Latest / The ACL Athlete Podcast / 156 | The 4 Guiding Principles For Returning to Sport After ACL Injury - Part 1

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156 | The 4 Guiding Principles For Returning to Sport After ACL Injury - Part 1 · The ACL Athlete Podcast

• 0:19
  SPEAKER_00: Welcome everyone to the ACL Athlete Podcast.
• 0:23
  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.
• 0:33
  SPEAKER_00: I'm your host, Dr.
• 0:34
  SPEAKER_00: Ravi Patel, performance physical therapist and coach.
• 0:38
  SPEAKER_00: Between myself and fellow guests and experts, you'll learn through the lens of the patient, the healthcare professional, and the coach.
• 0:46
  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.
• 0:57
  SPEAKER_00: Thanks for joining.
• 0:58
  SPEAKER_00: Now let's dive into today's episode.
• 1:04
  SPEAKER_00: What is up, team?
• 1:06
  SPEAKER_00: Welcome back to another episode on the ACL Athlete Podcast.
• 1:10
  SPEAKER_00: It's a rainy day here in Atlanta.
• 1:13
  SPEAKER_00: Prior to this, it was super cold, like North people cold, which we're not used to here in the South.
• 1:19
  SPEAKER_00: So I'm glad that is over with.
• 1:21
  SPEAKER_00: I have my coffee next to me, and we are talking the four guiding principles for returning to sport after ACL injury.
• 1:30
  SPEAKER_00: Part one.
• 1:31
  SPEAKER_00: So this is something that is just kind of taking a lot of the different pieces that we do in this process and trying to distill it down to four different areas, right?
• 1:42
  SPEAKER_00: And as we approach especially this return to sport, return to performance process, we are looking at certain buckets or principles to make sure that we have done our due diligence to make sure this athlete is prepared and making sure our ACL or can step on the field, court, get on their skis, get on the mat, whatever it is that they are trying to get back to do, that they are fully prepared to be able to do that.
• 2:06
  SPEAKER_00: And so when we break this down into the four guiding principles, we are looking at number one, physical preparation.
• 2:13
  SPEAKER_00: Number two, psychological readiness.
• 2:16
  SPEAKER_00: Number three, graded exposure.
• 2:19
  SPEAKER_00: Number four, load management.
• 2:21
  SPEAKER_00: So we're about to break these different pieces down.
• 2:23
  SPEAKER_00: In part one, here, as we are talking, we're gonna kind of go into the details of this a little bit.
• 2:29
  SPEAKER_00: And then in part two, we're actually gonna talk about all right, cool.
• 2:32
  SPEAKER_00: We we know what these areas are, but how do we objectively measure it?
• 2:36
  SPEAKER_00: How can we assign some sort of number?
• 2:39
  SPEAKER_00: How can we make sure that we are falling in line with where we need to be as we're moving our athletes along in this process, especially in those mid to late stages where there's a lot more moving pieces, it can get a little confusing.
• 2:53
  SPEAKER_00: How do we do that?
• 2:54
  SPEAKER_00: So we're gonna try and break this down very simply in this two-part series.
• 2:59
  SPEAKER_00: So, for number one of these guiding principles, physical preparation.
• 3:05
  SPEAKER_00: And when we think about our main domain as rehab professionals, as strength and conditioning coaches, this is our area, right?
• 3:12
  SPEAKER_00: This is the thing that we are trying to help prepare our athletes for because it's the most we can impact.
• 3:17
  SPEAKER_00: And it's also what we just kind of train and do for, right?
• 3:20
  SPEAKER_00: This is what we went and did our undergrad and our doctorate degrees and our certifications and the internships, all the things.
• 3:27
  SPEAKER_00: These are the things that is the primary focus is physical preparation.
• 3:31
  SPEAKER_00: And so the goal here is for us to make sure that we have the buckets.
• 3:36
  SPEAKER_00: And when I say buckets, these are just kind of different uh qualities or different domains that we are trying to fill up in order to make sure this athlete is as prepared as possible as they move closer and closer towards getting back to the thing.
• 3:50
  SPEAKER_00: When I say getting back to the thing is their goal, it's potentially getting back on the soccer field, it's getting uh back on the mat for wrestling, it is being able to get back on your skis.
• 4:02
  SPEAKER_00: It's your ACLers' goal, it's their dream, it's the thing.
