Latest / The ACL Athlete Podcast / 192 | Cleared But Not Ready: Understanding the Difference in Medical vs. Physical Clearance in ACL Rehab

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192 | Cleared But Not Ready: Understanding the Difference in Medical vs. Physical Clearance in ACL Rehab · The ACL Athlete Podcast

• 0:18
  SPEAKER_00: Welcome everyone to the ACL Athlete Podcast.
• 0:22
  SPEAKER_00: This is the podcast where we talk about everything related to the ACL, whether that's the injury itself, the rehab process, return to sport, and more.
• 0:31
  SPEAKER_00: I'm your host, Dr.
• 0:32
  SPEAKER_00: Ravi Patel, performance physical therapist and coach.
• 0:36
  SPEAKER_00: Between myself and fellow guests and experts, you'll learn through the lens of the patient, the healthcare professional, and the coach.
• 0:43
  SPEAKER_00: The goal of this podcast is to equip you, the athlete, with the education to make the best informed decision about your care and your ACL journey.
• 0:54
  SPEAKER_00: Thanks for joining.
• 0:55
  SPEAKER_00: Now let's dive into today's episode.
• 1:00
  SPEAKER_00: All right, team, we are jumping straight into it today.
• 1:04
  SPEAKER_00: This is all about reframing this term clearance or graduated.
• 1:10
  SPEAKER_00: And we're going to specifically focus on clearance because that's the one that is usually used in this process.
• 1:17
  SPEAKER_00: But I think it's important for many ACLers because they will face this situation where they get cleared or they've graduated ACL rehab.
• 1:27
  SPEAKER_00: Maybe you just kind of finish because you finished your insurance and your visits, or maybe it's just the value wasn't there.
• 1:36
  SPEAKER_00: So maybe you didn't even get to this point.
• 1:38
  SPEAKER_00: But a lot of times people are trying to chase this getting cleared or graduated in ACL rehab.
• 1:44
  SPEAKER_00: So let's try to address this particular idea and this concept that a lot of you will face.
• 1:52
  SPEAKER_00: This can come from the surgeon or physical therapist, maybe an athletic trainer or a combination of these stakeholders where you will get cleared or you've graduated to ACL rehab.
• 2:04
  SPEAKER_00: But usually, in most cases, the way it's done, it's the surgeon who ACLers look towards.
• 2:12
  SPEAKER_00: And I'm not quite sure why it's the surgeon's decision that weighs the most, if you will, mostly because they are assumed at the top of the totem pole.
• 2:22
  SPEAKER_00: And I'm using this with air quotes, or of this hierarchy, if you will.
• 2:26
  SPEAKER_00: They did the surgery.
• 2:28
  SPEAKER_00: They're the ones you talk to probably initially, because a lot of people don't connect with their physical therapist until after.
• 2:34
  SPEAKER_00: But with that said, they are the ones who are helping to navigate some of these decisions of like, all right, the surgery, they're doing this major expensive surgery.
• 2:43
  SPEAKER_00: It seems very important, which it is.
• 2:46
  SPEAKER_00: And so they're in this position of authority.
• 2:48
  SPEAKER_00: They're a medical doctor.
• 2:50
  SPEAKER_00: And so the PT or the rehab professional also is in a position of authority, if you will.
• 2:55
  SPEAKER_00: But for some reason, it's presented as this hierarchy.
• 2:59
  SPEAKER_00: It doesn't seem as high as the surgeon, right?
• 3:02
  SPEAKER_00: It's kind of like a house being built, and there's a project manager, and then there's all the contractors and people coming through, right?
• 3:11
  SPEAKER_00: But in all honesty, it's not like that.
• 3:14
  SPEAKER_00: There needs to be basically multi-project managers within this.
• 3:19
  SPEAKER_00: So they are working together as a team in order to decide what is the right path.
• 3:24
  SPEAKER_00: So there's checks and balances within this, but for some reason, it almost seems like the surgeon can dictate a little bit of this project management.
• 3:32
  SPEAKER_00: But this is where it can be challenging for a number of reasons.
• 3:36
  SPEAKER_00: Number one thing is that people will take the surgeon's advice at face value, especially if they have some type of reputation for a pro sports team or worked with this particular athlete.
• 3:48
  SPEAKER_00: And I get it, ACLers are unfamiliar with this process.
• 3:52
  SPEAKER_00: So you're looking for guidance.
• 3:54
  SPEAKER_00: And most importantly, to be cleared and done with this process.
• 3:57
  SPEAKER_00: No one wants to stay in it longer than they need to.
• 4:00
  SPEAKER_00: And so you are trusting this medical professional to be able to help guide you to give you appropriate advice on what to do, right?
