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220 | The One Question Every ACL Athlete Must Ask Their PT · 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'm excited about today's episode.
• 1:09
  SPEAKER_00: First, I hit you guys hard with the previous two episodes.
• 1:13
  SPEAKER_00: I know those were long.
• 1:15
  SPEAKER_00: I know those were heavy.
• 1:16
  SPEAKER_00: By the way, I'm slowly improving day by day.
• 1:19
  SPEAKER_00: So thank you to all of you who have sent messages and who have tuned in.
• 1:24
  SPEAKER_00: I really appreciate it.
• 1:25
  SPEAKER_00: And I'm making it, y'all.
• 1:27
  SPEAKER_00: It's interesting to be back in this process of being post-op roughly two weeks out now.
• 1:33
  SPEAKER_00: And yeah, just taking it day by day, as I tell our athletes, you know, brick by brick.
• 1:39
  SPEAKER_00: And I'm just focused on laying the next brick down.
• 1:42
  SPEAKER_00: And I'm not immune to any of this stuff.
• 1:44
  SPEAKER_00: I've had some thoughts creep in.
• 1:46
  SPEAKER_00: And so it's good for me to kind of be back here if I'm being honest.
• 1:50
  SPEAKER_00: Um, I wish that I wasn't, but here I am, and so I'm trying to use this as an opportunity to just be back into this kind of post-op mode, and so I'll be continuing to share with you guys as we move forward on how I'm doing, you know, maybe some of this process.
• 2:06
  SPEAKER_00: I know it's not necessarily ACL related, but it is still very parallel to that process, and it's so crazy how much parallel there is when comparing my two ACL injuries and surgeries to this hip surgery.
• 2:19
  SPEAKER_00: So I'll be sure to share more with you guys as time goes on.
• 2:23
  SPEAKER_00: But today, coming in a little bit lighter and back to the normal scheduled ACL content because honestly, I missed it.
• 2:30
  SPEAKER_00: I know you guys missed it.
• 2:32
  SPEAKER_00: So we're gonna get right into it.
• 2:33
  SPEAKER_00: So having the right physical therapist, physiotherapist, whatever rehab provider that you have and coach in your corner can make or break your ACL rehab process.
• 2:48
  SPEAKER_00: And I mean this with all that is within me.
• 2:51
  SPEAKER_00: And I'm not saying this as a biased physical therapist myself and coach, but it's really as going through this process twice myself and walking hundreds through this process, our team has walked so many athletes through this process and just being in this space for quite some time now.
• 3:09
  SPEAKER_00: This is my life, this is what I focus on.
• 3:11
  SPEAKER_00: Y'all, I don't pay attention to anything else besides ACL land.
• 3:15
  SPEAKER_00: And so, with that said, your person who is guiding you in this, I'm not even saying the surgeon here.
• 3:23
  SPEAKER_00: While, with all due respect, the surgeon is a part of the team, the physical therapist and the person who is with you day in and day out through this process, processing the day-to-day emotions, the ups and downs of pain, swelling, strength, getting back to your physical activities, all the things is typically your rehab provider.
• 3:44
  SPEAKER_00: And so I know different countries might have different terms for whoever the rehab provider is, or maybe the system you're in.
• 3:51
  SPEAKER_00: It could be an athletic trainer, it could be an athletic therapist, it could be a chiropractor, right?
• 3:55
  SPEAKER_00: Like it just depends.
• 3:56
  SPEAKER_00: But in majority of the world, in situations, it's a physical therapist or a physiotherapist who is helping with the post-op, post-injury, usually the especially the early mid-stages of ACL rehab, and it could also be a coach that is also involved, or they might be both, right?
• 4:16
  SPEAKER_00: So they can really influence this process.
• 4:19
  SPEAKER_00: It can really influence it from a sense of it could be a nine-month time frame, it could be a 12-month time frame and process, or it could be an 18-month, a two-year, or even three-year process.
• 4:31
  SPEAKER_00: I've seen it.
• 4:32
  SPEAKER_00: People have come to us in these time frames, whether it's three months out, six months out, nine, twelve, you know, you name it.
• 4:41
  SPEAKER_00: We've had people who have been five years out, ten years out, fifteen years out who have never gotten back to it.
• 4:46
  SPEAKER_00: And so we've seen it across the board.
• 4:49
  SPEAKER_00: And so the thing is, is that sometimes they just, you know, get dealt not their best hand ever.
• 4:56
  SPEAKER_00: And maybe they don't get the best physical therapist.
• 4:59
  SPEAKER_00: Maybe it's the new grad who you are their first ACL.
• 5:02
  SPEAKER_00: And don't get me wrong, I had to have my own first ACL.
• 5:06
  SPEAKER_00: The thing is, is that no one wants to be the first, right?
• 5:09
  SPEAKER_00: Like, I understand everyone needs to get the reps, and everyone's like, well, they gotta get the experience, right?
• 5:15
  SPEAKER_00: But you don't want to be that person, right?
• 5:17
  SPEAKER_00: Like, you don't want to be the person that's like, yeah, let me help you with this when the re-injury rates are so high for this.
• 5:23
  SPEAKER_00: Like, hey, I've got a little bit of a low back pain or my shoulder hurts a little bit.
• 5:27
  SPEAKER_00: Yeah, let me let me work with this new grad.
• 5:29
  SPEAKER_00: I'm I'm good with it.
