Latest / The ACL Athlete Podcast / 078 | Movement Compensations in ACL Rehab

Transcript

078 | Movement Compensations 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: Ravi Patel, performance physical therapist and coach.
• 0:38
  SPEAKER_00: Between myself and fellow guests and experts, you'll learn through the lens of the patient, the healthcare professional, and the coach.
• 0:46
  SPEAKER_00: The goal of this podcast is to equip you, the athlete, with the education to make the best informed decision about your care and your ACL journey.
• 0:57
  SPEAKER_00: Thanks for joining.
• 0:58
  SPEAKER_00: Now let's dive into today's episode.
• 1:03
  SPEAKER_00: What is up, ACL athletes, and welcome back to another episode on the ACL Athlete Podcast.
• 1:10
  SPEAKER_00: Today is episode number 78, and we are talking all about movement compensations and ACL rehab.
• 1:19
  SPEAKER_00: This is something that is very interesting and a very big topic in ACL rehab, in movement and rehab in general.
• 1:29
  SPEAKER_00: But ACL rehab is very interesting because the whole term compensation really fits in terms of the way that we move because our bodies are going to figure out ways to do what we need it to do, and we might not be paying attention to the how we do it or where we feel it, but it's more so like, okay, here's the squat, they're doing the squat, but that doesn't necessarily mean that we are getting out of it what we want to.
• 1:57
  SPEAKER_00: So today we're going to be diving into a little bit of research and to help bring this idea to life in terms of what's been seen and things that we're looking at that I think can be very helpful.
• 2:10
  SPEAKER_00: Whether you're the ACL athlete trying to implement this into your own process, or maybe you're a clinician or a coach trying to figure out, I keep having this issue, or I keep seeing this.
• 2:22
  SPEAKER_00: Is there any information or research about it and what can we do about it?
• 2:27
  SPEAKER_00: So when we're talking about movement compensations, to make it super clear here, we're essentially just talking about we are trying to do a specific movement or a certain task, is what we'll call it.
• 2:41
  SPEAKER_00: And our body figures out a way to do it.
• 2:44
  SPEAKER_00: So we figure out if we need to squat, if we need to walk, if we need to take the stairs, if we do not have the strength or the range of motion, our body is going to figure it out and find an option to be able to complete the task.
• 3:01
  SPEAKER_00: We are incredible movers and we're incredible at just completing a task no matter how it looks or how it feels.
• 3:08
  SPEAKER_00: And when you have an injury or a surgery that is limiting you, you'll still do it if you can, but you might figure out every single way to do it without impacting the area that has been damaged or injured or is in pain or might just be weak, right?
• 3:26
  SPEAKER_00: So we'll refer to a task here, and this is essentially our body finding a way to complete the task.
• 3:33
  SPEAKER_00: It doesn't matter how, but let's say, for example, if I line up 10 athletes, they've all had recent ACL reconstruction, and I ask them to step onto a stair, or let's say even just a squat, because that's super simple, do an air squat for me, every single one of these people, all 10 of them, will do it a different way.
• 3:55
  SPEAKER_00: Not only because of the way their body and their anatomy is, which everyone's not supposed to squat the same way, but everyone will have their own optimal, if you will, position and range to squat.
• 4:10
  SPEAKER_00: The thing is, is that when you have a knee injury or pain or swelling or limited range or lack of strength, especially in your quads, then we are going to figure out a way to squat, and all ten of these people will try to squat and they'll do it different ways because of where they're at in their process.
• 4:32
  SPEAKER_00: That's no fault to them, they're just told to do a squat.
• 4:35
  SPEAKER_00: So we need to make sure that they execute the squat the way that us as the clinician or the coach or the way we want it to look is there and we feel it in the right places as well.
• 4:48
  SPEAKER_00: And what we will typically see is people compensate by shifting to the unoperated side.
• 4:55
  SPEAKER_00: I know a lot of you listening are probably like, yep, I shift my butt over, and let's say it's my left knee that's been reconstructed.
• 5:02
  SPEAKER_00: I'll squat down and start shifting to the right, or I could see it in the mirror or a picture, or yeah, I'm just kind of leaning over to my right side because we want to offload or unweight the operated side to protect it.
• 5:17
  SPEAKER_00: It might not feel strong enough, and we have a strong side, so we're gonna focus on putting most of our weight over to that side, and that's super common.
• 5:27
  SPEAKER_00: And then the other thing is that we might shift our butt back instead of kind of dropping straight down in our squat, and that'll help us to shift our weight towards our glutes and our hamstrings as opposed to loading our quads or putting more stress towards the knee.
• 5:43
  SPEAKER_00: And this all is very common, and we're gonna break this down more specifically today.
