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136 | Manipulation Under Anesthesia (MUA) in ACL Rehab · The ACL Athlete Podcast

• 0:19
  SPEAKER_00: Welcome everyone to the ACL Athlete Podcast.
• 0:23
  SPEAKER_00: This is the podcast where we talk about everything related to the ACL, whether that's the injury itself, the rehab process, return to sport, and more.
• 0:33
  SPEAKER_00: I'm your host, Dr.
• 0:34
  SPEAKER_00: Robbie Patel, performance physical therapist and coach.
• 0:38
  SPEAKER_00: Between myself and fellow guests and experts, you'll learn through the lens of the patient, the healthcare professional, and the coach.
• 0:46
  SPEAKER_00: The goal of this podcast is to equip you, the athlete, with the education to make the best informed decision about your care and your ACL journey.
• 0:57
  SPEAKER_00: Thanks for joining.
• 0:58
  SPEAKER_00: Now let's dive into today's episode.
• 1:04
  SPEAKER_00: What is up, team, and welcome back to another episode on the ACL Athlete Podcast.
• 1:09
  SPEAKER_00: Of course, it's very fitting today when I go to record this podcast that there is someone else in our cul-de-sac that is mowing their grass, which is perfect.
• 1:20
  SPEAKER_00: I think that that is just some sort of sweet poetic thing that had started when I first started this podcast.
• 1:27
  SPEAKER_00: So if you have been listening since the beginning or have tuned into earlier episodes, you guys know what I'm talking about.
• 1:34
  SPEAKER_00: But, anyways, if you hear that, I apologize, but it's it's honestly just funny at this point.
• 1:40
  SPEAKER_00: So let's dive into today's episode: Manipulation under anesthesia in ACL rehab.
• 1:47
  SPEAKER_00: It's often referred to as a MUA as for the acronym for it.
• 1:52
  SPEAKER_00: So, what is this scary word or phrase in ACL rehab?
• 1:57
  SPEAKER_00: A lot of you are probably listening to this, and you're probably like curious, what is this manipulation under anesthesia?
• 2:04
  SPEAKER_00: Especially if you haven't heard it before, or maybe you have and you're curious what exactly it entails.
• 2:11
  SPEAKER_00: Am I a candidate for it?
• 2:12
  SPEAKER_00: So I'm gonna break this down as clear as I can and making sure that you guys understand who this could be for and who it might not be for.
• 2:21
  SPEAKER_00: Just know that this is not medical advice.
• 2:23
  SPEAKER_00: This is just purely educational to help you understand what that is.
• 2:27
  SPEAKER_00: And then see, you know what?
• 2:28
  SPEAKER_00: Maybe this is something to consider if you are someone who's dealing with some of these problems and having that conversation with your surgeon or ortho or who you're working with, right?
• 2:38
  SPEAKER_00: So, what is a manipulation under anesthesia?
• 2:42
  SPEAKER_00: It is a procedure that your surgeon will do if your range of motion, typically your knee flexion, has plateaued and is still limiting your overall function and progress in your ACL rehab.
• 2:54
  SPEAKER_00: So, why would you do uh manipulation under anesthesia or who might be the person this falls as a candidate for?
• 3:02
  SPEAKER_00: Well, range of motion is why it's done.
• 3:05
  SPEAKER_00: Range of motion is a big thing we're trying to accomplish post-injury and then post-surgery.
• 3:10
  SPEAKER_00: And so that can often plateau for a number of reasons.
• 3:14
  SPEAKER_00: So we typically see this on the table for potentially people who are less than 120 degrees of flexion, usually in that less than 100 degree range, especially the further out from ACL surgery that they are.
• 3:29
  SPEAKER_00: This is, you know, let's say, for example, you are eight weeks out and you're still struggling to get to 90 degrees, and then you're progressively trying to work on it and it's not getting anywhere, and you've been working on it diligently, then this can become of a question.
• 3:45
  SPEAKER_00: I would hope your surgeon and your physical therapist has already had a conversation with you about your range of motion.
• 3:51
  SPEAKER_00: If it feels like it's especially plateaued and you're working really hard on it.
• 3:56
  SPEAKER_00: The less flexion that you have and the more time that progresses, the more likely this can become an option that's on the table or a discussion.
