Latest / The ACL Athlete Podcast / 163 | Who Should Clear You to Start Running in ACL Rehab?

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163 | Who Should Clear You to Start Running 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.
• 1:04
  SPEAKER_00: I am excited to dive into this episode today.
• 1:08
  SPEAKER_00: Welcome everyone to the ACL Athlete Podcast.
• 1:13
  SPEAKER_00: We are going to be talking about who should clear you to start running an ACL rehab.
• 1:21
  SPEAKER_00: So it's three months post-op ACL.
• 1:24
  SPEAKER_00: Just imagine this.
• 1:25
  SPEAKER_00: You're three months post-op ACL.
• 1:27
  SPEAKER_00: You've got a checkup with your surgeon.
• 1:30
  SPEAKER_00: They see you for five, maybe ten minutes, check your knee on the table, do that Lockman test where they kind of pull it back and forth to check the test the ligament, maybe an air squat, kicking into their hands to assess strength.
• 1:44
  SPEAKER_00: Then they say, look strong and good.
• 1:47
  SPEAKER_00: You can start running.
• 1:48
  SPEAKER_00: I'll see you in three months.
• 1:50
  SPEAKER_00: They've been cleared to start running.
• 1:53
  SPEAKER_00: And when I said strength, I put quotes in the air because kicking into someone's hand, you know, where your person's hand is on the top of their thigh, and then typically the other hand to resist is at the ankle of the ACLer, and they're told to kick out, right?
• 2:09
  SPEAKER_00: To test your quad strength.
• 2:11
  SPEAKER_00: There's no testing going on, it's just to see can you kick into their hand?
• 2:15
  SPEAKER_00: That's really the only thing that's happening is no test of strength.
• 2:18
  SPEAKER_00: Let's be clear here.
• 2:20
  SPEAKER_00: And to follow this through, you know, they've been cleared, they're ready to start running based on the surgeon.
• 2:26
  SPEAKER_00: They've hit the timeline, they've had that five to ten minute checkup.
• 2:30
  SPEAKER_00: I've had countless athletes who go and see their surgeon, and this is what happens.
• 2:36
  SPEAKER_00: It happens more than it doesn't.
• 2:38
  SPEAKER_00: So this is definitely 50%, 51%, and I would argue almost 60 to 75% of what we see is what happens here.
• 2:48
  SPEAKER_00: And this is not all, of course, but it happens more than it doesn't, as I had just mentioned.
• 2:54
  SPEAKER_00: I had a call with an athlete recently where he mentioned his surgeon just cleared him to start running.
• 2:58
  SPEAKER_00: I asked based on what?
• 3:00
  SPEAKER_00: He said nothing, but time in the protocol.
• 3:02
  SPEAKER_00: He was like, you know, you're at three months, you look good.
• 3:04
  SPEAKER_00: Uh the protocol says you're good to start running, so let's do the thing.
• 3:08
  SPEAKER_00: So he started trying to run and he was dealing with pain and started to limp.
• 3:14
  SPEAKER_00: The problem here isn't that it was the surgeon who cleared him, it was what reasoning was used to clear him to start running.
• 3:21
  SPEAKER_00: Basically nothing but time and what the protocol says.
• 3:25
  SPEAKER_00: And let's also just look at the time of that protocol and its creation.
• 3:31
  SPEAKER_00: It's very unlikely that it was within 2020 and beyond, even though it's 2024.
• 3:38
  SPEAKER_00: It's not uncommon to look at the dates on these protocols if they have them, and they will say 2003, 2008.
• 3:46
  SPEAKER_00: And it's it's laughable to be honest, because you're just like, we have learned so much about ACL rehab and the things that we need to be hitting.
• 3:55
  SPEAKER_00: I would hope so, that if things that are not updated with such a major reconstructive surgery, with such a high reinjury risk, if we're not looking at this thing, can we not have someone in the practice looking at this thing and being like, is this thing up to date?
• 4:09
  SPEAKER_00: What are we using to base this protocol on?
• 4:11
  SPEAKER_00: What's the factual information?