• 5:48
  SPEAKER_00: But this is why we have to be so intentional and so specific about the movements we're doing and the education towards you guys or towards the patients, the ACL athletes on why we're doing it.
• 6:02
  SPEAKER_00: So, whenever I tell someone to squat, sure I'll give them some opportunities to do it and see how they look, how they feel.
• 6:09
  SPEAKER_00: It might be something where I don't say anything, but then at some point, especially if they are early on, we want to make sure that we cue the athlete.
• 6:18
  SPEAKER_00: We want to make sure they know why we are doing a certain movement and what the goal of the movement is, how it should feel.
• 6:27
  SPEAKER_00: And that's gonna be some very big pieces, but we have to be very intentional about it.
• 6:32
  SPEAKER_00: Otherwise, I've seen tons of people who have come in later where they're like, Yep, I'm doing a squat.
• 6:37
  SPEAKER_00: This is what I did in PT, and they squat down, one leg looks wonky, or they're just kind of shifting to the uninvolved side.
• 6:45
  SPEAKER_00: It's a classic thing that we see in ACL rehab, or they will shift their butt back and their shin is completely vertical.
• 6:52
  SPEAKER_00: Those are the things that we will commonly see, and that's the thing that we want to make sure we coach really, really well.
• 6:59
  SPEAKER_00: And sometimes it's instead of being like, hey, here's 10 different cues, which I would never recommend, it's gonna be creating the environment or constraining the movements to set it up.
• 7:10
  SPEAKER_00: So it might be going to a target, it might be setting up some sort of foam roller to one side, it might be something where we use a visual feedback like a mirror in order to make sure we're hitting the right target.
• 7:22
  SPEAKER_00: So all of these pieces will be very important when we're talking about movement compensations, but it's really going to depend a lot on what we call the task, the environment, and the person or the athlete, the organism is what is typically referenced in the research of the dynamical systems theory.
• 7:44
  SPEAKER_00: But this is something that we want to make sure that we can understand, and a lot of times it comes down to the task, the task that we're asking them to do, and then how are we organizing or self-organizing as the athlete to complete the task?
• 8:00
  SPEAKER_00: And if it's not doing that very well, then we need to set up our environment to allow the person to complete the task.
• 8:07
  SPEAKER_00: That's the thing that we're essentially saying, and to keep it as simple as possible.
• 8:12
  SPEAKER_00: All right, so we're gonna dive into some of this research as well as some of these terminologies to help understand this a little bit better.
• 8:20
  SPEAKER_00: So one of the things I want to talk about is understanding interlim versus intra-limb compensations.
• 8:28
  SPEAKER_00: Interlimb is INTER limb.
• 8:32
  SPEAKER_00: So we're talking about inter, so between limbs or between leg to leg, and then intra is within the same leg itself.
• 8:49
  SPEAKER_00: So you can kind of look at this as like from one side to the other versus within the same leg itself.
• 8:54
  SPEAKER_00: So with inter limb compensations, this is a shift from your ACL injured or operated side to the uninvolved or the non-operative side.
• 9:06
  SPEAKER_00: We see this all the time.
• 9:07
  SPEAKER_00: And a great simple example that I talked about earlier is the squat shift.
• 9:12
  SPEAKER_00: So if I ask someone to squat and they have an inter limb compensation, instead of squatting straight down the center, 50% on each side, they will shift to where most of the weight will shift to the uninvolved or the unoperated side.
• 9:29
  SPEAKER_00: Again, avoiding loading the operated side because it could be a strength thing, it could be a pain thing, a range of motion, it could even be something where they just have learned to adopt that pattern, but they are compensating via the interlimb to the unoperated side.
• 9:46
  SPEAKER_00: And then on the flip side, we have intra-limb compensation.
• 9:51
  SPEAKER_00: So that is a shift from one joint or a certain strategy or a muscle group on the same side leg to another.
• 10:00
  SPEAKER_00: And so, an example of this, if we keep rolling with the squat example, is a squat shift.
• 10:05
  SPEAKER_00: Instead of thinking about you, maybe you're centered and you have 50 to 50% distribution side to side, leg to leg.
• 10:13
  SPEAKER_00: But what you do is when you go to squat, instead of allowing the knees and the hips to break in the opposite directions and think about this as dropping straight down or between your legs, instead with the intra-limb compensation, you might end up shifting from allowing your knees to get loaded or your quads to a hip strategy where your butt goes back.
• 10:38
  SPEAKER_00: And the best example of this is when you go to squat down, instead of allowing yourself to just kind of squat normal, kind of very vertical, your torsos up and allowing the knees to go forward, you are literally shooting your butt super far back, and your shins remain very vertical.