• 4:05
  SPEAKER_00: So that's what I'm referring to when I say the thing.
• 4:08
  SPEAKER_00: Going back to the buckets here, when we look at different buckets, right?
• 4:12
  SPEAKER_00: Now, this isn't comprehensive by any means, but this is kind of based on you and what you assign as physical preparation, right?
• 4:20
  SPEAKER_00: But we do know there are certain domains.
• 4:22
  SPEAKER_00: So, for example, this could be related to their symptom management.
• 4:26
  SPEAKER_00: So, how is their overall symptom profile looking?
• 4:30
  SPEAKER_00: How is their swelling?
• 4:30
  SPEAKER_00: How is their pain?
• 4:31
  SPEAKER_00: How is like things like stiffness feeling, the perception of symptoms, right?
• 4:36
  SPEAKER_00: Like, what is that feeling like and can we manage those?
• 4:39
  SPEAKER_00: So we need to make sure that we are able to knock that out because that could be something that is a big bottleneck in the process.
• 4:46
  SPEAKER_00: So we got to make sure that we are attacking those, especially on the front end and anytime it comes up in the mid to late stages.
• 4:54
  SPEAKER_00: And then as we move along, right?
• 4:57
  SPEAKER_00: Looking at some other buckets, uh, range of motion, functional movements, strength.
• 5:02
  SPEAKER_00: So, you know, specifically quads and hamstrings, those are always the two top priorities, along with other areas, glutes, looking at the calves, um, the core, the lateral hip.
• 5:13
  SPEAKER_00: There's so many different areas that we are aiming for, especially for the lower body and the trunk.
• 5:20
  SPEAKER_00: But when we look at this, we got to make sure, especially quads are number one, hamstrings being number two, right?
• 5:26
  SPEAKER_00: We know that those are the major key players that get weak, especially if we're talking about donor sites that are taken as well.
• 5:33
  SPEAKER_00: But our quads, trying to get those things back up to speed, right?
• 5:36
  SPEAKER_00: So strength is a big bucket to fill.
• 5:38
  SPEAKER_00: And then when we're looking at power, this is something that we want to also make sure that we're improving.
• 5:43
  SPEAKER_00: It's cool if you have a lot of strength, but if you can't recruit that very quickly or be explosive, then that's going to make it very difficult too.
• 5:51
  SPEAKER_00: That's where rate of force development and power comes in, making sure that we are developing the ability to get to that ceiling as quickly as we can.
• 6:00
  SPEAKER_00: And then there's other domains, more dynamic, if you will, talking about running, jumping, cutting, sprinting, the conditioning aspects to make sure that the athlete has the energy systems built up to be prepared for the thing, too, right?
• 6:15
  SPEAKER_00: So these are the physical domains or the physical preparation that we're looking at and qualities we are trying to develop in order to make sure this athlete is getting as prepared as possible to get back to their goal.
• 6:28
  SPEAKER_00: And our goal mainly here is to help ASELers become physically ready to take on the demands of their sport, of their activities, of their goals and life, right?
• 6:39
  SPEAKER_00: Like we want to make sure that they are prepared for worst-case scenarios and making sure that they are equipped for the things that they want to do in life and don't feel fearful or worried something's gonna happen.
• 6:51
  SPEAKER_00: And that leads me to my next point, the guiding principle number two, which is psychological readiness.
• 6:58
  SPEAKER_00: Huge, huge, huge factor in this process.
• 7:01
  SPEAKER_00: One that gets overlooked all the time because there is such a physical component.
• 7:06
  SPEAKER_00: Of course, there's an injury that happens.
• 7:08
  SPEAKER_00: Of course, there is the recovery, the rehab.
• 7:12
  SPEAKER_00: You know, your physical therapist isn't working as much on the mindset pieces or the psychological aspects of this, right?
• 7:19
  SPEAKER_00: It kind of goes along for the ride.
• 7:21
  SPEAKER_00: And this is something that we're not trying to just go crazy over and spend all your time over because some athletes don't need this, but there are plenty of people who need this, right?
• 7:32
  SPEAKER_00: And what I mean by psychological readiness is really just making sure as we continue on in this process that that is aligning with the physical preparation and that is aligning also with getting uh confident to get back to their sport and getting back to the things that they want to do.
• 7:48
  SPEAKER_00: Huge, huge risk factor for re-injury, also huge risk factor for not returning to injury.
