Episode 84 | ACL Return to Sport – Who Should Clear You?

What is up team? If you are a new listener, thanks for joining us, and welcome to me talking about all things ACL related and breathing heavy, although I am trying to work on my aerobic capacity, so hopefully that has improved. If you are a longtime listener, I appreciate you. And let’s just dive into today’s episode and I hope you guys are ready because I’m probably going to bring some heat with this one. I’ve been feeling this for a while and I was like, let’s cue this up, and let’s talk about it. ACL return to sport, who should clear you, episode 84. 

Let’s dive in. It’s six months post-op ACL, you’ve got to check-up with your surgeon. They see you for about 5 to 10 minutes. Check your knee on the table. They do the Lachman test where they kind of wiggle it back and forth. They make you stand up, you do an air squat, and then maybe you’re on the table and you kick into their hand to assess “strength.” And yeah, I’m doing air quotes because that’s not really strength. But that’s what they do. And so what they say afterwards is that the ligament looks strong and good, and your knee looks good. That’s typically the result and the response after, as long as things are steady. This is at the six-month mark, so take that for what it’s worth. And then they tell you to work on cutting and jumping and then ease back into your sport over the following weeks and months. Basically, you’ve been cleared. That’s essentially what the surgeon is telling you. And they’re saying, progress on into the sport and you’ll be okay. And I cannot tell you the number of athletes that we have seen who go on and see their surgeons or say, healthcare professionals. And this is exactly how it plays out. Not all, but it happens more than it doesn’t.

Let me ask you this: what’s wrong with this? And please excuse me, as I go on this rant of what is wrong with this. It creates false hope. It’s based on, honestly, pretty terrible information. When you ask and you try to figure out what objective measures we’re taking to assess this, if there’s a Lachman test and air squat and kicking into your hands, that’s not going to do it. Did they see the athlete move dynamically? Were there any objective measures taken, especially for quadriceps or hamstring strength? Are they prepared for the demands of sport? How does it look when they cut at a 180-degree angle versus 120-degree, maybe a 45-degree angle? How does it change whenever you integrate the athlete’s sport within this? There are so many variables that play into how we assess readiness and criteria for any ACL athlete. It doesn’t matter if you’re 50 versus you’re 18. There are criteria for each and every one of you based on what we know about ACL athletes and return to sport. And there’s also criteria based on the specific things you’re trying to get back to.

And so clearance is the milestone that every single athlete, every single ACLer wants to get to. It’s the final one. It’s the light at the end of the tunnel. And what makes this dangerous is that you leave that checkup, thinking you are good to go. The surgeon has given you clearance when you’re really not. You are operating in a very dangerous place. This significantly increases your risk of re-injury when you go to do things that are testing your knee or going to play said sport that they said to ease back into.

And I don’t blame you as the ACLer. This is not your fault. I blame our system and honestly blame the healthcare professionals who are okay with this. And we wonder why re-injury rates are so high and it really pisses me off. And these are one of the biggest issues, and I think this is something that must stop.

First order of business for this episode: If you’re a healthcare professional, a coach, or anyone who is involved in making this decision to help clear an athlete, you better be sure you’re doing everything you can to set your ACLers up for success. This means testing through clinical testing through performance testing, using objective data to make sure that we have tangible information and quantitative data, as well as qualitative data to make sure that we can be sure that we are doing everything we can to minimize the risk of re-injury. And if you don’t have the capacity to do so, then refer them out. I have to swallow the ego here. And be okay with whether that insurance runs out, your clinic can’t do it, and if costs are an issue, well, a crane scale is about $50 on Amazon. So I’m sure every clinic can afford to do that. There’s 10 decks out there that even give you better results for a little over a hundred bucks. There’s so many clinics that are starting to implement this because they’re starting to realize that this information is so valuable. Even doing an isolated leg extension, leg curl, leg press, things that are going to help us measure strength in a more isolated fashion is going to be very valuable as well. We need to make sure that we have testing available to make these decisions.

And this especially goes for the surgeons and the physical therapists out there- stop with the nonsense. If you let them go and play the sport without doing these things and they reinjure, that’s on you. Is it possible to re-injure even if you tested and did everything right? Absolutely. However, the data is clear that those who pass appropriate criteria and testing significantly, significantly reduce their risk of re-injury. And that’s the biggest thing that we’re trying to fight here, as someone who tears their ACL. It’s not to reduce the risk of the first injury, although that’s great. But realistically, our role is to make sure that this only happens once and not again. And we can control that as much as we can.

And the biggest thing that leads to re-injury is failing to meet these specific criteria. So that has to be on us to make sure we are measuring and putting the best foot forward. Even if it creates more work on our end, we have to do it. And it’s for the health and the safety of every single ACLer out there.

Second order of business and the intention of this podcast: Who should clear you? Who should clear you for return to sport? A lot of times we’re looking at this hierarchy. And the surgeon does the surgery and then the physical therapist or whoever falls under the umbrella of that. And one of the things I suggest, and any good healthcare professional, whether it’s a surgeon or PT or whoever it is, would say that this is the all-team approach. There’s no hierarchies, there’s no levels, and everyone is sitting at the table together making a decision with the athlete at the center. And so that’s going to be very important to be able to look at it this way because in our own minds, usually, it is the surgeon who is making the decision. And I’m going to disagree here. I don’t think the surgeon should make the decision. I don’t think that the physical therapist should solely make the decision. I think that this should be a team approach. And if you go back to the episode where I talk about building your ACL team, this is who I’m talking about. This is essentially who needs to be a part of this clearance decision. These are your stakeholders, as we call them, the people who have stakes in this, and here are the few buckets and people who fall into each.

