Latest / The Driven Athlete / ACL Surgery Recovery & Rehab Expectations | Ep 78

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ACL Surgery Recovery & Rehab Expectations | Ep 78 · The Driven Athlete

• 0:00
  Speaker 1: If you're a driven, active person who wants to reach and pursue a higher quality life with some ambition, then guess what this podcast is for you.
• 0:07
  Speaker 1: This is the Driven Athlete Podcast.
• 0:10
  Speaker 1: So I realized we haven't even done any ACL topics yet, so I wanted to run through a whole gamut of like.
• 0:23
  Speaker 1: What is the ACL rehab process look like for ACL reconstructive surgery?
• 0:29
  Speaker 1: And I'm going to say this doesn't include a meniscus repair, because a meniscus repair is a little bit delayed, but it's still very similar, and it's not uncommon that a meniscectomy happens with an ACL reconstruction.
• 0:43
  Speaker 1: Um and ACL is the anterior cruciate ligament, and that's um, a very common injury that you hear in the new like for sports athletes, figures and stuff.
• 0:51
  Speaker 1: And, uh, an ACL injury happens with um, a guillotine effect, where the tibia is the shin bone and the femur is up top.
• 1:00
  Speaker 1: And if it, uh, if the tibia dives laterally and the femur dives medially, and so they shift different directions and they rotate a little bit at the same time, um, where the femur rotates internally and the tibia on a usually a fixed leg rotates um externally.
• 1:19
  Speaker 1: That's a, it's like a guillotine effect, and it slices out, it just cuts the ACL.
• 1:23
  Speaker 1: Something to keep in mind, though is the ACL injuries.
• 1:27
  Speaker 1: They call it like ligament fatigue, where the ACL actually gets frayed over multiple instances without even knowing it and then one more final blow kind of finishes the job and it tears the ACL completely, or enough to where there's enough symptoms or it's hanging on by a couple of fibers that needs to be reconstructed.
• 1:45
  Speaker 1: But it's not uncommon that the ACL goes through multiple injuries, micro injuries, over multiple episodes where they didn't know otherwise, and then now it's just enough to where there's enough symptoms and swelling and instability that comes with an ACL injury like that that leads to a person need to go to the doc.
• 2:05
  Speaker 1: You know like I heard my knee pop.
• 2:07
  Speaker 1: It's partially torn.
• 2:08
  Speaker 1: Now you know whatever or not, full torn, full tear.
• 2:12
  Speaker 1: Another really interesting to consider is the most common ACL injuries are non-contact, where it's not like, if you imagine, in soccer or football.
• 2:23
  Speaker 1: In soccer somebody slide, tackles a player and they get hit from the side and their knee buckles and twists and weird.
• 2:29
  Speaker 1: You know that in a very traumatic event.
• 2:31
  Speaker 1: Or in football somebody gets rolled on and their knee gets stuck and their foot gets stuck and then their knee twists.
• 2:37
  Speaker 1: I mean that happens.
• 2:38
  Speaker 1: But actually in the research the most common is non-impact, where somebody just plants and cuts in a in a uh opposite direction and for some reason their knee buckles and they're it twists in a weird fashion, like in that guillotine effect I was talking about, and that finishes the job.
• 2:54
  Speaker 1: Acls cut or uh, ruptures.
• 2:56
  Speaker 1: So, um, it's interesting to keep in mind, right.
• 3:00
  Speaker 1: So it's like all right.
• 3:00
  Speaker 1: With that being said, then how can we lower the risk for athletes of non-contact ACL injury?
• 3:06
  Speaker 1: We definitely have to work on single leg stability and control, proprioception, dynamic eccentric control and strength.
• 3:15
  Speaker 1: And that's like, can a person descend and load into their leg with a good control fashion, a good controlled fashion after, like, imagine landing from a single leg jump and volleyball like a slide jump or like a single leg jump, like that in a right side slide, or a basketball player going up for a single leg layup, and if they land again on one leg, that's uh, can they land when they hit the ground and accept their load of their body weight after jumping in a good fashion that looks controlled and not wobbly and unstable?
• 3:47
  Speaker 1: So those are the things to work on.
• 3:49
  Speaker 1: Then they also consider the females are actually higher likely of tearing an ACL and usually between the ages young female athletes like in their teenage years, teenage athlete females are the most common athletes.
• 4:04
  Speaker 1: Between like in their teenage years teenage athletes females are the most common highest risk for an ACL tear and following that, actually the highest risk of an ACL tear is a previous ACL tear.
• 4:15
  Speaker 1: So unfortunately it's not uncommon where um an athlete, even in high school, they've already had two ACL uh surgeries.
• 4:21
  Speaker 1: Now they're on the third right.
• 4:22
  Speaker 1: It's a bummer.
• 4:23
  Speaker 1: They usually represents represents it's just instability and poor movement control and dynamic eccentric control with ballistic movements like agility, cutting, landing, planting, stuff like that.