• 7:54
  SPEAKER_00: Toll et al.
• 7:56
  SPEAKER_00: in 2021 had shown 28% of people did not return to their sport due to fear of re-injury.
• 8:03
  SPEAKER_00: Now, there's a lot of layers to this, and I guarantee you this number was probably higher, but fear plays a huge role in this, and we got to make sure that this um is not something that athlete is dealing with as they are going back to doing their thing.
• 8:20
  SPEAKER_00: Just know that it's normal.
• 8:22
  SPEAKER_00: It is normal for this to rear its head.
• 8:24
  SPEAKER_00: It's just a matter of making sure that that slowly kind of comes down over time, and then their confidence and that aligns with their physical abilities goes up, right?
• 8:34
  SPEAKER_00: And so this is one of those things where we need to make sure we are communicating with our athletes, making sure that dialogue is open and regularly checking in with your athlete, right?
• 8:45
  SPEAKER_00: With all my athletes, with our team.
• 8:47
  SPEAKER_00: We check in on our athletes every single week, all the time.
• 8:49
  SPEAKER_00: And we're trying to make sure that they are kind of coming along, right?
• 8:53
  SPEAKER_00: And we're not only checking in on like, all right, how is their lifting going?
• 8:57
  SPEAKER_00: How are the numbers looking?
• 8:58
  SPEAKER_00: We're also checking in and seeing, all right, where are they at mentally, right?
• 9:02
  SPEAKER_00: Like, are they doing okay?
• 9:04
  SPEAKER_00: Are they struggling with something?
• 9:06
  SPEAKER_00: Right.
• 9:07
  SPEAKER_00: And these are things where if you have a good relationship with your athlete, they will be open to telling you this.
• 9:13
  SPEAKER_00: And it's crazy how much this brings, you know, the the clinician and the coach to their athlete, you know, into such a good synergy because they feel open to communicate about those things.
• 9:25
  SPEAKER_00: And so this is where we want to make sure that we dial in the psychological readiness, especially as this is getting closer and closer towards the goals of the athlete and making sure that that is in alignment with their physical preparation.
• 9:39
  SPEAKER_00: And we'll talk about some numbers as we get into part two, but this is something that is often overlooked, which is why I want to make sure I bring this up and it's it goes hand in hand really with the physical preparation, right?
• 9:53
  SPEAKER_00: And the thing that I do want to mention here for myself as I walk through this ACL rehab process twice now, this was the thing that took longer than the physical side.
• 10:05
  SPEAKER_00: I was cleared at nine months, but I didn't feel fully confident until 12 months, especially after that first ACL injury.
• 10:13
  SPEAKER_00: And this is something that you might hear some PTs, especially in the ACL world, say, but this is truly not only just from what they might say from hearing their athletes or talking with their athletes, anecdotally for myself, this is also something that feels pretty consistent.
• 10:30
  SPEAKER_00: Getting towards that 12-month mark, especially if things are going along, and you know, you get to that nine, 10-month mark and you are feeling pretty good, you do get cleared.
• 10:41
  SPEAKER_00: Now, again, this is based on what you get cleared by and what is that criteria.
• 10:45
  SPEAKER_00: But with that said, it takes time, and usually that psychological piece is lagging behind the physical piece, and that's okay.
• 10:54
  SPEAKER_00: And this can range from early in the process all the way to late in the process, and you might be listening to this and you're an ACLer and you're like 15 months out, you're two years out, and you're still kind of dealing with this.
• 11:07
  SPEAKER_00: That's totally fine, and it's something that doesn't get talked about super often.
• 11:12
  SPEAKER_00: But look, guys, I've talked to hundreds of ACLers at this point on the phone, consulted with them.
• 11:19
  SPEAKER_00: We've worked with hundreds of ACLers.
• 11:20
  SPEAKER_00: Like, this is the thing where when we get on the phone, the mental side of this is such a huge thing, and it's something that gets overlooked when people are going through this rehab process, it's kind of check in, check out, do the rehab, do the exercises, move along based on time.
• 11:38
  SPEAKER_00: Even when you think about orthopedics, like, not that your orthopedist is supposed to be this psychologist, but you know, that it's silly for us to just like examine a knee and just be like, all right, cool, you're on what you're on your way.
• 11:52
  SPEAKER_00: So I think that there are things that just kind of get missed or kind of get falls through the cracks.
