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288 | Should You Let Your PT Crank On Your Knee 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: Robbie Patel, performance physical therapist and coach.
• 0:36
  SPEAKER_00: Between myself and fellow guests and experts, you'll learn through the lens of the patient, the healthcare professional, and the coach.
• 0:43
  SPEAKER_00: The goal of this podcast is to equip you, the athlete, with the education to make the best informed decision about your care and your ACL journey.
• 0:54
  SPEAKER_00: Thanks for joining.
• 0:55
  SPEAKER_00: Now let's dive into today's episode.
• 1:00
  SPEAKER_00: I want to open this episode with a real case, a real live case.
• 1:06
  SPEAKER_00: And I'm just gonna warn you guys, I'm coming in super hot right now.
• 1:11
  SPEAKER_00: I'm actually recording this at a not normal time because I just felt so fired up about this call in this case.
• 1:21
  SPEAKER_00: I was like, you know what?
• 1:22
  SPEAKER_00: I'm just gonna go straight to recording a podcast.
• 1:24
  SPEAKER_00: So this is the raw, real stuff right after talking to someone, and I'm gonna call her Maria.
• 1:31
  SPEAKER_00: That's not her real name, but everything else about her story is true.
• 1:36
  SPEAKER_00: And it's something I hear quite often, but it's just one that sometimes it just really sets me off.
• 1:43
  SPEAKER_00: And this is one of those, and I know there are people listening to this that are gonna relate to this, so let's just get into it.
• 1:50
  SPEAKER_00: So Maria is about four and a half months post-op from her ACL reconstruction.
• 1:56
  SPEAKER_00: She had an allograft plus a meniscus repair.
• 2:00
  SPEAKER_00: She got hurt doing a burpee, and she felt a twist in her knee, and she felt the pop, and that was it.
• 2:08
  SPEAKER_00: And so from day one, her range of motion was her problem.
• 2:13
  SPEAKER_00: Her PT was super aggressive with it, and I mean aggressive, y'all.
• 2:18
  SPEAKER_00: She could get motion, but only with someone else forcing that range of motion.
• 2:24
  SPEAKER_00: Never really on her own a ton.
• 2:26
  SPEAKER_00: It just didn't seem like it budged as much.
• 2:30
  SPEAKER_00: Nobody caught the pattern early, but she had scar tissue building up, a cyclops lesion forming, and instead of that getting flagged, she kept getting pushed into these walls session after session, just running and jamming that knee into certain positions.
• 2:50
  SPEAKER_00: Eventually it got bad enough that she needed a second surgery, an MUA.
• 2:56
  SPEAKER_00: So she had the MUA, which stands for a manipulation under anesthesia, and then she also had a lysis of adhesions.
• 3:06
  SPEAKER_00: All this means in simple terminology, y'all, is that she had a scar tissue clean out and the surgeon manipulated and forced her knee into those ranges of motion, which can just kind of break up some things under anesthesia.
• 3:21
  SPEAKER_00: Only done in under anesthesia.
• 3:23
  SPEAKER_00: You cannot do this while you are awake because your muscles will block it, I promise you.
• 3:27
  SPEAKER_00: And so they were trying to get out the things in that knee after the surgery that had built up the scar tissue.
• 3:35
  SPEAKER_00: And so they had found a cyclops lesion in there that had been building up, saying it wasn't super big, but it was there.
• 3:43
  SPEAKER_00: And so when you think of scar tissue, it's not just that it's gonna sit around the ACL, and that cyclops will sit in front of that ACL, and it could typically block extension, yeah, it can influence flexion as well, but especially extension people feel it.
• 3:58
  SPEAKER_00: And then there could be other scar tissue that can form in the knee joint.
• 4:03
  SPEAKER_00: It's not just in front of that ACL, it could be in other areas because you got to remember they go in there and they clean things out, and there are some people who could just be more susceptible to scar tissue formation.
• 4:17
  SPEAKER_00: We don't have fully the details or factors as to why.
• 4:21
  SPEAKER_00: Some could be genetic, some could be the surgery procedure, the impact of the injury.
• 4:26
  SPEAKER_00: She also had surgery very quickly after her injury.
• 4:29
  SPEAKER_00: It was about three weeks later.