• 4:35
  Speaker 1: And a surgically repaired ACL is already compromised.
• 4:40
  Speaker 1: So it's super important to just crush stability and strength with that knee and not lead to compensation patterns or asymmetries between the knee and the strength.
• 4:52
  Speaker 1: All right, um, so anyway, I'm going to run through.
• 4:54
  Speaker 1: Like what does that look like?
• 4:55
  Speaker 1: Let's say somebody tears their acl, then what do you do?
• 4:57
  Speaker 1: And then what does the surgery and rehab look like afterwards?
• 4:59
  Speaker 1: All right, so the first step is uh, usually somebody has to get a consult with a doc, all right, and they get an mri.
• 5:10
  Speaker 1: The only way the whole, the golden standard is to is to check out an mri and see if the acl is torn and maybe other internal derangement which would be like meniscus, mcl, lcl or pcl.
• 5:22
  Speaker 1: Pcl is very uncommon.
• 5:23
  Speaker 1: Pcl is the posterior cruciate ligament and the most common way that they call it a dashboard injury, where imagine if someone gets in a car accident and their knee gets, or the dashboard shoves backwards into someone's knee as a passenger or the driver and that shoves the, the tibia, the shin, backwards against the femur and that stresses and overly stretches the PCL and that tears the PCL.
• 5:47
  Speaker 1: But so the first step got to get a doc consult and get an MRI and confirm that it's torn.
• 5:54
  Speaker 1: Let's say you get an MRI confirm it's torn.
• 5:56
  Speaker 1: Now what?
• 5:57
  Speaker 1: All right, you can set up with their specialist orthopedic surgeon and you know if it's appropriate, schedule surgery.
• 6:05
  Speaker 1: Um, usually, which they try to get surgery and as quickly as possible, and uh, getting prehab, getting rehab, uh, exercise and work done before surgery really improves the outcomes after surgery.
• 6:18
  Speaker 1: So it's really advocated to get some kind of physical therapy, sports, physical physical therapy, if that's possible and accessible for you to get before surgery and a lot better outcomes afterwards.
• 6:30
  Speaker 1: We can get some of the swelling out, get things strong and active as best as we can, because after injury like that very common.
• 6:38
  Speaker 1: The muscle girth and strength of the quadricep muscle and all the other surrounding musculature already is a little bit atrophied.
• 6:44
  Speaker 1: It deadens a little bit and it's a neural defense mechanism, the body's natural defense mechanism, to shut things off because things are injured.
• 6:54
  Speaker 1: So that happens.
• 6:56
  Speaker 1: So it's important to get things reactivated and strong and reinvigorated and normalize the range of motion, maybe even decrease swelling before surgery and the outcomes will be way better.
• 7:05
  Speaker 1: So a little bit of prehab for maybe a month, all right, or in three weeks and then surgery and then when you wake up from surgery, this is what we're going to talk about.
• 7:14
  Speaker 1: So initially things are going to be swollen and it's going to hurt and it's going to be tender and muscle atrophy happens really quick.
• 7:23
  Speaker 1: It's like as soon as you wake up from surgery your muscles are pretty much shut off, especially the quad.
• 7:28
  Speaker 1: The quadricep muscle on the front of the thigh is the first thing that we really focus on to get activated again.
• 7:34
  Speaker 1: All right.
• 7:35
  Speaker 1: So you wake up from surgery.
• 7:36
  Speaker 1: It's not unlikely that if there's no meniscus repair, they want to start rehab that week, like for pro athletes.
• 7:46
  Speaker 1: As an example, they're in there the next day, 24 hours later.
• 7:49
  Speaker 1: We're ready.
• 7:49
  Speaker 1: We're starting to do an exercise, exercise being like a range of motion, movements and a quad activation exercises calf pumps, ankle range of motion and um, beginning the process of some.
• 8:04
  Speaker 1: Um, weight bearing is tolerated, all right.
• 8:06
  Speaker 1: So usually weight bearing is tolerated.
• 8:08
  Speaker 1: You can put as much weight on as appropriate.
• 8:09
  Speaker 1: They just want to prevent injury.
• 8:12
  Speaker 1: So you're going to be in a brace, usually locked out in extension, for safety when you're ambulating around your house or in the community, or to and from physical therapy, so that you don't buckle.
• 8:22
  Speaker 1: All right, because everything's weak and, like the quad muscles, your knee is just weak, it's compromised.
• 8:28
  Speaker 1: They had a major surgery, they had to put tunnels and drill through bone in order to recreate the ACL.
• 8:33
  Speaker 1: So things are, you know, weak.
• 8:36
  Speaker 1: So it's just important to keep things safe.
• 8:38
  Speaker 1: And a knee brace that's locked out in extension doesn't let your knee bend, so that when you're ambulating around, when your crutches, that's locked out and extension doesn't let your knee bend, so that when you're ambulating around, when your crutches, uh, like a, your one leg is like a peg leg but you can put a little bit of weight through it, but, um, it's not going to buckle on you so you fall, because that would be, you know, no bueno, and that would lead to more swelling and pain, discomfort and potentially injure the graft site, which we don't want to do right.