• 4:09
  SPEAKER_00: And so this is something that you want help with, and we don't know any better because it might be our first time, it might be even our second time, right?
• 4:17
  SPEAKER_00: But we are trusting this person who has gone through and been educated on this and trained on this to be able to help give us really solid advice on this.
• 4:27
  SPEAKER_00: And while this is something that is important to take into consideration, their information that is provided, this is something that we need to make sure we factor into the entire decision-making process.
• 4:42
  SPEAKER_00: And what I want to do is share a story.
• 4:44
  SPEAKER_00: So I had an ACLer who is six-ish months post op get quote unquote cleared by their surgeon.
• 4:50
  SPEAKER_00: Now, prior to the six-month visit, we had this discussion, the work that still needs to be done for this athlete.
• 4:58
  SPEAKER_00: They are not at a point of clearance.
• 5:00
  SPEAKER_00: Also, it's a nine to 12 month process for us, especially getting back this athlete to playing a higher level cutting and pivoting sport.
• 5:09
  SPEAKER_00: So they knew that there was some time left, but they went to this surgeon's visit, and the surgeon said, You are good to go, you're cleared.
• 5:17
  SPEAKER_00: You don't need to come back and see me.
• 5:18
  SPEAKER_00: And this is the same song and dance we hear from so many athletes all of the time.
• 5:25
  SPEAKER_00: And it might be six months, it might be even at the nine month mark.
• 5:28
  SPEAKER_00: And the athlete, this particular athlete came back and said, and this particular athlete came back and said, Yeah, the surgeon said I could do all the things now.
• 5:38
  SPEAKER_00: And so I always, always, always ask my athletes when there especially is this discrepancy between what we've been talking about, where they're at, and what the timeline and the roadmap looks like, versus what some other professional surgeon, maybe it's another professional involved, says their timeline and what that process looks like as well.
• 6:01
  SPEAKER_00: And so I always ask my athletes, how much time did this person spend with you?
• 6:06
  SPEAKER_00: What did they do?
• 6:08
  SPEAKER_00: What did they make this decision based off ultimately the advice that they're giving you?
• 6:13
  SPEAKER_00: And also I ask them, how do you feel you are based on being cleared and their perception of where they are zero to a hundred percent?
• 6:23
  SPEAKER_00: Often this doesn't align.
• 6:26
  SPEAKER_00: And so, sure enough, when I asked this athlete, it was five minutes, tested my knee via a Lockman's test, and this is where everyone knows the surgeon will grab the top of the thigh, they will grab right underneath the kneecap with their hand, and they will pull this knee back and forth to test the integrity of the ACL ligament.
• 6:47
  SPEAKER_00: And a lot of times they will say the ACL is strong, and it's like, yeah, the ACL has an end feel, and so sure, it's there.
• 6:56
  SPEAKER_00: You can't tell if the ACL is strong or not, to be completely honest.
• 6:59
  SPEAKER_00: You need MRI, you would need so much more detail to know if the ACL, the thickness of it, and even then the composition of it is not truly there.
• 7:09
  SPEAKER_00: We know the ACL can take up to two years to heal.
• 7:12
  SPEAKER_00: So then, therefore, us doing a physical Lachman's test only tells us that the ACL is present and maybe a little bit of translation or the laxity of that ligament.
• 7:21
  SPEAKER_00: But other than that, to be honest, you cannot know if the ACL is quote unquote strong.
• 7:26
  SPEAKER_00: So this Lockman test just lets us know is there an end feel and is that ACL present, and maybe a little bit of laxity, especially if we compare side to side.
• 7:36
  SPEAKER_00: They will move it around.
• 7:38
  SPEAKER_00: So you might test some extension, some flexion on the table, and then the surgeon will potentially do a squat, maybe a single leg squat.
• 7:46
  SPEAKER_00: I remember whenever I had my conversations with my surgeons for quote unquote clearance.
• 7:52
  SPEAKER_00: There was no testing.
• 7:58
  SPEAKER_00: For my first ACL, I had no testing.
• 8:00
  SPEAKER_00: And so this is something that is bizarre and almost makes me think about you know, my second ACL tier.
• 8:06
  SPEAKER_00: And so, with that said, this is all based on a five-minute exam, maybe 10 minutes if you're lucky.
• 10:18
  SPEAKER_00: So, when we take a step back to assess how the decision was made, we start to see how this misses the mark on such a huge, huge decision.
• 10:28
  SPEAKER_00: We are saying that you can start going to play these sports and activities, and this is based on this five-minute exam.
• 10:39
  SPEAKER_00: In situations like this, this is where we need to be detailed in clearance.
