Latest / The ACL Athlete Podcast / 174 | Can You Accelerate the ACL Rehab Process? - Part 2

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174 | Can You Accelerate the ACL Rehab Process? - Part 2 · 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: What is up, team, and welcome back to another episode on the ACL Athlete Podcast.
• 1:06
  SPEAKER_00: So today we are continuing the conversation in this series answering the question: can you accelerate the ACL rehab process?
• 1:16
  SPEAKER_00: So, in part one, if you haven't listened to that yet, please go back and listen to that as it's important to help tee up this episode we're going to do today to create some context to help understand where people are coming from.
• 1:28
  SPEAKER_00: We talked mostly about the position from the ACLer or, you know, a supporting role like a parent or coach, someone else who is involved in the process, but especially from the lens of the ACL athlete themselves.
• 1:40
  SPEAKER_00: And then from the lens also from the companies and the surgeons and the PTs, the coaches, the people who claim they can get you back to sport faster.
• 1:50
  SPEAKER_00: Because we're always trying to move faster in an instant type society or instant gratification, being able to access things, being able to get answers very quickly, being able to expedite, if you will.
• 2:05
  SPEAKER_00: Why not do that with the ACL rehab process?
• 2:07
  SPEAKER_00: Can we do that?
• 2:09
  SPEAKER_00: And so that's the thing that a lot of people are looking for.
• 2:12
  SPEAKER_00: And there's a lot of marketing, um, and there's a lot of, you know, just trying to seek out sources to be able to potentially speed this process up.
• 2:21
  SPEAKER_00: And so we talked all about that in episode one and from the lens of these different people, and especially not to blame the ACL or especially if that's you listening, and you're like, well, yeah, I'm trying to speed this up.
• 2:34
  SPEAKER_00: How can I get back to doing the thing that I want to do?
• 2:37
  SPEAKER_00: And I don't blame you at all.
• 2:38
  SPEAKER_00: If there is some sort of way to do that, let's do it.
• 2:41
  SPEAKER_00: And so the part for today that I want to focus on is actually answering this question now that we've given a little bit of background, right?
• 2:51
  SPEAKER_00: And so if you have listened to episode one, you probably already know my answer.
• 2:56
  SPEAKER_00: If you follow me, you know my answer probably.
• 2:59
  SPEAKER_00: But I want to elaborate on this to give some context and to give you guys some understanding as to why you can't speed this process up.
• 3:07
  SPEAKER_00: And so, yep, that's my answer.
• 3:09
  SPEAKER_00: Can we accelerate ACL rehab?
• 3:11
  SPEAKER_00: And most importantly, returning to sport faster.
• 3:15
  SPEAKER_00: No, that's basically where we stand.
• 3:18
  SPEAKER_00: And based on May of 2024, this is where uh we are in terms of the landscape of ACL rehab.
• 3:26
  SPEAKER_00: And my opinion on this can always change, just as you guys know, more research can come out, technology can advance.
• 3:33
  SPEAKER_00: Um, there are things that can be a little crazy with the way technology is advancing, especially with AI and things.
• 3:40
  SPEAKER_00: Um, obviously, with ACL is probably not going to play a role, but with that said, it's going at lightning speeds.
• 3:46
  SPEAKER_00: And so, with that said, there are things that could come out, potentially new discoveries that maybe might change my mind.
• 3:52
  SPEAKER_00: And I hope so.
• 3:53
  SPEAKER_00: If there's a way that we can make this process uh, you know, three months, that'd be awesome.
• 3:59
  SPEAKER_00: Because then, therefore, a lot of people would be happier, it would be easier to do this.
• 4:03
  SPEAKER_00: Um, could you imagine someone who gets pregnant and you cut the nine-month time span into you know, four and a half months?
• 4:10
  SPEAKER_00: That would be a game changer.
• 4:11
  SPEAKER_00: So anyone would be happy to be able to do that.
• 4:15
  SPEAKER_00: So, with that said, though, with where we currently stand in 2024, we are currently in a place where my answer stands as can we accelerate the ACL rehab process and most importantly, really getting back to sport?
• 4:28
  SPEAKER_00: No.
• 4:29
  SPEAKER_00: And um, the thing is, I often compare this to you know, baking a cake in a sense, right?
• 4:35
  SPEAKER_00: You can't just turn up double the amount of heat, right?
• 4:39
  SPEAKER_00: And cook it at two times faster.
• 4:41
  SPEAKER_00: That's just not the case.
