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222 | Your Built-In Benchmark: Why the Uninvolved Side Can Be Your ACL Rehab Guide · 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, team, and welcome back to another episode on the ACL Athlete podcast.
• 1:07
  SPEAKER_00: So I've laid pretty heavy into you guys for some long episodes.
• 1:12
  SPEAKER_00: So this one is going to be short and sweet, I promise.
• 1:16
  SPEAKER_00: So I've been doing some thinking with some of my especially fresh post-op ACLers.
• 1:23
  SPEAKER_00: And this is something that I've discussed with them and inherently teach them to do post op.
• 1:29
  SPEAKER_00: And this also might be after someone has an ACL injury, they come in during the prehab process.
• 1:35
  SPEAKER_00: So they've kind of got that feeling of post-injury, or especially when they're post-op.
• 1:40
  SPEAKER_00: And this is what we're kind of working through.
• 1:43
  SPEAKER_00: And I started to think about the process for them a little bit in terms of just some of the things that I'm discussing with them in the session, and also for our remote ACLers.
• 1:56
  SPEAKER_00: And the thing with the injury and the surgery is that there's a lot going on.
• 2:01
  SPEAKER_00: There's pain, there's swelling, there's atrophy, your quads shut down.
• 2:06
  SPEAKER_00: You've got AMI, which is artogenic muscle inhibition, which is just basically this tug of war between getting the quads activated and awake, and basically this kind of disconnect of the battery, or we kind of use the Christmas light analogy, which is you know a normal functioning quad.
• 2:25
  SPEAKER_00: You've got Christmas lights on the Christmas tree, it's firing when you put the plug in.
• 2:30
  SPEAKER_00: The difference here is that whenever you have this injury, there is also a neurological change.
• 2:36
  SPEAKER_00: It's not just this local injury to the ACL.
• 2:40
  SPEAKER_00: There is this, you know, central spinal cord and brain changes as well as locally to the quad muscle, the knee itself.
• 2:50
  SPEAKER_00: And when AMI sets in, that this is something where when you plug in the Christmas tree, the lights, only maybe half of them come on or a quarter of them come on.
• 3:00
  SPEAKER_00: So you're just like, well, what's the disconnect?
• 3:02
  SPEAKER_00: And so that's where this ACL injury is not only just a knee injury, it's also a brain injury.
• 3:09
  SPEAKER_00: And not to give you guys any idea of like actually trauma to the brain itself, but more so of like it's just a neurological thing as well as it is a muscoskeletal thing.
• 3:19
  SPEAKER_00: So that's where it can kind of make it complicated.
• 3:22
  SPEAKER_00: And especially why connecting, why do we have so much atrophy?
• 3:26
  SPEAKER_00: Why do we have such a hard time getting the quads turned on and all these different pieces?
• 3:31
  SPEAKER_00: That to be honest, y'all, we don't know all the answers.
• 3:34
  SPEAKER_00: But the thing is, this stuff happens after the injury and surgery, and you're also apprehensive to just do all these things, like to bend the knee to straighten it, just because of there being a fresh ACL in there.
• 3:45
  SPEAKER_00: Maybe you had a graph done, and then this is also not to mention the other concomitant injuries like a meniscus, MCL, maybe it's other procedures within this that also might make this more complicated, therefore, also maybe more restricted based on post-op guidance.
• 4:04
  SPEAKER_00: Maybe you're in a brace, maybe you can't bend to only 90, maybe you can't put weight on it, or you know, it's just one of those things that you're also just going to be dealing with more just symptoms overall, typically.
• 4:16
  SPEAKER_00: So it just makes it a lot, right?
• 4:19
  SPEAKER_00: And so there's a lot of factors.
• 4:21
  SPEAKER_00: And so early post-op for us in our restore phases, we are aiming for a quiet knee.
• 4:28
  SPEAKER_00: That is in a nutshell what our goal is.
• 4:30
  SPEAKER_00: While we might be working on some other secondary goals, the quiet knee is our main focus.
• 4:36
  SPEAKER_00: We try to keep it super simple.
• 4:38
  SPEAKER_00: We are trying to regain full terminal knee extension.
• 4:42
  SPEAKER_00: Actively, we're trying to get our flexion back over progressive weeks from 90 degrees to 120 degrees, depending on restrictions.
• 4:50
  SPEAKER_00: We're trying to get pain and swelling down so our symptom profile managed as best as possible.