• 10:44
  SPEAKER_00: And this is my point of this podcast episode.
• 10:46
  SPEAKER_00: This is a medical clearance.
• 10:48
  SPEAKER_00: It is not a return to sport clearance, it is not for all activities clearance.
• 10:54
  SPEAKER_00: This is a medical clinical clearance, meaning they tested the knee clinically in their environment, typically a very small room.
• 11:03
  SPEAKER_00: It's very basic, and there's no possible way for someone to clear someone for a high-intense sport or activity by seeing them for five minutes in a small treatment room with a few table tests and maybe like a mini squat or something, right?
• 11:19
  SPEAKER_00: When we think about the degree of someone moves in terms of an activity, when we are looking at on-field stuff, on court stuff, when we're thinking about even skiers, when we're thinking about jujitsu athletes, when we're thinking about athletes who are doing parkour type stuff, handball, when we think about any of these sports, right?
• 11:38
  SPEAKER_00: This is going to be something where this athlete needs to be able to be strong, be able to have range of motion, and be able to move dynamically, right?
• 11:46
  SPEAKER_00: And can we grab this from being on a table?
• 11:49
  SPEAKER_00: Absolutely not.
• 11:51
  SPEAKER_00: This is always something that needs to come back to what the professional, if you will, is basing this advice and clearance on.
• 12:00
  SPEAKER_00: If it's via isolated objective strength measures, dynamic tasks such as running, jumping, cutting, then yeah, I am all game for them to be able to give a little bit more advice on saying, hey, yeah, I think you're cleared.
• 12:13
  SPEAKER_00: This is what this return to sport or activity progression should look like.
• 12:17
  SPEAKER_00: But this is basically just saying, hey, like you check out on the physical preparation checklist, if you will.
• 12:24
  SPEAKER_00: Good surgeons will do this in conjunction with information from good rehab professionals, physical therapists, athletic trainer, strength and conditioning coaches.
• 12:34
  SPEAKER_00: In most cases, when you think about a pro athlete, when you think about even collegiate athletes, especially a division one, there is a whole host of people making this decision based on data and based on talking with the athlete and based on talking with all the stakeholders, all the professionals involved, with the athlete being the center point, and maybe there's a parent, maybe there's other people, an agent involved.
• 12:59
  SPEAKER_00: But with that said, you think about this at the highest level.
• 13:03
  SPEAKER_00: Now, if we bring this down to recreational, high school, um, you know, where there's not as many resources because, of course, we're not at the collegiate or professional level, then therefore we don't have as many stakeholders involved as in those domains.
• 13:18
  SPEAKER_00: We also don't have access to the technology, to the time, to the testing, to the focus on that.
• 13:24
  SPEAKER_00: And we are based in, you know, this insurance-based system here in the States, other places.
• 13:29
  SPEAKER_00: It is different from, you know, universal healthcare.
• 13:33
  SPEAKER_00: And so there's limitations within all of them.
• 13:35
  SPEAKER_00: But with that said, most people who go through this injury are not going to have the glamour and all the bells and whistles for this.
• 13:44
  SPEAKER_00: They're not going to have the people to help look at all the data and be able to make this decision.
• 13:49
  SPEAKER_00: With insurance and with most healthcare systems, they're going off of volume and very bare information to make these decisions.
• 13:57
  SPEAKER_00: And a lot of it is based on timelines.
• 14:01
  SPEAKER_00: And so that's what makes this really challenging.
• 14:03
  SPEAKER_00: And if this decision is on the five-minute table test, it is only a medical clearance.
• 14:10
  SPEAKER_00: If they're like, hey, you're good to go, you're cleared.
• 14:13
  SPEAKER_00: I will push back on this and say it's only a medical clearance, not physical readiness and not clearance for return to sport.
• 14:20
  SPEAKER_00: This is all going to be based on what they're making their decision off of.
• 14:23
  SPEAKER_00: And they need to defend this.
• 14:25
  SPEAKER_00: If an athlete, if I clear them and if a surgeon clears them, we need to be able to defend why it is that I say you're ready.
• 14:33
  SPEAKER_00: It's not just because, hey, you're at nine months, like good to go.
• 14:37
  SPEAKER_00: Like you, you put in your work.
• 14:38
  SPEAKER_00: It's like great, like you've been working at this, but show me and prove to me and earn the right to be cleared.
• 14:45
  SPEAKER_00: And it needs to be focused on data and it needs to be focused on understanding where the athlete is, not only from that physical and objective standpoint, but also subjectively.
• 14:55
  SPEAKER_00: How's the athlete doing?