• 4:31
  SPEAKER_00: So she went in with a knee that was not very calmed down to begin with.
• 4:36
  SPEAKER_00: She didn't do a ton of prehab, and she moved right into surgery.
• 4:41
  SPEAKER_00: So another variable or reason to maybe delay the surgery a little bit longer, but again, no fault of their own.
• 4:49
  SPEAKER_00: They're just told, hey, get in there and have the surgery, right?
• 4:52
  SPEAKER_00: And so this is where it is very important in terms of this process to be able to recognize some of these patterns of what is happening, especially the fact that she's not making progress with her range of motion, and also just the fact that they are cranking on this knee, and she is continuing to have these challenges with range of motion.
• 5:17
  SPEAKER_00: Now, in our experience, we think that scar tissue and cyclops lesions, for example, are underestimated.
• 5:25
  SPEAKER_00: And this is something that I think will be proven true.
• 5:29
  SPEAKER_00: And this isn't something I can confirm, but I have a hunch that what we see in the research currently and even in previous episodes where I've talked about this, I think it is underestimated.
• 5:40
  SPEAKER_00: And I think it is more prominent in the quad tendon-specific graph type.
• 5:45
  SPEAKER_00: Now, with that said, this is an allograph, but the thing is that scar tissue and cyclops can still form in other procedures.
• 5:52
  SPEAKER_00: It's just we see the severity of them and the frequency of them lower compared to a quad graph, for example.
• 6:00
  SPEAKER_00: But the thing is, is that we think that this is very underestimated, and we see a lot of people who are dealing with this.
• 6:08
  SPEAKER_00: And I think sometimes people who are operating in life and in this process, they might just have a slight bit.
• 6:15
  SPEAKER_00: And so their range of motion isn't fully back.
• 6:18
  SPEAKER_00: It is really this gray area that exists, unless it's very obvious where your flexion is really limited or your extension is limited.
• 6:25
  SPEAKER_00: But if you're off a few degrees, like there's sometimes some situations where I'm like, maybe there is some scar tissue in there, but there is going to be certain conditions where it just doesn't make sense to go back in that knee and clean it out.
• 6:41
  SPEAKER_00: Again, I don't want to get into the nuance of that because that is not the point of this conversation and of this episode.
• 6:48
  SPEAKER_00: But with that said, it is underestimated in our opinion, and there's a lot more people walking around with it.
• 6:54
  SPEAKER_00: And so I think it's really important to be able to be identified.
• 6:58
  SPEAKER_00: And that's one of the things that our team has gotten so good at is identifying early on versus waiting until people are too far into this, especially when we start to notice these patterns.
• 7:11
  SPEAKER_00: And so we see this stuff consistently.
• 7:14
  SPEAKER_00: And I think that this is a case truly where this person could have been identified earlier and they could have been referred back to get an MRI and to be able to look at the knee because it's not adding up in terms of the range of motion and what she was feeling, and could have tackled this earlier and not had to deal with all these issues.
• 7:34
  SPEAKER_00: But the thing is, is that that's secondary to the actual what was happening, which was being cranked on on her knee.
• 7:41
  SPEAKER_00: Now I'm gonna keep going with this particular case and then we'll talk through this.
• 7:47
  SPEAKER_00: But after she was getting all this manipulation, just you know, hands-on kind of pressure of trying to force this knee into certain positions, she ended up having that surgery, the MUA and the license of adhesions, the scar tissue clean out.
• 8:04
  SPEAKER_00: And three weeks after that second surgery, we actually connected, which was actually today.
• 8:10
  SPEAKER_00: And I'm recording this right after because I told you I'm just fired up about it.
• 8:14
  SPEAKER_00: She has had 44-0 physical therapy sessions at this point.
• 8:18
  SPEAKER_00: 40.
• 8:19
  SPEAKER_00: And the last three, she said she would not let them bend her knee anymore.
• 8:24
  SPEAKER_00: She just could not take it.
• 10:30
  SPEAKER_00: And here's the part that really gets me.
• 10:32
  SPEAKER_00: Right after the second surgery, she had a nerve block.
• 10:37
  SPEAKER_00: And so for a couple sessions, they got her in immediately after, and they got her knee almost, you know, the knee flexion bent towards her glute, her heel towards her glute.
