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299 | More Than Exercises: Inside Our Team Meetings at The ACL Athlete · The ACL Athlete Podcast

• 0:18
  SPEAKER_00: Welcome everyone to the ACL Athlete Podcast.
• 0:22
  SPEAKER_00: This is the podcast where we talk about everything related to the ACL, whether that's the injury itself, the rehab process, return to sport, and more.
• 0:31
  SPEAKER_00: I'm your host, Dr.
• 0:32
  SPEAKER_00: Robbie Patel, performance physical therapist and coach.
• 0:36
  SPEAKER_00: Between myself and fellow guests and experts, you'll learn through the lens of the patient, the healthcare professional, and the coach.
• 0:43
  SPEAKER_00: The goal of this podcast is to equip you, the athlete, with the education to make the best informed decision about your care and your ACL journey.
• 0:54
  SPEAKER_00: Thanks for joining.
• 0:55
  SPEAKER_00: Now let's dive into today's episode.
• 1:00
  SPEAKER_00: An ACLr is 11 months out, her strength is up, her symmetry is up, and her knee still hurts, still swells, and still doesn't feel right.
• 1:13
  SPEAKER_00: That was one of the cases on the table in the recent team and coaches meeting.
• 1:19
  SPEAKER_00: Today I'm taking you inside that meeting.
• 1:22
  SPEAKER_00: Welcome back to the ACL Athlete Podcast.
• 1:25
  SPEAKER_00: I'm Robbie, the host.
• 1:27
  SPEAKER_00: If you're just joining us, welcome.
• 1:29
  SPEAKER_00: If you are returning, thank you so much for coming back, spending some time with me and with the podcast.
• 1:37
  SPEAKER_00: I hope that you were able to get something out of today's episode, and it's gonna be a little different.
• 1:43
  SPEAKER_00: Most ACLers never see what happens behind the scenes when you hire a physical therapist, a coach, especially when you're delineating between the in-person physical therapist and also a remote physical therapist or a coach.
• 2:00
  SPEAKER_00: And so we use those synonymously within our team.
• 2:03
  SPEAKER_00: A physical therapist is a coach, we are your coach, we're your PTs, we are your physical therapist.
• 2:09
  SPEAKER_00: And so that is something that we want to take you behind the scenes.
• 2:13
  SPEAKER_00: And a lot of people picture something like maybe looking at some exercises, writing them down on a list, and then sending them over to somebody.
• 2:23
  SPEAKER_00: And then, you know, you check in on them once a while, and plenty of rehab looks exactly like that.
• 2:29
  SPEAKER_00: You come in for your session, you talk to the PT, you start doing some exercises, maybe some modalities, and then you go through that, they check in, and then you get some exercise, you go home and you rinse repeat, right?
• 2:44
  SPEAKER_00: And it can look very black and white, but the thing is, is that that's not how we run things.
• 2:50
  SPEAKER_00: So today I'm just gonna show you.
• 2:51
  SPEAKER_00: I'm gonna walk through this.
• 2:53
  SPEAKER_00: And I was thinking about this, especially with our team meetings and our coaches' meetings.
• 2:59
  SPEAKER_00: So, for reference, we meet multiple times a week to talk through our rosters, through athletes we're working with, and just overall, as a team and as a company, we're looking at everything.
• 3:14
  SPEAKER_00: And so, this is something that I have just been reflecting on as we have had these meetings and the conversations that we have, and what our team as a whole brings to the table in these conversations, and it's something that there's just so much value, so much value in terms of honestly the humility and the ability to just talk amongst as a group and as a think tank and as a team, and to talk through different cases, to talk through what is going well, what are things that we can improve, what are some roadblocks and challenges, and continue to keep getting better as professionals, as people who are serving ACLers and this population, because it is so important to us.
• 4:03
  SPEAKER_00: And if you're someone who's working with us, I'm sure that that bleeds through with everything that you see, the responses.
• 4:10
  SPEAKER_00: And if you're listening to the podcast, we are about to approach 300 episodes.
• 4:14
  SPEAKER_00: And if you don't know that I care about this at this point, I don't know what to tell you.
• 4:18
  SPEAKER_00: I care so much about this because of how much there is a gap in this process, and it's just the you don't know what you don't know.
• 4:26
  SPEAKER_00: And a lot of times people are blindsided in this process, and it could be even the second or third time, right, that they tear their ACL, go through this process, and it's completely different, but it is just challenging.
• 4:38
  SPEAKER_00: And so the thing is that we want to be able to provide everything we can and more to keep growing, keep getting better.
• 4:47
  SPEAKER_00: And we want to just kind of showcase this, and that's something that's important to me today.
• 4:52
  SPEAKER_00: And I was thinking about this as sports, right?
• 4:55
  SPEAKER_00: You think about any really good team, they're not just running plays, they're not just, you know, randomly operating in silos on game day.
• 5:06
  SPEAKER_00: They go home, they watch film, they review, they sit down together, they look at what happened and ask, you know, what went well, what didn't go well, whose responsibilities are these, you know, who's struggling, what's working, what do we change before the next game?
• 5:24
  SPEAKER_00: Our coaches' meetings are our film sessions in a way for our ACLers and for us as a whole and what we're doing here, including our mentorship.
• 5:33
  SPEAKER_00: We hold multiple every week, as I shared, and we go through our athletes one by one.
• 5:39
  SPEAKER_00: Every single one of them, every single one of our athletes we work through.
• 5:43
  SPEAKER_00: We have a process to review them, to talk through them, and to make sure that we are talking about what it is that they are accomplishing, what are the next milestones, what are the road bumps they're dealing with, what are some of the challenging cases that are just really hard because we just deal with a hard, hard group of people because they're coming to us, you know, maybe further into the process.
• 6:09
  SPEAKER_00: They're six months, 12 months, two and a half years out, you name it.
• 6:14
  SPEAKER_00: Like they spread across the whole span of the spectrum.
• 6:17
  SPEAKER_00: So they're not these fresh pre-op post-op people, although we love that.
• 6:22
  SPEAKER_00: And we would do anything to be able to work with people as early as we can.