• 4:55
  SPEAKER_00: We are trying to get our gait restored, right?
• 4:58
  SPEAKER_00: We're trying to make sure our walking can slowly get restored over the course of time based on your restrictions and weight bearing status.
• 5:06
  SPEAKER_00: And we just want to make sure those quads can turn on.
• 5:09
  SPEAKER_00: You know, those are the things that are gonna really, really encompass this, especially early post-op phases.
• 5:16
  SPEAKER_00: And a big thing we are trying to tackle, as you guys know, is extension and quad activation.
• 5:21
  SPEAKER_00: And often the athlete is trying so hard to do the exercises, but it's just not clicking due to a number of those factors I mentioned.
• 5:31
  SPEAKER_00: And I was kind of thinking about this even during my own ACL rehabs, like this was still challenging for me.
• 5:36
  SPEAKER_00: Like, even the second ACL, for example, you're like, all right, I know the exercises, I got my quad to wake up before.
• 5:42
  SPEAKER_00: Let's do this again.
• 5:43
  SPEAKER_00: But the thing is, like, it just feels like there's a disconnect, right?
• 5:46
  SPEAKER_00: The feel of it.
• 5:47
  SPEAKER_00: It's like when you go to do an exercise, sometimes when you first start it, you're just like, I just feel my joints, or I just don't really feel nothing, right?
• 5:55
  SPEAKER_00: And of course, it depends on how many moving parts there are.
• 5:58
  SPEAKER_00: Are there multiple joints, or is it just one isolated, like a bicep curl, for example?
• 6:03
  SPEAKER_00: But the thing is, is like we are trying to also have this mind muscle connection for this, and that's something that just can be very challenging early post op.
• 6:14
  SPEAKER_00: And the thing with these exercises is that you can try and give them all the quote unquote best exercises, right?
• 6:21
  SPEAKER_00: The ones that are like our go-tos, for example.
• 6:23
  SPEAKER_00: You can give them the best cues, the best positions, um, the best uh, you know, NMES device, for example, and it still might not feel like it clicks.
• 6:32
  SPEAKER_00: You know, it might be something that helps maybe move it in the right direction, but it still doesn't feel like it should feel, right?
• 6:39
  SPEAKER_00: And any of you ACLers can relate to me, I know for sure, where you're just like, yeah, I remember I'm trying to do this, and I just feel my hamstrings and my glutes kick on, for example, when I'm doing a quad set.
• 6:50
  SPEAKER_00: But you're trying, right?
• 6:51
  SPEAKER_00: You're trying, you're looking at your quad and you're like, I don't see any movement, I don't see any activity.
• 6:56
  SPEAKER_00: And so one of the things that this makes me think of is essentially coming around to the point of this episode today is around this cross-education effect that comes up.
• 7:09
  SPEAKER_00: And so the cross-education effect is essentially this like kind of crossover effect where you're working on the uninvolved side, or if you know, for example, your left ACL is the one that's torn and has been uh reconstructed, then therefore your right leg is the uninvolved side.
• 7:27
  SPEAKER_00: So there's this kind of crossover effect, if you will, that research has shown where it's more neurally mediated, in meaning it is an increase in the brain muscle excitation.
• 7:38
  SPEAKER_00: There's these neural pathways, the body is kind of wild, y'all, in terms of the way that it works, but it's very neurologically driven.
• 7:46
  SPEAKER_00: And the research shows that, especially whenever we're talking more about strength levels, that strength training the uninvolved limb can help keep the ACL-operated side strength up.
• 7:58
  SPEAKER_00: So it allows for it to not drop as much and also to regain that strength better.
• 8:03
  SPEAKER_00: Again, not necessarily saying like you're making all these strides with getting peak strength, but more so it's a neural-mediated thing that helps keep the strength on the involved side, the ACL-operated side up.
• 8:17
  SPEAKER_00: And so this is what leads me more directly to my point for today is using the uninvolved side as a helpful proxy in terms of finding quote unquote normal.
• 8:29
  SPEAKER_00: And this is something that we reference a lot with our ACLers, because everyone's always like, Well, when is this gonna feel normal?
• 8:37
  SPEAKER_00: When am I gonna get back to normal with this?
• 8:39
  SPEAKER_00: You know, should this feel normal?
• 8:41
  SPEAKER_00: So, this is something we get a lot of the times, and yeah, protocol might say, like, at this point, you'll be doing this, or when we do this, then you'll feel quote unquote normal.
