Latest / The ACL Athlete Podcast / 185 | 10 Ways To Improve Your Post-Op ACL Rehab Outcomes

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185 | 10 Ways To Improve Your Post-Op ACL Rehab Outcomes · 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.
• 0:58
  SPEAKER_00: What's up, guys?
• 0:59
  SPEAKER_00: Welcome back to another episode on the ACL Athlete Podcast.
• 1:03
  SPEAKER_00: So today we are diving into 10 ways to improve your post-op ACL rehab outcomes.
• 1:11
  SPEAKER_00: So let's get straight into it.
• 1:13
  SPEAKER_00: Post op ACL rehab.
• 1:16
  SPEAKER_00: It's assumed to be super easy or straightforward.
• 1:20
  SPEAKER_00: And this is something that I'll have a lot of conversations with ACLers and even clinicians, right?
• 1:25
  SPEAKER_00: Where they're just like, yeah, it's it's very basic, right?
• 1:28
  SPEAKER_00: They're gonna start off with just like quad sets, range of motion stuff, and being able to, you know, start doing some basic exercises, straight leg raises, all the things, right?
• 1:38
  SPEAKER_00: The thing that is always interesting is that we will get ACLers later in the process, or we'll talk to PTs, and they will still be struggling with basically the things that should have been straightforward early in the process that athletes are still dealing with three months later, six months later, nine months later.
• 1:58
  SPEAKER_00: And I think a lot of times it's because maybe the initial post op process was overlooked a little bit.
• 2:05
  SPEAKER_00: And I think it is one of the most overlooked phases in this process because I think there's this assumption that it's straightforward.
• 2:12
  SPEAKER_00: But in reality, there's a lot of nuances to it.
• 2:14
  SPEAKER_00: Sure, like a lot of people do start off with similar things, but you got to think about the nuances of, you know, is it an athlete's first, second, third ACL injury?
• 2:25
  SPEAKER_00: And then comparing it to the other side, right?
• 2:27
  SPEAKER_00: Like, is it uh second injury on the other leg, right?
• 2:32
  SPEAKER_00: Then your normative values are a little different.
• 2:34
  SPEAKER_00: What kind of graph type did they get?
• 2:36
  SPEAKER_00: Is there any concomitant injuries?
• 2:39
  SPEAKER_00: Is there other stuff like meniscus repair, MCL repair?
• 2:43
  SPEAKER_00: Is there any other procedures that were done in this process?
• 2:48
  SPEAKER_00: Maybe it was an LET, right?
• 2:50
  SPEAKER_00: And so then, therefore, we're going to make sure that we are mindful of the postdoc process, and that's going to also impact the way that we design our programs, the way that we guide athletes.
• 3:00
  SPEAKER_00: If you get a quad tendon, guess what?
• 3:02
  SPEAKER_00: We're going to be a little bit more intentional about certain positions and also about pain compared to maybe a hamstring graft.
• 3:09
  SPEAKER_00: But I think what happens is that all these protocols just kind of generalize them.
• 3:14
  SPEAKER_00: And there's this assumption that, okay, well, as long as you don't have a meniscus repair, you can kind of stay steady with the same exercises and progress at week four, six, and eight.
• 3:23
  SPEAKER_00: When in reality, there is so much variance, as you guys know, through this ACL rehab process.
• 3:29
  SPEAKER_00: So this is something where I just want to share some 10 different ways that you can improve your outcomes.
• 3:38
  SPEAKER_00: Post op ACL rehab, this applies to post-injury as well.
• 3:42
  SPEAKER_00: Um, but this is something that can really, really make a difference, especially not only in the post-op process, but I'm talking about mid and late stages.
• 3:52
  SPEAKER_00: When you are at, let's say, six months or nine months, or even like 12 months out.
• 3:57
  SPEAKER_00: This can make or break the difference of you being in a certain place where you were expecting to be, or where in theory most people would get to.
• 4:06
  SPEAKER_00: Or is it something where you're kind of delayed?
• 4:08
  SPEAKER_00: And often I see this because maybe this post op process wasn't taken seriously enough, or maybe there wasn't good compliance with the athlete.
