Latest / The ACL Athlete Podcast / 243 | Inside the OR: Important Lessons I Took From Watching ACL Surgery Firsthand - Part 3

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243 | Inside the OR: Important Lessons I Took From Watching ACL Surgery Firsthand - Part 3 · The ACL Athlete Podcast

• 0:18
  SPEAKER_00: Welcome everyone to the ACL Athlete Podcast.
• 0:22
  SPEAKER_00: This is the podcast where we talk about everything related to the ACL, whether that's the injury itself, the rehab process, return to sport, and more.
• 0:31
  SPEAKER_00: I'm your host, Dr.
• 0:32
  SPEAKER_00: Ravi Patel, performance physical therapist and coach.
• 0:36
  SPEAKER_00: Between myself and fellow guests and experts, you'll learn through the lens of the patient, the healthcare professional, and the coach.
• 0:43
  SPEAKER_00: The goal of this podcast is to equip you, the athlete, with the education to make the best informed decision about your care and your ACL journey.
• 0:54
  SPEAKER_00: Thanks for joining.
• 0:55
  SPEAKER_00: Now let's dive into today's episode.
• 1:00
  SPEAKER_00: What is up, y'all?
• 1:02
  SPEAKER_00: Welcome back to the final episode of this three-part series talking about my experience shadowing an orthopedic surgeon recently.
• 1:13
  SPEAKER_00: And I just want to share the last part of this.
• 1:18
  SPEAKER_00: If you haven't caught the first two parts, then go check that out.
• 1:23
  SPEAKER_00: That helps to build on what I'm going to share today.
• 1:26
  SPEAKER_00: But it's really some clinical pearls, some nuances to this process.
• 1:31
  SPEAKER_00: So whether you're an ACLer, you are a coach or a clinician who is working with ACLers, it's just talking through some of the details, noticing in the surgeries themselves, and then also talking with the surgeon, as well as myself going through this, working with many ACLers with different graph types and different procedures as well, just trying to connect some dots here.
• 1:56
  SPEAKER_00: And so I just wanted to share my thoughts and takeaways from it.
• 2:00
  SPEAKER_00: So go check out the first two episodes if you haven't.
• 2:03
  SPEAKER_00: Otherwise, let's dive into today's episode as we round things out.
• 2:09
  SPEAKER_00: So as we start, the next point that I want to bring up, number 12, technically, is that the torn ACL.
• 2:18
  SPEAKER_00: It was very interesting to just look and see the ACL itself, the torn ACL, the stumps, whether it was kind of retracted a little bit or it was still there, and the trauma and looking at the vascularity of the ACL specifically.
• 2:36
  SPEAKER_00: And so there was a ton of vascularity.
• 2:39
  SPEAKER_00: And so sometimes we just think of it as this like white ligament.
• 2:43
  SPEAKER_00: And yes, it is white, but then there's also a lot of red around it.
• 2:48
  SPEAKER_00: And that red is just small little blood vessels that are running through that ACL all along it.
• 2:54
  SPEAKER_00: And there's also a ton of nerves that we can't necessarily see directly, especially within that tissue.
• 3:02
  SPEAKER_00: And when you get that small, depending on the nerve size, of course, blood vessels are easier because they're red.
• 3:09
  SPEAKER_00: But whenever it's nerves, um I remember even in cadaver lab, when you see a nerve, it just depends on the size of the nerve.
• 3:16
  SPEAKER_00: Um, of course, if it's like a main nerve that comes into the leg, like the femoral nerve or the sciatic nerve, it's a little bit more obvious.
• 3:24
  SPEAKER_00: But then as it starts to branch into the different muscles and gets further down, they branch into smaller, different networks or uh different roads, if you will.
• 3:36
  SPEAKER_00: Think about like a main highway versus you get off the interstate, you are on these main roads, and then you go into suburbs.
• 3:43
  SPEAKER_00: Like the roads are smaller and smaller and more narrow, right?
• 3:46
  SPEAKER_00: And so then, therefore, it's kind of the same thing here with smaller blood vessels and with nerves as well.
• 3:53
  SPEAKER_00: And so that's also happening within the ACL itself, but it's harder to see the nerves that are running through the ACL.
• 4:01
  SPEAKER_00: And so it's a neurovascular structure as well.
• 4:04
  SPEAKER_00: And so the ACL receives the sensory innervation from branches of the tibial nerve, particularly it goes through the posterior articular branch that travels with the middle genicular artery into the knee joint capsule itself.
• 4:22
  SPEAKER_00: So those are a lot of big words, but basically it's talking about the path that it travels because of the innervation and that network and then going into the ACL.
• 4:30
  SPEAKER_00: And so I think this is really important because these nerves they are essentially an important part of the ACL and the proprioception.
• 4:39
  SPEAKER_00: And then just looking at the ACL itself with the blood vessels and looking at how it actually had a pretty good amount of blood supply to it.
• 4:50
  SPEAKER_00: The thing that I think often gets mistaken is that the ACL itself can't heal.
• 4:56
  SPEAKER_00: Now, while there is now new literature to show there is the possibilities of the ACL healing, but I'll leave that for a later date to touch on for a podcast episode.
• 5:07
  SPEAKER_00: The other thing that's interesting, especially diving into more of the bear procedure, which is the bridge enhanced repair, um, this is something where they basically put, think about a peanut-sized like cotton piece or foam that is basically bridging the two ACL pieces together, and then they inject it with blood, and then that creates the scaffolding for the ACL to try and heal and bridge together to become the full heal ACL.