• 5:30
  SPEAKER_00: I'm sure I'm gonna recover from it.
• 5:32
  SPEAKER_00: I just need some guidance.
• 5:33
  SPEAKER_00: Re-indjury rates that are one out of four, one out of three people, yeah.
• 5:38
  SPEAKER_00: And this rehab process takes at least nine to 12 months.
• 5:41
  SPEAKER_00: Yeah, don't give me the new grad.
• 5:43
  SPEAKER_00: Don't give me the person who is inexperienced.
• 5:44
  SPEAKER_00: Give me the person who knows how to do this and is super experienced with this.
• 5:50
  SPEAKER_00: And so this is something that's super important because people come in and they're like, man, I just didn't have the best PT, or maybe they were nice, or whatever it may be.
• 6:00
  SPEAKER_00: Maybe it's the insurance and it's a busy clinic, maybe they were a great therapist, but they just didn't have the time and the bandwidth to help you.
• 6:07
  SPEAKER_00: They didn't have the time to individualize it, right?
• 6:10
  SPEAKER_00: And so that's what makes this very challenging.
• 6:12
  SPEAKER_00: But we see people come in later, and you know, if they started with a good rehab provider from the start, it could have eliminated three months, six months, 12 months of time where things could have been caught, the plan could have been progressed, you could have been tested, and you could have been back to doing your stuff way faster.
• 6:32
  SPEAKER_00: Now, that is not to your own fault until you know better, right?
• 6:35
  SPEAKER_00: And when you know better, then you have to do better.
• 6:38
  SPEAKER_00: But you know, we uh by nature have to just kind of trust the system that we're in and hoping that healthcare providers are going to have our best interest in mind and be able to help us.
• 6:49
  SPEAKER_00: But the thing that's challenging is that there's just a system that plays against us.
• 6:53
  SPEAKER_00: So this is something that I just want to make sure that you guys have it clear.
• 6:57
  SPEAKER_00: And I'm sure if you've listened to previous episodes, you know how I feel about this.
• 7:01
  SPEAKER_00: But it really does make such a huge difference.
• 7:06
  SPEAKER_00: It could be the difference in having a smooth, expected ACL process, or it could be the difference in it being a rough, scary, up and down, unexpected process.
• 7:17
  SPEAKER_00: Now, your ACL rehab, even with the best providers, will have some ups and downs.
• 7:21
  SPEAKER_00: But the question is, was this expected or unexpected?
• 7:24
  SPEAKER_00: And that's where setting expectations with a good provider will help to frame this properly.
• 7:30
  SPEAKER_00: We do this with every single one of our athletes.
• 7:32
  SPEAKER_00: We don't sugarcoat this process to be like it's just a straight line up.
• 7:36
  SPEAKER_00: Like there's gonna be ups and downs.
• 7:37
  SPEAKER_00: You might have a setback.
• 7:38
  SPEAKER_00: Guess what?
• 7:39
  SPEAKER_00: You might have multiple setbacks.
• 7:40
  SPEAKER_00: That's a part of the process.
• 7:42
  SPEAKER_00: But if you didn't know that, it makes it rough when the setback happens.
• 7:46
  SPEAKER_00: So that's the difference between a good provider and someone who really doesn't know this stuff, to be honest.
• 7:53
  SPEAKER_00: It could be the difference in lots of anxiety, or it could be complete peace and reassurance with knowing, all right, we've got a game plan, we've been assessing, we know that there is expertise in this process, that you've walked multiple people through this, and you've seen a lot of different stuff.
• 8:09
  SPEAKER_00: So nothing really phases us at this point, to be completely honest, because y'all, we've seen a mess of stuff in ACL LAN, a mess of it.
• 8:18
  SPEAKER_00: I've seen so much craziness from surgeries to complications and to the physical therapy to people's like knees just doing all kinds of crazy stuff.
• 8:31
  SPEAKER_00: And a lot of times it ends up coming back to the guidance that they have, and that is something that I want to make sure that we can kind of tackle this today.
• 8:41
  SPEAKER_00: I see it honestly similar, your physical therapist, your guide as your GPS.
• 8:46
  SPEAKER_00: I refer to this all the time, but we are your GPS.
• 8:49
  SPEAKER_00: You get in your car, you are the one driving the car, but then you type in to your GPS where you want to go.
• 8:56
  SPEAKER_00: It gives you a few options based on time, detours, tolls, etc.
• 9:01
  SPEAKER_00: Right.
• 9:01
  SPEAKER_00: And it also knows where you're starting at.
• 9:04
  SPEAKER_00: That's really important.
• 9:05
  SPEAKER_00: And your physical therapist and coach should be this for you at all times, in my opinion, during this process.
• 9:12
  SPEAKER_00: Always.
• 9:12
  SPEAKER_00: They should always be your GPS, you're driving the car.
• 9:15
  SPEAKER_00: And that's the way we want to treat our athletes at all times.
• 9:19
  SPEAKER_00: Majority of the time, just to kind of break this down, people go through this ACL process, they tear their ACL, you know, eventually they find a surgeon, and then either that surgeon refers them to a physical therapy clinic associated with them, or just says to find physical therapy near right where you live.
• 9:38
  SPEAKER_00: They'll get a prescription typically here in the states, and they will find a physical therapy clinic near them.
• 9:45
  SPEAKER_00: And so most people don't really pick the PT based on if they're experts, right?