• 4:17
  SPEAKER_00: There are a lot of things that can play into this, right?
• 4:20
  SPEAKER_00: Even the healing of the body, which there's controllables and there's uncontrollables, which is biology, right?
• 4:26
  SPEAKER_00: We can't control all those things.
• 4:28
  SPEAKER_00: But we do want to focus on the controllables, and that's what we're going to talk about today with these 10 different ways.
• 4:34
  SPEAKER_00: So let's get into it.
• 4:35
  SPEAKER_00: Number one, don't rush the first six weeks.
• 4:39
  SPEAKER_00: I've seen a lot of people try to overdo it in this phase and they go hot out of the gate, and then that's something that can really flare the knee up.
• 4:48
  SPEAKER_00: Or maybe on the flip side, they don't take it too seriously, right?
• 4:51
  SPEAKER_00: For us, we look at this first, especially six to eight weeks, we're really building a foundation.
• 4:58
  SPEAKER_00: And I've seen this really delay the ACL rehab process because if you go hot out of the gate, you're going to also flare the knee up.
• 5:06
  SPEAKER_00: And if you don't find the right consistency and repetitions and hit the right criteria for extension, flexion, trying to get the knee quiet, right?
• 5:15
  SPEAKER_00: Getting pain down, getting swelling down, being able to normalize your gait, some of those different pieces are going to play such a big role to set up that foundation.
• 5:25
  SPEAKER_00: But also you're just trying to get back to normal life.
• 5:27
  SPEAKER_00: So if we can find the sweet spot with this where you're not doing too much, you're not doing too little, you have certain goals you're targeting, then man, it's a huge game changer.
• 5:38
  SPEAKER_00: But what I've seen is that if you rush that six-week process, then it's something that can really set you back in terms of where you're at at three months, at six months, and so on because of rushing it.
• 5:53
  SPEAKER_00: Number two, use NMES on your quad.
• 5:57
  SPEAKER_00: This is electrical stimulation.
• 5:58
  SPEAKER_00: NMES stands for neuromuscular electrical stimulation specifically.
• 6:03
  SPEAKER_00: You cannot use a tens unit.
• 6:05
  SPEAKER_00: The most important thing that I want to stress here is that you cannot use a tens unit.
• 6:11
  SPEAKER_00: TENS unit is for pain.
• 6:13
  SPEAKER_00: You might get lucky with a diamond in the rough here, where a tens unit is a combo of an NMES unit.
• 6:20
  SPEAKER_00: It's sometimes also called an EMS, electrical muscle stimulator.
• 6:24
  SPEAKER_00: That's probably more the umbrella term, if you will.
• 6:26
  SPEAKER_00: But NMES has a very specific setting and output that we want to have.
• 6:33
  SPEAKER_00: So we want to make sure that we get a specific NMES unit.
• 6:38
  SPEAKER_00: I know a lot of people have either parents or friends or maybe a partner or somebody who's got a TENS unit because they got it off of Amazon and it's cheap and it helps with pain.
• 6:48
  SPEAKER_00: And I think that's the goal we want to make sure we address here.
• 6:51
  SPEAKER_00: It's not for pain, it is for electrical stimulation of the muscle.
• 6:56
  SPEAKER_00: So it's going to be a different setting.
• 6:57
  SPEAKER_00: You can control it typically.
• 6:59
  SPEAKER_00: There's fancy ones out there.
• 7:01
  SPEAKER_00: We recommend the Bulego NMES device.
• 7:05
  SPEAKER_00: It's, I think, roughly 60 bucks on Amazon.
• 7:08
  SPEAKER_00: We have no affiliates with this.
• 7:10
  SPEAKER_00: Um, the thing is that it's just the most affordable, it's the easiest that people can get quickly, and it's just something that we want to make sure athletes are doing post op.
• 7:19
  SPEAKER_00: And the tips I want to recommend to you here is that it should be at an uncomfortable but tolerable intensity.
• 7:26
  SPEAKER_00: People kind of set it and they're like, okay, I can see my quad kind of come on and stuff, and I feel it.
