Episode 202 | The KPI-Driven ACL Athlete: Anchoring Your Process to Criteria, Not Time

What is up and welcome back to another episode on the ACL Athlete Podcast. I have observed a lot in the ACL world, how rehab is done here in the States and all over the world. We work with people all over the world and it has been very interesting and fascinating to see the way that the world takes on ACL injuries and surgeries and the procedures, and also the way that the care and the rehab is manage. And what is typically used to guide the process and what is also not used to guide the process. 

And while it’s easy to see a bunch of ACL folks on Instagram, for example, all these ACL PTs or coaches pushing criteria-based approaches and objective testing. We do that and it’s great because we want to get the message out there. It’s also very specific to the people who are potentially looking. Majority of the time, if people are not looking out there or being exposed to this stuff, majority are still using timelines. And so evident because when people come to us, whether they are post-injury, post-op, whatever that might be, they may be way far in the process, six months, it might be two years, five, 10 years out. It’s very interesting because they shared these things of how things have been approached by their previous PT and/or maybe it is their surgeon that has a protocol, a time guiding it. And that’s probably a big piece that is influencing all of this is that we’re kind of relying on the surgeon’s protocol, if you will, when in reality, the surgeons do the surgery, and of course we do need to be respectful of the type of surgery, healing, timelines, protecting things. 

But in general, I think there’s a certain point maybe after eight weeks, 12 weeks, sure, we’re respecting that healing process. But in reality, I don’t think really those protocols are influencing too much of how rehab should be done. Even in the early stages, sometimes there’s almost like ultra conservative to a point where it’s regressing the athlete back. But with that said, these protocols are often having time guiding it. If you Googled the ACL protocols right now, if you went on there and you looked, and if you looked at what is kind of progressing the different phases, you will find majority of these will be using time specifically. And that’s how it’s been done for years and years and years and years. 

And don’t get me wrong. There are ones out there with specific entry and exit criteria, some objective numbers, some specific guidelines that are better than just time or along with time. But again, majority will have time using this. And we see this time and time again, when the athletes are coming in and they’re like, oh, well, here’s my surgeon’s protocol. I’m here around—even Atlanta looking at surgeons protocols, majority of them are using time. They’re like three pages of sheets of paper or this PDF. It fits everything that someone needs to do exercises and the whole ACL rehab process on three sheets of paper, easy-peasy. But it’s so much more than that. 

And what you’ll find is, oh, well, post-op two weeks do these exercises; and then move on four to six weeks, you’re doing this; and then weeks six to 12, do these exercises. And a lot of times they don’t necessarily have the criteria where it’s like, all right, at the end of these four weeks, these are our goals we’re trying to hit and then we’re aiming to move on. That’s what we call exit criteria or maybe entry criteria to move into the next phase. And that can get us into trouble if it’s just time and exercises. That we’ve always done it this way, which plays into the ACL reinjury rates and people not returning back to activities and the sports that they love and honestly, just a normal life. Since we all use time to anchor everything in life, we understand that. And we have even certain ranges that we utilize within the ACL athlete, but it is honestly not guiding anything for us specifically.

For us and any good ACL rehab or physical therapist is all within the individual consideration and cases that we’re working with and the timeline is not guiding this process. I cannot stress this enough. We are using time as a factor and it is within respect of maybe planning. But with that said, it is a moving target and it is a range. The thing that is guiding this for us, as I had mentioned, is the individual considerations of their injury, their surgery, their history, there’s a lot of factors. But especially what is guiding us at the ACL Athlete in any good ACL physical therapist and specialist, is going to be using KPIs (key performance indicators). And that’s going to be specifically criteria and objective benchmarks we’re aiming for. It’s very difficult for us to just say, subjectively, this person has better range of motion; this person has better strength. And that’s kind of what the MMT, where someone is putting their hand on someone’s ankle, stabilizing the top of the thigh and the athlete is kicking into their hand and we’re like, oh, this athlete strong. Well, no, it’s really just making sure their muscle can turn on. That is basically it. It was created in the polio epidemic whenever we needed to just make sure the muscles are functioning and firing, and then they created this scale and that’s where the MMT and the “strength” testing of your quad or hamstring comes from. But that’s not true strength testing. 

And so with that said, that’s a subjective measure, even though we might attach some sort of objective number to it. It’s truly not a measure; it’s not an output measure. What we’re looking for specifically are true criteria and objective benchmarks, KPIs that help us guide the process. And these are going to be certain exit criteria and entry criteria for different phases and different blocks of how we work with our individual athletes. And the thing that I want to stress the most and the point of this episode is defining specific targets and having targets set for each of our ACLers and for yourself. Or, if you’re a clinician or coach listening to this, setting these for your athletes as we are going through this process. We’re going to have certain targets and criteria and certain benchmarks for returning to sport and performance. But for each phase and block of their process, we’re talking about post-op, we’re talking about after you get out of post-op or maybe it’s post-injury, after you are out of those phases into mid and late stages. We need to have certain things that we are aiming towards and setting our sights on. But for each of these phases and blocks, we need to make sure we are tracking KPIs and that could be ranging from range of motion. It might be your extension, it might be getting that heel pop, it might be sitting from a tall kneeling to rocking back onto your butts, it might knee flexion, range of motion all the way to functional positions. We might be looking at capacity testing, maybe as quad hamstring strength isolated and then maybe some compound movements and maybe we’re looking at some dynamic stuff, some single leg jumping, vertical, horizontal. It could be some changes in direction and agility test. 

