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264 | Your ACL Rehab Is Hard… But Is It Actually Helping? · 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.
• 1:01
  SPEAKER_00: What is up, team, and welcome back to another episode on the ACL Athlete Podcast.
• 1:07
  SPEAKER_00: So let me ask you something.
• 1:11
  SPEAKER_00: If your PT session leaves you drenched in sweat, you know, your heart rate is up, your legs are shaking and fatigued, does that automatically mean it was a good session?
• 1:25
  SPEAKER_00: And so this is something that I hear all the time.
• 1:28
  SPEAKER_00: How's rehab going?
• 1:29
  SPEAKER_00: It's hard.
• 1:30
  SPEAKER_00: Oh good.
• 1:31
  SPEAKER_00: That means it's working, right?
• 1:33
  SPEAKER_00: But then I ask some more questions, and this is usually whenever people are inquiring, asking for more help and more guidance because of what they're getting in person.
• 1:42
  SPEAKER_00: Like, well, the sessions are hard.
• 1:45
  SPEAKER_00: But as we dig into the details of what's within those sessions and what they're doing, they start sharing, you know, they're jumping, lots of jumping, you know, they're sweating a lot for the next 30, 45 minutes, maybe an hour.
• 1:59
  SPEAKER_00: And then I hear this, they're like, but the knee was kind of puffy the next day or still aching, and it feels tight again, right?
• 2:08
  SPEAKER_00: The knee is still having issues, but they had a workout that was really hard.
• 2:13
  SPEAKER_00: So today, one thing that I do want to share and make clear to make sure that there's no confusion around this is that PT being hard does not automatically mean that PT is good.
• 2:26
  SPEAKER_00: We have been conditioned to think sweat equals effort, effort equals progress, exhaustion equals the growth, right?
• 2:34
  SPEAKER_00: And so this is something that works in conditioning, yes, maybe, but it does not automatically mean it works in rehab like ACL rehab.
• 2:43
  SPEAKER_00: Rehab is not about who can survive the hardest workouts, rehab is about applying the right stress, the targeted stress, at the right time and at the right dose.
• 2:55
  SPEAKER_00: Anyone, to be completely honest, can make you tired.
• 2:58
  SPEAKER_00: Very few people can dose load correctly.
• 3:01
  SPEAKER_00: The thing is, is that I can make you a workout and make you sweat, hate yourself, and feel like a hard workout by doing 50 burpees.
• 3:09
  SPEAKER_00: You would hate your life and do it for time.
• 3:11
  SPEAKER_00: But the thing is, is like that's not gonna be a very targeted workout.
• 3:15
  SPEAKER_00: And the thing is, is that if you have a knee that's not necessarily responding to load, it's not gonna be super productive.
• 3:22
  SPEAKER_00: And so let's not talk about something common, right?
• 3:26
  SPEAKER_00: What we see is that you're six, maybe 12 months out from surgery, you're cleared to jump, or it's been incorporated in your rehab.
• 3:34
  SPEAKER_00: So, what happens?
• 3:35
  SPEAKER_00: You start doing some jumping, and then all of a sudden your sessions start to become a lot more of jumping, continuous plyometrics, higher volume, minimal rest, you're sweaty, you're gassed.
• 3:46
  SPEAKER_00: And in the moment, you know, the knee might be okay.
• 3:49
  SPEAKER_00: Like you're not feeling a ton of that feeling of discomfort, swelling, all the things that you might feel from a symptom standpoint.
• 3:58
  SPEAKER_00: But the knee doesn't care how hard you worked, it cares how much load it can absorb relative to its capacity, or better said, how much tolerance it has, right?
• 4:11
  SPEAKER_00: Every landing is forced, every deceleration is forced, it's more quad demand, more knee demand, every contact is stressed through that joint, right?
• 4:20
  SPEAKER_00: And so if the volume exceeds what your knee currently tolerates, it's gonna talk back to you.
• 4:25
  SPEAKER_00: Not during always, but sometimes after.
• 4:28
  SPEAKER_00: That leads to swelling, stiffness, maybe some extension, flexion issues, some range of motion.
