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178 | Is Manual Therapy Needed for ACL Rehab? · The ACL Athlete Podcast

• 0:18
  SPEAKER_00: Welcome everyone to the ACL Athlete Podcast.
• 0:22
  SPEAKER_00: This is the podcast where we talk about everything related to the ACL, whether that's the injury itself, the rehab process, return to sport, and more.
• 0:31
  SPEAKER_00: I'm your host, Dr.
• 0:32
  SPEAKER_00: 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.
• 1:02
  SPEAKER_00: What is up, team, and welcome back to another episode on the ACL Athlete Podcast.
• 1:07
  SPEAKER_00: So today we are answering the question: Is manual therapy needed for ACL rehab?
• 1:14
  SPEAKER_00: And one of the things I want to do today is keep today super short because previous episodes I've gotten a little lengthy on you guys.
• 1:20
  SPEAKER_00: So we're gonna try and keep this very concise to the points you can enjoy this on probably 1.5 or 2x speed.
• 1:28
  SPEAKER_00: Or if you're really spicy, you might do 2.5 or 3.
• 1:33
  SPEAKER_00: But we are going to dive into this question today: manual therapy, is it needed?
• 1:38
  SPEAKER_00: So manual therapy to define this in a very, you know, basic sense, basically anything where the rehab provider you're working with, your physical therapist typically, or athletic trainer, might be a chiropractor, whoever is working with you in your ACL rehab, they put their hands on you to manipulate the knee joint, the kneecap, basically working on range of motion, flexion, or extension, maybe it's some rotation there.
• 2:05
  SPEAKER_00: Maybe it is something where they are working on soft tissues around the area.
• 2:10
  SPEAKER_00: It could be the hamstrings, it could be the quads, it could be the glutes, calves, you name it.
• 2:16
  SPEAKER_00: But it's essentially just hands-on work.
• 2:18
  SPEAKER_00: Some people will refer to it as massaging.
• 2:21
  SPEAKER_00: You know, there could be some more rhyme and reason to it, physical therapy.
• 2:25
  SPEAKER_00: Basically, it is called manual therapy.
• 2:28
  SPEAKER_00: And so then, therefore, this is something that relates to ACL rehab, in a sense, especially more prevalent in the post-op and especially post-injury, where the knee is a bit more restricted and needs some assistance, if you will, some passive assistance, because we are guarded with it.
• 2:46
  SPEAKER_00: So then, therefore, it just feels like there needs to be some manipulation of the joint.
• 2:51
  SPEAKER_00: And especially a lot of you listening to this probably feel this, especially when you are post-op.
• 2:56
  SPEAKER_00: This is when you're needing some type of assistance because you feel pain in the joint and you're a little guarded, and you're also worried about this brand new ACL that you have.
• 3:06
  SPEAKER_00: Um, and especially bending the knee feels really difficult.
• 3:11
  SPEAKER_00: You're scared you're going to pop something or the ACL is gonna do something.
• 3:15
  SPEAKER_00: Just so you know, you're totally fine.
• 3:17
  SPEAKER_00: That thing is locked in there and anchored in there.
• 3:20
  SPEAKER_00: But it feels that way because you have had a major reconstruction, or even after the injury, you have had a major injury to the joint.
• 3:29
  SPEAKER_00: So your body is doing its thing to protect the joint.
• 3:32
  SPEAKER_00: So then it's it's in this like acute inflammatory phase.
• 3:36
  SPEAKER_00: But the thing is that we need to get the knee to move a little bit so then that way you don't get locked up, so that way you can restore your range of motion, get the quads going, all the things, right?
• 3:46
  SPEAKER_00: And so what is very common in this process is once you are post-injury or post-op, you will see your physical therapist in person and they will start to assist you with especially some range of motion pieces.
• 3:58
  SPEAKER_00: Um, now there could be some caveats here if you have a meniscus repair and you might have some sort of restriction there or maybe some sort of other procedure.
• 4:07
  SPEAKER_00: But let's talk about just basic ACL reconstruction that most people get, usually are able to extend and flex a leg as they need to, even with a meniscus repair up to 90 degrees, is usually at least the most conservative baseline that we'll see with most surgeons.
• 4:23
  SPEAKER_00: So basically, you got to get the thing moving.
• 4:26
  SPEAKER_00: And so, yeah, when you show up to physical therapy, your BT is typically gonna help assist you to move that knee, right?
