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017 | The Most Important Muscle in ACL Rehab · The ACL Athlete Podcast

• 0:19
  SPEAKER_00: Welcome everyone to the ACL Athlete Podcast.
• 0:23
  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.
• 0:33
  SPEAKER_00: I'm your host, Dr.
• 0:34
  SPEAKER_00: Robbie Patel, performance physical therapist and coach.
• 0:38
  SPEAKER_00: Between myself and fellow guests and experts, you'll learn through the lens of the patient, the healthcare professional, and the coach.
• 0:46
  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.
• 0:57
  SPEAKER_00: Thanks for joining.
• 0:58
  SPEAKER_00: Now let's dive into today's episode.
• 1:04
  SPEAKER_00: What's up, ACL athletes, and welcome back to another episode.
• 1:08
  SPEAKER_00: Today we are talking about the most important muscle in ACL rehab.
• 1:15
  SPEAKER_00: The most important muscle.
• 1:16
  SPEAKER_00: But before we get there, I wanted to talk about this recent interview I had with Ibrahim Ugrda.
• 1:24
  SPEAKER_00: He came onto the podcast and we recorded the episode.
• 1:28
  SPEAKER_00: He's a semi-professional soccer player in England.
• 1:32
  SPEAKER_00: And this episode was just a deep dive into his ACL story, having to deal with COVID, and how that was a setback for his recovery.
• 1:42
  SPEAKER_00: Some of the mental battles that he faced, which we dove really deep into.
• 1:46
  SPEAKER_00: And then just some advice that he had about his recovery.
• 1:50
  SPEAKER_00: He's about five to six months out now.
• 1:53
  SPEAKER_00: So I think that this could be incredibly valuable for anyone who is going through this process.
• 1:59
  SPEAKER_00: And if you're coaching people through it as well.
• 2:01
  SPEAKER_00: It's just so humbling to see an athlete get after it, but he doesn't shy away from some of the hardships that he had during this time and still that he faces to today.
• 2:12
  SPEAKER_00: So this will be coming out next week.
• 2:14
  SPEAKER_00: So keep your eyes peeled on this episode.
• 2:18
  SPEAKER_00: But now back to the important part of this episode: the most important muscle and ACL rehab.
• 2:26
  SPEAKER_00: So I put out a poll on Instagram that asked what is the most important muscle in ACL rehab.
• 2:35
  SPEAKER_00: And one choice was hamstrings, the other was quads.
• 2:39
  SPEAKER_00: And for those of you who are not familiar with those terms, the quadricep quads, as we call it a lot of times, is the front thigh muscle, and the hamstrings are the back thigh muscle.
• 2:52
  SPEAKER_00: So what we ended up getting was a 20% vote for the hamstrings and 80% vote for the quads, which made me incredibly happy.
• 3:02
  SPEAKER_00: I know I have a lot of clinician friends as well, so hopefully that did end up pulling that number over.
• 3:09
  SPEAKER_00: But there's still people who think that the hamstrings are important, so that's why this podcast episode is going to touch on this because we need to know what is most important so we can prioritize.
• 3:21
  SPEAKER_00: Now, the main argument that you'll hear is that the hamstrings are the primary antagonist to anterior tibial translation.
• 3:31
  SPEAKER_00: Oh, that's a mouthful.
• 3:33
  SPEAKER_00: The primary antagonist to anterior tibul translation.
• 3:38
  SPEAKER_00: And what I mean by that is the ACL itself helps protect your bottom bone, your shin bone, from moving forward on your high up bone, your thigh bone.
• 3:51
  SPEAKER_00: So just imagine that bottom bone just moving forward.
• 3:54
  SPEAKER_00: That's anterior tibual translation.
• 3:56
  SPEAKER_00: We call that the tibia.
• 3:58
  SPEAKER_00: Now the ACL is strained during that motion, and there are some other movements combined that cause it to tear whenever it does.
• 4:08
  SPEAKER_00: But usually that anterior tibule translation is a big component of it.