• 7:32
  SPEAKER_00: But this thing needs to be strong, man.
• 7:34
  SPEAKER_00: Like you need input to that quad, and we need to make sure that it is strong and you're uncomfortable, honestly, but it's tolerable because you're not going to do it forever, but you are going to try and hit this.
• 7:45
  SPEAKER_00: And it's something that we want athletes to try and hit one to three times a day.
• 7:50
  SPEAKER_00: You know, with physical therapy, the thing that's interesting is that it depends on your frequency of when you go, typically in person.
• 7:57
  SPEAKER_00: So it might be two times a week, it might be three times a week.
• 8:00
  SPEAKER_00: That's only three times of the whole week that you are getting that input.
• 8:04
  SPEAKER_00: And it's maybe just that one bout.
• 8:06
  SPEAKER_00: So it might be 30 minutes total in your whole week.
• 8:08
  SPEAKER_00: Think about the spread of a whole week, how often you're hitting range of motion stuff.
• 8:12
  SPEAKER_00: Think about if you can uh really do that one to three times a day.
• 8:18
  SPEAKER_00: You think about how much that can accelerate your quad's ability to contract and really be able to get input, and that's what all of our athletes do.
• 8:26
  SPEAKER_00: We get them a device in person or remotely, and they order it, they get it, they have it in there, and they're hitting that thing one to three times a day.
• 8:35
  SPEAKER_00: And the research shows how effective it is.
• 8:38
  SPEAKER_00: There's nothing to argue against it not being effective.
• 8:41
  SPEAKER_00: So if your PT is not doing NMES, especially post op, then that's a problem in and of itself.
• 8:46
  SPEAKER_00: But this is something that you need to do from battling arthrogenic muscle inhibition, AMI, to connecting, you know, kind of that mind muscle connection.
• 8:55
  SPEAKER_00: I remember when I had my first ACL and I had that NMES device on my quad.
• 9:02
  SPEAKER_00: Before I did that, when I was trying to contract it, it just felt like I could not connect it.
• 9:06
  SPEAKER_00: I couldn't contract it.
• 9:08
  SPEAKER_00: Like, you know, it's like when you try to flex your bicep, you can feel that bicep.
• 9:11
  SPEAKER_00: But when you try to do it and you look at your quad, it's like just that hot dog that's sitting there.
• 9:16
  SPEAKER_00: You're just like, come on, flex.
• 9:18
  SPEAKER_00: And you can't.
• 9:19
  SPEAKER_00: And all my ACLers know this feeling.
• 9:22
  SPEAKER_00: And so when you have that NMES on there, it sends this signal that allows you to be able to connect your brain to that contraction, that mind muscle connection.
• 9:31
  SPEAKER_00: And you just kind of start to feel it fire, and then you start to feel like that wiring starts to connect faster and faster.
• 9:38
  SPEAKER_00: And so, think about the more frequency and input you get it, the faster you can get those quads to get rolling, the better you are early post op from a strength standpoint, from being able to get your extension back, from being able to take stairs, all the things that build off of just getting your quads to wake up.
• 9:55
  SPEAKER_00: And so that's gonna be key because then that's gonna help you to get stronger and therefore get to the things potentially sooner rather than having a delay in muscle strength.
• 10:04
  SPEAKER_00: And the other thing that I want to mention here is that I'll have athletes do it into mid and even late stages of ACL rehab.
• 10:11
  SPEAKER_00: It's not just this post-op thing.
• 10:13
  SPEAKER_00: And there are research groups, um, University of Delaware, for example, they will also look at this and they'll even have athletes do it up to you know 70 to 80 percent of symmetry.
• 10:24
  SPEAKER_00: So it's not just this post-op, you know, four-week window.
• 10:28
  SPEAKER_00: This can be used in the mid and late stages if you're still getting some delay in the quads and up to a certain level.
• 10:36
  SPEAKER_00: So there's no set cutoff.
• 10:38
  SPEAKER_00: I think it's just assume that like once the quads get going, that we don't need it anymore.
