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260 | Arthrofibrosis After ACLR: Trusting Your Gut When Rehab Isn’t Adding Up · 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.
• 1:01
  SPEAKER_00: What is up, team, and welcome back to another episode on the ACL Athlete Podcast.
• 1:07
  SPEAKER_00: Today I want to talk about something that doesn't get enough attention in ACL rehab, and that is listening to your gut when your knee just doesn't feel right.
• 1:20
  SPEAKER_00: Because a lot of athletes know something is off, but they're told to work through it.
• 1:27
  SPEAKER_00: So the common scenario, I see this all of the time.
• 1:31
  SPEAKER_00: You're working hard, you are consistent with things, you're checking the boxes, right?
• 1:36
  SPEAKER_00: You're doing the work day in and day out.
• 1:38
  SPEAKER_00: But the knee might feel stiff no matter what, won't fully straighten or bend normally, it gets irritated super quickly, it feels maybe like there's a wall or it's blocked or tight or getting kind of jammed.
• 1:53
  SPEAKER_00: Especially when we're talking about extension.
• 1:55
  SPEAKER_00: Can also happen with flexion too.
• 1:57
  SPEAKER_00: But it just isn't progressing the way that it should, right?
• 2:01
  SPEAKER_00: And it's something that can be challenging, and the response is often, you know, scar tissue is normal, give it more time, push through it.
• 2:10
  SPEAKER_00: Sometimes that's appropriate in certain situations, but sometimes it's not.
• 2:15
  SPEAKER_00: And so I've had so many situations over the years with ACLers where unfortunately they're we're on the other side of this where they have been in this process, they've been with their PT, their surgeon, and they're months and months into this, right?
• 2:32
  SPEAKER_00: And there are definitely situations, don't get me wrong, where early on it's a little challenging, especially to get your extension.
• 2:40
  SPEAKER_00: And there's some people who have to just really work at it, and there's certain graph types that can cater to making that a little bit more challenging.
• 2:46
  SPEAKER_00: But with that said, like you're working on it, and it's one of those things, like let's say you're someone who is doing all the things, right?
• 2:55
  SPEAKER_00: But it just doesn't seem to add up.
• 2:56
  SPEAKER_00: You're not getting that extension back, and it's not appreciable to where you know you're at zero or getting into the hyperextension and to the negatives, and it just completely regresses, right?
• 3:07
  SPEAKER_00: And it might not be drastic, it might not be plus 10.
• 3:10
  SPEAKER_00: It might just be like, okay, now it's back to zero or plus two, plus three, versus like in that hyperextension that you work so hard to get.
• 3:17
  SPEAKER_00: And then as soon as you maybe work on that for 10, 15, 20, maybe an hour, right?
• 3:23
  SPEAKER_00: That's how long you're working on it.
• 3:25
  SPEAKER_00: You go to bend your knee or you stay in a seated position, it automatically regresses back, right?
• 3:30
  SPEAKER_00: And I know many of you are probably nodding your head listening to this because you're like, Yeah, I feel that.
• 3:35
  SPEAKER_00: And so the most important thing before we continue with this episode is that while some of these feelings will be relatable and this will hit home for a lot of you guys, I also want to make sure that you just don't go running to your surgeon or your PT and say, Hey, I have a problem.
• 3:52
  SPEAKER_00: But what I'm saying here is also important to listen to your gut, especially if there's something that consistently is just showing that it's just not adding up.
• 4:03
  SPEAKER_00: And I know you guys know that feeling, whether you've dealt with it, you might be actively dealing with it, or it might happen in the future.
• 4:10
  SPEAKER_00: And the main thing that I want to talk about with this, there could be a number of things happening, but in reality, the number one thing that I want to talk about based on this is arthofis.
• 4:21
  SPEAKER_00: And arthofibrosis is essentially just scar tissue, right?
• 4:24
  SPEAKER_00: It's excessive scar tissue that is kind of forming in the knee.
• 4:28
  SPEAKER_00: And while we don't want to chop everything up to like, oh, it's scar tissue, and that's the problem, it is real, right?
• 4:34
  SPEAKER_00: Like at the end of the day, there's an inflammatory process.
• 4:36
  SPEAKER_00: They go in and they do some work to your knee, they clean things out, it's inflamed.