• 10:48
  SPEAKER_00: And it didn't hurt at all.
• 10:50
  SPEAKER_00: And you know, in that moment, I'm sure it felt like a win.
• 10:53
  SPEAKER_00: And there's this pressure of like, hey, we need to get your range of motion back, you know, you just had the surgery, and yeah, we need to be more intentional about the range of motion.
• 11:03
  SPEAKER_00: But when the nerve block wore off, the pain hit like crazy, and she hit a wall.
• 11:11
  SPEAKER_00: And her words to me on the call was, I'm I was guarding my knee, my body's stiff.
• 11:17
  SPEAKER_00: And she said to them, You guys are traumatizing me.
• 11:19
  SPEAKER_00: And she told me on the phone, she was like, I feel traumatized by this.
• 11:23
  SPEAKER_00: And her partner was actually on the call too, and he described what he'd watch happen in that clinic.
• 11:30
  SPEAKER_00: His words, they would push on her legs and be like, Yeah, you're gonna cry and hold her down.
• 11:36
  SPEAKER_00: It looks like absolute torture.
• 11:38
  SPEAKER_00: This is literally verbatim, his words.
• 11:40
  SPEAKER_00: And she told me she'd scream, she'd curse, she'd cry.
• 11:43
  SPEAKER_00: She looked at the PT mid-session and said, I can't do this anymore.
• 11:47
  SPEAKER_00: This is bigger than me.
• 11:49
  SPEAKER_00: And this is a woman who doesn't quit.
• 11:51
  SPEAKER_00: Her own partner said it.
• 11:53
  SPEAKER_00: Most people would have stopped weeks into this, and she lasted for almost 40 sessions.
• 11:58
  SPEAKER_00: And each session, there was manual manipulation of pushing her into range of motion.
• 12:04
  SPEAKER_00: Y'all, that is not rehab, it's not normal.
• 12:07
  SPEAKER_00: And I need you guys to hear this because too many people think it is.
• 12:12
  SPEAKER_00: There's a normalization of this, and this is not just one bad clinic or one bad physical therapist having a bad day.
• 12:20
  SPEAKER_00: It's a pattern, and I hear it on a lot of intakes and conversations with ACLers.
• 12:28
  SPEAKER_00: I think people normalize this.
• 12:30
  SPEAKER_00: Um, you know, they'll say, like, oh, I got tortured by my physical therapist, ha ha ha.
• 12:35
  SPEAKER_00: Almost like it's a rite of passage.
• 12:37
  SPEAKER_00: Like it's just part of the process.
• 12:39
  SPEAKER_00: You should be kind of manipulated and tortured to get your range of motion back.
• 12:44
  SPEAKER_00: And I think this also people can probably relate in the total knee replacement community because that is also to be known as well, is because people struggle with range of motion.
• 12:55
  SPEAKER_00: And so then their PT will manipulate it and put people in pain.
• 12:59
  SPEAKER_00: I saw this random video that was getting circulated that someone sent me that the PT was pulling on this strap while he was trying to bend the hell out of someone's knee, total knee post op.
• 13:10
  SPEAKER_00: I was like, You're kidding me.
• 13:12
  SPEAKER_00: I'm like, this is not gonna get the job done, especially for a joint like that.
• 13:16
  SPEAKER_00: The way that they were even manipulating it didn't make sense because of the architecture of the knee because of a total knee.
• 13:22
  SPEAKER_00: I digress, but, anyways, that is something that was just so crazy to me is that it can happen and people normalize it like it's a part of that process, and it is not, and it should never be treated as a joke or some badge of honor, rite of passage, whatever the hell you want to call it.
• 13:39
  SPEAKER_00: It's not.
• 13:41
  SPEAKER_00: And I remember that there was also a clip of Neymar, the famous soccer player, elite athlete, elite medical staff, and he's in this video in agony, absolute agony.
• 13:55
  SPEAKER_00: He's crying, he's screaming, and they video this, and his own team is holding him down while trying to force to flex and bend his knee further.
• 14:04
  SPEAKER_00: And if that is happening on camera to a professional athlete with some of the best resources in the world, and I'm gonna use best resources in quotes, because y'all, that is not good resources.