• 11:56
  SPEAKER_00: And I think we can't leave this up to chance.
• 11:59
  SPEAKER_00: And that's why I'm talking about these principles, because if we can iron these out, man, we can set our athletes up for success.
• 12:06
  SPEAKER_00: And so these are two that are super important the physical preparation, psychological readiness.
• 12:12
  SPEAKER_00: And when we look into the next two, we've got graded exposure and load management.
• 12:17
  SPEAKER_00: So graded exposure in a nutshell, this is essentially gradually exposing you to the physical stressors and rehab and the training process.
• 12:27
  SPEAKER_00: But this is also exposing you to your sport and your activity and to life.
• 12:32
  SPEAKER_00: The athlete is trying to get back to, right?
• 12:34
  SPEAKER_00: So we are trying to make sure that the athlete is exposed to those things, um, sure in the gym and in our training.
• 12:40
  SPEAKER_00: But then there's more, if we can kind of think about it as like a funnel, you kind of start from a general standpoint and move more specific towards the thing.
• 12:49
  SPEAKER_00: And so then, therefore, some of the interventions and some of the things that you're doing, mostly from the sport side, will start to get a little bit more specific to the athlete.
• 13:01
  SPEAKER_00: And a lot of that they're getting through their sport, through the practices, through just kind of going through some of the motions of it and then slowly building it back up, right?
• 13:11
  SPEAKER_00: And this also means preparing for the tactical side of things, the technical side of things as well.
• 13:18
  SPEAKER_00: This comes back to working with other stakeholders.
• 13:20
  SPEAKER_00: So this might be the coach for the team, or it might just be you and the athlete because they are either playing a less organized sport.
• 13:28
  SPEAKER_00: Let's say they're in rec sports, they don't necessarily have this team that they can go back to, they're just playing pickup soccer, or maybe it's activities that are a little bit more independent, like skiing.
• 13:39
  SPEAKER_00: Always a good example here.
• 13:41
  SPEAKER_00: You know, you're not kind of depending on other people or needing other bodies around you.
• 13:46
  SPEAKER_00: It's more so of just kind of getting back on your skis and slowly progressing back, right?
• 13:51
  SPEAKER_00: But there's more to it than that.
• 13:53
  SPEAKER_00: But graded exposure allows you to build up your body and your tissues to get prepared for those demands of the thing you're trying to get back to, but also mentally keep things in check and allow you to build that up.
• 14:07
  SPEAKER_00: So those are the ways that we can kind of start to look at this is like, how can we use that dimmer switch analogy, if you will, and be able to gradually expose ourselves back to the thing versus doing this on and off switch and just being like, all right, well, you cleared your return to sport testing.
• 14:25
  SPEAKER_00: Well, now you could just go play soccer.
• 14:27
  SPEAKER_00: And it does not work that way.
• 14:28
  SPEAKER_00: I don't care who says it does, it does not work that way.
• 14:33
  SPEAKER_00: And this is something that I guarantee you, if you had an athlete who passed all the return to sport testing and you threw them into a full-blown soccer match at full speed, they would start to freak out a little bit because they haven't been exposed to it yet.
• 14:46
  SPEAKER_00: So there needs to be this kind of graded return process from participation to sport to performance, which is our continuum we use.
• 14:54
  SPEAKER_00: And it's something that has to be gradually exposed, right?
• 14:59
  SPEAKER_00: And then that leads me into the fourth principle, which is load management.
• 15:04
  SPEAKER_00: So for load management, this all comes back to balancing stress.
• 15:07
  SPEAKER_00: When we think about load, that is stress coming into your system, and we want to make sure that we are balancing that appropriately, especially as you get into the later stages of this process.
• 15:19
  SPEAKER_00: There's a lot more to balance from the rehab side of things, the training side of things, and of course the sport and activity-specific work, right?
• 15:27
  SPEAKER_00: So there's a lot more of those moving pieces.
• 15:30
  SPEAKER_00: So then, therefore, we have to have more of a grip on what that looks like from a stressor standpoint.
• 15:36
  SPEAKER_00: The athletes also tend to be really excited here, right?
• 15:39
  SPEAKER_00: They're not feeling kind of the lag behind of the early process.
• 15:43
  SPEAKER_00: They're feeling more like themselves, they're feeling more physically competent, more mentally competent.
