Latest / The ACL Athlete Podcast / 276 | Two-Stage Revision ACL Reconstruction Part 2: The Surgery, the Research, and the Road Back

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276 | Two-Stage Revision ACL Reconstruction Part 2: The Surgery, the Research, and the Road Back · 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.
• 0:59
  SPEAKER_00: What is up, team, and welcome back to the ACL Athlete Podcast.
• 1:05
  SPEAKER_00: So today we are diving into part two of our series on the two-stage ACL reconstruction.
• 1:13
  SPEAKER_00: If you haven't listened to part one yet, I'd encourage you to go back and start there.
• 1:18
  SPEAKER_00: We've covered what a two-stage is, why it happens, the specific indications that leads a surgeon to recommend it.
• 1:26
  SPEAKER_00: And we opened with the story of an athlete I'm currently working with who's navigating this process right now.
• 1:32
  SPEAKER_00: Part one is the foundation.
• 1:34
  SPEAKER_00: This episode builds on it.
• 1:37
  SPEAKER_00: For those of you who did listen to part one, here's a quick recap before we go deeper.
• 1:43
  SPEAKER_00: And for those of you who are like, let me get this recap.
• 1:46
  SPEAKER_00: So then that way I don't need to listen to it.
• 1:48
  SPEAKER_00: Go listen to it, put it on 2x, 3x speed, whatever you prefer.
• 1:53
  SPEAKER_00: I know I talk slow sometimes.
• 1:55
  SPEAKER_00: And capture it because there's a lot of value in that episode.
• 1:58
  SPEAKER_00: So go listen to that.
• 1:59
  SPEAKER_00: But for the recap here, a two-stage ACL reconstruction is a planned sequential revision strategy.
• 2:07
  SPEAKER_00: There's an intentional sequence to it.
• 2:10
  SPEAKER_00: Stage one is a bone procedure and a clean out procedure.
• 2:15
  SPEAKER_00: The surgeon removes the old graft and hardware, cleans out the damaged tunnels, and fills them with a bone graft to restore that structural integrity of the knee.
• 2:24
  SPEAKER_00: The athlete leaves stage one with no ACL graft in place.
• 2:29
  SPEAKER_00: Stage two happens months later, once imaging confirms the bone has healed, and that's when the actual reconstruction is performed with a new graft in place.
• 2:42
  SPEAKER_00: The two primary reasons this becomes necessary the tunnel widening beyond roughly 12 to 14 millimeters, give or take, where there simply isn't enough solid bone to secure a new graft.
• 2:58
  SPEAKER_00: And tunnel malposition where the original surgery basically did not do a good alignment of what that is.
• 3:09
  SPEAKER_00: And so there are different ways that that could be done.
• 3:11
  SPEAKER_00: There's anatomical, transtibule, there could be other techniques as well, but those are the two most common.
• 3:17
  SPEAKER_00: But where the new anatomic tunnel would overlap so significantly with the old hole and drill that was done that you can't necessarily safely place that graft without filling it in and healing the original tunnel first.
• 3:33
  SPEAKER_00: They would essentially overlap with each other.
• 3:35
  SPEAKER_00: And I kind of use the analogy of if you drill one hole into the wall, then you're trying to drill another one that's directly next to it or maybe at a different angle, but they intersect, right?
• 3:46
  SPEAKER_00: And so that's gonna make it really hard to run something through and especially to put a screw in, right?
• 3:52
  SPEAKER_00: And that's what's gonna help us to anchor essentially where this ACL is gonna kind of slide through.
• 3:57
  SPEAKER_00: And so we don't want to have excessive movement, and we also want to make sure that those are as tight as possible to help secure that ACL in place, right?
• 4:07
  SPEAKER_00: So that's where we left off.
• 4:09
  SPEAKER_00: Today we're going into the surgery itself in more detail, the interstage period between stage one and stage two, that argue is most underappreciated part of this entire process, and what that research actually says about outcomes for this two-stage process and what athletes and clinicians need to take away from all of this practically.
• 4:31
  SPEAKER_00: So let's get into it.
• 4:33
  SPEAKER_00: So, what is actually happening in that first surgery?
• 4:36
  SPEAKER_00: I want to give you a clearer picture of what stage one involves because I think understanding it changes how you think about the interstage or the between the stage one and stage two period that follows.
• 4:48
  SPEAKER_00: When the surgeon goes into stage one, they are not just doing a cleanup, they're doing foundational reconstruction.
• 4:56
  SPEAKER_00: So we're talking about building that foundation up.
• 4:59
  SPEAKER_00: I compared this to essentially doing this in your home and imagining that first, before we fix the home itself, we need to fix the foundation that it is built on, right?
• 5:12
  SPEAKER_00: We can't do a good stage two where we put a new ACL in there if we don't have a good foundation to start with, which is the bone itself, right?
• 5:19
  SPEAKER_00: Because that's where the ACL is going to be anchored to.
• 5:22
  SPEAKER_00: And so they're doing this foundational reconstructive work on the bony architecture of the knee.
• 5:28
  SPEAKER_00: The old graph gets removed, they clean it up typically, the hardware gets removed typically, and then the tunnels get debrised, meaning the surgeon clears out the fibrous tissue, lining the walls until they're back down to essentially bleeding cancellous bone.
• 5:46
  SPEAKER_00: So, sorry, that might have been a little too graphic, but basically they're trying to clean that stuff out, and the bleeding actually isn't a bad thing.
• 5:53
  SPEAKER_00: The bleeding surface is helpful.
• 5:55
  SPEAKER_00: That allows the bone graft to integrate.
• 5:58
  SPEAKER_00: Bleeding tends to sell inflammatory cells and healing cells towards what we need in those areas.
• 6:04
  SPEAKER_00: So it starts our immune process to be able to build things back up.
• 6:09
  SPEAKER_00: And so none of that you will necessarily directly feel.
• 6:12
  SPEAKER_00: It's just what's happening within the bone.
• 6:14
  SPEAKER_00: I mean, yeah, you'll have some post-op soreness and maybe discomfort, but this is what needs to happen in order for that bone graph to really integrate.
• 6:23
  SPEAKER_00: But then this is where they do that clean out, then the tunnels get filled.
• 6:28
  SPEAKER_00: The material used to fill them matters.
• 6:31
  SPEAKER_00: And your surgeon will make that decision based on the size of, you know, the holes, your anatomy, their preferences and experience, because there are all kinds of different things that surgeons may potentially integrate into this material.
• 6:44
  SPEAKER_00: But I would say majority of the time it's pretty consistent.
• 6:47
  SPEAKER_00: And the most commonly used option are maybe sometimes people will take like an autograft, which is taken from yourself, which can be taken from potentially like your iliac crest, which is that kind of like hip bone that you have if you just kind of take your hand and run it over there, which bone can be harvested from your own pelvis in that hip bone.
• 7:07
  SPEAKER_00: And it can also be an allographed bone, which comes from a donor.
• 7:12
  SPEAKER_00: The iliac crest autographed is generally considered the gold standard for this application.
• 7:16
  SPEAKER_00: It's your own biology.
• 7:18
  SPEAKER_00: It carries living cells that drive incorporation and it typically can consolidate faster.