• 14:56
  SPEAKER_00: When I'm checking in from their, you know, psychological side, we do some questionnaires, ACL RSI to check in on this stuff.
• 15:03
  SPEAKER_00: It is going to be really important to be able to do this.
• 15:06
  SPEAKER_00: And I know our bias in ACL rehab process is to be done.
• 15:10
  SPEAKER_00: We want to be done as athletes.
• 15:13
  SPEAKER_00: We don't want to be in this any longer than we need to.
• 15:16
  SPEAKER_00: And to hear that clearance or graduated word, but it has to be based on legit information.
• 15:23
  SPEAKER_00: We want to hear those things.
• 15:24
  SPEAKER_00: So then, therefore, when we hear it, we're excited, but we need to make sure it's proven based on information that is legit, not that six or nine month timeline and protocol.
• 15:34
  SPEAKER_00: And that's what a lot of these decisions are made off of.
• 15:38
  SPEAKER_00: And I do think this is a very, very big factor as to why re-injury rates are as high as they are.
• 15:44
  SPEAKER_00: Underlying this is because there is not enough testing to be able to see where these athletes are, ensure it's like medical system limitations.
• 15:54
  SPEAKER_00: But with that said, testing is not being done.
• 15:57
  SPEAKER_00: And then also appropriate programming and exercise prescription and helping these athletes get to these appropriate criteria that is proven in the research to reduce re-injury rates.
• 16:09
  SPEAKER_00: And so I think that this is something that really does lead to re-injury rates because we just let people go, whether it's just, you know, they don't have a continuation of the plan or clearance is given whenever it shouldn't be given or there needs to be more context of what type of clearance.
• 16:25
  SPEAKER_00: Most professionals use timelines, they don't test, and they make these decisions off of very limited data, which is dangerous.
• 16:33
  SPEAKER_00: Think about this.
• 16:34
  SPEAKER_00: If you got in your car, you got into a wreck, right?
• 16:37
  SPEAKER_00: Where the fender was bent, the wheel was busted up, the axle that attaches to the wheel was bent as well as busted up.
• 16:45
  SPEAKER_00: And then you went and had it repaired by a mechanic, right?
• 16:48
  SPEAKER_00: And when you went to pick it up, your mechanic showed you it's good by just turning the steering wheel.
• 16:54
  SPEAKER_00: No way I would drive that thing back on the highway.
• 16:57
  SPEAKER_00: They would need to show me they've test drove it at different speeds, show me the new parts, the performance, and the testing of it.
• 17:05
  SPEAKER_00: Usually there is a checklist that mechanics will go through, especially for a major accident like this, even for something basic, they will have things that they will need to check off to make sure that this has been done.
• 17:16
  SPEAKER_00: And so it's it checks and balances to make sure, like, hey, is this repaired?
• 17:20
  SPEAKER_00: And of course, sure, if you go to certain places, they don't have these standards or parameters.
• 17:26
  SPEAKER_00: But if you are talking about a car that you could be risking getting into another wreck or an issue or putting someone else at injury or or at stake here, right?
• 17:35
  SPEAKER_00: Then that is something that falls on you.
• 17:37
  SPEAKER_00: And you want to make sure that you protect yourself as well as other people to make sure this car checks out the way it does.
• 17:44
  SPEAKER_00: And so then, therefore, you're gonna make sure that what you've invested and the work that's been put in, you're gonna make sure it's tested and done appropriately before you drive the car again.
• 17:54
  SPEAKER_00: And while I know ACL rehab is not a car and humans and cars are different because it's mechanical versus we're this complex thing, it is similar in the sense of we can't just leave this up to blind trust.
• 18:05
  SPEAKER_00: We can't just trust the mechanic did it and we're good to go.
• 18:08
  SPEAKER_00: We need to be convinced why they say it's good to go, just like the knee.
• 18:13
  SPEAKER_00: And it can't just be rotating the tire by saying, like, all right, cool, you're good to go.
• 18:17
  SPEAKER_00: It's like, no, it needs to be tested and it needs to be pressure tested, to be honest.
• 18:22
  SPEAKER_00: We need to know that this thing can be able to keep up with the demands of driving on the highway, of changing different speeds, changing different lanes, being able to brake when you need to.
• 18:33
  SPEAKER_00: Um, the same thing with our knee and our body is we need to make sure that it is pressure tested to make sure it can handle all the different situations that we are going to have to navigate with it, especially if you're going back to a higher level cutting and pivoting sport or just something that is very demanding on the knee.
• 18:53
  SPEAKER_00: We need to be proven why we're physically and mentally ready, not just be an ACL ligament Lockman test.
• 19:00
  SPEAKER_00: It is so, so much more than that.