• 4:33
  SPEAKER_00: You're going to uh potentially take off the brace if you have one, and then the goal is going to be start working on some quad sets, getting the quads going, getting some flexion, some heel slides, probably of some sort.
• 4:46
  SPEAKER_00: And this is something where your physical therapist might assist with the hands-on work.
• 4:50
  SPEAKER_00: So range of motion here.
• 4:52
  SPEAKER_00: And so the thing that we will often get the question about and some skepticism, which is fair, right?
• 4:58
  SPEAKER_00: From ACLers who are interested in working with us remotely, they're like, How are you going to be able to move my knee?
• 5:04
  SPEAKER_00: Especially in this post-op or post-indric process.
• 5:07
  SPEAKER_00: And these ACLers, especially who are very stuck on this, end up being the ones who um have potentially gone through their rehab process for maybe even, let's say, a few weeks, if not like, you know, a month or two months, or even look, we've seen this up to six months and beyond, where people are still working on range of motion pieces, or maybe it's just a part of the philosophy of the physical therapist and their clinic.
• 5:32
  SPEAKER_00: And so this is the one where people are potentially just kind of guarded in the sense of, well, you know, I'm used to this manual therapy, and how are you going to manipulate my leg?
• 5:44
  SPEAKER_00: And especially if that provider has had a very strong stance on utilizing it in your sessions, right?
• 5:50
  SPEAKER_00: And they're gonna be working on typically your range of motion passively, they might be doing some soft tissue work around the musculature, whether it is the hamstrings and the quads, maybe the calf.
• 6:02
  SPEAKER_00: Those are usually some areas you're working on.
• 6:05
  SPEAKER_00: And now I could also ask the question about this if that's worth the time that's being directed for it for the session, right?
• 6:14
  SPEAKER_00: Or maybe they bill manual therapy as a code and they have it as a standard that everyone gets.
• 6:20
  SPEAKER_00: You know, this is something that you guys think might not happen, but it happens a lot.
• 6:26
  SPEAKER_00: And we are in the landscape of healthcare, we're in the landscape of insurance, we are in the landscape of coding and billing and time per units.
• 6:34
  SPEAKER_00: And so then, therefore, reimbursement is gonna be dictated based on the codes that you are are putting in.
• 6:40
  SPEAKER_00: So then, therefore, there are clinics that have standard procedures of, hey, you're going to do manual therapy for X amount of minutes, so we can make sure we build this, and it's justifiable enough medically to be like, yeah, let's that's gonna be a part of your plan.
• 6:55
  SPEAKER_00: And people just kind of almost get like into that process, and even physical therapists, because that's just what the norm is.
• 7:03
  SPEAKER_00: But I'm not saying the norm is good, and so this is also not saying that every single physical therapist and every single clinic is doing this, but there are a lot of them that are doing this, and so this is mostly because uh why I'm bringing this up is because sometimes it just doesn't add up to the time that is being spent.
• 7:23
  SPEAKER_00: And this is all about opportunity cost at the end of the day.
• 7:26
  SPEAKER_00: And it's like, well, should we spend a lot of time working on this range of motion, or should we be focusing on some things that are maybe more active and maybe more things that maybe you can do at home, maybe things that you need a little bit more of an eye with, or maybe you need some more guidance with, um, and maybe some things that are just more exercise based in nature.
• 7:47
  SPEAKER_00: And we just literally had an athlete start working with us when I asked her how her PT was before.
• 7:53
  SPEAKER_00: She mentioned that she would walk into the clinic, she would literally do almost an hour's worth of hands-on work, range of motion, some massage work, and then she would walk out.
• 8:04
  SPEAKER_00: No exercises, no active thing for her to do.
• 8:08
  SPEAKER_00: And now this is an extreme example, but it's really common for this to be a part of the treatment session, especially earlier in the ACL rehab process.
• 8:16
  SPEAKER_00: And again, nothing wrong with this.
• 8:18
  SPEAKER_00: This is something that can have some value and carryover to it.
• 8:22
  SPEAKER_00: But the biggest question that we're asking here is is it needed?
• 8:26
  SPEAKER_00: Is it wanted?
• 8:27
  SPEAKER_00: Maybe you like it, sure.
• 8:28
  SPEAKER_00: But is it needed and is it a must for a successful outcome of ACL rehab?
• 8:33
  SPEAKER_00: And one of the things that I do want to share with you is my stance on this as both a clinician and an ACLer going through this process, especially when we're talking about the range of motion and the patellar mobility.