• 4:42
  SPEAKER_00: You know, you want to bake a cake, right?
• 4:44
  SPEAKER_00: And let's say you put it at 350 and it takes 45 minutes.
• 4:49
  SPEAKER_00: Well, if you put it at 700, it's not like it's gonna take, you know, 22.5 minutes to be able to cook the cake, right?
• 4:56
  SPEAKER_00: It just doesn't work that way.
• 4:58
  SPEAKER_00: And that's the way the human body, in all honesty, works in a very simplified and reductionist type view.
• 5:04
  SPEAKER_00: It's just so complex, and our human bodies and biologies just can't do things faster like that, even though we are getting better with medicine and technology.
• 5:16
  SPEAKER_00: This is where it's just something that we have to let it do its thing, and with the current state of where we're at.
• 5:22
  SPEAKER_00: So let's dive a little bit deeper because there are three things that I really, really want to hit on in terms of laying out why we can't currently, as we stand today, accelerate this process.
• 5:34
  SPEAKER_00: Number one and most important is what does the data and the research say, right?
• 5:41
  SPEAKER_00: If we just go based on anecdote, there are a lot of things that can lead us to think, oh, well, yeah, sure, we could do that.
• 5:48
  SPEAKER_00: And we might get lucky with that, but what does the comprehensive scientific method and the process itself show us?
• 5:55
  SPEAKER_00: So research shows us many reasons why it's a bad idea to rush back from a time standpoint, from increased reinjury rates, poor performance, strength deficits, fear of re-injury, etc.
• 6:07
  SPEAKER_00: There's an entire list of things that plays into when we rush back to playing the thing or doing the thing that we want to do, especially if it is a higher level cutting and pivoting sport.
• 6:21
  SPEAKER_00: Um, this is something where we are at an increased risk of re-injury, and also our performance uh is not typically that great because we haven't rebuilt to the place that we need to be.
• 6:32
  SPEAKER_00: And there's just issues, and there's a lot of mental pieces that also align with this as well.
• 6:37
  SPEAKER_00: And there's one that really sticks out it's by Grindham et al.
• 6:41
  SPEAKER_00: in 2016, and it says, for every month that return to sport is delayed until nine months after ACL reconstruction, the rate of re-injury for your knee is reduced by 51% for every month.
• 6:57
  SPEAKER_00: So that's a very, very big deal because I'm gonna take 51% for every month that is reduced up until nine months, right?
• 7:04
  SPEAKER_00: And we use nine months as this cutoff because this is where a lot of the research lands in terms of this threshold, if you will, of we know that an athlete can be in a good place in terms of just purely from a time standpoint.
• 7:18
  SPEAKER_00: That's not factoring in all the other criteria, it's just accounting for time, nine months.
• 7:24
  SPEAKER_00: Young athletes who return to sport before nine months, after an ACL reconstruction, have a rate of new injury seven times that of those who delay return.
• 7:36
  SPEAKER_00: So basically, we are saying that you have a 7x likelihood of re-injury in nine months, or before nine months, if you will, if you return to play.
• 7:47
  SPEAKER_00: And so this is by Bisher et al.
• 7:49
  SPEAKER_00: in 2020.
• 7:50
  SPEAKER_00: That's a study that was done in young athletes.
• 7:53
  SPEAKER_00: And while a lot of the research does focus on more of younger athletes, active athletes, that's where we pull this from because it just goes without saying, like, you know, with a lot of those sports, athletes will tear their ACL, especially if you're talking about higher level jumping, cutting, and pivoting, uh, you know, soccer, basketball, football, things of that nature, especially when there's contact involved as well.
• 8:16
  SPEAKER_00: You know, there's a whole lot of sports um that have ACL injuries as a part of this, right?
• 8:21
  SPEAKER_00: But those are ones, especially when it's demanding a lot from the knee, the lower body, a lot of reactivity, contact in the sports, those are ones with higher rates of re-injury and ACL tears in general.
• 8:33
  SPEAKER_00: And so then, therefore, this is something that's saying, you know, research and guys, I could share, you know, tons of articles on this, and I'm not gonna bore this podcast with this.
• 8:44
  SPEAKER_00: But with that said, the the overwhelming majority of research shows that basically up until nine months for right this point right now um is a safe point for us.
• 8:56
  SPEAKER_00: Um, so when we are told, you know, we can get you back in six months, based on what information, right?
• 9:03
  SPEAKER_00: Is it just based on uh it's promising you something that is something that you want to hear?