• 4:13
  SPEAKER_00: What is the the the researchers who are crushing it with this ACL rehab stuff?
• 4:19
  SPEAKER_00: Um, what do they say in terms of their criteria of return to running or for return to sport, whatever it is?
• 4:26
  SPEAKER_00: You know, why don't we have some sort of fact check every year about this instead of looking at the 2003 protocol that the surgeon is still basing their clearance on, which is typically just time, because maybe that's what they learn, or they're like, ah, it's good enough time frame, like that way people just have concrete answers.
• 4:44
  SPEAKER_00: And I don't think that's healthy, but this is the thing that can get people into trouble.
• 4:49
  SPEAKER_00: And so what I don't want to sound like, which I probably do is sound like a broken record, but for every one person I hear that does get testing performed, there's probably nine other people that haven't, right?
• 5:04
  SPEAKER_00: And this isn't pointing fingers directly at just the surgeon, it's the whole system and all the professionals involved who aren't doing their due diligence.
• 5:12
  SPEAKER_00: The thing that I want to pose to you is imagine this your driver's license, you're getting it, because you just turned 16.
• 5:20
  SPEAKER_00: You got it.
• 5:20
  SPEAKER_00: No written test, no practical test, just because you're 16 based on the calendar, right?
• 5:25
  SPEAKER_00: How terrible would that be for the teenager who never operated a car and then just magically crossed that date to do it?
• 5:34
  SPEAKER_00: And the other thing, too, is that could you imagine being also the drivers on the road and being like, oh, all these 16-year-olds who hit their birth date are now able to drive.
• 5:44
  SPEAKER_00: They didn't get tested.
• 5:45
  SPEAKER_00: There was no process to be able to make sure that they're can operate a car appropriately and safely.
• 5:53
  SPEAKER_00: It's just like they've hit a calendar point and we're good.
• 5:56
  SPEAKER_00: That would be awful.
• 5:57
  SPEAKER_00: And it's probably because it would lead to death because there will be car wrecks.
• 6:02
  SPEAKER_00: And so, therefore, you know, whenever someone starts running, you're probably not gonna die.
• 6:07
  SPEAKER_00: But it's likely that you are just gonna be dealing with the repercussions of not being ready for it, right?
• 6:12
  SPEAKER_00: And the thing is that when we get our driver's test, either there's a written test or there's a practical component to it.
• 6:17
  SPEAKER_00: So this is the thing that's important here that we assess and make sure readiness is there.
• 6:22
  SPEAKER_00: That's key here.
• 6:24
  SPEAKER_00: We got to make sure the readiness is there.
• 6:26
  SPEAKER_00: You show the appropriate preparation, and then therefore that crosses potentially this line where you could start to run.
• 6:33
  SPEAKER_00: And this is honestly exactly what happens is that we got the time that sneaks up, and then they're like, Okay, you're good.
• 6:41
  SPEAKER_00: Now you might be like, okay, Robbie, it really is just running, but let's take a second to think about the domino effect here and the sequence of events.
• 6:50
  SPEAKER_00: Someone has been inappropriately told they can start running.
• 6:53
  SPEAKER_00: They do, they start experiencing problems, they might have pain, they might have swelling, they might have stiffness, maybe they start limping, maybe they have a combination of all these things, and likely so.
• 7:06
  SPEAKER_00: But they've been cleared, so they almost feel crazy thinking something's wrong.
• 7:11
  SPEAKER_00: So they carry on.
• 7:12
  SPEAKER_00: This impacts their strength numbers, it impacts their compensation patterns, this impacts the athlete getting into more dynamic movements that are more demanding, that need typically running as a prerequisite.
• 7:24
  SPEAKER_00: Not to mention they're dealing with a grumpy knee.
• 7:27
  SPEAKER_00: Could be a few weeks, could be months, it could be even be years.
• 7:31
  SPEAKER_00: You think I'm kidding here, but we've had people reach out six months out, eight months out, twelve months out, or literally years out, not running because of issues like this that could have been addressed if they would have just had appropriate criteria and more of a team-based approach to this decision-making process.