• 4:40
  SPEAKER_00: And so then, therefore, there can be something where people lay down scar tissue as it heals as a just byproduct of the healing process, and sometimes that can get in the way.
• 4:53
  SPEAKER_00: Now, can that manifest as a cyclops lesion where there is a tissue that has hypertrophied and built in that front of that ACL that is limiting the ability to fully extend?
• 5:04
  SPEAKER_00: Yes, that often can happen.
• 5:07
  SPEAKER_00: I truly believe that the percentage is higher than what the research shows.
• 5:14
  SPEAKER_00: Um, and I've done an episode on this before, multiple, talking about cyclops lesions, but I think it's also more prevalent in quadriceps graphs that people get that are autographs.
• 5:25
  SPEAKER_00: I think that there's just something to the thickness, maybe a graph being too thick, and that can influence essentially like maybe it having some stress put on it, and it's kind of laying down some tissue on top of that because our bodies do respond to stress and it could build kind of tissue along those lines.
• 5:44
  SPEAKER_00: And so that's something that I notice with people, and then also there could just be some general just scar tissue that can build up in different areas of the knee, whether that's like in the anterior compartment where there's around the patella, the fat pad, um, there's different releases that can be done and clean out procedures.
• 6:02
  SPEAKER_00: So it's not unheard of that people go in to get a scar tissue clean out, especially if their extension or flexion is pretty limited, especially over a course of time.
• 6:12
  SPEAKER_00: And it's just not adding up, right?
• 6:14
  SPEAKER_00: And there's those people who are like it's very obvious where their range of motion is really bad.
• 6:19
  SPEAKER_00: They can only get to 70 degrees of flexion or 90 degrees, and it's been months and months, or their extension is stuck at like 10 degrees plus, five degrees plus, you know, it's creating a lot of issues from just extending the knee, you know, painful knee, swollen knee, those types of things that can be pretty common to see with ACLers.
• 6:41
  SPEAKER_00: And so that's something that I do want to share is something that is existent in this world and more common, right?
• 6:51
  SPEAKER_00: And you know, when we look at the research across arthrofibrosis, it's roughly around two to ten percent of patients after ACL reconstruction will have arthofrosis.
• 7:03
  SPEAKER_00: Now, it's not clearly defined, and you know, it's kind of hard to measure, especially in these studies and whatnot.
• 7:11
  SPEAKER_00: But you know, there could be different layers to it.
• 7:13
  SPEAKER_00: Is it like, okay, there's a little bit?
• 7:15
  SPEAKER_00: Is there, you know, a lot more than that?
• 7:19
  SPEAKER_00: Is it just like a ton of scar tissue?
• 7:21
  SPEAKER_00: And I've seen knees over the course of years that have really, really just lined the whole spectrum.
• 7:28
  SPEAKER_00: And the other challenging thing, too, especially if we're talking about cyclops, is that sometimes it doesn't develop early.
• 7:34
  SPEAKER_00: It develops, you know, months and months after, and that could just be depending on the athletes and depending on their situations.
• 7:42
  SPEAKER_00: Now, the thing that's important, and this amount may seem small, just know that like people might be dealing with a variation of this, and this is where I think it's important to kind of listen to your gut on this, especially if you're doing all the things, getting it assessed and whatnot.
• 7:59
  SPEAKER_00: And I'm hoping that you have a you know, surgeon and especially a physical therapist who is working with you day in and day out assessing this and also checking in on your symptoms, and and especially if you're doing everything.
• 8:12
  SPEAKER_00: Now, there is the category of people who are not doing their home exercise programs, they're not doing their rehab, their training.
• 8:20
  SPEAKER_00: And this is where it is a bit challenging because if you don't put in the work at the end of the day, like, yeah, the extension reflection issues might be more related to compliance of exercise than it is more so of like what's going on in the knee.
• 8:33
  SPEAKER_00: So that's why I'm saying also don't just go run to your surgeon or your PT.
• 8:38
  SPEAKER_00: But let's say that you are hitting all the stuff, you're doing all the right movements, and you're working consistently on this, right?
• 8:46
  SPEAKER_00: I think it's important to be able to analyze this and to listen to your gut because when it does happen, it can significantly limit your range of motion, it can keep pain and swelling around for longer, alter the movement mechanics of how you are doing things, even just as simple as walking.
• 9:04
  SPEAKER_00: You're probably limping.