• 10:43
  SPEAKER_00: Now you might decrease the use of it as you get into mid and late stages, but what's the harm in it if you have the opportunity to do it and you're still trying to chase down quad strength?
• 12:58
  SPEAKER_00: Number three, get your swelling down ASAP, ASAP.
• 13:03
  SPEAKER_00: In my opinion, like this is literally the biggest bottleneck in A cell rehab, even outside of pain.
• 13:08
  SPEAKER_00: Sure, like pain can be a limiter here, but I think swelling is one of the biggest bottlenecks.
• 13:14
  SPEAKER_00: It shuts down the quads, and we know this through the research for orthogenic muscle inhibition, AMI, that swelling is not great for this.
• 13:23
  SPEAKER_00: It limits your range of motion from flexion and extension.
• 13:26
  SPEAKER_00: Um, when you get that balloon feeling in your knee, it just wants you to just kind of compensate.
• 13:32
  SPEAKER_00: So whenever you're trying to go into a squat or a lunge or step up or anything with the knee, right, you're going to try and offload that leg because it just doesn't feel great.
• 13:42
  SPEAKER_00: I know this feeling of that balloon feeling, it feels puffy.
• 13:45
  SPEAKER_00: You don't want to sit back on your heels, you don't want to go into the position.
• 13:48
  SPEAKER_00: So you'll kind of torque your body or your hips or you'll shift to the uninvolved side and you want to offload the stress.
• 13:55
  SPEAKER_00: So then, therefore, we're not even stressing the proper tissues because of that swelling.
• 14:00
  SPEAKER_00: So it just has a heap of issues that we want to try and get the swelling down.
• 14:04
  SPEAKER_00: We don't want it to hang out, we want to get it down, especially post-op.
• 14:08
  SPEAKER_00: And usually if there's a sign of swelling, it means that your knee is not tolerating what's going on, especially after that post-op or post-injury phase, right?
• 14:17
  SPEAKER_00: Where there's that acute rush of swelling due to the trauma.
• 14:20
  SPEAKER_00: Once you're later in this process, you want to get that swelling down because otherwise, that's telling us the ability to tolerate the stress is being exceeded.
• 14:30
  SPEAKER_00: Like your capacity is being exceeded.
• 14:33
  SPEAKER_00: Basically, like we're overshooting that.
• 14:35
  SPEAKER_00: So we need to adjust things to do that, especially on the early front end.
• 14:40
  SPEAKER_00: This is going to be really important because you're going to start accumulating steps.
• 14:45
  SPEAKER_00: If you have a vacation plan, be on the lookout because that is something that can really accumulate some steps and trigger the knee.
• 14:52
  SPEAKER_00: And people don't assume this.
• 14:55
  SPEAKER_00: And I get it, but it is something that I've seen time and time and time again.
• 14:59
  SPEAKER_00: Someone has surgery, they're early, they haven't accumulated steps, they can kind of start walking, and then they go off on this trip and they accumulate 10,000 steps, 20,000 steps, and their knee blows up because you're increasing how much you're vertical, you're putting a lot of miles on your knee, and it's just not used to it.
• 15:18
  SPEAKER_00: Your load that you have accumulated and your step volume hasn't built up to that.
• 15:23
  SPEAKER_00: So that's one of the things that could be sneaky.
• 15:26
  SPEAKER_00: So consider that into this with your swelling.
• 15:30
  SPEAKER_00: Also, impact-related work can really stress that knee.
• 15:34
  SPEAKER_00: And so that is also something to factor in is that once you start adding in some jumping or some running, that the knee can also get a little tricky and feel some swelling and some puffiness.
• 15:45
  SPEAKER_00: So just some things to look out for early on, but get that swelling down ASAP.
• 15:51
  SPEAKER_00: Regain active knee extension, matching your uninvolved side.
• 15:56
  SPEAKER_00: This is number four.
• 15:58
  SPEAKER_00: And a great proxy for this is getting your heel pop.
• 16:00
  SPEAKER_00: So that means basically trying to do a quad set and seeing if that heel can pop up off of the ground without compensating into your glutes and hamstrings.