• 9:08
  SPEAKER_00: Um, and so I can get you there in six months, but you know, the research doesn't align with that notion of six months.
• 9:15
  SPEAKER_00: And if you guys can send me something that shows uh taking the whole body of research and saying, hey, six months is good, I'll jump on board with it.
• 9:25
  SPEAKER_00: But I feel like this is something that you see very, very repeatedly that nine months is a very good threshold for us.
• 9:32
  SPEAKER_00: And it's not just like nine months is just this magical threshold, just because.
• 9:37
  SPEAKER_00: Um, and I'll talk about that here in a second, why that plays a big role.
• 9:42
  SPEAKER_00: But it's just something that we notice in the research that that's a threshold that we see where reinjury rates and performance improves and re-injury rates are better.
• 9:52
  SPEAKER_00: So, this is something that we want to factor in is like what does the evidence show us?
• 9:57
  SPEAKER_00: Next, I want to talk about the ACL ligamentization process.
• 10:02
  SPEAKER_00: So, this is basically when the ACL turns from a tendon that goes into the knee at the reconstruction to a ligament.
• 10:10
  SPEAKER_00: Now, I'm talking about an ACL reconstruction, as I had mentioned previously, that's the focus of this.
• 10:16
  SPEAKER_00: Can you accelerate the ACL rehab process?
• 10:18
  SPEAKER_00: Is based on what majority of people go through, which is an ACL reconstruction.
• 10:23
  SPEAKER_00: They get a new ligament put into there for their new ACL.
• 10:27
  SPEAKER_00: And so this takes a minute to go from a tendon to a ligament.
• 10:31
  SPEAKER_00: And to remind you guys, a tendon attaches a muscle to bone, a ligament attaches bone to bone.
• 10:37
  SPEAKER_00: And so the ACL, the native ACL, attaches bone to bone.
• 10:41
  SPEAKER_00: It attaches the femur, your thigh bone, to your lower leg bone, your tibia.
• 10:46
  SPEAKER_00: And the thing is, is that when you get a new ACL, as we currently stand with the way that that new graft is put in there, it's a tendon.
• 10:55
  SPEAKER_00: It's either taken from yourself, which is usually the big three.
• 11:00
  SPEAKER_00: So you have your quad tendon, your patellar tendon, or your hamstring tendon, or it's a cadaver and it's usually pulled from one of those three.
• 11:07
  SPEAKER_00: It could be an Achilles tendon.
• 11:09
  SPEAKER_00: I've seen some other tendons used as well.
• 11:11
  SPEAKER_00: But with that said, um, it's still tendon, right?
• 11:15
  SPEAKER_00: And so for this process to unfold is called ligamentization.
• 11:21
  SPEAKER_00: So basically, we are turning that thing from a tendon and into a uh ligament, right?
• 11:27
  SPEAKER_00: We need it to be an ACL ligament to do its thing to naturally, you know, uh reduce the restraint of anterior translation of the knee, some rotational forces, what the native ACL did.
• 11:39
  SPEAKER_00: And we find, you know, when you look at the research, that that threshold for it to get to a place where that ligament is good enough or that tendon changes into a ligament is somewhere around the nine-month threshold, but can continue to happen over the course of two plus years.
• 11:59
  SPEAKER_00: Studies such as Clays, and that's spelled C-L-A-E-S et al.
• 12:06
  SPEAKER_00: 2011, uh Croningen 2012, and YAL, YAO, 2021.
• 12:14
  SPEAKER_00: These are all studies looking at ACL ligamentization process and it going through different phases of healing.
• 12:21
  SPEAKER_00: So we are talking about normal healing process, just like anything else in the body, right?
• 12:25
  SPEAKER_00: There's an inflammatory or like this early phase, there's a proliferation phase, remodeling phase, and a maturation phase.
• 12:32
  SPEAKER_00: This is all basic.
• 12:34
  SPEAKER_00: I remember in exercise physiology when we're learning tissue healing, these are the basic phases of what tissues go through in our body in order to turn over and heal.
• 12:44
  SPEAKER_00: When you get a cut, that's what happens.
• 12:46
  SPEAKER_00: It goes through an inflammatory phase, it goes through proliferation, remodeling, maturation phase.
• 12:51
  SPEAKER_00: Anything in your body for the most part does this.
• 12:53
  SPEAKER_00: And so the ACL is no different when it's going through a ligamentization process.
• 12:58
  SPEAKER_00: It's actually at its weakest from three to six months-ish.