• 9:03
  Speaker 1: So that process is, you know, from zero to three weeks.
• 9:07
  Speaker 1: That first three weeks of time.
• 9:10
  Speaker 1: The goal of that time frame is just to get the swelling down, start some range of motion movements and get your knee to bend and extend comfortably, usually up to a little bit of a restriction.
• 9:24
  Speaker 1: We don't go past 90 degrees if the meniscus isn't repaired.
• 9:28
  Speaker 1: Just allow the graft site to heal.
• 9:31
  Speaker 1: Compression sleeves, ankle pumps, range of motion, quad activations probably the most important thing, followed by sorry, I take it back the most important thing is to get your knee fully straight and extended, all right, and then normalize your gait pattern.
• 9:46
  Speaker 1: Those are the first most important three things.
• 9:48
  Speaker 1: Get the knee to fully straighten out again, get the quad to start to activate and turn on, and then normalize the gait pattern, all right, those are the top three most important things.
• 10:00
  Speaker 1: Getting the knee to bend and flex is important, but with, as the swelling decreases, that will improve, and I'm an advocate to not crush and overly push to bend the knee yet.
• 10:12
  Speaker 1: All right, you will bend the knee.
• 10:14
  Speaker 1: I feel like I sound like game of thrones bend the knee.
• 10:18
  Speaker 1: You will bend the knee, just I don't.
• 10:22
  Speaker 1: There's not a rush, all right, because it's sometimes overly pushing it into flexion like that can increase irritation and swelling.
• 10:28
  Speaker 1: That's going to ultimately lead to more quad inhibition like deactivation and atrophy or just lack of activation for the quad, and it's going to limit and hinder the flexion range of motion anyway and keep the swelling in there.
• 10:39
  Speaker 1: So I'm like there's a, there's a threshold.
• 10:40
  Speaker 1: We want to push a little, you know, bend it, just get comfortable with it, but that will come.
• 10:42
  Speaker 1: It's not a threshold.
• 10:42
  Speaker 1: We want to push a little, you know, bend it, just get comfortable with it, but that will come.
• 10:45
  Speaker 1: It's not a rush, but getting it to fully straighten very important.
• 10:50
  Speaker 1: It's important to get that thing pain-free full extension or a little bit of hyperextension to match the other leg if it's like a plus one or a little bit of hyperextension to match the other one by six weeks.
• 11:03
  Speaker 1: So at six weeks the knee needs to be fully able to fully straighten or a little bit, a tiny bit of hyperextension just to match the other side by six weeks.
• 11:13
  Speaker 1: Um, after that it gets gets more and more challenging and we don't want to have to like really crush to push into extension after that.
• 11:20
  Speaker 1: It just uh, it just sucks and it's a delayed process that can be avoided.
• 11:29
  Speaker 1: The thing that I recommend to people is don't sleep with a pillow under your knee when you can just let your knee have your heel propped up and let your knee sag and sink to the floor.
• 11:41
  Speaker 1: Let gravity just pull the knee down and get comfortable with being uncomfortable.
• 11:45
  Speaker 1: You have to be a little bit.
• 11:46
  Speaker 1: You have to be okay with some discomfort for the sake of your knee getting fully straight for a long-term benefit.
• 11:51
  Speaker 1: So watching TV with your foot on an ottoman in front of you, and let the knee be unsupported so it can just sink to the floor with gravity.
• 11:59
  Speaker 1: Don't sleep with a pillow under your leg.
• 12:01
  Speaker 1: Sit with a towel under your heel when you're just in bed or when you're laying around so that the knee can be unsupported and allow it to just fully straighten out and sag to the floor with gravity all the time.
• 12:15
  Speaker 1: Just get comfortable being uncomfortable for the sake of getting the knee to straighten.
• 12:20
  Speaker 1: That's the most important thing.
• 12:22
  Speaker 1: That top priority is to get the knee fully extended.
• 12:25
  Speaker 1: I've seen a lot, even total knee replacements, patients that are like in their 50s and 60s and like, 12 weeks out, their knee is still a little bit not able to get fully extended.
• 12:38
  Speaker 1: It's a little bit of a flexion contracture.
• 12:39
  Speaker 1: That's going to.
• 12:39
  Speaker 1: They're going to live with that for the rest of their life.
• 12:41
  Speaker 1: It sucks and their, their whole gait pattern is going to be jacked up because of that.
• 12:45
  Speaker 1: And you can imagine, like a 64 year old, overweight female that had a total knee replacement that's never exercised a day in her life, like getting that thing to fully straighten is impossible at that point.
• 12:58
  Speaker 1: So it's just really important to get that thing straightened right away.
• 13:02
  Speaker 1: While you're still on pain meds and that's okay Take pain meds at the beginning.
• 13:06
  Speaker 1: That's what they're there for, so you can sleep.