• 4:05
  SPEAKER_00: And it can happen with extension, especially if that is really off compared to the other side.
• 4:12
  SPEAKER_00: But a lot of times this will happen with flexion when you're doing a manipulation under anesthesia.
• 4:16
  SPEAKER_00: I'm gonna start referring to it as MUA, just because that's a lot of words.
• 4:20
  SPEAKER_00: So with an MUA, this is something where you have to be the right candidate for this.
• 4:25
  SPEAKER_00: Patients and athletes will often feel stiffness and they'll feel kind of like this block, or they will hit this quote unquote wall that they describe.
• 4:34
  SPEAKER_00: It's like they try and try and they'll work on it, and they just hit this wall that just doesn't go away.
• 4:39
  SPEAKER_00: And they've been diligent with working on it.
• 4:42
  SPEAKER_00: And sometimes this ends up usually as a result of artrofibrosis.
• 4:47
  SPEAKER_00: And so let's just break down what this term means.
• 4:50
  SPEAKER_00: I'm sure some of you have probably heard of it, but arthro means joint, and fibrosis means the formation of scar tissue.
• 4:57
  SPEAKER_00: So we are talking about scar tissue, and we're not 100% sure why scar tissue forms in the first place, but it can form for a number of reasons.
• 5:07
  SPEAKER_00: I've talked about this in previous episodes, but this is just something that can be tough to kind of deal with with the ACL rehab process, and it can come back to, you know, the the injury itself, to honestly your genetics can play a role in this, to maybe it's just the way that your body heals.
• 5:25
  SPEAKER_00: Um, it lays down a lot of scar tissue.
• 5:27
  SPEAKER_00: It could be the complexity of the procedure itself, or it could be just because you weren't compliant and you didn't really do a lot of work after you had your injury, or maybe after your surgery, especially, and things just started sticking together because you were like, it'll just come along with time and you just didn't do your work.
• 5:45
  SPEAKER_00: And that can happen.
• 5:46
  SPEAKER_00: So this is something that you just have to consider in terms of when arthofibrosis or scar tissue forms in the knee, which is usually an indicator of some sort of intervention.
• 5:58
  SPEAKER_00: Usually for extension, we'll see something more like a cyclops lesion, which I've talked about, where it's just scar tissue forming around the ACL, which will impact that extension.
• 6:07
  SPEAKER_00: Or if it's more flexion-based, it could just be general scar tissue in different areas, and it's just potentially limiting that joint from getting the rest of the way.
• 6:16
  SPEAKER_00: And so this is where we talk about when is uh MUA done.
• 6:21
  SPEAKER_00: This is gonna come back to the surgeon that you're working with and their specific preference.
• 6:26
  SPEAKER_00: I've had some surgeons who want to intervene early, and I've had some surgeons where they're like, nope, you know, they're making just enough, or I want to wait like X number of months or weeks before we see this.
• 6:38
  SPEAKER_00: Everyone's got their own preference based on their own experiences, background, you know, X, Y, and Z of the reasons they're going to share why they do a certain intervention or not yet.
• 6:50
  SPEAKER_00: Usually after the 12-week mark is when we will see it with any of our athletes, for example.
• 6:55
  SPEAKER_00: And let's get this straight here that this is something that we got to make sure that you have been putting in the work and you have been working on your extension, your flexion diligently, you've been doing your rehab, and this is where we're considering this.
• 7:09
  SPEAKER_00: It could also be the flip side of someone not doing their work, which I'll talk about later.
• 7:14
  SPEAKER_00: But let's just assume all this has you've been putting in the work and it's still not moving the needle whatsoever.
• 7:20
  SPEAKER_00: So then usually after 12 weeks, there is a strong consideration of like, okay, where is the flexion at and the extension?
• 7:28
  SPEAKER_00: And let's make sure that we are intervening like we need to before we have this kind of opportunity cost where you know, the further you get along in this process, if you don't have that range of motion, it is a major requisite need for being able to do all the other things.
• 7:44
  SPEAKER_00: If you don't have flexion, you can't get on the bike, for example.
• 7:47
  SPEAKER_00: You can't be able to even go through a normal cycle of being able to run with the flexion to extension.