• 13:03
  SPEAKER_00: Okay, there's some give or take here based on the research, but basically what you can imagine is that when this ACL goes in, it's actually at its strongest as a tendon.
• 13:14
  SPEAKER_00: And then it drops in its tensile strength and its strength overall because it's being broken down by the body and it's going through that healing process and being turned over into a ligament.
• 13:25
  SPEAKER_00: And so then what happens is that it starts at a very, very high uh tensile strength and then it comes down and then it drops really low.
• 13:33
  SPEAKER_00: And then it starts to come back up slowly over time, but that's over the periods of months.
• 13:40
  SPEAKER_00: It's not weeks, it's not um, you know, this short time span, it's over months and months and months.
• 13:46
  SPEAKER_00: And they have measured this over the span of uh a couple years in some of these studies, right?
• 13:53
  SPEAKER_00: Showing that the healing can go beyond a year into two years and onward.
• 13:58
  SPEAKER_00: So um it shows, you know, that closer to that nine-month threshold um is whenever it starts to get to a good remodeling and mature phase of the ACL.
• 14:09
  SPEAKER_00: Um, some variations, of course, within the studies.
• 14:12
  SPEAKER_00: The systematic review from AJSM in 2011, that was the one by Clays, uh, and that's uh the ligamentization process and anterior cruciate ligament reconstruction.
• 14:23
  SPEAKER_00: They looked at four different biopsy studies on the patellar tendon and hamstring autograft reconstructions.
• 14:30
  SPEAKER_00: It showed maturation of the graft as determined by mainly what they looked at was the vascularity and cellularity of the ACL.
• 14:39
  SPEAKER_00: Um, it wasn't complete until 12 months at the earliest.
• 14:42
  SPEAKER_00: So this one's even referencing hey, it didn't even get there until 12 months.
• 14:45
  SPEAKER_00: Um showed that the healing continued to two years and after that.
• 16:54
  SPEAKER_00: So this is something that's really important because uh you can't rush biology.
• 16:59
  SPEAKER_00: Take all the PRP shots, do all the things that we have in regenerative medicine.
• 17:05
  SPEAKER_00: We currently don't have something yet that shows, hey, we could speed this up when we do an ACL reconstruction.
• 17:11
  SPEAKER_00: And so um, this is something that's important to consider because even if you feel like a million bucks, you pass all your criteria and you're at five months post-op.
• 17:21
  SPEAKER_00: Let's say you just are, you know, that certain percent that you just crushed it, right?
• 17:26
  SPEAKER_00: And we've had certain athletes who have done this and they're like, hey, I'm ready to go, I feel good.
• 17:31
  SPEAKER_00: And it's one of those things where we have to be very careful because you know, they feel amazing, but that ligament is still in a very vulnerable place.
• 17:39
  SPEAKER_00: And so then, therefore, even though physically they feel ready, they go to do something that demands that ACL and it's still weak and not doing its job.
• 17:48
  SPEAKER_00: Guess what?
• 17:48
  SPEAKER_00: It's gonna tear again because it is not matured enough to a point where it needs to do its job.
• 17:54
  SPEAKER_00: And so, this is another, you know, nail in the coffin, if you will, of why we can't accelerate the ACL rehab process because this ACL needs to go through a ligamentization process.
• 18:05
  SPEAKER_00: And then lastly, here I'm going to mention is this injury is one of the hardest injuries to come back from outside of something super traumatic like a spinal cord injury, um, you know, something very like accident-based in terms of like multiple crush injuries and things of that nature.
• 18:24
  SPEAKER_00: We're talking about if you are playing a sport, what is one of the most you know difficult injuries to come back from?
• 18:31
  SPEAKER_00: ACL is one of the hardest ones, in my personal opinion, based on my personal experiences, and over 10 plus different injuries that I've I've dealt with from uh you know a broken ankle to uh you know some hip issues where I've got bony growth to shoulder dislocations, ACL will still take the cake on all that because it is just so difficult.
• 18:54
  SPEAKER_00: And it's not even just the grueling pain, if you will, of the injury itself.
• 18:59
  SPEAKER_00: It sucks.
• 19:00
  SPEAKER_00: But with that said, that's not even what I remember, it's the long recovery process going through it, right?
• 19:06
  SPEAKER_00: You have to get the surgery, you feel like you're rebuilding from the ground up, and that's truly what this injury is.
• 19:12
  SPEAKER_00: And any of you who are going through this, you feel this.