• 8:51
  SPEAKER_00: But normal, y'all, as we know in ACL land is quite a blurry gray area, and especially with something that has been injured, has been operated on potentially, and so of course it's gonna be a little blurred, it's changed, so therefore, we need to figure out what we can use as what can be a normal benchmark and what's a feeling for you, but then also from a actually like performance-sided outcome as well.
• 9:19
  SPEAKER_00: And now some of you may be like, Well, I'm on my second ACL and it's the other side, and that's okay.
• 9:27
  SPEAKER_00: Still use the uninvolved side of where you currently are.
• 9:30
  SPEAKER_00: So let's say, for example, you previously injured your right side and you've rehabbed from that, and your left side is now the current ACL reconstructed side.
• 9:40
  SPEAKER_00: Well, continue using your right side because hopefully you have regained it back to a point where it's functional and doing your stuff.
• 9:46
  SPEAKER_00: If not, then you need to tackle both of these things.
• 9:50
  SPEAKER_00: But with that said, like with your first one that you did, still use that as your uninvolved side because the thing that's going to be your involved side is going to be the ACL injured and reconstructed side.
• 10:03
  SPEAKER_00: So that's what we're going to use here, and that's okay.
• 10:07
  SPEAKER_00: And the main thing here is that we're more so targeting the feel or potentially even the look of it, right?
• 10:13
  SPEAKER_00: And there's such a thing to lean into with the feel of a movement or the feel of a muscle, the feel of a range of motion exercise that we don't want to overlook because we're not going a lot based on just like the look of it initially, because you know, when you're trying to turn on your quad, for example, it's a little bit more challenging, right?
• 10:34
  SPEAKER_00: And the other thing for those of you listening with only one knee that has had an ACL injury, or maybe as multiple on the same knee, guess what?
• 10:42
  SPEAKER_00: You can use your uninvolved side as a proxy for this process as well, right?
• 10:47
  SPEAKER_00: So you're gonna have one side that hasn't had an A cell injury and one side that has had one or maybe multiple to it, and you're working through your rehab.
• 10:56
  SPEAKER_00: So, bridging off of this, what I'll do is tell my athletes your uninvolved side is going to be your gold standard.
• 11:05
  SPEAKER_00: Now, one caveat here that I do want to share is that I want to disregard strength levels a little bit here for comparisons.
• 11:14
  SPEAKER_00: Um, or maybe someone with just like excessive hypermobility, for example, just things are kind of out of the norm, but then also strength levels because the uninvolved side can have some drop in strength.
• 11:26
  SPEAKER_00: So then, therefore, we can't necessarily say that's the gold standard for you.
• 11:31
  SPEAKER_00: But when it comes to things like your range of motion and things that are kind of like a feel of muscle activation, then these are things that we can look at in terms of symmetry.
• 11:42
  SPEAKER_00: But the other thing with strength that I want to specifically point out, and potentially some jump metrics, some dynamic tasks, is that we're gonna look at some symmetry.
• 11:51
  SPEAKER_00: We're gonna look at normative values out there for your same age and population and maybe sport.
• 11:56
  SPEAKER_00: And then we're also gonna be looking at relative to your body weight.
• 11:59
  SPEAKER_00: So we need to be mindful of these things, and especially when we're using it as a proxy.
• 12:05
  SPEAKER_00: So those are the caveats.
• 12:07
  SPEAKER_00: But here's how this is going to apply practically for you by using the uninvolved side, especially if you're someone post-op going through this process.
• 12:16
  SPEAKER_00: I want to talk about some examples that are gonna be really helpful to hit home for this.
• 12:20
  SPEAKER_00: And this is probably the one that I use the most, and it's going to be for knee extensions, it's going to be for trying to get that terminal knee extension, looking at the heel pop and range of motion as your comparison on the uninvolved side.
• 12:34
  SPEAKER_00: So you might lay on the ground, you might just sit and have your back against the wall, make sure you are not on carpet and you are on a flat hardwood floor surface, so there's no give to it.
• 12:45
  SPEAKER_00: Don't do it on your bed.
• 12:46
  SPEAKER_00: But what we're gonna do is have both legs out, right?
• 12:49
  SPEAKER_00: And then we're just going to allow for that uninvolved side to go into a quadset.
• 12:54
  SPEAKER_00: And typically you're gonna let your heel kind of lift up a little bit in most cases for hyperextension.
