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286 | 5 Signs It's Time to Switch Your PT · The ACL Athlete Podcast

• 0:18
  SPEAKER_00: Welcome everyone to the ACL Athlete Podcast.
• 0:22
  SPEAKER_00: This is the podcast where we talk about everything related to the ACL, whether that's the injury itself, the rehab process, return to sport, and more.
• 0:31
  SPEAKER_00: I'm your host, Dr.
• 0:32
  SPEAKER_00: Ravi Patel, performance physical therapist and coach.
• 0:36
  SPEAKER_00: Between myself and fellow guests and experts, you'll learn through the lens of the patient, the healthcare professional, and the coach.
• 0:43
  SPEAKER_00: The goal of this podcast is to equip you, the athlete, with the education to make the best informed decision about your care and your ACL journey.
• 0:54
  SPEAKER_00: Thanks for joining.
• 0:55
  SPEAKER_00: Now let's dive into today's episode.
• 1:00
  SPEAKER_00: What is up, team, and welcome back to another episode on the ACL Athlete Podcast.
• 1:06
  SPEAKER_00: I want to start this one with something personal.
• 1:10
  SPEAKER_00: Well, first, before that, if you did not check out the previous podcast episode talking about the mental toll of ACL rehab, I want you to listen to that.
• 1:20
  SPEAKER_00: If you're an ACLer, go listen to it.
• 1:23
  SPEAKER_00: If you are a clinician working with ACLs, go listen to it.
• 1:28
  SPEAKER_00: And it is something that I felt was very raw, and I received a lot of messages and notes, and so I appreciate you guys for reaching out and sharing that because it continues to put a fire in me for doing this, but then also knowing that that related and to hit.
• 1:46
  SPEAKER_00: And I just want you guys to know that you're seen in this.
• 1:50
  SPEAKER_00: And so this episode is related to maybe some of your cases, many of you, I'm sure, that you're mulling over.
• 2:02
  SPEAKER_00: And starting this from the personal side of knowing that I have torn my ACL twice, one on each knee.
• 2:08
  SPEAKER_00: Going through it twice didn't make the second time easier.
• 2:12
  SPEAKER_00: It actually made it harder because I knew what exactly was at stake.
• 2:17
  SPEAKER_00: And you think you go through it once, and then so then therefore you're like, okay, I know what to expect and what to do.
• 2:22
  SPEAKER_00: But it's a double-edged sword because you compare to something that is different, especially if it's one side versus the other or the same side.
• 2:31
  SPEAKER_00: And it's an overall different process.
• 2:34
  SPEAKER_00: It's something that is really hard for you to compare.
• 2:37
  SPEAKER_00: And there's also a bit of a question of like, okay, if you did it again, then was that the right thing to compare to, anyways?
• 2:44
  SPEAKER_00: So we won't go down that rabbit hole.
• 2:46
  SPEAKER_00: But here's what I have realized: is that looking back at both of those ACL tears and recoveries, and now after years of taking calls with hundreds and thousands of athletes going through the same ACL process, the single biggest factor in how your recovery goes is not your surgeon.
• 3:04
  SPEAKER_00: It's not going to be your graph choice.
• 3:07
  SPEAKER_00: It's who you trust to guide you week to week.
• 3:11
  SPEAKER_00: Your PT, your physical therapist, your coach, whoever that person is for you, your GPS.
• 3:18
  SPEAKER_00: And this is something that I've thought about so much over the years.
• 3:23
  SPEAKER_00: And I think about what are the important factors that help people move forward and the things that are just a normal part of the process.
• 3:34
  SPEAKER_00: And what are the things that we weigh the most in terms of what is going to really make the difference for you getting back to what you want to do?
• 3:43
  SPEAKER_00: And I think about that in my own recoveries, and then I think about that with the people we work with, the people we talk to, and where the breakdowns are.
• 3:51
  SPEAKER_00: And yeah, there are biological things that happen from the healing standpoint that we can't always control.
• 3:56
  SPEAKER_00: And yeah, there are other factors that kind of play into this, but the person who is guiding you in this, who is providing that support day in and day out, is going to be so key.
• 4:08
  SPEAKER_00: Your surgeon might see you for 10 minutes, a handful of times over the course of a year.
• 4:14
  SPEAKER_00: There's plenty of people who could probably put a single hour of actual access less than that of their surgeon the entire time they work with somebody through an entire year.
• 4:26
  SPEAKER_00: Less than an hour.
• 4:28
  SPEAKER_00: And you might touch that with one single session with your physical therapist.
• 4:32
  SPEAKER_00: They are the North Star in this process.
• 4:34
  SPEAKER_00: And if that person is not actually up to date, if they are not doing the things that are truly good ACL rehab things that are required, it can turn a nine to 12 month recovery into an 18-month to a 24-month plus recovery.
• 4:50
  SPEAKER_00: And I've seen this time and time again.