• 7:54
  SPEAKER_00: You can't be able to probably navigate stairs normally.
• 7:57
  SPEAKER_00: It just all depends on what that degree is.
• 8:00
  SPEAKER_00: And then that's going to potentially impact you in further things down the road, especially when you're talking about getting stronger and being able to do more dynamic tasks with your knee and with your body.
• 8:11
  SPEAKER_00: And so, as I mentioned before, with the plateau with flexion is when we'll typically see this.
• 8:17
  SPEAKER_00: The athlete is stuck at a certain level of flexion, 80 degrees, let's say, for example, and even when working consistently on it, they can't get past it.
• 8:26
  SPEAKER_00: Or maybe they will a little bit and then they'll regress back.
• 8:29
  SPEAKER_00: Usually it's that wall that they hit.
• 8:32
  SPEAKER_00: And the other flip side to this is that once you hit the 120-ish mark of 120 degrees of flexion, surgeons are more hesitant to do any type of manipulation.
• 8:42
  SPEAKER_00: And I've seen this with surgeons across the board.
• 8:44
  SPEAKER_00: And even from our own experience, once athletes get to this 120 mark, which is such a huge goal for us in that first four weeks, especially, ideally to get to that point, unless there's any type of restriction, like a meniscus or anything where we don't want to push past that, then if they hit the 120 mark, usually the rest of that does come back over time if there's consistent work to it.
• 9:09
  SPEAKER_00: But if you're in the 60s, 70s, 80 degrees, even 90 degrees, and you're 12 plus weeks out and it's not budging whatsoever.
• 9:18
  SPEAKER_00: And let's say you've been working consistently on it for two weeks, three weeks, and it's not moving the needle whatsoever.
• 9:25
  SPEAKER_00: This is a conversation with the surgeon, making sure a conversation with your physical therapist, of course, you're working with, and conversation to see what are next steps, because I think that there's a massive opportunity cost if you're just like, ah, it'll come along, it'll come along, and you're still in that low degree of let's say 70 to 90 degrees, and you're pretty decent amount of time out, something needs to be looked at or done, or we need to check in with your own compliance of doing your work, right?
• 9:55
  SPEAKER_00: So let's talk about the research because I think it's important to make sure that we have some data and some information to kind of help validate why we do these things.
• 10:03
  SPEAKER_00: So when we're looking at uh a certain study in 2018 by Julio, H-U-L-E-A-T-T, Juliat, Hullet, risk factors for manipulation under anesthesia and or lysis of adhesions after anterior cruciate ligament reconstruction.
• 12:25
  SPEAKER_00: Research studies and their titles are always so fascinating.
• 12:29
  SPEAKER_00: They looked at 2,424 ACLRs, so ACL reconstructive surgeries.
• 12:37
  SPEAKER_00: This review had an average of looking at people 57 months over a 10-year period, and the MUA andor a lysis of an adhesion with art fibrosis was 4.5% of these people, so 108 patients.
• 12:54
  SPEAKER_00: Of these risk factors, graph type, infection, concomitant, meniscal repair, and a primary reconstruction are significant risk factors for undergoing a MUA or a lysis of adhesions after ACL reconstruction.
• 13:11
  SPEAKER_00: Now, before you worry about your graph type and you falling into these buckets of a primary reconstruction, which is most people, with that said, they're just you know correlating anybody who falls into one of these categories or multiple, and then people who might have gone on to also have this manipulation under anesthesia or the lysis of an adhesion, which basically means they just kind of cut it away or removed it.
• 13:36
  SPEAKER_00: So, with that said, remember they took 2,424 patients, and of those, over time, only 108 of those were realistically impacted by arthofosis of some sort where they needed some sort of intervention, and that was less than 5%.
• 13:54
  SPEAKER_00: So it is not a high number here.
• 13:56
  SPEAKER_00: So they're just sharing okay, there are some relationships between some of these pieces, but these are more correlations than anything.
• 14:04
  SPEAKER_00: So take that for what it's worth.
• 14:05
  SPEAKER_00: But it is something helpful to know that okay, of this group, you know, less than 5% of people were affected by some sort of issue with artofibrosis.