• 19:03
  SPEAKER_00: And I think this is the thing that can kind of fool people sometimes because there's this test of the ACL ligament, and then our brains we're like, well, that's the thing that got repaired.
• 19:12
  SPEAKER_00: So if that thing is there, the surgeon tests it, then yeah, that should be good to go.
• 19:17
  SPEAKER_00: But in reality, that is a fraction of the stress that it'll feel.
• 19:21
  SPEAKER_00: And what the surgeon is testing is is it there?
• 19:24
  SPEAKER_00: That's it.
• 19:25
  SPEAKER_00: Nothing else besides that, and maybe a little bit of laxity.
• 19:29
  SPEAKER_00: But other than that, you are not going to get the quote unquote strength of that ACL by any handheld test.
• 19:35
  SPEAKER_00: And so this is where I get it, though.
• 19:39
  SPEAKER_00: A lot of surgeons have their options and what they provide exhausted, right?
• 19:45
  SPEAKER_00: When you think about the options that exist, it's usually to do nothing, maybe give some medication, to inject, cut, and that's mostly it.
• 19:55
  SPEAKER_00: That's the focus of their solutions, if you will.
• 19:59
  SPEAKER_00: So I'm not expecting it to be this hour-long session where they watch everything and see you do that.
• 20:05
  SPEAKER_00: That's not their job, to be completely honest.
• 20:08
  SPEAKER_00: They were the ones who did the surgery, so their goal is to make sure that the surgery was done right and the knee is healing.
• 20:15
  SPEAKER_00: Would that be awesome that they can look at this and be able to assess these things?
• 20:18
  SPEAKER_00: Great.
• 20:19
  SPEAKER_00: But it's not their job, as I had said.
• 20:21
  SPEAKER_00: The issue I have is that clearance and understanding it is not full clearance for anything, it is medical clearance, especially for the typical five to 10 minute exam that 90% of ACLers will get.
• 20:36
  SPEAKER_00: Now, this surgeon is getting information from their sports science, from their physical therapist, from other stakeholders where they're like, hey, I've got range of motion, I've got their strength testing isolated, I have their dynamic profile.
• 20:52
  SPEAKER_00: So looking at running, jumping, cutting, all these different metrics and numbers that they're looking at, and they have particular criteria for you to hit, then awesome.
• 21:01
  SPEAKER_00: I've got some surgeons here in Atlanta who do an amazing job of this.
• 21:05
  SPEAKER_00: And one of the biggest things that they are having as a non-negotiable is strength, which aligns so much with the research, aligns so much with my bias and what our philosophy is, because we know this is such a big re-injury risk.
• 21:20
  SPEAKER_00: So that's awesome.
• 21:21
  SPEAKER_00: But that is far and few between, to be completely honest, for most professionals.
• 21:26
  SPEAKER_00: And so then that's what makes this challenging to make a decision like this.
• 21:30
  SPEAKER_00: And so what's tough for us is that in this type of situation, we have to be the bad cop and help reset expectations when an athlete does get their hopes up.
• 21:41
  SPEAKER_00: I've seen on multiple, multiple, multiple occasions where, you know, this athlete knows where they're heading.
• 21:47
  SPEAKER_00: We've talked about it, and all of a sudden they go see their surgeon.
• 21:50
  SPEAKER_00: The surgeon tells them something like, Hey, you're ready to go, you're ready to do this.
• 21:53
  SPEAKER_00: And it's not based on anything, it's just the timeline.
• 21:56
  SPEAKER_00: And they leave and they're like, Yeah, like this is awesome, and I'm so excited, and I can do this.
• 22:01
  SPEAKER_00: And I have to bring them back to earth because it's like, hey, like, you're still only a 50% quad strength.
• 22:07
  SPEAKER_00: Like, I love that this surgeon did tell you this, but to be completely honest, there was no basis on this.
• 22:12
  SPEAKER_00: And so that's what can be so challenging for us.
• 22:15
  SPEAKER_00: And don't get me wrong, I'm not here to just point fingers at the surgeon.
• 22:20
  SPEAKER_00: I know I'm talking about this a lot, but PTs can quite be guilty of this too.
• 22:26
  SPEAKER_00: You know, we are not the best at being able to navigate this stuff either.
• 22:31
  SPEAKER_00: But what I do see and hear about a lot with ACLers is that the surgeon, because they have such a unique position and this control in this process, as I had alluded to earlier.
• 22:45
  SPEAKER_00: And so I wanted to offer most importantly some solutions because you guys know me.
• 22:50
  SPEAKER_00: I want to make it practical.
• 22:51
  SPEAKER_00: This isn't just, hey, complain about it and then preach it out to the world.