• 4:52
  SPEAKER_00: We have people on our roster right now who are the byproduct of this.
• 4:57
  SPEAKER_00: It can turn a controlled process into unfortunately a re-injury.
• 5:02
  SPEAKER_00: And it could really be the difference between feeling like you really have a plan, you have clarity and control, and also feeling completely lost, having the anxiety and just kind of the fear of the unknown.
• 5:16
  SPEAKER_00: So today I want to walk you through the things that I hear on these calls over and over, and the things that people tell me someone's PT is not exactly where they need to be.
• 5:26
  SPEAKER_00: They share these things.
• 5:28
  SPEAKER_00: And I'm not faulting anyone for this because you don't know what you don't know.
• 5:34
  SPEAKER_00: Like we're not expecting everyone to walk into an ACL injury and surgery and know how the process goes and know how PT should be.
• 5:41
  SPEAKER_00: Everyone sounds super smart in this process.
• 5:44
  SPEAKER_00: You see someone with a doctorate of physical therapy, and you're like, oh, you're clearly qualified.
• 5:48
  SPEAKER_00: And that's assuming every medical doctor, every teacher, every single profession, as soon as you see a license, they're qualified.
• 5:57
  SPEAKER_00: And at the bare minimum, yes, but we have good and bad and mediocre in every single profession that exists.
• 6:04
  SPEAKER_00: I think it's very important for people to understand today that we can talk through what this is in terms of someone's PT not necessarily fully being there and where they need to be.
• 6:17
  SPEAKER_00: And it's not to scare you, it's not to make you distrust everyone in this field, although you need to be skeptical because there are a lot of incredible clinicians out there, incredible ones.
• 6:31
  SPEAKER_00: And this is mainly just so you know what to ask, what to listen for, and what should make you pause.
• 6:38
  SPEAKER_00: And at this point, I just am able to filter through so much of like, okay, tell me you know what you're talking about without telling me know what you're talking about, right?
• 6:47
  SPEAKER_00: Or the vice versa, it's like, tell me you're not up to date without telling me you're not up to date.
• 6:51
  SPEAKER_00: And it's these things that people share with me that I'm like, man, that is that's pretty old fashioned.
• 6:58
  SPEAKER_00: That's not what is up to date current research.
• 7:01
  SPEAKER_00: Even if you looked at a recent study in the past few years, you'd be like, it's very different.
• 7:06
  SPEAKER_00: And so the thing is, is that that's really challenging.
• 7:09
  SPEAKER_00: And even in PT school, for example, we had no access or no experience to strength testing, none whatsoever.
• 7:18
  SPEAKER_00: I didn't even know what a dynamometer was in that very moment that you could hook up.
• 7:23
  SPEAKER_00: And so the thing is, is that it's something that has to be beyond the schooling that has to be accessed and learned, and there's just so much more beyond that.
• 7:34
  SPEAKER_00: And so the thing that I want you to sit with more than anything for a second is think about two athletes that can have the same exact surgery, exact same graft, exact same surgeon.
• 7:46
  SPEAKER_00: And six months later, one of them is running, lifting, feeling more confident, and the other one still dealing with some swelling, has a little bit of like a limp in their gait, um, still kind of scared to be in the gym and trusting their knee.
• 8:01
  SPEAKER_00: What is that difference?
• 8:03
  SPEAKER_00: Almost always in these types of situations, it ends up being who is guiding them and what they're doing.
• 8:10
  SPEAKER_00: Yeah, there are subsets of these that isn't always about what they're doing in the physical therapist, but I find in most of these cases when people are struggling this much with being months out, it ends up being less about the healing or their knee or what's going on, and it tends to be way more about the rehab that they are doing.
• 8:33
  SPEAKER_00: And this is not about blame.
• 8:35
  SPEAKER_00: Most of you trust your PT because that is what you're supposed to do.
• 8:39
  SPEAKER_00: We have the letters behind our name, and I fully understand that you should do that.
• 8:44
  SPEAKER_00: We have spent years in school.
• 8:46
  SPEAKER_00: Of course, you should trust them.
• 8:48
  SPEAKER_00: This episode is not making you paranoid about this field or the physical therapist.
• 8:53
  SPEAKER_00: It's about making sure that it's giving you the tools, the education to vet, to properly see signs that you should start to be more skeptical or you should lean in more.
• 9:04
  SPEAKER_00: And that's essentially what I want you to do: to make sure that the trust is actually earned and not just because it's a bubbly personality, because we're all super nice.
• 9:14
  SPEAKER_00: We don't get into physical therapy for money.
• 9:17
  SPEAKER_00: I promise you, ask all of my friends.
• 9:20
  SPEAKER_00: We are not here for the money.
• 9:22
  SPEAKER_00: We are here because we like to help people move and we like to help people feel better and get better out of pain.