• 9:50
  SPEAKER_00: But more so based on if number one, they take their insurance.
• 9:54
  SPEAKER_00: It's the number one question PT clinics get.
• 9:57
  SPEAKER_00: Here's my insurance.
• 9:58
  SPEAKER_00: Do you take this?
• 9:59
  SPEAKER_00: AKA, can this get covered by my insurance?
• 10:02
  SPEAKER_00: And is it convenient based on school, life, whatever it may be?
• 10:07
  SPEAKER_00: Is it convenient like three minutes down the road, five minutes down the road, 10 minutes down the road, right?
• 10:12
  SPEAKER_00: Can I get there easily in order to make sure I can make these appointments and it fits into my schedule perfectly?
• 10:18
  SPEAKER_00: Right.
• 10:19
  SPEAKER_00: So those are typically the two main things that people will do.
• 10:22
  SPEAKER_00: And those of you listening, you're probably like, yeah, I did that, right?
• 10:26
  SPEAKER_00: And so that's all fair stuff, right?
• 10:28
  SPEAKER_00: I'm not saying that's the wrong way to do it.
• 10:30
  SPEAKER_00: It's all fair, and I don't blame anyone for doing that.
• 10:34
  SPEAKER_00: That is what makes the most sense.
• 10:36
  SPEAKER_00: And some people may look at reviews, right?
• 10:39
  SPEAKER_00: Like that's what we typically do to just make sure this place isn't like a dungeon and or something or they're super, super outdated, right?
• 10:46
  SPEAKER_00: We want to make sure like people actually have something to say about them.
• 10:49
  SPEAKER_00: So you may look at some reviews, but lots of people really think that physical therapy is the same.
• 10:56
  SPEAKER_00: Like when people have an injury, for example, and they go to this cookie cutter PT clinic, they'll just be like, Oh, well, PT didn't work.
• 11:03
  SPEAKER_00: And it's like, if you got diabetes, y'all, and you just went to this primary care, would you just say, like, yeah, the doctor didn't work, right?
• 11:12
  SPEAKER_00: No, you'd find somebody else that would actually solve your problem.
• 11:15
  SPEAKER_00: And it's the same thing in physical therapy, but it's just challenging with the way that the perception of physical therapy is that is quote unquote created the same.
• 11:24
  SPEAKER_00: And guess what?
• 11:24
  SPEAKER_00: PT is not created equal, just like any single profession.
• 11:29
  SPEAKER_00: It is not created equal.
• 11:31
  SPEAKER_00: And I promise you, there is differences across the board, and health and wellness, and fitness, and medicine, there's so much out there, y'all, that it is very, very volatile, if you will, in terms of like what experiences you can get with professionals.
• 11:48
  SPEAKER_00: And the challenge is that most don't get to meet their PT, most ACLs don't get to meet their PTs until they are post-op.
• 11:57
  SPEAKER_00: It's just the way that it kind of goes in this process.
• 12:00
  SPEAKER_00: Typically, unless a surgeon is very prehab focused, I would say most will just like say, like, yeah, just do some stuff and then go to surgery and then schedule your PT, right?
• 12:11
  SPEAKER_00: That's typically what happens.
• 12:13
  SPEAKER_00: And I know in other countries as well, with athletes we have worked with, that a lot of times they don't necessarily get to go unless they have educated themselves earlier on to find a PT, or if their surgeon may have recommended it, then it's awesome.
• 12:28
  SPEAKER_00: But with that said, a lot of times what naturally happens is that the PT will be after they are post-op.
• 12:37
  SPEAKER_00: So then it's like, well, if you're the ACL or do I change now?
• 12:41
  SPEAKER_00: I'm like three days, five days, seven days post-op.
• 12:44
  SPEAKER_00: Do I really want to go through this process to find another PT?
• 12:48
  SPEAKER_00: And you don't even know if this PT is good or not.
• 12:50
  SPEAKER_00: So you just kind of go with it, right?
• 12:52
  SPEAKER_00: And so there's a lot of the system itself that creates these issues that makes it really challenging, and it almost kind of like handcuffs people a little bit into just kind of sticking with who they they have when they start.
• 13:06
  SPEAKER_00: And so the other thing with this is that not to mention your PT is probably nice.
• 13:12
  SPEAKER_00: And guess what, y'all?
• 13:14
  SPEAKER_00: We do not get into physical therapy for the money.
• 13:17
  SPEAKER_00: I promise you that.
• 13:19
  SPEAKER_00: By nature of this job, you're going to find a nice PT more than likely.
• 13:24
  SPEAKER_00: You might get the grumpy person here and there, but with that said, by nature, if you met my entire PT class, like we're all we're all cool, good humans, right?
• 13:35
  SPEAKER_00: Like some of us might be introverts and some might be extroverts, but I promise you, any of these people, whenever you meet them, especially as a patient, they are gonna seem like the friendliest person that is there to help you.
• 13:46
  SPEAKER_00: And that's just the nature of what physical therapists are.
• 13:50
  SPEAKER_00: We're nice people.
• 13:52
  SPEAKER_00: It's like going to a Chick-fil-A or hospice care company, and you're kind of looking for mean people.
• 13:57
  SPEAKER_00: You're just not going to.
• 13:58
  SPEAKER_00: It's just by nature of the choice of the profession.
• 14:01
  SPEAKER_00: And the thing that I want to just make sure is that just because they're nice doesn't mean they're experts.