• 22:55
  SPEAKER_00: It's like, no, let's let's do something about this.
• 22:57
  SPEAKER_00: And that's what this podcast is about, and that's what I am here to help do.
• 23:02
  SPEAKER_00: So let's talk about practical solutions if you find yourself in this.
• 23:06
  SPEAKER_00: If you've been given advice, i.e., you know, return to running or especially returning to sport and activities, especially when you have hit a certain milestone that is pretty big, especially the return to sport and activities, when you've been cleared or graduated, ask yourself, what was this based on?
• 23:28
  SPEAKER_00: Does it make sense with what they looked at?
• 23:32
  SPEAKER_00: Was there any strength testing done, specifically having objective numbers for isolated quad and hamstring strength?
• 23:41
  SPEAKER_00: Other measures are great as well, and we would love to see that.
• 23:45
  SPEAKER_00: But this is absolute bare minimum as a standard, no matter any ACL or procedure, goals, etc.
• 23:54
  SPEAKER_00: Ask yourself if this aligns with how you feel if you say zero to a hundred percent.
• 24:01
  SPEAKER_00: If you say a hundred percent was pre injury.
• 24:04
  SPEAKER_00: Then if you go to look at yourself now and you've had this advice given, you're cleared for X, ask yourself zero to a hundred percent, where do you feel like you're at?
• 24:14
  SPEAKER_00: And if you feel like you're at 90 to 100%, then cool, maybe that does align with it.
• 24:20
  SPEAKER_00: And therefore, you might be good to go as long as you have numbers to back that up.
• 24:24
  SPEAKER_00: But let's say you are cleared, but you only say you're at 60%, 70%, that's still a huge gap, right?
• 24:31
  SPEAKER_00: So therefore, we need to listen to this and be able to address this gap and understand why do I feel this gap?
• 24:40
  SPEAKER_00: And you inherently know it or not.
• 24:43
  SPEAKER_00: When I talk to any of my athletes, even if they give me a number different than what I'm seeing, they know it.
• 24:49
  SPEAKER_00: And the thing is that they just want to believe they are more than they are.
• 24:52
  SPEAKER_00: And I get it, guys.
• 24:53
  SPEAKER_00: Like I've been through this twice.
• 24:56
  SPEAKER_00: And the thing is, I understand, like, you want to be through this, you want to be more than where you're at.
• 25:01
  SPEAKER_00: And I think the biggest thing is making sure we're honest with ourselves because we owe it to ourselves and we do not want to do this again.
• 25:08
  SPEAKER_00: Make this the last ACL injury that you ever have.
• 25:11
  SPEAKER_00: And the way you do that is by doing this right, not just following through whatever the step-by-steps are that this traditional system has given us.
• 25:19
  SPEAKER_00: So, this is where this podcast comes into play.
• 25:22
  SPEAKER_00: And being able to educate yourself and put this stuff in play.
• 25:26
  SPEAKER_00: You need to have numbers to help back up this clearance.
• 25:29
  SPEAKER_00: That is the thing that I want to really hit home here.
• 25:32
  SPEAKER_00: So, whether that's your PT, rehab provider, strength coach, whatever that is, or ask your surgeon, be like, hey, like, I don't know that I necessarily agree with this.
• 25:43
  SPEAKER_00: But even then, like you could just kind of let it be what it is.
• 25:46
  SPEAKER_00: More so ask, like, hey, like, is there a way for me to get strength tested?
• 25:50
  SPEAKER_00: Is there a way for me to get isokinetic testing or get a dynamometer and be able to be referred somewhere?
• 25:57
  SPEAKER_00: And if they don't know what you're talking about, that is red flag number one.
• 26:02
  SPEAKER_00: Number two is that they might say, we don't necessarily have the resources or I don't know, and that's okay.
• 26:08
  SPEAKER_00: Then you're kind of left to your own devices of like what you need to do and tackle.
• 26:13
  SPEAKER_00: But this is something that is worth a shot to ask your surgeon.
• 26:17
  SPEAKER_00: Um, and this should have been something maybe vetted prior to even having the surgery just to see what they believe.
• 26:23
  SPEAKER_00: But with that said, most don't necessarily do this.
• 26:26
  SPEAKER_00: So that's okay if yours doesn't.
• 26:29
  SPEAKER_00: You just need to know that the standard is not where it needs to be in terms of testing athletes and also where things need to be in terms of minimizing re-injury risk and getting you back to full performance.
• 26:41
  SPEAKER_00: And so this is where we want to be able to ask, yeah, the local PT, uh, strength coach, maybe it's calling around to clinics or university settings and being able to ask, do they have access to testing equipment?