• 9:27
  SPEAKER_00: But if you ask most of my friends, they are not the ones who are crushing it and buying multiple homes and cars and all the things.
• 9:34
  SPEAKER_00: We're trying to pay off our debts and we're just trying to just live an average American life or wherever you live, right?
• 9:42
  SPEAKER_00: The thing is that we are trying to be able to make sure that you in this situation have the tools you need to make a very good judgment.
• 9:52
  SPEAKER_00: Here are the five things that I wanted to touch on.
• 9:54
  SPEAKER_00: Number one, and I've done an episode on this of just like the number one red flag.
• 9:59
  SPEAKER_00: And to me, this is still the number one red flag.
• 10:02
  SPEAKER_00: It's the really tell me that you really are not up to date.
• 10:06
  SPEAKER_00: And the thing is, is no strength testing.
• 10:11
  SPEAKER_00: If you have actually been strength tested, I promise you, I promise you, you know it.
• 10:17
  SPEAKER_00: You can tell me how it was done, you can tell me your numbers or roughly, and that is how you know it happened.
• 10:25
  SPEAKER_00: You know the setup of it.
• 10:27
  SPEAKER_00: There's a lot of nuances to what truly strength testing is that we're able to know, like, okay, this is exactly what it is, and you should be able to explain that.
• 10:37
  SPEAKER_00: And in reality, there are only three primary ways to do strength testing.
• 10:42
  SPEAKER_00: There's isokinetic where you get strapped into this like very expensive big knee extension-based contraption, and that's either using a humac norm typically or a biodex isometrically through a dynamometer where it is going to be fixed to like a chain or a strap, and it is outputting a very specific number.
• 11:04
  SPEAKER_00: It's kind of like a weight scale, but it's like strapped to something and you're kicking into it, it's fixed.
• 11:09
  SPEAKER_00: And then there's a rep maximum.
• 11:11
  SPEAKER_00: So that could be on a knee extension, it could be on a leg curl.
• 11:15
  SPEAKER_00: Yes, you can do this on a leg press.
• 11:17
  SPEAKER_00: And while we take proxies of this, the thing is that it's very important to know that just because you did a leg press or you know, you did a seated sit-to-stand, those are not truly like those strength testing, especially in isolation.
• 11:33
  SPEAKER_00: There's multiple joints moving, so then therefore, it gives us a proxy of things, but therefore you got to understand that it's not isolated strength testing.
• 11:42
  SPEAKER_00: The knee extension, five rep max can give us that, the leg curl can give us that, still different from isometric and isokinetic, but just know that this needs to be intentional.
• 11:52
  SPEAKER_00: Like there needs to be intentional testing behind it.
• 11:55
  SPEAKER_00: That's really it.
• 11:57
  SPEAKER_00: And so, if your PT, your physical therapist or coach cannot describe which one they use, and you can't either, it did not happen in any way that actually matters.
• 12:06
  SPEAKER_00: I had a call this week with someone whose PT told them they have not had the time to strength test.
• 12:13
  SPEAKER_00: I'm just gonna pause there for a second.
• 12:15
  SPEAKER_00: Moment of silence.
• 12:16
  SPEAKER_00: Think about that for a second.
• 12:19
  SPEAKER_00: She has been months out and has not had it on the radar whatsoever because they have not had time.
• 12:27
  SPEAKER_00: I don't even know what that really means, if I'm honest, because in physical therapy, if you're insurance based, you have to report objective measures anyways.
• 12:36
  SPEAKER_00: And so I can't think of a more objective way to test something than to be able to strap it up to something and kick out into it and get a number.
• 12:44
  SPEAKER_00: Even pushing against your hand, that's what the MMT is.
• 12:48
  SPEAKER_00: That's not truly a strength test.
• 12:51
  SPEAKER_00: It just tells us your muscle is on, right?
• 12:53
  SPEAKER_00: And so the thing is, is that not having the time is actually bizarre to me when she told me this.
• 12:58
  SPEAKER_00: Testing takes maybe minutes.
• 13:00
  SPEAKER_00: If you have it really dialed in, like I can have someone come in, really test in five, 10 minutes max.
• 13:08
  SPEAKER_00: If there's no time for that, then there's no time for probably the one thing that is going to be the actual big needle mover and the thing that's going to be making decisions in your process.
• 13:21
  SPEAKER_00: And here's the earlier version of this same red flag.
• 13:25
  SPEAKER_00: Before you even get to the bigger milestones, are they testing you before you run?
• 13:29
  SPEAKER_00: Not asking you how you feel, not eyeballing your squat, actually testing it.
• 13:34
  SPEAKER_00: A lot of people tell me that their PT tested me, you know, for being able to do X, Y, and Z.
• 13:41
  SPEAKER_00: But when I ask them specifically what it looked like or what their numbers were, there's not really an answer.
• 13:47
  SPEAKER_00: It's like they want to say yes.