• 14:17
  SPEAKER_00: I promise you, though, that this is happening in outpatient clinics everywhere without a camera, without anyone questioning it, because they feel like it's normalized, because people don't know any better.
• 14:28
  SPEAKER_00: So then when you have a doctorate of physical therapy or someone who has been trained in physical therapy who is doing this and they're telling you, oh, this is what we need to do, you're like, okay, I guess this is a part of the process.
• 14:39
  SPEAKER_00: Or you might be like, I'm an outlier case that needs to work on my range of motion.
• 14:42
  SPEAKER_00: So yeah, let's do it.
• 14:44
  SPEAKER_00: So let me say this.
• 14:46
  SPEAKER_00: If you ever have, you know, bitten onto a towel or a piece of clothing, screamed, cursed, or dreaded walking into your PT session because you know your knee is going to be cranked on, that is not what good rehab looks like.
• 15:02
  SPEAKER_00: This is a failure on the physical therapist, the clinic, and that is a full freaking stop, y'all.
• 15:09
  SPEAKER_00: Full freaking stop.
• 15:12
  SPEAKER_00: And it broke my absolute heart being on this call as she was breaking down on the call, just talking through this, and her partner there talking and just kind of supporting her.
• 15:23
  SPEAKER_00: And then for us to talk through what a plan actually looks like of like how she can tackle this, and she doesn't need someone to just manipulate her knee, and she can actually control this process, and it's just so so crazy to me.
• 15:37
  SPEAKER_00: But the first thing I want to do before we kind of dive into any more of this is talk about why this actually makes things worse, manipulating and cranking on the knee, why it backfires and why it makes it worse and not make it better.
• 15:52
  SPEAKER_00: When someone forces your knee past what it can tolerate, and we're going to say tolerate as a certain threshold.
• 16:01
  SPEAKER_00: Now, when you look at the pain scale, let's just kind of use that zero to 10, right?
• 16:06
  SPEAKER_00: There are certain degrees of pain people will feel.
• 16:09
  SPEAKER_00: Instead of getting too caught up in numbers, let's just say people have a low level of pain, a moderate level of pain, and a high level of pain that they are sensing.
• 16:19
  SPEAKER_00: And when we say tolerate, I'm just gonna use the green light zone area, is what we call it.
• 16:25
  SPEAKER_00: If we're using green light, yellow light, red light.
• 16:27
  SPEAKER_00: Green light, low level of pain, yellow light, moderate level of pain, red light, high levels of pain, right?
• 16:35
  SPEAKER_00: And usually people can identify that.
• 16:37
  SPEAKER_00: They could tell themselves I'm in a low, moderate, or high about a pain.
• 16:41
  SPEAKER_00: And when you say what I could tolerate, everyone's gonna say I have a high pain threshold, I could tolerate a lot of pain.
• 16:48
  SPEAKER_00: Every single person says it in the the course of being a patient as a as a rehab person.
• 16:54
  SPEAKER_00: Um but the thing is that what you can tolerate doesn't mean let's go into the red light, high, high levels of pain.
• 17:02
  SPEAKER_00: We're talking green light, ideally.
• 17:04
  SPEAKER_00: Yes, you might experience some discomfort, but it needs to be truly tolerable.
• 17:09
  SPEAKER_00: The thing is that pain is a noxious stimulus.
• 17:12
  SPEAKER_00: You are pushing tissue beyond its threshold.
• 17:16
  SPEAKER_00: And that is an alarm sounding off on your body.
• 17:20
  SPEAKER_00: And so you need to know when you need to poke the bear versus when you are really pissing that bear off.
• 17:26
  SPEAKER_00: And that is really, really important.
• 17:29
  SPEAKER_00: And your body doesn't just shrug it off when you push it behind beyond its threshold, it responds to it just like a threat.
• 17:38
  SPEAKER_00: More swelling, more pain, more guarding.
• 17:41
  SPEAKER_00: You are teaching your own knee to protect itself against, you know, this person who is supposed to be trying to help you, but it's protect, it's going into fight or flight mode, and it's like, yo, I don't like this, and it's kind of pissing me off.
• 17:54
  SPEAKER_00: And so think about what happened to Maria with that nerve block.