• 19:15
  SPEAKER_00: You have the injury, your your quad shrinks up, and your legs that you've worked so hard of has uh shrunk to a hot dog, and then you go and have a surgery, probably, and it shrinks up again, right?
• 19:28
  SPEAKER_00: And then you're immobile, and so it really breaks you down to be completely honest on that side because you are limited, you can't really do much, and for some reason, our bodies do something really weird whenever this ACL injury happens because it is not just a knee joint issue, it is a nervous system issue that we are still learning about, where there's changes in the spinal cord, there's changes in the brain, and there's something about the disconnect of the nervous system to the muscle.
• 19:57
  SPEAKER_00: And so for some reason it just shuts the knee down and shuts the quad down.
• 20:01
  SPEAKER_00: And so we're still trying to figure this out and we're still trying to understand how we can build these athletes back up better.
• 20:07
  SPEAKER_00: But the thing that I do know from personal experience, but also working with athletes going through this through a variety of, you know, the first tear to third and fourth tears, which is terrible, but it happens, right?
• 20:20
  SPEAKER_00: And the thing is, you are building from the ground up after this injury.
• 20:23
  SPEAKER_00: This injury takes so much away from our athletic and physical abilities due to the nature of the injury and how the body, the knee, the quad and surrounding tissues respond.
• 20:33
  SPEAKER_00: I've been a strength and conditioning coach, and in this space for 10 plus years now, we don't magically just gain muscle and get strong and get athletic, especially with an injury like this.
• 20:46
  SPEAKER_00: It takes time.
• 20:47
  SPEAKER_00: It is even more complicated with an ACL injury, and I was saying that even outside of an injury, right?
• 20:55
  SPEAKER_00: It takes time to get athletic and strong and gain muscle.
• 20:58
  SPEAKER_00: Now you complicate that with an ACL injury because there's that nurse nervous system changes I had mentioned.
• 21:04
  SPEAKER_00: The brain and spinal cord has some changes.
• 21:06
  SPEAKER_00: We have to respect the healing process and also rebuild back.
• 21:11
  SPEAKER_00: That's one of our main phases.
• 21:13
  SPEAKER_00: So after we get out of a restore phase, we have a rebuild phase, which is a very big phase for our athletes.
• 21:19
  SPEAKER_00: And we walk them through these different phases and different criteria they need to meet, but we spend a lot of time in this rebuilding process.
• 21:27
  SPEAKER_00: And so this is something that we are trying to really focus on to get them to return back to the things, which is our next phase.
• 21:34
  SPEAKER_00: And so that is something that is not just range of motion or just quad strength.
• 21:39
  SPEAKER_00: It's all the things to be mobile, it's to get them back to being super, super strong, explosive, reactive, making sure we can run, jump, cut, sprint.
• 21:50
  SPEAKER_00: And these all are progressions within each other.
• 21:53
  SPEAKER_00: You can't just go sprint if you can't run, right?
• 21:56
  SPEAKER_00: Um, you can't really cut very well if your apply metric abilities and your jumping abilities aren't great yet.
• 22:02
  SPEAKER_00: So there are all these prerequisites that we have to have because if you don't have the strength, well, guess what?
• 22:07
  SPEAKER_00: You can't really run, jump, or cut really well or sprint.
• 22:10
  SPEAKER_00: So we have to build all these things up over a period of time.
• 22:14
  SPEAKER_00: And the strength piece is the hardest piece.
• 22:16
  SPEAKER_00: It's the hardest piece for most people, especially people who get autographs because there have been more tissue damage to their knee.
• 22:23
  SPEAKER_00: And so then, therefore, this is something that just takes some time.
• 22:27
  SPEAKER_00: Even in healthy, untrained humans, it takes a minute if there's no base that has been built yet.
• 22:34
  SPEAKER_00: So that is something that you have to factor into this process, is that it's not just something, no matter at what advantages you have or base you have, um, you look at the most elite of elite of elite athletes, and you look at the timing of what it takes to get back from an ACL reconstruction and getting back to feeling 100%.
• 22:56
  SPEAKER_00: And you go look at most stories, and most people are taking nine plus months, if not a year, to get back to the thing.
• 23:03
  SPEAKER_00: Of course, like you look at them and they have the best resources possible at their disposal.
• 23:11
  SPEAKER_00: And for most of us, we don't have all these resources.
• 23:15
  SPEAKER_00: We just get to work with the medical system that is, you know, close to us and what we have that is convenient in a sense, and maybe what our medical system or insurance provides, right?