• 13:08
  Speaker 1: Sleep is gonna be very challenging after ACL rehab surgery, sorry, after the rehab process.
• 13:13
  Speaker 1: So the pain meds are there as needed.
• 13:17
  Speaker 1: With the right mental approach, going with end up taking pain meds of like this isn't a, this isn't a solution, it's just temporary pain modulation so I don't have to live in agony and I can sleep and I can move around and go to Publix, I can go to school, I can do my job, I go to work whatever, just sparingly, as needed.
• 13:35
  Speaker 1: Pain meds can be helpful so I can do my.
• 13:36
  Speaker 1: I go to work whatever, just sparingly, as needed.
• 13:37
  Speaker 1: Pain meds can be helpful so you can live not in agony, recovering from just the trauma of the surgery in general.
• 13:43
  Speaker 1: All right, because it's more like carpentry than it is like delicate surgery.
• 13:47
  Speaker 1: All right, so that's the first three weeks.
• 13:50
  Speaker 1: We could just get the knee fully straight, get the quad to activate, help to decrease the swelling and be okay with being uncomfortable at the sake of just getting your knee to fully straighten.
• 14:02
  Speaker 1: Weeks three to six then we really hit the gas pedal.
• 14:07
  Speaker 1: No pun intended, hit like nothing crazy to normalize your gait pattern by three to six weeks.
• 14:13
  Speaker 1: Three weeks for a young, healthy person.
• 14:16
  Speaker 1: By four weeks the goal is to be off the crutches and walking without crutches in a brace with a normalized gait pattern, which means they need to have almost full extension at this point.
• 14:28
  Speaker 1: Good quad activation and the swelling is decreasing.
• 14:32
  Speaker 1: We have confidence putting weight through their leg.
• 14:35
  Speaker 1: They're doing a little bit at a time to get more confidence through their leg of weight bearing and the range of motion is improving and by six weeks the goal is for the knee to be fully straight and a little bit of hyperextension, like I said, to match the other leg where the other knee is.
• 14:51
  Speaker 1: The goal is to be symmetrical.
• 14:52
  Speaker 1: So by six weeks we need to be there and if we're not, we got to push it at that point Like it's going to be uncomfortable.
• 14:58
  Speaker 1: But we have to get that thing straight, otherwise it's way worse in the future.
• 15:04
  Speaker 1: All right, by week six to 12, we're gaining more functionality.
• 15:09
  Speaker 1: Our gait is normalized, we're out of the crutches, we're getting more confidence, the range of motion, full extension and almost full knee flexion.
• 15:20
  Speaker 1: At this point Some of the residual swelling is not uncommon.
• 15:22
  Speaker 1: We're at the very end of full flexion of the knee.
• 15:25
  Speaker 1: It still bothers you a little bit with a little bit of pain, but that's okay.
• 15:27
  Speaker 1: Definitely need to be like a 120 to 140, right, like 130.
• 15:31
  Speaker 1: Right now we're getting more confident and more functional.
• 15:34
  Speaker 1: But right now we're getting more confident and more functional and the initial we're strengthening at this point Like we need to get some strength from week six to 12 so that we can start a running progression.
• 15:44
  Speaker 1: That's next.
• 15:45
  Speaker 1: At this point we're also doing some single leg balance and getting proprioception.
• 15:49
  Speaker 1: Proprioception is like knowing where your joint awareness is in space, knowing where your joint is in space.
• 15:55
  Speaker 1: Knowing where your joint is in space, then all the nerve endings that innervate your joints in the joint capsule and all the tendons and ligaments in your joints they have little nerve endings are in there called mechanoreceptors, and that lets you know where they are in space when you're not looking at them.
• 16:10
  Speaker 1: All right, so proprioception is just awareness in space where your joints are in your body and those nerve endings are deadened and affected because of the surgery.
• 16:19
  Speaker 1: So we have to get those things activated again and working on balance and proprioception little exercises is part of the rehab process and that's really important.
• 16:29
  Speaker 1: So we're initially doing some of that stuff that we, you know, from week six on or earlier if it's, if they're able to balance and work on some confidence with balance and then the you know, the initial strengthening, because oftentimes for most people a lot of surgeons it's we want to start initially doing some running progressions and initiating and starting some running at week earliest week 12, but definitely by week 16.
• 17:00
  Speaker 1: So for pediatrics under like age, you know, usually I say like from 18 under, imagine like a 13 to 14, a 14 year old kid athlete we don't want to start running progressions until maybe week 16.
• 17:14
  Speaker 1: There was a pediatric surgeon orthopedic pediatric surgeon I was working with in Houston a while a lot and he was like the risk benefit ratio wasn't there.
• 17:21
  Speaker 1: There's nothing wrong with starting running progressions at 16 weeks instead of 12, just to make sure things are strong enough and they have a good understanding of what's going on and they feel confident the swelling has improved week 16.
• 17:34
  Speaker 1: Confident the swelling is improved week 16.