• 13:50
  SPEAKER_00: And then the thing is when they answer, they can't really repeat it back.
• 13:54
  SPEAKER_00: And so that's something that I find is very interesting in these types of scenarios where someone is trying to explain the testing, but they necessarily can't.
• 14:06
  SPEAKER_00: Number two is time over criteria.
• 14:09
  SPEAKER_00: Your body doesn't necessarily know what week it is during this process.
• 14:13
  SPEAKER_00: Um, I had a call with someone four months post-op, swollen knee, limping while they were walking, no testing done at all.
• 14:20
  SPEAKER_00: And their PT told them to start running.
• 14:23
  SPEAKER_00: So they did because their physical therapist told them to start running.
• 14:28
  SPEAKER_00: Make that make sense to me.
• 14:31
  SPEAKER_00: A swollen limping knee is not a running knee.
• 14:36
  SPEAKER_00: No matter what the calendar says, a lot of times we see that people are at 12 weeks, and a lot of protocols will say at 12 weeks you can start running.
• 14:46
  SPEAKER_00: And that doesn't necessarily mean anything on its own.
• 14:49
  SPEAKER_00: It just means that 12 weeks have passed by.
• 14:52
  SPEAKER_00: Even 16 weeks does not mean anything on its own.
• 14:55
  SPEAKER_00: What matters is what your knee can actually prove to do and has earned the right to do right now, today.
• 15:02
  SPEAKER_00: And so a good provider is going to be making decisions off of criteria versus using a timeline or a time-based approach.
• 15:11
  SPEAKER_00: So we want a criteria-based approach in this process where we are using those things over time in terms of being able to make decisions.
• 15:23
  SPEAKER_00: Do we factor in time and give some ranges?
• 15:26
  SPEAKER_00: Sure.
• 15:26
  SPEAKER_00: Like we're gonna say a ballpark range based on where people are.
• 15:30
  SPEAKER_00: The thing is that it's a very flexible timeline, if you will, versus set, like at this point, you're going to be able to do this.
• 15:40
  SPEAKER_00: We need to make sure that we are heavily weighting the proper criteria that is going to determine success for doing running, for example, or whatever it is that they can do next.
• 15:52
  SPEAKER_00: So that is a very important one.
• 15:54
  SPEAKER_00: Number two, being the criteria and not using time as the focus, which is the red flag, is using time.
• 18:11
  SPEAKER_00: Number three is you can't talk to them.
• 18:15
  SPEAKER_00: You don't feel like there's an open communication line.
• 18:18
  SPEAKER_00: It's very difficult to ask them questions, you almost feel a little bit guarded.
• 18:24
  SPEAKER_00: It seems simple, but it really matters.
• 18:28
  SPEAKER_00: And I really think about the headspace that a lot of us ACLers are in during this process.
• 18:35
  SPEAKER_00: Can you ask your provider a real question and get a real answer?
• 18:39
  SPEAKER_00: Someone who actually knows what they are doing can explain their reasoning to you in plain language, very simple language.
• 18:45
  SPEAKER_00: It doesn't need to sound super smart, super complicated.
• 18:50
  SPEAKER_00: Why are we doing this today?
• 18:52
  SPEAKER_00: Why are we not doing that?
• 18:53
  SPEAKER_00: What are we building towards?
• 18:55
  SPEAKER_00: If your physical therapist gets defensive when you're asking, or maybe shrugs it off or says a generic answer, or it makes you feel like you're being difficult for wanting to understand your own recovery, that is not a communication style issue.
• 19:13
  SPEAKER_00: Usually that is some defensiveness, maybe covering up for the fact that there's no real reasoning, or I'm not sure exactly what it is.
• 19:23
  SPEAKER_00: Um, but I get this a lot where people are listening to this podcast or they're researching on their own and AI being a big piece of this now because people are becoming more and more educated and asking questions.
• 19:37
  SPEAKER_00: And so their physical therapist that they're working with start to get irritated or just doesn't like the fact that they're doing their own research.
• 19:48
  SPEAKER_00: And so then, therefore, they might get defensive or not have the answers to it.
• 19:54
  SPEAKER_00: And look, I'm not saying we have the answers to every single thing in this process, 100%.
• 19:59
  SPEAKER_00: If we don't know something, we'll tell you.
• 20:01
  SPEAKER_00: We're like, I don't know.
• 20:02
  SPEAKER_00: I'm gonna go find out though, and we'll research it, we'll figure it out, we'll talk as a team, whatever it is.
• 20:07
  SPEAKER_00: But there should be a way to communicate anything in this process very simply, as if like we're talking to a third grader and being like, this is what's happening, right?
• 20:17
  SPEAKER_00: And that's to me, knowing your stuff is when you can communicate it very simply to someone.
• 20:24
  SPEAKER_00: But I think that most importantly, there has to be an open line of communication that's so key.