• 6:26
  SPEAKER_00: But we are often the ones who are coming in later and having to help these complex cases, or just people who just never got the help that they need and they're still feeling like they're struggling, or they want something on top of what they're already doing because they feel like it's not gonna get them all the way there.
• 6:43
  SPEAKER_00: And here's a quick promise to you guys I'm gonna be honest about the hard parts because this isn't perfect.
• 6:49
  SPEAKER_00: If someone is showcasing the highlight reel and they're like, everyone's successful and they're crushing it, and they are having no hiccups or no problems, they're either not seeing enough ACLs or they're just hiding it.
• 7:03
  SPEAKER_00: They're not really showcasing that.
• 7:04
  SPEAKER_00: And I get that as a company, it is not great to market the hard cases or the challenging ones, or the ones that are not necessarily moving through the best, right?
• 7:16
  SPEAKER_00: But today my goal is to just share with this because we deal with those complicated cases, as I shared.
• 7:23
  SPEAKER_00: We have really hard conversations with athletes, and it could be a number of factors that play into this.
• 7:29
  SPEAKER_00: And sometimes we don't have the answer, and sometimes that is what we have to share.
• 7:35
  SPEAKER_00: And I think that this is very important in healthcare, in what we're dealing with, because it's the human body, there's biology at play, there are definitely things that we can't control because it's also each individual person.
• 7:50
  SPEAKER_00: Some people are in the thick of school with a lot of other variables going on.
• 7:55
  SPEAKER_00: Some people have multiple jobs, some people travel for work, people have kids, young kids, babies, they're pregnant.
• 8:04
  SPEAKER_00: There are so many different factors that play into every single person's context of life, and it can really influence their recovery.
• 8:14
  SPEAKER_00: So these are the things that we're having to work through as well is each individual person's context alongside a very challenging recovery.
• 8:24
  SPEAKER_00: So everything I share today, it's anonymized and blended, so really no one can be identified because I want to be really careful about people's identity here.
• 8:36
  SPEAKER_00: But I'm gonna share situations versus the people.
• 8:40
  SPEAKER_00: So let's just jump into it so you guys can hear a little bit of insight from this.
• 8:45
  SPEAKER_00: And to just share a little bit of how it works.
• 8:48
  SPEAKER_00: We meet multiple times as I shared.
• 8:51
  SPEAKER_00: Each meeting, we go through our ACLers, we update each other on where everyone is along in their spectrum, in their process.
• 8:58
  SPEAKER_00: We ask the same few questions every time of, you know, what is going well with this person?
• 9:04
  SPEAKER_00: What are some things that we're working on?
• 9:07
  SPEAKER_00: Who has a roadblock or who have some next steps that we need to tackle?
• 9:11
  SPEAKER_00: Who's gone quiet?
• 9:12
  SPEAKER_00: Who's maybe kind of pulled back a little bit, right?
• 9:15
  SPEAKER_00: Not everyone is cruising 100% compliance.
• 9:19
  SPEAKER_00: People go through different phases, whether it could be headspace, it could be life, like people get super sick and they're down for the count for a week or two.
• 9:27
  SPEAKER_00: People travel.
• 9:28
  SPEAKER_00: You think that these youth athletes have all the time in the summer with no school?
• 9:32
  SPEAKER_00: No, they're busy, they're traveling, they're doing things too.
• 9:35
  SPEAKER_00: So there's a lot of things that we have to deal with.
• 9:38
  SPEAKER_00: And the other thing, too, is who needs another set of eyes?
• 9:43
  SPEAKER_00: Who needs more opinions?
• 9:44
  SPEAKER_00: And a coach might say, Here's an athlete who flared up after a big weekend, right?
• 9:49
  SPEAKER_00: Or I'm not sure what to say to this athlete about skiing, right?
• 9:54
  SPEAKER_00: Because each context is so different, so it could be really challenging.
• 9:58
  SPEAKER_00: The answer isn't always so obvious, especially when we're dealing with so many different factors and when re-injury is on the table and something they want to do.
• 10:08
  SPEAKER_00: And so we talk through a lot of these athletes, and I would say together as a whole, like our team as a whole have seen thousands of knees.
• 10:18
  SPEAKER_00: Thousands of knees, thousands of ACLs, like we have tackled a lot of ACLs.
• 10:23
  SPEAKER_00: And so, therefore, we're able to have the context of this athlete, the details, their assessments, their numbers, their subjective criteria, and then we are able to talk through this as a whole, as a team, to make sure we're looking at this through all the different lenses, and then also being able to tackle this as best as we can for this particular athlete, especially the ones who have some challenging cases.
• 10:50
  SPEAKER_00: And it's not just talk, every case ends with a next step, and that's what's really important here.
• 10:56
  SPEAKER_00: Whether it's a message getting sent, you know, a call that needs to be followed up, a test that's scheduled, maybe it's a follow-up with a surgeon or another professional, right?
• 11:05
  SPEAKER_00: Like we're helping to make sure people get the next step.
• 11:08
  SPEAKER_00: And we're also talking to the athletes who might have gone quiet a little bit.
• 11:13
  SPEAKER_00: But that's the whole point of this is to make sure everyone has accountability and that they know what that next step is and where they are.
• 11:21
  SPEAKER_00: So important to us.
• 11:22
  SPEAKER_00: And as I shared earlier, and as you have probably learned from previous episodes, is that we're not the ones who just get handed the easy cases.
• 11:34
  SPEAKER_00: We don't always get the ACL or day one.
• 11:37
  SPEAKER_00: When we do, as I shared, we love it, but we build the plan from where they are, right?
• 11:42
  SPEAKER_00: And so people find us all along the spectrum from you know pre-surgery to non-operative to a few months out to years and years out.
• 11:54
  SPEAKER_00: And usually after being handed, you know, some sort of timeline that they were told, but it didn't work out, right?
• 12:03
  SPEAKER_00: They're told nine to twelve months, and yeah, that's a rough proxy, but again, people are gonna vary so much and they should be continued to be updated along in the process.
• 12:13
  SPEAKER_00: So they have a more complicated surgery or history, a rehab history, lingering symptoms, or it's MRIs that don't necessarily get ordered, or some things get missed.