There are a lot of things that we can look at and you don’t necessarily need the whole range. It’s going to be specific to each athlete, but there are certain ones that we weight heavy and are non-negotiables versus ones where it might not be as important. Do we care as much about vertical jump testing side to side for the athlete that just wants to get back to walking and they injured their ACL, falling off a chair. Maybe not, but we’re going to make sure their strength is there, their range of motion, certain things that are going to set them up for success, short-term and long-term. And make sure if they ever do try to pursue other activities or athletics, they’re in a good place to do so. This is going to be really important in this process. 

And other things that we’re looking at, is taking into account the individual’s history, what the totality and just overall the ACL research as a whole, looking at that, and what is showing as promising indicators and different factors and criteria, that’s going to help athletes succeed for returning to performance. But then also long term for osteoarthritis and for knee health and for athletic performance. We’re trying to look at this as a whole and knowing what does that look like? How do we get this athlete back to performance based on their goals and their specific sport or activity? And also looking at normative data. If it’s a range of athletes from 18 to 22 years old and they’re males. Well, we’re going to look at that data and see what is their strength look like? What is their jump testing look like? What is the normative data? Whenever we’re comparing it, not to themselves and what the ACL research shows, but also to their peers. All super important pieces and these are all guiding their process. Notice, I didn’t say anything about time that is going to truly influence this. Of course, if people have sensitive goals that are time-sensitive, then we’re going to be factoring that in, more intentionally. And we’re not trying to drag this process out by any means. ACLers don’t want to be in this longer than they need to, but we need to make sure we have enough time to be able to build this stuff back up. And most importantly, set this athlete up for success to make sure this isn’t someone that is at risk for another reinjury. 

We have general proxies of timelines as we go through this process. We have an idea of how we’d love to get range of motion for flexion at this point. I’ll give you an example. For extension, for us, we’re looking for getting that heel pop and terminal knee extension ASAP. That is literally our number one goal for ACL rehab afterwards. We also have healthy timelines of flexion. We’re trying to get to 90 degrees by two weeks and then 120 degrees by four weeks, roughly. 

Now with that said, there’s caveats: are you a meniscus repair? Does your surgeon have other restrictions on this? Are there other procedures that were done with this? And also we know that those are healthy targets because we see athletes can get there. But we also know each individual athlete there’s so much variance. Maybe the athlete is dealing with crazy swelling. Maybe they have a hamstring graft that they’re dealing with. These are all things that we might adjust how this timeline looks, but we’re going to give some healthy proxies of timelines. While we might not be perfect, it honestly can just kind of vary person to person, but it can be healthy during this process. 

The other thing with this, with the variance is that extension we want to get that ASAP, but guess what? If you have a quad tendon, you’re likely going to have a little bit of delay. Some people, they might get it immediately, but a lot of quad tendons take time to get their extension back. We want to get it back ASAP, that’s our goal, but I don’t have this perfect like magical. Everyone’s going to hit it at four weeks. That would be awesome, but it’s not the world of ACL rehab and especially not quad tendons. This is really important. But we do make sure our athletes know what they are aiming for specific criteria and objective measures, and also ways for them to check in on themselves. For example, the extension to see, can I get the active heel pop and how does this compare to my uninvolved side? And then we can also give healthy timeframes to get after it. And most of the time ACLers are sharing with us they feel lost, they feel no structure and don’t know what to do.

And honestly, that really sucks and I hate hearing it, but it is a very common story and theme that I hear. I’m sure some of you listening are like, yeah, I feel this. I’ve been there too with my ACL injuries and with my recoveries, but having intention with targets is key. And that’s the goal of this podcast and this episode is that I want you to be able to figure out how to define your targets or your specific KPIs and criteria you’re aiming for. Because this is where it’s going to be really key to keep you going in this process. 

For example, in this block, here are our goals, here are our KPIs and main priorities we’re focusing on and then here are the exercises to help us get there, to help bridge the gap between your quad strength is at 2.2 Nm/Kg. We want to get this thing to 2.7. That may be our target for that particular block. We’re going to be dedicating specific exercises to be the extensions to really get this quad ramped up and get this thing strong and to get it to hit that KPI. Now, are we perfect to hit that KPI every single time? No, but that’s where testing comes into play to know, are we on the right track or not? Did it increase by how much? But we’re using numbers in these criteria to help guide us. But if you’re just six months in the process and you’re just doing exercises and you don’t know where you’re aiming for, then how do you really know how effective your exercises are? At what point do you stop? Is it just a feel? And a lot of times what we see is that athletes are in this process or maybe they’ve graduated PT, maybe they’ve finished up their visits because the insurance doesn’t cover it. And they’re like, oh, I feel good. But the thing is that it’s always about testing that thing and also maybe you haven’t been exposed to those certain things. There’s some people who come to us and they’re non-operative or they go conservative route and they don’t get ACL surgery. We’re very careful to implement dynamic activities like running, jumping, cutting, because that’s what’s going to really stress the ACL. 