• 5:38
  SPEAKER_00: And this has been very recent, if you will, or developing by Martha Murray.
• 5:42
  SPEAKER_00: I'm gonna do a podcast episode on this and a deeper dive too.
• 5:46
  SPEAKER_00: But going back to this point is that basically there is an enzyme in this novial fluid, the fluid that's in the knee joint itself, that washes away a lot of this blood clotting formation.
• 5:57
  SPEAKER_00: And we actually need a blood clot for the ACL to heal.
• 6:00
  SPEAKER_00: Now, we still don't know the true details in enzyme because the ACL does have the potential to heal in some cases, in some cases it doesn't.
• 6:08
  SPEAKER_00: And so we don't know conclusively who's a good candidate for that.
• 6:12
  SPEAKER_00: But with that said, it is interesting to see that the ACL itself is vascular, but the thing is is that makes it tough is that you cannot get the scab to form because of that synovial fluid.
• 6:28
  SPEAKER_00: So it's almost like basically the two ends are disconnected, and to reconnect it, the bridge that needs to happen isn't as productive because of that fluid washing away the scab that needs to form in order for that to be able to bridge back together and heal.
• 6:44
  SPEAKER_00: That's essentially how all tissue heals, is that there is a clot formation, and then that allows for other different cells to come and to be able to turn it over and proliferate and then mature.
• 6:57
  SPEAKER_00: That's how our body heals in general and turns over tissue.
• 7:01
  SPEAKER_00: The thing is, the ACL is it's challenging because we don't necessarily have those two points touching each other, so then therefore it makes it more challenging because it can't send those cells there.
• 7:12
  SPEAKER_00: So that is something that I was just kind of thinking about.
• 7:15
  SPEAKER_00: This is a very nerdy route I'm taking on you guys, but essentially thinking about that ACL, it's not just you know white and it's just a ligament, there's a lot of things going on.
• 7:26
  SPEAKER_00: And the other thing that I want to touch on is also the nerves itself, is that it comes through the posterior aspect of that tibule attachment of the of the uh nerve, if you will, and then spreads within the ligament.
• 7:41
  SPEAKER_00: And then the big thing about this is that it helps appropriate reception, reflexes, and even pain.
• 7:47
  SPEAKER_00: Remember, it's a sensory nerve.
• 7:48
  SPEAKER_00: And so then, therefore, the it's a super important detail because when we get a new graft put in, that's all gonna get removed, right?
• 7:56
  SPEAKER_00: You remove that ACL remaining, whether it's the stump, the pieces of the ACL.
• 8:03
  SPEAKER_00: And I don't know if any of the innervation itself is preserved, to be honest.
• 8:08
  SPEAKER_00: Like you think about a new graft, a new tendon getting in there.
• 8:11
  SPEAKER_00: Sure, new vascularity eventually develops over it, but I don't really know about the neural component of the ACL.
• 8:18
  SPEAKER_00: Like, does it re-innervate, especially if they cut away all those pieces?
• 8:23
  SPEAKER_00: Maybe, but I also think that there are a lot of situations where it does not, um, just because nerves are also a different beast than blood vessels to regrow within a certain area.
• 8:35
  SPEAKER_00: And so um, yeah, I think that that's super important.
• 8:38
  SPEAKER_00: And I don't think that there's any research or anything to show that the nerves just regenerate, right?
• 8:45
  SPEAKER_00: Proprioception is a big thing that we are also working really hard on post-op, especially, but it also makes sense why it's so hard.
• 8:53
  SPEAKER_00: Proprioception is our ability to sense where we are in space.
• 8:57
  SPEAKER_00: So if we close our eyes, we know where our hands are, our feet are, our knee are.
• 9:01
  SPEAKER_00: Doesn't mean that it completely goes away because you have other things also sending that sensory information back, but the ACL is a very important detail to that.
• 9:13
  SPEAKER_00: So then, therefore, it can kind of throw the proprioception off when we don't have that.
• 9:17
  SPEAKER_00: So the big thing to always think about is with ACL is that not it not only is it like a muscoskeletal injury, but it's also a neural injury, not only locally to the ACL when that thing is injured and then removed, but then also there are also crazy things happening at the spinal cord and the brain that changes that we are not starting to see a lot more with a lot of the research, with a lot of the AMI arthogenic muscle inhibition, and the the footprint that we're seeing within this, which has been very interesting to see from the researchers who are leading this.
• 9:53
  SPEAKER_00: So, this is one thing that I wanted to share in terms of just seeing that ACL in the surgery, seeing the vascularity of it, seeing there being some bleeding in there, but just noticing that, you know, it doesn't form that scab that we were hoping to form whenever we are trying to heal a tissue or the blood clot formation.
• 10:12
  SPEAKER_00: The next point I want to share is that that new ACL graft is locked in there.
• 12:23
  SPEAKER_00: People are often hesitant because there's a new graft and they'll think they'll damage it.
• 12:28
  SPEAKER_00: I felt the exact same way with my ACL surgeries.
• 12:31
  SPEAKER_00: I don't blame any of you guys, and even for PTs listening, like it just feels like a very fragile and delicate thing, right?
• 12:39
  SPEAKER_00: Just when we kind of think about the procedure, it's intense, like the knee itself has a hyper response with pain and swelling and guarding.
• 12:47
  SPEAKER_00: So when you go to move it, it feels like the sense of that internal alarm goes off and you're scared to mess it up, especially given it being a major procedure.