• 14:08
  SPEAKER_00: I'm gonna repeat this again.
• 14:10
  SPEAKER_00: Just because they are nice, just because you can be friends with them, you can be pals with them, you can cut up with them, does not mean that they are good at ACL rehab.
• 14:20
  SPEAKER_00: It does not mean that they are experts.
• 14:22
  SPEAKER_00: And I think people get handcuffed in this a lot because this often happens where people are like, well, you know, I like them a lot, or they've had history with them where they've been with them for the past two, three months.
• 14:34
  SPEAKER_00: So they feel like for some reason it's kind of like the boyfriend and girlfriend who keep having issues, and you know, they've had that long history, so you feel like you need to stay together.
• 14:45
  SPEAKER_00: Guess what, guys?
• 14:46
  SPEAKER_00: It's probably not gonna get better.
• 14:47
  SPEAKER_00: So then, therefore, we need to make sure we move on to make some changes.
• 14:50
  SPEAKER_00: So, this is the same thing here where we want to make sure that you are connected with a professional that is going to help you in this process because, like I said, they're gonna make or break this ACL rehab process.
• 15:05
  SPEAKER_00: I promise you that.
• 15:07
  SPEAKER_00: Now, the goal of this conversation and my long-winded way of leading up to this is how can you make sure that you can ask the right question to see if your PT is legit?
• 15:22
  SPEAKER_00: The number one question to see if your PT is legit.
• 15:26
  SPEAKER_00: That's gonna be the goal for today to vet them appropriately.
• 15:29
  SPEAKER_00: And while it should be more than this one question, and I've done episodes on this previously and some series around asking surgeons and also asking your PT to vet them, to ask them these questions just to see are they the right person for you?
• 15:44
  SPEAKER_00: And also red flags.
• 15:46
  SPEAKER_00: But this is one question that will tell you a lot if I'm being completely honest.
• 15:53
  SPEAKER_00: It's the tell me you don't know what you're talking about without telling me you don't know what you're talking about, truly.
• 16:00
  SPEAKER_00: And that question is how do you objectively measure quadriceps strength?
• 18:11
  SPEAKER_00: And if they say MMT, where they push, you know, their hand up against your ankle and hold the top of your thigh, and you're gonna kick into their hand, that's a red flag, and that is not legit.
• 18:27
  SPEAKER_00: That is also not strength testing.
• 18:29
  SPEAKER_00: It's like me picking you up and guessing how much you weigh.
• 18:32
  SPEAKER_00: It's based on how much I can pick up, aka my strength, and also how much you weigh, right?
• 18:37
  SPEAKER_00: So then, therefore, like it's just an estimate like of what you think, but you're you're just completely guessing.
• 18:43
  SPEAKER_00: You really don't know.
• 18:44
  SPEAKER_00: So an MMT essentially serves for that.
• 18:47
  SPEAKER_00: And you know, background MMTs, the kicking into people's hands, that literally goes back to the polio epidemic back in the day to make sure people can at least kick on their muscles and use them, and then they eventually turned it into a grading scale.
• 19:01
  SPEAKER_00: I hate it, I understand that it has its own purpose, but in terms of strength testing, it's just not it.
• 19:07
  SPEAKER_00: So, MMT, red flag, not legit.
• 19:11
  SPEAKER_00: If they say something like, okay, a leg press or a single leg squat, then we kind of have to understand more and ask more questions.
• 19:20
  SPEAKER_00: The thing that's challenging with anything that is not like a leg extension or a knee extension is that you can't isolate the quadricep muscle with any of these movements, like a leg press, a single leg squat, because there's multiple joints moving, there's multiple muscles working, and your body can compensate.
• 19:40
  SPEAKER_00: So sometimes we'll have people say, Yeah, I had a leg press strength test, or I had did single leg squat.
• 19:46
  SPEAKER_00: First of all, single leg squat in reality is actually not an assessment of strength, truly, it's actually an assessment of endurance and capacity.
• 19:55
  SPEAKER_00: So it's something that doesn't truly give you, and what we're after is peak strength, meaning what is the highest amount of strength I can put out by my quadricep muscle?
• 20:04
  SPEAKER_00: That is what we are measuring, and usually most people will understand that with objectively measuring quadricep strength.
• 20:11
  SPEAKER_00: And so your single leg squat will not measure that, your leg press will not measure that because there are multiple joints moving.
• 20:18
  SPEAKER_00: Can you compare side to side?
• 20:20
  SPEAKER_00: Sure.
• 20:20
  SPEAKER_00: But it's still not going to objectively measure quadricep strength.
• 20:24
  SPEAKER_00: And I'll get to why in a minute, but this is just important for us to understand because we have people that say, Oh, well, the single leg squat is going to be the thing that's going to make sure like I'm safe for things.
• 20:35
  SPEAKER_00: And it's like, no, it's not.
• 20:37
  SPEAKER_00: Just because you can sit down with a single leg to a chair and get back up, doesn't mean you're super strong.
• 20:42
  SPEAKER_00: It just means you can do that task very specifically, and that's about it.
• 20:46
  SPEAKER_00: And so, therefore, next order of business, if if they say, you know, MMT, no, if leg press or single leg squat or some sort of compound base multi-joint movement, that's not gonna do it either.
• 20:59
  SPEAKER_00: But it's okay, at least they said something related to an actual assessment of some type of movement.