• 14:15
  SPEAKER_00: And so then if we kind of go into this next study, which was back in 1991 by Dodds, results of knee manipulations after intercruciate ligament reconstructions.
• 14:26
  SPEAKER_00: So they did 42 knees.
• 14:27
  SPEAKER_00: The average time from ACLR to manip was seven months, which I think is a pretty long time.
• 14:33
  SPEAKER_00: At the manipulation, average flexion was increased from 95 degrees to 136 degrees, and average extension from 11 degrees in the positive, so they got a bent and bend in there, um, to three degrees.
• 14:48
  SPEAKER_00: So followed up with these people 26 months after their ACL reconstruction.
• 14:53
  SPEAKER_00: So give or take about 19 months after this uh manipulation after anesthesia, and the knees with that extension deficit that was greater than or equal to 15 degrees achieved significantly less final extension than the knees with less pre-manipulation deficits.
• 15:11
  SPEAKER_00: So basically, the people going into the manipulation with a larger knee extension deficit had a larger knee extension deficit whenever they finished and they checked on these people, which makes sense.
• 15:23
  SPEAKER_00: You know, you would hope that all that comes back, but if they were having an extension problem from the beginning and it was a lot, we're talking about 15 degrees, which for extension that is a lot of a difference when you're trying to aim to zero to the negatives of hyperextension.
• 15:38
  SPEAKER_00: It makes sense.
• 15:39
  SPEAKER_00: A lot of times you will see this, and I've seen this even in my own practice and with our ACLers.
• 15:43
  SPEAKER_00: If people don't get it, then they have a hard time getting close to that, you know, extension that we ideally want.
• 15:49
  SPEAKER_00: And it might be because of a number of reasons, but that is something that showcases with practice.
• 15:56
  SPEAKER_00: And at the end, they said overall manipulations were a safe and effective method for improving both flexion and extension in 86% of the knees that had restricted motion after ACL reconstruction.
• 16:07
  SPEAKER_00: So it had a pretty positive carryover for these people.
• 16:11
  SPEAKER_00: So if you take 86% of those 42 people, that's a pretty good chunk of those people who ended up having improvements because they were stuck at 95, right?
• 16:20
  SPEAKER_00: And you see the average flexion here in this study, even back then, was at 95 at seven months.
• 16:27
  SPEAKER_00: That's a pretty bad restriction, in my opinion.
• 16:29
  SPEAKER_00: And even 11 degrees in extension is a pretty bad deficit if most people sit into the negatives for hyperextension.
• 16:37
  SPEAKER_00: So this further implies that, you know, we need to make sure that things are taken care of.
• 16:42
  SPEAKER_00: And even in this study, you know, maybe it's just the way that they set it up, but the average time of manipulation being seven months, in my opinion, is way too long.
• 16:51
  SPEAKER_00: You think about at seven months, man, you could be on the field running, cutting, jumping, um, you could be back to be hiking, you could be back to doing a lot of different things at seven months if we're just like, you know, going from a zero to seven month standpoint.
• 17:06
  SPEAKER_00: But if your flexion or extension is limiting you, that needs to be addressed early on in the process.
• 17:12
  SPEAKER_00: Now don't go running to your surgeon or your physical therapist if it's not moving in the first four weeks.
• 17:17
  SPEAKER_00: And I want to add some caveats here because let's say, for example, you had a meniscus repair and you have restrictions to not be able to bend past 90 for four weeks or six weeks, which we've seen before.
• 17:30
  SPEAKER_00: And that's something that can make your flexion come back slower, and it can also make your knee want to potentially form scar tissue that would want to protect it from moving into that deeper degree of flexion.
• 17:42
  SPEAKER_00: But you know, if you just kind of follow the guidelines and work really hard, that is the biggest thing here is that if you're diligent day in and day out, we call them our daily bricks.
• 17:50
  SPEAKER_00: We're laying the foundation brick by brick, and this includes your extension and your flexion until it is no longer a problem, and you hit the proper KPIs and the symmetry that we are looking for in this process.
• 18:03
  SPEAKER_00: So that's what's gonna be key here in this process.
• 18:06
  SPEAKER_00: Just know that you know it's always gonna depend on a number of factors.