• 12:56
  SPEAKER_00: You don't want to undo that.
• 12:58
  SPEAKER_00: But just know that thing is in there, y'all.
• 13:02
  SPEAKER_00: And you would have to do something really, really dumb to mess it up.
• 13:05
  SPEAKER_00: Now, the thing that we're not worried about is necessarily the graft itself at in those moments, it's actually the fixation points.
• 13:14
  SPEAKER_00: But those fixation points are really, really locked in.
• 13:16
  SPEAKER_00: I mean, they get that thing in there and they anchor it down.
• 13:20
  SPEAKER_00: So you would have to, like I said, do something really dumb in order to really mess it up.
• 13:26
  SPEAKER_00: And the only other caveat that I'll say is that like there could be a slip, right?
• 13:30
  SPEAKER_00: Someone could be in a snowy area or out when it rains.
• 13:34
  SPEAKER_00: And yeah, accidents happen.
• 13:36
  SPEAKER_00: And I have heard about this, and things like this happen all the time.
• 13:40
  SPEAKER_00: I've had athletes where their dog, their big dog, runs straight into their knee while it's propped out.
• 13:45
  SPEAKER_00: So situations happen, and a lot of times they don't end up re-injuring it, but it can create a response that you're just like, did I mess it up?
• 13:54
  SPEAKER_00: And that's very fair with an accident like that.
• 13:57
  SPEAKER_00: But outside of uncontrollable accidents, right?
• 14:00
  SPEAKER_00: Situations like that, as long as you are smart, I promise that that ACL is not going anywhere.
• 14:05
  SPEAKER_00: It's locked in there with the new screw and the button to reinforce it.
• 14:09
  SPEAKER_00: Not to mention everything else in and around the knee is still supporting the surgery.
• 14:15
  SPEAKER_00: Remember, you got all your muscles around it.
• 14:17
  SPEAKER_00: Sadly, what the quad has shrunk down to, but you still have a supporting structure and network.
• 14:23
  SPEAKER_00: You have tendons, ligaments, and bone, and all kinds of other things that are around there that's gonna reinforce that knee.
• 14:29
  SPEAKER_00: So know that it's not just like this very fragile knee that is very volatile and any step will tear it.
• 14:36
  SPEAKER_00: And I know it feels that way, but it won't.
• 14:40
  SPEAKER_00: They even in this surgery tested the Lockman's test after the ACL is put in to make sure it has its end feel properly and it doesn't give too much.
• 14:48
  SPEAKER_00: So they're putting that ACL into direct tension and into that compromised position to begin with.
• 14:54
  SPEAKER_00: So if that gives you any peace of mind.
• 14:56
  SPEAKER_00: The last point I want to mention here is that the tendon that is put in is initially the strongest it will ever be in that knee.
• 15:03
  SPEAKER_00: Then it will break down and go through the ligamentization process and become a actual true ligament over the course of one year, two years and beyond, which handles less strain than the initial tendon that went in there.
• 15:18
  SPEAKER_00: Tendons are stronger than ligaments, so the tendon itself will actually be able to respond and handle more stress.
• 15:25
  SPEAKER_00: The things that we are more so intentional about, and while we don't push it, are more the fixation points because again, it's anchored in there by screws, by buttons, by certain sutures and tape.
• 15:38
  SPEAKER_00: Um, and I'm using tape loosely as like these fibered braids.
• 15:41
  SPEAKER_00: But basically, those are things that are gonna be in there to really anchor that thing in there.
• 15:46
  SPEAKER_00: And then, of course, with a patellar tendon, you're gonna have bone on both sides typically.
• 15:50
  SPEAKER_00: So you have a lot of reinforcement that helps this.
• 15:53
  SPEAKER_00: And so I think that's something to just consider, especially with there being a very strong tendon that goes in there initially.
• 16:00
  SPEAKER_00: And I feel even more confident pushing the joint a little bit more because of the bony plugs, because that heals faster with the BTB.
• 16:09
  SPEAKER_00: Next point I want to share is that the internal brace was used along with these BTBs with this surgeon.
• 16:16
  SPEAKER_00: And so to break this down before you guys, the internal brace is a strong braided suture-like rope or band, if you will.
• 16:25
  SPEAKER_00: It's called fiber tape.
• 16:27
  SPEAKER_00: It's placed along the ACL graft.
• 16:29
  SPEAKER_00: So think about that graft having, I mean, if you even think about the size of you maybe like your index finger or middle finger, the length of it.
• 16:37
  SPEAKER_00: That is going to be essentially the ACL.
• 16:40
  SPEAKER_00: And just think about there being this almost like wire that is going to run alongside it.
• 16:45
  SPEAKER_00: I feel like I've seen it mainly the color blue for some reason.
• 16:50
  SPEAKER_00: But basically, that is going to run along the line of where that ACL is to help with it being essentially focused as like a seatbelt, if you will.
• 17:02
  SPEAKER_00: So basically, it goes through the joint just like the normal tunnels, fixed at the tibia and the femur, along with that graph, and then it's going to be right alongside it, um, hugging it, um, and yeah, acting like a reinforcement backup system.
• 17:18
  SPEAKER_00: So then, therefore, it allows that strain to also have that reinforcement of the internal brace.
• 17:26
  SPEAKER_00: And I think we're going to continue to keep seeing this more and more of the internal braces with ACLs.