• 13:01
  SPEAKER_00: That's our heel pop test or our gold standard of what we're looking for.
• 13:04
  SPEAKER_00: Again, if you're someone who has like 15 degrees of hyperextension, 20 degrees, then maybe that's not going to be the thing that we're targeting.
• 13:14
  SPEAKER_00: But in majority of normal situations, we're gonna be targeting somewhere in the negative fives to maybe negative 10 for someone with typical hyperextension, right?
• 13:24
  SPEAKER_00: And so that's what we're gonna be looking at.
• 13:26
  SPEAKER_00: And your uninvolved side is gonna be super helpful to be able to gauge that.
• 13:31
  SPEAKER_00: And then the thing for quad activation is that I'm asking you to potentially feel your uninvolved side as it is doing a quad set.
• 13:41
  SPEAKER_00: Again, you're gonna be doing a heel pop, they just kind of coincide typically as the same movement, and you're going to try and connect that with that ACL operated side or injured side.
• 13:53
  SPEAKER_00: You're gonna try and do the right side, and for example, if that is the uninvolved side, and then you're gonna do the involved side, the left side.
• 14:00
  SPEAKER_00: You're gonna go and hit that quad set, for example, or the heel pop and see if you can get that rolling.
• 14:06
  SPEAKER_00: And a lot of times it's gonna take some reps, it's gonna take some time.
• 14:10
  SPEAKER_00: And then try doing them together, right?
• 14:12
  SPEAKER_00: Doing them one after another.
• 14:14
  SPEAKER_00: So use your uninvolved side to help get that feel of it.
• 14:18
  SPEAKER_00: And it's something that I think is so simple, but oftentimes it gets missed.
• 14:22
  SPEAKER_00: And even with my own athletes here, sometimes they'll be like, Oh yeah, I forgot to do that, or yeah, oh, and when we work on it, they're like, Oh, okay, like it they kind of find the rhythm, and then all of a sudden we're starting to find a little bit of more quad activation, some extension, and it's allowing us to really connect the mind to muscle to that feeling.
• 14:41
  SPEAKER_00: And I think a lot of this has some like of that cross-education effect that I'm talking about, which is why I brought that up earlier.
• 14:48
  SPEAKER_00: And I also think that it's just something that our brains are so in tune with movement that, especially from a range of motion, from especially like a muscle working activation standpoint, that I think that there could be a lot of value out of this that doesn't necessarily get utilized a lot.
• 15:07
  SPEAKER_00: We just kind of focus on the ACL side, that's where all of our attention goes to.
• 15:11
  SPEAKER_00: We're like, all right, come on, work.
• 15:12
  SPEAKER_00: We're just kind of looking at it, trying to see if that quad will actually even like move a little bit.
• 15:17
  SPEAKER_00: Sometimes it does, sometimes we don't recognize it, but maybe the hamstrings and the glutes are actually doing the work, and that's one of the kind of faults or things to look out for with this.
• 15:29
  SPEAKER_00: But if you can do it on the uninvolved side and be like, all right, can I get this close to the involved side?
• 15:37
  SPEAKER_00: That's gonna be a huge game changer because as you continue to move along, that's only gonna get better.
• 15:42
  SPEAKER_00: And guess what?
• 15:43
  SPEAKER_00: You get the uninvolved side as something you can continue to compare it to.
• 15:47
  SPEAKER_00: Now, as we go into looking at things and feeling things, the feel is gonna be important, but then also the look, right?
• 15:55
  SPEAKER_00: So we can compare this to the uninvolved side again.
• 15:58
  SPEAKER_00: And this is something we're doing throughout ACL rehab, right?
• 16:01
  SPEAKER_00: And we just got to find when it's the right time to compare it to the uninvolved side versus some of the other measures we might have.
• 16:09
  SPEAKER_00: So, for example, when we're doing a split squat or a lunge, a lot of times if an athlete is starting off with this, or maybe they're coming to me three months in, six months in later on in the process, and I might just have them do walking lunges, right?
• 16:23
  SPEAKER_00: That's an assessment for me, um, depending on if they can get into those positions.
• 16:28
  SPEAKER_00: But I'll ask them to do it.
• 16:29
  SPEAKER_00: And what I'll do is I'll actually record from the side and I'll look at their shin angles and I'll look at their torso angles and do a qualitative assessment and see, all right, what does their shin angle look like?
• 16:40
  SPEAKER_00: Can that thing get you know positive where it's not just vertical, but is moving your knee past your toes on the uninvolved side, and then look at what it looks like on the involved side.