• 4:12
  SPEAKER_00: And the hamstring, because if you think about the place where it attaches to the back of the knee, so if you imagine that back muscle contracted, it helps to prevent or reduce that tibual translation.
• 4:25
  SPEAKER_00: And while the hamstrings are important, they are not the most important.
• 4:29
  SPEAKER_00: And this is based on the science and research of ACL rehab and re-injury rates.
• 4:36
  SPEAKER_00: And we're gonna actually dive into some of this stuff.
• 4:38
  SPEAKER_00: But the quadriceps are the most important muscle in ACL rehab.
• 4:44
  SPEAKER_00: It's one of the components of the quiet knee that I've talked about in previous episodes.
• 4:49
  SPEAKER_00: And a lot of times what people will say is that they're fearful of stressing the graft, so sometimes it can almost be avoided, and so let's strengthen our posterior chain or our hamstrings and our glutes to be able to minimize stress on that graft.
• 5:06
  SPEAKER_00: But this actually does not need to be a concern, and it kind of needs to stop more than anything because we need to load the quads as early as we can and as safely as we can, and hopefully this episode will shed some more light on it.
• 5:21
  SPEAKER_00: But let's kind of get this out of the way.
• 5:24
  SPEAKER_00: This is not an or, it's not the hamstrings or the quadriceps, it's an and.
• 5:30
  SPEAKER_00: Uh one of my mentors used to say and not or.
• 5:33
  SPEAKER_00: So I'm saying a lot of these words here, but it essentially means that all of these things are important.
• 5:39
  SPEAKER_00: The hamstrings are important, the quadriceps are important, your calves are important, your glutes, adductors, abductors, tons of muscles.
• 5:47
  SPEAKER_00: They're all important.
• 5:48
  SPEAKER_00: Now, if we're about to rank these from let's say one, two, three, four, number one is always going to be the quads.
• 5:56
  SPEAKER_00: Number two, hamstrings, glutes, all of these other muscles are gonna fall into place.
• 6:02
  SPEAKER_00: But hopefully, after this episode, you will know that the quads are the most important muscle.
• 6:09
  SPEAKER_00: And if the training is not focused on that and all the other muscle groups, then no matter what else you do, it's going to fall short.
• 6:18
  SPEAKER_00: So we're going to break this down into some of the research because I want you to hear about this, not just from an anecdotal point of view, or just, oh, this is what people have seen, but this needs to be grounded in the research because that is what's going to tell us first and foremost how to guide our clinical decisions and also like what you're just going to be doing in rehab.
• 6:43
  SPEAKER_00: That's how we know we're doing things right.
• 6:46
  SPEAKER_00: And it's the body of that research and not just one specific article.
• 6:51
  SPEAKER_00: And then we're going to dive into some practical reasons because I always want you guys to take away practical stuff from this.
• 6:57
  SPEAKER_00: It's really important to be able to know, okay, I'm done with this podcast.
• 7:01
  SPEAKER_00: Now, what do I do moving forward?
• 7:03
  SPEAKER_00: Whether that's talking to my physical therapist, or even if you're trying to like take this on your own, what are some ways that I can start implementing and thinking about this instead of just following this protocol or just what my PT says?
• 7:17
  SPEAKER_00: So I want to start this first part of this podcast off by saying, sure, like I've learned some things on my own experiences that is valuable, um, whether it's from my own two ACL surgeries and recoveries, or is treating a bunch of other athletes who have gone through this process themselves.
• 7:35
  SPEAKER_00: But just want to stress that I'm not sitting here recreating the wheel in any way, and all this stuff is just my own experience.
• 7:43
  SPEAKER_00: Um, I am learning from other people, and I am really just standing on the shoulder of giants who have come before me, uh, who have made these concepts easier, who have done so much of the research, who I think don't get enough credit, um, which helps guide us in this process.
• 8:01
  SPEAKER_00: So that's important to just consider as we move forward.
• 8:04
  SPEAKER_00: And one of the people that I want to mention is Eric Mira, who is an incredibly brilliant clinician.