• 23:25
  SPEAKER_00: And so this is where we do have to potentially step outside of what that is in order to make sure we get the best care.
• 23:32
  SPEAKER_00: But then, of course, that comes at a cost and an investment, but it is worth it to make sure that we get the best outcome possible.
• 23:41
  SPEAKER_00: And also, more importantly, people don't evaluate what is the cost of another injury, not only from a financial aspect, but what about biologically, like physically?
• 23:51
  SPEAKER_00: What is the cost of that?
• 23:53
  SPEAKER_00: But more importantly, mentally, right?
• 23:55
  SPEAKER_00: Like, what is the cost of that?
• 23:57
  SPEAKER_00: Like, what would you pay for your chances to be reduced at the maximum to make sure you can go back and do what you love.
• 24:04
  SPEAKER_00: To do with an ACL injury and making sure that you are as best protected and know that you met the right criteria, right?
• 24:12
  SPEAKER_00: And that's something that I think you can almost not account for a certain amount of uh money, if you will, based on the mental aspects, especially of another re injury.
• 24:21
  SPEAKER_00: And take that from someone who has injured his ACL twice.
• 24:25
  SPEAKER_00: This is something that is brutal and it can be tough to deal with.
• 24:28
  SPEAKER_00: And this is why I am really trying to hammer home and share with you guys that this isn't something that you can shortcut.
• 24:35
  SPEAKER_00: There's nothing to this.
• 24:37
  SPEAKER_00: And if you have worked hard for anything in your life, ask yourself, was there any shortcut to it, to be completely honest?
• 24:45
  SPEAKER_00: When I think about this business, what I've been able to build with this and what I've been able to share with people, there was no shortcut.
• 24:52
  SPEAKER_00: There was no, you know, roadmap for it.
• 24:54
  SPEAKER_00: It's like you figure it out and you're you're trying to find some direction with it.
• 25:00
  SPEAKER_00: But what I do know is that there wasn't no easy route to get here.
• 25:03
  SPEAKER_00: It was something that was very difficult.
• 25:05
  SPEAKER_00: I look at playing sports, I look at this ACL recovery.
• 25:09
  SPEAKER_00: All of it was hard work.
• 25:11
  SPEAKER_00: There were no shortcuts to it.
• 25:13
  SPEAKER_00: It was just honestly really good rehab and strength and conditioning, doing the basics really, really, really well over a long period of time, having something to work towards, right?
• 25:26
  SPEAKER_00: And achieving the appropriate KPIs and criteria to do that.
• 25:30
  SPEAKER_00: I think the nine months serves as a great proxy to get back to that spot without rushing or skipping over the steps.
• 25:37
  SPEAKER_00: And now walking hundreds of athletes through this, I feel very confident in this, right?
• 25:41
  SPEAKER_00: When I think about, you know, trying to rebuild athletes and trying to get them from this post-operative phase into this rebuilding phase.
• 25:50
  SPEAKER_00: It is a process and it takes a lot of patience, it takes a lot of uh energy, a lot from you, right?
• 25:58
  SPEAKER_00: And it's something that takes a long time to be able to do that.
• 26:03
  SPEAKER_00: And so this is something that I think is really important to consider during this process and knowing what you're signing up for and the expectations of this.
• 26:15
  SPEAKER_00: And the last thing that I do want to touch on is are there athletes who go back earlier than nine months?
• 26:21
  SPEAKER_00: Sure.
• 26:21
  SPEAKER_00: I've had athletes who have done that before.
• 26:24
  SPEAKER_00: And it's conversations around this.
• 26:27
  SPEAKER_00: Now it just depends because there are gray areas around navigating this process, right?
• 26:32
  SPEAKER_00: That doesn't necessarily mean you get a green light just because you check off all your criteria.
• 26:37
  SPEAKER_00: There's a lot of things that factor into this based on their goals, um, what's at stake, you know, it's a risk-reward analysis at the end of the day.
• 26:45
  SPEAKER_00: And so the thing is, is when these athletes go back to nine months and these are the things that they are uh considering for a number of reasons, right?
• 26:54
  SPEAKER_00: It could be due to the poor rehab, no testing and poor guidance and misinformation.
• 26:59
  SPEAKER_00: To be completely honest, this is the most common.
• 27:02
  SPEAKER_00: Also, in my belief, why we have the re-injury rates that we have for ACL rehab, because I think that we do have poor guidance in this space, poor information, no testing.