• 16:53
  SPEAKER_00: That's gonna give me insight into okay, like this person.
• 16:56
  SPEAKER_00: What we'll see a lot of times that's a common fault, is the person wants to keep their shin vertical or kind of almost hits this brick wall when they try to move their knee over their toes.
• 17:08
  SPEAKER_00: It's almost like it stops, and then what happens is that their hips do a lot of the work.
• 17:13
  SPEAKER_00: And so we want to get an idea of this and then start to be a detective and be like, okay, well, why is this happening?
• 17:19
  SPEAKER_00: Is it weak quads?
• 17:20
  SPEAKER_00: Is it pain in the knee?
• 17:21
  SPEAKER_00: Is it a donor side issue that's causing some resistance?
• 17:25
  SPEAKER_00: Is it limited knee flexion?
• 17:27
  SPEAKER_00: Is it something where it's in the hip or maybe in the foot?
• 17:30
  SPEAKER_00: Like, so we're kind of trying to play detective when we look at these things.
• 17:34
  SPEAKER_00: And other things we're gonna be looking at single leg jumping, cutting, dynamic tasks.
• 17:40
  SPEAKER_00: So, video can be super helpful for this.
• 17:43
  SPEAKER_00: And it's the things that we do here in person, it's what we do remote to be able to see this.
• 17:48
  SPEAKER_00: But I encourage you guys to just record yourselves.
• 17:51
  SPEAKER_00: Like right now, I'm going through some rehab for my hip, and I record myself looking at different movements and being like, all right, how does this look side to side?
• 17:59
  SPEAKER_00: If I'm doing it with both legs, like a squat, for example, or hinging, I'm gonna look and see, like, all right, does my body look equal if I cut it in half?
• 18:07
  SPEAKER_00: Or does one side look like it's leaning over?
• 18:09
  SPEAKER_00: Does my hip do something weird?
• 18:11
  SPEAKER_00: And then I'm definitely looking at things if I'm doing single leg stuff or one side versus the other, just to be like, okay, how does this feel?
• 18:18
  SPEAKER_00: And I'm personally like feeling how does my glute feel side to side with some of this stuff?
• 18:23
  SPEAKER_00: How does like my hip extension, how does you know, rotating my hips feel side to side?
• 18:28
  SPEAKER_00: And then I'm trying to compare and see like how can I get to my other hip, right?
• 18:32
  SPEAKER_00: That's my gold standard.
• 18:33
  SPEAKER_00: I'm looking at, and so don't be ashamed of videoing yourself, guys.
• 18:37
  SPEAKER_00: Like, this can be super helpful in this process and super valuable.
• 18:42
  SPEAKER_00: And so, what we can do is compare side to side to see this qualitatively via the video, how it looks from an assessment standpoint.
• 18:50
  SPEAKER_00: But you can also break this down from your own standpoint on how it feels.
• 18:56
  SPEAKER_00: And one of the main things that I really want to hit home here is that if you're listening to this and you're trying to get your extension back, you're trying to get that quad activated, use that uninvolved side as a proxy, as a target for yourself.
• 19:10
  SPEAKER_00: And at least you know you're getting back to a place where this is what I was born with, this is exactly what feels quote unquote normal for you.
• 19:19
  SPEAKER_00: And that's one of the things I find ACLers are always on the search for is like what is normal.
• 19:24
  SPEAKER_00: And while it could feel a little blurred, especially post op, we want to give you some sort of direction with that.
• 19:30
  SPEAKER_00: So use that uninvolved side as much as you can as a comparison.
• 19:34
  SPEAKER_00: Don't compare yourself to other people because other people have different genetics, different injuries, different graphs, all those things.
• 19:40
  SPEAKER_00: So that's the one thing you want to get away from is comparing to other people.
• 19:43
  SPEAKER_00: Use your uninvolved side if you are looking for comparison here, and then ask your rehab provider to help guide you on maybe what are some benchmarks and milestones and criteria for you to hit to help marry all these things together.
• 19:58
  SPEAKER_00: But use that mind muscle connection, look at things, look at video, but then also assess the feel of it on the uninvolved side, and that's gonna help a ton to help hammer that home for the involved side.
• 20:10
  SPEAKER_00: I hope this helps, y'all.
• 20:11
  SPEAKER_00: Until next time, this is your host, Robbie Patel, signing off.