Episode 110 | Answering the Question – When Can You ______ In ACL Rehab?

What is up team? Hope you’re having a beautiful day, beautiful morning, and night, whenever you’re listening to this. Today, we are getting straight into it. It is covering the topic: when can you [blank]? And this is insert any activity or sport or any type of thing that most ACLers will ask at some point in the process. I want to walk through this and talk through how to think about this, how to be able to get the answer that you want, and to be very dialed in as you approach some of these answers. You can insert anything you want. When can you get off crutches, when can you walk, when can I drive, when can you go to the gym, when can I run, jump cut, when can I hike, when can I go travel to X destination, when can I walk my dog safely, when can I play soccer, when can I do BJJ, ski, football, insert anything that you physically need to do? 

My goal today is to create some clarity around this question, and then that way it helps to frame the process and frame the expectations needed to be able to get to that activity or sport. I want to start this off by saying this question itself actually gets you into a bit of trouble and I’ll explain why. The answer is set up to use time as usually the only criteria if you will, to answer the question. It’s when we use and start the question with when. When can I do this, when can I do that? And it’s natural and it’s so fair for us humans to ask that question. If we’re in this process, we anchor ourselves to time. And as human beings, we create certainty. We want to make sure that we know, okay, when can I expect this so I could do said activity or sport or task or whatever it is. Rather than the uncertainty of being like, well, it’ll just kind of come with time. We want to have some sort of grasp or some sort of certainty to know when is that point where I can do this. The first milestone for most ACLers is when can I get off the crutches? Is this in a week? Is it two weeks? Is it four weeks? 

I’ve got ACLers who are in high school. They don’t want to be on crutches all the time. Walking around in high school, having to get out of class to go to the elevator. The same thing goes for our ACLers who want to travel or who have to go to work and walk around and move. No one wants to be on crutches, so you’re like, when can I get off crutches? That’s the huge question mark and so many other things that we want to do in this process that have question marks around them. And what typically happens is we’re given time, and time is fair. I don’t hate time completely. But it’s the thing that I think gives us a false sense of certainty of where we’re going to be in this process. And that’s ACL rehab in a nutshell if you will. There are so many unknowns of the things that are to come.

We want to have some certainty around like, okay, when can I run, when can I start like playing my sport again to some degree. And there are a lot of pieces that we just want to be able to know. And especially with this process being so long, it’s hard to make a specific recommendation that is across every single ACLer because everyone is so different, from the surgery to the recovery, to how their body develops, how it heals. Are there any setbacks, any issues along the process? There’s so many factors. It’s so individualized. And I think that’s the thing where we’re getting into trouble is when we say, when can we do this?

Well, it’s tough because of those factors we have to take into account. And also we are working with a body that you don’t necessarily control. It’s just going to do its thing as you nurture it and give it the things that it needs. So that’s where we can have a hard time with protocols because protocols do take in the average if you will, and it’s also important to understand where these protocols are being created from. That’s the big thing is, is it just like, all right, we see people start walking in a week, maybe two weeks, or we see them start running around three. Does it mean they’re doing it right? Who knows? So that’s the thing that I think is important to consider. 

And if you scroll through previous episodes, I’ve done ones on crutches, I’ve done ones on walking and driving, and things of that nature. But take notice of what we cover in each of those. Time, sure, but there are other criteria that we have to make sure that we cover in order to fulfill those and time serves as a proxy. It’s not the time itself that is just going to be so magical. It’s what’s done in that time. And that’s where the type of rehab and the program you’re doing is so important. The reason why we use nine months as the bare minimum for the return to sport process is because the research across the board shows that re-injury decreases significantly after that. But nine months is also a good proxy for being able to develop the characteristics and the qualities we need in order to really build up to get back to the sport. That’s one of the big pieces that I think allows for that nine-month timeline to be so helpful is to do all those things and build back up like we need to. 

And as I mentioned, you guys know I don’t really hate the timelines at the end of the day. We give our athletes rough timelines as they go through this process. But they’re always individualized to where they’re at, and also the factors that are considered in this process. A meniscus repair, for example, is going to alter the initial phases of your ACL rehab process. For us to say that you’re going to come back to running at three months or 12 weeks for the person who just had a very simple autograft ACL versus a meniscus repair and all these other pieces. The timeline might look a little different, and I think that’s where we get into trouble is that we try to do this broad brush across and say like, “Oh, everyone will get there in 12 weeks.” Not likely, especially for someone who’s been on crutches for four weeks, maybe six weeks.

So that’s the thing that’s important is that we always give our athletes rough timelines, but it also allows us to give healthy deadlines and set expectations in the process. If we’re not running by month sixth or maybe even month eighth, then that’s a problem. We need to address that. But we’re not going to say: “Hey, you have to be running at three months, because that could lead to a poor outcome.” And also mindset is such a big piece in this, which we would talk about here in a second. But we do this along with other concrete data and criteria. You can’t run from movement capacity or quad strength from symmetry to body weight, your tolerance to certain movements, our reactive strength index, these are all certain KPIs that we’re looking at for each of our athletes to see, okay, how are they moving from a functional standpoint? What does the strength look like? What do their plyometrics, their pain and swelling tolerance, and their ability to react very quickly? We are looking at using time based on averages and criteria. And that’s where I want to make sure we shift our mindset is not just when, but what and using what criteria.

The problem I have with healthcare professionals and people in this space who are guiding you ACLers in this process is that time is typically what is being told to most people. When we have our athletes come back from a follow-up visit with their surgeon or ortho or maybe seeing another pt, they’re like, okay, yeah, you’ll be doing this in X amount of time. And it’s a bit frustrating because we’re like, they just spent five minutes with you and they didn’t even see you do the thing or do anything that is remotely close to the thing. And yet they’re giving you kind of this time of like, all right, in four weeks you will be able to run. It is just hard to connect like, okay, this assessment to what you’re gonna be able to do, especially if it is something that is a little bit more involved, like running, cutting, or jumping.