• 8:10
  SPEAKER_00: He's a big thought leader in the sports and science realm of physical therapy.
• 8:15
  SPEAKER_00: And one of the things that he talks about, and he says, it's the quads until it's not the quads.
• 8:21
  SPEAKER_00: And I could not agree more with a statement like this.
• 8:24
  SPEAKER_00: So now let's see what some of the research says about quad strengthening in ACL rehab.
• 8:31
  SPEAKER_00: So, buckle up, guys, we're about to go through some stats and some information.
• 8:36
  SPEAKER_00: And if you take the collective body of ACL research, the most commonly reported and researched impairment is a significant decrease in quad strength from early on to years later.
• 8:50
  SPEAKER_00: There are so many studies out there that have reported this finding, so we're gonna go through some right now.
• 8:57
  SPEAKER_00: The big one is by Lepley in 2015, and it states overwhelming evidence links quadriceps strength with essential outcomes: normal walking and running gait, function, self-reported success, return to sport, a subsequent knee injury, and long-term progression of knee osteoarthritis.
• 9:22
  SPEAKER_00: This one buckets a lot of these things and looks at the relationship, and it essentially finds a strong relationship between all of these different areas and quadriceps strength.
• 9:33
  SPEAKER_00: Tool et al.
• 9:34
  SPEAKER_00: in 2017, less than half of athletes meet quadriceps strength symmetry goals when they are cleared to return to sport after ACL reconstruction.
• 9:44
  SPEAKER_00: Grindom in 2016 reported 33% of players who return to sport with a limb symmetry index of less than 90%.
• 9:55
  SPEAKER_00: So we're talking about taking that injured side and comparing it to the uninjured side and seeing if that's within 90%.
• 10:04
  SPEAKER_00: Uh, those people who did less than 90% sustained another knee injury over the next two years upon their return to sport.
• 10:12
  SPEAKER_00: That's pretty big.
• 10:13
  SPEAKER_00: A third of the people did.
• 10:15
  SPEAKER_00: Whereas only 12% sustained another knee injury if they were above that 90% threshold.
• 10:21
  SPEAKER_00: And that is looking at that quad symmetry index.
• 10:26
  SPEAKER_00: The authors of that same study also found that for every 1% of that limb symmetry index, less than 90% equated to 3% increase in risk of further knee injury over the two years period.
• 10:42
  SPEAKER_00: So, to make that practical, if an athlete chooses to return to sport with a limb symmetry index of 80%, it carries a 30% increased risk of future knee reinjury compared to someone who waited to return to sport with 90%.
• 10:58
  SPEAKER_00: You take that 10% and you multiply it by that 3% for every 1% increase, so then that's where you get that 30% increased risk.
• 11:08
  SPEAKER_00: I know there's a lot of math going on in here, but bear with me.
• 11:11
  SPEAKER_00: I want you to be able to kind of see these different points, um, not only just from function, but return to sport to re injury risk.
• 11:18
  SPEAKER_00: These are all important things to factor in.
• 11:20
  SPEAKER_00: Next up is Schmidt in 2012.
• 11:24
  SPEAKER_00: Quad strength was a good predictor of function and performance on hop tests.
• 11:29
  SPEAKER_00: More specifically, patients with less than 85% quad strength index demonstrated decreased function and poor performance on hop tests.
• 11:38
  SPEAKER_00: Uh, and the thing that's important to note with this one is that it was the same regardless of graph type, the presence of any meniscus injury or any other knee pain or symptoms.
• 11:51
  SPEAKER_00: Uh greater than 80% quad strength after ACLR is associated with less severe patellar cartilage damage of short-term follow-up, weighing 2015.
• 12:02
  SPEAKER_00: If you're looking at something like landing mechanics where you go to jump and you land, and the relationship between weaker quads showed more asymmetry, and that was studied by Schmidt in 2015.