• 16:09
  SPEAKER_00: Um, I like to get athletes on the edge of the treatment table where their heels are hanging off, and the basically their Achilles tendon is the thing that is on the edge of a table.
• 16:19
  SPEAKER_00: And then I get them to do a heel pop on their uninvolved side, and then I'll get them to do the heel pop on the involved side.
• 16:26
  SPEAKER_00: So that's basically a quad set, if you will.
• 16:28
  SPEAKER_00: And then we're trying to basically match that uninvolved side.
• 16:32
  SPEAKER_00: And then once you do achieve and get this, work on to maintain it because it can regress.
• 16:38
  SPEAKER_00: People assume once you get it, you can keep it.
• 16:41
  SPEAKER_00: And yeah, you can to some degree, but I've noticed that if you don't work on it, there are some people who can regress and then they start to feel that their extension is starting to lose a little bit.
• 16:53
  SPEAKER_00: So then, therefore, this is always a check-in point every single week for yourself to keep working on it, to make sure you have that heel pop.
• 17:00
  SPEAKER_00: It doesn't take but just a second to check in on it to see the differences.
• 17:05
  SPEAKER_00: And the other thing that I will mention is that zero degrees is not enough unless it is on your uninvolved side.
• 17:12
  SPEAKER_00: There are some people I've worked with where they sit in a little bit of positive or maybe at zero degrees, and that's okay because that is their normal human anatomy.
• 17:21
  SPEAKER_00: But majority of humans have hyperextension at their knee.
• 17:24
  SPEAKER_00: That means they go beyond zero, roughly, you know, five degrees, 10 degrees.
• 17:30
  SPEAKER_00: If you're someone who's hypermobile and you get to 15 to 20 degrees hyperextension, then you can kind of slowly work towards five to 10 and then don't worry about the rest because there is a certain point for this particular population of hypermobile athletes where you don't need to rush to get that back.
• 17:47
  SPEAKER_00: But for majority of people, you're gonna want to get that matching to your uninvolved side.
• 17:53
  SPEAKER_00: That is your goal.
• 17:55
  SPEAKER_00: That is the proxy, which is going to be the heel pop, which is what we use at the ACL athlete.
• 18:01
  SPEAKER_00: Get your hyperextension back.
• 18:03
  SPEAKER_00: Number five, let pain and swelling be your guide.
• 18:07
  SPEAKER_00: One of the biggest things here is making sure pain is not equaling gain here.
• 18:12
  SPEAKER_00: And swelling is a sign, as I had mentioned, that your knees, capacity, and tolerance is being exceeded.
• 18:17
  SPEAKER_00: Respect that healing process, especially early post op.
• 18:21
  SPEAKER_00: And then find that green light zone so we give our athletes this traffic light feedback loop.
• 18:26
  SPEAKER_00: So, you know, if pain is, you know, dull-ish and making sure it's not sharp, and then it's in that one to three out of 10 range.
• 18:35
  SPEAKER_00: So that's our green light zone.
• 18:36
  SPEAKER_00: Four to five out of 10 is that yellow light, and then six and above, so six, seven, eight, nine, ten pain out of ten is the red light.
• 18:44
  SPEAKER_00: So don't touch the red light, yellow light, you're you could be kind of cautious, but we want to find movements and intensities where you're in the green light zone where we're not triggering such a high output of pain.
• 18:57
  SPEAKER_00: And that's gonna help us to progress forward and know are we moving forward in the right direction or not.
• 19:03
  SPEAKER_00: Number six, work intentionally on gate mechanics.
• 19:06
  SPEAKER_00: It does not come back naturally.
• 19:08
  SPEAKER_00: I don't care what your PT says, I don't care what your surgeon says, I don't care what Bertha at the corner of your clinic says.
• 19:15
  SPEAKER_00: It's not gonna come back naturally, and it's something you need to work on.
• 19:19
  SPEAKER_00: It's a skill just like anything else: lifting, running, jumping, cutting, work on it daily.