• 17:40
  Speaker 1: So for pro athletes, probably 12.
• 17:41
  Speaker 1: Week 12 for a grown man, grown woman.
• 17:42
  Speaker 1: But for pediatrics we're thinking 16 weeks.
• 17:43
  Speaker 1: But that's gonna be dependent on an individual.
• 17:44
  Speaker 1: If they're not ready yet, they're not ready, we're not gonna go that.
• 17:46
  Speaker 1: We're not gonna start early at the expense of creating more inflammation, pain and instability.
• 17:51
  Speaker 1: That's not, that's no bueno.
• 17:52
  Speaker 1: It's gonna delay the process.
• 17:53
  Speaker 1: And one more thing I want to paint with this.
• 17:56
  Speaker 1: So that's week six to 12.
• 17:59
  Speaker 1: In 12 to 16 weeks we're doing the initial running progressions.
• 18:02
  Speaker 1: We're getting more consistent and aggressive with strengthening.
• 18:05
  Speaker 1: We need to be doing some eccentric strength, progressing into some eccentric strength control, which is like how well can you descend on one leg to a box right, like a box squat or like stepping down stairs?
• 18:18
  Speaker 1: How well can the surgery leg be okay with descending down to the next stair on one leg without wobbling or collapsing or being shaky with it or getting stuck.
• 18:30
  Speaker 1: So it's really important to work on the eccentric strength control of the quadricep muscle and the load acceptance through the joint and the patellar tendon and the kneecap with good quad control and strength, because that's super important for running.
• 18:48
  Speaker 1: If you think about jogging and running, the initial stages of these running and jogging progressions is like the day one at week 15, let's say, or 16, that they look.
• 18:57
  Speaker 1: You know they look good week 15.
• 18:58
  Speaker 1: It's like we're just going to start trundling along and I'd start some jogging right Just to see what it looks like.
• 19:05
  Speaker 1: But jogging and running it's a series of single leg falls every single time, like you catch yourself as you're advancing forward on the ground.
• 19:16
  Speaker 1: They're like individual single leg falls.
• 19:18
  Speaker 1: So your quadricep muscle has to be really good at accepting that load and eccentrically controlling for the next step.
• 19:27
  Speaker 1: And if it's not ready yet, compensation patterns happen.
• 19:29
  Speaker 1: Or if you progress too fast and the load is too much, it's going to cause tendonitis.
• 19:34
  Speaker 1: All right, patellar tendonitis Super common.
• 19:37
  Speaker 1: It just means you're going too fast and the eccentric control isn't there yet and we're just progressing a little bit too much for the strength that's there right now.
• 19:43
  Speaker 1: So you have to wean back a little bit and solidify some things and then progress again.
• 19:50
  Speaker 1: It's not worth it to try to push through, because tendonitis doesn't just work itself out, especially post-surgical like this.
• 19:57
  Speaker 1: Yeah, pardon me.
• 20:04
  Speaker 1: So I went to the zoo yesterday with my kiddos, the big zoo in miami and we're just like they're like having blast and run around and yelling at my kids like, hey, don't go too far, hey, come over here.
• 20:14
  Speaker 1: Hey, look at this cool alligator, you know just yeah.
• 20:17
  Speaker 1: So I'm a little, uh, my throat's a little, bothered this morning, all right.
• 20:23
  Speaker 1: So one thing I wanted to paint the picture.
• 20:25
  Speaker 1: So right now we're at week 16, where we're beginning load acceptance, as in like can you load through your knee and it feels okay, beginning the process of jogging and running.
• 20:34
  Speaker 1: But week, I mean date, 24 hours out, and week 16 I mean we're you're not just sitting around doing nothing, like we were up and moving this, this rehab process, like you're moving, you're walking, you're up and about, you're moving your leg around, range of motion, you're always working on range of motion, extension, quad activation.
• 20:56
  Speaker 1: Literally, it's like your job, like your number one priority and consumed in your life is just getting your freaking knee to be confident and active and strong and range of motion for the first five, four months, because that's a very important initial phase of progressing and for very active individuals it consumes your life for the first eight to 10 months and then after that it's more sports, specific and you feel pretty confident in your knee If you've done everything right at the beginning.
• 21:27
  Speaker 1: This is full invest, like it consumes your life.
• 21:32
  Speaker 1: Cause if you really need to focus and prioritize getting that thing strong cause I've seen it when it wasn't prioritized and it's not a good trajectory but it's just at the beginning.
• 21:42
  Speaker 1: It's just six months.
• 21:43
  Speaker 1: It's really not that long, if you think about it, to set yourself up for success for like years to come.
• 21:47
  Speaker 1: Right, all right.
• 21:50
  Speaker 1: So at week 16 to 24 weeks, which is six months, we're doing single leg strength and power, initial agility, work load acceptance, again with agility and single leg loading.
• 21:59
  Speaker 1: So this is where the fun stuff begins Week 16 to 24 weeks.