• 8:45
  SPEAKER_00: So, first as an ACLer, with my two ACL experiences, I had my PT help me with moving my knee post op.
• 8:53
  SPEAKER_00: It was great, right?
• 8:54
  SPEAKER_00: Like I felt confidence with like allowing that person to help me for the initial uh piece of it.
• 9:00
  SPEAKER_00: It gave me some comfort.
• 9:01
  SPEAKER_00: It was almost similar to some degree as the CPM machine.
• 9:05
  SPEAKER_00: So it's funny, for my first ACL, I did not get any CPM machine.
• 9:10
  SPEAKER_00: And my second one, I did get a CPM machine.
• 9:12
  SPEAKER_00: And for my second one, I got a little reliant on the CPM machine.
• 9:15
  SPEAKER_00: And so I was like, oh, well, I'm doing my flexion work, it's doing some range of motion stuff.
• 9:19
  SPEAKER_00: Cool.
• 9:20
  SPEAKER_00: Here's the thing that was so interesting was that I got too reliant on it.
• 9:25
  SPEAKER_00: It was a problem, and it was all passive work.
• 9:28
  SPEAKER_00: So, especially if you're physical therapist or you know, you're in a CPM machine.
• 9:33
  SPEAKER_00: Um, this is all passive work, and sure.
• 9:36
  SPEAKER_00: Initially, we're talking, guys, like maybe for the first week or two, and of course, this varies per person, but passive work should slowly phase out.
• 9:46
  SPEAKER_00: But when I say slowly, like within a few weeks at most, right?
• 9:50
  SPEAKER_00: Um, this is something that we're wanting to make sure that you're not just passively rolling along, like there's active work that is at least combined with the passive work, even if it goes beyond that.
• 10:02
  SPEAKER_00: And the thing with me as an ACLer is that like I actually had some delays in my range of motion because I got too reliant on my physical therapist helping me with some of the passive work and with my CPM.
• 10:13
  SPEAKER_00: And so then this is where I think manual therapy could be a double-edged sword.
• 10:18
  SPEAKER_00: Sure, like that initial entry into it, this is something that can be helpful to kind of help with the fears of maybe moving the knee around, which I think is the main thing that a lot of people deal with.
• 10:29
  SPEAKER_00: And then it's a matter of just almost getting too reliant on the passive work where there's not enough active work that you're doing, and then you're hoping that your range of motion will come along with the passive work.
• 10:40
  SPEAKER_00: And what I mean by the passive work here is that it's basically don't think about any muscles working, you're just using either gravity or someone else, or maybe you're using a strap to be able to help assist it.
• 10:52
  SPEAKER_00: And then no muscles are really engaging to be able to do the active pieces.
• 10:58
  SPEAKER_00: So that's what we call the passive range of motion versus the active range of motion.
• 11:02
  SPEAKER_00: And so this is really interesting because at the end of the day, like we need the active to match the passive, and we need the passive to match the uninjured side, right?
• 11:13
  SPEAKER_00: And so there's these pieces or these like kind of heuristics, if you will, that help guide us in getting our range of motion back.
• 11:20
  SPEAKER_00: But the thing is, is that if we just rely on the passive pieces, it can make it difficult to get the active components if it's not embedded in there as well.
• 11:29
  SPEAKER_00: And so, as a PT for my in-person ACL or specifically, sure, I might help them with the first session or so, but you can literally ask any of them.
• 11:39
  SPEAKER_00: That's pretty much it.
• 11:41
  SPEAKER_00: After that, I show them what they need to be doing at home, and we focus our efforts on other areas that are more exercise-based and active.
• 11:50
  SPEAKER_00: To me, that is worth our time together because I can teach you strategies to be on top of that on your own.
• 11:57
  SPEAKER_00: You can be at home working on this stuff with so many different strategies to work on range of motion passively and actively, which is awesome.
• 12:06
  SPEAKER_00: And I love because that puts you in control of the process.
• 12:09
  SPEAKER_00: And so, this is something that I want to make sure that we do educate our athletes as best as possible.
• 12:15
  SPEAKER_00: And then this also allows us to focus our time on other areas that we might want to target together, and then they have that accountability and focus on things outside of our sessions.
• 12:25
  SPEAKER_00: Even then, let's say you are getting physical therapy three times a week and you get an hour for it, right?