• 17:58
  SPEAKER_00: It's the same as taking, I kind of told her, like a bunch of painkillers, right?
• 18:02
  SPEAKER_00: So you can just push through anything.
• 18:05
  SPEAKER_00: The pain is masked, but it's not gone.
• 18:07
  SPEAKER_00: You're just changing the signal, you're blocking the signal, and that's what a nerve block does.
• 18:12
  SPEAKER_00: It just blocks the pain signal, the sensory signal.
• 18:15
  SPEAKER_00: So that way you are not feeling that.
• 18:17
  SPEAKER_00: But I promise you, behind the scenes, the tissue and everything that's happening is telling you, hey, we don't like this, especially if it's pushed beyond a certain threshold.
• 18:26
  SPEAKER_00: And so this is something that is challenging because when that block wears off, your nervous system comes roaring back online.
• 18:35
  SPEAKER_00: It like is like, yo, I'm here, and it overcorrects.
• 18:39
  SPEAKER_00: And that's exactly what happened to her.
• 18:41
  SPEAKER_00: Now you repeat that for 40 sessions, right?
• 18:45
  SPEAKER_00: Maybe not as aggressive as like post-scar tissue clean out where she had that block.
• 18:52
  SPEAKER_00: But when she is going to these sessions and she is getting her knee manipulated and cranked on, then that is going to be something that you're just not going to be building range of motion at that point, to be honest.
• 19:06
  SPEAKER_00: You're training your nervous system, you know, that the flexion or extension you're being cranked into is danger.
• 19:13
  SPEAKER_00: And you're honestly working against the exact outcome you're trying to create.
• 19:17
  SPEAKER_00: And I will stand by this.
• 19:18
  SPEAKER_00: And I've seen this again.
• 19:20
  SPEAKER_00: And I have had my moments when I was early in my career where I was like, oh, let me just kind of push into this.
• 19:26
  SPEAKER_00: And I have learned that it never works.
• 19:29
  SPEAKER_00: It never works.
• 19:30
  SPEAKER_00: The small degrees that you might get back a little bit is just not worth it because then the knee swells up, it gets angry, and it honestly just starts guarding.
• 19:40
  SPEAKER_00: Everything around it starts guarding, the quads, the hamstrings, especially, and the calves, and your whole body is just kind of rigid and locked up.
• 19:48
  SPEAKER_00: That is not an environment to push more range of motion.
• 19:52
  SPEAKER_00: That is actually going to work against you.
• 19:54
  SPEAKER_00: And here's the framework around this.
• 19:58
  SPEAKER_00: This is how we have gotten range of motion back for hundreds and hundreds of ACLers we have worked with while never putting our hands on them.
• 20:08
  SPEAKER_00: Remote coaching, y'all.
• 20:10
  SPEAKER_00: Don't touch them.
• 20:11
  SPEAKER_00: We don't see them.
• 20:12
  SPEAKER_00: We've never worked with them in person.
• 20:14
  SPEAKER_00: They have been across the entire side of the country in other countries.
• 20:19
  SPEAKER_00: So we have physically been unable to touch them, and they have been able to get their range of motion back.
• 20:25
  SPEAKER_00: The thing is, is that yes, we work into passive range of motion, and that is going to be an assessment and a proxy for us, but we're also going to prioritize active range of motion as well.
• 20:36
  SPEAKER_00: And this is the problem that happened here is that they were focusing too much on passive range of motion here and relying too much on end range and using the PT to reinforce that, even though her body was telling her no.
• 20:51
  SPEAKER_00: And so the lasting range of motion comes from the ACL or the patient producing that motion themselves.
• 20:59
  SPEAKER_00: That's why the CPM, y'all, when those little machines post op that some people get that just bend your knee for you, kind of like a sliding scale, those things, yes, it will help move the knee some, but guess what?
• 21:12
  SPEAKER_00: People's range of motion doesn't magically come back because they do that.
• 21:16
  SPEAKER_00: They still have to actively work to get that knee to move.
• 21:19
  SPEAKER_00: And I can attest to this because I used my first ACL without that, and then my second ACL, my surgeon recommended it.
• 21:26
  SPEAKER_00: I didn't know any different.