• 19:24
  SPEAKER_00: It's something that is important to learn how to walk normal again because again, proprioception is one of the things where we are trying to make our knee aware of the space it's in.
• 19:35
  SPEAKER_00: Basically, when you close your eyes, how do you know where your hand is, right?
• 19:38
  SPEAKER_00: It's proprioception.
• 19:40
  SPEAKER_00: So the same thing with our knee and our foot and the way that we walk, we're not looking down at it, but we do have to re-ingrain this pattern and where it is.
• 19:49
  SPEAKER_00: So that helps by working on the skill and the mechanics of gait.
• 19:52
  SPEAKER_00: And that means you need extension, flexion.
• 19:55
  SPEAKER_00: You need to make sure that you can go through a heel-to-toe uh type process or the gait cycle, if you will, to be able to do this.
• 20:03
  SPEAKER_00: And it needs to be intentionally worked on.
• 20:05
  SPEAKER_00: Number seven, ditch your brace before your crutches.
• 20:09
  SPEAKER_00: Now, I'm gonna add a caveat here because everyone has surgeons' precautions and restrictions and all the things.
• 20:16
  SPEAKER_00: But the thing that I see the most is that ACLers see braces, the brace on the knee as protection and crutches as a limiter, right?
• 20:26
  SPEAKER_00: People want to ditch their crutches, but they want to keep the brace because they think it's protecting the knee joint.
• 20:32
  SPEAKER_00: And I get that, I even thought that, right?
• 20:34
  SPEAKER_00: But now working with a lot of ACLers, talking with surgeons and seeing different approaches, the brace is actually the limiter.
• 20:41
  SPEAKER_00: And weaning slowly off their crutches, going from two crutches to one crutch will save you from being that limper, right?
• 20:49
  SPEAKER_00: The thing that I see the most is people get off their crutches too fast, they don't have their full range of motion, they have this brace locked into a straight extension, and they're just limping around and they're whipping their leg around.
• 21:03
  SPEAKER_00: And I know you want to get from point A to point B, but this is not the way I know you want to get from point A to point B, but this is not the way to do it.
• 21:13
  SPEAKER_00: Be able to get off your brace as soon as possible within your surgeon's restrictions, and then slowly wean off their crutches.
• 21:21
  SPEAKER_00: I know they're annoying, but I promise you that it will be worth it to get your gait back normally and to get your swelling down.
• 21:28
  SPEAKER_00: And this is something that I have changed my mind on because before I would be like, okay, let's try to get you off crutches so we can get you moving.
• 21:35
  SPEAKER_00: But now I really encourage staying on the crutches a little bit longer because long term it will be so beneficial from so many of these pieces, from relearning how to walk, from being able to allow the knee to adjust back to weight bearing, especially if you're someone who has a meniscus repair and is non-weight bearing for a bit.
• 21:57
  SPEAKER_00: That will be even more important because it's going to shock your system a little bit whenever you start to put weight back on it and you're non-weight bearing for two weeks or four weeks or even six weeks.
• 22:06
  SPEAKER_00: So this is something that I think is a key piece.
• 22:10
  SPEAKER_00: But of course, within the respect and the restrictions of the surgeon.
• 22:15
  SPEAKER_00: And if you have an issue with this, then you can talk to the surgeon and their team, and you could also have your physical therapist, or if you're a PT listening, reach out to the surgeon and be like, hey, like, is there any wiggle room within the this for the brace?
• 22:27
  SPEAKER_00: Like, can we open this thing up?
• 22:29
  SPEAKER_00: Can't I've seen athletes do really well this way and show just kind of your experience.
• 22:34
  SPEAKER_00: And of course, just respect that process.
• 22:36
  SPEAKER_00: Don't try to go to the opposite end and just say, hey, this sucks, like we don't need to do this.
• 22:41
  SPEAKER_00: Um, instead, it's just like, hey, come with it with an open mind and being able to ask them, like, well, is there any range to be able to get out of this brace a little bit sooner if the athlete's doing well, or we see certain um criteria to be able to do that?
• 22:54
  SPEAKER_00: So something important to note in this early reset, in this early rehab process.