• 27:13
  SPEAKER_00: Um, when you look at most athletes who are coming out of this, even here locally in Atlanta, to be completely honest, if I did a survey, I would probably venture to guess that 80% of athletes are not getting, you know, strict criteria, guidance, or testing that they need to in order to reduce their reinjury risk.
• 27:32
  SPEAKER_00: It's just like, hey, like I go to my surgeon, they test out my ACL, they say I'm strong, and you know, I've done my therapy for the time being, right?
• 27:40
  SPEAKER_00: And you feel good enough.
• 27:42
  SPEAKER_00: And then guess what?
• 27:43
  SPEAKER_00: It happens again.
• 27:44
  SPEAKER_00: And a lot of it is because of a system issue.
• 27:46
  SPEAKER_00: And I think that that is a very big reason for the ACL reinjury rates we have.
• 27:50
  SPEAKER_00: And it's one of the reasons why people, you know, go on to do it earlier than nine months because of the poor guidance and misinformation.
• 27:59
  SPEAKER_00: Along with this, it could be due to a lack of resources, it could be insurance or coverage, medical systems, socioeconomic status, geography, equipment, etc.
• 28:08
  SPEAKER_00: This plays into the previous factor that I had mentioned, leads to poor rehab, testing, and misguidance.
• 28:14
  SPEAKER_00: It could be because they assess the risk reward, as I had mentioned earlier, and they live in that gray area of the return to performance criteria and their goals.
• 28:22
  SPEAKER_00: And they're okay with that.
• 28:24
  SPEAKER_00: At the end of the day, we can educate folks, and then it is up to them to make that decision ultimately.
• 28:29
  SPEAKER_00: Or it could be because they have a dream on the line, right?
• 28:33
  SPEAKER_00: They're like, I don't care.
• 28:35
  SPEAKER_00: This is something that I want to do because there's the World Cup coming up, right?
• 28:40
  SPEAKER_00: Or this is something because, you know, I am, you know, putting my cleats up for the last time.
• 28:45
  SPEAKER_00: I just want to go play in this game.
• 28:46
  SPEAKER_00: I know I'm putting my knee at risk for other stuff, but it is totally worth it.
• 28:50
  SPEAKER_00: And so that is a conversation to have with the athlete and all the other stakeholders, but there's a lot of factors to weigh into the decision of getting back to the thing.
• 29:01
  SPEAKER_00: So it really is important to have this in your own context and with your own stakeholders in conversation and making sure that everyone is on the same page.
• 29:11
  SPEAKER_00: Most importantly, from this episode, know this process can be accelerated.
• 29:16
  SPEAKER_00: Even with the most perfect, perfect, perfect program, single exercise or coaching, honestly.
• 29:23
  SPEAKER_00: If you sought out the best ACL coach, by the way, any good ACL coach is going to tell you you're not going to be able to accelerate it.
• 29:30
  SPEAKER_00: Um, so that's the thing is that if someone is telling you that they can, then I would question their knowledge of the space and being able to actually guide you through the ACL rehab process because they're actually telling you something that isn't proven by any means other than marketing and maybe business, to be completely honest.
• 29:51
  SPEAKER_00: So to put simply, we just can't speed up biology right now based on our current information and body of knowledge.
• 29:59
  SPEAKER_00: That alone should be the number one reason the accelerated programs don't work.
• 30:04
  SPEAKER_00: Now, don't get me wrong, we can get people moving and doing things sooner during the rehab process if they hit the right criteria.
• 30:12
  SPEAKER_00: Meaning, you know, maybe they're able to run a little bit faster.
• 30:15
  SPEAKER_00: Maybe it's not at three or four months, maybe they're able to start running at two and a half months because they're crushing it.
• 30:21
  SPEAKER_00: They had an allograft, their knee responded really well, they did prehab leading up to it.
• 30:26
  SPEAKER_00: They were doing all the things like BFR from the get-go.
• 30:30
  SPEAKER_00: There are a lot of things that people can put in place to make sure they set themselves up for success.
• 30:35
  SPEAKER_00: And there's some people who just respond better because of genetics, or maybe just their body responded better to the surgery itself.
• 30:41
  SPEAKER_00: And so maybe they start doing things a little bit faster during this rehab process.
• 30:47
  SPEAKER_00: So, yeah, we can move along in this continuum as long as it's not at the detriment of the athlete and they're checking off the right boxes.
• 30:55
  SPEAKER_00: But that doesn't necessarily mean we release them to be free to go play a high-level sport, especially, you know, going back to soccer and you're a 16-year-old female athlete, right?