• 7:24
  SPEAKER_00: You can also consider this the same as ACL graphs.
• 7:26
  SPEAKER_00: Autographs, you take it from your own body versus an allograph, you're taking it from a cadaver.
• 7:31
  SPEAKER_00: The integration of an allograph in general will typically be slower than what is of your own body because of the way that the body registers it being potentially foreign or different compared to what is a part of your cellular makeup, if you will.
• 7:46
  SPEAKER_00: Most iliac crest autographs cases are ready for stage two, somewhere in the range of four to six months.
• 7:53
  SPEAKER_00: The trade-off is the donor site morbidity.
• 7:56
  SPEAKER_00: There's a second area of the body that was operated on, and that area is going to be sore for a period of time.
• 8:01
  SPEAKER_00: Some athletes find that more disruptive than they expected.
• 8:06
  SPEAKER_00: The allograph bone dowels that are used are common alternatives when surgeons or athletes want to avoid the donor site.
• 8:13
  SPEAKER_00: Pre-shaped plugs of donor bone are packed into the tunnels.
• 8:18
  SPEAKER_00: Incorporation is reliable, but typically slower.
• 8:23
  SPEAKER_00: And it can take longer.
• 8:24
  SPEAKER_00: It could be, yes, three months, six months, maybe even nine months, depending on healing and different people and how their bodies respond to it.
• 8:31
  SPEAKER_00: Some programs add bone marrow, aspirate, concentrate, often called BMAC, to the allograph to try to accelerate that biology.
• 8:40
  SPEAKER_00: The evidence on that is still developing, but the rationale is sound in and of itself.
• 8:46
  SPEAKER_00: And I do see a lot of surgeons starting to use this in terms of trying to help with maximizing the environment and the recovery and the healing process.
• 8:55
  SPEAKER_00: But here's the key thing to understand about stage one.
• 8:58
  SPEAKER_00: Before the surgeon can schedule stage two, they need to confirm on imaging that the graft has incorporated.
• 9:05
  SPEAKER_00: Graft meaning the bone graft.
• 9:07
  SPEAKER_00: Plain radiographs at about three months can give an early look for this.
• 9:12
  SPEAKER_00: A CT scan at four to six months gives the definitive picture for this to be able to see this really well.
• 9:18
  SPEAKER_00: If the consolidation isn't there on imaging, stage two is going to be delayed and pushed.
• 9:24
  SPEAKER_00: The timeline is driven by the biology and how you heal and not by just this calendar, right?
• 9:30
  SPEAKER_00: And this is, you know, the theme of ACL rehab is that biology is in control here.
• 9:35
  SPEAKER_00: We can't control that necessarily as we think about every person's individual situation, their healing.
• 9:42
  SPEAKER_00: Um, you know, someone who is 14 is going to have healing potential that is going to be way different than the 50-year-old that is also getting the same procedure during.
• 9:52
  SPEAKER_00: So that is something to just consider here is that biology is a driving factor.
• 9:57
  SPEAKER_00: That's one of the things athletes in this process just kind of need to accept early because waiting on an imaging confirmation that hasn't come yet is a specific kind of difficult to just kind of navigate, if you will.
• 10:10
  SPEAKER_00: So I think that's really important to understand.
• 10:13
  SPEAKER_00: I would say that more surgeons are getting away from autographs just by nature of like trying to get into a certain other area of the body and are seeing that, you know, the allographs also do incorporate well, may take a little bit longer, which is why you see different timelines.
• 10:30
  SPEAKER_00: And maybe being able to stimulate a better healing environment can help to speed that up a little bit because we can rely a little bit more on bone healing within bone.
• 10:39
  SPEAKER_00: Like bone tends to regenerate and do really well.
• 10:43
  SPEAKER_00: It doesn't come back super weak.
• 10:45
  SPEAKER_00: That's why, you know, when you break your leg, for example, and it heals up, it actually heals up stronger.
• 10:50
  SPEAKER_00: And so that is something that we can rely on.
• 10:53
  SPEAKER_00: We just don't know how quickly that can happen for certain people.
• 10:57
  SPEAKER_00: And that's where imaging is going to help us to understand that and see if it's incorporated fully, or do we need more time?
• 11:04
  SPEAKER_00: So these are just more background just to understand fully, okay, what is happening in this situation.
• 11:11
  SPEAKER_00: So we are essentially cleaning out that knee, making it into a good environment.
• 11:17
  SPEAKER_00: I mentioned there are situations where a surgeon may, you know, if they find something in there like a meniscus slightly torn, they may fix it then and repair it or clean it up just because of the timing of that situation while they're in there.
• 11:32
  SPEAKER_00: So then therefore you don't have to deal with that when you have the ACL reconstructed, for example.
• 11:36
  SPEAKER_00: So there are other things that can happen in the knee depending on, you know, the injury or what has evolved as to why you're doing the two stage.
• 11:45
  SPEAKER_00: But this is something that could just be helpful to grasp.
• 11:48
  SPEAKER_00: Is it gonna be an allograft?
• 11:49
  SPEAKER_00: Is it gonna be an autograph?
• 11:51
  SPEAKER_00: Knowing that allograft tends to be a bit more popular right now with what we're seeing.
• 11:58
  SPEAKER_00: But that's gonna be helpful for us to set the stage for stage two.
• 12:03
  SPEAKER_00: But before we go there, I want to talk about that interstage period, the stage between stage one and stage two.
• 12:11
  SPEAKER_00: This is the part that really no one really prepares you for.
• 12:15
  SPEAKER_00: Um, and I said in part one that the interstage period deserves its own versation, and I meant it.
• 12:21
  SPEAKER_00: This is the stretch between that two-stage process.
• 12:24
  SPEAKER_00: And as I shared, on average can be anywhere from three to six months, sometimes longer.
• 12:30
  SPEAKER_00: The other thing, too, is that your medical system will influence this.
• 12:34
  SPEAKER_00: If you have, you know, something like a socialized medicine, it might be longer.
• 12:39
  SPEAKER_00: It might be even faster, depending on if something opens up.
• 12:43
  SPEAKER_00: Um, and then obviously with insurance or states-based, usually it's a little bit more of availability and also these healing timelines.
• 12:50
  SPEAKER_00: So there's a lot of influence on this, but using that three to six month mark is a healthy frame overall.
• 12:56
  SPEAKER_00: And in my experience, it's this part of the process that athletes are a bit less prepared for because they do the stage one and then they kind of feel like they're in this limbo process, um, waiting for stage two.
• 13:10
  SPEAKER_00: And here's what makes it uniquely hard.
• 13:13
  SPEAKER_00: Your knee has no ACL.
• 13:15
  SPEAKER_00: You know that.
• 13:16
  SPEAKER_00: Every time you navigate a curb or get out of a car or walk on uneven surfaces, some part of your brain registers that the primary stabilizer of your knee is not there.
• 13:28
  SPEAKER_00: That awareness doesn't go away just because you're doing your rehab diligently.
• 13:34
  SPEAKER_00: It kind of lives in the background and it compounds over months, right?