• 21:05
  SPEAKER_00: Really, what we're looking for is if they say they're using isokinetic testing, that could be via a biodex, it could be via HUMAC norm, cyback system, a Kincom.
• 21:17
  SPEAKER_00: This is the gold standard of isolated quadriceps strength testing.
• 21:22
  SPEAKER_00: An isokinetic machine, which is where you're gonna sit in this machine, they're gonna kind of strap you in, and your leg is gonna be fixed, and you're gonna essentially kick out like a knee extension machine and curl back like a seated hamstring curl machine.
• 21:36
  SPEAKER_00: So that thing is seated, it's set at a certain speed, and you're gonna be testing how much strength you can kick into that thing, and it's measuring every single degree of that.
• 21:47
  SPEAKER_00: And then as you get through that, it allows us to get a lot of data in terms of how your quadricep and hamstring is doing.
• 21:54
  SPEAKER_00: That's the gold standard.
• 21:56
  SPEAKER_00: Now, these machines are$50,000 give or take, right?
• 22:01
  SPEAKER_00: So not everyone has access to them, even here in Atlanta.
• 22:04
  SPEAKER_00: We have certain people around, certain clinics around that might have them, but they're far and few between, to be honest.
• 22:11
  SPEAKER_00: But every major city for the most part, you can typically find one.
• 22:15
  SPEAKER_00: We refer athletes, our remote athletes, especially to different places to get tested.
• 22:20
  SPEAKER_00: And if that doesn't work, guess what?
• 22:22
  SPEAKER_00: We have something that is just equally as helpful and it has been proven by the research, and that is using a handheld dynamometer.
• 22:30
  SPEAKER_00: Really, it's going to be anchored and it's going to be uh being able to use essentially a strain gauge, same thing, a crane scale, but it's essentially like a pull dynamometer.
• 22:42
  SPEAKER_00: And so what you're going to be doing is essentially being seated in that knee extension machine or some sort of setup like this.
• 22:50
  SPEAKER_00: And then typically there is an ankle strap on your ankle, and then you are going to have some sort of device on there, and that is going to be the thing that is measuring the force output.
• 23:01
  SPEAKER_00: And so that's going to give us an amount of weight.
• 23:04
  SPEAKER_00: Kind of think about if you hold your luggage on a crane scale, that's going to give you the amount of weight that that that luggage weighs.
• 23:10
  SPEAKER_00: That's essentially what this thing is doing is it's a strain gauge that's going to tell us how much force your quadriceps can kick out.
• 23:17
  SPEAKER_00: And so that is basically the next layer, if you will, for us to be able to measure this and the next best after an isokinetic machine.
• 23:28
  SPEAKER_00: And so this is something that I have.
• 23:30
  SPEAKER_00: So I test athletes here in person, all of our team does where they are.
• 23:35
  SPEAKER_00: And then we have so many providers now across all kinds of different states, even countries that have these units, and there's so many different brands and types, but they get them and they're able to test athletes based on this.
• 23:51
  SPEAKER_00: And so we can get an actual objective number associated with your quadriceps and your hamstrings.
• 23:57
  SPEAKER_00: Now, if they say they don't mention that, they don't mention astinetic testing.
• 24:02
  SPEAKER_00: Maybe if they say they're using Using a knee extension machine and comparing side to side.
• 24:07
  SPEAKER_00: This is actually also acceptable.
• 24:09
  SPEAKER_00: Like this is assuming isokinetic and the handheld dynamometers are not available, then therefore a knee extension machine can also be fine.
• 24:18
  SPEAKER_00: And so this has been also shown by the research to give us a good estimate of quadricep strength by comparing one side to the other and seeing what those differences are.
• 24:28
  SPEAKER_00: So this is acceptable, and it's actually something that we utilize based on our athletes, the resources they have available.
• 24:37
  SPEAKER_00: We have athletes in certain countries where they just don't have access to this type of professional or equipment or any of that stuff.
• 24:45
  SPEAKER_00: So then guess what?
• 24:46
  SPEAKER_00: We still need to measure strength.
• 24:47
  SPEAKER_00: And so then the knee extension machine ends up being a game changer for us because we could still measure it.
• 24:53
  SPEAKER_00: So that's our pyramid, if you will.
• 24:56
  SPEAKER_00: So basically, if you kind of look at it, our gold standard is going to be the isokinetic machine dynamometer.
• 25:04
  SPEAKER_00: Then there's the handheld dynamometer, the strain gauge, the crane scale.
• 25:08
  SPEAKER_00: You know, we use something called the Tin Deck, which is a certain brand that basically is able to measure that strength, but it's just this small little device that spits out a number for us.
• 25:19
  SPEAKER_00: Imagine, like the, as I had mentioned, the crane scale that allows us to see the luggage that is being weighed and what that weight is.
• 25:27
  SPEAKER_00: That's essentially what we're looking at.
• 25:30
  SPEAKER_00: So that's super helpful, and that's a part of our pyramid, and what you'll probably see in most clinics because it's most affordable.
• 25:38
  SPEAKER_00: And then at the base of this is being able to do knee extension machine and being able to compare side to side.
• 25:44
  SPEAKER_00: You could do full range or you could go from 90 to 45 degrees.
• 25:48
  SPEAKER_00: And this gives us a good proxy of what your quadricep strength is.