• 15:49
  SPEAKER_00: And so then, therefore, this can also lead to the athlete overdoing it if you're not giving the appropriate constraints and boundaries around this.
• 15:57
  SPEAKER_00: So we want to make sure that we can provide this for our athletes because otherwise, they will come out hot out of the gate, and then that will flare the knee up because it's not used to it.
• 16:07
  SPEAKER_00: So you have to make sure that this is approached very strategically.
• 16:11
  SPEAKER_00: The big thing here with load management.
• 16:14
  SPEAKER_00: So, Tim Gabbett, huge researcher in the space of load.
• 16:18
  SPEAKER_00: And this is really cool, the work that he's done in terms of looking at specific numbers, but the goal here isn't to focus on that and sure there could be some pushback on the range of the specific numbers.
• 16:31
  SPEAKER_00: The idea here is more so the principle or the concept of load management.
• 16:34
  SPEAKER_00: And it's making sure that we remove any big spikes in training and making sure that the athlete is adapting well to the stressors and recovering well, right?
• 16:43
  SPEAKER_00: We want to make sure that the athlete is not underprepared, right?
• 16:47
  SPEAKER_00: We don't want to make sure it's an overuse injury.
• 16:50
  SPEAKER_00: We don't want to make sure that we are preparing the athlete in that sweet spot.
• 16:55
  SPEAKER_00: And a lot of this kind of comes back to load management, especially as we handle the mid and especially the late stages.
• 17:03
  SPEAKER_00: That is going to be such a key factor for our athletes in terms of making sure that as they are getting back on the field, on the court, on their skis, all the different things, even hiking, all the things that we would consider kind of less ACL stressor activities, all those things we still want to make sure that we are managing that load and continuing to move the needle in the right direction.
• 17:29
  SPEAKER_00: So these are things when we are looking at athletes, when we're getting into the return to sport process, especially, we are needing to take a step back and evaluate these four guiding principles.
• 17:41
  SPEAKER_00: And if we can confidently say we've quote unquote checked the box on these, you've got a really well-prepared athlete.
• 17:49
  SPEAKER_00: They are physically prepared, they are psychologically ready, they have had graded exposure to the thing and their load has been managed and their chronic load, the load that has been built up over, let's say four weeks, has been built up to the thing that they're trying to get back to, right?
• 18:06
  SPEAKER_00: And so then therefore, you can kind of look at this and be like, man, this athlete is ready.
• 18:10
  SPEAKER_00: They're ready to rock.
• 18:12
  SPEAKER_00: But the only key in knowing this, though, truly, is to have objective numbers and KPIs, what we call key performance indicators, to back this up.
• 18:21
  SPEAKER_00: If you say you're feeling strong, we got to make sure you have a number associated that is valid and reliable based on the research and science to show that this is something that backs it up, right?
• 18:33
  SPEAKER_00: And this will lead to improved performance and most importantly, reducing that risk of reinjury, right?
• 18:40
  SPEAKER_00: If we can kind of base that on the science research, the data that we know, then therefore we can set our athletes up for success.
• 18:47
  SPEAKER_00: And we got to have objective measures to align with our subjective pieces, the conversations we're having, what we're seeing that doesn't necessarily give us numbers, and making sure that those align together and meet the criteria we need for our athletes, right?
• 19:02
  SPEAKER_00: That's the goal here.
• 19:03
  SPEAKER_00: And so that's the thing that we are going to tackle in part two because we can't leave this up to chance.
• 19:09
  SPEAKER_00: That's the key thing here, right?
• 19:11
  SPEAKER_00: The reinjury rates are too high for ACLers.
• 19:13
  SPEAKER_00: So we got to make sure we do our due diligence and making sure that we align our subjective and objective measures, having key KPIs, right?
• 19:22
  SPEAKER_00: To be able to uh tackle this and to make sure that the athlete is as prepared as possible in all the ways.
• 19:29
  SPEAKER_00: So in part two, we will talk about the objective measures and KPIs that play into managing these four guiding principles so you can make sure it aligns subjectively with what you're hearing and making sure that it also aligns with what you're seeing and you can feel as confident as possible being able to get your athlete back to the thing.
• 19:51
  SPEAKER_00: So, tune in next week for part two where we dive into some of those objective measures.
• 19:56
  SPEAKER_00: Hope you guys have a good rest of your day, week, wherever you are listening to this.
• 20:02
  SPEAKER_00: Appreciate y'all.