• 10:57
  SPEAKER_00: It's almost like a straight line up towards the the sky.
• 11:01
  SPEAKER_00: And that's the thing that you will often see because what we'll do is avoid loading the knee and the quads, because again, coming back to pain, swelling, range of motion, weakness, fear, there's so many different factors that play into this.
• 11:16
  SPEAKER_00: But what we'll do is we'll shift our butt back.
• 11:18
  SPEAKER_00: So we're completing the squat, and I've seen this thousands of times, thousands of times at this point, where literally they will go, they'll squat, and they'll just kind of shoot their butt back, and they're like, I did it, but then I'm like, that looks really different compared to us trying to execute a really good even squat.
• 11:39
  SPEAKER_00: So that's the intra-limb compensation.
• 11:41
  SPEAKER_00: So instead of loading our knee and our quads and the whole leg, we end up shooting our butt back in order to load our hamstrings and glutes, and we feel safe there.
• 11:50
  SPEAKER_00: And that's called a hip strategy with that butt back instead of allowing to let the knee come forward with it.
• 11:57
  SPEAKER_00: And so let's dive into this huge study.
• 12:00
  SPEAKER_00: It was a really awesome study.
• 12:02
  SPEAKER_00: This is one of the coolest studies, I think, out there, where they really noticed a difference between this three-month mark and five-month mark with ACL athletes.
• 12:12
  SPEAKER_00: So the title of this study is Compensatory Strategies that reduce knee extensor demand during a bilateral squat change from three to five months following anterior cruciate ligament reconstruction by Susan Sigward in 2018.
• 12:30
  SPEAKER_00: Those are a lot of big words.
• 12:32
  SPEAKER_00: It's essentially the compensations that will reduce the quadriceps strength, like the demand on it, when we're doing a squat.
• 12:41
  SPEAKER_00: And we're looking at the changes from three to five months after an ACL reconstruction.
• 12:45
  SPEAKER_00: That's the normal human terminology here.
• 12:49
  SPEAKER_00: And so when we're looking at this incredible study by Sigward, Susan Sigward is at USC and she does great research with ACLs.
• 12:58
  SPEAKER_00: And this was one of those that really highlights this compensatory strategies that we're going to talk about.
• 13:05
  SPEAKER_00: So the goal of this study was to assess loading patterns in a bilateral squat, so a normal squat and the way that we load it, and individuals following ACL reconstruction at three months and at five months.
• 15:23
  SPEAKER_00: And we wanted to determine how the compensations contributed to the reduced knee extensor moments.
• 15:30
  SPEAKER_00: So essentially how much it's reduced in terms of our quadriceps strength and output.
• 15:35
  SPEAKER_00: So when we're looking at the methods, they took 11 patients and they did 3D motion analysis and were asked to perform squats on a force platform.
• 15:45
  SPEAKER_00: So they had force plates, they had a whole system where they were assessing this, and they were instructed to squat down as low as possible without pain and performed two trials of five consecutive squats without any additional weights.
• 15:59
  SPEAKER_00: So we're talking just air squats, two sets of five, testing this out to get an average of how they move.
• 16:06
  SPEAKER_00: And the outcome measures or the things that they looked at to measure was the peak hip and knee flexion angles, the knee extensor moment, or what we typically associate as your quadriceps knee extensor strength, the vertical ground reaction forces, and the hip to knee extensor moment ratios.
• 16:26
  SPEAKER_00: So essentially the comparison of how much our knee extensor versus our hip extensors, so our quads versus our glutes and hamstrings, and the ratios between the two and how they're utilized.
• 16:37
  SPEAKER_00: So I hope that this is something that is making sense.
• 16:40
  SPEAKER_00: I know that there's a lot of big terms here, but we're gonna try and make this simple and practical and good takeaways for you guys, and that way it helps to paint a better picture for when you are trying to help with your compensations.
• 16:54
  SPEAKER_00: Let's talk about the big takeaways from this study.
• 16:58
  SPEAKER_00: When an athlete squats, it goes from combined inter limb and intralimb to just intra-limb compensations from three-month to five-month mark in these tested patients.
• 17:13
  SPEAKER_00: So, in layman's terms, what we ended up seeing is that at the three-month mark when they were tested, they had both an inter limb, so they shifted to the unoperated side, and then an intralb compensation as well, so they shifted their butt back as well to use the quads in the knee less and more at the hip with their glutes and hamstrings.
• 17:35
  SPEAKER_00: So we saw that at three months, and then when they retested at five months, you know, they've had some rehab, they've been working on some of this stuff, and that five months when they retested, the thing that went away was the interlimb compensation, and the intralb was more prevalent.