• 13:38
  SPEAKER_00: It's one of those things that even people after an ACL tear, they are thinking about navigating, kind of walking, I wouldn't say on eggshells, depending on your general overall process, maybe, but it is something that you do have a little bit more of a cautious, you know, approach to just generally walking and doing things, especially if you have an unstable knee or the knee itself gives way a good bit, versus some people they may not notice it or ever feel it give way, right?
• 14:08
  SPEAKER_00: And this is gonna vary across the board.
• 14:10
  SPEAKER_00: But at the same time, you're also recovering from surgery without the reward of knowing a new graft was in place, right?
• 14:18
  SPEAKER_00: In the standard ACL reconstruction, when the early hard weeks are behind you, there's a mental anchor available, right?
• 14:24
  SPEAKER_00: The graft is in there, you know, you're kind of comforted with that.
• 14:28
  SPEAKER_00: We're building towards something in the interstage period.
• 14:31
  SPEAKER_00: You don't have that anchor.
• 14:32
  SPEAKER_00: You're recovering from a surgery, you're working, you know, you're being patient, but the thing you're working toward is still another surgery that hasn't happened yet.
• 14:42
  SPEAKER_00: There's also the activity restriction reality of what this lives in.
• 14:46
  SPEAKER_00: You know, there's no cutting, pivoting, you know, you're not doing your sports or activities that you're typically doing.
• 16:59
  SPEAKER_00: There's a modification that is happening during this window.
• 17:03
  SPEAKER_00: And it's challenging.
• 17:05
  SPEAKER_00: And for the most of these athletes who end up in this stage two process, these are athletes who have been restricted for a long time already, adding another three to six months of restrictions on top of everything that came before is a weight that builds.
• 17:22
  SPEAKER_00: It really does.
• 17:24
  SPEAKER_00: So, what does this period actually look like from a rehab standpoint?
• 17:30
  SPEAKER_00: The first six weeks are focused on the basics swelling control, restoring full range of motion, getting the quads active and back online.
• 17:38
  SPEAKER_00: This is where we're just aiming for that quiet knee, get that into a really, really good place, get it into a dry and happy knee.
• 17:45
  SPEAKER_00: How many different knee variations can we talk about?
• 17:49
  SPEAKER_00: The surgical insult from stage one is real, even though no ligament was placed.
• 17:55
  SPEAKER_00: And that's important to know.
• 17:57
  SPEAKER_00: So we need to let the knee settle, just like post op for anything else.
• 18:02
  SPEAKER_00: So, from roughly that, you know, six weeks and onward, the work becomes about maintaining and building, you know, stationary bike stuff, pull work if you can, being able to make sure that the cardiovascular aspects you can continue to keep working on, continue to keep loading without stressing that joint too much.
• 18:21
  SPEAKER_00: So we're gonna be progressing through a lot of these different progressions in this particular phase.
• 18:29
  SPEAKER_00: And one tool that I do want to share with you guys that I think can be valuable that we do share with our athletes, whether they are in a non-weight bearing phase, maybe they're in a phase where they can't do as much aggressive loading.
• 18:44
  SPEAKER_00: Um, and this is something that I need to do a podcast on, which is about blood flow restriction training.
• 18:50
  SPEAKER_00: BFR can be super helpful to allow us to build and maintain muscle with loads that are a fraction of what you'd normally need to create a training stimulus for.
• 19:01
  SPEAKER_00: And so for a knee that can't really tolerate high loads in an ACL deficient state that's recovering, it can be valuable.
• 19:09
  SPEAKER_00: The evidence base for BFR and the ACL population is growing.
• 19:12
  SPEAKER_00: It's pretty strong.
• 19:14
  SPEAKER_00: Um, I've used it myself.
• 19:15
  SPEAKER_00: Uh, you know, we use it with a lot of athletes for us in person and remotely as well.
• 19:21
  SPEAKER_00: And it's awesome.
• 19:22
  SPEAKER_00: I love it.
• 19:23
  SPEAKER_00: I'm a big fan of it.
• 19:24
  SPEAKER_00: It's not a silver bullet by any means.
• 19:27
  SPEAKER_00: And if we can load heavy, we will still load heavy, but it is also a helpful tool in this process.
• 19:33
  SPEAKER_00: But for especially the interstage period specifically, it does help fill in a gap, otherwise, that can be sometimes hard to fill.
• 19:40
  SPEAKER_00: The goal entering stage two is not to have been, you know, sitting still for six months.
• 19:47
  SPEAKER_00: And sometimes people do take these windows, maybe it's from injury to ACL reconstruction, and they don't take advantage of it.
• 19:57
  SPEAKER_00: And a lot of times it's just more so of lack of not knowing or doing things, or they may do some basic things, but they kind of stay safe and they don't necessarily load the knee.
• 20:07
  SPEAKER_00: And so they kind of start themselves from a lower position than they could be from a fitness strength and all the things that we could be building in prehab, right?
• 20:16
  SPEAKER_00: And so this interstage period is essentially another prehab period, if you will, right?
• 20:20
  SPEAKER_00: We're we're trying to get us ready for that second procedure, which is going to put the new ACL in.
• 20:27
  SPEAKER_00: And so the biggest thing is to make sure that you have been doing the proper amount of work because you are gonna have better outcomes.
• 20:33
  SPEAKER_00: Across the board, people who do prehab, who do things before they have the ACL reconstruction, come out better.
• 20:39
  SPEAKER_00: Uh and the research shows a prehab does improve long-term outcomes in ACL rehab.
• 20:46
  SPEAKER_00: So we want to make sure that you have built up some fitness.
• 20:49
  SPEAKER_00: We want to make sure your quad strength is in a very solid place, your contralateral leg is strong.
• 20:54
  SPEAKER_00: You know, you continue to work your core, your upper body, making sure glutes, hamstrings, um, calves, everything in your arsenal is built up as much as possible without putting a ton of risk on the knee itself.
• 21:09
  SPEAKER_00: And usually that is going to be more so influenced by dynamic movement, like running, jumping, cutting, things that are really going to make the knee translate in high forces and high impacts.
• 21:21
  SPEAKER_00: And so the thing that we want to make sure is your body is just ready to hop into this stage two the moment that that graph goes in, right?
• 21:30
  SPEAKER_00: We want to make sure that body is feeling in a really solid place.
• 21:34
  SPEAKER_00: Now, the other thing I want to talk about is a psychological piece because the research is clear, and I think clinicians and athletes both need to hear this.
• 21:42
  SPEAKER_00: A 2025 study by Tarchala and colleagues.
• 21:47
  SPEAKER_00: This was published in the knee surgery, sports traumatology, arthroscopy, measured ACL RSI scores in revision ACL patients versus primary ACL patients.
• 22:01
  SPEAKER_00: ACL RSI is a validated tool that measures psychological readiness to return to sport.
• 22:06
  SPEAKER_00: Every one of our athletes gets ACL RSIs.
• 22:09
  SPEAKER_00: If you're not getting ACL RSI, I would question your PT is not up to date.
• 22:14
  SPEAKER_00: They're finding in this study revision patients scored 17 points lower than the primary patients.
• 22:21
  SPEAKER_00: 17 points.
• 22:23
  SPEAKER_00: That's not a small difference.