• 22:03
  Speaker 1: The single stuff begins.
• 22:08
  Speaker 1: Week 16 to 24 weeks.
• 22:09
  Speaker 1: The single leg strength is really important, the number one test that we ask our athletes or that in the literature it's like hey, can you play sports?
• 22:13
  Speaker 1: Hey, coach, I'm ready.
• 22:14
  Speaker 1: All right, show me 10 single leg squats, pistol squats with good form, good mechanics, the knee isn't wobbling and isn't hurt compared to the other leg.
• 22:24
  Speaker 1: Right, that's the number one, that's one of the main tests.
• 22:26
  Speaker 1: And if they don't do good with that, then like you're not ready, like we have to keep, we have to keep working right.
• 22:32
  Speaker 1: But this is where we start progressing into stuff like that, right, single leg squat stuff, Bulgarian split squats, reverse lunges, a lot of closed kinematic chains, strength exercise, glute, hip stability, strength, balance, proprioception, all that stuff.
• 22:47
  Speaker 1: This is where we get all those things and initial agility like agility, ladder and load acceptance through that, some lateral movement, lateral agility and maybe some rotational agility movements and transverse plane stuff, as long as their knee looks good and confident, because we don't want to rush that process.
• 23:10
  Speaker 1: It's going to create tendonitis and just more swelling and pain.
• 23:13
  Speaker 1: You can't cook horns with this.
• 23:15
  Speaker 1: And then, maybe at six to eight months, is when we start testing, just to get a look at what the single leg strength compared to the other leg looks like, and we call that a limb symmetry index testing, where we do a battery of tests on that surgery leg and the non-surgery leg to see what does the strength and power look like compared?
• 23:35
  Speaker 1: What percentage strength is this one compared to the other one?
• 23:38
  Speaker 1: What symmetry level are we at right now?
• 23:40
  Speaker 1: So we do like the best ones we found in the research is a single leg vertical jump test.
• 23:46
  Speaker 1: So you stand on the non-surgical leg and you jump as high as you can, right, and you do that twice.
• 23:51
  Speaker 1: What's the displacement?
• 23:53
  Speaker 1: That's your vertical jump.
• 23:53
  Speaker 1: And then you test the surgery leg Single leg vertical jump.
• 23:56
  Speaker 1: How high are you getting, right?
• 23:57
  Speaker 1: We document those numbers.
• 23:59
  Speaker 1: Then a single leg forward hop test same thing Two trials on the non-surgical leg and then two trials on the surgical leg.
• 24:06
  Speaker 1: And what was the distance jumped compared to both?
• 24:15
  Speaker 1: And then a triple hop.
• 24:15
  Speaker 1: A triple forward hop is another good option of a test of like what's the total distance at three hops in a row on the same single leg, over and over and over again for three hops compared to the surgical leg?
• 24:23
  Speaker 1: You have two trials each one and you compare the numbers.
• 24:26
  Speaker 1: A crossover hop test is another good one that's been found in the research, where you jump laterally and forward at the same time and see the distance jumped and we're also looking at, just subjectively, what does the quality of movement look like?
• 24:39
  Speaker 1: Like, are they really unstable and wobbly, or are they loading and landing well and landing and decelerating in a good fashion, that's under control, without pain, right?
• 24:48
  Speaker 1: That's another big one too.
• 24:49
  Speaker 1: And another big one is a six meter timed hop.
• 24:52
  Speaker 1: So like a single leg sprint from for six meters and how fast?
• 24:58
  Speaker 1: Like a 40 yard dash, right, but on one leg for six meters.
• 25:00
  Speaker 1: How fast can you get there when the non-surgical leg, two trials.
• 25:05
  Speaker 1: And then how fast can you run that distance on non-surgical leg, two trials, and then how fast can you run that distance on the surgical leg, for two trials.
• 25:08
  Speaker 1: And you compare those numbers and then those four or five or at least four tests, you compile all the numbers and you have your overall comparison, called your limb symmetry index, and you get a good percentage of like.
• 25:21
  Speaker 1: Let's say somebody jumps 10, just for the sake of numbers 10 inches on their non-surgical leg, on the single leg vertical jump, and they jump eight inches on the surgical leg on the vertical jump, right.
• 25:32
  Speaker 1: That'd be like an 80% symmetry index, right, it's 80% strong compared to the other one.
• 25:37
  Speaker 1: And then a forward hop test.
• 25:38
  Speaker 1: Let's say they jump, just for the sake of numbers, 50 inches on the non-surgical leg and the surgical leg.
• 25:44
  Speaker 1: They jump 40 inches right again.
• 25:47
  Speaker 1: That's 80 percent of the distance.
• 25:49
  Speaker 1: So right now we're at like an 80 percent limb symmetry index and that's the case across the board for all those four or five battery tests.
• 25:55
  Speaker 1: That's a good indicator of like.
• 25:58
  Speaker 1: What's the strength look like on the non-surgical leg compared to the surgical leg?