• 17:53
  SPEAKER_00: And so the thing that they had mentioned though is that it's less obvious, and that our bodies are very good at hiding this.
• 18:01
  SPEAKER_00: So essentially, what happened is instead of shifting to the unoperated side that went away at the five-month mark, and they just shifted towards the glutes and the hamstrings and had the intra-limb compensation.
• 18:14
  SPEAKER_00: And this is essentially athletes who are avoiding loading the ACL reconstructed knee.
• 18:21
  SPEAKER_00: Instead of shifting to the uninvolved, now they're shifting towards their ankle and their hips on the involved side.
• 18:27
  SPEAKER_00: So instead of so we call these strategies, and the strategies are the ankle, the knee, and hip strategies.
• 18:33
  SPEAKER_00: And we talked about the hip strategy where they'll shoot their butt back and use the hamstrings and glutes in order to complete the squat.
• 18:41
  SPEAKER_00: Well, here they're saying that these intra-limb compensations can take place with just a three to five degree change at the knee, with no change at all at the hip or the ankle.
• 18:54
  SPEAKER_00: And this can occur when the patient or the client or the ACL athlete can shift their weight or their center of pressure minimally to different parts of the foot, changing the force vectors and the moment arm through the knee joint.
• 19:09
  SPEAKER_00: So essentially, this is a way of saying we are really freaking smart at figuring out how to do a movement and still avoiding loading our knee and our quads.
• 19:19
  SPEAKER_00: And the thing that is so tricky with this is that when you see it talked about in the study, and even based on this previous comment that I made, the three to five degree change at the knee is barely visible to the naked eye.
• 19:33
  SPEAKER_00: That type of change, I mean, think about three-degree change in your flexion whenever you're working on it.
• 19:38
  SPEAKER_00: That's not very much.
• 19:40
  SPEAKER_00: So when we're thinking about a squat and we're thinking about the five-month mark where they retested and the intra-limb compensation was more prevalent, we figured out a way, these athletes figured out a way to be able to do it as evenly as possible to the naked eye, but they were still able to use more of the hip and the ankle strategies as opposed to the knee and the quadriceps.
• 20:06
  SPEAKER_00: First, I want to just point out how incredibly smart our bodies are, and us as humans, even to be able to complete a task, make it look very similar.
• 20:17
  SPEAKER_00: And I guarantee you that these 11 patients who came in to test at five months weren't like, oh, let me see how I can throw this off.
• 20:26
  SPEAKER_00: They were definitely like trying to do this as best as they could, and their body was still able to figure out a way to avoid the knee.
• 20:34
  SPEAKER_00: And that's the thing that I want to drive home here is that even though we can visibly see a normal squat, we need to make sure that we can control the strategies that are taking place, and that might be through different cues and through different ways that we're working on the squat, whether it's an isolated joint movement or it's a bigger movement, and constraining the movements themselves, setting up the environment, setting up the individual to make sure that they can execute it the way that we want them to.
• 21:09
  SPEAKER_00: And the last thing that I want to add to this is that there was a study by RIM in 2020 where they looked at the role of the tricep surray muscles in patients undergoing ACL reconstruction, a match case control study.
• 21:24
  SPEAKER_00: So this one was really interesting because when we're talking about movement compensations, this plays into it.
• 21:31
  SPEAKER_00: So what they saw with this study is that the strength of the thigh muscles was reduced.
• 21:36
  SPEAKER_00: So they reduced using the quads, and what they did was look at what the acceleration time of those muscles, and at one year, it was very slow for the quad muscle, but the tricep cerea, and that is our calf muscle, was faster than that of the controls.
• 21:57
  SPEAKER_00: And what they concluded is essentially that this may implicate a compensatory mechanism by our calf muscles for the weakness and the delay in potential hamstrings and quadricep muscles for the ACL side.
• 22:11
  SPEAKER_00: So we might start using our calves a little bit more with our ACL knee to compensate, and that would be related to our ankle strategy a little bit to help take over and help with completing a task or a movement such as a squat or a step up or anything that will demand the knee.
• 22:30
  SPEAKER_00: So what ends up happening is that we can mimic the normal squat kinematics or the way that it looks with even weight bearing when the quads are weak by engaging our planar flexors or our calf muscles.
• 22:44
  SPEAKER_00: And what ends up happening without getting too technical is that we move the ground reaction forces closer to the knee, and that reduces the demands on our quad.
• 22:53
  SPEAKER_00: So we're able to essentially complete the movement with our calves and our ankle strategy in order to make sure that we're doing it.
• 23:02
  SPEAKER_00: And that is what is so bizarre with this, especially with a normal squat.