• 12:26
  SPEAKER_00: And if I asked our coaches to rate the complexity of our roster from zero to ten, I think we would say a probably solid, oh man, probably nine out of ten, eight, nine out of ten on average.
• 12:42
  SPEAKER_00: And that's a team stat, of course, or an opinion, um, more so my opinion, they may rate it a little differently.
• 12:49
  SPEAKER_00: But I would say that we are in that high complexity range, and if we can get the straightforward ones, we love it.
• 12:58
  SPEAKER_00: But again, this is the thing that we open our arms to because we're the ones who are like we take it as a challenge, and we want to be able to help this person because a lot of times this is someone who has also seen multiple providers, people have just kind of written it off or did been dismissive, and it's something that we also want to make sure that someone has the next steps, especially if they're feeling lost.
• 13:22
  SPEAKER_00: We think that there is something to do with every single case that we can control.
• 13:28
  SPEAKER_00: And if not, we're gonna get you into the right hands and make sure we take a next step to get you back and to be able to take those right steps.
• 13:37
  SPEAKER_00: And so I'm not saying all this for you to feel sorry for us.
• 13:40
  SPEAKER_00: I really don't.
• 13:41
  SPEAKER_00: It's because we really do enjoy what we do here, and so complicated is what we tend to spend our time on.
• 13:49
  SPEAKER_00: But again, we have also some of those that are going through this process that they don't have the complexities, they just have the pure, you know, ACL, they're three months out and their insurance ran out, or they're just feeling lost.
• 14:02
  SPEAKER_00: And so that's the thing that is beautiful about this process and the people we work with is that it is a spectrum, and we are excited to work with anyone who wants to work with us.
• 14:16
  SPEAKER_00: And the point I'm trying to bring up here is that I do believe it's important that your PT and who you're working with is continuing to grow, that they have a sounding board and a team.
• 14:29
  SPEAKER_00: And I think it's also important to be able to continue to keep getting better each and every week, not just piling on volume without the ability to meet and to get better clinically and as a professional and personally, but this is so important for us to keep growing because these are going to dictate our outcomes for our athletes.
• 14:49
  SPEAKER_00: And it's the same if you're a clinician or coach listening to this, is that I hope what we provide today is that you're able to take some of this stuff and carry it on with you for the athletes you work with, and also find those people you can talk to, whether it's mentorship or something local at your clinic or a group, if you will, to be able to continue to keep growing because that's how we're gonna continue to change this for the better.
• 15:14
  SPEAKER_00: And so let me walk you through one case that stuck with me.
• 15:17
  SPEAKER_00: Picture an ACLR about a year and a half out.
• 15:20
  SPEAKER_00: Skiing isn't just a hobby for her, it's a part of her work, her identity.
• 15:25
  SPEAKER_00: She has a big demanding winter course coming up that's gonna be involved with skiing.
• 15:30
  SPEAKER_00: It's an intensive for a week, and she has to commit within a week or two.
• 15:34
  SPEAKER_00: So this is in October.
• 15:36
  SPEAKER_00: She hasn't skied yet.
• 15:38
  SPEAKER_00: She wants to know one thing.
• 15:40
  SPEAKER_00: Am I good to ski?
• 15:41
  SPEAKER_00: And this has been a really hard case, y'all.
• 15:44
  SPEAKER_00: It's not been straightforward, it's been something that has ups and downs, and there's some personal things connected to this, as well as just, you know, this isn't the first ACL in knee that she has been dealing with.
• 15:55
  SPEAKER_00: But let me give you some numbers.
• 15:57
  SPEAKER_00: So at 60 degrees, when her knee was tested isometrically, her quad strength was 95% in symmetry.
• 16:03
  SPEAKER_00: Awesome.
• 16:03
  SPEAKER_00: At 90 degrees, it was 65%.
• 16:06
  SPEAKER_00: So we just brought that angle down a little bit.
• 16:09
  SPEAKER_00: Her five rep max on the knee extension was around 80%.
• 16:12
  SPEAKER_00: So we tried to test out some proxies here, and that was limited more by the discomfort than it was by strength.
• 16:18
  SPEAKER_00: So we're gathering multitudes of information to be able to understand this.
• 16:23
  SPEAKER_00: Her single leg drop jump was 97% symmetry, so hop testing from a vertical jump testing, which has equal contribution of the knee, hip, and ankle versus horizontal hop testing.
• 16:35
  SPEAKER_00: It looked good.
• 16:36
  SPEAKER_00: So that's great to be able to see the symmetry in that.
• 16:38
  SPEAKER_00: And even from a qualitative perspective, the jumping looked great.
• 16:43
  SPEAKER_00: Now, her ACL RSI, which measures confidence and readiness, it is a questionnaire that we give to all our athletes at certain time intervals that has a strong relationship between re-injury and confidence returning to sport.
• 16:58
  SPEAKER_00: And this is something that we assess with every athlete.
• 17:01
  SPEAKER_00: It was in the 50s earlier this year.
• 17:04
  SPEAKER_00: The last two checks, it was in the 30s.
• 17:06
  SPEAKER_00: It decreased.
• 17:07
  SPEAKER_00: So strength is going up, confidence is going down.
• 17:12
  SPEAKER_00: Those two are typically going together, they are correlated positively, typically, and they weren't in this case.
• 17:25
  SPEAKER_00: So, number one is testing where that demand lives.
• 17:30
  SPEAKER_00: So skiing at speed means getting into that 90 degree position and you know recovering when you land in that back seat or when you're really sitting back, especially if you're going down some really difficult terrain that is very vertical in nature, you're gonna have to sit back a lot to counteract those forces.
• 17:49
  SPEAKER_00: So looking great at 60 degrees doesn't necessarily cover that because you're gonna be in deeper ranges when you're trying to hit those positions.
• 17:56
  SPEAKER_00: In our experience with a quad tendon graft, it takes longer to catch up in those deeper ranges, and that is very consistent.
• 18:04
  SPEAKER_00: And people will report discomfort in the donor site or just weakness.
• 18:08
  SPEAKER_00: And we told her that's common.