• 20:31
  SPEAKER_00: And that could be the difference in continuing to have anxiety and wondering about this process versus feeling very you can exhale, feel confident.
• 20:41
  SPEAKER_00: You have someone in your corner who's your guide.
• 20:43
  SPEAKER_00: Yes, we are here to help guide this process in terms of like the week and testing and the exercises and the progressions and getting you back to what you want to do.
• 20:54
  SPEAKER_00: But there's such an element of the emotional and communication side that we are tackling to be able to make sure that you feel supported.
• 21:03
  SPEAKER_00: You understand that this is also the mental process that we're navigating.
• 21:06
  SPEAKER_00: So we're talking through these things.
• 21:08
  SPEAKER_00: We're not just dancing around it, but a lot of that is going to put you at ease knowing you have someone you can talk to and communicate about what is going on and maybe concerns that you're having, right?
• 21:19
  SPEAKER_00: Maybe there's some anxieties that are in there that you're like, hey, can we just talk through this?
• 21:24
  SPEAKER_00: Can you tell me what's going on?
• 21:26
  SPEAKER_00: And I think that that is so important, so crucial.
• 21:30
  SPEAKER_00: And the challenges with current state of physical therapy is that we just don't have the time in a traditional model.
• 21:39
  SPEAKER_00: It is high volume based.
• 21:41
  SPEAKER_00: We don't even have the time because we're seeing two to four people an hour, if not more, that it is challenging to be able to give you that individualized response and very consistently through the week.
• 21:54
  SPEAKER_00: Because if someone's seeing 20, 30 patients in a day, and let's say they're different patients each week or some of the same, right?
• 22:02
  SPEAKER_00: Let's say across the week it's who knows, maybe like 50 to 100 different patients, then how do you expect for someone to be able to respond to each of those people every single week very consistently while they're in the clinic trying to rehab them and do those things, right?
• 22:21
  SPEAKER_00: It's hard.
• 22:23
  SPEAKER_00: So I'm not blaming our PTs for the whole thing.
• 22:27
  SPEAKER_00: It's a model that is challenging to be able to provide the support for.
• 22:31
  SPEAKER_00: And so I think the thing is that you want to make sure that your PT has the ability to communicate and share these things, and most importantly, it's an open door conversation both ways, and you don't feel like you have to hide anything.
• 22:47
  SPEAKER_00: Number four is that you don't have any structure outside of your sessions.
• 22:55
  SPEAKER_00: You are not really having anything happening as much between that, or maybe it's the same rinse repeat.
• 23:02
  SPEAKER_00: But here's the math on this one.
• 23:04
  SPEAKER_00: Your PT sees you for maybe one hour if you have a session that week, maybe two or three hours a week if you're lucky, if you're doing two to three times a week.
• 23:14
  SPEAKER_00: I would say on average, most people probably hover around the two times per week based on their insurance.
• 23:22
  SPEAKER_00: Your recovery happens in the other 160 some odd hours in your week.
• 23:29
  SPEAKER_00: It's not just those one, two, or three hours.
• 23:32
  SPEAKER_00: So if you're only seeing your PT once or the twice a week, and there is no structure for what happens outside of that, or it's a laundry list of exercises, there's no way that you're really getting what you need.
• 23:46
  SPEAKER_00: Three times a week with real intention, you might be scraping by.
• 23:50
  SPEAKER_00: But even if you're going three times a week, I promise you that you're doing stuff outside of those sessions, depending on what phase you're on and doing things and your goals.
• 24:00
  SPEAKER_00: But with once or twice a week with nothing else, there's no way that.
• 24:04
  SPEAKER_00: You're going to move the needle with what you need to do, especially if you don't have structure outside of those sessions.
• 24:10
  SPEAKER_00: And this shows up two different ways.
• 24:12
  SPEAKER_00: Sometimes it's the total silence, nothing is given to you outside of your sessions at all.
• 24:17
  SPEAKER_00: And sometimes it's the quite the opposite.
• 24:20
  SPEAKER_00: And it's the massive list I talked about earlier of exercises where you're doing an hour, two hours every single day that just keep piling up.
• 24:29
  SPEAKER_00: They never actually like truly change, if you will.
• 24:32
  SPEAKER_00: Like you almost have the first exercise to the second exercise, the third that you started with.
• 24:36
  SPEAKER_00: And then it just continues this list versus progressions, very clear-cut structure of a training and rehab program that has progressed week to week.
• 24:46
  SPEAKER_00: It ends up being just kind of like a laundry list of exercises.
• 24:51
  SPEAKER_00: And I can't tell you the number of people we have come to us, and they're even months out, months and months out.
• 24:59
  SPEAKER_00: And they're doing two to three hours of just like at-home rehab every day.
• 25:03
  SPEAKER_00: They're trying to get to it and they're burning out.
• 25:05
  SPEAKER_00: And I'm like, no wonder.