• 23:06
  SPEAKER_00: You would imagine, like, oh, well, surely the knee, the quad, the hamstring sclutes are all doing their job, but our body is internally figuring out what are other ways we can do this movement without necessarily engaging these areas that we're trying to protect or maybe aren't strong enough to take this on.
• 23:28
  SPEAKER_00: And this is something that I have learned from Eric Mira, who is a very brilliant man when it comes to biomechanics and really practically applying things, especially for ACL rehab.
• 23:40
  SPEAKER_00: And so, one of the things that he will use with this and a cue is to shift the weight to the heels as you're doing a squat and drive the knees forward at the same time.
• 23:52
  SPEAKER_00: And the cue that he will give is wiggle those toes, and so then that way you're not pushing down really hard with your toes and engaging your calf muscles.
• 24:01
  SPEAKER_00: So you got to go down in your squat, make sure the weight.
• 24:04
  SPEAKER_00: Is a little bit more towards your heels, your knee is going forward to demand more on the quad, and wiggle those toes so you are not pushing into your planar flexors or your calf muscle in order to have that intra-limb compensation.
• 24:20
  SPEAKER_00: What makes this so difficult is that sure there's the inter limb, which we can visually see, and hopefully that is being corrected early on.
• 24:30
  SPEAKER_00: But the hard part is the intra-limb compensations.
• 24:34
  SPEAKER_00: They're very subtle and sometimes look quote unquote perfect, or what we would consider, oh, that's a great squat.
• 24:41
  SPEAKER_00: But what we saw in the Sigward study is that there can be a three to five degree change at the knee and no change that you will really see at the hip or the ankle, but we still are able to shift the pressure of our feet and our body to reduce the demand on the quads.
• 24:59
  SPEAKER_00: Wild.
• 25:00
  SPEAKER_00: If this tells you anything, it's basically that our bodies are crazy good at figuring things out, and we are great compensators, and we just have really cool bodies.
• 25:11
  SPEAKER_00: It's something to appreciate, but I wish that this did not happen with ACL rehab and with our knees and with all kinds of other injuries and things like that.
• 25:20
  SPEAKER_00: But this is just something that really highlights these crazy small nuances with compensations related to movement.
• 25:29
  SPEAKER_00: And so I want to talk a little practically here.
• 25:32
  SPEAKER_00: And one of the things that we need to make sure from the get-go is the importance of not allowing daily tasks to contribute to this.
• 25:42
  SPEAKER_00: So let's say, for example, when you think about your daily tasks.
• 25:46
  SPEAKER_00: So we're talking about walking, standing up, getting out of bed, getting into the shower, taking the stairs, getting into our car, all these things that we do repeatedly day in and day out, especially something like sitting down.
• 26:00
  SPEAKER_00: So we call that like a sit to stand or squatting to a chair and back up or to the toilet.
• 26:05
  SPEAKER_00: Think about all these things we do in our day-to-day.
• 26:08
  SPEAKER_00: The other thing is our stairs.
• 26:10
  SPEAKER_00: So we need to be aware of this very, very early, ensure we're going to be limited or constrained by the injury and the surgery.
• 26:20
  SPEAKER_00: So there's only so much we can do.
• 26:22
  SPEAKER_00: And again, we're going to try and complete the movement or the task to get from point A to point B.
• 26:28
  SPEAKER_00: You're not going to really care how much you sit down to your chair or to the toilet, really.
• 26:33
  SPEAKER_00: You're just like, I just need to get there and we'll figure out how to do it.
• 26:37
  SPEAKER_00: And when you're post-op, you're not really too worried about it.
• 26:39
  SPEAKER_00: But as we get out of that initial acute first week to two weeks, we need to make sure that we're continuing to be mindful of this, especially the compensatory strategies that can come into play.
• 26:52
  SPEAKER_00: So this could be sitting down to the chair or to take the stairs.
• 26:57
  SPEAKER_00: I think we need to just be more aware of the way that we complete these movements.
• 27:02
  SPEAKER_00: That doesn't mean that you have to be so slow and so strategized with each movement.
• 27:08
  SPEAKER_00: Sure, go when you need to, but we need to make sure that these specific tasks in our day, we do them so much that we're not contributing to this compensatory pattern, that we are intentional and that we allow us to put deposits into the way that we want to move, as opposed to just doing our rehab and doing that time.
• 27:31
  SPEAKER_00: Maybe that's the 30 minutes or hour in your day, or every three, four days.
• 27:37
  SPEAKER_00: That's what you're doing, and you're doing it quote unquote right.
• 27:39
  SPEAKER_00: And then you have the rest of your day where you're not necessarily thinking about it.
• 27:44
  SPEAKER_00: And then that's contributing to the opposite end of the spectrum where we are looking at, okay, doing a squat to a chair or taking the stairs, and we're still adopting that ankle or hip strategy as opposed to allowing our knee to get used to that type of movement.