• 7:51
  SPEAKER_00: And while you might say my surgeon and PT are nice, nice doesn't mean that they know what they're doing and are up to date.
• 7:58
  SPEAKER_00: It's the thing that I honestly find so funny because we do not get into physical therapy to make a lot of money.
• 8:06
  SPEAKER_00: We do not.
• 8:06
  SPEAKER_00: If you look at how much we were paid 20, 30 years ago versus what we're paid today, it's mar very marginally like not different whatsoever.
• 8:16
  SPEAKER_00: There's very little change.
• 8:18
  SPEAKER_00: Um, and especially going from a you know, bachelor's to a master's to a doctorate, there's not a lot of shift except for the increased student debt.
• 8:27
  SPEAKER_00: And so we don't get into physical therapy because we want to make a ton of money.
• 8:32
  SPEAKER_00: We get into it typically, if you ask most PT students, they're like, I want to help people.
• 8:36
  SPEAKER_00: I want to be able to connect with my patients, I want to be able to have movement as a part of my practice and what I do.
• 8:43
  SPEAKER_00: That's a very common thing that people in the physical therapy world and especially the students, you will hear.
• 8:50
  SPEAKER_00: And so the thing is that more likely than not, you're gonna have a nice physical therapist.
• 8:55
  SPEAKER_00: We're also people oriented people.
• 8:59
  SPEAKER_00: We love to talk to people in most cases.
• 9:01
  SPEAKER_00: We're people facing for the most part.
• 9:04
  SPEAKER_00: So if you are a person who doesn't like people, doesn't like talking, introverted, which doesn't mean that there's that's a bad thing.
• 9:12
  SPEAKER_00: It's just you're less likely to pick a physical therapy profession because it's just not self-selecting to that.
• 9:19
  SPEAKER_00: You have to be a little bit more outward-facing, and typically these humans are nice in general.
• 9:24
  SPEAKER_00: You're gonna find a nice PT versus a not nice PT.
• 9:28
  SPEAKER_00: And so that's the thing that I want to mention here is that just because they're nice doesn't mean that they're really good at what they do.
• 11:39
  SPEAKER_00: Now I'm going to say something a bit more aggressive here.
• 11:44
  SPEAKER_00: Why?
• 11:45
  SPEAKER_00: I've just been feeling real spicy lately, so I don't really care.
• 11:49
  SPEAKER_00: And this is where we have to stay in our lane as our profession and professionals.
• 11:57
  SPEAKER_00: If you haven't truly tested the athlete, seen their numbers, and know the ins and outs of what they've been doing, you have no business giving recommendations on what they can do, when they can do it.
• 12:12
  SPEAKER_00: And this goes to any surgeon, orthos, physical therapists, athletic trainers, coaches, mom, dad, whoever, come at me.
• 12:19
  SPEAKER_00: This doesn't make sense for someone to make these decisions based on basically lack of information.
• 12:26
  SPEAKER_00: And just because you're constrained to a five to ten minute visit doesn't give you the authority to do that, in my opinion.
• 12:32
  SPEAKER_00: And this is something where I think is a big gap that we need to readdress from a system standpoint because we need to make sure all of the players are involved, or at least the person who is fully aware of what the numbers look like, what the criteria is for that, which is probably a problem in and of itself, is that we can't agree on this, but we do know that there needs to be some sort of objective measures to be able to know is this person ready?
• 13:01
  SPEAKER_00: Outside of time.
• 13:02
  SPEAKER_00: Time alone is not gonna do the thing.
• 13:03
  SPEAKER_00: And we know we need to measure things like range of motion, quad strength, hamstring strength, plymetric ability, and there's other things that we can list here, but we need to make sure that this person is prepared and ready for the thing we're gonna ask them to do.
• 13:18
  SPEAKER_00: And so this is where the person or the team who is involved with this need to know what those numbers stand.
• 13:25
  SPEAKER_00: What has this athlete been doing, right?
• 13:28
  SPEAKER_00: If we just say, all right, like at three or four months, you could start running, but all they've been doing is like air squats and you know, heel slides, you think this athlete is going to be ready to start running the demands of running and what that is?