• 18:11
  SPEAKER_00: Um, it's going to be very important to see where you are from your injury and especially your surgery.
• 18:16
  SPEAKER_00: I'm including injury in here too, because if you are injured and you're not gonna have ACL surgery, but let's say you are still restricted by your flexion or extension by let's say three months or six months, um, and there's been an evaluation and looking at all the details around this and what you're feeling, um, then there's potentially people who might need it even if they didn't have surgery, because scar tissue can still form because you still had an injury, right?
• 18:43
  SPEAKER_00: So the knee has to go through healing.
• 18:45
  SPEAKER_00: So whether it's injury or even surgery, the thing that I will say is your baseline going into surgery will determine so much of also how potentially you'll do after the surgery.
• 18:57
  SPEAKER_00: It'll also give us information and know how you're doing.
• 19:00
  SPEAKER_00: So then that way we know, okay, pre-surgery, you're able to get to X amount.
• 19:05
  SPEAKER_00: So then, therefore, we should be able to at least get to this, if not further beyond that.
• 19:10
  SPEAKER_00: So, what to expect?
• 19:12
  SPEAKER_00: How do they do this?
• 19:13
  SPEAKER_00: What happens?
• 19:14
  SPEAKER_00: So, fibrotic changes happen in that periarticular, so just kind of around these joints that are kind of touching each other, and in the intra-articular soft tissues hindering that movement.
• 19:27
  SPEAKER_00: So, just think about scar tissue in the knee joint, um, in certain areas that could be potentially restricting uh that movement, right?
• 19:35
  SPEAKER_00: So, then what they will do is anesthesia will reduce the muscle tone and those protective reflexes.
• 19:41
  SPEAKER_00: That's why they put you under anesthesia.
• 19:43
  SPEAKER_00: Um, and then the surgeon is going to basically break up the scar tissue to gain more range of motion.
• 19:50
  SPEAKER_00: So, usually it's a very quick procedure.
• 19:52
  SPEAKER_00: People are in and out within 30 minutes.
• 19:55
  SPEAKER_00: Um, it's something where they just literally force your knee into that position because you don't have that muscle tone or protective reflex.
• 20:03
  SPEAKER_00: Um, because could you imagine this when you're actually awake?
• 20:07
  SPEAKER_00: No freaking way.
• 20:09
  SPEAKER_00: Um, this is something that you want to make sure that you have no control over or reacting to.
• 20:15
  SPEAKER_00: Um, you want them to do their thing.
• 20:16
  SPEAKER_00: And then a lot of times after this is done, people can walk out of it.
• 20:20
  SPEAKER_00: Um, there's soreness that people will report and some achiness, obviously, because you kind of work through that and it was forced into a range of motion.
• 20:28
  SPEAKER_00: Um, rather than like a true pain or sharpness, like you feel, like the post op or post-injury, where you get that acute, really sharp pain, right?
• 20:37
  SPEAKER_00: Um, so that will kind of be what people will feel.
• 20:41
  SPEAKER_00: Um, I've never had it myself, so I can't speak from experience, but this is me, you know, with some of our ACLers who have had to do this or who have done it before they came to work with us.
• 20:52
  SPEAKER_00: This is how they experience it.
• 20:54
  SPEAKER_00: This is what they share.
• 20:55
  SPEAKER_00: And even talking with surgeons, this is typically their process for going about it.
• 21:00
  SPEAKER_00: Now I'm gonna share some advice with you guys and some recommendations.
• 21:03
  SPEAKER_00: So if you're listening to this and you're pre-op or early post-op, this is your reminder to do your range of motion work multiple times a day, every single day.
• 21:14
  SPEAKER_00: Literally make it a religious habit to do it and make sure that when someone asks you, hey, are you doing your work?
• 21:22
  SPEAKER_00: And you talk to your PT, you talk to your surgeon, you talk to whoever you're working with, and they're like, Hey, like, are you doing this at home multiple times?
• 21:29
  SPEAKER_00: And you're really pushing into it and listening to your body while it's healing, but also working into this as much as you can.
• 21:36
  SPEAKER_00: Um, you want to be able to say yes.
• 21:38
  SPEAKER_00: You want to be able to say, I've worked as hard as I can on this.