• 23:02
  SPEAKER_00: Number eight, break your range of motion work into small chunks throughout the day versus one intense hour.
• 23:10
  SPEAKER_00: It allows you to see a dose response relationship from the small blocks of work you're doing and create micro adjustments before the knee gets grumpy compared to these like big bolus or big bouts of work.
• 23:22
  SPEAKER_00: And it's easier to fit into the day for an ACL or because then you can split it up into these small little 10, 15 minute sessions versus this big hour-long session you need to set aside.
• 23:32
  SPEAKER_00: So then, therefore, you're hitting that more consistently through the day and you can see how the knee responds to it.
• 23:39
  SPEAKER_00: Number nine, focus on isolated strength and don't rush into integrated strength.
• 23:44
  SPEAKER_00: This is a big mistake I used to make.
• 23:46
  SPEAKER_00: And it's something that I want to make sure that you guys know that as ACLers and clinicians, you know, you want to get into the compound lifts.
• 23:54
  SPEAKER_00: I get it.
• 23:54
  SPEAKER_00: You want to start lifting, lifting heavy, um, ideally, but our body is smart and we'll find other ways to complete the task to be able to do the movement.
• 24:03
  SPEAKER_00: And so I did make this mistake a lot early because I wanted to get people back to lifting heavy, but I started to realize people would compensate.
• 24:11
  SPEAKER_00: Now, what I do is take a lot more time on isolated capacity, so isolating muscle groups.
• 24:17
  SPEAKER_00: So, you know, trying to focus on knee extensions for the quads, you know, hamstring curls for the hamstring group, glute stuff, calf stuff.
• 24:26
  SPEAKER_00: And I'm great with hanging out and doing more isolated work early on because that's gonna also allow us to target the right tissues, be able to build up more hypertrophy and focus on more force output, and then start integrating those into you know compound-based movements and then starting to work on rate or speed velocity type work.
• 24:47
  SPEAKER_00: So go from isolated, spend more time on this than you think, then focus on integrated work, and then be able to add in more velocity-based movements as well.
• 24:57
  SPEAKER_00: Number 10, set realistic expectations and have a positive mindset.
• 25:02
  SPEAKER_00: The mental side of this process is so much harder than the physical, and only ACLers can see this, to be completely honest.
• 25:09
  SPEAKER_00: And it's one of those things where the physical is just the visual thing we see because there's just a knee impairment.
• 25:15
  SPEAKER_00: But internally, there's a lot going on with us ACLers.
• 25:18
  SPEAKER_00: It's so crazy, and even in different stages of life, different seasons, multiple retails versus the first one.
• 25:25
  SPEAKER_00: There's a lot of things that are going on.
• 25:27
  SPEAKER_00: So part of this process is setting the expectations, not getting too caught up on timelines and protocols, which you guys know me.
• 25:34
  SPEAKER_00: That's very, very big to know that you are running your own race.
• 25:39
  SPEAKER_00: So have an adaptable plan and focus on the small wins.
• 25:42
  SPEAKER_00: Seriously, write those out, stack those up.
• 25:45
  SPEAKER_00: It's going to be so, so crucial and so, so key in this process.
• 25:50
  SPEAKER_00: Our mindset drives our actions.
• 25:52
  SPEAKER_00: So this is going to be really important to set the tone for ACLers, clinicians as you're working with your ACLers to make sure expectations are realistic and make sure they're connected to reality versus this far-fetched expectation of, like, yeah, you'll get back to this thing in six months, for example, or running in three months.
• 26:11
  SPEAKER_00: So I hope that these 10 points were helpful for you guys.
• 26:16
  SPEAKER_00: It's some things that I just wanted to share, um, some different nuances to these pieces that don't get talked about often.
• 26:22
  SPEAKER_00: But I want to share this with my experience with working with so many athletes and being able to also just see the things at work and also the things that I didn't do as well.
• 26:32
  SPEAKER_00: So this is really important to be able to set the tone for early post-op post injury for ACL rehab.
• 26:39
  SPEAKER_00: Until next time, team, this is your host, Robbie Patel, signing off.