• 25:06
  SPEAKER_00: It's because you're still doing short arc quads and straight leg raises.
• 25:10
  SPEAKER_00: I legit had someone I talked to last week four months out, still doing short arc quads, straight leg raises.
• 25:17
  SPEAKER_00: Four months out.
• 25:19
  SPEAKER_00: Y'all, that's that's a problem.
• 25:21
  SPEAKER_00: That means that there are some things that have not been progressed, especially when you're that far out.
• 25:27
  SPEAKER_00: I don't care where they're at in the process.
• 25:29
  SPEAKER_00: It's very rare that someone is still doing those things that far out.
• 25:34
  SPEAKER_00: And the thing that is really important is that this gives us a little bit of the litmus of like, okay, they're not really getting things.
• 25:41
  SPEAKER_00: You're being given things, but it's not really meeting you where you are.
• 25:44
  SPEAKER_00: So this is a stalled situation, but either way, it's the same root problem.
• 25:50
  SPEAKER_00: There's no real plan for majority of your week, which is where you're going to be doing the heavy work for your ACL rehab.
• 25:56
  SPEAKER_00: So you have to have structure outside of your in-person sessions.
• 26:02
  SPEAKER_00: It's not just, hey, do some of these exercises.
• 26:05
  SPEAKER_00: These are good ideas to hit at the gym.
• 26:08
  SPEAKER_00: And I think there's almost this like kind of gray area that exists where people get some exercises and they're told to do it, you know, two or three times a week, depending on how often they're going to PT.
• 26:21
  SPEAKER_00: But there's no structure.
• 26:22
  SPEAKER_00: It might just be like, all right, hit leg press, leg extension, leg curl, you know, squats, lunges, whatever it is.
• 26:27
  SPEAKER_00: And then you're like, oh, cool, that's a program.
• 26:30
  SPEAKER_00: There's no like progressions on dosage, no progression on intensity, there's no progression on the variation.
• 26:38
  SPEAKER_00: It's not constrained to be able to hit particular groups of muscles.
• 26:42
  SPEAKER_00: There's no like structure or flow to it, like a true training program.
• 26:46
  SPEAKER_00: And it's just very generic and almost kind of like rinse repeat of what it is.
• 26:51
  SPEAKER_00: And I think that's really important to be able to differentiate because sometimes it's a placeholder, but people are kind of doing the same things or they're not really being progressive, like, all right, well, this is the rep range we need to hit.
• 27:04
  SPEAKER_00: Because when we're looking at hypertrophy, strength, power, different muscle groups, there needs to be different rep ranges, different intents behind it, and also different variations.
• 27:17
  SPEAKER_00: Because the one thing that you will find is that people will compensate consistently for months and months and months and months in this process.
• 27:26
  SPEAKER_00: So if you're doing just very general movements, the thing is there need to be constraints in the process to be able to work around to make sure your body is not compensating and we're hitting the targeted tissue.
• 27:42
  SPEAKER_00: Number five is fear of doing knee extension work.
• 27:47
  SPEAKER_00: If your physical therapist tells you that all open chain knee extensions, or sometimes can be called open kinetic chain, OKC knee extensions, if they say it's bad for your graft, that's a full stop for me.
• 28:04
  SPEAKER_00: Full stop, red flag.
• 28:06
  SPEAKER_00: That's about as equal to me as the strength testing.
• 28:11
  SPEAKER_00: Forever, that is outdated thinking.
• 28:13
  SPEAKER_00: At this point, we have disproved this through the research.
• 28:18
  SPEAKER_00: There are some annoying situations where it's continuing to float around because people don't update the research that they are reading or what they learned in 1945.
• 28:32
  SPEAKER_00: And it is just something that is crazy because you're talking about the one thing that could probably move the needle the most for you, you're gonna leave on the table.
• 28:42
  SPEAKER_00: And so we have research showing that walking can put more stress on the ACL compared to doing a lightweight knee extension.
• 28:50
  SPEAKER_00: The ACL is not even taught or on tension in the first 90 to 45 degrees of knee extension.
• 29:00
  SPEAKER_00: So if you're seated on a chair, for example, you're at 90 degrees with your feet on the floor.
• 29:06
  SPEAKER_00: If you just kick halfway between full extension, that your ACL is not even being taught.
• 29:12
  SPEAKER_00: It's not being tensioned whatsoever.
• 29:14
  SPEAKER_00: So you can't even make the graph lax if you want to.
• 29:32
  SPEAKER_00: And more often than not, when people are like, Well, I'm having these issues with my knee, a lot of things can be traced back to likely a lack of quad strength.
• 29:45
  SPEAKER_00: It is the number one player in why people are struggling in this process, more than likely.
• 29:52
  SPEAKER_00: If I had to pick one single factor that if we could improve quadriceps strength and the output that that quad can do and tolerate, and that force and the speed of it, that we would have less re-injuries in ACL rehab, and that people would be back to doing things more and more in this process.