• 12:32
  SPEAKER_00: Like that's usually the um higher end of it three times a week.
• 12:36
  SPEAKER_00: You go there for an hour.
• 12:38
  SPEAKER_00: And if you spend 20 to 30 minutes of each of those sessions doing manual therapy work, I think that that is a huge miss, to be completely honest.
• 12:47
  SPEAKER_00: Unless there is like some small or certain situations where you might fit into where that makes sense.
• 12:52
  SPEAKER_00: But for the majority of ACLers, that's a huge opportunity cost.
• 12:57
  SPEAKER_00: It's something where, you know, is this something that's worth the time that you're going into there when you could be working on probably 90 to 95% of that work you're doing there at home?
• 13:07
  SPEAKER_00: So then why can't we focus a little bit more on some other areas where you can really reap the benefits of being in person and being able to get that work with that person you're working with?
• 13:19
  SPEAKER_00: And the thing is, is that this is the exact same thing for our remote athletes.
• 13:22
  SPEAKER_00: We teach them the goals we're aiming for, the range of motion targets, um, our milestones we're aiming for, and set up these goals and the movements, we give them the visuals, we give them the demos, all the things that they're supposed to be feeling, cueing, and you execute on that, right?
• 13:39
  SPEAKER_00: And if you can follow those things, which majority of people can, then they don't have any difference in outcomes compared to the people who are going in person.
• 13:49
  SPEAKER_00: They've just been educated and guided on it.
• 13:51
  SPEAKER_00: And we get to continue to monitor and measure that over time to see the progress or potentially lack thereof, right?
• 13:58
  SPEAKER_00: And the same thing goes for any type of soft tissue work.
• 14:01
  SPEAKER_00: Instead of focusing our time on that in our sessions, we know strategies at home using a foam roller, lacrosse ball, tennis ball, massage gun, any other implements, all accomplish a very, very similar outcome.
• 14:15
  SPEAKER_00: There's nothing magical about our hands as much as a lot of us physical therapists would like to think there are.
• 14:21
  SPEAKER_00: Pressing into someone's tissue or muscles for relaxation compared to one of these objects.
• 14:27
  SPEAKER_00: You know, if you lined up 10 people and someone put their hands and did a massage on a certain area and they did it with a foam roller or a lacrosse ball or some massage gun, they're probably gonna feel some similar-ish benefits if the pressure is all equaled out here.
• 14:43
  SPEAKER_00: And it's not like the carryover is going to be so drastic over days and weeks and months, right?
• 14:49
  SPEAKER_00: It's a very transient feeling to begin with, anyways.
• 14:52
  SPEAKER_00: So, this is something that we try to teach our athletes to have their own self-assistive work, that we would want to spend more time focusing on other areas and potentially plugging these types of things in on certain days or strategically placing them to make sure that they're able to chip away at it over time actively.
• 15:13
  SPEAKER_00: In terms of why I actually love this perspective of being more hands-off, if you will, and active in our philosophy and our approach, it more importantly shifts the locus of control, the athlete, and who is feeling empowered in this process, in a sense.
• 15:32
  SPEAKER_00: It shifts from the provider to the athlete, right?
• 15:36
  SPEAKER_00: Instead of relying on the provider to feel like the safe place to move the knee or be reliant on doing the range of motion work passively, the athlete is in control of their process.
• 15:48
  SPEAKER_00: They're the ones who are given the responsibility to do the work.
• 15:51
  SPEAKER_00: It creates autonomy and independence early on in the process.
• 15:56
  SPEAKER_00: It includes them in on the process.
• 15:59
  SPEAKER_00: And I think that it is something that really does promote the active piece of it because a lot of times we can get so passive having things done to us.
• 16:08
  SPEAKER_00: And so then I think that there can be a huge carryover with being able to allow the athlete and teaching the athlete how to do this and spending our time wisely during our sessions, whether it is in the in-person piece or whether you are working with ACLers remotely, like this is something that I think we have to just be very strategic about like, all right, what is our lowest hanging fruit?
• 16:32
  SPEAKER_00: What is worth our time here?
• 16:34
  SPEAKER_00: And what is something that we can teach the athlete to really do on their own and just continue to monitor the progress of it over time.
• 16:41
  SPEAKER_00: Now, don't get me wrong, it can have its place.
• 16:44
  SPEAKER_00: I'm not saying it's bad.