• 13:42
  SPEAKER_00: Definitely not.
• 13:43
  SPEAKER_00: But if you don't ask or you don't know, then there's no reason for you to give advice on that.
• 13:47
  SPEAKER_00: That's just like a blind recommendation that doesn't make any sense.
• 13:51
  SPEAKER_00: So one of the things I always ask my athletes to do is when you leave a visit, whether it's with your physical therapist, with your surgeon, whether it's with a coach, whoever gives you advice on certain things, always ask why or be able to explain exactly what it is that advice was derived from.
• 14:10
  SPEAKER_00: And this is the thing that's always the lie bulb moment that I love is that you know, we're we're working with athletes and they go see their surgeon and the surgeon tells them they can start running, right?
• 14:20
  SPEAKER_00: And then I'll start asking questions.
• 14:22
  SPEAKER_00: I'll be like, Well, how long did you see your surgeon for?
• 14:25
  SPEAKER_00: And they were like, Well, five minutes.
• 14:27
  SPEAKER_00: I was like, Okay, what did they do?
• 14:29
  SPEAKER_00: And they're like, Well, they checked my range of motion, they did that like test where they checked the ligament, you know, kicked into his hand.
• 14:36
  SPEAKER_00: Um, and this is typically the most run-in-the-mill type situation.
• 14:40
  SPEAKER_00: Um, and then they're like, Yeah, you're good.
• 14:42
  SPEAKER_00: I'll see you in three months.
• 14:43
  SPEAKER_00: Um, you can start running now, just don't go too crazy with it.
• 14:46
  SPEAKER_00: I'm like, cool, that's great.
• 14:49
  SPEAKER_00: And then it's an uphill battle because especially if you got an athlete who isn't as in tune in with the process and is very, you know, aggressive with the rehab or wanting to get back to running if that's a big goal.
• 15:01
  SPEAKER_00: Man, trying to walk that back is really hard.
• 15:04
  SPEAKER_00: And so then, therefore, it's just something that is kind of blind advice with just a system-based issue and a protocol versus it being something that is more oriented to the information, the data, and what they've been doing, right?
• 15:18
  SPEAKER_00: And so these are things where we have to kind of check ourselves a little bit.
• 15:22
  SPEAKER_00: And the big thing here is that we have to have objective testing.
• 15:26
  SPEAKER_00: What does their symmetry look like for their quads?
• 15:28
  SPEAKER_00: What about for hamstrings?
• 15:30
  SPEAKER_00: What about how does that look like normalized to their body weight?
• 15:34
  SPEAKER_00: Are they, you know, 75% symmetry in their quads, but their newton meters per kg is like, you know, 1.2.
• 15:42
  SPEAKER_00: Well, great.
• 15:43
  SPEAKER_00: They're not ready for running because of the research that we know, we probably need to hit somewhere around a 1.7 to 1.8 threshold relative to your body weight.
• 15:52
  SPEAKER_00: And you would only know that is if you tested the athlete's strength.
• 15:56
  SPEAKER_00: It's a very strong correlation with running mechanics and with symptoms and with all the things that trickle down to this.
• 16:04
  SPEAKER_00: And I've done a whole episode on strength testing and how the quad's lack of strength leads to such a chain reaction of things that are problems down the road.
• 16:13
  SPEAKER_00: So this is something where we have to keep in check.
• 16:17
  SPEAKER_00: We got to make sure that the range of motion is fully restored.
• 16:20
  SPEAKER_00: Um, you know, there's some knee flexion that's involved, there's some extension that's involved whenever the the body hits the ground, the foot hits the ground.
• 16:27
  SPEAKER_00: And so then, therefore, if we don't have that prerequisite, guess what?
• 16:31
  SPEAKER_00: We're gonna figure out a way to work around it.
• 16:33
  SPEAKER_00: We're gonna shorten our stride a little bit, we're gonna not go through that cycle as much, we're gonna lean on the other side.
• 16:38
  SPEAKER_00: We might have some trunk sway, some rotation.