• 28:01
  SPEAKER_00: So this is essentially saying make sure that in your daily tasks that you carry over what you're learning to be able to load your knee and your quad well and not just playing against all these movements that you're trying to unlearn and work on during your rehab.
• 28:17
  SPEAKER_00: So I'm gonna leave you with some strategies.
• 28:20
  SPEAKER_00: And this is again coming from Eric Mira because he is way smarter than I am, and I'm just gonna talk you guys through it because I think it is a great algorithm or a great way to proceed with this.
• 28:33
  SPEAKER_00: And it's the way that I approach a lot of my athletes in the way that we are trying to load them in their movement strategies, different types of movements, and also the different muscle groups.
• 28:44
  SPEAKER_00: So we want to make sure that we improve our local tolerance, then the capacity, then the movement strategy.
• 28:52
  SPEAKER_00: So this means local to global, and then the tolerance, then the capacity, then the strength, and the rate.
• 29:00
  SPEAKER_00: This is all a lot of terminology, but let me break it down.
• 29:03
  SPEAKER_00: Okay.
• 29:03
  SPEAKER_00: So the local tolerance, we're talking about how the knee and the quads are handling it.
• 29:09
  SPEAKER_00: And so we want to make sure that they can handle certain movements.
• 29:13
  SPEAKER_00: So let's say as simple as a quad set to a seated knee extension with no weight, and then we're slowly starting to work on maybe an ankle weight or a seated knee machine to be able to improve our local tolerance, and then we're gonna try and build up our capacity at the local site.
• 29:32
  SPEAKER_00: So that means again, and this is great because if you haven't caught the last episode, we talk all about this.
• 29:38
  SPEAKER_00: So capacity is essentially how can we make sure that we can do that for a certain amount of repetitions or build up, if you want to say, the endurance of it.
• 29:47
  SPEAKER_00: And then we're looking at the movement strategy because if we have the foundations of the local tolerance, the knee can handle the movement, and then we're looking at it can handle it with capacity with multiple repetitions, and then we're plugging that into certain movement strategies.
• 30:05
  SPEAKER_00: So then we're like, okay, well, now let's go to a squat or a split squat and see how that looks.
• 30:11
  SPEAKER_00: But if we are weak on the local tolerance and the capacity, then the movement strategy is gonna easily shift to that interlimb or intra-limb because we don't have the base or the foundation that we need to build up.
• 30:24
  SPEAKER_00: So we need to go from local, specific to the joint and the muscles, and then kind of take a bigger step back and then start moving towards bigger movements like compound movements, squatting, deadlifting, step ups, things of that nature that is gonna help to be able to plug those pieces in.
• 30:43
  SPEAKER_00: And then we're looking at the tolerance, making sure that we have that capacity.
• 30:48
  SPEAKER_00: We got to make sure that we're building up the strength of it, so the actual peak force of the quadriceps muscle, because if that's there, then we can develop the rate or how quickly we get to that peak force.
• 31:00
  SPEAKER_00: If we are able to work along this spectrum or this continuum, then these movement strategies will be less likely because they have the foundational pieces to plug into these bigger movements.
• 31:14
  SPEAKER_00: So if you do not have tolerance, if you do not have capacity, if you do not have strength, if you do not have rate, then what happens is that we'll shift towards our hip or towards our ankle because we don't have those prerequisites there in order to accomplish the movement.
• 31:30
  SPEAKER_00: And one of the things that Eric talks about is if the function is attempted before building the capacity, new strategies will emerge if given enough time.
• 31:40
  SPEAKER_00: And so what this means is that if you don't focus on building that local capacity that we just talked about, then you try to jump towards, let's say what happens is that we'll move towards like a squat or some sort of big compound movement, especially with weight, then what happens is that we'll just figure out a way to do it, like the study showed, and that will create new strategies.
• 32:04
  SPEAKER_00: So whether it's that intra or interlimb strategies, um, if we allow time and allow them to learn those ways to do it, and that becomes the new strategy or the new movements.
• 32:18
  SPEAKER_00: And those strategies can even stick around if the capacity is restored later, because our body is so freaking smart at learning how to adopt certain movements, it kind of goes to the whole bad habits or you can't teach an old dog new tricks.
• 32:34
  SPEAKER_00: And while you're not old or the athlete you're working with is not old, the further away they get from their ACL rehab, the injury or the surgery, it's kind of that distance, and it is really hard to undo some of these habits, bad habits, or strategies.
• 32:50
  SPEAKER_00: So that's what we're talking about specifically here is that if we jump towards learning functional stuff like squatting, deadlifting, step ups, before we build up that local capacity at the knee joint, at the quad, then these strategies will stick.
