Episode 137 | The Value of Using Time in ACL Rehab

What is up team? We’re getting straight into it today — the value of using time in ACL rehab. Now, a lot of you know that I don’t like using time in ACL Rehab. I think that it can set up people for failure. And I think that there are a lot of things that we’re going to dive into today that I’m going to kind of flip the script on a little bit and share why there can be value in using time during this process. But there’s going to be caveats with it, as you know. 

Now, I do often say that this is one of the worst things to base this entire ACL rehab process on using time alone, why? Because everyone has their own journey, and it really is so individualized. My recovery from my right knee with my ACL reconstruction was different from my left knee. And you’d think in my second time I would have a better recovery and more experience, more effective — not the case at all. My second one was actually harder, dealt with a lot more setbacks and issues. It really threw me for a whirl. And I’m sure any of you listening who might have done this more than once can probably agree with me here. It always comes back to being very individualized, not to mention just the number of complexities in this process. 

And there’s been a number of athletes I thought who were absolutely going to crush it, that I’ve been working with based on their early progression and how they’re doing and get back to those dynamic tasks like running, jumping, and cutting early. But then the knee may not agree for some reason. They might hit this certain block and it might not be immediately postop; it could be later down the road. 

Take a Cyclops lesion, for example, it doesn’t rear its head until you know it months down the road. And then there’s the opposite, people who struggle in the early phases that can somehow turn that magical corner and start just crushing it. It varies from person to person, procedure to procedure, non-op to op, all the things in this process, so much variety. No single ACL rehab is the same, not a single one, even for the same person on the same knee.

So time, why do I care so much? Well, as I alluded to it before, it can set you up for failure. If we say, if your surgeon says, if your ortho says, if your PT says, if your coach says, whoever is involved in this process, says that you can run at three months and you’re barely walking. Well, that’s a recipe for disaster, seriously. It’s a recipe for just like some failure mindset. And as humans, we want to accomplish goals. We have been conditioned to meet certain expectations or to be able to surpass this certain goal that someone has set for us. You think about school, you think about college, you think about sports. Usually, if you injure your ACL, you are typically in that competitive sense or wanting to be active and trying to achieve something. 

So with that said, this can set you up, especially with time being the only factor of being like, “Well, okay, at this point, I should be doing this.” But then if you get there and you’re not, man, you’ll be hard on yourself or you’ll be like, well, I’m behind. And that’s always a tough thing in this process. And if we zoom out for a quick second, we look at the reasons why re-injury rates are so high and also people not returning to sport being so low. There are a number of factors, but some of them come back to testing and basing this process on time.

I’m going to reference two studies here, one by Barber-Westin: Factors used to determine return to unrestricted sports activities after ACL reconstruction. They looked at 264 studies out of 716 that they identified. Of these studies, 105, 40% of them failed to provide any criteria for return to sports after ACL reconstruction. And then the same study said in 84 of these studies, 32% of the 264 included, the amount of time post-operatively was the only criterion provided. 

I’ll give you guys a raw example. One of my athletes, last week, told me that his surgeon saw him for the six-month check-in and said, wow, you look so good. You’re good to ease back into things. And if you want to be conservative, wait 12 months. You don’t need to come back here. I asked how long the visit was. He said it was five minutes with his surgeon. And I was like, what does that even mean? Based on what? That’s a very large time frame from six months to 12 months. He’s like if you want to be conservative wait 12 months, which you know, okay. But then he said he’s back into things. Well, what kind of things? He didn’t even ask him what he did. What his sport was or anything like that? He was just like he’s into it.

This is just the uphill battle that we’re dealing with. I just want to share literally the things that I talk with my athletes about and things that come up. The reality of this space and you have to take care of yourself and why time can’t be the proxy and the determinant of why you can do things. It just can’t. And I’m just going to digress here because I could keep rolling with this. But now I’m going to flip the script on why time can be valuable. And it can be healthy and give reasons why we could use it in ACL rehab.

But I’m going to add caveats to this as I mentioned, because time can be really, really helpful. But, we need time, plus, insert [blank] criteria needed for the goal that we’re trying to get ready to do. If you give some sort of permission, if you give some sort of clearance, if you give a go on being able to do something, well, cool, you’re three months plus you have passed X, Y, and Z criteria to do this thing. Think about it. We use time for everything in life. And that’s why I don’t want to just say like, hey guys, just throw time out. Don’t use it. Just work on these like criteria. Usually, time is very helpful. It’s very helpful for us as human beings. It’s what we anchor to. It’s what we kind of set expectations on for things ahead.

We navigate everything based on our calendar and our time. So whether that’s a goal we’re chasing for competition, like running a half marathon, or maybe it’s to prepare for a big game that’s coming up or to like legit life, school or work progressions, a house you bought that is being built very opposite. And let’s just say life expectancy for someone with cancer, maybe. All of these things have time-associated milestones on them. But let’s also add in, well, these are all estimates for the most part. Some of these might be more fixed, of course, but they’re all relative estimates. 