• 26:57
  SPEAKER_00: More specifically, you know, every major city for the most part has it.
• 27:01
  SPEAKER_00: And there's lots of clinics that are starting to do this more and more, whether it's with the dynamometer, with the force plates, with isokinetic machine.
• 27:10
  SPEAKER_00: But what you're looking for is asking, hey, do you do A scale return to sport testing?
• 27:15
  SPEAKER_00: Now, this is where this needs to get very specific.
• 27:19
  SPEAKER_00: And most importantly, the number one thing, numero uno, specifically asking for isometric quad and hamstring strength testing.
• 27:30
  SPEAKER_00: They'll either have a dynamometer, so it's this device that you are able to measure force with, and that is where you can test your knee extension and hamstring strength to be able to see what is the quad and hamstring strength looking like from an objective standpoint.
• 27:47
  SPEAKER_00: A cherry on top is if the place has an isokinetic machine that's where you're fixed into this big machine and you're going to be kicking in and out of it.
• 27:56
  SPEAKER_00: That's awesome.
• 27:57
  SPEAKER_00: The names of those are typically a Kincom.
• 28:00
  SPEAKER_00: The the other ones are the biodex and being able to look at a cybex.
• 28:06
  SPEAKER_00: So those are the ones that are the brands that are usually rotating throughout.
• 28:10
  SPEAKER_00: You can look at different university settings, a lot of sports science, um, extra and sports science have testing related to this.
• 28:18
  SPEAKER_00: Um, they're doing research related to this typically.
• 28:21
  SPEAKER_00: So um, you can try and find some new grad who's looking to get data for an ACL subject and be able to try and get some information from that.
• 28:29
  SPEAKER_00: But usually hospital systems, university systems, there's somewhere in isokinetic machine, if not a local clinic, has a dynamometer to be able to objectively measure your quad strength and hamstring strength.
• 28:41
  SPEAKER_00: When you ask for ACL return to sport testing, the one thing I want you to be cautious of is if all they do is hop testing.
• 28:48
  SPEAKER_00: If you are just doing a, you know, a single leg horizontal hop test, a six-meter hop test, a crossover triple hop test, like if you're just like hopping on a single leg horizontally over some space, that is not ACL return to sport testing.
• 29:03
  SPEAKER_00: While you might get some information there, that is not what we would be looking for in terms of trying to get an understanding of your strength profile and your movement profile.
• 29:14
  SPEAKER_00: And so that's one other thing that we see in the space, whether it is at the surgeon's office or in PT clinics where people will have return to sport testing and it's just these hop tests, and then they're cleared.
• 29:25
  SPEAKER_00: We literally just had an athlete who had a hop test done and they were in the 90 percentiles for most of them, comparing side to side for how far they could jump distance-wise.
• 29:36
  SPEAKER_00: And then when the strength was looked at, um, there they were doing this testing at a different clinic for in-person working with us remotely.
• 29:43
  SPEAKER_00: And when we looked at their strength via isokinetic, they were only at 60% strength.
• 29:48
  SPEAKER_00: But the PT at the in-person clinic had said, hey, like you're good to go with doing some of this stuff, but it didn't make any sense because their strength wasn't there yet.
• 29:57
  SPEAKER_00: So there's discrepancies in these different tests as well.
• 30:00
  SPEAKER_00: But to keep this very tactical, your goal is to find a place that can isometrically test your quad strength and your hamstring strength and have objective numbers tied to that.
• 30:11
  SPEAKER_00: Hopefully, you'll be able to get some other jump testing and some cutting measures, but this at the bare minimum.
• 30:17
  SPEAKER_00: And then, worst case scenario, which is still better than what most is happening, is capturing some objective strength numbers for your quads and hamstrings via the gym.
• 30:27
  SPEAKER_00: So you're looking to try and hop on a leg press, leg extension, leg curl machine.
• 30:33
  SPEAKER_00: So those three machines, and you're aiming to do a three to five repetition maximum for a single leg and comparing each side to each other.
• 30:42
  SPEAKER_00: And then, therefore, you do have a comparison side to side to see, all right, are these similar or not?
• 30:48
  SPEAKER_00: And then, therefore, you can even associate a percentage or a symmetry to that and be able to see, all right, cool.
• 30:55
  SPEAKER_00: Well, we need to make sure are both legs strong and making sure, especially the one you're comparing to is strong.
• 31:02
  SPEAKER_00: And then, therefore, we can use this as a proxy of strength, at least for isolated strength for your quads and hamstrings, if you don't have access to these other means of a dynamometer or isokinetic machine.