• 16:41
  SPEAKER_00: There's so many things that can just kind of come into play to just complete the task of running because you've hit that, you know, threshold because the you know professional has told you to do so.
• 16:52
  SPEAKER_00: So you're like, I'd be crazy if I didn't start trying it because it's something I've been wanting to do.
• 16:57
  SPEAKER_00: But you don't have the prerequisites, so then therefore it should have never been suggested in the first place.
• 17:03
  SPEAKER_00: And this also should mean that they've done running drills and some single leg plyometrics where you're you're working on that stretch shortening cycle because the running forces are going to demand some of that.
• 17:14
  SPEAKER_00: So we got to make sure you're prepared.
• 17:17
  SPEAKER_00: If you're going to run a full marathon, you got to make sure your body is prepared to build up to that mileage and it's there when you go to run it.
• 17:25
  SPEAKER_00: If you've only been running two miles and you're going to run 26.2 miles, God bless your soul, that's not gonna work because your body's gonna be like, what's happening?
• 17:35
  SPEAKER_00: I haven't trained for this, I'm not prepared for this.
• 17:37
  SPEAKER_00: So preparation is key here, and then those who have the information can kind of give you that guidance or recommendation for what is the next thing to do.
• 17:46
  SPEAKER_00: Now, the intention with this podcast is to determine who should clear you.
• 17:50
  SPEAKER_00: I know I sound like I'm always complaining, but this is the thing that we deal with in this space as we currently stand in terms of just poor information and guidance.
• 17:59
  SPEAKER_00: So I'm here to try and help set the record straight as much as I can.
• 18:03
  SPEAKER_00: And I'm not saying I have all the answers and I have the solutions.
• 18:06
  SPEAKER_00: It's just ways to for you to feel educated and for you to have a better grasp of like, okay, this is what I've been told.
• 18:15
  SPEAKER_00: How does this kind of play into this?
• 18:16
  SPEAKER_00: And starting to make those light mold moments come to play, just like my athletes, when I'm like, how can they take away this much information and give you a green light to start running from five minutes of your time?
• 18:27
  SPEAKER_00: I don't care what I do for five minutes, I'm the fastest person possible to assess things.
• 18:31
  SPEAKER_00: You can't even test someone's quad strength in five minutes efficiently on one leg.
• 18:36
  SPEAKER_00: So there's no way that they have enough of that information unless it's this like lucky, you know, college or private school or pro level type situation.
• 18:48
  SPEAKER_00: Well, in that case, you probably have 10 people that you can account for that's gonna help make this decision.
• 18:53
  SPEAKER_00: The surgeon isn't the only one that's making that decision in these types of scenarios.
• 18:58
  SPEAKER_00: And so this is where I want to make sure you understand well, who should clear you?
• 19:03
  SPEAKER_00: In my opinion, this is analyzing who is your ACL team and stakeholders involved.
• 19:09
  SPEAKER_00: This is where this first starts.
• 19:11
  SPEAKER_00: So here are a few buckets and people who fall into each.
• 19:14
  SPEAKER_00: It's not completely comprehensive, but this is most people.
• 19:18
  SPEAKER_00: This can include, you know, sports medicine, whether it's the physical therapist, orthopedic doc in the team, athletic trainer, sports psych, family and friends, parents, and significant others can play a role in this.
• 19:30
  SPEAKER_00: You have sports performance.
• 19:31
  SPEAKER_00: So you have strength coach, the sport coach, others could be agent, sports science, management or owner of a team or an organization.
• 19:39
  SPEAKER_00: And the athlete is at the center of this.
• 19:41
  SPEAKER_00: You, as the athlete, the ACLR is at the center of this.
• 19:45
  SPEAKER_00: You are being, you know, the one who gets to have input on this and the conversations.
• 19:50
  SPEAKER_00: Hopefully, each athlete will be different based on their own context, and this will also create different stakeholders, right?
• 19:57
  SPEAKER_00: The college recreational athlete stakeholders might just be the ortho, PT, and parents and sport coach.