• 30:15
  SPEAKER_00: And the one, if we're talking like sniper approach here, the one thing that's gonna get it done is doing knee extensions.
• 30:23
  SPEAKER_00: Now, it doesn't mean you go all out here, but it is going to be very important to have this in the program.
• 30:30
  SPEAKER_00: And I want to be fair here because there is some nuance.
• 30:34
  SPEAKER_00: And there are some situations, yes, real, like legitimate, time-bound reasons to modify those certain loads and ranges early on, as I said.
• 30:44
  SPEAKER_00: Maybe it is in the upper range and heavier loading, sure.
• 30:48
  SPEAKER_00: And Graph type is also gonna play into this, but that's not what I'm talking about in this situation.
• 30:54
  SPEAKER_00: What I'm talking about is more so of a provider who just blanketly uses a permanent rule of like we're not gonna do knee extensions.
• 31:01
  SPEAKER_00: And especially if people are months and months out and still saying that that's a problem.
• 31:06
  SPEAKER_00: And especially if they're kind of putting fear into you, saying it'll stretch the graft, it'll make laxity.
• 31:12
  SPEAKER_00: It's just not true.
• 31:14
  SPEAKER_00: Laxity can happen for a number of reasons.
• 31:17
  SPEAKER_00: Um, if someone's being super stupid, then yeah, sure, that could play into it.
• 31:21
  SPEAKER_00: But in most cases, that is not the case.
• 31:24
  SPEAKER_00: And the research strongly supports this.
• 31:27
  SPEAKER_00: And so this is something that we continue to see in the surgical community.
• 31:32
  SPEAKER_00: A lot of surgeons still don't like it.
• 31:34
  SPEAKER_00: Um, and then the other thing is that we will see still a lot of physical therapists who will either listen to the surgeons and don't do their own research, or they have just kind of learned outdated methods, and this is their belief.
• 31:50
  SPEAKER_00: So, this is a very important component of number five is if there is someone who is saying the extensions are bad or a stretcher graft, that is a problem.
• 32:02
  SPEAKER_00: So, now here is what I really want you to take away from this.
• 32:06
  SPEAKER_00: Take all five of those things, and here is what you're left with if they are all present or just some of them.
• 32:13
  SPEAKER_00: You're probably feeling lost, you do not have clarity on your plan, on what today has to do with getting you back to your sport, on where you actually stand.
• 32:24
  SPEAKER_00: You're told things will get better with time, your swelling will get better with time, your range of motion, your limp will get better with time.
• 32:32
  SPEAKER_00: Instead of actually being given a reason and an actual plan to tackle it, or having it assessed and being like, this is the problem, this is how we're gonna tackle it.
• 32:40
  SPEAKER_00: And at the end of all of it, there's no true like return to sport criteria.
• 32:45
  SPEAKER_00: There's not really a lot of strength numbers in there.
• 32:48
  SPEAKER_00: There's no like dynamics assessment of like vertical jump testing, single leg dynamic testing, looking at change of direction and agility, having a reintegration framework for returning to sport and activities.
• 33:01
  SPEAKER_00: It's really just the time passing along on a calendar, a date, and kind of like a good luck, right?
• 33:08
  SPEAKER_00: Hoping you get there with just a protocol and some exercises.
• 33:12
  SPEAKER_00: And if that is how you feel right now, I want you to hear this.
• 33:18
  SPEAKER_00: It is not you failing your rehab, it is your rehab failing you.
• 33:23
  SPEAKER_00: And I don't like to say this very much, but I think I need to really be transparent and share what I am like hearing so consistently of these themes that ACLers are bringing to these conversations and the challenges that they're facing.
• 33:42
  SPEAKER_00: And I really do believe that if you are facing one of these five issues, regardless, it's a conversation with your physical therapist or if your surgeon is bringing this up and asking why.
• 33:57
  SPEAKER_00: And I think that if I had to just kind of really distill down these five things, it could be one, it could be two, it could be, you know, all five, right?
• 34:08
  SPEAKER_00: These are things that really stand out to me of you need to think about switching PTs.
• 34:14
  SPEAKER_00: You can ask some questions, and I'm always a big fan of like, hey, ask some questions, don't go attack mode, don't just blow them up and just be like, hey, I heard this on this podcast.
• 34:25
  SPEAKER_00: I don't want PTs to start being just pissed off because they're like, well, they heard this from this rando on this podcast complaining about ACLs.
• 34:34
  SPEAKER_00: I want you to go in just wanting to be understanding of what the plan is or why their reasoning is.
• 34:40
  SPEAKER_00: And again, if they can't explain it or if they stand by it, then be very skeptical because these are five things that I stand truly by after being in this space for a very long time, almost a decade at this point, very clearly, with a lot of ACL athletes that we have worked with, going through this myself, and also just fielding so many conversations.