• 31:16
  SPEAKER_00: I'm fortunate to have some great resources and people here in Atlanta to help me with testing for isokinetic strength testing.
• 31:23
  SPEAKER_00: And for our remote athletes, we often have someone nearby we can connect them with to get them tested.
• 31:30
  SPEAKER_00: For ours who have limits of geography, maybe finances, for example, we could still utilize the machines in the gym because that still gives us a decent proxy.
• 31:41
  SPEAKER_00: But we are going to try and push for trying to get some isometric or isokinetic testing just to make sure we have even more of the gold standard assessments for quad and hamstring strength.
• 31:54
  SPEAKER_00: And then we can assess all these other things via remotely very easily to be able to give our athlete the best chance for returning to their sport and their activities and be able to give an accuracy of clearance.
• 32:07
  SPEAKER_00: And so this is something that is just really important for this episode.
• 32:11
  SPEAKER_00: My point here is if you're making a big ACL decision, you need to have objective numbers to back it up, not just a table test and not just five minutes.
• 32:21
  SPEAKER_00: That is a medical clearance, and that's it.
• 32:24
  SPEAKER_00: Bare minimum.
• 32:25
  SPEAKER_00: And until someone can prove me otherwise, like, and I've been through it, seen it, done it, heard about it over multiple occasions, multiple times, many different athletes.
• 32:36
  SPEAKER_00: And the thing is, it just doesn't make sense.
• 32:38
  SPEAKER_00: But I know the perception is that it's clearance to do the thing, but it's not.
• 32:43
  SPEAKER_00: You need to have physical and return to sport clearance via true testing, and that is different and should be thoroughly tested and assessed.
• 32:52
  SPEAKER_00: We do not have time to leave it to chances ACL rehab process.
• 32:56
  SPEAKER_00: This is where we get in trouble with re injury rates and poor long-term knee outcomes and health.
• 33:02
  SPEAKER_00: So we're not gonna do that.
• 33:03
  SPEAKER_00: That's not going to be you.
• 33:04
  SPEAKER_00: You've listened to this podcast episode.
• 33:06
  SPEAKER_00: I've I've rifted on this for 30 minutes, and you're like, Ravi, this could have been five minutes.
• 33:11
  SPEAKER_00: But here I am because I wanted to make sure it is clear to share the perspective that I see through so many different lenses and to be able to call out the things that are out there.
• 33:22
  SPEAKER_00: And as I had mentioned, this is not just pointing the finger at surgeons.
• 33:26
  SPEAKER_00: This is for every professional that is involved in helping ACLers.
• 33:30
  SPEAKER_00: But more importantly, for you to be equipped as an ACLer to know, all right, if if I am given this, and I know many of you shook your head and was like, yeah, this definitely was me.
• 33:40
  SPEAKER_00: And I'm still feeling lost, and I still don't feel like myself, right?
• 33:43
  SPEAKER_00: And so listen to that.
• 33:45
  SPEAKER_00: Get tested, be able to find someone who is an expert in this to guide you, to give you the roadmap and the plan that is structured and specific to you.
• 33:55
  SPEAKER_00: And that's what you deserve in this process.
• 33:57
  SPEAKER_00: As the take home here, when you go into that six-month or nine-month visit and they test you for five to 10 minutes, and there is this clearance given, whether it's a surgeon, a physical therapist, whoever the person is, if they clear you or say graduated, back that up.
• 34:17
  SPEAKER_00: Otherwise, that is just a medical clearance.
• 34:21
  SPEAKER_00: There needs to be more than just table testing, a single leg squat, and five minutes.
• 34:27
  SPEAKER_00: And that is going to be so key.
• 34:29
  SPEAKER_00: And if we are trying to change this narrative around re-injury rates, this is a very, very big place on where we can start and really make an impact.
• 34:37
  SPEAKER_00: So I hope that this was helpful, team.
• 34:40
  SPEAKER_00: I am hoping that if there are any surgeons listening, that we will be able to change this narrative.
• 34:46
  SPEAKER_00: If you're a physical therapist, rehab provider listening, changing this narrative to be able to help our ACLers.
• 34:52
  SPEAKER_00: That is so important and giving ACLers the best shot in this process.
• 34:58
  SPEAKER_00: And so the statistics don't continue to rise.
• 35:00
  SPEAKER_00: One day we will be able to flip the script and be able to say, hey, we are doing better with this, and we're actually seeing re injury rates decrease, but we're not there yet.
• 35:10
  SPEAKER_00: So we've got work to do.
• 35:12
  SPEAKER_00: So hopefully this was helpful, y'all.
• 35:14
  SPEAKER_00: Until next time, team, this is your host, Robbie Patel, signing off.