• 26:00
  Speaker 1: Are they ready for sports yet?
• 26:02
  Speaker 1: Well, according to the, they say at least 90% limb symmetry index is what's indicated to be like you're good, you know, go go play.
• 26:09
  Speaker 1: Let's get cleared by the doc.
• 26:11
  Speaker 1: Doc looks at the limb symmetry index numbers, talks to the physical therapist and it's like now we think you're good, right, what does that look like?
• 26:20
  Speaker 1: It's usually at least a 90% limb symmetry index.
• 26:23
  Speaker 1: On our end we would love 95% and we would love 100%, of course, but sometimes there's time constraints and time windows that run out that we need to push the envelope a little bit.
• 26:34
  Speaker 1: Where it's like are you good, we're right at the cusp, do we play or not?
• 26:37
  Speaker 1: Playoffs are coming up right.
• 26:38
  Speaker 1: That's where pro athletes are really pushing the envelope with that.
• 26:41
  Speaker 1: So that's what limb symmetry index looks like and we're starting that at like six to eight months to look at and see what kind of paint the picture.
• 26:48
  Speaker 1: Where's our knee at and what do we need to focus on and prioritize for the remaining four months of this year-long journey is what they suggest.
• 26:55
  Speaker 1: So now we're six to eight months.
• 26:59
  Speaker 1: We're still trying to get full confidence with load acceptance I would say the priority with this, starting at 16 weeks.
• 27:05
  Speaker 1: Even with 12 weeks of like descending and decelerating in a confident, non-painful, strong way right, but definitely by six months we're like you need to do some single legs, progressing, a single leg hopping and landing in a good, decelerating and a load-acceptant way that looks confident and not hitching but landing in a smooth fashion and then able to jump back up again and land in a smooth fashion.
• 27:34
  Speaker 1: So it looks very fluid versus a land and a hitch and the knee's wobbly and they're not confident loading through their knee.
• 27:41
  Speaker 1: It just takes time.
• 27:41
  Speaker 1: That's just the process.
• 27:42
  Speaker 1: But we're looking for confidence and all that fluidity through deceleration and the descent and then back up again and then once they look good and they feel confident, it's not hurting.
• 27:54
  Speaker 1: The pain is number one.
• 27:55
  Speaker 1: You know thing that we look at, uh, and just the overall fluidity and confidence and movement.
• 27:59
  Speaker 1: But then we progress that, right, they're doing single leg box jumps, single leg dip, depth landing and all the fun, cool, creative exercises that you see on Instagram of like of a knee, stability and agility exercises and strength and power exercise.
• 28:12
  Speaker 1: And then by eight to 12 months we're getting into sports specific stuff with speed, agility explosion, single leg speed, single leg agility, single leg explosion Definitely some transverse plane like rotational agility, single leg explosion, definitely some transverse plane like rotational agility movements and lateral movements, sports specific.
• 28:33
  Speaker 1: And another big one is just endurance and then load capacity, as in like we're doing a bunch of training stuff but they're just out of shape, right.
• 28:40
  Speaker 1: They just haven't been able to do this kind of stuff at this high level for a long time, right?
• 28:44
  Speaker 1: So just endurance and load capacity and then, once they look good on one leg as an example, descending and exploding back up again in like a single leg hop and Bulgarian split squats, revert lunges, step ups, lateral lunges, like single leg strength exercises.
• 29:06
  Speaker 1: Once they look good and we notice they're not they're not too far off from the other leg, like 90, 95% that's when we can start feeling confident to introduce like double leg strength exercises like barbell, squats, deadlifts, power cleans, snatches, olympic lifting stuff.
• 29:21
  Speaker 1: Because if they're not demonstrating single leg strength that's symmetrical the other leg they're just going to compensate with the other leg with doing those, those double leg exercises.
• 29:30
  Speaker 1: So I'm a huge advocate for single leg strength exercises up to like eight month, eight right, or maybe at least six months until they show, at least right, that they're not going to compensate with the other leg when doing a double leg exercise like a squat or something.
• 29:46
  Speaker 1: So we're definitely prioritizing single leg strength exercises first.
• 29:53
  Speaker 1: But in general that's like the um, the overall picture from month week zero to month 12 um, where the research indicates usually it's like a year-long process.
• 30:03
  Speaker 1: They say like it's like a year-long process.
• 30:05
  Speaker 1: They say like it's like a year-long process.
• 30:06
  Speaker 1: They say 12 months is what we want to shoot for.
• 30:10
  Speaker 1: At least have some kind of an expectation.
• 30:15
  Speaker 1: We don't want to rush this process versus like oh, adrian Peterson a while back did it in seven months, I'm going to do it in six.
• 30:22
  Speaker 1: It's like ah, it just takes time for nerves to reinvigorate and activate again and for strength and stability.
• 30:29
  Speaker 1: We can't rush this process.
• 30:31
  Speaker 1: It's just going to create a lot of problems in the future if we cut corners or go too fast, tendonitis being one of them.