• 21:41
  SPEAKER_00: So then that way the next steps that need to be taken can be evaluated very appropriately versus them being like, Well, you're just not a compliant patient, so we don't know if this is more so you just need to work on this, or is it just something where uh you have been working on this and it's just not progressing or it's plateaued pretty, pretty uh consistently.
• 22:02
  SPEAKER_00: So if you are at this point where an MUA is being considered, just ask yourself if you've been diligent and consistent with your range of motion work.
• 22:10
  SPEAKER_00: Cool.
• 22:10
  SPEAKER_00: If you have, um have you been pushing into that tolerable level of discomfort to push?
• 22:16
  SPEAKER_00: Um, and then if so, great.
• 22:18
  SPEAKER_00: Like I said, you've done all that you can that's controllable.
• 22:22
  SPEAKER_00: And if not, then it's gonna be important to make sure you don't make the same mistake again, especially if you've had an MUA.
• 22:28
  SPEAKER_00: You want to make sure you get after that range of motion, maintain it.
• 22:32
  SPEAKER_00: If you don't use it, you'll lose it.
• 22:35
  SPEAKER_00: Very good idea here.
• 22:36
  SPEAKER_00: And I remember this very clearly.
• 22:38
  SPEAKER_00: I just worked really hard on my range of motion, my extension, my flexion.
• 22:43
  SPEAKER_00: This was just something that I was very religious about, made sure I did every day, multiple times a day.
• 22:48
  SPEAKER_00: Um, I was a good rule of follower, but I also wanted to, you know, kind of hit the goals that were targeted, especially in that early post op phase.
• 22:55
  SPEAKER_00: So this is a huge, huge reminder of making sure that you work on your range of motion and stay consistent with it.
• 23:02
  SPEAKER_00: Um, don't just do one big bulk of it and then just revisit it, you know, two days later.
• 23:07
  SPEAKER_00: Instead, spread it out through your day, do smaller sets, um, and then be able to chip away at it little by little by little, each day and every day.
• 23:17
  SPEAKER_00: So this is going to be really key in terms of if you get your MUA, you want to schedule PT the next day.
• 23:25
  SPEAKER_00: You should already know what you're doing, but it'll be key to make sure that you get that PT in as early as you can post manipulation because range of motion is going to be so so key.
• 23:37
  SPEAKER_00: The same thing as after a cyclops lesion, you're wanting to make sure you retain that range of motion because what can happen is after you get this, sometimes the knee will kind of want to go back to where it was.
• 23:50
  SPEAKER_00: So make sure that you maintain that as much as you can.
• 23:52
  SPEAKER_00: I'm a huge fan of post injury, post op, and post manipulation to get the knee moving with PT the next day.
• 23:59
  SPEAKER_00: You guys know that, especially post manipulation, don't lose that precious range.
• 24:04
  SPEAKER_00: Of motion that you just got, prioritize your range and hit it each and every day.
• 24:09
  SPEAKER_00: So as we wrap up here, the last thing that I want to mention here are factors to consider if you're pre-op and in prehab, right?
• 24:16
  SPEAKER_00: The big key here is don't rush into surgery, especially if you jacked up your knee pretty bad.
• 24:21
  SPEAKER_00: Um, you know, whenever I, you know, people are like, ah, it wasn't too bad.
• 24:25
  SPEAKER_00: And then people share all the injuries that they had with it.
• 24:28
  SPEAKER_00: They're like, all right, tore my ACL, um, meniscus tear, um, MCL injury, bone bruise, uh, fracture on my tibia plateau, um patellar, uh, dislocation.
• 24:39
  SPEAKER_00: You know, I'm like, that's it's bad, man.
• 24:42
  SPEAKER_00: It's really bad, and you're probably feeling it.
• 24:44
  SPEAKER_00: Um, but with that said, if you had some pretty, you know, big swelling, restrictions in range of motion, instead of rushing into surgery, I I'm not a big fan of this, and this only applies to maybe 1% of people who really have a time sensitivity to do that or some sort of complication that needs to be addressed very quickly.
• 25:03
  SPEAKER_00: The 99% of you guys who are doing this process can wait for surgery for a little bit, get the knee as normal and as quiet as possible, and that will be a massive, massive, massive game changer.