• 18:10
  SPEAKER_00: And while we would hope for this to be in a better place at a year plus, it's not always the case.
• 18:16
  SPEAKER_00: And again, there are things that you can work on to be able to help with this, and then there's some things that are just biological, and it's the choose your own adventure.
• 18:24
  SPEAKER_00: You're not gonna pick any graph where you're not gonna have any downside to it outside of, you know, even an allo graph where it's cadaver, there can be some downsides to it.
• 18:33
  SPEAKER_00: So, with that said, everyone has its pros and cons, and there's no perfect one out there, and some people have more residual issues, and it's because we have structurally changed things and we have borrowed from something else, so we're not expecting that thing to necessarily return to 100%, or it might take longer, or some people have residual issues after.
• 18:54
  SPEAKER_00: So that's something really important to be able to share.
• 18:57
  SPEAKER_00: Number two is not handing her, you know, a final decision here.
• 19:01
  SPEAKER_00: If a coach tells a frustrated athlete you're not ready, she may just stop listening.
• 19:06
  SPEAKER_00: So we ask, how do you feel about skiing?
• 19:10
  SPEAKER_00: What would you need to feel ready?
• 19:12
  SPEAKER_00: Where would you rate yourself zero to 100%?
• 19:14
  SPEAKER_00: It's really important for us to ask questions to help them understand and feel where they are, especially from the psychological side, but then also see how they feel physically.
• 19:24
  SPEAKER_00: And we're starting to connect those testing pieces that we do along with some of the things they fill out, like the questionnaire, but then also answering these questions and seeing what they say, right?
• 19:35
  SPEAKER_00: So we have to be very, very careful because of this journey, because of the emotional roller coaster and the whiplash that it can create.
• 19:47
  SPEAKER_00: You have high highs and you have low lows, and it's hard to stay in the middle.
• 19:50
  SPEAKER_00: And if you're at three months versus six months versus you know, 12 plus months like this athlete, it makes it hard, y'all.
• 19:57
  SPEAKER_00: And it's not just gonna be easy to be like, okay, well, just keep working at it, celebrate the small wins.
• 20:03
  SPEAKER_00: You do that, but again, this thing that is so important to her has a time cost to it.
• 20:08
  SPEAKER_00: And so a decision has to be made without knowing all the full details.
• 20:13
  SPEAKER_00: So that is really important.
• 20:14
  SPEAKER_00: We have to navigate a lot of emotional pieces in this process and to take that into context to make sure that we don't make a decision just because this is exactly what we think, but more so taking into consideration that context to be able to relay this to the athlete the proper way and understanding the gray that exists in these decisions.
• 20:37
  SPEAKER_00: It's not black and white all the time.
• 20:40
  SPEAKER_00: Number three is let her say that risk out loud.
• 20:43
  SPEAKER_00: That was something that we processed through together.
• 20:45
  SPEAKER_00: We're like, let her be the one to say that.
• 20:48
  SPEAKER_00: Instead of us saying, like, hey, this risk is, you know, you have a higher risk of a reinjury.
• 20:53
  SPEAKER_00: This is not a good idea because of these positions.
• 20:55
  SPEAKER_00: Let's see if we can have the athlete be the person who comes around to this conclusion, but maybe they won't, right?
• 21:04
  SPEAKER_00: But if she gets the answer herself, she owns it, right?
• 21:07
  SPEAKER_00: That's her saying these things.
• 21:09
  SPEAKER_00: If we say it, then it might shut her down.
• 21:12
  SPEAKER_00: If we're like, hey, you're gonna re-injure, or you know, this is not a good idea because of this, it might be challenging.
• 21:20
  SPEAKER_00: And that doesn't necessarily mean that we don't do this in other conversations.
• 21:23
  SPEAKER_00: It was the context of this particular athlete that we had to navigate more carefully.
• 21:29
  SPEAKER_00: And then number four is, you know, considering the context, she was someone who wanted real input in her programming.
• 21:37
  SPEAKER_00: So we build her ideas into what she wants to do, right?
• 21:41
  SPEAKER_00: And we're overall still guiding and steering and providing the GPS, but we're still building in ideas that allows her to have some autonomy with it, let her have choices, let her have influence on it because it's still moving the needle in the things we want to do.
• 21:57
  SPEAKER_00: And then the last one I'll mention here is number five.
• 22:00
  SPEAKER_00: Is using stories.
• 22:01
  SPEAKER_00: Stories are so powerful.
• 22:03
  SPEAKER_00: Storytelling is so powerful.
• 22:05
  SPEAKER_00: And it's sharing stories of skiers that we have worked with and currently work with who didn't necessarily trust their knee until they maybe got on the powder, on the snow, and were able to start getting their feet wet a little bit and being able to get into the groove with things, right?
• 22:23
  SPEAKER_00: And I want to share where it landed.
• 22:27
  SPEAKER_00: We don't want to hand out a green light when there are still real deficits, and that's really important.
• 22:33
  SPEAKER_00: But we're also aware that she might still go either way.
• 22:37
  SPEAKER_00: So the plan is just a clear map.
• 22:40
  SPEAKER_00: Two months of focus work on tolerance into deeper positions and an honest conversation about the risk she'd be accepting if she skis.
• 22:49
  SPEAKER_00: And this is one that it's very important for her to be able to talk about this more so than us just blurting out all these potential negative consequences if she were to do it.
• 23:02
  SPEAKER_00: We're not here to necessarily throw a bunch of negativity on it.
• 23:06
  SPEAKER_00: We're here to be able to highlight some of these things.
• 23:09
  SPEAKER_00: And at the end of the day, everyone can make their own choice.
• 23:12
  SPEAKER_00: We could say, hey, it's bad for this youth athlete to go back to play sport in six months, but they could say, I want to do it, and their parents are on board, right?
• 23:20
  SPEAKER_00: And at the end of the day, we are not the ones that can say, no, you cannot.
• 23:24
  SPEAKER_00: They have the ultimate decision.
• 23:26
  SPEAKER_00: And we are the ones who are making the advice.