• 22:24
  SPEAKER_00: That's a clinically meaningful gap that reflects the accumulated mental weight of going through this twice, navigating a more complex process and facing a longer timeline.
• 22:35
  SPEAKER_00: I would almost bet that it would probably be a bit lower with a lot of these athletes, but you know, we're we're kind of capturing what that average is here.
• 22:44
  SPEAKER_00: And 17 points is lower than the primary, which does make sense it's lower.
• 22:49
  SPEAKER_00: And a separate 2025 study by Michelees and colleagues published in the Orthopedic Journal of SportsMed, went further.
• 22:58
  SPEAKER_00: They looked at what was actually preventing athletes from returning to play after a revision ACL reconstruction.
• 23:04
  SPEAKER_00: Conclusion was psychological readiness was the primary barrier, not laxity, not strength, not hop testing.
• 23:12
  SPEAKER_00: The mental peace was the dominant limiting factor.
• 23:15
  SPEAKER_00: What that means practically is this if you're an athlete in this process, the mental work is not optional.
• 23:22
  SPEAKER_00: It's not soft, it's not secondary.
• 23:25
  SPEAKER_00: It's the thing that the research is pointing to as the rate limiting step in getting back.
• 23:29
  SPEAKER_00: That means working with a sports psychologist if you have access to one.
• 23:34
  SPEAKER_00: It means having honest conversations with your rehab team about where your head is at.
• 23:39
  SPEAKER_00: It means tracking your ACL RSI score at regular intervals throughout the process and treating a low score as a clinical finding, not something that would be a personal failure.
• 23:51
  SPEAKER_00: And if you're a clinician or coach working with athletes in this process, the same research is your mandate in this situation.
• 23:58
  SPEAKER_00: Screen for psychological readiness, y'all.
• 24:00
  SPEAKER_00: ACR RSI is so simple, so easy.
• 24:03
  SPEAKER_00: Read through.
• 24:04
  SPEAKER_00: It ortho tools has a great questionnaire that you the athlete can fill out and then be able to get that information back and even grade it for you.
• 24:12
  SPEAKER_00: It's beautiful, it's done.
• 24:13
  SPEAKER_00: They could send the PDF, you could save the score.
• 24:16
  SPEAKER_00: It's what our athletes do, it's there for you.
• 24:19
  SPEAKER_00: But the thing is, look into the scores, look into what they answer.
• 24:22
  SPEAKER_00: If you have a bunch of 80s across and then you have one that's a 30, look at the 30 score.
• 24:27
  SPEAKER_00: Why is it 30?
• 24:28
  SPEAKER_00: What made them answer that?
• 24:30
  SPEAKER_00: Address it explicitly.
• 24:32
  SPEAKER_00: Don't wait until your athlete is physically cleared and psychologically nowhere near ready to discover that the mental piece wasn't addressed.
• 24:42
  SPEAKER_00: We need to make sure that these are aligned side by side.
• 24:46
  SPEAKER_00: It's okay that, you know, physical or psychological kind of has its roller coasters and it's going to.
• 24:51
  SPEAKER_00: Usually there is a direct relationship, but they can be off as well in this process.
• 24:56
  SPEAKER_00: But we need to make sure that we are objectively testing this and making sure that we know where the athlete is from that physical and psychological standpoint, but we only know that if we test and measure it.
• 25:08
  SPEAKER_00: Otherwise, we are just assuming.
• 25:10
  SPEAKER_00: And the most dangerous athlete is one that is psychologically overly confident and not physically ready, but then vice versa.
• 25:18
  SPEAKER_00: They are physically ready, but psychologically not confident.
• 25:21
  SPEAKER_00: And those are two athletes that we do not want engaging in things because they are not in alignment.
• 25:28
  SPEAKER_00: Now, let's talk through stage two because once imaging confirms the tunnels have consolidated, stage two is scheduled.
• 25:35
  SPEAKER_00: The surgeon goes back in and performs the ACL reconstruction.
• 25:39
  SPEAKER_00: New anatomic tunnels drilled into solid healed bone.
• 25:43
  SPEAKER_00: Now, hoping that this is an anatomical approach here.
• 25:47
  SPEAKER_00: New graft threaded through and fixed into place.
• 25:51
  SPEAKER_00: Done correctly.
• 25:52
  SPEAKER_00: This is a reconstruction that has a good structural foundation beneath it to actually hold, which is awesome.
• 25:59
  SPEAKER_00: Now, graph choice for stage two matters, and the research is fairly clear on this.
• 26:03
  SPEAKER_00: Autograft outperforms allograph in the revision setting.
• 26:07
  SPEAKER_00: The Mars Group, which is the multi-center ACL revision study and one of the largest ACL revision registries in the world, found that autograph was roughly 2.78 times less likely to rerupture than allograft at two-year follow-up.
• 26:25
  SPEAKER_00: That's a significant difference in a population that has already been through enough.
• 26:29
  SPEAKER_00: The common autograph choices are bone patellar tendon, bone, a BTB, quadriceps tendon, and hamstring tendon, which are obviously the three main ones.
• 26:40
  SPEAKER_00: Each has trade-offs in terms of the donor side, graph size, and rerupture risk.
• 26:45
  SPEAKER_00: Your surgeon will guide that decision based on your anatomy, your history, and what's available given prior surgeries.
• 26:53
  SPEAKER_00: One of the other things that you do need to consider is just your injury history.
• 26:57
  SPEAKER_00: Have you had any tendinitis or any issues in the knee before that?
• 27:02
  SPEAKER_00: Maybe these re-injury also influenced things in the knee joint.
• 27:07
  SPEAKER_00: So that all needs to be factored in.
• 27:09
  SPEAKER_00: And this is where it can be a very wide variety of choices based on that person, but then also the surgeon.
• 27:18
  SPEAKER_00: There can be so many situations where you know they got an autograph initially and then secondary got an allographed.
• 27:25
  SPEAKER_00: And a lot of times that decision can be influenced by yes, age, but then also by your goals and also the fact that you may not want two different donor sites taken on the same knee.
• 27:40
  SPEAKER_00: For example, you got a patellar tendon on the first one.
• 27:43
  SPEAKER_00: Let's say that that didn't graft well, incorporate, or the tunnels got too wide, or you know, it re-injured.
• 27:52
  SPEAKER_00: So then you have to go round two and you're doing this two stage.
• 27:55
  SPEAKER_00: Then there will be conversations around like, what are the goals?
• 27:59
  SPEAKER_00: You know, what is your age?
• 28:00
  SPEAKER_00: Because those things typically influence the choices.
• 28:03
  SPEAKER_00: But sometimes it might be a decision of an allograft, or maybe it is the decision of taking your hamstring.
• 28:09
  SPEAKER_00: So then that way you don't take the quad graft itself and you don't influence the knee extensor mechanism, which is your quad into your quad tendon, into your patella, into your patellar tendon, which attaches to the tibial tuberosity or tubular tubercle, that is going to be really important here in this process to consider.
• 28:32
  SPEAKER_00: And I think it's important to say here that if that extensor mechanism on the patellar tendon and that quad graft is taken, and I've seen this happen before for revision cases.