• 30:37
  Speaker 1: And then ACL re-injury on the same leg or the other leg is the other biggest common thing which we want to avoid for sure, which we want to avoid for sure.
• 30:44
  Speaker 1: So I would say, at earliest, 10 months would be like for a very strong, grown individual that's mature, versus like a pediatric patient that's still growing and still learning their body or growing into their body.
• 30:58
  Speaker 1: That's going to be at least 12 months.
• 31:00
  Speaker 1: It is what it is, but we'll be here every step of the way, doing the best we can to get you to 100% and lower the risk of injury from the future for other things.
• 31:09
  Speaker 1: And then back to playing sports.
• 31:10
  Speaker 1: That's the ultimate goal is to get back to playing your sports or having fun or doing the things you want to do in life.
• 31:15
  Speaker 1: If you're past the age of college sports and you're an adult weekend warrior, there's no rush.
• 31:25
  Speaker 1: An adult, a weekend warrior, there's no rush.
• 31:31
  Speaker 1: But getting you back to a hundred percent is the goal, and that we want to go as fast as possible, of course, but we don't want to rush and skip steps and just progress for the sake of looking like we're progressing when we're actually.
• 31:39
  Speaker 1: It's detrimental of the process, of the, of the speed we're going, of progressions, and sometimes you have to back it up.
• 31:45
  Speaker 1: You know the whole journey isn't just a straight linear journey.
• 31:49
  Speaker 1: It's going to be good days and bad days and good days and bad days, but over several weeks and several months the overall trajectory should be a positive trend when you zoom out far enough.
• 31:59
  Speaker 1: So I'm not going to jump off a cliff when it's like a bad day and it's like sore, and not going to be like elated and say like I'm done and I'm good to go when I go after a good day, right, but um, we want to minimize the rollercoaster and minimize the bad days and then, um, ride the momentum of good days so that we can keep a good trajectory.
• 32:20
  Speaker 1: But, um, that's what the picture looks like.
• 32:22
  Speaker 1: So, um, hopefully this helps shed some light for some people where, like you're not after surgery, you're not going to be like laying in bed for weeks on weeks and not doing anything, waiting quote for things to heal.
• 32:36
  Speaker 1: It's like, bro, everything's good, like you're structurally sound.
• 32:40
  Speaker 1: Now, if the surgeon did a good job, where at this point, like we're pretty confident that you know surgery is the surgeons are going to be doing a good job, especially this point.
• 32:45
  Speaker 1: Like, we're pretty confident that you know surgery is the surgeons are going to be doing a good job, especially if they have range of motion, quickly come back.
• 32:49
  Speaker 1: That means things are aligned pretty well.
• 32:50
  Speaker 1: But, um, uh, you're not what you're moving.
• 32:54
  Speaker 1: Like we got to get up and move that thing pretty quickly, right, even though you don't want to.
• 32:57
  Speaker 1: But, um, so hopefully this paints a picture and if you have any questions don't hesitate to reach out.
• 33:02
  Speaker 1: But that's like an overall general summary for, uh, acl rehab and surgery and process and there's different graphs, though before we, before we end this land the plane, there's different types of acl grafting so that you can do a, an autographed, where they use your tendon and it's usually either the hamstring tendon, a groin muscle tendon, the gracilis, or a bone, patellar bone, which is from the patellar tendon and the kneecap and the tibial bone, and that's just the reason why they do bone.
• 33:35
  Speaker 1: Patellar bone is bone to bone is.
• 33:39
  Speaker 1: It's a faster healing progression.
• 33:42
  Speaker 1: So the bone solidifies in the bone tunnels that they create to implant the new ACL.
• 33:49
  Speaker 1: It just heals faster.
• 33:51
  Speaker 1: But anyway, it just depends on what the surgeon does.
• 33:55
  Speaker 1: The Achilles tendon could be another one that they use, and the other common one is just using a cadaver.
• 34:00
  Speaker 1: They harvest a ligament or tendon from a cadaver and they create a new ACL on what you need from that.
• 34:10
  Speaker 1: So those are the most common graft options.
• 34:13
  Speaker 1: It just depends on what the surgeon wants, what they think might be the best option for you and your body and what their comfortability level is and confidence.
• 34:19
  Speaker 1: So it just depends it's case to case and you get multiple opinions.
• 34:23
  Speaker 1: It's okay to get multiple opinions, but if you have any questions, don't hesitate to reach out.
• 34:27
  Speaker 1: We've done this a bunch and it's always a journey.
• 34:30
  Speaker 1: There's no rush, but it will heal and it will get better if you work on the right things.
• 34:35
  Speaker 1: So don't hesitate to reach out.
• 34:36
  Speaker 1: We are always open to questions, comments, concerns, complete opinions, and call us if you have any questions at 895-61-899-8725, or you can email us at our administrative email team at athlete rccom.
• 34:52
  Speaker 1: We'd love to hear from you.