• 16:46
  SPEAKER_00: It's just whenever we have athletes who are talking to us and I'm consulting with them or they're wanting some opinions.
• 16:54
  SPEAKER_00: And a lot of times I'll hear, yeah, I'm laying on the table for 30 to 40 minutes of the session, or all I'm doing is stretches and range of motion work.
• 17:04
  SPEAKER_00: I'm like, man, like there's so many other areas that are untapped, and I almost feel like it's a limitation of that physical therapist or their model that you're not being served your best.
• 17:15
  SPEAKER_00: And I can't think of many situations where majority of the time that should be your focus.
• 17:20
  SPEAKER_00: Even with the ACLers who have such difficult range of motion, and I'm talking about they're stuck at 70 degrees flexion, they're stuck at, you know, plus 10 degrees of extension.
• 17:29
  SPEAKER_00: Like we've seen them all.
• 17:31
  SPEAKER_00: I've seen them all.
• 17:32
  SPEAKER_00: And the thing is, is that there are ways for us to still strategize things to focus on the range of motion as a big priority.
• 17:39
  SPEAKER_00: But then we can also move the needle in other areas, especially strengthening and being able to educate our athletes on doing other active pieces just outside of the passive range of motion or manual therapy work that can be a part of ACL rehab.
• 17:56
  SPEAKER_00: So this is something that I just want you to kind of view as a pie, right?
• 18:01
  SPEAKER_00: Like a pie chart.
• 18:02
  SPEAKER_00: And a lot of times in the early post op phases, this kind of manual therapy or assistance and range of motion can be anywhere from 50 to 70, 80%, right?
• 18:14
  SPEAKER_00: But what if we reduce that down in terms of like how much of that pie that should be a part of your sessions?
• 18:21
  SPEAKER_00: And sure it's a huge priority for you to work on.
• 18:24
  SPEAKER_00: But what if you can allocate that time to something else with your rehab provider where you can get a lot out of the strengthening pieces, positioning, maybe you guys can throw in some conditioning work that can make you feel a little bit more like you're working on some metabolic stuff, some energy system stuff.
• 18:41
  SPEAKER_00: And you're able to go home on those other hours outside of the three hours that you're only with your PT in person to be able to go work on this range of motion pieces.
• 18:50
  SPEAKER_00: Or if you're remotely, then you can just kind of build it out however it's best for your schedule.
• 18:54
  SPEAKER_00: And then you can also be able to utilize your training sessions and be very targeted with those, right?
• 19:00
  SPEAKER_00: So this is just something that has come up, and we get questions about this.
• 19:05
  SPEAKER_00: And I think one of the things is the reliance and the passive nature of what manual therapy can do, and knowing that really you shouldn't be on the table all that much with ACL rehab.
• 19:17
  SPEAKER_00: And I think that there's this notion of like, yeah, we got to get on the table, we're gonna do our quad sets, our straight leg raises, our uh clamshells, our hip abduction, hip adduction.
• 19:29
  SPEAKER_00: I'm naming all the basic post-op exercises that you'll get, the starter kit, if you will, for ACL rehab, not our starter kit, but most starter kits everywhere else.
• 19:38
  SPEAKER_00: And the thing is, is that, you know, at some point in time we do got to progress past that.
• 19:43
  SPEAKER_00: And I think what can happen is that we get kind of funneled into this kind of process and system where it's just like this is the routine, this is what we do.
• 19:53
  SPEAKER_00: And I think that time can be optimized better.
• 19:56
  SPEAKER_00: And the most important takeaway here is that there should never be a reliance on someone else, especially for hands-on work in this ACL rehab process.
• 20:05
  SPEAKER_00: Um, it's something that I honestly get away from as quickly as I can with my athletes, especially in person, because they don't need me for it.
• 20:13
  SPEAKER_00: And guess what?
• 20:14
  SPEAKER_00: They are able to get the range in motion back as they need to, um, being able to have their own self-management strategies and being able to work on that stuff actively on their own.
• 20:25
  SPEAKER_00: So if you guys have any questions on this, you know where to find me.
• 20:29
  SPEAKER_00: Send me a message on Instagram, ravipatel.dpt.
• 20:33
  SPEAKER_00: Um, you can send me an email.
• 20:35
  SPEAKER_00: Uh, you can also send a message through the show notes below.
• 20:39
  SPEAKER_00: Until next time, team.
• 20:40
  SPEAKER_00: This is your host, Ravi Patel, signing off.