• 9:05
  SPEAKER_00: Somebody called it a pimp walk the other day.
• 9:07
  SPEAKER_00: I was like, okay, um, on our call.
• 9:10
  SPEAKER_00: And yeah, I mean, at the end of the day, it's the reality of what it looks like, you know?
• 9:14
  SPEAKER_00: And it's just something that you don't want to deal with, and it can really impede gaining strength and being able to progress in this process.
• 9:22
  SPEAKER_00: And so that's something that we want to make sure that we are making sure that we are looking at things from a just holistic standpoint of this process and not just saying, oh, it will get better with time, which is the thing that we commonly hear.
• 9:38
  SPEAKER_00: And I can think of instances, so many, where myself and our team have had athletes who, you know, they're presenting with potentially some of these issues, like their extension is not getting better, maybe their flexion is kind of stalled really, really poorly.
• 9:56
  SPEAKER_00: And, you know, whether that's someone who starts with us or maybe someone who we inherit, and it's something that we are always evaluating and saying, okay, how does this look from a objective standpoint?
• 10:08
  SPEAKER_00: How does it feel from a subjective standpoint?
• 10:11
  SPEAKER_00: And we're tracking that along the way.
• 10:14
  SPEAKER_00: And the biggest thing for me is that I do not want to waste your time.
• 10:18
  SPEAKER_00: Our team does not want to waste your time.
• 10:21
  SPEAKER_00: And so this is something that we can tackle within the first few months versus just saying it'll get better with time because extension is kind of tricky.
• 10:30
  SPEAKER_00: It's one of those things where it kind of looks like it gets better.
• 10:32
  SPEAKER_00: I've had athletes who come in and they're like, Yeah, it's better today, like I feel better with it.
• 10:37
  SPEAKER_00: And it's almost this kind of like thing they want to almost like convince themselves it's better, but it's, you know, I measure it and it's kind of the same.
• 10:45
  SPEAKER_00: And they're doing everything, they're working really hard.
• 10:48
  SPEAKER_00: So it's no fault to them, of course, uh, that it's not getting better.
• 10:52
  SPEAKER_00: We're dealing with a knee that is going through this biological process that is healing.
• 10:59
  SPEAKER_00: Our bodies are not built for surgery necessarily.
• 11:01
  SPEAKER_00: We need it, and it's great for medical intervention when needed.
• 11:04
  SPEAKER_00: But at the end of the day, like people's bodies are gonna respond differently to this human-based, you know, medical intervention that has been created to help fix this problem, right?
• 11:14
  SPEAKER_00: And there might be side effects from it and issues such as people getting a byproduct of scar tissue because there has been an inflammatory process from the from the surgery, right?
• 11:25
  SPEAKER_00: And so that's really important.
• 11:27
  SPEAKER_00: So I have seen in situations where people have been told at the especially let's say the three-month mark where it doesn't seem to add up, they go see their surgeon, the surgeon's like, just keep working on it, it's getting better.
• 13:45
  SPEAKER_00: They don't know, man.
• 13:47
  SPEAKER_00: They don't know.
• 13:48
  SPEAKER_00: They they they don't remember where your extension was before.
• 13:51
  SPEAKER_00: Hopefully they measured it, but you know, they're kind of looking at it within their five, 10-minute exam, and they're like, Yeah, it's good, keep working on it.
• 13:59
  SPEAKER_00: We still got some time, right?
• 14:01
  SPEAKER_00: And don't get me wrong, it is warranted in certain cases, but there's so many situations where I've seen where people are working hard on it and they're at months three and four.
• 14:11
  SPEAKER_00: And, you know, if we inherit them later, later in the process, and it's not improving, right?
• 14:17
  SPEAKER_00: So then instead of just being like, let's just hope it gets better with time, let's get some answers, man.
• 14:22
  SPEAKER_00: Like the thing that always confuses me is that there's such a quick jump to get an MRI when an ACL is torn, but when there is something that the patient or the PT or a parent has a hunch on, and we request and advocate for ourselves to get some imaging, it's like, nope, unless I came up with the idea as the surgeon, we were we're not gonna do it.
• 14:43
  SPEAKER_00: And I know I'm throwing shade right now, but I find these situations very challenging because it puts people in a tough place because then therefore, like you kind of do have the power to request the imaging, especially if we're using the medical system and insurance to put a script in for that, right?