• 25:52
  SPEAKER_00: And so this doesn't matter if you're in person or remote, really, because it's going to just be dictated based on access and the resources that you have.
• 26:01
  SPEAKER_00: But here's the thing: we have to make sure there is testing.
• 26:06
  SPEAKER_00: And if we want to go just kind of like a next level deeper, you can also follow up on this and just ask them, you know, what numbers am I looking for?
• 26:16
  SPEAKER_00: Let's say they do say, Yeah, we are we do test quadriceps strength objectively.
• 26:22
  SPEAKER_00: And so then cool, it'd be like, okay, so just so I know, like what numbers will I be aiming for to start running, and then also for returning to sport and to get cleared.
• 26:34
  SPEAKER_00: And so they should have these numbers.
• 26:36
  SPEAKER_00: This shouldn't be something they need to run and look up.
• 26:38
  SPEAKER_00: They should know these numbers.
• 26:40
  SPEAKER_00: This should be a concrete answer, if you will, of course, considering all other variables of how you're doing, but this should be just something that's like a key performance indicator, a KPI for your ACL rehab process.
• 26:53
  SPEAKER_00: So, for example, for us, for running, you should at least be at 70% limb symmetry index.
• 27:01
  SPEAKER_00: So basically 70% of the uninvolved side.
• 27:04
  SPEAKER_00: That's a minimum standard for us.
• 27:07
  SPEAKER_00: Or if we're using torque to body weight, so we're basically measuring the strength compared to your body weight of your quadricep, we're aiming for that to be 1.7 Newton meters per kg of body weight.
• 27:18
  SPEAKER_00: So basically it's saying that we want to make sure that that is going to measure out appropriate to your body weight, because sometimes even symmetry can be challenging because if the uninvolved side got weaker, then you're kind of chasing a weaker leg.
• 27:34
  SPEAKER_00: But with that said, even if they 70%, at least you got something there.
• 27:37
  SPEAKER_00: But if they don't have anything, a little bit of a yellow red flag there.
• 27:43
  SPEAKER_00: For return to performance or return to sport, and for clearance, 90% is typically what you'll hear is a limb symmetry index.
• 27:51
  SPEAKER_00: So getting that 90% of the uninvolved side, or what we aim for is at least a 3.0 newton meters per kg body weight.
• 28:00
  SPEAKER_00: That basically means your quad can kick out 100% of your body weight when that measures out to like foot pounds, which is a different unit.
• 28:08
  SPEAKER_00: But with that said, that is going to help us make sure that you are at a place where you feel prepared enough from a strength standpoint, and that's going to really help us to make sure that you are in a solid spot as you move forward.
• 28:25
  SPEAKER_00: Now, this is how it currently stands as I record this in 2025.
• 28:29
  SPEAKER_00: Of course, this can change, and I have the right to reserve and change that as more information comes out.
• 28:35
  SPEAKER_00: But guys, this is backed up by a lot of research and a lot of evidence, y'all, to be completely honest.
• 28:40
  SPEAKER_00: So this isn't changing for a hot minute.
• 28:43
  SPEAKER_00: And if you're listening to this, you're likely going to be like, okay, these are the numbers we're looking at, right?
• 28:50
  SPEAKER_00: And so if your PT doesn't do this, my biggest thing here is don't just jump on them and say they suck, right?
• 28:58
  SPEAKER_00: Or they're not good, right?
• 29:00
  SPEAKER_00: And I one thing I want to clarify here, I'm not here speaking from this high pulpit saying, like, I know right, and others don't like guys.
• 29:09
  SPEAKER_00: Like, I'm just trying to be fully transparent here with just being in this space for so long and just seeing this stuff day in and day out, seeing situations where it could have been avoided more than likely because they should have just gotten tested and they should have just gotten good rehab.
• 29:26
  SPEAKER_00: And it makes me so sad whenever I hear about the reinjury rates, and then I hear people these same reinjuries when I asked them about their previous rehab, they tell me about situations like this.
• 29:37
  SPEAKER_00: Never got tested, they got released too early, they followed the protocol, um, and they ended up tearing their ACL again.
• 29:45
  SPEAKER_00: And the thing is, it ends up being that person who suffers, and the PT just moves on.
• 29:50
  SPEAKER_00: They don't, you know, typically hear about it because the person doesn't go back to them, but they typically don't hear about it.
• 29:56
  SPEAKER_00: And so then the thing is, like, they just carry on and there's no repercussions.
• 30:00
  SPEAKER_00: Same thing for the surgeon as well.
• 30:02
  SPEAKER_00: But the thing is, y'all, is that this makes such a huge difference.
• 30:06
  SPEAKER_00: And so this is why I'm so passionate about this.
• 30:09
  SPEAKER_00: This is why I'm sharing this with you guys because I've fielded thousands of calls at this point with different people all over the world, and I'm sharing just what is out there, what is real, the full transparency of what this is, and that's the goal of this podcast.
• 30:22
  SPEAKER_00: And so I want to make sure that things change and change for the better.
• 30:26
  SPEAKER_00: And so I want to make sure you guys are fully equipped, and when you know better, you do better.
• 30:31
  SPEAKER_00: And so that's the goal of this episode.
• 30:33
  SPEAKER_00: Why I'm saying asking these questions is gonna be so helpful.
• 30:38
  SPEAKER_00: And so, going back to like if your PT doesn't do this, don't jump on them on it, right?