• 33:07
  SPEAKER_00: Even if you were to take a step back and to work on these the capacity later, they'll still learn these strategies.
• 33:15
  SPEAKER_00: So, what is the best way to do it?
• 33:17
  SPEAKER_00: Working on the capacity early first and making sure that is taken care of, and then you can work within the strategies or the task, the function within whatever that capacity is.
• 33:33
  SPEAKER_00: So you essentially have this certain threshold and you want to work within that as opposed to pushing past that threshold and forcing things, and that's where these can arise.
• 33:44
  SPEAKER_00: And then I'm gonna share this kind of excerpt from him and to give him all the credit here is to expand on this, is you don't want to progress more than what the quads can take through any phases of your ACL rehab.
• 33:58
  SPEAKER_00: So essentially, you don't want to force someone to squat when their quads can't really handle the movement.
• 34:04
  SPEAKER_00: So then that means that we need to take a step back and fulfill that local capacity as we talked about in order to plug that back in later.
• 34:14
  SPEAKER_00: So, to create an example here, if someone shifts away from a squat, shifts their weight away.
• 34:21
  SPEAKER_00: So this is where we're talking about that interlimb compensation.
• 34:25
  SPEAKER_00: Then are we thinking this is a capacity issue?
• 34:28
  SPEAKER_00: We have to ask this question is it a capacity issue?
• 34:31
  SPEAKER_00: Before thinking, is it a movement strategy issue?
• 34:35
  SPEAKER_00: So that means does the quad in the knee have the ability to even complete the movement, or is this something that they've just adopted as a bad habit or a bad skill?
• 34:47
  SPEAKER_00: And if there's not enough capacity, then that's what we need to work on.
• 34:51
  SPEAKER_00: So we need to take that out, work on that isolated strength and build that up.
• 34:55
  SPEAKER_00: And if there is enough, like let's say we test it and the strength is there, the rate is there, then we got to start working towards the movement strategy itself.
• 35:04
  SPEAKER_00: So to give you a very simple example, let's say there's a squat, someone shifts away from the squat, and we're trying to ask them to do it.
• 35:11
  SPEAKER_00: Then we have to figure out is this a capacity/slash strength issue at the knee or the quads, or is this something that is a movement strategy that they're shifting away from that operated side to the unoperated side?
• 35:26
  SPEAKER_00: So, first we need to check the capacity.
• 35:29
  SPEAKER_00: Is there enough there?
• 35:30
  SPEAKER_00: And if not, we're gonna start there.
• 35:32
  SPEAKER_00: We're gonna work on the knee and the quads.
• 35:34
  SPEAKER_00: It might be doing certain isolated quad movements like heel-elevated wall sits, or it might be something where you're doing seated knee extensions, it could be a variety of different ways to develop the quads, but we start and build the capacity there, and then if that hits a certain threshold through objective testing, then we are going to address the movement strategy, or for this specific example is readdress the squat and see how do you move and how can we coach this up because that capacity is there.
• 36:08
  SPEAKER_00: So then the questions you have to ask is essentially how much quad does this require?
• 36:13
  SPEAKER_00: How much quad do I have?
• 36:15
  SPEAKER_00: And that will essentially help you in this to decide, well, is it something where I do have enough quad to do this movement, or maybe you don't, and we push this off until you do?
• 36:29
  SPEAKER_00: And that's where working with a coach and a physical therapist who is very familiar with this will be incredibly key because this is so nuanced that you got to be able to make sure that this is coached appropriately and guided and cued appropriately.
• 36:44
  SPEAKER_00: The thing that will be mentioned is that fixing a squat, so let's say a squat gets fixed and it looks great, just fixes the squat.
• 36:51
  SPEAKER_00: It doesn't necessarily do anything else.
• 36:53
  SPEAKER_00: Sure, we can bias things a little bit, but as I had mentioned, that our bodies are good at figuring things out, even if it looks perfect.
• 37:02
  SPEAKER_00: So we need to make sure that we can almost take this local capacity approach towards a more movement strategy approach as opposed to the reverse, which often what you'll see in protocols or in just generic rehab is that we'll just work on the movement and hopefully that that'll take care of it when it really doesn't.
• 37:22
  SPEAKER_00: And this is something that I myself have changed a lot.
• 37:25
  SPEAKER_00: So instead of trying to get someone to squat super, super early, what I will do is focus a little bit more because there is time, I will focus a little bit more on isolated work and building up that capacity and tolerance and the strength of things, and then we start plugging that into more movement strategies such as squats or deadlifts, or especially dynamic movements, because that stuff happens so fast that we can't necessarily catch it with the naked eye so easily.