• 17:31
  SPEAKER_00: I'm starting to see it with a lot more surgeons.
• 17:33
  SPEAKER_00: We're hearing about it more.
• 17:35
  SPEAKER_00: We're seeing this a little bit more uh even with local surgeons here and around the world, and especially here in the US.
• 17:43
  SPEAKER_00: And the research is showing some early positive results.
• 17:46
  SPEAKER_00: So I think this will be something that we'll continue to see that people will be offered ACL plus the internal brace just to reinforce this.
• 17:55
  SPEAKER_00: And I'll be curious if this evolves into more.
• 17:58
  SPEAKER_00: Or maybe, you know, studies start to show over time that this doesn't prove to be any better.
• 18:03
  SPEAKER_00: So I'll be kind of curious from that aspect.
• 18:06
  SPEAKER_00: But, you know, logically it makes sense.
• 18:07
  SPEAKER_00: Why not put another kind of rope in there that's going to help to secure that, especially from the early stages of healing, to protect that joint in case it does get stressed a little bit more, even into later, whenever it's put to its test, right?
• 18:22
  SPEAKER_00: Like you have another seatbelt reinforcement in there along with the ACL to just be like, all right, we were giving it its best shot, especially if it gets put to the test of strain, right?
• 18:33
  SPEAKER_00: So I thought that that was pretty cool to see, and then to also talk about the next thing that I wanted to share was the reality of re injuries are real.
• 18:46
  SPEAKER_00: So there was a 15-year-old female athlete on her second ACL on her other side.
• 18:55
  SPEAKER_00: So she had her first when she was you guessed it, 10 years old.
• 19:02
  SPEAKER_00: And if you had to guess her sport, what would you guess?
• 19:05
  SPEAKER_00: I'll give you a second.
• 19:08
  SPEAKER_00: Yep, it was soccer.
• 19:10
  SPEAKER_00: And this really made me sad when we were looking at the history of this athlete and kind of talking through some of the details, and it also makes me wonder what is the underlying cause here?
• 19:21
  SPEAKER_00: What has caused this athlete who is 15 years old to have two pretty major surgeries that will likely influence her physical activity, her playing sports, and her knee health for the rest of her life, right?
• 19:38
  SPEAKER_00: And I know that we will never know this particular answer for this girl.
• 19:43
  SPEAKER_00: Um, and no one could answer it because it is multifactorial, and many people can point the finger at different directions.
• 19:50
  SPEAKER_00: But I'm just gonna take a stab at this because I feel like I have enough here to be able to take a stab at it.
• 19:59
  SPEAKER_00: So let's talk about three important points.
• 20:01
  SPEAKER_00: Number one, too much soccer at a young age.
• 20:04
  SPEAKER_00: The club level soccer and club level sports in general, and just sports specialization has gone insane and I hate it.
• 20:13
  SPEAKER_00: And as much as I understand it is a very cultural thing.
• 20:17
  SPEAKER_00: Look, I've talked to parents about this, I've talked to coaches, I've talked to other PTs, uh, people in the space about this, and it is a very complex topic to tackle because there's not only things about you know their friends are playing, it's something they're good at.
• 20:36
  SPEAKER_00: There's also a business surrounded by it.
• 20:39
  SPEAKER_00: So yeah, if you increase sports year-round, guess what?
• 20:42
  SPEAKER_00: The sport makes more money, they become more reputable, they push out more athletes.
• 20:46
  SPEAKER_00: It's a whole cycle of things, right?
• 20:50
  SPEAKER_00: And there's a lot of layers I didn't even mention into this.
• 20:53
  SPEAKER_00: But the thing that is really, really challenging here is you know, the surgeon himself was like, she plays soccer at a very high level in a very high-level athletic family.
• 21:05
  SPEAKER_00: Her brother was a big-time volleyball player, and youth specialization too early is just crushing our youth injuries and also burning them out.
• 21:15
  SPEAKER_00: Burnout is a big thing that just progressively goes on.
• 21:18
  SPEAKER_00: Parents are vicariously living through their kids.
• 21:20
  SPEAKER_00: Um, maybe they were an ex-athlete, or uh it is something where they just feel like they need to keep going because their friends are doing it, right?
• 21:29
  SPEAKER_00: But they're falling out of love with it.
• 21:31
  SPEAKER_00: So that's the burnout piece, which plays into potentially doing things, putting yourself at risk, not caring or working as hard.
• 21:38
  SPEAKER_00: But then the other thing is more so of like when kids are early in this process, it's just kind of cutthroat.
• 21:44
  SPEAKER_00: They're going as hard as they can, you know, they're practicing multiple times a week, and then they're going to play multiple games on the weekends and then trying to redo that all over again the following week with no strength training, no proper recovery.
• 21:58
  SPEAKER_00: And because they're younger, guess what?
• 22:00
  SPEAKER_00: You can bounce back faster, but at some point you reach a threshold where it's too much.
• 22:05
  SPEAKER_00: And so the youth specialization piece I want to share.
• 22:10
  SPEAKER_00: Uh, Eric Cressy, so he is a world-renowned strength and conditioning coach.
• 22:15
  SPEAKER_00: He specializes especially in baseball, which I would say that has a sports specialization issue as well, um, especially with pitchers.
• 22:25
  SPEAKER_00: And so the thing that he shared the other day is that he said, We opened Cressy sports performance in 2007.
• 22:33
  SPEAKER_00: He is an OG, y'all.
• 22:35
  SPEAKER_00: He is one of the ones that I learned from from the beginning.