• 12:15
  SPEAKER_00: So, how about let's look at maybe a different patient population, maybe ones who are not even dealing with ACL-related issues, uh, but it is knee specific.
• 12:24
  SPEAKER_00: So, quad strength is a major determinant of both performance-based and self-reported physical function in patients with knee osteoarthritis, Mallee in 2016, sorry, 2006, Misner in 2005, uh, after total knee arthroplasty, quadricep strength was the most highly correlated impairment with functional performance.
• 12:48
  SPEAKER_00: Are you guys seeing a trend here?
• 12:50
  SPEAKER_00: All right, a few more.
• 12:51
  SPEAKER_00: So, a study by Meredith Shiput, shout out Meredith, uh, from this year actually, quadriceps strength influences patient function more than single-leg hop forward test uh during the late stages of ACL rehab, uh, which was a really cool study.
• 13:08
  SPEAKER_00: So they saw that there's a relationship more between quad strength and functional outcome measure from a patient than a hop test, which we're starting to see strength is starting to become a very prominent figure and role in this.
• 13:22
  SPEAKER_00: Ithburn in 2018, young athletes after ACL reconstruction with quadriceps strengths asymmetry at the time of return to sport demonstrated decreased knee function one year later.
• 13:36
  SPEAKER_00: So basically, if they had an asymmetry side to side in their quad strength, their knee function a year later was not great.
• 13:46
  SPEAKER_00: And then let's do one related to running.
• 13:49
  SPEAKER_00: Iwami uh 2021, so this year as well, which is really cool.
• 13:54
  SPEAKER_00: And this is one of the things that I use as well for my return to sport, especially for return to running.
• 14:00
  SPEAKER_00: But it used essentially quadricep strength related to body weight ratio as a significant indicator for initiating jogging after ACL reconstruction.
• 14:10
  SPEAKER_00: So they looked at the quadricep strength, the body weight ratio, and used that as a significant indicator to initiate jogging.
• 14:17
  SPEAKER_00: They looked at roughly three months for people, and that cutoff value was 1.45 newton meters per kilogram.
• 14:26
  SPEAKER_00: And those are the people who had a very good outcome uh to be able to run and without a recurrence of a contralateral injury by 10 months after the injury.
• 16:43
  SPEAKER_00: What do you guys think?
• 16:45
  SPEAKER_00: Is quadriceps strength important?
• 16:49
  SPEAKER_00: So, to put this all in summary, decreased quad strength is a great predictor of decreased function in many different ways after ACL reconstruction.
• 17:01
  SPEAKER_00: We looked at this from not only just your quality of life, from knee osteoarthritis to landing mechanics to running to uh just being able to return to sport, there are all of these different factors that we look at, and quadricep strength is at the base of a lot of these things.
• 17:23
  SPEAKER_00: It's not the only thing, but this podcast episode is focused on showing you why it's the most important muscle in ACL rehab.
• 17:32
  SPEAKER_00: And if quad strength is so important and well researched at this point, then rehab programs have to have a very big emphasis on regaining quad strength.
• 17:45
  SPEAKER_00: But you know what?
• 17:46
  SPEAKER_00: Every clinician will be like, Yep, I do it, it's out there, but really the research shows us that we're not really hitting these marks that we need to.
• 17:56
  SPEAKER_00: And guys, I hate to say it, but quad sets and straight leg raises are not gonna get you there.
• 18:02
  SPEAKER_00: They're just not.
• 18:04
  SPEAKER_00: So, one of the most obvious ways to get after this is actually doing knee extensions, and we'll talk about this a little bit later in this practical piece.
• 18:13
  SPEAKER_00: But knee extensions are very valuable as well as other loading uh movements and parameters and exercises that are going to be important to put into your ACL rehab process, but uh I can't stress knee extensions enough, but this is going to be something that's going to be very dependent on your situation.
• 18:34
  SPEAKER_00: Um, but if you're a clinician, please do not be afraid of them.
• 18:37
  SPEAKER_00: Just know how to use that tool really well.