• 21:27
  SPEAKER_00: And the thing is, is that you're still going to need to do it actively, not from someone else forcing it on the knee.
• 21:35
  SPEAKER_00: Passive work does have its place as I shared, and we use it.
• 21:39
  SPEAKER_00: The thing is, it has to be dosed in correctly, but then the active piece is really going to drive the change.
• 21:45
  SPEAKER_00: That's the real change.
• 21:46
  SPEAKER_00: Micro dosing over a bolus of dosing is so, so key.
• 21:52
  SPEAKER_00: I'll repeat that just because that's a weird word.
• 21:55
  SPEAKER_00: Micro dosing versus this bolus or large bolus of dosing is the key here.
• 22:01
  SPEAKER_00: Instead of one brutal 20, 30 minute session of aggressive range of motion stretching, you spread short, low intensity bouts throughout the day.
• 22:14
  SPEAKER_00: Higher frequency, lower intensity, especially early post op.
• 22:19
  SPEAKER_00: Undercook it, then titrate that dosage.
• 22:23
  SPEAKER_00: Even if it's a degree or a few degrees by day, you will get there, I promise you, versus trying to win this entire thing in a day or two.
• 22:32
  SPEAKER_00: And that's what people try to do.
• 22:34
  SPEAKER_00: And I feel like sometimes PTs try to do this when they're working on this range of motion, that they should really not really bother with.
• 22:41
  SPEAKER_00: Look, I get it whenever they're early post-op and you might want to help with some passive movement to get them comfortable bending the knee, especially if it was an early surgery or pain is intense and they're very apprehensive.
• 22:53
  SPEAKER_00: Look, I get that.
• 22:54
  SPEAKER_00: Again, we could still guide that without any hands-on work, but I get it.
• 22:58
  SPEAKER_00: But if you're cranking into these end ranges, that is just a full red flag.
• 23:04
  SPEAKER_00: And so when you talk about undercooking it and then titrating that dosage in, you start below what you think the knee can handle.
• 23:12
  SPEAKER_00: You watch how it responds, you adjust from there.
• 23:16
  SPEAKER_00: You are never trying to deliver a giant bolus of stress to a joint that is already sensitive and reactive.
• 23:26
  SPEAKER_00: It is just looking for another thing to be pissed off about.
• 23:29
  SPEAKER_00: So the dose response is your feedback loop here because each small bout that you do, you can actually see how the knee reacts to that exact stimulus.
• 23:39
  SPEAKER_00: That feedback is an important part of this system because then the second you go all in on one aggressive session, you lose that information because it is just going to override and it's likely going to flare the knee up.
• 23:55
  SPEAKER_00: And so then instead, what is going to be important here is that we just kind of insert these micro doses of sessions and Higher frequency across the day, and you can nudge the system, nudge the knee into the range of motion it needs to.
• 24:11
  SPEAKER_00: Extension, flexion, both, y'all.
• 24:13
  SPEAKER_00: And I'll say the track record part again because it really matters.
• 24:17
  SPEAKER_00: Hundreds of ACL athletes we have worked through remotely, never touched them, and never seen them physically, their range of motion came back anyway.
• 24:26
  SPEAKER_00: That is just not a theory, y'all.
• 24:29
  SPEAKER_00: I'm telling you this.
• 24:30
  SPEAKER_00: This is something that we have tested repeatedly over and over and over.
• 24:35
  SPEAKER_00: And it's not just someone who has been fresh post op.
• 24:39
  SPEAKER_00: These are people who have been months and years out.
• 24:41
  SPEAKER_00: We've had people five, 10 plus years out who never got end range flexion back or didn't necessarily get their extension back.
• 24:49
  SPEAKER_00: And in those cases, there have been people who have gotten that stuff back, even that far out.
• 24:55
  SPEAKER_00: They just weren't given the right prescription and the dosage and the right movements to be able to tackle these things.
• 25:01
  SPEAKER_00: And sometimes people almost allow themselves to be like, okay, 70, 80% of the range of motion is good.
• 25:08
  SPEAKER_00: The tests that we always utilize that are good proxies for extension is doing your heel pop tests, laying on the ground, being able to do a quad set, use your uninvolved side as the comparison, and then see how high your heel gets on that and try to do it on the involved side.