• 37:55
  SPEAKER_00: And that's where each person will have such a variety of movement compared to a controlled movement like a squat or a step up or a deadlift.
• 38:04
  SPEAKER_00: And one last thing that I want to provide here with this compensation is that instead of there being tons of cues with coaching and being like, hey, put your knee here or do this.
• 38:18
  SPEAKER_00: What we want to do when we're evaluating the individual, the task, and the environment, we are looking at, okay, the task is again, let's stick with the squat.
• 38:28
  SPEAKER_00: When we're looking at the individual, they are the one who is completing the said task in the environment.
• 38:34
  SPEAKER_00: So we need to essentially set up our environment to constrain what we want to get.
• 38:40
  SPEAKER_00: And this comes back to cueing.
• 38:42
  SPEAKER_00: So this will be another podcast episode, but internal versus external cueing, internal is like, hey, bend your knee more.
• 38:50
  SPEAKER_00: And then external is something like hit your knee to this foam roller.
• 38:55
  SPEAKER_00: And this is where it leads us into a constraints-led coaching approach or constraints-based.
• 39:01
  SPEAKER_00: So constraints essentially mean how can we constrain this movement to get the outcome that we want.
• 39:07
  SPEAKER_00: So this is really great for movement compensations.
• 39:10
  SPEAKER_00: So I'll give you a good example is that when someone goes to do an interlimb squat shift, so let's say they have an operation ACL on the left side, they go to squat and they shift to the right side.
• 39:24
  SPEAKER_00: They're shifting to their right leg.
• 39:26
  SPEAKER_00: So instead of saying, hey, shift to your left, that could be helpful sometimes.
• 39:31
  SPEAKER_00: I will try to change their environment.
• 39:34
  SPEAKER_00: So I will either put something under their right foot to make sure that they put more weight into the left side, or I'll put a foam roller and say, Don't touch this with your hip.
• 39:44
  SPEAKER_00: So they can't shift over to their right.
• 39:46
  SPEAKER_00: It's just subtle things like this that can really help to clean things up, as opposed to constantly saying, hey, shift back over or center your squats.
• 39:56
  SPEAKER_00: You could just make sure the environment cues them into doing it the best way we can.
• 40:01
  SPEAKER_00: And then there's all the things that we talked about today related to the compensations.
• 40:07
  SPEAKER_00: So the intra limb and intra limb at three months versus moving towards the five months, which is mostly intra-limb at the ankle and the hip versus using the knee.
• 40:19
  SPEAKER_00: And then how we can also use our planar flexors or our calf muscles in order to compensate and offload the knee.
• 40:26
  SPEAKER_00: And then we're looking at the whole concept of going from local to global in terms of capacity and then making sure that we could build the movement strategies as long as the capacity is there.
• 40:39
  SPEAKER_00: Those are the things that we want to make sure we work towards and have a good constraints-led approach with coaching.
• 40:46
  SPEAKER_00: So if you have hung with me through all of this talk about movement compensations in ACL rehab, I appreciate you.
• 40:54
  SPEAKER_00: Thanks for hanging out.
• 40:56
  SPEAKER_00: This was a very, very deep dive into this, and it is one that I have been looking at and wanting to make sure that this gets discussed, especially for my ACL athletes, where this is such a common place for this to happen.
• 41:11
  SPEAKER_00: And while this should not be left to you to figure out, I wanted to make sure that was information out there, and that way you can also discuss this with your physical therapist, or if you're feeling like you are kind of in this specific scenario, then reaching out to get help to correct this.
• 41:29
  SPEAKER_00: And that's what's going to be really key.
• 41:30
  SPEAKER_00: If you're a physical therapist or coach listening to this, then make sure that we are looking at our athletes in different ways and being able to see this much further out than just the first couple months, and that at five months or even further, depending on the athlete, that this could be something that could still be very present.
• 41:51
  SPEAKER_00: So we need to make sure that we cue and coach and develop a lot of these different movements in the way that is going to serve our athletes.
• 42:01
  SPEAKER_00: All right, team, that is going to do it for today.
• 42:05
  SPEAKER_00: I've talked long enough about compensations.
• 42:09
  SPEAKER_00: If you have any questions, if you need some guidance, you can find the information in the show notes.
• 42:16
  SPEAKER_00: If you have stuck with me and you appreciate the episode today, please leave us a review so that way we can reach more and more athletes similar to your position or other physical therapists and coaches, because we want to make sure that every ACL athlete that is going through this process is well equipped and the people they are working with are well equipped as well.
• 42:39
  SPEAKER_00: So thank you all so much.
• 42:41
  SPEAKER_00: This is your host, Robbie Patel, signing off.