• 35:06
  SPEAKER_00: And I think that if any of these are sticking out to you, there needs to be more in-depth understanding.
• 35:13
  SPEAKER_00: And I think in reality, what this is gonna lead to is just knowing that you're gonna need to switch your physical therapists sooner rather than later.
• 35:21
  SPEAKER_00: And I hope that this is a call to action or a nudge to you that if you're listening to this and you're like, man, that's my PT.
• 35:27
  SPEAKER_00: Or yeah, like I don't feel like I can talk to them.
• 35:29
  SPEAKER_00: We're not doing any strength testing.
• 35:31
  SPEAKER_00: And I've been like four months, six months into this, and I haven't had a single number that has been collected on my quad or hamstring strength.
• 35:38
  SPEAKER_00: You're saying that I can do knee extensions because they said it'll stretch the graft.
• 35:43
  SPEAKER_00: You're not really having true structure between your sessions.
• 35:46
  SPEAKER_00: Like you're just going to the PT sessions.
• 35:48
  SPEAKER_00: Maybe you have an app or a sheet of paper and you're just doing some of those exercises, but there's no true structure, there's no specifics to it, and it's not progress week to week, right?
• 36:01
  SPEAKER_00: And I just really think the big one is 100% that you feel like you can't really communicate or talk to them or get answers out of them.
• 36:09
  SPEAKER_00: And then the fact that they're just using time to progress things.
• 36:13
  SPEAKER_00: Those are all red flags, those are things that to be cautious of.
• 36:17
  SPEAKER_00: And this is exactly why we do what we do.
• 36:20
  SPEAKER_00: This is exactly why the podcast exists.
• 36:22
  SPEAKER_00: My goal is to make sure that you feel equipped, educated, and for you to catch these early.
• 36:30
  SPEAKER_00: It makes my heart so happy whenever someone is like, hey, I decided to switch physical therapists because I was not getting the attention I deserved.
• 36:40
  SPEAKER_00: I was struggling, and I found someone who actually listens to me and who has studied and learned this process and cares about it.
• 36:50
  SPEAKER_00: And I would rather have someone who is in the process of learning and doesn't know everything, but is willing to be open about it versus someone who is set in these ways and won't do the testing or is using time or, you know, not necessarily being open to the things that you want to say, right?
• 37:07
  SPEAKER_00: That's really important here because I know what this is like to be on the other side of this, not knowing if the person guiding you actually knows what they are doing.
• 37:15
  SPEAKER_00: And I never want a single ACL athlete to ever feel lost and feel that way.
• 37:20
  SPEAKER_00: So if any of this hit home for you, I would love for you to check out what we do.
• 37:24
  SPEAKER_00: We're here to help.
• 37:25
  SPEAKER_00: The information is in the show notes for remote coaching.
• 37:28
  SPEAKER_00: Regardless, like I just want you to feel fired up.
• 37:32
  SPEAKER_00: And if you feel in your gut you need to make a change, make a change.
• 37:35
  SPEAKER_00: Whether that's local to you, go explore some options.
• 37:39
  SPEAKER_00: It is so important.
• 37:41
  SPEAKER_00: And I will stand by this forever for right now.
• 37:45
  SPEAKER_00: And I know I'm biased to this, but the single most important person that you will choose in this ACL rehab process will be your physical therapist and that coach and who is guiding you back to get you back to what you want to do.
• 37:57
  SPEAKER_00: They will be there with you alongside and should be there with you, and that will make or break whether your potential first four months is very brutal or maybe it's very smooth.
• 38:09
  SPEAKER_00: It could turn a nine-month process into an 18-month process or even longer than that.
• 38:15
  SPEAKER_00: It can also turn it into a re-injury.
• 38:17
  SPEAKER_00: And I hate to say that, but I've seen and had so many of these conversations where it could have been prevented, it could have been different, but it wasn't tested, it wasn't guided appropriately.
• 38:29
  SPEAKER_00: And as a byproduct, it's not them who is going to be suffering from it.
• 38:33
  SPEAKER_00: It's the ACL athlete, it's you.
• 38:36
  SPEAKER_00: And they're just gonna, you know, brush off their hands and be like, you know what, I tried to do my best, but doing our best is important, sure.
• 38:45
  SPEAKER_00: But we need to make sure in this, we can't leave it to chance.
• 38:48
  SPEAKER_00: We just can't.
• 38:49
  SPEAKER_00: You can't do it.
• 38:50
  SPEAKER_00: You have too much on the line, you can't do this again.
• 38:53
  SPEAKER_00: So please, if you just feel moved at all on this episode, make a change.
• 38:59
  SPEAKER_00: That's all I asked you to do.
• 39:01
  SPEAKER_00: That's gonna be it for y'all.
• 39:03
  SPEAKER_00: Until next time, this is your host, Ravi Patel, signing off.