• 30:43
  SPEAKER_00: Like, just don't say, like, ah, you suck.
• 30:45
  SPEAKER_00: Like, really, you just need to be curious and ask questions.
• 30:49
  SPEAKER_00: Maybe it's something where they do understand this, but you need to go a little bit deeper on this, but just start being curious, ask questions.
• 30:57
  SPEAKER_00: Your gut will start to tell you whether they know things or not, and you'll start to notice it in your rehab as well.
• 31:02
  SPEAKER_00: You start to feel lost, you don't really have direction.
• 31:04
  SPEAKER_00: When you ask questions, they kind of either repeat themselves or they just kind of like they just like kind of dodge it, if you will.
• 31:12
  SPEAKER_00: But the thing is like be curious, ask questions, be respectful.
• 31:16
  SPEAKER_00: That is super important here.
• 31:17
  SPEAKER_00: Don't say that, Robbie said go ask this question, if not fire your PT.
• 31:21
  SPEAKER_00: But with that said, like it's it's your job to make sure you find the right person because no one else is looking out for you.
• 31:30
  SPEAKER_00: You have to look out for yourself, and it's something that's so important, and you don't want to be too far gone in this or be that person who is that re-injury because you didn't do anything about it.
• 31:43
  SPEAKER_00: So, guys, it's 2025.
• 31:46
  SPEAKER_00: Here's the other thing: the ability to strength test is cheaper than ever, it's available in so many places, so many places.
• 31:54
  SPEAKER_00: We have athletes all over who go and get strength tested in clinics by people, by our network, by mentees who we have uh gone through the mentorship with us and have taught them about these things.
• 32:08
  SPEAKER_00: The network is awesome, y'all.
• 32:10
  SPEAKER_00: So the thing is, is like you don't have to just settle for like, oh well, it's not available.
• 32:15
  SPEAKER_00: Yeah, it might be another expense, yeah, it might be a little bit of a drive, but I promise you, this versus a re-indury, you'll pick this anytime, it'll be worth it, and you can't really put a price on it.
• 32:26
  SPEAKER_00: Um, and so this is something that I really do encourage you to do.
• 32:31
  SPEAKER_00: And I find often that the thing is if PTs and PT clinics don't strength test, they are not up to date with current standards, and this is honestly not acceptable with where we are.
• 32:46
  SPEAKER_00: It's just the way that it goes because if they're not strength testing, there is a very, very strong chance that they're following a protocol or just some cookie cutter thing, and you're just gonna be funneled along in the process.
• 32:59
  SPEAKER_00: Now, typically, in most situations, strength testing can happen probably around the three-month mark, is a healthy place to say.
• 33:08
  SPEAKER_00: It could be sooner, it could be later based on your process, but there's gonna need to be some sort of assessment of strength objectively, and that's what is going to be most important.
• 33:18
  SPEAKER_00: If you're approaching three months, four months, and there's no conversation around it, maybe you started running and there's been no like, hey, we need to test your quad strength, then to me, that is something that needs to be vetted and it needs to be uh questioned a little bit because we need to make sure we know where that number stands, and here is why this is so important.
• 33:41
  SPEAKER_00: We have two big problems in ACL rehab people not returning to the sports and activities they love, aka we have really low return to sport rates, re-injury rates are at an all-time high.
• 33:58
  SPEAKER_00: Why?
• 33:59
  SPEAKER_00: I believe it is a lack of preparation, and the research also backs this up.
• 34:05
  SPEAKER_00: It's the physical components, the mental components, and so much more out there.
• 34:10
  SPEAKER_00: But a big part of not being prepared is because of yeah, maybe it's insurance, maybe it's not the proper skill set of the PTs, but this would all be exposed if we were being properly tested, and we're not being properly tested.
• 34:26
  SPEAKER_00: And when we test and we test the right way, as I mentioned, sharing like what are the proper ways to test, and we went through that pyramid.
• 34:36
  SPEAKER_00: Strength testing is a big chunk of the pie here, y'all.
• 34:41
  SPEAKER_00: Big, big, big chunk.
• 34:43
  SPEAKER_00: What is the maximum strength of my quadriceps?
• 34:46
  SPEAKER_00: What is the maximum strength of my hamstrings?
• 34:48
  SPEAKER_00: What is that number?
• 34:49
  SPEAKER_00: How does it compare side to side?
• 34:51
  SPEAKER_00: How does it look compared to body weight?
• 34:53
  SPEAKER_00: And also, how does it compare to normative data, people similar to myself, right?
• 34:57
  SPEAKER_00: So those are things we look at to make sure is this athlete prepared?
• 35:02
  SPEAKER_00: And so this is a big chunk of this testing.
• 35:05
  SPEAKER_00: And the main thing that I want to simplify is not going out there and being like, we need to test all these things, like to just keep it simple, if there's quadricep and hamstring strength, I'm probably gonna be mostly happy with people if they're like, Yeah, my PT tests these things.
• 35:20
  SPEAKER_00: They could do hop testing and all this other stuff, and I might be like, oh, okay.
• 35:25
  SPEAKER_00: But if there's a dialed-in process for your quadricep strength testing, hamstring strength testing, I'm gonna be on board with it.
• 35:32
  SPEAKER_00: And I've shared countless episodes on how strength is so important for ACL rehab and these outcomes.
• 35:38
  SPEAKER_00: And the research really does support this.