And if we do that and we use just time and protocols, it’s setting you up for failure. And let me tell you why. What happens is that a surgeon or a PT will tell you, you can run at three months. You guys have heard me talk about this, so let’s just entertain this for a second. Three months come and you’re ready to run. Either they push you to do the running and the knee hates it, or you’re let down because they told you you’re not ready. But you said three months as you kind of talked to the PT or the surgeon. Insert the mental spiral that happens of not pushing yourself the past three months. The comparison, maybe Bertha in the corner is now running at three months, feeling like a failure. That’s what it makes you feel like if you don’t meet that expectation. When in reality, it was your professional’s words and guidance that steered you wrong. Not to mention you have a complex knee injury, a patellar tendon graft, oh, and a meniscus repair with four weeks of non-weightbearing. That set you up for a longer rehab from the get-go.

And that’s one of the things that is really tough is that we don’t take these factors into consideration. And the protocol says, up at 12 weeks or three months, you’re going to run expectations, people. That is literally this process in a nutshell. One important point with timelines and criteria is to know that this process is also not linear. You guys have heard me mention that before. Think about it you’re getting in your car to go somewhere with your GPS. You get the route set, but then traffic pops up. You have an alternate route. Might take more time, but you expected it. And we do, especially with Atlanta traffic, we’re always going to expect to get into the car and be like, all right, it’s probably going to take longer than what it would typically take.

And that’s a big part of this process with ACL rehab. If you can operate to know that that is how it can be, then you’ll be able to roll with any of the road bumps that come along in this process. Knowing that it’s not going to be smooth, knowing that there are going to be potentially some setbacks, and that’s going to alter the timeline if you will because you might have to roll with that. And protocols are usually based on timelines. It’s easy and it goes based on the averages. That’s cool. Great. But again, there’s so many factors that are in place in ACL rehab that you just can’t use timelines a lot of the time. We’ve had people all across the board from being able to get off crutches, to be able to start running, to be able to start doing some jumping-related activities or certain things because there are so many factors in their process that might prevent them from being able to do that on the average timeline. And so then it needs to be and must be accompanied by more tangible criteria. It should be the goal is X weeks or months along with concrete criteria. These criteria should be prerequisites for a set activity, that milestone or sport. 

For example, for running three months is often used, right? That’s what we just talked about. And for us, we use four months as our criteria. No sense in rushing. Really, this process and the benefits outweigh the cost significantly of building strength versus getting a grumpy knee from starting too soon. Why rush if you’re going to have to wait nine months anyway, to really start to be able to do that sport or activity? Let’s not rush the process. I’ll tell athletes a minimum of four months along with other criteria: extension matching the other side, flexion within 95%, capacity movements at 90% symmetry, doing and executing the same way, 70%, 80% symmetry, and absolute strength of their quads for around two Newton-meters per kilogram body weight, step count built up to tolerate certain running, tolerance of extensive low-level plyometrics, and then tolerance of locomotive and running drills. We need to see all these prerequisites before you start running. You can’t just go out and start running. As easy as it sounds, there’s so many ways our bodies can compensate and we need to make sure that those individual pieces are there to be able to make sure that the hole comes together and actually is performed correctly.

And I’m totally game in using, when can I do this question, but I’d like to help propose a different option that will set you up for success, physically and mentally. Physically, you’re ready for that specific thing you want to do without compromising the big-picture goal of being cleared and back to being you. Don’t want to sacrifice rushing it and setting yourself back. Running is a super common example you hear in this process, mentally so you don’t fail that time-based expectation. Instead, ask what criteria I need to meet to do X? Set another way, what boxes do I need to check and meet in order to do X insert activity or sport? Instead of when that only provides a time-based answer solely based on the nature of how you ask the question. If you focus on criteria, you can position yourself well and have time included as a part of that process. We have to reverse engineer that set activity or sport and find what prerequisites we need to meet before being able to do it.

For example, when can I get off crutches after having a meniscus repair? The goal in general is to be in a place where you have all the prerequisites needed to do that specific activity. So basically walk and the criteria I’m going to give you is the first time, typically five to six weeks after if non-weightbearing for the first four weeks. This helps understand the expectation of what to expect from a time standpoint. And range, full extension, matching the other side, inflection ideally to 120 degrees, strength quads are active in end range extension. You don’t have a quad lag with a knee extension or with a straight-leg raise. Pain and swelling are little to none. No limping with any gate mechanics type work, especially as you dwindle down from two crutches to one crutch to some assistance. Making sure that the gate mechanics and the flow of the gate cycle are going very smoothly. And then guess what? You can roll without the crutches. We just have to make sure we meet this in order to set ourselves up for success. 

If you start the question with when you’re often going to get time. And it’s easy for a healthcare professional to just give you time. It’s a simple answer. It doesn’t require more detail. But it’s not the right answer. If you start the question with what criteria, you should get a list of objective measures to ensure you’re ready for that activity or sport you’re wanting to do. And this can include time. It just shouldn’t be the only answer. 

I hope this was helpful, team. It’s a question I get all the time. And it’s one that is a big pet peeve of mine from healthcare professionals more so of what they give as answers. Instead of really guiding you guys and the ACLers that we work with in terms of just this timeline expectation versus really anchoring to criteria which will just help from not only the physical aspects but so much from the mental aspects, which we know is so big in this process.

If you have any questions, of course, you guys know where to find us. Please reach out. Thank you guys so much for listening. This is your host, Ravi Patel, signing off.