• 18:39
  SPEAKER_00: And if you're an ACL athlete, you need to have this in your program and ask questions if it's not there.
• 18:46
  SPEAKER_00: Now, let's talk about this a little more practically.
• 18:50
  SPEAKER_00: So the quadriceps weakness is there, it happens, people have it all the time.
• 18:56
  SPEAKER_00: It's one of the toughest things about ACL rehab, and in this process, I just talked to you about the research.
• 19:02
  SPEAKER_00: Now, let's see how this actually translates.
• 19:05
  SPEAKER_00: Now, if we're looking at a base of a pyramid, that is most important, the root of all this, it's the strength of that quadricep and that knee extension strength.
• 19:14
  SPEAKER_00: So straightening out that leg and that front thigh muscle, how strong is it?
• 19:19
  SPEAKER_00: Um, and also the speed of how quickly it can create that force.
• 19:24
  SPEAKER_00: Now, before we get into those nitty-gritty details, I want to talk through how this cascade can affect things.
• 19:32
  SPEAKER_00: So if we're looking at a weakness of quadriceps, that can lead to bad mechanics.
• 19:37
  SPEAKER_00: So that can lead to uh maybe landing an awkward way, maybe you can't control, maybe you can't slow down, maybe single-leg type stuff doesn't feel great because you're just not strong enough to handle those stressors that you're putting on it.
• 19:53
  SPEAKER_00: It can lead to compensations and it can lead to fear, honestly, of a re-injury, of just something happening.
• 20:00
  SPEAKER_00: Uh, people see weight shifting all the time where we might shift over to that leg that is not injured, um, that is stronger.
• 20:08
  SPEAKER_00: I see that all the time.
• 20:11
  SPEAKER_00: And I've consulted a bunch of cases where someone is strong, but they have difficulty with mechanics.
• 20:19
  SPEAKER_00: And so I question this a little bit because it can happen, but usually it ends up being because a lack of quad strength, and they suck at it.
• 20:31
  SPEAKER_00: So we need to put some objectivity to it and actually test those numbers and see, okay, where is that quad strength at?
• 20:38
  SPEAKER_00: And let's just say it does check out, then we have to look at the speed of which that strength comes.
• 20:44
  SPEAKER_00: So we talk about this as called the rate of force development, RFD, and that's how quickly you can produce that force or that torque uh per unit of time.
• 20:56
  SPEAKER_00: So, how quickly can we get that muscle to get to that high peak point uh per unit of time?
• 21:04
  SPEAKER_00: So consider these thoughts about the strength and speed.
• 21:08
  SPEAKER_00: So if you're weak and can get there fast, that's not really helpful because you're getting to a very weak point very fast.
• 21:18
  SPEAKER_00: So that's not really helpful for you.
• 21:20
  SPEAKER_00: If you're strong and can't get there fast, then you can't really use all of it when you need to.
• 21:26
  SPEAKER_00: Because if that timing is needed in a shorter period of time, you can't get to that max strength that you need.
• 21:35
  SPEAKER_00: So that's not helpful either.
• 21:37
  SPEAKER_00: So that's where you need to focus first on getting really strong and then adding speed to that.
• 21:45
  SPEAKER_00: Uh, because as we had just talked about, uh getting speed first isn't going to do much if you're not strong.
• 21:50
  SPEAKER_00: Now, once you get strong, the development of speed is very important with that, especially as an athlete.
• 21:57
  SPEAKER_00: So, with usually multiple tears, you see the quads never get back in the first place.
• 22:04
  SPEAKER_00: Um, and that's where other compensations and other fears can come in.
• 22:08
  SPEAKER_00: So these are just things to kind of think about.
• 22:11
  SPEAKER_00: Uh, it's just more of this trend that the quads were never emphasized in the first place.
• 22:16
  SPEAKER_00: So let's talk about biomechanics, compensations.
• 22:19
  SPEAKER_00: So picture this you're doing a broad jump, a single leg broad jump, so that's where you just kind of hop forward.