• 23:30
  SPEAKER_00: We are the ones who are guiding and helping to make the best calculated decisions based on what we know about the research, about the data, about the testing, about the science, and about what re-injury is and also what performance is.
• 23:44
  SPEAKER_00: And we're taking all these things into context of this athlete, their short-term goals, but especially long-term goals and their health.
• 23:52
  SPEAKER_00: And so we can make a recommendation, but then therefore every athlete still has their own ability to make that decision.
• 24:02
  SPEAKER_00: And it might be high risk, but it's something that is important to them and they've weighed those.
• 24:07
  SPEAKER_00: That's the important thing here.
• 24:09
  SPEAKER_00: And that's some of the things that we talk about so much in decision making.
• 24:12
  SPEAKER_00: If someone is living in this gray of, you know, there's this one event coming up or this final season, and you know, they're not necessarily hitting all the perfect metrics, but they're kind of in the gray.
• 24:25
  SPEAKER_00: They're not necessarily 90% symmetry plus, they are 82%.
• 24:31
  SPEAKER_00: They still kind of look a little off side to side when they shift with the symmetries.
• 24:37
  SPEAKER_00: There are some other aspects that we kind of factor into this, so it's not always a clear black and white.
• 24:43
  SPEAKER_00: So we have these conversations and we have to understand the context of each athlete.
• 24:48
  SPEAKER_00: But she is the one who makes the full call with that information.
• 24:51
  SPEAKER_00: It's not our job, not to decide for her and not also to leave her guessing.
• 24:56
  SPEAKER_00: Like she needs to know all the information and lead with the objectives, but then also being able to help in making the best decision for herself.
• 25:06
  SPEAKER_00: Here's the second case, and it's a tough one.
• 25:09
  SPEAKER_00: This is the athlete that I mentioned from the start of the podcast.
• 25:12
  SPEAKER_00: ACL are 11 months out from a partial ACL tear.
• 25:15
  SPEAKER_00: Her strength testing is in the 80s and her symmetry has gotten better.
• 25:19
  SPEAKER_00: But her pain, her swelling, and her heel pop haven't changed.
• 25:23
  SPEAKER_00: She feels strong, she's happy about that, but it's not touching what is bothering her the most.
• 25:28
  SPEAKER_00: Her MRI shows a partial tear and a few other findings, including a possible cyclops type lesion, no giving way, no instability.
• 25:38
  SPEAKER_00: And it's fair she's annoyed by this.
• 25:43
  SPEAKER_00: When the strength climbs and symptoms don't move, we have to say out loud that rehab alone may not always be the answer.
• 25:51
  SPEAKER_00: And that's hard to say.
• 25:53
  SPEAKER_00: But part of our job is knowing what we can't fix.
• 25:56
  SPEAKER_00: As much as we know what we can fix, we need to know what we cannot fix.
• 26:01
  SPEAKER_00: A cyclops lesion, we can't.
• 26:03
  SPEAKER_00: A cartilage issue?
• 26:04
  SPEAKER_00: Nope.
• 26:05
  SPEAKER_00: And similar findings don't get solved with just doing more reps or exercises.
• 26:11
  SPEAKER_00: The biggest thing that I have shared with you is pattern recognition and spotting them early and getting an ACLer to the right care is valuable.
• 26:20
  SPEAKER_00: So valuable.
• 26:21
  SPEAKER_00: One of our coaches had a strong hunch about what was going on, and we chose not to say it to her.
• 26:27
  SPEAKER_00: If you plant a diagnosis in someone's head before there's evidence, it changes how they hear the surgeon.
• 26:33
  SPEAKER_00: So we hold the hunch and we help her walk in it with a good question and a series of questions to make sure she is equipped to tackle that conversation.
• 26:45
  SPEAKER_00: We also prep for the possibility that the answer is nothing to operate on.
• 26:50
  SPEAKER_00: That's a harder thing to hear.
• 26:52
  SPEAKER_00: So we plan for it ahead of time.
• 26:53
  SPEAKER_00: But it's important to talk through these things.
• 26:56
  SPEAKER_00: And here's something else we see a lot.
• 26:58
  SPEAKER_00: Many ACLers still carry a nine to 12 month timeline in their head because that's what they were told.
• 27:04
  SPEAKER_00: When the year arrives and they're not where they expected, it can feel like rock bottom.
• 27:10
  SPEAKER_00: And it's not necessarily a failure.
• 27:12
  SPEAKER_00: And I think that's really important to share here.
• 27:14
  SPEAKER_00: That's an ACLer who was potentially handed the wrong map, if you will, not necessarily the perfect guidance in this, not necessarily something that she could biologically control.
• 27:27
  SPEAKER_00: But we're able to pick up and be able to take it week by week, no rush on big decisions, but we look for a winnable moment in the next few weeks and build on it.
• 27:37
  SPEAKER_00: It's huge here.
• 27:38
  SPEAKER_00: And as a team, we see a lot of variety, different graph types.
• 27:42
  SPEAKER_00: We have every single graph type on our roster and multiple procedures, surgeons, protocols, different time points entering, non-operative as well.
• 27:51
  SPEAKER_00: We have some that are non-ACL as well.
• 27:54
  SPEAKER_00: Like some people come to us for other knee conditions that we deal with in surgeries.
• 27:59
  SPEAKER_00: Some of our pattern recognition came from early cases that didn't add up.
• 28:04
  SPEAKER_00: That's really important here.
• 28:05
  SPEAKER_00: And especially from my own mistakes, I have learned so much from unfortunately the early cases that I might not have caught.
• 28:14
  SPEAKER_00: And now, because of repetitions and because of these conversations and seeing patterns and seeing the way that testing goes and what people report, we can almost be able to pull some of this stuff even from just a single conversation of what they're explaining.
• 28:30
  SPEAKER_00: And there's an athlete we just had start with us that was like, I knew within my gut what was happening.
• 28:37
  SPEAKER_00: I did not share this, but it is something that I could just hear her share exactly what was happening and just her description of her past history and what she was feeling.
• 28:47
  SPEAKER_00: And it was something that I was like, okay, I think this is what's going on.
• 28:51
  SPEAKER_00: But I wanted to reinforce that with testing and some data before we were able to share that.