• 28:43
  SPEAKER_00: Let's not say it's a two-stage, but in, you know, a reinjury, there is a chance, let's say, for a 16-year-old who has torn their ACL twice, a surgeon might do a patellar tendon, then a quad graft.
• 28:55
  SPEAKER_00: Now, I'm not gonna sit here and debate what is the best choices here because that's not the purpose of this episode, but I think that we need to think long and hard about really influencing the quad and that entire chain of that knee extensor mechanism for a graft.
• 29:13
  SPEAKER_00: Because if the quad is down for the count, because of just how much impact it's had through those two grafts, it might almost influence so much of that strength coming back, the pain that they might deal with donor sites, but then also just really trying to get them back to sport in especially a recent time.
• 29:32
  SPEAKER_00: So there are a lot of arguments to be made around autographed, allographed with these types of cases.
• 29:39
  SPEAKER_00: But I always do come back to what is your goal or goals?
• 29:44
  SPEAKER_00: What is, yes, your stage of life and age does influence some of these decisions.
• 29:49
  SPEAKER_00: Um, yes, if you're a 14-year-old versus you are 55, there's potentially gonna be some considerations there.
• 29:56
  SPEAKER_00: While age is not something that we make many decisions on, it is just going to influence some of the factors that we talk through and weighting things.
• 30:04
  SPEAKER_00: And then, of course, your surgeons' expertise and what they prefer to do, right?
• 30:09
  SPEAKER_00: Those are gonna be things that are going to be weighed into a lot of these things as we are deciding what is gonna make the best choice.
• 30:16
  SPEAKER_00: Y'all, we've seen things also where, you know, they take the graph from the other knee, right?
• 30:21
  SPEAKER_00: So patellar tendon taken, quad graft taken, hamstring taken.
• 30:25
  SPEAKER_00: It happens.
• 30:26
  SPEAKER_00: And you would be surprised how often that happens too.
• 30:28
  SPEAKER_00: It's not very common in revision, but it surgeons do have their training based on things like that too.
• 30:34
  SPEAKER_00: So just some things to consider with these revision cases, and we also need to dissect as well, like why the initial one didn't incorporate well, or why did it re-injure?
• 30:45
  SPEAKER_00: Was it a testing issue, or was it maybe a graft issue?
• 30:49
  SPEAKER_00: You know, hamstring grafts can tend to have more tunnel widening.
• 30:52
  SPEAKER_00: So there are just some things that we need to factor in.
• 30:55
  SPEAKER_00: But the one thing I want to share here is that there's no graft here to blame as to why it happened specifically, but more so to say, like each one has their choose your own adventure.
• 31:09
  SPEAKER_00: So we need to weigh these because it's gonna be very, very important for the long-term health of the knee, and then also getting back to doing the thing that you care about, getting your strength back, all those things that can make or break a little bit more of the rehab process and honestly the timeline of the whole recovery itself.
• 31:28
  SPEAKER_00: So just some things that will need to be very intentionally thought about and discussed with your team about what makes the most sense.
• 31:38
  SPEAKER_00: Now, one adjunct that's getting more attention in revision settings is the lateral extraarticular tenodesis or LET, another one that I need to do an episode on.
• 31:51
  SPEAKER_00: I know sharing all this stuff.
• 31:53
  SPEAKER_00: So I'm gonna tee that up and hopefully talk about that here soon.
• 31:56
  SPEAKER_00: But this is a procedure done alongside the ACL reconstruction that adds rotational stability to the knee.
• 32:03
  SPEAKER_00: And that is the thing that surgeons are looking at for something like this.
• 32:07
  SPEAKER_00: We're seeing it more in primary cases as well, especially for younger female athletes.
• 32:13
  SPEAKER_00: But this is something that is growing and the evidence is growing.
• 32:17
  SPEAKER_00: A 2025 meta-analysis by Sutton and colleagues found that adding the LET to revision, ACL reconstruction, improved return to sport rates.
• 32:27
  SPEAKER_00: It's not universal and not every revision needs it, but it's worth talking to your surgeon about it, especially if you're in a pivoting sport.
• 32:37
  SPEAKER_00: That is something to just consider in this.
• 32:39
  SPEAKER_00: But um, we do see people do well.
• 32:42
  SPEAKER_00: There can be some stickiness and some getting extension, um, and then some lateral discomfort, maybe some kind of pinching that sometimes people can kind of feel as a symptom.
• 32:52
  SPEAKER_00: But overall, I would say people do fairly well.
• 32:55
  SPEAKER_00: And just to kind of explain this LET, they basically take a small strip of your IT band on the outside of your knee and they anchor it down to the tibia to help from preventing rotation of that tibia or excessive rotation and what they will kind of define as rotational instability.
• 33:13
  SPEAKER_00: And so they want to incorporate and stabilize that.
• 33:16
  SPEAKER_00: So then, therefore, that tibia has more stability as it rotates, so then therefore, it's less excessive strain on the ACL.
• 33:23
  SPEAKER_00: So the way I like to think about it is that it is a secondary seat belt.
• 33:27
  SPEAKER_00: Your ACL is your primary seat belt of your knee.
• 33:30
  SPEAKER_00: That LET comes in there to help to be another seat belt to help anchor you down.
• 33:34
  SPEAKER_00: And that's what's helpful to kind of envision with this.
• 33:37
  SPEAKER_00: Again, not all cases, but in a lot of revision cases, we're starting to see this more and more just because they want to be able to kind of stabilize that knee and give it the best shot possible.
• 33:49
  SPEAKER_00: So after stage two, the rehab structure follows a primary ACL reconstruction pathway or progression, if you will, in its general shape.
• 34:00
  SPEAKER_00: You know, protect that graph, restore range of motion, um, be able to activate the quads early, get gate going, and then the rest of the process, right?
• 34:08
  SPEAKER_00: Building strength, capacity, power, being able to do more dynamic things, you know, running mechanics, being able to develop your apply metrics, being able to run, jump, cut, all the different things that we're gonna work through in this process while continuing to build strength and power and continuing to build towards the criteria at each part of this ACEL rehab process.
• 34:31
  SPEAKER_00: Remember, it is not a clock, it is criteria that is based on the research and based on the science and athletic performance that we are guiding this process through.
• 34:41
  SPEAKER_00: And again, typically most people might look at a nine to 12 month process from a stage two for returning to sport.
• 34:51
  SPEAKER_00: I would honestly say that most people are probably gonna lean towards 12 months or longer after that reconstruction because it is also another revision case.
• 35:01
  SPEAKER_00: So we want to give your body the maximal window to be able to develop, get back to sport, to be able to get stronger, build up progressions back to sport or activities.
• 35:12
  SPEAKER_00: So we're not trying to rush things unless you have something very, very big on the line, then that might have some different conversations around the speed of getting you back to playing, right?
• 35:24
  SPEAKER_00: But when you add that nine to 12 month process, you know, when we're just kind of factoring this all in, you add in the interstage interval of three to six months or so.
• 35:33
  SPEAKER_00: The total window from stage one to returning to sport and activity is somewhere in the range of 14 to 24 months, y'all.
• 35:43
  SPEAKER_00: And that's just an honest number here.
• 35:45
  SPEAKER_00: That's the number athletes deserve to know before they start this process.
