_00: And then, of course, working into maybe some other jumping related work and then especially accessory work that's going to be so valuable.
• 31:21
  SPEAKER_00: Maybe that's going to be some uh hamstring isolation work, quad isolation work, of course, calf isolation work.
• 31:30
  SPEAKER_00: Um, it might be exploring different ranges of motion, different planes of motion.
• 31:35
  SPEAKER_00: So this is all gonna be based on where you are in the process, but the goal isn't for our athletes to figure that out.
• 31:40
  SPEAKER_00: We're not just gonna say, like, hey, like, okay, we have these ideas, go do this.
• 31:44
  SPEAKER_00: We're gonna structure that and program that in.
• 31:46
  SPEAKER_00: That's so important.
• 31:48
  SPEAKER_00: You don't need to be the person that gets in your car and then types in, okay, this is what I want.
• 31:53
  SPEAKER_00: And then you have to pull out a roadmap to decide which road you're taking to the destination.
• 31:57
  SPEAKER_00: Instead, you type in the GPS address, and then the GPS takes care of it for you.
• 32:03
  SPEAKER_00: That is what this should look like for every session, every single week you exist in this process.
• 32:08
  SPEAKER_00: Structure means each session has purpose that connects to where you are in the process, not just, you know, a laundry list of exercises, a reason those exercises were chosen, a target to hit, and a way to know whether you did enough or too much.
• 32:24
  SPEAKER_00: Like these are all super important and understanding what that dose is for us to move that needle forward and be very calculated and targeted at the goals we're trying to aim for, not just trying to throw things at the wall and seeing what sticks.
• 32:40
  SPEAKER_00: Structure means in this process, your programming is being updated consistently.
• 32:46
  SPEAKER_00: It's not the same thing for the next four weeks or the next eight weeks.
• 32:50
  SPEAKER_00: The ACL rehab process is volatile.
• 32:53
  SPEAKER_00: Responses change.
• 32:54
  SPEAKER_00: What challenged you, you know, two or three weeks ago needs to be different now.
• 32:58
  SPEAKER_00: If your program looks identical to what you had last month, you know, something might be wrong.
• 33:06
  SPEAKER_00: You know, and so I think that that's really important to consider.
• 33:09
  SPEAKER_00: Now, there are cases where we're navigating some setbacks and issues and where we don't necessarily want to change everything, right?
• 33:16
  SPEAKER_00: And we need to control some variables.
• 33:18
  SPEAKER_00: So I'm not saying it needs to change every week, but if you're making meaningful progress, not dealing with any setbacks or pain, your program needs to be changing pretty consistently.
• 33:29
  SPEAKER_00: And so for us, we work in four to six week blocks in order for us to be targeted towards meaningful goals and particular criteria we are aiming for.
• 33:38
  SPEAKER_00: And every athlete should always know what that is within the block that we're working in.
• 33:43
  SPEAKER_00: And so that is something that is very, very important in this process.
• 33:47
  SPEAKER_00: And so we would just want to make sure that it's not always constantly looking identical to what it looked like, you know, eight weeks ago.
• 33:55
  SPEAKER_00: That's something that's really important because we need progressive overload, and athletes also can get bored with this process.
• 34:02
  SPEAKER_00: And so we want to just make sure that we are being intentional about this.
• 34:06
  SPEAKER_00: And the other thing that I want to mention is that structure just means someone is reviewing what you're doing.
• 34:11
  SPEAKER_00: I can't stress this enough.
• 34:12
  SPEAKER_00: Not just giving you the plan and walking away, it's following up, adjusting when your knee reacts differently than expected.
• 34:20
  SPEAKER_00: It's going to with certain movements.
• 34:22
  SPEAKER_00: So that's what's important to communicate to your PT and coach to know, like, okay, what adjustments do we need to make?
• 34:27
  SPEAKER_00: Was this too, you know, sensitive for your knee?
• 34:30
  SPEAKER_00: Was this too much dose?
• 34:32
  SPEAKER_00: Was this too much volume?
• 34:34
  SPEAKER_00: Maybe this other position will work better.
• 34:36
  SPEAKER_00: You know, there's not this perfect set program and things to do.
• 34:40
  SPEAKER_00: It's going to be different based on a graph type, the person, you know, their structure, the things that they tolerate well.
• 34:45
  SPEAKER_00: And so we need to consider those things.
• 34:48
  SPEAKER_00: You know, this is important where you're having the questions answered that comes up on a Wednesday afternoon, you know, whenever your PT isn't necessarily around, right?
• 34:56
  SPEAKER_00: Like that's going to be important.
• 34:58
  SPEAKER_00: That accountability part of the structure, which can get lost.
• 35:01
  SPEAKER_00: It's not soft, it's what converts a written plan into something that's actually you're going to execute on, right?
• 35:10
  SPEAKER_00: And so what structure does not require is having someone physically next to you every day.
• 35:15
  SPEAKER_00: And I want to stress this because we have tested this over hundreds and hundreds and hundreds of ACLers remotely.
• 35:22
  SPEAKER_00: Structure does not require having someone physically next to you every day.
• 35:26
  SPEAKER_00: That's the thing about even remote coaching for us.
• 35:29
  SPEAKER_00: We build this entire model around, yes, I see people locally here in Atlanta, but remotely we work with people all over the world.
• 35:36
  SPEAKER_00: You can have elite-level structure, elite level programming, and genuine expertise oversight without being in the same room as your provider.
• 35:44
  SPEAKER_00: We do that, and there's so many friends and colleagues I know who do that all over the world.