• 20:05
  SPEAKER_00: And then for the 28-year-old who wants to just get back to skiing, it might just be the ortho and PT.
• 20:10
  SPEAKER_00: This is something that we commonly see.
• 20:12
  SPEAKER_00: It's just the surgeons, office, whoever you are working with there, your physical therapist, and you.
• 20:19
  SPEAKER_00: That's it.
• 20:20
  SPEAKER_00: Especially in the typical insurance-based model.
• 20:23
  SPEAKER_00: So then, therefore, these are the people who need to be involved in that decision-making process.
• 20:28
  SPEAKER_00: It's not one or the other.
• 20:29
  SPEAKER_00: Um, and it just kind of depends on how much weight they carry within knowing the information and being able to help you make this decision.
• 20:37
  SPEAKER_00: I would say most of these folks, as I mentioned, just have the surgeon and the physical therapist.
• 20:42
  SPEAKER_00: So then, therefore, for your own situation, you have to assess your own stakeholders and who they are.
• 20:47
  SPEAKER_00: A good way to look at this is who is and has been involved in this process that has something at stake, who is capturing the qualitative and quantitative or the objective data to help me meet my criteria.
• 21:01
  SPEAKER_00: And hopefully, you have criteria.
• 21:03
  SPEAKER_00: That's probably the number one thing that we need to tackle.
• 21:06
  SPEAKER_00: Write these people out and make sure when it time comes to be cleared for X, Y, and Z or to move on to something, everyone is on the same page about it, about where you're at, and that makes sense.
• 21:19
  SPEAKER_00: So, now to answer this question, who should clear you?
• 21:22
  SPEAKER_00: It's not just one person, it should be a collective decision based on your ACL team and all the stakeholders.
• 21:28
  SPEAKER_00: It really is the people who are seeing you through it all, the testing that you're doing, getting that objective measures, making sure you hit every criteria of return to running, to sport, since those are two obviously very big kind of milestones in this process, and making sure you're just meeting the demands of what that task is, right?
• 21:49
  SPEAKER_00: Um, if we have athletes who are wanting to go hiking, but you know, there's not clear-cut criteria for hiking.
• 21:56
  SPEAKER_00: We just kind of do a needs analysis of it.
• 21:57
  SPEAKER_00: And we're like, all right, can you do this, this, and this?
• 22:00
  SPEAKER_00: Has your capacity build up to this?
• 22:01
  SPEAKER_00: This is what we typically see with hiking and based on the terrain of it.
• 22:05
  SPEAKER_00: So then we're just making sure that physical preparation is there so you could take on the demands of it.
• 22:09
  SPEAKER_00: And so then, therefore, we're trying to make sure that you have met said, you know, capacity and strength and criteria in order to make sure you feel ready enough to do that.
• 22:18
  SPEAKER_00: And so we're having that conversation with you about it and also risk reward of it.
• 22:23
  SPEAKER_00: Is it worth it if you have something else coming up pretty quickly and this might bug out the knee when we need to make sure we meet the thing that's coming up that's more important to you?
• 22:32
  SPEAKER_00: So these are all conversations we have with our athletes to make sure that this is all weighed in, and it's very important to do that.
• 22:39
  SPEAKER_00: So this means everyone has to be on the same page and communicating.
• 22:43
  SPEAKER_00: This means putting egos aside, there's no hierarchy here, and it is a team-based approach and focusing on the athlete in front of us.
• 22:50
  SPEAKER_00: And this is something that is always tough because with us, even like you know, we do communicate with other stakeholders.
• 22:58
  SPEAKER_00: Sometimes it's just hard to communicate with other stakeholders, and people are asking questions, well, am I ready to do this?
• 23:04
  SPEAKER_00: Or maybe the surgeon's office or whoever they're working with is pretty disconnected.
• 23:09
  SPEAKER_00: There's not a lot of you know, guidance.
• 23:11
  SPEAKER_00: They're just like, I did the surgery, um, and now your physical therapist is responsible for the rest of it.
• 23:17
  SPEAKER_00: Um, so it just kind of depends on the involvement and what this looks like, which is important to determine.