• 4:34
  SPEAKER_00: You're just gonna kind of notice it in that joint, a feeling like you kind of take a little bit of a step backwards.
• 4:39
  SPEAKER_00: And again, that's not weakness, it's just more so a dosage thing.
• 4:43
  SPEAKER_00: And so this is one thing that I think is super interesting and something that we see a lot.
• 4:48
  SPEAKER_00: And so the framework that I want you to remember is that your capacity is what your tissues can handle.
• 4:56
  SPEAKER_00: That is the amount that you can tolerate, right?
• 4:58
  SPEAKER_00: Capacity.
• 5:00
  SPEAKER_00: But the thing is, your tolerance is how your knee responds the next 24 to 48 hours later.
• 5:06
  SPEAKER_00: If your knee is puffy, more painful, stiffer, becomes worse in the next session, then we likely exceeded that tolerance.
• 5:15
  SPEAKER_00: And the worst thing you can do is say, well, it was a hard workout, so it must be good, right?
• 5:19
  SPEAKER_00: Hard is not necessarily the metric.
• 5:21
  SPEAKER_00: We want to make sure the stimulus and the response that you get from that, the adaptation is the metric, the thing we're trying to change.
• 5:30
  SPEAKER_00: And so intentional rehab looks a little different.
• 5:33
  SPEAKER_00: It looks like you're tracking the volume.
• 5:35
  SPEAKER_00: We are looking at the ground contacts being managed, we are making sure that the strength levels are being assessed, hop performance is continuing to be measured, especially in a vertical direction.
• 5:46
  SPEAKER_00: We're seeing how the knee responds to a horizontal impact.
• 5:50
  SPEAKER_00: Recovery days are built in.
• 5:52
  SPEAKER_00: I've talked about the high-low approach, and I think that that is super important from a foundational programming principle, which is so important in this process to balance recovery.
• 6:01
  SPEAKER_00: And your swelling and pain is going to be monitored.
• 6:04
  SPEAKER_00: So we're gonna always make sure we build from assessing, giving the proper prescription, seeing how the response to it is, and then adjusting as we need to.
• 6:14
  SPEAKER_00: We're not just gonna say, hey, let's have a hard workout, hope that it feels hard, you know, you respond and the knee doesn't freak out, and then we repeat it, right?
• 6:23
  SPEAKER_00: Because you can train hard in ACL rehab, and you should, but it needs to be very precise and prescriptive and it needs to be targeted, not random.
• 6:32
  SPEAKER_00: And that's what I typically see in rehab is that a lot of times people will flare up or they'll have a hard workout.
• 6:38
  SPEAKER_00: But the thing is that the knee is not responding positively to it, or it might even just be working around it.
• 6:44
  SPEAKER_00: So you're doing a ton of box jumps, but you're not working on plyometrics because a box jump isn't even a plyometric.
• 6:50
  SPEAKER_00: It is a part of a jumping cycle, yes, but it is not a true plyometric because there's no actual stress shortening cycle within it.
• 6:58
  SPEAKER_00: And so if you are an athlete listening, the main thing here is to pay attention to how your knee responds the next day.
• 7:06
  SPEAKER_00: That's going to be feedback, not failure, not a lack of toughness, right?
• 7:10
  SPEAKER_00: If you're a parent listening, when your kid says, you know, PT is hard, we kind of want to ask, like, is it progressing?
• 7:17
  SPEAKER_00: Is the swelling being monitored?
• 7:18
  SPEAKER_00: Is the volume being adjusted?
• 7:20
  SPEAKER_00: Is there a clear plan, right?
• 7:23
  SPEAKER_00: Hard workouts are easy to create.
• 7:25
  SPEAKER_00: I promise you, anyone can make a really hard workout.
• 7:28
  SPEAKER_00: Smart rehab is much, much harder to design.
• 7:32
  SPEAKER_00: And so these are the things that we want to make sure that we are looking for in this process because it is so key in the ASL rehab process to make sure that we are dosing things appropriately, balancing recovery, and making sure that there is a strong dose response to these things, and making sure that we don't mistake hard for being quality or good, right?