• 25:24
  SPEAKER_00: And that's gonna tell you how much of a difference there is.
• 25:27
  SPEAKER_00: And then when we do this from a knee flexion standpoint, doing a tall kneeling rock back where you just kind of sit back on your heels and try to get your butt to your heels, that is such a good proxy of knee flexion.
• 25:40
  SPEAKER_00: It is going to test that thing out under pressure and we're gonna see how it feels.
• 25:44
  SPEAKER_00: Usually people will kind of lean to the uninvolved side if there's any difference, or they'll feel pressure in the involved ACL side, and sometimes that hip will hike as well.
• 25:54
  SPEAKER_00: And so this is something that we repeatedly see we can assess remotely and we can gauge the feel of it as well through our athletes.
• 26:02
  SPEAKER_00: And this is something that if you titrate in the proper amount across the week and across weeks to come, that you get there.
• 26:12
  SPEAKER_00: You get there.
• 26:13
  SPEAKER_00: And the thing that we're always trying to nudge people towards is typically getting them to 120 degrees of flexion, and that's where we're gonna be like, okay, we're feeling pretty good about this based on how they feel.
• 26:25
  SPEAKER_00: Of course, we're gonna do a full profile and testing and then be able to see, like, okay, what else do we need to tap into here?
• 26:32
  SPEAKER_00: Or is this something that we just need to nudge along?
• 26:35
  SPEAKER_00: And some people it comes quickly, and some people it just takes time.
• 26:39
  SPEAKER_00: But this is why you have to work with someone who knows this stuff that isn't cranking in to your knee.
• 26:46
  SPEAKER_00: And I want to be fair here because this isn't just a simple manipulation is bad, active work is good for every single case.
• 26:55
  SPEAKER_00: Sometimes there is a true and real mechanical block to this.
• 26:59
  SPEAKER_00: It could be scar tissue, it could be cyclops lesion, other things going on in the knee.
• 27:04
  SPEAKER_00: And in those cases, no amount of active range of motion work or microdosing is going to get you there because you're also not necessarily dealing with a mobility issue.
• 27:13
  SPEAKER_00: You're actually running into a physical wall.
• 27:16
  SPEAKER_00: So that is exactly what happened to Maria before her second surgery.
• 27:21
  SPEAKER_00: That pattern should have been caught earlier, and that's what's really important here.
• 27:26
  SPEAKER_00: And manipulating a knee that is just blocked mechanically here, it's not gonna break up that scar tissue.
• 27:34
  SPEAKER_00: It's just gonna reinforce that cycle, the the stress cycle that they are dealing with of having that swelling, having the pain, having the guarding without truly ever solving the actual problem underneath it.
• 27:48
  SPEAKER_00: And what happens is that these people they develop PTSD with these types of situations.
• 27:56
  SPEAKER_00: I kid you not, this person was so emotional, and I could just feel it and I could palpate like just how it felt.
• 28:04
  SPEAKER_00: And this is something that we see through this process with people working with in-person PTs, and sometimes their surgeon even is proactively like, yeah, have them crank on it.
• 28:16
  SPEAKER_00: And I'm just like, man, where are we at in this place that people think that this is going to be the thing that gets them there?
• 28:21
  SPEAKER_00: And logically, sure, it makes sense, but I'm not faulting any of you for this because you're not supposed to know this.
• 28:28
  SPEAKER_00: It's supposed to be your provider who is supposed to be able to provide the guidance, and that's the thing that is so challenging with this, is because a lot of people just never update what they're doing or learn further in this, and then they are just like, oh, well, this is how I'm gonna get everyone's range of motion back.
• 28:45
  SPEAKER_00: And to me, if I just had to just call this out, and I see this a lot, is uh I think a very poor environment for the knee, and what I mean is consistent swelling, pain, muscle guarding, and just an inflammatory cycle that just lives there.
• 29:08
  SPEAKER_00: And it's something that I think really perpetuates this scar tissue formation because you have this knee that is healing and trying to calm down, and you're further reinforcing just this perpetual inflammatory cycle that is just gonna really make the scar tissue lay down, and I don't love it, and I think it contributes a lot to people just continuing to build more scar tissue.