• 15:03
  SPEAKER_00: You can go pay out of pocket, and I would almost say, like, if you have the means to do that, it might be worth it if you can't find the surgeon who's going to be able to get the imaging for you.
• 15:12
  SPEAKER_00: And worst case, y'all, it comes back clean.
• 15:15
  SPEAKER_00: The ACL is healing, it's doing its thing.
• 15:18
  SPEAKER_00: You know what?
• 15:20
  SPEAKER_00: We have a good knee.
• 15:21
  SPEAKER_00: Great.
• 15:21
  SPEAKER_00: That is such a great response to this, and of course, maybe we just need to push harder and work through some different solutions for this.
• 15:29
  SPEAKER_00: But oftentimes, y'all, anytime that this happens, where the athlete's telling me this, we are tracking this with our athletes, and we're telling them to go get it, and they get the imaging.
• 15:41
  SPEAKER_00: I wish I had a statistic of like the times that we do have people come back with a cyclops or scar tissue.
• 15:48
  SPEAKER_00: And I would venture to say it's probably around 90%.
• 15:52
  SPEAKER_00: 90% of times, like when this stuff adds up and we're tracking it with them, and we're kind of following our guts and their guts, it's pretty consistent.
• 16:02
  SPEAKER_00: And I think the research kind of alludes to a lower number than what's the reality of what a cyclops or artrofibrosis is.
• 16:10
  SPEAKER_00: And of course, it's a wide net of like varying degree of like, is it worth operating on?
• 16:15
  SPEAKER_00: But if it's impacting things from a range of motion, from a symptom standpoint, from a strength development standpoint, or even just basic functional like walking, we need to do something, especially if you're working on it and you're just like, it's not getting any better.
• 16:30
  SPEAKER_00: And so I had a hard run of this with an athlete from last year that had an extension issue, quad graft, autographed.
• 16:41
  SPEAKER_00: We started working from day one together.
• 16:43
  SPEAKER_00: And I had a hunch within you know, six to eight weeks that she had a cyclops.
• 16:48
  SPEAKER_00: I just had a hunch, and she was working on it consistently, it just didn't feel right.
• 16:53
  SPEAKER_00: And so I was like, let's give it some more time.
• 16:56
  SPEAKER_00: And so I usually give it until that roughly like three-month mark.
• 16:59
  SPEAKER_00: If we've been working straight from that startup process to about three months, just to see because she was kind of in this gray area of like, yeah, could it improve maybe over time?
• 17:09
  SPEAKER_00: Maybe let's get the swelling down more.
• 17:12
  SPEAKER_00: But she kind of kept going through this rotation of like the knee was kind of swollen, and she was controlling everything, compressing it, modifying step count.
• 17:20
  SPEAKER_00: We were we were modifying rehab as needed.
• 17:23
  SPEAKER_00: She was having um some of the extension issues, some some just kind of pain here and there.
• 17:29
  SPEAKER_00: And so I just had a hunch, I was like, I think you have a cyclops lesion.
• 17:33
  SPEAKER_00: And I communicated that to the athlete and the parents, and the surgeon what wanted to dismiss it.
• 17:40
  SPEAKER_00: I didn't a podcast episode actually on this about advocating for yourself because he wanted to just kind of work through it and just say, like, it'll get better with time.
• 17:49
  SPEAKER_00: And it was this big thing.
• 17:51
  SPEAKER_00: It did not need to be this big thing.
• 17:52
  SPEAKER_00: The parent was super frustrated with how the surgeon handled it.
• 17:55
  SPEAKER_00: And I was just trying to advocate for them because otherwise, this athlete would continue on for the next m months, like two, three months, then have a clean out procedure, and then you know, kind of feel gaslit of like why they weren't progressing, and they would just be so hard on themselves.
• 18:12
  SPEAKER_00: When all we need to do is potentially get some imaging to confirm or deny it, right?
• 18:18
  SPEAKER_00: And also be able to say, like, okay, do we need to do this?
• 18:22
  SPEAKER_00: And so when the surgeon looked at the knee after he got all frustrated about this and said, Now that it's in your head that you have a cyclops, you're gonna think you have a cyclops, and you won't think it'll get better unless I clean it out.