• 25:15
  SPEAKER_00: And it'll also potentially help you from laying down scar tissue and maybe preventing you from having to get a manipulation down the road if you are someone who falls into this category.
• 25:26
  SPEAKER_00: Um, there was a paper from Kozgaria from 1995 that showed that arthrofibrosis scar tissue was less when the acute ACL reconstruction was delayed at least three weeks from surgery.
• 25:40
  SPEAKER_00: ACLers in this study who got their knee extension range better was less likely to have arthrofibrosis.
• 25:47
  SPEAKER_00: Another reason why getting your range of motion post-injury and post-surgery are going to be so key, but this paper talks about post-injury.
• 25:55
  SPEAKER_00: So make sure you do that.
• 25:57
  SPEAKER_00: In review team, it happens.
• 26:00
  SPEAKER_00: You know, people for some reason or another will have their knees where they can hit a wall.
• 26:05
  SPEAKER_00: Um, even if you've been consistent, that's the only thing that you can control.
• 26:10
  SPEAKER_00: So if you're hitting that stuff day in and day out, right on.
• 26:13
  SPEAKER_00: Keep doing it.
• 26:14
  SPEAKER_00: And then, you know, have that conversation earlier with your PT and with your surgeon, especially if you kind of fall into this bucket where you're stuck, you know, less than that 90 degrees, especially, and you're, you know, two months out, three months out from surgery, and it's still kind of not moving, right?
• 26:31
  SPEAKER_00: Our goal, at least for our ACLers that we set ideally, and let's take no restrictions out.
• 26:36
  SPEAKER_00: We tell our A sailers to aim for 90 degrees by two weeks, and by four weeks, we're aiming for 120 degrees.
• 26:43
  SPEAKER_00: If you get this stuff earlier, awesome.
• 26:45
  SPEAKER_00: That will be beneficial to you.
• 26:47
  SPEAKER_00: If it takes longer, that's great too.
• 26:50
  SPEAKER_00: Guess what?
• 26:50
  SPEAKER_00: Most people take longer to get it, and that's okay, but we want to set these targets, we want these time frames because man, this opens up a world uh for us to do things as well as not having to backtrack um on the front end to be able to make sure that we can kind of keep this thing going.
• 27:08
  SPEAKER_00: But just know I've had Asailers who have come in stuck at you know, uh 100 degrees, 110 degrees, and they're you know, four months out, they're six months out.
• 27:18
  SPEAKER_00: Um, and then it could have been just because they weren't doing the thing, their PT wasn't giving them good guidance, maybe they're dealing with a lot of issues here, and then there's that small subset category where people just run into that wall, even though they're diligently working on it, and they may have to get a manipulation.
• 27:34
  SPEAKER_00: And so let's just make sure at the end of the day, you're doing everything you can to work on this flexion, you don't fall into this bucket.
• 27:41
  SPEAKER_00: But the goal here today is to make sure that you own your range as you get through this process, work on it consistently after.
• 27:49
  SPEAKER_00: If you do have one, if you are pre-op, then make sure you get the knee settled and quiet down, and this will help your chances of scar tissue forming and honestly the rest of this process.
• 28:01
  SPEAKER_00: So I hope that this was helpful, guys.
• 28:02
  SPEAKER_00: I know it was super long, but I didn't want to do a short episode on this because I think you just need the context, the details, the research to show okay, how much of people kind of get this type of procedure.
• 28:15
  SPEAKER_00: So as long as you've got the good guidance and expert in your corner, um making sure that you're communicating well, doing all the things, then just keep rocking.
• 28:24
  SPEAKER_00: Maybe you're listening to this and you kind of fall into this bucket and you're curious, you want another opinion, reach out to us, send us an email, send us a message on Instagram.
• 28:34
  SPEAKER_00: This could be something that we'd be happy to just kind of give you an opinion about.
• 28:38
  SPEAKER_00: Of course, just our own thoughts working with ACLers, nothing medical, but this is something that I think can get missed often.
• 28:45
  SPEAKER_00: So make sure that you have all the things that you need to be able to take care of yourself in this process.
• 28:52
  SPEAKER_00: Until next time, team, this is your host, Robbie Patel, signing off.