• 22:38
  SPEAKER_00: He is someone I attribute that I uh have learned a lot of strength and conditioning from.
• 22:42
  SPEAKER_00: A lot of my mentors did, and he has led the field and the charge, especially with just educating others.
• 22:49
  SPEAKER_00: I've seen him live, and he even like used me as a demonstration.
• 22:53
  SPEAKER_00: It was super awesome.
• 22:54
  SPEAKER_00: So I respect this guy a lot because he's also uh working for the the Yankees as per sport performance.
• 23:02
  SPEAKER_00: And so, anyways, the guy knows a lot, and so he's been in the field, been in the space for a long time.
• 23:08
  SPEAKER_00: And he said, We opened Christy's sports performance in 2007 and didn't see a Tommy John surgery in our first five years, even though we were training dozens and sometimes hundreds of baseball players daily.
• 23:21
  SPEAKER_00: And Tommy John is where the uh UCL, um, this is a ligament on the inside of the elbow, tears, and so then therefore, they have to go in and they have to repair it because of the repeated stress from pitching so much.
• 23:35
  SPEAKER_00: And so this happens a lot to pitchers, and so they have to have Tommy John surgery, which is a very famous surgery.
• 23:41
  SPEAKER_00: Um, it's basically the ACL of the elbow.
• 23:43
  SPEAKER_00: And so then, therefore, it's very commonly done to baseball players.
• 23:48
  SPEAKER_00: And so he said in this same tweet that this week I interacted with two 15 year olds who've both already had Tommy John, and then he said, Let that sink in.
• 24:00
  SPEAKER_00: And really the point that he was getting at.
• 24:04
  SPEAKER_00: Which a lot of us in the performance space, especially when we're seeing these injuries and we're like, why are these happening?
• 24:10
  SPEAKER_00: Well, this is a very big problem.
• 24:13
  SPEAKER_00: It's like because kids need to play a bunch of different sports when they're growing up and getting skeletally mature, and they don't need to specialize until they get into their late teen years, into getting more into college.
• 24:26
  SPEAKER_00: And I get like, yes, towards junior and senior year, get a little bit more specialized, if you will.
• 24:32
  SPEAKER_00: But now kids are specializing at the age of like six and seven, and it's like let them be kids.
• 24:38
  SPEAKER_00: And I get it.
• 24:39
  SPEAKER_00: A lot of times the logic is let's let them play the sport and get really good at it, and that'll make them better and better at it.
• 24:45
  SPEAKER_00: And to maybe some degree.
• 24:48
  SPEAKER_00: But when kids are developing and building a foundation of movement, it's actually better for them to get a lot more movement variability through different sports.
• 24:57
  SPEAKER_00: And it helps them to actually be better at that one thing because they're able to express themselves in multiple ways and develop different qualities athletically versus being so hyper-focused, which leads to repeated stress on the same areas and tissues, which then therefore leads to why these athletes are, for example, getting Tommy John so early.
• 25:17
  SPEAKER_00: They get too much stress of that ligament over days and days and weeks and so much work and pitching because they're also young and they can't control it because they just push themselves and they bounce back, but it still stresses that joint and that ligament.
• 25:34
  SPEAKER_00: And so that is something that I think is really important in terms of discussing the reality of re-injuries, is that sport specialization is playing a huge role into this.
• 25:45
  SPEAKER_00: The other point I want to also mention here is that given the research and what I've seen, most ACLers are not tested for returning to sport.
• 25:54
  SPEAKER_00: While there's more education around this, and yeah, in the social media space, it's getting better to understand this.
• 26:01
  SPEAKER_00: It's still a very low percentage.
• 26:04
  SPEAKER_00: Like for the people that I talk to, they're all just like, yeah, I had an MMT where I kicked into someone's leg, or basically it was just a timeline-based or just hop testing, and that's it.
• 26:15
  SPEAKER_00: So we still need to get better at testing.
• 26:17
  SPEAKER_00: And when it's done, a lot of times it's just not the right test, like isolated hamstring and quadriceps strength testing or even vertical jump testing.
• 26:27
  SPEAKER_00: I also know where this athlete had her previous surgery and currently work with athletes from that group, and they don't really strength test.
• 26:37
  SPEAKER_00: They have their own strength proxies, but there's nothing that's isolated quadricep or hamstring strength.
• 26:43
  SPEAKER_00: And so I feel pretty confident that there was no true return to sport testing on her first ACL being 10 years old.
• 26:50
  SPEAKER_00: So if I had to guess, this athlete was cleared, and then she had built up compensations over time and relied on her uninvolved and eventually tore her other side.
• 27:02
  SPEAKER_00: And sadly, this is way too common.
• 27:04
  SPEAKER_00: Y'all, I can't prove this, but I'm gonna just tell you this based on just being so obsessed in this space and working in this space for quite some time now that this is something that I see, and we just want to kind of call it out in a situation like this, right?
• 27:24
  SPEAKER_00: Um, and then in the third point I want to bring out here that I think contributes to this are that female athletes are not given the same development experience and cultural experiences as male athletes, their counterparts.
• 27:37
  SPEAKER_00: Culturally, it's normal for boys to roughhouse and also lift weights earlier than girls.
• 27:42
  SPEAKER_00: They're also provided typically better resources.
• 27:46
  SPEAKER_00: I even remember, like in my high school, like we had a strength training class for guys.
• 27:50
  SPEAKER_00: There wasn't one for girls yet.