But what does this time marker give you that really is important here? A deadline. It gives you something that needs to be accomplished and accompanied by something else typically to prove you’re there besides just that time point alone. Let’s take the half marathon, sure, you’re going to be having this target that you’re getting ready for. But you’re also going to be accumulating distance over a period of time. And it’s not just like, all right, it’s three months and the date has arrived or six months alone and you’re ready. You’re going to also use other criteria to make sure you’re ready to do that thing, as it approaches, preparing for a big game. You’ve accumulated plays, strategies, minutes, training sessions, and even objectives within those sessions to know you’re ready.

Not just showing up because the season started and it’s the first game. Same for those life examples. School, you wouldn’t progress to the next grade or college just because you’re older. If you got Fs on everything or if you didn’t show up half the time, then how could you expect to move forward or earn the right to progress? Does this sound familiar? The house. The phases of the house and the building and the safety and maintenance checks to ensure everything is up to code. The criteria are being checked constantly for this. Could you imagine a builder who is building this house, getting it all setup, that you would live in and move into and say, ah, we’re done. It’s nine months. We’ll give you the keys. But that house had no evaluations in it for the code, the building inspection to make sure it just doesn’t crumble or catch fire because the electricity was wired all incorrectly. There are codes and criteria that need to be met in order to make sure that someone who moves into a home is meeting all those expectations, not just because the builder put up a house in nine months, right? And even with the life expectancy. And I know that this is kind of going on the opposite end here. But guys, they still use criteria to be able to test these people and to give the docs, an idea of how much time is left. And it’s not 100% accurate. People defy these odds all the time. But that’s why we have something in addition to the time as a proxy for how long someone has left, for example. You guys get my point here. We use time plus something else. Criteria wise or some sort of objectives to be able to kind of meet the goal or to be able to do the thing.

And for some reason in ACL rehab, we just allow for someone to walk into an office for five minutes and be like, “Hey, you’re good. Just ease back into things.” We wonder why this injury and this recovery have so many complications and it’s because we have just set this on time alone. And I just want to make sure I hammer this home that time alone cannot do the thing; it’s time plus something else.

Let’s continue to talk about why the time-plus criteria can be so helpful. For example, return to running, we’re not just going to tell you in four months, you’re going to be ready to run. We’re going to say four months, ideally, plus 95% symmetry of range of motion, making sure your knee is quiet, with little to no pain and swelling, and your capacity symmetry testing of a knee dominant, hip dominant, and ankle dominant movement. Usually, these are single-leg squat-to-box, side-to-side, hamstring bridge, and calf raise. We’re going to test those, and see where they are at. Then we’re looking at 70% quad index ideally, or if we have the ability to test, we’re going to get a 1.8 Newton meters per kilogram quad torque to body weight. This is something that shows in the research that compensations are less with running. Eccentric quad capacity and tolerance: think about breaking when you lower yourself in a squat or whenever you are doing that with speed. That is like our eccentric strength and it is also our ability to recall that fast.

Then, we’re going to look at lower-level extensive plyometrics. Can you tolerate them? Can you do pogos on double leg or single leg? Can you do some bounding and you’re comfortable with those things? Guess what? Running is repeated jumps over and over and over at a low intensity. We need to make sure that you can tolerate the things that demand that.

And at the end of the day, it’s reverse engineering what the goals and the demands of that activity are. And where you currently sit and what we need to do to bridge that gap. The other piece of this is also making sure you have a step count that you can tolerate whatever the duration is, for your walking day plus the impact and the steps you’ll take with the running as well. Are you able to tolerate maybe 6,000 to 8, 000 steps in a day? These are all criteria plus the time, which is also a criterion. We’re not just saying time for the sake of time or for protocol. We are reverse engineering those needs as I had mentioned. Four months is just a proxy to give us enough time to develop these qualities appropriately to be ready for running.

And it falls into a bell curve. There are some people who can do this earlier, and then there are some people who have to do this later. There are a number of reasons that I can share why. But you guys know that this does really vary. And four months just gives us the opportunity to build up these qualities to be able to get to running. Hopefully, we’re getting the range of motion, hopefully, we’re getting the strength, how we’re getting all the things that I had just mentioned to you of those criteria. And that gives us enough time to be able to do that, not in two months and definitely not in one month. But with enough data and with seeing enough athletes and seeing how this recovery processes and those qualities that need to be trained up, we know that at a minimum, you need three to four months ideally to be able to get to that point. But that’s not going to be the only thing that’s going to tell us, it’s going to be these other criteria that are so important that really show us that the knees are ready to do it. The time is just that proxy to be able to get to that point, potentially. And I get it. People base a lot of things on time, as I had mentioned and people want to know how long till X. Instead of saying, I don’t know, I think that any really good therapist, any good PT, physio, strength coach can share a time, it might take to train up to get that quality appropriately up to par.