• 23:22
  SPEAKER_00: But a lot of times we end up having to make that decision.
• 23:26
  SPEAKER_00: And I think rightfully so, if I'm being completely honest, because we are in the throes with the athletes, being day in and day out, seeing what they're doing in rehab, what they can do, what they can't do, um, talking to them, being able to test subjectively.
• 23:42
  SPEAKER_00: And if this is also being done at the surgeon's office, that's awesome.
• 23:45
  SPEAKER_00: We have surgeons around here in Atlanta who do an incredible job of this and we communicate based on this.
• 23:50
  SPEAKER_00: But this it can be tough for the ones where it's kind of a little bit silo-based and they're kind of operating like, all right, you check the box, you came for the visit, your ACL is not torn, keep moving.
• 24:00
  SPEAKER_00: Protocol says this.
• 24:02
  SPEAKER_00: Well, there needs to be a pause here because we need to make sure that you're ready for it, because this can be such a domino effect into the rest of your rehab and you getting back to the things that you want to do ultimately.
• 24:14
  SPEAKER_00: And when someone gives you an opinion, this is what I want you to take away here.
• 24:19
  SPEAKER_00: Especially passing a big milestone or quote unquote clearance to start doing something, ask them why and based on what.
• 24:27
  SPEAKER_00: Ask them why and based on what.
• 24:30
  SPEAKER_00: If they haven't measured your quad strength or your hamstring strength objectively, then I think you really need to reevaluate that decision and that you know guidance and that advice you've been given, as they are likely not up to date of the latest of what's needed to make that decision.
• 24:47
  SPEAKER_00: Point blank.
• 24:48
  SPEAKER_00: If they haven't measured it and they give you some sort of like, all right, you can start running, you can especially return to some high-level cutting and pivoting sport and your quad strength and your hamstring strength at the minimum.
• 25:01
  SPEAKER_00: There are other things that we would test, but that is at the minimum hasn't been tested appropriately using a dynamometer for isometric strength or isokinetically, or even worst case scenario, a one repetition maximum or a three to five repetition maximum.
• 25:15
  SPEAKER_00: And if they don't have that information of what your symmetry is or normalized to your body weight, they have no business making that decision yet.
• 25:23
  SPEAKER_00: And so this is something that I want you to take away of knowing, all right, if I get this info, if I'm told this, what do I do with it?
• 25:31
  SPEAKER_00: And how do I make this decision and make sure it's the best in my health in my journey?
• 25:37
  SPEAKER_00: And this is where knowing who is a part of that team and who's helping to make that decision and ultimately who is also collecting that information to make that decision for you or help you guide that and get back to the thing.
• 25:52
  SPEAKER_00: And running is a big one that I often see miss.
• 25:54
  SPEAKER_00: I've talked about returning to sport and performance, but I think running is one that is kind of this like door that opens that opens up a lot for people.
• 26:03
  SPEAKER_00: It's one of the biggest milestones that people are looking towards after that post-op process because you're like, all right, if I'm running, I can start doing an X, Y, and Z.
• 26:11
  SPEAKER_00: I feel more like an athlete, which is what we're trying to do with this.
• 26:14
  SPEAKER_00: So this is where it is very, very crucial to make sure we have a process.
• 26:19
  SPEAKER_00: We question things and we know who our stakeholders are, and whatever that guidance and clearance is that we have uh data and information to back that up.
• 26:29
  SPEAKER_00: So who should clear you?
• 26:31
  SPEAKER_00: It depends.
• 26:32
  SPEAKER_00: It's really based on your stakeholders and who is collecting that information.
• 26:37
  SPEAKER_00: I hope this was helpful, team.
• 26:38
  SPEAKER_00: If you guys have any questions about this, if you're like, I'm kind of confused, um, I'm kind of in a tough spot, reach out to us.
• 26:45
  SPEAKER_00: We're happy to help in any way that we can.
• 26:47
  SPEAKER_00: But otherwise, I will catch you next week.
• 26:51
  SPEAKER_00: This is your host, Robbie Patel, signing off.