• 28:58
  SPEAKER_00: But we were able to recognize these patterns, especially the things that don't add up.
• 29:03
  SPEAKER_00: And now we talk those patterns through as a team every single week and we catch them faster and faster and faster.
• 29:10
  SPEAKER_00: And we have a process of here is what we need to do next in order to get this athlete the quickest and best solution.
• 29:17
  SPEAKER_00: Now let me shift gears to something lighter, but just as important.
• 29:20
  SPEAKER_00: One of our coaches shared a conversation with a high-level athlete.
• 29:23
  SPEAKER_00: She had a heavy sports schedule outside of her knee work, and she was drained.
• 29:29
  SPEAKER_00: Her coach ended up just cutting down her ACL rehab and training from three days a week to two with the quad as the priority and dropped the work that didn't necessarily matter right now.
• 29:40
  SPEAKER_00: It was almost like secondary work.
• 29:42
  SPEAKER_00: It wasn't the high priority stuff.
• 29:44
  SPEAKER_00: There was relief on her hand, and it was very obvious, and she shared that with us.
• 29:50
  SPEAKER_00: A perfect program on paper fails if the athlete is overloaded or potentially underfueled.
• 29:57
  SPEAKER_00: It's not normal to feel run down every day and miss your numbers, and we don't normalize that.
• 30:04
  SPEAKER_00: We start with less.
• 30:05
  SPEAKER_00: It's far easier to add a session than to backtrack after giving someone too much.
• 30:11
  SPEAKER_00: We use our 80-20 rule as well.
• 30:14
  SPEAKER_00: If you cut 80% of the plan, what is the 20% that you would keep?
• 30:19
  SPEAKER_00: Maybe three or four really well-chosen exercises and movements often will get hit harder.
• 30:26
  SPEAKER_00: You'll get more intent behind it.
• 30:28
  SPEAKER_00: Imagine you're looking at a workout and you have three or four exercises on it versus maybe a list of 10, right?
• 30:34
  SPEAKER_00: That could take over an hour.
• 30:37
  SPEAKER_00: And you explain the why.
• 30:40
  SPEAKER_00: When an athlete understands the reason behind two shorter sessions, they buy into it, they understand.
• 30:46
  SPEAKER_00: We're able to explain the science behind it that you're still not going to lose out if you just reduce the amount of sessions you have because we're still going to be looking at the proper volume and sets to failure and fatigue that we're going to be able to still get the stimulus we need.
• 31:02
  SPEAKER_00: That's explaining the why pulling the science into this and the research to understand what it is that's still going to move the needle.
• 31:08
  SPEAKER_00: And that's so, so crucial because we have so many ways to adapt this.
• 31:15
  SPEAKER_00: And this is how physical therapy should be.
• 31:18
  SPEAKER_00: This is how rehab should be.
• 31:20
  SPEAKER_00: Anything can be adapted to meet you where you are, whether it's the context of your life and the season of life you're in, whether it's some changes, there's some travel, sickness, you know, time constraints, work, school, whatever it may be, that could change.
• 31:37
  SPEAKER_00: Or maybe you have other active things you're doing.
• 31:40
  SPEAKER_00: And so we're trying to figure out how do we condense it down to make sure it's still moving the needle for what we need while you're still able to do all these other things.
• 31:51
  SPEAKER_00: And so it's important for us to be able to break that down and explain the why.
• 31:55
  SPEAKER_00: And when we do, we see that our athletes lean in a bit more.
• 31:59
  SPEAKER_00: One of our coaches put it best people don't always want more.
• 32:04
  SPEAKER_00: Sometimes they're waiting for us to tell them they need less.
• 32:09
  SPEAKER_00: I'm gonna say that again because it was such a good quote.
• 32:12
  SPEAKER_00: People don't always want more.
• 32:14
  SPEAKER_00: Sometimes they're waiting for us to tell them they need less.
• 32:20
  SPEAKER_00: They just think that they need to keep grinding and keep going.
• 32:23
  SPEAKER_00: But in reality, this is where that principle less is more, or addition by subtraction really shines, and it's something that can really help some folks.
• 32:35
  SPEAKER_00: And then a quick one here, we had an ACLer who has been with us for a while, and she's been crushing it and more in this resilience phase, and she had a quick flare-up, and she had a pretty stacked week and a day.
• 32:50
  SPEAKER_00: She ran with her kids, tennis, had a workout that night, and the knee flared up.
• 32:55
  SPEAKER_00: And so this was something that we had to make some adjustments for.
• 32:58
  SPEAKER_00: It wasn't just all right, let's wait it out and see.
• 33:01
  SPEAKER_00: It was something to make some higher touch adjustments with what she was doing, some strategies to work around this.
• 33:08
  SPEAKER_00: And instead of waiting a week or two to hopefully get it to calm down, we continue to keep things moving but making adaptations to it.
• 33:18
  SPEAKER_00: And so these are just small little flare-ups that happen along the way because guess what?
• 33:22
  SPEAKER_00: They're pushing their knee, they're trying to stress the knee.
• 33:24
  SPEAKER_00: And this is something that we want to keep the person moving forward, but also not try to make the problem more and more or make it louder and louder, right?
• 33:35
  SPEAKER_00: We want to try and get this thing calmed down so they can keep carrying on through this process and keep building.
• 33:41
  SPEAKER_00: And so this is something that we do navigate a lot with just flare-ups through this process, and people sometimes sneak in more work than we are sharing with them, or sometimes it can be overloaded for a number of reasons, or it could just happen for no reason.
• 33:56
  SPEAKER_00: The biggest thing is to have a plan adapt quickly and adjust, so then that way it's a quick detour versus being this long, drawn-out detour that was so unnecessary.
• 34:08
  SPEAKER_00: And so I want to end the case discussion with the honest part about the meeting.
• 34:14
  SPEAKER_00: Some ACLers don't get the clean ending, some leave with symptoms unresolved, some drift away, and a few stay a mystery even after our team has spent real time on them.
• 36:33
  SPEAKER_00: We control the controllables.
• 36:36
  SPEAKER_00: That's something that's so important for us.