Of course, bearing there are no true setbacks in this process. We try to do that for our athletes. We don’t just say like, ah, okay, here are these numbers, hit those, and then you can go. It’s a very comprehensive experience from what the athletes are telling us and what they feel, how far out they are from injury and from surgery. And then we’re also looking at these criteria in terms of what it is that they have hit so far and what they have left to hit. People don’t always perfectly hit — a 70-percent quad index, for example. Or maybe they don’t hit that symmetry perfectly like we want. 

But what is the whole story here? And based on that, we can give athletes a very accurate representation of like, okay, here’s where you currently are, and here’s where you want to be based on this specific goal. And I think it can be valuable and very healthy, honestly, to share a rough timeline or time frame reference to be able to get laser-focused.

So for us, we work in blocks of strength and conditioning, rehab-based blocks, and we have a certain time frame to achieve certain goals that we’re aiming for. But they know that there’s a timeframe plus those goals and criteria we need to meet. And if we don’t meet certain ones, then that might affect the timeline, right? But we just know that is an adaptable process. It’s not fixed. No one’s perfect in these four months. It might be three and a half months. It might be 4.5 months. It might be six months. We don’t really know that. And that’s where I’m saying we don’t hit 100% on the time. No, but we have worked with a lot of ACLers, hundreds of ACLers (in person and remote). 

With this number and with our specialty and focus on this, the precision becomes more and more accurate and we can give athletes a more accurate estimate of when we will try to target this and hit it. And we’re basing this mostly not on time, but mostly on those criteria and where they are and where they need to be. And this might be, hey, we’ve got four weeks to work really hard on these particular things. And if we can hit that, then awesome. Then we can clear hopefully to be able to start running, or maybe just start jumping, or maybe just start doing some hiking, things like that. 

The other thing that I want to talk about here is that we can also fall victim to what’s called Parkinson’s law, which is why having a healthy deadline or timeframe can be valuable. Parkinson’s law is basically you’ll just feel the time that you’re given to complete a certain task or achieve a certain goal. This is pretty evident in like school and work, especially for us as humans we have a deadline to get something done for a project or a paper. Let’s say it’s two months. You might have just filled that time with nonsense, researching, perfecting a few things, and procrastinating. You’ve got time, right? But if that thing is due in two days, would you get it done? Heck yeah. And would it probably be good enough? Heck yeah. The thing is, though, is that… it’s a similar thing here in ACL rehab, only difference is that you cannot speed up your human physiology, unfortunately. So having a 20 to 24-week deadline to start running might be just as harmful as a 10 to 12-week window.

I’m not saying little time is good or more time is good, but there’s a sweet spot here. And that’s why you have to have criteria alongside these time-based guidelines for you to have more precision and accuracy to know, okay, I can probably see this as a physical therapist for you to be able to do this specific thing in four to six weeks. And guess what? As time goes on, you’re able to refine that and you could either be like, hey, we’re on track. Maybe something came up where it’s going to be a little bit longer than we think. Or maybe it’s like man, this knee’s rocking and we’re going to be able to get to this a little faster than we thought, right? But that’s where you kind of collect data points and see what that trend looks like and you’re able to do that based on not only time but also being able to make sure the criteria is tackled with it.

The other point I want to mention here is that not everyone who enters this ACL rehab process is so gung ho about tackling it and doing work for 9 to 12-plus months. It’s a long time guys. You guys know this? Especially for people who do not love the gym or who do not necessarily love just athletic movement. They just kind of want to just do their thing. They may not love the gym or have been in the gym much. And you may fall into that category. A lot of times people have super busy lives. Let’s say parents who have a lot of kids or they have a busy work life, or maybe you are a younger athlete who is in high school or maybe you’re in college, there’s a lot going on. And then sometimes it’s just trying to connect the value of being able to be in the gym and what this process will look like. And especially I see this sometimes with, let’s say the younger athletes. So giving healthy pressure of time we need to achieve X goal by Y date can be very valuable to motivate athletes to get things done.

And this is something that over time, I’ve slowly developed to try and find these sweet spots of not trying to set them up for failure, but also creating healthy pressure for them to work really hard and meet certain criteria by a certain deadline. If we don’t get there, we’re constantly adjusting just to make sure. And I’m kind of framing that narrative with them. Our team does this constantly with our athletes to make sure that we’re kind of nudging them in the right direction. 