• 35:49
  SPEAKER_00: And I shared that with you guys because I think it is so, so important for people to know what to expect.
• 35:55
  SPEAKER_00: Not to sugarcoat it, but just for people to know what to expect.
• 35:59
  SPEAKER_00: Now I want to walk you through the key studies here because I think having a real picture of what the research shows is more useful than either, you know, false optimism or building in unnecessary fear.
• 36:11
  SPEAKER_00: Let's ground ourselves to what the data shows.
• 36:14
  SPEAKER_00: And I want to be upfront that the research base on the two-stage ACL reconstruction is there, but it's not super comprehensive.
• 36:24
  SPEAKER_00: You know, most studies are smaller, more retrospective.
• 36:27
  SPEAKER_00: There are no large, you know, randomized control trials comparing one stage to two-stage directly.
• 36:33
  SPEAKER_00: What we have is enough to inform decision making.
• 36:36
  SPEAKER_00: And here's what it shows.
• 36:37
  SPEAKER_00: So Mitchell and colleagues published a study in AJSM in 2017 that directly compared 39 single-stage revisions to 49 two-stage revisions.
• 36:50
  SPEAKER_00: The failure rate was 10% in the single-stage group and 6% in the two-stage group.
• 36:58
  SPEAKER_00: That difference wasn't statistically significant, but the direction is favorable for the two-stage and the right indications.
• 37:04
  SPEAKER_00: Functional outcomes were similar between groups at minimum of a two-year follow-up.
• 37:09
  SPEAKER_00: In 2023, Gopinoth and colleagues published a systematic review, 13 studies, 355 patients who underwent two-stage ACLR.
• 37:19
  SPEAKER_00: When the right indications were met, meaning tunnel widening beyond 10 to 14 millimeters and tunnel malpositioning, two-stage revision consistently led to meaningful improvements in lysome scores, IKDC scores, and overall knee function.
• 37:36
  SPEAKER_00: The indications were consistent across studies even when the surgical techniques varied.
• 37:43
  SPEAKER_00: The Danish knee ligament registry published data in 2024 looking at over 1,500 patients.
• 37:51
  SPEAKER_00: Re-revision rates were nearly identical between single stage and two-stage of two years, 2.79% versus 2.93%.
• 38:01
  SPEAKER_00: No significant difference.
• 38:03
  SPEAKER_00: That finding is important because it suggests that when the indication for two-stage is correct, the procedure isn't adding risk.
• 38:10
  SPEAKER_00: It's managing it, which is great.
• 38:14
  SPEAKER_00: A 2024 retrospective study published in the knee surgery and related research found that two-stage reduced graft failure risk by 85% compared to single stage.
• 38:26
  SPEAKER_00: That's a pretty dramatic number.
• 38:28
  SPEAKER_00: But it's also found the patients in the two-stage group reported lower CUS scores, KOS, in pain and symptoms, and a higher rate of anterior knee pain.
• 38:39
  SPEAKER_00: I think that's worth naming, honestly, because it illustrates something real about this process.
• 38:45
  SPEAKER_00: Two-stage may protect the structural outcome of the graph, but the patient experience is more demanding.
• 38:50
  SPEAKER_00: The complexity of the process, the additional surgery, the more stress on the knee itself, the longer timeline, the donor side, all of it has a cost that shows up in how patients report feeling.
• 39:00
  SPEAKER_00: Understanding the trade-off is part of what informed decision making looks like.
• 39:06
  SPEAKER_00: And now, what about return to sport overall?
• 39:09
  SPEAKER_00: A 2025 meta-analysis by Sutton and colleagues is probably the most comprehensive data we have right now on return to sport after a revision ACL reconstruction.
• 39:19
  SPEAKER_00: They looked at 3,800 patients across 52 studies.
• 39:26
  SPEAKER_00: About 78% return to some level of sport, only 48% return to their pre-injury level.
• 39:32
  SPEAKER_00: That means the mean time to return to sport was 9.3 months from the reconstruction itself.
• 39:39
  SPEAKER_00: I want you to sit with those numbers for a second.
• 39:41
  SPEAKER_00: 78% return to some level of sport is actually reasonable.
• 39:47
  SPEAKER_00: 48% returning to their pre-injury level is lower.
• 39:51
  SPEAKER_00: And that gap matters.
• 39:53
  SPEAKER_00: It's an important gap.
• 39:54
  SPEAKER_00: It's not a reason to have not have the surgery, right?
• 39:58
  SPEAKER_00: It's a reason to go in with clear eyes about what this process requires, which includes the physical work and the mental work in equal measure of doing this.
• 40:09
  SPEAKER_00: The fear of reinjury, by the way, was the most commonly cited reason for not returning to sport in the literature.
• 40:15
  SPEAKER_00: Not physical limitations, not surgical failure, fear.
• 40:19
  SPEAKER_00: Which brings us back to what Michaelis and colleagues found.
• 40:23
  SPEAKER_00: The mental piece is the rate limiting step.
• 40:26
  SPEAKER_00: Build it into the plan from day one.
• 40:29
  SPEAKER_00: And that is so key, y'all.
• 40:30
  SPEAKER_00: Make sure to address it, to tackle it.
• 40:33
  SPEAKER_00: Now, what should athletes, should clinicians take from this?
• 40:38
  SPEAKER_00: Let me give you two clear takeaways, one for athletes and one for clinicians.
• 40:44
  SPEAKER_00: If you're an athlete, if you've had a previous ACL surgery and something doesn't feel right, trust that.
• 40:51
  SPEAKER_00: You know your body, get a second opinion, always share that.
• 40:55
  SPEAKER_00: Find a surgeon who has real experience with revision cases and who will order, you know, potentially a CT scan or an MRI to properly evaluate tunnels, plain radiographs can sometimes miss things that CT can catch.
• 41:09
  SPEAKER_00: The difference between a surgeon who says everything looks fine and one who can actually assess a failed reconstruction is enormous.
• 41:16
  SPEAKER_00: And the difference changes your entire path forward.
• 41:20
  SPEAKER_00: I cannot tell you guys the number of consultations that I've had where I've had to talk through this with athletes and with athletes we're working with.
• 41:29
  SPEAKER_00: I currently have cases that I'm consulting that I am helping athletes navigate through this process.
• 41:35
  SPEAKER_00: And some of them are super complex.
• 41:37
  SPEAKER_00: Like not just, you know, one, two surgical opinions or revisions.
• 41:43
  SPEAKER_00: It is three, four, five, even six different opinions.
• 41:48
  SPEAKER_00: I know that seems excessive, but it's also surgery to your knee.
• 41:52
  SPEAKER_00: It's also your livelihood.
• 41:54
  SPEAKER_00: Um, you're not just gonna go to the first or second house that you buy.
• 41:57
  SPEAKER_00: You might need to figure out okay, if there are certain specific situations or factors, you might need to see five, 10, 15 right houses that you might want to buy in order to find the right one and the timing and everything that aligns with that.
• 42:11
  SPEAKER_00: Again, not saying you need to just overall stretch yourself to get so many different ones that you're confused.