• 36:37
  SPEAKER_00: And I'm just being fully transparent here, and I think it's important.
• 36:41
  SPEAKER_00: I don't think that this is shared enough in this space, and I think that you just see the highlight reels.
• 36:47
  SPEAKER_00: So I think this is something that we are always trying to get better and improve, and there's again a number of reasons why things can happen.
• 36:56
  SPEAKER_00: But we control the controllables, the athlete controls the controllables as much as they can.
• 37:01
  SPEAKER_00: We give people a clear picture of where they are and what is the next step.
• 37:05
  SPEAKER_00: Scar tissue, maybe cartilage-based things, biology are outside of anyone's control.
• 37:11
  SPEAKER_00: Maybe it's a hardware issue, maybe there are some systemic things that are going on, autoimmune things.
• 37:19
  SPEAKER_00: There are not just these ACL rehab processes that are happening in isolation.
• 37:24
  SPEAKER_00: They're happening along with a body that is continuing along with someone who has a life, who has either school or an occupation or other things that they are doing.
• 37:34
  SPEAKER_00: So it doesn't live in a vacuum.
• 37:37
  SPEAKER_00: And so we are always going to measure against reality, not necessarily perfection.
• 37:42
  SPEAKER_00: Return to sport and the research is far from 100% for everyone.
• 37:47
  SPEAKER_00: If you chase a perfect record in this, you will feel not great about any of the good work that you do, to be honest.
• 37:54
  SPEAKER_00: You have to stay in the middle with this.
• 37:56
  SPEAKER_00: And so we zoom out.
• 37:58
  SPEAKER_00: When a coach looks at their whole caseload, most athletes are progressing well.
• 38:01
  SPEAKER_00: And that's what's important to us.
• 38:04
  SPEAKER_00: The one or two hard cases stand out because they're hard.
• 38:07
  SPEAKER_00: They just, they're just hard.
• 38:09
  SPEAKER_00: When you've got the ACLer who's torn their ACL for the third time, their knee is stiff, they have had the hardest craft, and they have multiple procedures.
• 38:18
  SPEAKER_00: They have a quad tendon, they have a LET, they had a meniscus repair, they were locked in a brace for six weeks, non-weight bearing.
• 38:27
  SPEAKER_00: That's a hard recovery, y'all.
• 38:28
  SPEAKER_00: That is really, really hard.
• 38:30
  SPEAKER_00: And so the thing is that those cases can stand out, especially when we don't necessarily get to start with them from day one.
• 38:38
  SPEAKER_00: We might be starting with them month six or month 12, even, or month 18.
• 38:43
  SPEAKER_00: And so these are the things that we have to take into stride and we have to understand the question isn't, did I fix them?
• 38:50
  SPEAKER_00: And that's something important for us as a team and as a physical therapist and coach.
• 38:54
  SPEAKER_00: Did I fix them?
• 38:56
  SPEAKER_00: For us, it's did I leave this person better off and equipped to handle more as they, you know, progress on their own, whether that's graduation or they finish up, and there could be a number of reasons why.
• 39:07
  SPEAKER_00: But an athlete who ended up needing more care elsewhere told us it was a relief to know he'd done everything right in rehab.
• 39:16
  SPEAKER_00: He didn't have to wonder anymore if poor rehab was the reason, and that was a real outcome in this.
• 39:21
  SPEAKER_00: And this was someone who needed more surgical insight and a very, very nuanced case that is very challenging.
• 39:29
  SPEAKER_00: And so, this is something that we wanted to make sure that as he continued, that he was seeking out those opinions to be able to get this fixed, along with other things going on in his life.
• 39:41
  SPEAKER_00: And so, for my PTs, clinicians that are listening, coaches, early in my career, I felt personally responsible for saving people.
• 39:52
  SPEAKER_00: I really did.
• 39:53
  SPEAKER_00: If someone didn't get back, I felt like it was my fault.
• 39:57
  SPEAKER_00: I took it personal.
• 39:58
  SPEAKER_00: There are so many variables in these ACLers' lives and in your lives as you guys are listening that we can't touch.
• 40:07
  SPEAKER_00: No matter how good the plan is, no matter how good the exercise prescription, no matter how good the accountability, the communication, the testing, all those things.
• 40:17
  SPEAKER_00: There's so many variables, y'all.
• 40:20
  SPEAKER_00: We're here to help, we're not here to rescue.
• 40:23
  SPEAKER_00: We're here to be the GPS, we are not here to drive the car.
• 40:26
  SPEAKER_00: And that's the thing that is so important.
• 40:29
  SPEAKER_00: And so the ACLers who meet us there, so important, and they're the ones who get there.
• 40:35
  SPEAKER_00: But it's very important to have this team-based approach to make sure that you're able to be guided, you feel like it could be individualized to you, you feel like you're able to be assessed and you feel like you're supported in this, and that you're able to also meet halfway with that.
• 40:50
  SPEAKER_00: And there are also those cases that are challenging where both sides are doing everything they can and the progress is slow, or it just kind of feels like a roller coaster and it's up and down, right?
• 41:00
  SPEAKER_00: And I think that that's just something very important to understand in this rehab process, is that that can be the reality for some people.
• 41:09
  SPEAKER_00: And so it is just a longer game process to get there.
• 41:13
  SPEAKER_00: But as I had shared to this day, there's still not a case, I believe, that we have had to say, you're at the end of the road, this is it.
• 41:21
  SPEAKER_00: There's always something more that can be done.
• 41:24
  SPEAKER_00: And again, it is always got to be something that has to be considered with the person, their life, the timing, and everything, because someone might need a second surgery, but they're not in a place because they just had a newborn, or they're taking care of a family member who is not doing well, or they got fired from a job, or you know, they are supporting someone else.
• 41:50
  SPEAKER_00: There are so many other factors in this that the context will dictate so much of this and the variables in this.
• 42:00
  SPEAKER_00: So it's not a failure when the variables outside our control win.
• 42:04
  SPEAKER_00: As long as we did our due diligence, that is what is so important to me.
• 42:08
  SPEAKER_00: And as a team, we talk about this because we are always trying to reflect on as much of what we could do better every single week.