But let’s say that there is a season that is coming up that is kind of hanging in the balance if they don’t get their butts in gear, they need to put in the work and they have been kind of maybe lazier doing things half the way that they need to. But, if there’s a possibility of them not doing the thing that they want to get back to or missing out on that opportunity and you tell them, “Hey, this is three months away and we don’t have time to waste anymore.” I promise you that they will get their butts in gear. That is something that I’ve seen time and time again, especially with my younger athletes or even people who have just these very focused goals, but maybe they fall into this busy lifestyle or think that they have the luxury of time.

Let’s even say you’re someone who is working on a range of motion, or maybe the lack of compliant on working on your range of motion and you’re three months out and your surgeon or your PT talks to you and says: “Hey, manipulation might be in the cards.” You wouldn’t tell me that you wouldn’t do the work to avoid going under anesthesia and getting your knee manipulated. It sucks. It might have to come to that, but it does happen for some people. 

I have this one high school athlete. He came in about a year ago. He had been in another PT clinic. He was, I think, eight, nine weeks out when we first met. And his knee could not get to 90 degrees and his extension was at 10-plus degrees. It was not good. It was swollen. It was painful. I was like, what are they doing? And so anyway we had a long conversation. We’re like, hey man, let’s get to work. Let’s do this. He came in the next week and I asked him, did you do some of this stuff? And he said, ah, here there. And then his mom was like, he barely did anything.

And then I had a very transparent conversation with him. I’m like, look, man, I don’t know if you’ve talked to your surgeon yet, but if you don’t get your butt in gear. Then in the next meeting with your surgeon, they’re likely going to tell you: “Hey, we need to manipulate your knee.” And you’re going to be mad at yourself because you didn’t put in the work. Guess what? He put in the work and I kid you not, three weeks later, that guy had full knee extension, hyperextension minus eight. And then he got his flexion to 120 and beyond. He just needed the motivation to know, okay, there’s a potentially negative consequence to this, as well as a timeline that I gave him, like hey, we need to hit this by this date and then put his butt in gear.

I’m sharing this because sometimes it can serve as a motivator in a healthy way. But it all comes back to making sure it’s not just arbitrary time points. And it’s anchored to something that is realistic and achievable for their results so these athletes are not disappointed and you’re not disappointed in this process.

This is again where it comes back to having an ACL specialist is so key. Not just someone who treats a few ACLs. It’s someone who knows this stuff and is so passionate about it. And I know that might be tough for some of you to access, but there are remote options available with many ACL specialists all over. There are ways to be able to just dump your current one and go to someone else who is more focused on this. It might also require an investment. But the thing is, you don’t want to do this multiple times and you want to make sure that this process goes as smoothly as possible you have a good guide that you can trust and you can make sure their advice is helpful to you, empowering and it’s not just based on a protocol or time by itself, which is where we get into trouble in this process. 

That’s going to be it for today, guys. I just wanted to share why time could be really valuable and my goal here is to show that if you use time alone it’s more harmful than it is helpful. However, time can be very healthy as a proxy for achieving certain goals, milestones, qualities we want to develop, and especially criteria in this process. Time should always be anchored to additional criteria just like the running example I gave, or the other examples, time plus X, Y, Z criteria. It serves as a good motivator for athletes. But this needs to be founded on science, research, criteria, and good all just human biology and physiology.

I believe it’s a big reason why this process in the research shows that 9 to 12 months support the minimum for return to sport guidance. Why? Number one, the ACL has ligament ties to a point where it has the integrity to mimic the native ACL graft. And then it’ll keep healing for the next year plus. You can’t rush biology with this. So that’s why you can’t just return between that three to six-month window. Let’s say you even hit all the perfect criteria because the ACL ligament itself is at its weakest and it’s religamentizing and nine months is where we show it hits enough of a good structure and integrity to make sure it is similar to that native ACL.

Number two, time serves as a proxy to develop the qualities we need in this process. It allows our need to heal and get restored. It allows us to rebuild our foundation and this whole entire process. From the range to strength, to power, to reactivity, to elasticity, to actually progressing into controlled to a chaotic environment, it all takes time, so much time. Even getting that bounciness feeling, that kind of springiness, that usually comes later in this process, it takes time, man. And you got to build up all the foundational stuff in order to feel that bouncing and springiness. If you don’t have range, if you don’t have strength, if you don’t have power, guess what? You’re not going to be springy. So that’s why it takes time. And this 9 to 12-month process serves as a proxy to develop all these things again.

If you use it as a healthy encouragement to meet a certain threshold along with other criteria, then man, it could be a huge game changer in this process. Here’s my take on why time can be helpful and valuable in the ACL rehab process. But make sure if you use it, anchor it to something other than just time alone and to a protocol. Do it with stuff that really matters, especially based on what you want to get back to doing. And most importantly, have someone in your corner that knows this stuff and that can guide you day in and day out. If you need help with that, please reach out to us. Check out our website. We are here to help in any capacity that we can. We just want to make sure that you guys have the support and resources needed in this process. 

Until next time team, this is your host Ravi Patel, signing off.