• 29:33
  SPEAKER_00: So I can't prove this, but who's to say that also this cranking into the knee and perpetual just inflammatory response, the swelling and the pain didn't also exacerbate some of that scar tissue formation.
• 29:46
  SPEAKER_00: Versus let's listen to the knee, let's get it quiet, let's allow her to titrate the loading and the pushing of the range of motion work, that is what's gonna help it get there and probably keep the knee a bit more calm and less guarded, and especially the inflammatory process to chill out a little bit because that's what we're trying to do in that knee.
• 30:09
  SPEAKER_00: So if you're getting cranked on in these sessions and session after session, and especially if it is not making progress, then that is a signal that something needs to be looked at.
• 30:23
  SPEAKER_00: It's not a signal to push harder, and a lot of times people are like, no pain, no gain here, and that's not the case.
• 30:29
  SPEAKER_00: It is just not the case, and I hope that I have conveyed that strongly in this episode.
• 30:36
  SPEAKER_00: So if you are in agony during range of motion work, if you feel anxious before every session, if you're having something close to some PTSD around your physical therapy visits, I need you to hear this very, very clearly just because I'm bawling up my fist and I'm just like, uh that is that was never supposed to be the deal in this case, and you should never be feeling this.
• 30:59
  SPEAKER_00: I don't care who told you what needs to happen, whether it's your surgeon or your physical therapist, you do not need someone cranking on your knee to get your range of motion back.
• 31:09
  SPEAKER_00: And it is not too late.
• 31:10
  SPEAKER_00: We have worked with people, as I had shared, years out with range of motion loss who got it back without ever being manipulated.
• 31:18
  SPEAKER_00: And if your PT is cranking on your knee and you're in pain, if you're biting a towel, screaming, you know, cursing, that's your sign.
• 31:26
  SPEAKER_00: You need to get rid of them, you need to fire them, you need to change PTs, someone who knows this process.
• 31:33
  SPEAKER_00: And I would almost bet you, I would put money on it, that if you found a physical therapist who accurately and does objective strength testing, like they use a dynamometer or they refer out, or they know someone who has an isokinetic machine, and they objectively test your strength.
• 31:51
  SPEAKER_00: And if you looked at those PTs and you looked at the PTs who cranked on your knee, there would be an inverse relationship.
• 31:59
  SPEAKER_00: Meaning there will be a strong relationship between those who truly strength tested and the people who cranked on your knee would be very, very low, aka non-existent.
• 32:09
  SPEAKER_00: Because usually those people who are strength testing are also keeping up with the literature.
• 32:13
  SPEAKER_00: And guess what?
• 32:13
  SPEAKER_00: I asked this person has your knee been strength tested at all?
• 32:17
  SPEAKER_00: Has your PT talked about it?
• 32:19
  SPEAKER_00: Have you seen anyone else doing it in the clinic?
• 32:21
  SPEAKER_00: And she said no.
• 32:22
  SPEAKER_00: I was like, oh, go figure.
• 32:24
  SPEAKER_00: And so this is something that you need to make sure that if this is happening, get rid of them, find a different one.
• 32:31
  SPEAKER_00: And I'm gonna be pretty strong on this.
• 32:34
  SPEAKER_00: Find someone who understands load management, how to be able to get you there without being in this pain and agony, and how the nervous system actually responds to stress and not someone who is just kind of forcing, you know, these things or trying to be macho because they're a PT.
• 32:51
  SPEAKER_00: It's just not gonna work, y'all.
• 32:53
  SPEAKER_00: You should never have to be in agony to get your range of motion back, ever.
• 32:57
  SPEAKER_00: If someone tells you otherwise, they do not understand what they are doing.
• 33:01
  SPEAKER_00: And that's gonna be my episode for today.
• 33:03
  SPEAKER_00: So if you feel that this is who you're working with, please make a change.
• 33:08
  SPEAKER_00: I promise you it will be worth it.
• 33:10
  SPEAKER_00: Whatever growing pains that come from it, it will be worth it, especially in the long run.
• 33:15
  SPEAKER_00: And if you need any help, we are here to help.
• 33:19
  SPEAKER_00: This is your host, Robbie Patel, signing off.