• 27:52
  SPEAKER_00: And so it's just something that I think, you know, is something that starts from the beginning and then they are thrown into sports and expected to adapt physically the same as boys, right?
• 28:04
  SPEAKER_00: But there's limited resources, education, and not to mention the stigma around weightlifting and getting bulky and toned, um, or bulky versus toned, if you will.
• 28:14
  SPEAKER_00: I know this narrative is changing for the better, but it still exists because I currently work with young female athlete ACLers and they're still very, very, very cognizant of their image, and they will say, I don't want to get too bulky.
• 28:28
  SPEAKER_00: And so this is just something that persists as much as you know, we want it to not.
• 28:35
  SPEAKER_00: And so it's just something that's really important.
• 28:38
  SPEAKER_00: And the initial point of the overspecialization too early makes this harder because there's no quote unquote time to do this.
• 28:45
  SPEAKER_00: I've worked with entire soccer clubs working so hard on this, doing injury prevention that shows that it helps with re-injury rates and all of the things decrease medical costs, healthcare costs.
• 29:00
  SPEAKER_00: And there are studies and studies and studies that show that the FIFA 11, for example, for soccer clubs and soccer teams will reduce the risk of injury and future injury.
• 29:10
  SPEAKER_00: But there is a complicated mess around just basically how coaches can implement it, the timing, the education around it.
• 29:18
  SPEAKER_00: And there's a big big disconnect, and it's challenging, y'all.
• 29:21
  SPEAKER_00: It's easy for someone to say, oh, yeah, let's go and implement it, but it has to be a top-down thing.
• 29:27
  SPEAKER_00: If it comes from, you know, FIFA, or if it comes from the club president or the one who runs the show and it's mandatory, I bet we will see it improve.
• 29:37
  SPEAKER_00: Until then, it's gonna be really hard because coaches want to focus on soccer, for example, or baseball versus all this prehab or uh strength training, thinking that it'll take time away from them.
• 29:49
  SPEAKER_00: You know, so I do hope that this shifts um as we get more with the times and especially as the research helps us to highlight these areas.
• 29:56
  SPEAKER_00: So this is the reality of re-injuries.
• 29:59
  SPEAKER_00: There's a lot of layers to it that I didn't even talk about.
• 30:03
  SPEAKER_00: But talking about an athlete who has torn her ACL and she was 10 and now she's 15 twice is just just really sad.
• 30:13
  SPEAKER_00: And so then, therefore, I wanted to open up and share basically what I think is layering into a lot of this on the bigger grand scheme of these things.
• 30:23
  SPEAKER_00: And if we were able to really shift these three things, we would really make a dent in how people are getting injured and the way that we could successfully come back and not re-injure.
• 30:36
  SPEAKER_00: The next point to spin this into a positive note here is that from a range of motion standpoint, you have full range of motion after the surgery, including knee hyperextension, which they did check in these surgeries.
• 30:50
  SPEAKER_00: So I that was just something that I wanted to see how they manipulated it and test it.
• 30:55
  SPEAKER_00: And yeah, the athletes had full hyperextension, so it makes you think about a lot of the factors that play into the struggles of regaining it post-op, which are many pain, swelling, neural input to the quads to get it to activate, surgical restrictions, being locked in a brace, poor rehab guidance, maybe someone saying go to zero versus hyperextend, compliance on the patient's end, graph type, of course, plays into this.
• 31:20
  SPEAKER_00: Did you have a patella or a quad?
• 31:21
  SPEAKER_00: Or did you have a hamstring, right?
• 31:23
  SPEAKER_00: Did you have an allograph?
• 31:24
  SPEAKER_00: Biology doing its own thing that we can't necessarily fully control, and so much more, y'all.
• 31:31
  SPEAKER_00: But there's a lot of layers to this, but it is there, the range of motion.
• 31:35
  SPEAKER_00: So it's important for us to especially get this back ASAP, especially extension.
• 31:39
  SPEAKER_00: I get the flexion piece, especially because that's a little bit more daunting, if you will, because you're gonna have to bend the knee.
• 31:45
  SPEAKER_00: The knee is already semi-straight whenever you come out of surgery.
• 31:49
  SPEAKER_00: And then the other thing is that as you flex it, the swelling tends to pressurize the joint a little bit more, so that's a little bit more apprehensive.
• 31:57
  SPEAKER_00: The extension is just harder because the quads shut down because of this surgery, and then also it could be some of the guidance pieces that we typically see as well.
• 32:07
  SPEAKER_00: And then the last thing that I want to note here to round this out is that prehab and rehab was really important to this surgeon.
• 32:14
  SPEAKER_00: He was huge on doing prehab, for example, to get the knee quiet before surgery.
• 32:20
  SPEAKER_00: Um, he said he at least likes to see six weeks of it and said he consistently sees better outcomes versus someone jumping into the surgery.
• 32:28
  SPEAKER_00: And I could not agree more.
• 32:30
  SPEAKER_00: Going into the surgery with an angry, grumpy knee will result in a much more grumpy, pissed off knee whenever you get out of surgery and a much harder time being able to get things back, versus if you go into the surgery with a happy and quiet knee, you will see that the knee will respond better, plus knowing that uh you have gotten it to a good state, and then therefore you're not also climbing an even bigger mountain.
• 33:00
  SPEAKER_00: And so this surgeon literally said the physical therapy portion is the most important, which was so refreshing to hear.