• 22:27
  SPEAKER_00: And let's just say we're doing this on a single leg.
• 22:29
  SPEAKER_00: So, you know, I've torn my right ACL, I'm rehabbing, we're working on jumping forward, and I jump from my right leg by itself onto the right leg and landing.
• 22:40
  SPEAKER_00: Now, let's just think about watching this from the side and let's see what my body does.
• 22:49
  SPEAKER_00: So, whenever I go to jump, do I land where it looks like there might be a plywood in front of my shin and I just shift my butt back?
• 23:02
  SPEAKER_00: Like, is my shin very vertical and I just shift my butt back?
• 23:06
  SPEAKER_00: We call that a hip dominance strategy where we're trying to load more into our glutes and our hips and our hamstrings instead of loading our quads.
• 23:15
  SPEAKER_00: And I see this all the time.
• 23:17
  SPEAKER_00: I'll ask people to even do a squat, and what'll happen is instead of letting their knees go slightly forward and their butt go back, where they do a normal squat, they will keep their shin or their tibia very vertical and they'll shift their butt way, way back, and that just turns on different muscles, more so your glutes and your hamstrings than your quadriceps.
• 23:39
  SPEAKER_00: So on the flip side of this, if that person lands in that jump and their foot stays flat, their knees go over their toes, and their butt goes back, but it's more of an even distribution, then we're seeing this more as like, okay, this is how someone should land, and they're actually loading up their quads as opposed to just.
• 24:04
  SPEAKER_00: Shifting that butt back and having that vertical shin.
• 24:08
  SPEAKER_00: So this is just something qualitatively that I will look at from the side with athletes and see are they loading into that quad or into those glutes?
• 24:17
  SPEAKER_00: If they're shifting that butt back, then first we need to look at is it a quad weakness?
• 24:23
  SPEAKER_00: And again, going to the earlier points, if that's not that quad weakness, then maybe we need to train that because that muscle can't get to that need of force and speed as quickly as possible.
• 24:34
  SPEAKER_00: Now let's talk about some practical exercises because I want you to understand this.
• 24:40
  SPEAKER_00: And again, this is going to be very specific to you and where you're at, so don't just go off and do all these things without some clear guidance from a medical professional, especially if you're post-op.
• 24:52
  SPEAKER_00: But you want to think about it in terms of getting strong, and you want to think about it in terms of getting really fast.
• 24:57
  SPEAKER_00: And the other piece that I would add into this is the contraction type.
• 25:01
  SPEAKER_00: So we have three different contractions within a muscle: the eccentric piece, which is the lengthening of a muscle, the isometric where there's tension but there's no change in the length, or the concentric where it's actually shortening the muscle.
• 25:15
  SPEAKER_00: So let's think about this in terms of a knee extension.
• 25:18
  SPEAKER_00: So if my knee is at 90 degrees and I'm in a knee extension machine, or maybe it's anchored to a band, if I go to kick my leg out, that is the concentric piece of a knee extension.
• 25:32
  SPEAKER_00: Then there's an isometric piece, you know, you could stop at any angle.
• 25:36
  SPEAKER_00: Let's say we just stop at the top and we hold it, that means there's no change in length, but that muscle is still engaged and contracted.
• 25:43
  SPEAKER_00: And then if we slowly lower that leg down, you still feel that muscle working, and that's the lengthening piece, which we call the eccentric.
• 25:52
  SPEAKER_00: So all those components are important.
• 25:55
  SPEAKER_00: Um, and being able to train those different pieces are important depending on where you're at in your ACL rehab process and recovery.
• 26:03
  SPEAKER_00: Some of those things might be emphasized more, like isometrics early, and then eccentrics when you're trying to learn on load absorption, and concentric maybe when you're trying to get faster and adding speed.
• 26:16
  SPEAKER_00: Um, but these are just some things to think about as you're getting more into the practical components.
• 26:21
  SPEAKER_00: Uh, some exercise, really, you know, the first ones that you always start out with are quad sets, and they could ramp up to split squats, step-ups, squats, knee extensions is something that I stressed earlier that everyone should be doing in some sort of way or form.