• 35:40
  SPEAKER_00: And if we don't test it the right way, we do not know and are guessing, and we're leaving it up to chance.
• 35:47
  SPEAKER_00: We truly are.
• 35:49
  SPEAKER_00: Now, what do you do if you have a PT who doesn't strength test?
• 35:56
  SPEAKER_00: First off, you ask if there is a way they can assess this via the means that I shared.
• 36:02
  SPEAKER_00: You know, whether it is the isokinetic, can they refer you out somewhere?
• 36:06
  SPEAKER_00: Can they do it in the clinic?
• 36:08
  SPEAKER_00: Maybe someone else in the clinic has a strain gauge to test it, you know.
• 36:13
  SPEAKER_00: Maybe you can do a knee extension test and see if that is there, right?
• 36:18
  SPEAKER_00: But you want to make sure that aligns with the PT, but you can ask and see if there is a way to objectively assess it, right?
• 36:26
  SPEAKER_00: Now that's gonna be interesting coming from the patient side, but I do think that this is worth asking.
• 36:33
  SPEAKER_00: And then if you feel they're a good provider, then you can always continue and then find someone else local to assess this, right?
• 36:41
  SPEAKER_00: If you like them as a provider, you think they actually provide good rehab, maybe they just don't do strength testing, then you can always find someone local to assess this.
• 36:50
  SPEAKER_00: And I think the big thing is trying to find a PT who does these things and ideally through your own physical therapist.
• 36:59
  SPEAKER_00: But if you also feel like the quality is lacking, plus they don't strength test, then find someone else, y'all.
• 37:05
  SPEAKER_00: Fire your PT, find someone else, don't waste time.
• 37:08
  SPEAKER_00: It is your health, your knee, that is going to be at the end of the day the most important.
• 37:13
  SPEAKER_00: So that's gonna be really key here.
• 37:16
  SPEAKER_00: Regardless, I will tell you that at some point, if you want to give yourself the best shot of getting back to what you love, long-term outcomes, and good knee health, and especially for re-injury purposes, you're going to need to find someone else who does measure your quadricep strength, your hamstring strength, and help base things off of this, as well as your entire profile of things that are being tested and assessed, right?
• 37:46
  SPEAKER_00: If it's just like, all right, we are in week 12 and you start running just because the protocol says so, red flag, and this is not something that they're basing decisions off of.
• 37:56
  SPEAKER_00: It's just a timeline.
• 37:57
  SPEAKER_00: And y'all, the more and more I look at protocols, the more and more I'm just like, man, these things are really doing us a disservice because it eliminates a lot of critical thinking, it eliminates the ability to assess.
• 38:10
  SPEAKER_00: There are some out there that are really good that can be helpful if they're utilized with testing and use the testing to make decisions, but for the most part, they're two pages, three pages, four pages, often created by the surgeon, maybe some assistant, maybe an athletic trainer.
• 38:27
  SPEAKER_00: And guys, it never goes to plan.
• 38:30
  SPEAKER_00: Never, ever, ever goes to plan.
• 38:34
  SPEAKER_00: So please make sure that you are finding someone who can help you with this and make sure that it is based off of objective data.
• 38:43
  SPEAKER_00: And often, if they're not strength testing, it kind of just gives me a little bit of insight into them not being up to date and also probably not making decisions based off that.
• 38:54
  SPEAKER_00: And guess what?
• 38:55
  SPEAKER_00: Every single phase, every single block, every single week, like all these things for our ACLers we work with remotely and in person, we are basing this off of data and we're basing it off of like how people are testing.
• 39:09
  SPEAKER_00: Whether they go somewhere locally, whether they're seeing us, whether they are assessing via a knee extension machine, guys, we are using data and we are making sure that we're making decisions based on this, based on the human, based on their goals, based on the context of where they are, and based on their entire profile.
• 39:26
  SPEAKER_00: I'm not just saying strength is the only thing, but it is such a big part of the pie that it's one of those things that truly mean tell me you're good without telling me you're good, or tell me you're bad without telling me you're bad.
• 39:40
  SPEAKER_00: Right.
• 39:41
  SPEAKER_00: And so this is one of those things that if I had to dilute it down to one question, I think this really tells a lot and answers the question if your PT is legit or not.
• 39:53
  SPEAKER_00: So I hope this is helpful.
• 39:54
  SPEAKER_00: This is way too long of an episode on this.
• 39:57
  SPEAKER_00: I thought I was gonna cut it shorter, but man, I just got going and you know what?
• 40:02
  SPEAKER_00: I think you guys need to make sure you have all the details and make sure you can make the best decision, feel well informed.
• 40:10
  SPEAKER_00: And so I hope that this was helpful.
• 40:12
  SPEAKER_00: Now, if you're going to approach your BT, be respectful and just see what it's about, ask them the questions and just gather information, and then from there you can make some decisions on what are the best moves for you and your care.
• 40:28
  SPEAKER_00: If you need any help, please reach out.
• 40:31
  SPEAKER_00: We help people all over the world.
• 40:33
  SPEAKER_00: We're here for you.
• 40:34
  SPEAKER_00: If you just need to send us a message, a question, we got you.
• 40:38
  SPEAKER_00: Hit the show notes for ways to contact us and our team.
• 40:42
  SPEAKER_00: Until next time, y'all.
• 40:44
  SPEAKER_00: This is your host, Robbie Patel, signing off.