• 33:07
  SPEAKER_00: I truly believe that even the most average surgeon with the best rehab will always beat the best surgeon with the worst or average rehab for an ACLR.
• 33:20
  SPEAKER_00: Rehab really is the difference maker, and it was so cool to hear that from this surgeon.
• 33:26
  SPEAKER_00: I understand I'm biased, y'all.
• 33:27
  SPEAKER_00: I'm a physical therapist, this is what I do, but I also just believe it in my bones that this is truly the way.
• 33:35
  SPEAKER_00: And if you have good rehab, you have good guidance, it will take care of majority of this.
• 33:42
  SPEAKER_00: You would have to have a pretty negligent surgeon for this to not turn out to be more positive than negative for you.
• 33:50
  SPEAKER_00: And so what I want to do as we round this out is just kind of talk through some brief points about this of what I touched on, in case maybe you're catching part three and you want to go back and catch part one, part two, or maybe one of those, um, which I encourage you to do.
• 34:08
  SPEAKER_00: But going through this here, number one, ACL surgery is a lot of work.
• 34:12
  SPEAKER_00: It's hard work, y'all.
• 34:14
  SPEAKER_00: There's a lot of trauma to the knee, depending on the injury, the repairs, all the things that are done.
• 34:19
  SPEAKER_00: There's a lot going on.
• 34:20
  SPEAKER_00: And so then that leads to number point number three, the symptoms compound.
• 34:24
  SPEAKER_00: Think about if you had one simple procedure versus multiple procedures, that's going to layer into how the knee is feeling post-op.
• 34:32
  SPEAKER_00: I promise you that.
• 34:34
  SPEAKER_00: LETs are something that are in a little bit of a newer kind of entrance here, but they've been around for a while.
• 34:43
  SPEAKER_00: Um, but we're seeing it more and more and more, especially for revisions for surgeries or rotational instability.
• 34:51
  SPEAKER_00: The menisectomy versus meniscus repair, that is going to be dictated a lot of times in the surgery.
• 34:58
  SPEAKER_00: So when you wake up, don't be surprised if you had a repair or maybe the opposite of menisectomy when one was initially planned.
• 35:05
  SPEAKER_00: Um, so that is something that is important for all Asailers know going into surgery.
• 35:10
  SPEAKER_00: Biggest point is non-weight bearing or limited inflection if you have a repair.
• 35:15
  SPEAKER_00: Meniscus repair precautions and restrictions, listen to those.
• 35:19
  SPEAKER_00: The surgeon is in that knee.
• 35:22
  SPEAKER_00: So you want to make sure that you listen to them in terms of what they are recommending, especially based on the meniscus recommendations.
• 35:31
  SPEAKER_00: Um, so this is gonna be really important.
• 35:33
  SPEAKER_00: Uh, and then you know, they may make a decision if something's 50-50, whether they repair it or whether they end up doing a menasectomy based on the athlete themselves and the compliance that could potentially happen or lack thereof.
• 35:47
  SPEAKER_00: Graph type, I think patellar tendons are awesome.
• 35:50
  SPEAKER_00: I think every graph type has its own cases that I have even recommended for certain athletes.
• 35:56
  SPEAKER_00: Um, but I think that maybe we need to just be careful of the type of graphs that you know a surgeon recommends just because it's their go-to, um, but more so like why they say the other graphs are not a good fit for certain clients.
• 36:15
  SPEAKER_00: I think they sometimes almost fit people into like, oh no, this quad tendon is the best because there's no anterior knee pain, less of an incision site, or this hamstring tendon um is not good because uh it's too thin.
• 36:31
  SPEAKER_00: Uh, we sometimes have to triple double bundle it, quadruple bundle it, um, and it's not as thick, right?
• 36:36
  SPEAKER_00: Or the patellar tendon um is better because it's the gold standard, right?
• 36:41
  SPEAKER_00: And so there are different ways that it is communicated.
• 36:44
  SPEAKER_00: So I think we just need to be cautious of this.
• 36:46
  SPEAKER_00: But I do think that patellar tendon is awesome.
• 36:49
  SPEAKER_00: I think quad tendon in the right athlete is awesome.
• 36:51
  SPEAKER_00: Same with hamstring.
• 36:53
  SPEAKER_00: I think it is an underestimated graft in terms of being able to do this procedure, as well as like it doesn't impact the patellar tendon or the quads.
• 37:03
  SPEAKER_00: The knee extensor as a whole remains in good shape.
• 37:08
  SPEAKER_00: So I think that there's a positive to that.
• 37:10
  SPEAKER_00: And then I think allographs have their place too for the right person, right fit.
• 37:15
  SPEAKER_00: Um, graph harvest, the harvest site or the donor site takes a hit, y'all.
• 37:22
  SPEAKER_00: It takes a huge hit.
• 37:23
  SPEAKER_00: So we need to really think about this.
• 37:25
  SPEAKER_00: What if that was done in isolation?
• 37:27
  SPEAKER_00: How would you treat that?
• 37:28
  SPEAKER_00: You know, that's really important for us versus overlooking it.
• 37:32
  SPEAKER_00: But there's a lot done there, so we need to make sure that that is a priority for us because that could sometimes be the brakes on the rehab that we're trying to press the gas pedal on.
• 37:42
  SPEAKER_00: Some things surgeons decide to do and don't, it could be due to being paid for it, maybe not.
• 37:49
  SPEAKER_00: There are some who may cut corners and there are a lot that don't.