• 42:18
  SPEAKER_00: But once you start to figure out, okay, if this is something that's complicated, then therefore, once you get very well vetted opinions, and you know, let's say two, three, four start to converge together and they're pretty similar in terms of alignment, and these surgeons have been vetted for their expertise, then you could start to think about like, okay, maybe I am getting a consolidation of an answer here versus it being just one single opinion.
• 42:50
  SPEAKER_00: So for me, my rule of thumb is the more complicated it is, the more opinions you need.
• 42:54
  SPEAKER_00: And then once you start to find overlap between vetted surgeons and physical therapists, for example, of this is what needs to be done and this is what we need to tackle, then you can start to be like, okay, well, who is going to be the person that I dive the best with, who best flavor that I like in terms of a surgeon and demeanor, and who you want in your corner and on your team, right?
• 43:16
  SPEAKER_00: And so that's helping to navigate multiple opinions and professionals.
• 43:20
  SPEAKER_00: Same thing can be said with physical therapists, which I think is very important, that you do not need to feel handcuffed to any professional, no matter what procedure they did in your healthcare or medical process.
• 43:35
  SPEAKER_00: Now, continuing on with this, if a two-stage is what is recommended for you, understand what it means and why.
• 43:43
  SPEAKER_00: This path exists because it gives your knee the best possible foundation for a new graft.
• 43:48
  SPEAKER_00: It's not a punishment for you.
• 43:50
  SPEAKER_00: It's not a sign that your case is hopeless and we need more steps to this.
• 43:54
  SPEAKER_00: It's just making it more precise to address the actual problem instead of working around it.
• 44:00
  SPEAKER_00: And I've had situations where, you know, athletes have said the surgeon will go into the knee and take a look and see what happens.
• 44:07
  SPEAKER_00: They may do the two-stage based on the status of the knee and what they find, or they may just do it in a single stage.
• 44:12
  SPEAKER_00: And that could also be something that can be a bit nerve-wracking, right?
• 44:15
  SPEAKER_00: You could come out being ready to just hit the rehab process with no surgery, or you could also be in the stage of where you have two different steps to it, right?
• 44:25
  SPEAKER_00: So that could be also very daunting.
• 44:27
  SPEAKER_00: And I've seen athletes on the other side of both of these, and you know, they all have their pros and cons to it and also different outcomes.
• 44:34
  SPEAKER_00: And so this is just something to consider in this.
• 44:37
  SPEAKER_00: But, you know, if the surgeon is recommending it, can clearly explain the tunnel measurements, for example, the positioning of the ACL and show you, not just saying this is what it is, this is what I suggest, goodbye.
• 44:49
  SPEAKER_00: Like they need to educate you, they don't need to rush you.
• 44:52
  SPEAKER_00: It's a very important procedure.
• 44:55
  SPEAKER_00: And maybe also explaining why a single stage won't work for your specific anatomy.
• 45:00
  SPEAKER_00: That's a surgeon who is thinking about your knee correctly.
• 45:03
  SPEAKER_00: And again, I don't think that there's any fault in getting two or three opinions on this.
• 45:07
  SPEAKER_00: It might be a matter of inconvenience, maybe some time taken out of your schedule, but it is worth it, y'all.
• 45:13
  SPEAKER_00: This is something that is so key.
• 45:14
  SPEAKER_00: If you're having heart surgery, you probably want to find a couple opinions at least, right?
• 45:19
  SPEAKER_00: Like just to see what these docs have to say and being able to see, okay, is there alignment on the overall game plan, especially if it's a complicated heart procedure?
• 45:29
  SPEAKER_00: This is a complicated knee procedure.
• 45:31
  SPEAKER_00: It's not just, you know, going in, get it done, and then you're out.
• 45:35
  SPEAKER_00: It's complicated.
• 45:36
  SPEAKER_00: So we want to make sure we want to have the best alignment of what they educate you on and also what is the best process based on the research and what they recommend.
• 45:45
  SPEAKER_00: Now, if you're a clinician and coach, the thing that's important here is to understand when this might happen, right?
• 45:53
  SPEAKER_00: Tunnel widening beyond that 12 to 14 millimeters, tunnel malposition, if you will, with significant overlap between the old and new planned tunnel placement, hardware.
• 46:04
  SPEAKER_00: That can't necessarily come out cleanly.
• 46:06
  SPEAKER_00: Maybe there's significant artrofibrosis and scar tissue, alignment issues that might need to be corrected first.
• 46:12
  SPEAKER_00: So if you're managing a failed ACL case or ACL athlete case and your surgeon's plan doesn't clearly address those criteria, ask about them.
• 46:22
  SPEAKER_00: Ask your athlete, ask the surgeon, you know, if you need to refer them somewhere else because it just doesn't seem right, that's okay.
• 46:29
  SPEAKER_00: Your athlete is counting on you to be that person in the room who is asking the right questions.
• 46:35
  SPEAKER_00: And I can't tell you how many cases we are working with currently as a team where we are having to navigate so many complicated situations, complicated cases.
• 46:46
  SPEAKER_00: And again, people coming in ideally early to us, but a lot of mid-late stages are just knees are just not in a good place.
• 46:53
  SPEAKER_00: They have not rehabbed well, bad rehab, surgeons blowing them off.
• 46:58
  SPEAKER_00: And so we are always here to support and help our athletes through it.
• 47:01
  SPEAKER_00: So we have so many different cases we're consulting with and helping them navigate rehab, but then also questions, complications, you know, whether it's a screw issue, tunneling issue, graph choice issue, surgeons blowing them off because something is coming up in the knee that doesn't add up.
• 47:18
  SPEAKER_00: So then we're having to help to filter through this stuff and help GPS and navigate through this with our own expertise to be like, hmm, this isn't adding up, and it doesn't make sense.
• 47:29
  SPEAKER_00: And our team has had a recent discussion, and I'm just gonna say this because I can what we're noticing when we are communicating with our athletes, and their knees are just not progressing in the typical normal way that we would know with proper dosage rehab adjustments that you would typically see during this process, the knee is just dealing with some biological challenges.
• 47:55
  SPEAKER_00: And it could be hardware related, it could be scar tissue related, it could be graph incorporation related, it could be range of motion issues, it could be pinpoint issues, it could be more global issues with the knee.
• 48:07
  SPEAKER_00: And so it's just things that just don't necessarily add up.
• 48:11
  SPEAKER_00: And so whenever we refer them back to the surgeon or say, hey, this is something that needs to be discussed with your surgeon, it's pretty mind-blowing how many times people are surgeons specifically are just potentially just overlooking it and just saying, ah, just keep rehabbing it, keep working on it, keep getting stronger, you know, work with your PT.
• 48:36
  SPEAKER_00: But I find it very interesting that they're not very detailed or quick to try and evaluate it in detail and especially order imaging or to see if there's something else going on.
• 48:49
  SPEAKER_00: And a lot of times it's like, oh, my surgery did great.
• 48:52
  SPEAKER_00: I don't want to mess with that.
• 48:53
  SPEAKER_00: Like it looks good, the knee looks good, the graft is strong.
• 48:55
  SPEAKER_00: I think this is a rehab thing.