• 42:20
  SPEAKER_00: And there's always stuff we can get better at, always, and that will never end.
• 42:24
  SPEAKER_00: We will never reach a defined point where we have made it.
• 42:28
  SPEAKER_00: We are always trying to grow and get better, and this is something that we just have to understand, especially as we come become more and more seasoned as clinicians and coaches, that it is this ongoing complex system that we're working with the human body, a human being, and a very complicated process that has a high reinjury rate and very poor health care and a model that is surrounding it that is typical that most people go through.
• 42:58
  SPEAKER_00: So then, therefore, we are here to try and fill that gap.
• 43:01
  SPEAKER_00: And so sometimes it's not easy whenever some of these come to our front door and we are trying to work with them because of a number of these factors that I have shared.
• 43:11
  SPEAKER_00: And so, while I am sharing these hard cases, or I say the complex cases, when we zoom out as a team and look at our caseload, and we're like, man, this person came in here and look at where they're at now.
• 43:24
  SPEAKER_00: And it is amazing to see that.
• 43:26
  SPEAKER_00: And it's all because of the work that our team has put in to be able to grow and get better and to be diligent about this process, but also the athletes who lean into this process who are like, I'm drawing a line in the sand here.
• 43:39
  SPEAKER_00: I'm gonna see if I could really lean into this and get the most out of it.
• 43:43
  SPEAKER_00: And I would say 98% of these people do.
• 43:47
  SPEAKER_00: 98% of these people do.
• 43:49
  SPEAKER_00: And I'm saying that with the 2% of the caveat of some of these contexts of these people, but this is the thing that's really important in this process to highlight is that it's not always sunshine and rainbows, but if you really do lean into it, you can get there.
• 44:04
  SPEAKER_00: It might not be as fast as you want, but you can get there.
• 44:07
  SPEAKER_00: And there's always turns that probably come up that you unexpect, but that is something that as long as you have the guide, that is the thing that is going to be key in this process to get you there.
• 44:19
  SPEAKER_00: So let's pull this together.
• 44:21
  SPEAKER_00: What I want you to take away coaching is a team sport.
• 44:24
  SPEAKER_00: Your coach has a backup.
• 44:25
  SPEAKER_00: We talk about every single ACL or every single week.
• 44:28
  SPEAKER_00: That is something important to us.
• 44:30
  SPEAKER_00: Readiness is a conversation, it's not just a number.
• 44:33
  SPEAKER_00: The data tells us where to look, the conversation tells us what we're actually going to do about it.
• 44:38
  SPEAKER_00: Number three, sometimes rehab can't fix the thing.
• 44:42
  SPEAKER_00: Part of our job is knowing that and getting you to the right person who can help with the next step.
• 44:47
  SPEAKER_00: Number four, less is often more, and you're allowed to ask for it as an ACLR.
• 44:55
  SPEAKER_00: Number five, we won't get every outcome perfect.
• 44:59
  SPEAKER_00: But I promise you, we will show up for you and you will know what to do next.
• 45:04
  SPEAKER_00: And you will know what that path is going to look like, and we're going to be there every step of the way.
• 45:10
  SPEAKER_00: And this is exactly how your physical therapist that you're working with, your coach, your team should be.
• 45:16
  SPEAKER_00: It shouldn't be with you left wandering, it should be with someone in your corner ready to tackle it with you.
• 45:22
  SPEAKER_00: And so this is just peeling back the curtain a little bit of our coaches' meeting, of some of the things that we talk through, some of the nuances of these discussions, and what we're trying to continue to get better at and for us to grow as a team and as individuals.
• 45:39
  SPEAKER_00: And also knowing that we are reviewing our athletes, being able to see what is next, what we can do better.
• 45:46
  SPEAKER_00: And I think that this is just such an important part of the process.
• 45:51
  SPEAKER_00: And so that way, what the goal here is for our ACLers to get back to what they want to do faster, better, stronger, without as many road bumps and hiccups in the process to feel seen, heard, to be able to be guided, to have a roadmap, a plan, to be able to be tested objectively, to be able to listen to them and see how that aligns with how they are feeling.
• 46:16
  SPEAKER_00: And that is what this is.
• 46:17
  SPEAKER_00: And to make sure that they can get back to doing the thing, the thing that they want, the thing that they care about.
• 46:23
  SPEAKER_00: And if we do not have that answer, we help them with the next step and get that answer.
• 46:29
  SPEAKER_00: That is what is so key.
• 46:31
  SPEAKER_00: And this is what the standard should be for ACEL rehab.
• 46:34
  SPEAKER_00: So if you're listening to this, this is just to pull back that curtain to share a little bit of insight from some of the things that we talk about, some of the cases we talk about, some of the complexities.
• 46:45
  SPEAKER_00: And there's a whole host more.
• 46:47
  SPEAKER_00: And what I will do is aim to share a little bit more of this for you guys so you can just take away some lessons from it or some things that maybe allow you to be able to move forward in your own process.
• 47:00
  SPEAKER_00: And if you want a team that thinks about your knee this way, if you're looking for someone who is able to take the time and to be able to individualize this and to be able to look at this objectively, but also hear your story and to guide you in this process, we are here to help.
• 47:19
  SPEAKER_00: You can find the information in the show notes.
• 47:21
  SPEAKER_00: We have been having amazing ACLers joining us who are in challenging places, and we are so excited to be a part of the journey with them, whether they are seeing someone in person or whether they are just fully leaning into the remote side.
• 47:34
  SPEAKER_00: But this is something that we do, this is something that we're not going to shy away from, and it's something that I know will help serve more and more ACLers, and so we are here for that.
• 47:46
  SPEAKER_00: And so I appreciate you for getting through this long episode.
• 47:49
  SPEAKER_00: I know it was a little different than usual, but I just wanted to share that it's important to be able to have a team behind you and to support you in this process.
• 48:00
  SPEAKER_00: So that's gonna be it for today.
• 48:03
  SPEAKER_00: Take care of you, yourself, your knee, your rehab, and I will catch you in the next episode.
• 48:10
  SPEAKER_00: This is your host, Robbie Patel, signing off.