• 18:35
  SPEAKER_00: The thing that's kind of crazy is that he was like, Yeah, let's do the procedure in that moment.
• 18:40
  SPEAKER_00: So then they planned the procedure.
• 18:42
  SPEAKER_00: They went in there and there was so much scar tissue in that knee and a big old cyclops that it was just it's crazy to me.
• 18:49
  SPEAKER_00: And I was like, what was the big deal about being able to talk about the concerns of this particular issue and to be able to potentially order some imaging because there's a concern for the patient and to see what solutions we have versus just doing the same thing over and over, expecting it to get better, right?
• 19:10
  SPEAKER_00: And don't get me wrong, this is a long game process.
• 19:13
  SPEAKER_00: There are some things like getting those quads woken up and the strength up takes a long time, but there are certain things that we just need to listen to and we need to make sure that you are not dismissed and it is not minimized.
• 19:26
  SPEAKER_00: And so that's one thing that I want to make sure because why pushing through can backfire is like the here's the distinction if your limitation is muscular or capacity based, we can work on that through rehab.
• 19:42
  SPEAKER_00: But if it's scar tissue is mechanically blocking that joint, more exercises won't fix it.
• 19:48
  SPEAKER_00: It won't break up, it won't go away.
• 19:50
  SPEAKER_00: You can't break up scar tissue, any of that crunching stuff, it's not breaking up scar tissue, no matter what your PT says.
• 19:57
  SPEAKER_00: It's something that is just in there, it is kind of healed that way.
• 20:00
  SPEAKER_00: And so, in terms of like the research itself, shows that like the delayed recognition of arthofosis, if we take too long, it's associated with longer rehab timelines, that makes sense, worse motions um outcomes.
• 20:16
  SPEAKER_00: So that means that people are moving not as well later on, and then higher frustration and dropout rate of rehab.
• 20:22
  SPEAKER_00: Because guess what?
• 20:23
  SPEAKER_00: If you have a longer rehab and people aren't moving well and not feeling well, they're just gonna kind of get frustrated with it because at some point they're just gonna be like, this is not worth it.
• 20:31
  SPEAKER_00: And so they're just gonna also get defeated.
• 20:34
  SPEAKER_00: So pushing harder doesn't remove the scar tissue, it just inflames it.
• 20:38
  SPEAKER_00: So that's why we also need to make sure.
• 20:40
  SPEAKER_00: Um, I talked to a parent the other day, and she said that they were working so hard for months and months, and the daughter said that it didn't feel right in terms of how her knee felt.
• 20:52
  SPEAKER_00: And you know, it's no fault to any of them, right?
• 20:55
  SPEAKER_00: Like you're hoping that the PT or the surgeon catches that and is able to say, Hey, I don't think that this is adding up with where she should be objectively and what she's feeling.
• 21:06
  SPEAKER_00: Let's get this checked out, right?
• 21:08
  SPEAKER_00: And this is where I wish that there was a little bit more detail around this.
• 21:13
  SPEAKER_00: But some of this is a little bit more of like it could be caught if it was just good PT and they were measuring things.
• 21:20
  SPEAKER_00: But even then, like I think that at this point you guys know you have to be your own advocate in this, right?
• 21:26
  SPEAKER_00: And you have to speak up, even if they're not gonna listen.
• 21:30
  SPEAKER_00: Of course, you want to get multiple opinions, especially if it doesn't seem to add up.
• 21:35
  SPEAKER_00: But I think that that's super important.
• 21:37
  SPEAKER_00: So listening early is going to be better for better outcomes.
• 21:41
  SPEAKER_00: You know, the athletes who speak up early and are properly evaluated, they're gonna do much better long term, especially when the intervention happens sooner rather than later, so we don't waste time.
• 21:52
  SPEAKER_00: And that could be adjusting the rehab strategy, it could be pulling back on load, it could be on getting imaging, or in some cases, as I shared, it could be a minimally invasive cleanup.
• 22:03
  SPEAKER_00: Again, with insurance, you kind of have to potentially time this if you're at the end of the year.
• 22:08
  SPEAKER_00: So that'd be something that you want to knock out within reason that makes sense for you in your situation, right?
• 22:15
  SPEAKER_00: And I wish we didn't have to play that game, but you kind of have to do that.
• 22:19
  SPEAKER_00: Um, and people will dictate their procedures based on their deductibles and the year of coverage and is it expiring?