• 48:57
  SPEAKER_00: And when we refer them and they're just like, oh, well, let's do this, let's just kind of give it some time, for example, or uh, you know, I'll see you back in three months and let's just kind of keep working at it with rehab.
• 49:10
  SPEAKER_00: Um, they're resistant to order imaging or resistant to look at it deeper.
• 49:15
  SPEAKER_00: And one of the things that we have been talking about as a team, because we just kind of know with certain procedures, for example, that might be in research studies, they're tracking data, is that they want this to cleanly fit their bias.
• 49:28
  SPEAKER_00: And as much as we want research and evidence to be non-biased, it's easy to cherry pick and decide, like, okay, this is gonna help promote my graft or my technique better, or this is gonna help this procedure really show within our surgical center.
• 49:44
  SPEAKER_00: And so there is importance and a certain clout around like being able to say, like, our research shows, you know, 90% return to sport rates, right?
• 49:53
  SPEAKER_00: And everyone loves to tout that.
• 49:55
  SPEAKER_00: The thing that I find is that whenever an athlete goes in with a complication, it's easy to be dismissed on it.
• 50:01
  SPEAKER_00: And that's the biggest thing that we see.
• 50:03
  SPEAKER_00: So that's just something that I want to share with you guys.
• 50:06
  SPEAKER_00: We've been talking about it as a team, and we're just like, man, why does this happen so much?
• 50:10
  SPEAKER_00: They're so quick to jump to an MRI whenever an ACL is torn, but then whenever the procedure is done and there's a problem six months down the road, nine months down the road, maybe a year down the road, they're just like, oh, well, let's just kind of see how things go versus being like, no, let's grab some imaging.
• 50:27
  SPEAKER_00: And again, this is not all surgeons.
• 50:29
  SPEAKER_00: We have plenty of surgeons and athletes who have surgeons they work with that are amazing and in their corner and willing to do that.
• 50:36
  SPEAKER_00: But the resistance to it and the dismissiveness needs to be addressed.
• 50:41
  SPEAKER_00: And that is where it's really important to me to understand you don't have to be handcuffed to your surgeon.
• 50:47
  SPEAKER_00: You don't have to be handcuffed to your PT.
• 50:49
  SPEAKER_00: No one in this process, it's very important to know that there can be another opinion and multiple opinions.
• 50:58
  SPEAKER_00: Um, and maybe sometimes it's helpful for someone not biased to who did your procedure to also evaluate it not from their own lens, right?
• 51:09
  SPEAKER_00: So then, therefore, they can give you a non-biased opinion on like, well, based on my experience, this is what I recommend, or this is what I see.
• 51:18
  SPEAKER_00: And so then, therefore, you're able to get something that is maybe helpful to put the details and create a clearer picture.
• 51:26
  SPEAKER_00: And so this is something that you just have to make sure you are asking the right questions and making sure that as a PT or a coach, clinician, that you're there for your athlete in their corner.
• 51:40
  SPEAKER_00: And then the other piece I want to discuss is you know, treat the interstage period as a training window.
• 51:46
  SPEAKER_00: You know, this is a phase that's important, just like prehab to help with especially the psychological side and also the physical performance side.
• 51:53
  SPEAKER_00: So then, therefore, we can make sure we make it the most.
• 51:56
  SPEAKER_00: And then that way it's gonna help with the stage two and the recovery afterwards of that.
• 52:01
  SPEAKER_00: And then the third last thing of this I want to share is just tracking psychological readiness, be intentional, regular intervals.
• 52:10
  SPEAKER_00: You know, every three months is a great kind of proxy for ACL RSI.
• 52:14
  SPEAKER_00: You could do it every eight weeks, you know.
• 52:15
  SPEAKER_00: I think every three months is probably a good interval to do, and that's what we do internally to be able to track things and see.
• 52:23
  SPEAKER_00: Um, we might do it and adjust it based on the athlete in front of us.
• 52:27
  SPEAKER_00: But having these honest conversations around fear of reinjury, you know, referring out to sports psychology when needed, the research has told us what the primary barrier is to return.
• 52:37
  SPEAKER_00: So build your program around it and address it.
• 52:41
  SPEAKER_00: So, to bring this all home, the athlete in today's story, or should I say stage one and stage two, the two-part series, where I discussed, especially in part one, about this athlete.
• 52:54
  SPEAKER_00: She is now in the stage two rehab right now.
• 52:57
  SPEAKER_00: She's not at the finish line yet.
• 52:58
  SPEAKER_00: She knows that, but here's what's different now versus where she was when this process started.
• 53:04
  SPEAKER_00: She knows what happened in her knee.
• 53:06
  SPEAKER_00: She knows why the original surgery failed.
• 53:08
  SPEAKER_00: She knows what was done in stage one and why.
• 53:12
  SPEAKER_00: She knows what's in her knee now and what it's designed to do.
• 53:16
  SPEAKER_00: And she has confidence in her team that she didn't have before.
• 53:21
  SPEAKER_00: Because this time someone actually looked at what was going on.
• 53:24
  SPEAKER_00: They heard her, listen to her story, addressed a solution, and has a real answer for it.
• 53:31
  SPEAKER_00: That clarity is not a small thing, y'all, and it's so important here.
• 53:34
  SPEAKER_00: You should always have clarity in this process.
• 53:37
  SPEAKER_00: When you go through something this long and this demanding, knowing exactly where you are, where you're going, and what the next step is, it's not a luxury, to be honest.
• 53:46
  SPEAKER_00: It should be the requirement in this process.
• 53:48
  SPEAKER_00: And that's the foundation that allows you to do meaningful work and to just be able to show up more intentionally.
• 53:56
  SPEAKER_00: She is getting there, and that's what this honestly all is about.
• 53:59
  SPEAKER_00: It's not about perfect outcomes, it's being more so informed.
• 54:03
  SPEAKER_00: Athletes who understand their need, trust their team, and know that the road, however long it is, is actually going somewhere.
• 54:10
  SPEAKER_00: And I think that's really important to share here.
• 54:13
  SPEAKER_00: So I just want to share with you guys that if you need any help in this process, we are here to help.
• 54:21
  SPEAKER_00: Thanks to all ACL athletes, clinicians, coaches, supporting roles, whoever is listening to listening to both parts of this series.
• 54:28
  SPEAKER_00: And if it was useful to you, share it with someone who needs it.
• 54:33
  SPEAKER_00: An athlete going through this, clinician working with one, a parent trying to understand what their kid is facing.
• 54:39
  SPEAKER_00: This is the kind of information that changes how people experience this process.
• 54:43
  SPEAKER_00: Being educated, being more informed, feeling more empowered, that creates more intention in this.
• 54:49
  SPEAKER_00: So reach out if you need any help.
• 54:52
  SPEAKER_00: We work with athletes as I share exactly in these situations every single day, and there is a path forward.
• 54:58
  SPEAKER_00: So if you're not feeling hope, we want to be able to give you that hope.
• 55:02
  SPEAKER_00: So please find our details in the show notes.
• 55:04
  SPEAKER_00: We can point you in the right direction.
• 55:07
  SPEAKER_00: I'll see you guys in the next episode.
• 55:09
  SPEAKER_00: This is your host, Robbie Patel, signing off.