• 26:38
  SPEAKER_00: Um, whether it is that isometric starting out, and then after they get four, eight, especially 12 weeks out, they're 100% doing knee extensions for really the remainder of the recovery process.
• 26:51
  SPEAKER_00: There's not a single ACL athlete that I have that is not doing knee extensions.
• 26:56
  SPEAKER_00: They will always be doing that because there's really not any other exercise that I know of and that I have talked to other friends and clinicians about that really can isolate your quad muscle like a knee extension.
• 27:11
  SPEAKER_00: Um, and then if we're thinking about more speed and that rate of force development, we're starting to look into uh power movements such as like plyometrics, where we are trying to create more speed, uh Olympic lifts, other different movements that we're adding velocity to to be able to work on that rate of force development.
• 27:31
  SPEAKER_00: And then again, this depends on you, what your goals are, your case, maybe you have some other restrictions.
• 27:38
  SPEAKER_00: So it is gonna be important to make sure you're working with somebody who can help you and making sure guide you along this process all the way to the end.
• 27:48
  SPEAKER_00: So in review, quads are the most important muscle in ACL rehab.
• 27:54
  SPEAKER_00: Hamstrings are still important, but they're not as important as the quads.
• 27:59
  SPEAKER_00: But that doesn't mean that we're not gonna train all of these different muscles as you're recovering.
• 28:05
  SPEAKER_00: Research supports this based on walking, running, return to sport, subsequent knee injuries, and long-term progression of knee osteoarthritis, quality of life.
• 28:16
  SPEAKER_00: The list goes on.
• 28:18
  SPEAKER_00: Strength and rate of creating that strength/slash force is important.
• 28:23
  SPEAKER_00: So you need that strength first, and then we need to work on getting that to go quickly.
• 28:30
  SPEAKER_00: Bad biomechanics and compensations can come from this, so it's just something to understand.
• 28:36
  SPEAKER_00: It's one of those things where you can hear clinicians say biomechanics don't matter, but I disagree completely.
• 28:44
  SPEAKER_00: Now, there's a sweet spot with everything, it's not going to be the end all be all of everything, but it will help from a performance standpoint and reducing risk of injury later.
• 28:55
  SPEAKER_00: So that does not need to get missed, and especially if that is coming from a weak quad that needs to be addressed.
• 29:01
  SPEAKER_00: And then we talked about different exercises.
• 29:04
  SPEAKER_00: This is literally a drop in the bucket of what needs to be done.
• 29:08
  SPEAKER_00: Um, but these are just some things to think about uh that I will incorporate into programs with my athletes, just depending on where they're at.
• 29:17
  SPEAKER_00: Alright, guys, that's it.
• 29:19
  SPEAKER_00: This was a long one, but I think that this needed to be said because if you're listening to this, I think that there needs to be enough education and understanding why the quadriceps are so important in ACL rehab, and this wasn't even exhaustive of all the things, but I hope that this helps show you why it is.
• 29:40
  SPEAKER_00: If you have any questions, any feedback, uh, if you want to talk more about this, please reach out to me.
• 29:48
  SPEAKER_00: Uh reach out via email ravi ravi at theaclathete.com or follow me on Instagram, reach out to me, uh Robbie Patel.dpt, and let's connect.
• 30:02
  SPEAKER_00: All right, team.
• 30:03
  SPEAKER_00: That's it for today.
• 30:05
  SPEAKER_00: As always, thank you guys so much for the support and so much for listening.
• 30:10
  SPEAKER_00: I mean, who wants to listen to me rant about quads for almost thirty minutes?
• 30:16
  SPEAKER_00: I guess you do.
• 30:17
  SPEAKER_00: So I appreciate you.
• 30:19
  SPEAKER_00: I'm getting out of here.
• 30:20
  SPEAKER_00: Thank you guys so much.
• 30:21
  SPEAKER_00: See you on the next episode.