This can include sports medicine, so that’s the physical therapist, the orthopedic doctor, the surgeon, the team that the orthopedist has, the athletic trainer, possibly, there’s a sports psychologist, potentially, with family and friends. It might be parents significant others or other stakeholders within that bucket. For sports performance, it might be the strength coach or sports coach. Others that could be included are the agent, sports science, management, or owner of a team. And guess who’s at the center of all this? The ACLer is the person who the decision is being made about. And you are the most important person in this and should be the most important stakeholder in all of this, alongside your team. And each athlete will be different based on their own context. I just listed a bunch of different positions, but of course, many of you listening are like, I don’t have half of that stuff, which makes sense because of your own situation. This will also create different stakeholders. 

For the high school basketball player, the stakeholders might be the orthopedic surgeon, the physical therapist, the athletic trainer for the team, the parents, and the sports coach. The 40-year-old wanting to get back to skiing might be their orthopedic surgeon, the physical therapist, and maybe their husband. I would say most ACLers who are in recreational-type sports are typically dealing with a surgeon and a physical therapist in most cases. A lot of our ACLers we work with remotely on our team, they all are dealing with a surgeon and maybe the surgical team and then working with us remotely. And so then we got to make sure we’re all communicating and on the same page in terms of where they’re at. A lot of times these meetings with surgeons can go like this, and then we have to go back and be like, no, no, no, like this. You’re not there yet. Even though they say the ACL is good. It’s like, great, saw you for five minutes, but that’s not enough. We have to make sure that there’s a comprehensive view and overlook of what’s going on. Every stakeholder involved is helping to make these decisions. 

How do you assess your own stakeholders in your ACL situation? A good way to look at this is who is and has been involved in this process from the start that has something at stake. Usually, a surgeon’s involved, usually a physical therapist is involved, and then there are branches of maybe it’s supporting roles or maybe it’s sports-related roles. For me and my second one, I was graduating undergrad and my brother was actually helping me with this process. He actually was a stakeholder in this because we were trying to figure out the financial pieces to make ends meet for the surgery itself. And so he had a part in it. When I started doing running and cutting and pivoting sports and doing something like skiing, he and I even had a conversation about it because he was technically a stakeholder in it. And I wanted to get his opinion and make sure that he was also good with where I was at because he was a part of that team. And that is something that’s going to be really important for you to assess is who are your stakeholders. 

And the other thing that I’m going to say is, who is capturing the qualitative and quantitative or objective data to help you meet your criteria? You need to write these people out and make sure when the time comes to be cleared. Everyone’s on the same page about where you’re at. If the surgeon’s saying you’re at six months and you’re cleared, and the PT is saying, well, you’re only at 50% quad symmetry, then there’s a problem here. And so there might just be a miscommunication or it might just be something where it’s difficult to get on the same page with the surgeon, which happens too. This is something that I suggest that you write out so you know who is in your corner and who is on your team. 

To answer the question: Who should clear you? It’s not just one person. It should be a collective decision based on your ACL team and all the stakeholders. It’s really the people who are seeing you through it all, testing you, getting objective measures, and making sure you are hitting every single criterion for ACL return to sport and meeting the demands of your specific sport. That means everyone has to be on the same page, communicating. This means putting your egos aside, having no hierarchy, a team-based approach, and focusing on the athlete in front of us, the ACLer. 

I’m going to finish this episode with a call to action. So whoever you are listening to, if you’re a healthcare professional or a coach, please take this to heart and please make sure that we are doing everything we can to serve our ACLers. If you’re an ACLer, the goal of this podcast is to help you be in the driver’s seat, to take control of the process. So that means you are writing out your stakeholders and knowing that you are getting tested. And that the six-month mark, when your surgeon says you’re cleared, ask yourself what did they clear you based on that. Maybe your PT clears you. What do they clear you on? What are those measures? Ask for them. Ask them to explain it based on what. And if they don’t have some sort of sound reasoning behind, well, this is why X, Y, and Z, or this is what you look like compared to your normative data. Or these are the criteria we’re looking at and this is what we’re looking at for your set goals and sport, then you might need to look elsewhere or you might need to just take a step back and reevaluate who is on your team. Be very judicious about who clears you and why. And that’ll help so much for your own sake and for your own confidence when you’re trying to get back to whatever it is you love to do.

I hope that this was helpful team. I had a conversation with a recent ACLer where they had this exact same scenario: six-month checkup, table testing, and that was it. And they were cleared to rock and roll, do whatever they wanted, and told to ease into it. They got super excited, and jacked up, leaving the office visit. And I was like, whoa, whoa, whoa. We still have a lot of work to do and their quad index is not even at 80% yet. We need to make sure that we stop ourselves and understand what is based on. 

If you have any questions, as always, please feel free to reach out. The recent love and support from the podcast have been amazing. Appreciate you guys so much. If you need any help from me or our team, then please feel free to reach out, or message us. Send us an email, carrier pigeon, or whatever you need, so we can get connected and help you on your ACL journey. Until next time, this is your host, Ravi Patel, signing off.