But there are some times in this process where they’re like, man, I feel good. I’ve been doing strength exercises for, let’s say, two, three months and they’re like, I feel really good. I think I’m good to go. But then we’re like no. We haven’t even stepped into the stuff that’s really going to test the ACL and what is required for. When you’re sitting in a leg press, when you’re doing a knee extension, when you’re doing a split squat or a back squat, the ACL is there and it might be helping some, but you’re not moving dynamically enough to stress that ACL or that knee. 

Now, when you’re running, jumping, cutting, the forces are really being exerted on the knee and that’s where we get to really test that thing out. But we have to be progressive. Sometimes what we see athletes struggle with sometimes is that they just haven’t been exposed to the stressors or the movements positions that wi’ll be tested with or need experience with. And that makes it tough because it’s this illusion of feeling good when they haven’t really took the car out and traffic, if you will, they haven’t put it on the runway yet. And so that’s the thing that can make this challenging and that’s why we want to make sure we have criteria and objective measures to help guide this process. 

And the other thing with this is also just having healthy timelines and timeframes to get after it. A clear plan, a roadmap, specific targets and KPIs and understanding the why to help athlete buy in is so huge. This can create a healthy competition as well to hit the targets, but also setting expectation here is key to know. It can vary depending on what we’re aiming for and where the athlete is. We’ve had athletes who crushed getting their quad strength back, and we’ve had athletes who have struggled to get their quad strength back, and there could be a number of factors at play. But understanding that and educating your athlete on what to expect in this process helps, especially for the low blows and maybe they go get tested and their strength hasn’t improved as much as we’d hope. But that is something that can really help us with redirecting the path, but we need to set the expectation from the front end. But feeling like you’re just getting exercises because of a protocol and these perfect timelines on these protocols that’s just wild to me. Imagine if we force every single baby and kid that is born to perfectly fit to two to four week ranges and milestones. You’d have a lot of parents freaking out. I know we’d freak out if it was just so perfectly, like, all right, at two months you need to be doing this right. And our little guy, Asher, he hasn’t hit some of these and some of these he’s exceeded. Therefore, these are one of those things where we were just trying to anchor ourselves and understand like, alright, are these ones that he needs to really hit at this point? Or is he okay and it’s really a range? And then you find out it’s like a range from eight to 12 months, instead of it being this at eight months, they need to do this. And while we have proxies for these milestones, they’re not set in stone as some babies might walk at, for example, 10 months and some might not until 15 months. Human beings are all different even twin babies. And so that’s the thing that we need to consider with this. We sometimes expect the 35-year-old mom that has a full-time job and three kids, who got a quad tendon autograft to progress at the same rate as the 17-yea- old male soccer player with a quad tendon autograft. The ACL world is wild. It’s the wild wild west. For some reason, we think everyone needs to fit to this perfect box in this perfect timeline. 

The main point here that I want to share is to set targets in your ACL rehab. Don’t get stuck to time and know it is a range. Use it as healthy pressure to push yourself. Don’t just do a laundry list of exercises or be in purgatory without knowing what direction you’re going. It’s like getting in your car and not knowing where to drive, but you also don’t know where you’re starting and that would be terrible because then you’re like, well, what do I do? You just start driving. If you need to get somewhere, you need to know where you are and you need to know where you need to go. And that’s where a GPS, which we all use, is going to help you. Ask what these targets are specifically. Ask them to your physical therapist, your coach, who are you working with. Honestly, if they can’t tell you, this is a red flag. Don’t take a vague answer is like, oh, we’re working on neuromuscular control. Or like, all this stuff is like, no, very specifically, like, what am I aiming for? What does this process look like? They need to have specific criteria, specific objective measures. If they don’t mention quad strength testing and isolated muscle testing for your quads and your hamstrings and there is no number associated and MMT value of five out of five is not going to count. You need a specific output of torque to body weight; you need a specific output of at least pounds or kilograms; and that needs to be converted to torque. Then that way we can be able to know how does this compare, especially side to side and get symmetry for that and compare it to body weight. Don’t take the vague answers as fine. Get specific and ask why. 

If you’re feeling lost, you have no structure and no guidance, then make the change. If it’s happening now, I promise you over time, it will not get better. It will just continue to get worse. Your guts probably telling you, you need to change or something needs to shift. Make that choice and be able to vet the people you’re working with. But most importantly, as you’re going through this process, set up targets, have certain priorities that you’re focusing on and have some objective numbers that you’re aiming for that is going to be so helpful for you to know, all right, cool, I’m heading in this direction. That’s what these exercises are for and that’s what this program and these blocks, or however it’s structured with your PT, to be able to aim towards certain aspects of this process. 

I hope that this is helpful team. If you have any questions, please reach out. We’re always here to support as much as we can. Until next time, this is your host, Ravi Patel, signing off.