• 37:53
  SPEAKER_00: And that is going to be dependent on the surgeon, the surgery, maybe even the day that they come in.
• 37:58
  SPEAKER_00: It's hard work, y'all.
• 38:00
  SPEAKER_00: And as you know, like no one is here to necessarily do bad work or intentionally, but you know, it just might be the case in any profession, whether it's good, bad, and everything in between.
• 38:13
  SPEAKER_00: Nerve pain, sensation, those things happen, especially because that nerve branch is going to be impacted of the saphnus nerve, the inferior branch, especially.
• 38:26
  SPEAKER_00: So just know that this is pretty normal in terms of feeling that, and especially with a patellar tendon or that incision on the front side, that will influence it.
• 38:36
  SPEAKER_00: Tunnel drilling and the placement is crucial.
• 38:39
  SPEAKER_00: So we want an anatomical over a transtibual or vertical approach that's gonna help us to just naturally let the ACL do its thing.
• 38:49
  SPEAKER_00: The torn ACL itself is packed with neurovascular structures, so we just want to make sure we're reminded of that from the loss of proprioception to the healing potential or lack thereof of the ACL.
• 39:03
  SPEAKER_00: The new ACL is locked in there.
• 39:05
  SPEAKER_00: I mean, they tighten that thing in there and it is locked in.
• 39:09
  SPEAKER_00: So just know that you're not gonna damage anything and it's not a fragile knee.
• 39:14
  SPEAKER_00: Internal bracing is something where they put that rope in there, and I think we're gonna start to see that more and more with ACLs to help reinforce that joint.
• 39:24
  SPEAKER_00: And then I share the reality of ACL and reinjuries and how they're real and the three points discussing uh this female athlete who has had two under the age of 15, sports specialization, knowing that we're not necessarily doing our due diligence of proper return to sport testing, and then just the quality of female athletes to male athletes in terms of their development and cultural experiences.
• 39:51
  SPEAKER_00: And then the last two points I'll mention here is range of motion.
• 39:55
  SPEAKER_00: You have it full, and then we have to do a job of being able to get that back once we wake up and get to the rehab.
• 40:02
  SPEAKER_00: The whole post op kind of starts to weigh in with swelling and pain and whatnot that is influencing this process, but we get that extension, so we want to regain that.
• 40:13
  SPEAKER_00: And then lastly, how there was just the same page of doing rehab and the importance of rehab in this process and being the most important thing.
• 40:25
  SPEAKER_00: Those are the 17 points in this episode and my reflection of observing this surgery and to just be able to be in that room and talk with the surgeon and watch this team do their thing.
• 40:41
  SPEAKER_00: They work so hard, and I have so much respect for what they do.
• 40:46
  SPEAKER_00: And the most important thing here is let's just respect this process and what's been done.
• 40:53
  SPEAKER_00: And for me, it also makes me want to double down even more on just keeping it simple, focusing on the basics versus trying to hit the gas pedal at the go because this procedure is a lot on the knee, and we just need to respect what is going on in the biology and the healing of the human body.
• 41:13
  SPEAKER_00: Doesn't mean we sit to the side and lay on the couch for two weeks, but we want to find a sweet spot to make sure we are doing what we need to do to be able to move this along, but also respect this process because if we do, we're gonna let swelling go down, pain go down, that's gonna help improve range of motion, your quads are gonna wake up a little bit better, that's gonna help you get walking more, and that's gonna help move things along in this process.
• 41:37
  SPEAKER_00: So I really hope that this series was helpful for you.
• 41:41
  SPEAKER_00: I hope you're able to pull something from it.
• 41:43
  SPEAKER_00: I know I went on some tangents, but it's my podcast.
• 41:47
  SPEAKER_00: I can do whatever I want, and I hope you enjoyed it.
• 41:50
  SPEAKER_00: But I hope that you guys really do take away something from this.
• 41:55
  SPEAKER_00: If you did, then send me a message.
• 41:57
  SPEAKER_00: I'd love to hear, whether it's sending me on Instagram, Ravi Patel DPT.
• 42:03
  SPEAKER_00: Um, you can send me an email, uh, you can send me snail mail, pigeon, you know, mail in in the air, writing me a letter.
• 42:12
  SPEAKER_00: Whatever it is, I'd love to hear from you.
• 42:14
  SPEAKER_00: Last thing before we sign off here, leave us a review, please.
• 42:18
  SPEAKER_00: Like I really took a lot of time to break this down and to make these episodes.
• 42:23
  SPEAKER_00: So hopefully you guys can take some clinical pearls away from this, being able to understand a little bit deeper about your process and maybe what you went through or what your ACLers are going through.
• 42:35
  SPEAKER_00: And for us to be able to just more importantly reach more and more ACLers.
• 42:39
  SPEAKER_00: That's all that I care about to be able to redefine how we do rehab in this space, how we educate others.
• 42:46
  SPEAKER_00: And so you feel empowered in this process, whether you are the one who is guiding someone in this or whether you are the ACLer yourself.
• 42:54
  SPEAKER_00: So please head to Spotify.
• 42:56
  SPEAKER_00: It takes like one second to Apple Podcasts to be able to just give us a review.
• 43:02
  SPEAKER_00: That means the world to me, to the team, and to this podcast.
• 43:07
  SPEAKER_00: And that is it.
• 43:08
  SPEAKER_00: And I will catch you guys next time.
• 43:10
  SPEAKER_00: This is your host, Robbie Patel, signing off.