• 7:55
  SPEAKER_00: And so that's the main thing here is that we want to make sure that it is continuing to move the needle and the things that need to be moving.
• 8:03
  SPEAKER_00: So, therefore, making sure we're consistently testing the things that are important in this process, like quad strength, hamstring strength, power development, jumping abilities, and being able to make sure range of motion, our symptom profile like swelling and pain are really dialed in.
• 8:18
  SPEAKER_00: And then, of course, we're gonna continue to be very surgical in our approach to make sure that your programming, the way that it is structured in your week, the way that it is balanced based on the days that you have, is gonna be so important because that's gonna help with the recovery process and getting those adaptations we are looking for.
• 8:35
  SPEAKER_00: We want you to work hard.
• 8:37
  SPEAKER_00: We have sessions where athletes are, yes, sweating and they are fatigued, but we need to make sure that that is meeting them where they are in terms of the dose response and making sure that it's not just hard for the sake of beating them up.
• 8:50
  SPEAKER_00: I can't tell you the number of times that even in the past, like, you know, going through sports, like coaches think that running people into their ground is going to be valuable and get them conditioned.
• 8:59
  SPEAKER_00: That's one way to potentially do it, but it's not the smart way to do it.
• 9:03
  SPEAKER_00: And instead, there is a lot of physiology involved, making sure we use good strength and conditioning principles, rehab principles to make sure we are able to progress athletes and be more specific in the way that we are being able to program things.
• 9:19
  SPEAKER_00: And so we do want you to work hard, we do want you to feel challenged, we do want you to feel pushed, but we want to make sure it is aligned with what stages you're in, your strength levels, your performance goals, and also what you can tolerate and what your capacity is and making sure you can recover from that.
• 9:36
  SPEAKER_00: So anyone can make these sessions hard, just know that very few people can truly make it precise.
• 9:44
  SPEAKER_00: And that is what's going to really get you back and continue in this process.
• 9:47
  SPEAKER_00: So I think that's really important for you to be able to discern within your PT.
• 9:52
  SPEAKER_00: Of course, if you feel like you're also going so slow, that is also the flip side of this.
• 9:56
  SPEAKER_00: So this is where having things dialed in to meet you where you are in this process, individualize it.
• 10:02
  SPEAKER_00: We base it off of testing and we continue to test through this process, but making sure that the programming is meeting you and also trying to first undercook it.
• 10:13
  SPEAKER_00: It's okay to be not as high intensity as you were hoping.
• 10:17
  SPEAKER_00: And then, you know what?
• 10:18
  SPEAKER_00: We can nudge things forward to find the right stimulus and the dose response.
• 10:22
  SPEAKER_00: And that's what's going to be important here whenever we're talking about ACL rehab, especially in the mid and late stages when there's more variables to juggle and the dynamic responses of you know, jumping, running, cutting, things like that, where there's more total stress to the knee and more load going through that joint.
• 10:41
  SPEAKER_00: So that's gonna be really key here.
• 10:43
  SPEAKER_00: I hope that this was helpful, y'all, in terms of being able to just look at your sessions and seeing, like, okay, is it hard and of quality and very targeted, or is it just hard?
• 10:54
  SPEAKER_00: Right.
• 10:54
  SPEAKER_00: And that's where you can start to discern things and be like, okay, well, start to ask some questions.
• 10:59
  SPEAKER_00: Like, what am I working on here?
• 11:01
  SPEAKER_00: Okay, what is the next point we're working on?
• 11:04
  SPEAKER_00: And how is that aligning me to my long-term goals?
• 11:06
  SPEAKER_00: And more importantly, is like, how does this connect to my criteria that is going to help me to get there to make sure I get back to playing sports or activities at my highest performance level, but also reducing the risk of this ever happening again.
• 11:19
  SPEAKER_00: So I hope that this is helpful, y'all.
• 11:21
  SPEAKER_00: If you have any questions, please reach out.
• 11:23
  SPEAKER_00: This is your host, Robbie Patel, signing off.