• 35:50
  SPEAKER_00: And it is bizarre how much value you can gain from this.
• 35:53
  SPEAKER_00: In fact, I'd argue that for mid and late stage of ACL rehab specifically, a well-run remote program with daily programming and support, weekly check-ins, a coach who actually knows this injury delivers more structure than a twice a weekly in-person sessions that are mostly level level exercises, maybe passive treatment on the table, and you're not really getting much structure outside of that.
• 36:18
  SPEAKER_00: The room in this case doesn't build you.
• 36:21
  SPEAKER_00: The thing that's important is that the plan is what's really going to influence this more than anything.
• 36:27
  SPEAKER_00: And so I want to close with this.
• 36:29
  SPEAKER_00: Already long enough, all these podcast episodes recently have been long, but I feel like I've just needed to really share this is that I think the most important thing I can leave you with today, at some point in your ACL rehab, probably sooner than you expect, the formal PT sessions are going to become less frequent.
• 36:45
  SPEAKER_00: Maybe that's already where you are.
• 36:47
  SPEAKER_00: And when that happens, there are two ways it can go.
• 36:51
  SPEAKER_00: Option one, the structure disappears with the frequency.
• 36:54
  SPEAKER_00: You lose the appointments and you lose the plan.
• 36:56
  SPEAKER_00: You're doing your best, but you're improvising most of it.
• 37:00
  SPEAKER_00: Months go by, progress stalls.
• 37:03
  SPEAKER_00: You're not sure if you're ready to return to your sport or activity, but because honestly, nobody's been tracking it closely enough to tell you.
• 37:11
  SPEAKER_00: You haven't really been tested at all.
• 37:13
  SPEAKER_00: And then option two is the structure stays.
• 37:17
  SPEAKER_00: You know, the plan adapts to lower in-person frequency, but it doesn't disappear.
• 37:22
  SPEAKER_00: Your week is still mapped out.
• 37:23
  SPEAKER_00: There's clear criteria and intention behind every single session and week.
• 37:28
  SPEAKER_00: Your programming is still being updated.
• 37:31
  SPEAKER_00: Someone is still having eyes on you on what you're doing and how you're moving and making adjustments when the process requires it.
• 37:38
  SPEAKER_00: You know exactly where you are, where you're going, and what the next step looks like.
• 37:43
  SPEAKER_00: That second version is what you deserve.
• 37:45
  SPEAKER_00: I'm going to stress this.
• 37:46
  SPEAKER_00: This is what every human deserves in healthcare and in ACL rehab.
• 37:50
  SPEAKER_00: It's what every ACLer should be asking for from the very beginning of this process.
• 37:55
  SPEAKER_00: So wherever you are right now, here's what I want you to do: take an honest look of your week.
• 38:02
  SPEAKER_00: Not just the days you go to PT, all seven days.
• 38:06
  SPEAKER_00: Is there a real plan for the hours outside your sessions?
• 38:09
  SPEAKER_00: Is it written down somewhere?
• 38:11
  SPEAKER_00: Does it connect to where you are in your recovery?
• 38:13
  SPEAKER_00: Is it progressing from week to week?
• 38:16
  SPEAKER_00: And if you can say yes to all of that with confidence, you're in a good spot.
• 38:20
  SPEAKER_00: Keep going.
• 38:21
  SPEAKER_00: If you can't, that's where the work is, and that's where the biggest opportunity is in your ACL rehab right now.
• 38:28
  SPEAKER_00: There are 168 hours that are yours, and it is so important to make them count, y'all.
• 38:34
  SPEAKER_00: Yes, you're gonna be sleeping.
• 38:35
  SPEAKER_00: Yes, you're gonna be doing other stuff.
• 38:37
  SPEAKER_00: But with that said, like think about spending intentional, you know, five to eight hours a week, right?
• 38:44
  SPEAKER_00: Like just really, really focusing.
• 38:46
  SPEAKER_00: That doesn't mean you're just doing quad exercises on repeat, but very intentionally focused sessions in the week.
• 38:53
  SPEAKER_00: And you can get away with, you know, putting in three, four good hours as long as those are very intentionally structured based on where you are and where you need to go.
• 39:03
  SPEAKER_00: And the thing is, is that I just want to stress to you that if you do not have structure, if you do not feel like your week is mapped out, especially if you don't know where you are in this process objectively, and you don't know what the next steps are, you feel like you're flying blind, you need to make sure you find a different solution because it's not going to improve.
• 39:23
  SPEAKER_00: You can ask, and maybe that'll improve for temporarily, but usually that doesn't improve.
• 39:29
  SPEAKER_00: And so I ask you to follow your gut in this, make sure to make it right.
• 39:34
  SPEAKER_00: Make this your last ACL injury, your last rehab, do it right.
• 39:39
  SPEAKER_00: And as always, y'all, if you have questions or you're looking for more support through this process, we are here.
• 39:45
  SPEAKER_00: Find us at the ACL Athletes.
• 39:48
  SPEAKER_00: We are here to support you in any way that we can.
• 39:50
  SPEAKER_00: And if you feel like someone in your life needs to hear this, share this episode with them.
• 39:56
  SPEAKER_00: This hopefully can be helpful for many of you because I feel like many folks run into issues where they're just not getting the structure and the guidance that they need.
• 40:06
  SPEAKER_00: So let's make sure we do that.
• 40:08
  SPEAKER_00: Let's do the thing, y'all.
• 40:10
  SPEAKER_00: This is your host, Ravi Patel, signing off.