• 31:06
  SPEAKER_00: That's not something that we're just gonna be like, yeah, you're you're looking good.
• 31:09
  SPEAKER_00: So at six months, you're good to go, because the research still shows us the ACL is healing.
• 31:15
  SPEAKER_00: We probably have some stuff to work on, to be completely honest.
• 31:17
  SPEAKER_00: Even if not, the other thing is that we want to make sure that we allow that graph to ligamentize as long as it needs to, and making sure that the re-injury rates is as reduced as possible of that risk, right?
• 31:30
  SPEAKER_00: And so that's the thing that I do want to make sure I share here, because that doesn't necessarily mean you can't start doing things within your rehab, like getting back to practices and things of that nature in a modified version.
• 31:44
  SPEAKER_00: But in terms of doing the thing when it has high-level cutting and pivoting, and especially if they're a youth athlete, this is a very hard criteria for us.
• 31:54
  SPEAKER_00: We're going to make sure we're we're at that nine months.
• 31:56
  SPEAKER_00: Because we're also trying to think long term, right?
• 31:59
  SPEAKER_00: It might be middle school or high school.
• 32:01
  SPEAKER_00: What about college?
• 32:02
  SPEAKER_00: What about like later on in life, right?
• 32:05
  SPEAKER_00: What about, you know, when they're 30 and 40 and 50?
• 32:08
  SPEAKER_00: What's at risk here?
• 32:09
  SPEAKER_00: You know, we need to do a uh a risk reward analysis of the short term, but we also need to do this for the long term, man.
• 32:16
  SPEAKER_00: Like ACL injuries, you automatically are signing up for an increased risk of OA, right?
• 32:22
  SPEAKER_00: That's not by your own choice, it's just the nature of what the injury uh leads to, right?
• 32:28
  SPEAKER_00: It's just like you can have an increased risk of osteoarthritis down the road, especially if you have a meniscus injury with it and a menasectomy with it.
• 32:36
  SPEAKER_00: And so this is something that we want to make sure we factor into this, is not only the short term, but the long term, because there are some athletes I know who have who have given their life to everything in you know, this eight-year window of playing sports and they've had three or four ACL tears.
• 32:53
  SPEAKER_00: And I'm like, man, what is this gonna look like whenever it's 20 years down the road for you and you have kids and you're trying to, you know, run around with them and do the thing with them, right?
• 33:03
  SPEAKER_00: So I think these are all things to factor into this process.
• 33:07
  SPEAKER_00: And I truly think the sooner ACLers can understand these expectations that we can't speed it up.
• 33:13
  SPEAKER_00: There's no reason to, and you're at a risk if you do.
• 33:17
  SPEAKER_00: If we can understand these expectations, the easier this process and this road can get, because then they're not racing against time.
• 33:24
  SPEAKER_00: You're not you're not fighting it.
• 33:26
  SPEAKER_00: You're not like, all right, I can get back in six months.
• 33:28
  SPEAKER_00: You're targeting a nine-month-ish threshold.
• 33:31
  SPEAKER_00: And to be completely honest, I think it's healthier for us to aim for a one-year mark.
• 33:37
  SPEAKER_00: And of course, nine months is something that could be like a soft landing spot because I do think that it really does take a year for athletes to get into this place where they feel like themselves, playing like themselves, competing like themselves, and it just takes time.
• 33:53
  SPEAKER_00: And I think it better sets us up for success if we set that expectation from the front end and as we continue through the ACL rehab process.
• 34:02
  SPEAKER_00: So I hope that this was helpful, team.
• 34:05
  SPEAKER_00: I know I talked a lot about this, um, and in these different categories, but I think it's important to elaborate on these particular areas.
• 34:14
  SPEAKER_00: And there are some other things that, you know, I didn't even mention, but these are the three things when we look at it that are really hard stands for why it is that we can't accelerate this process in May of 2024.
• 34:28
  SPEAKER_00: And until evidence comes out to show differently, based on an ACL reconstruction, this is where I'm gonna stand.
• 34:36
  SPEAKER_00: And I hope that this was helpful for you guys to hear it and understand from the perspective of myself, but then also what does it look like in the landscape, what the research says, what does the ligamentization process look like, and also just rehabbing so many different athletes from this injury, this is what it does look like.
• 34:56
  SPEAKER_00: Until next time, team.
• 34:57
  SPEAKER_00: This is your host, Robbie Hattel, signing off.