• 22:26
  SPEAKER_00: But it's really not as intensive of a procedure as ACL.
• 22:30
  SPEAKER_00: So I think that's one thing to just know is that people come out and a lot of times they could be walking, you know, your range of motion and the feeling of it is instantly improved.
• 22:39
  SPEAKER_00: And we just have to keep at it and work at it, right?
• 22:42
  SPEAKER_00: But the goal isn't surgery, the goal is not wasting months fighting the wrong problem.
• 22:47
  SPEAKER_00: And I think that's what frustrates me the most is that I just don't want you to waste time and I want you to make sure that you make the most of this and also just don't beat yourself up for it not improving, no matter how hard you work.
• 23:01
  SPEAKER_00: So advocate for yourself.
• 23:03
  SPEAKER_00: If your gut says something isn't right, listen to it, especially if you're consistent, strength is improving, but motion or comfort isn't improving, right?
• 23:12
  SPEAKER_00: Symptoms aren't trending in the right direction over time.
• 23:14
  SPEAKER_00: That is something to also listen to, right?
• 23:17
  SPEAKER_00: Advocating for yourself isn't being difficult, you you're just being informed, and I think that's really important to share here.
• 23:24
  SPEAKER_00: So your knee is giving that feedback to you for a reason.
• 23:28
  SPEAKER_00: So the process here or progress isn't about just grinding harder.
• 23:33
  SPEAKER_00: You just need to be smarter in this process.
• 23:36
  SPEAKER_00: And I think part of this is just so challenging from the ACL or side or the parent side or the supporting side because you're just listening to the professionals who are in your corner to help you.
• 23:46
  SPEAKER_00: But sometimes the details get missed, and it's not up to you to just be like, okay, like this is exactly how this goes, this is how this plan, this is when I need to go and talk to the person that is responsible to help me with this.
• 24:00
  SPEAKER_00: It's your ACL team's responsibility.
• 24:03
  SPEAKER_00: But as you guys know, things fall through the cracks, and this process is messy.
• 24:10
  SPEAKER_00: There's a lot of subjective feelings around it, there's a lot of symptoms that you're kind of navigating, a lot of day-to-day stuff.
• 24:17
  SPEAKER_00: Um, and sometimes range of motion, especially, can be put on the back burner, and there's a lot of assumptions it'll get better with time.
• 24:23
  SPEAKER_00: It doesn't get better with time in this process, it rarely ever does.
• 24:27
  SPEAKER_00: And many of you can nod your head to this and you know that it doesn't.
• 24:31
  SPEAKER_00: So you have to do something about it.
• 24:33
  SPEAKER_00: So listening to your body and speaking up early can save you months of frustration, y'all, and keep your rehab moving forward.
• 24:40
  SPEAKER_00: And for those of you where this might pop up at month six, seven, eight, that's okay.
• 24:45
  SPEAKER_00: Like it happens.
• 24:46
  SPEAKER_00: And the thing is, is just communicate that to the people you're working with and make sure they know.
• 24:52
  SPEAKER_00: And don't go too long without with letting that be the normal, right?
• 24:57
  SPEAKER_00: Make sure that that is something you make moves on, and if this resonates with you, then I want you to do something about it.
• 25:05
  SPEAKER_00: So listen to your gut and making sure to advocate for yourself in this process, especially if you feel like the knee is just not adding up and you're working as hard as you can.
• 25:17
  SPEAKER_00: So we're here for you.
• 25:18
  SPEAKER_00: If you have any questions or you need any support on that standpoint, then we're here to answer any of those questions and support you through this.
• 25:26
  SPEAKER_00: We want to make sure you make this the shortest but most efficient time possible in this process so that way you can get back to doing what you love and also not waste months where you just feel like you're just frustrated because you're working so hard, but the needle is not moving.
• 25:42
  SPEAKER_00: And oftentimes that's because there needs to be something else looked at.
• 25:45
  SPEAKER_00: So advocate for yourself, folks.
• 25:47
  SPEAKER_00: That is the name of the game in healthcare and in ACL rehab, especially, because you have to look out for yourself in this process and just make sure you have a good team in your corner to support you every step of the way.
• 26:00
  SPEAKER_00: Until next time, team, this is your host, Robbie Patel, signing off.