Episode 113 | Athlete Wins 6.0

Show Notes:

In this episode, we discuss the ins and outs of a specific ACLer story. We  share what we see in the athletes who end up with the best outcomes and returning to sport vs. the ones who might not.

What is up team? We are back with another episode: Athlete Wins 6.0. And if you’re new to this and tuning in, this is where we like to talk about some of our athlete’s wins, highlight some of the ups and downs in the process. But especially, those positives and those ACLer wins that we’re looking for, especially when this process can be so long and so daunting. It’s hard to see the light at the end of the tunnel. We love to bring to light some of our athletes who are absolutely crushing it.

This week we are coming at you with one of the most dedicated ACLers we’ve ever worked with. And her name is Rebecca and she is a remote ACLer graduate. Someone I had the pleasure of working with and it’s pretty cool. She recently got cleared to return to full competition. And she actually had a competition this past weekend that I want to highlight. 

But before we do that, I actually want to take you on a little bit of a journey that Rebecca had with her ACL injury, with her surgery, with her rehab. Because I think a lot of you tuning in are always wondering what it looks like with the people we work with. But also like what is the journey? Are there ups and downs in the process? Or is it just a smooth recovery? Short answer: No, not smooth. And you’ll see with Rebecca’s story that there were a lot of road bumps along the way.

And our goal is to just show and share exactly how these things look like in the process. Especially for those of you who feel very isolated and who might be hitting issues, not only in the early parts but maybe in the mid and late stages where you’re not getting back to things. Especially if you’re sitting maybe around nine months or 12 months, just know there can still be roadblocks along the way. But what does that plan look like and what do the adjustments look like? And then how much work are we putting in to get to that point we want to?

Here’s our aim to just cover our ACLer Rebecca, because she absolutely did a remarkable job just staying in the grind of it and being able to communicate and being able to work super hard. Let’s dive into her background. Her initial injury was actually a takedown injury at a BJJ tournament. For those of you who don’t know what BJJ is, it’s Brazilian Jiujitsu. She was at a tournament and she wasn’t really sure if it was a contact or a planting foot injury when attempting an outside trip to an opponent. And this took place in July of 2021.

The next day she had an ortho visit and was diagnosed with an MCL sprain. She tried to return back to BJJ and return to sports but kept feeling instability. She went to an ortho in early November and asked for an MRI. Turns out she had an ACL tear, lateral meniscus tear, and a possible medial meniscus tear. That’s a pretty long time between the injury itself, which was July 10th, and then November for her to get a consult of what’s going on with her knee.

She had some months pass by where it was like, oh, it was an MCL sprain versus an actual like oh ACL tear that she was dealing with. And good on her for going in and being like, I don’t think this is what it is. Let’s get an MRI to see. And what ended up happening, she did and had surgery on November 22, 2021. She had a quad tendon autograft, a lateral meniscus root repair, and a small medial meniscus repair. A lot of that had to be done here. She got an autograft from that quad tendon. That lateral meniscus root repairs are no joke here, and then the meniscus repair as well. So usually with these types of situations, you are non-weightbearing for a hot minute.

The restriction she had was zero to 90 degrees of flexion, a range of motion for the first four weeks. She was non-weightbearing for six weeks. She had to be on crutches for six weeks. And then no squatting past 90 degrees until four months and may add open kinetic chain exercises at four months. Basically something like a knee extension which we worked around because we wanted to build up her quad. We were able to kick that in a little bit early.

But training prior to that ACL injury, she was training 8 to 10 hours per week pre-injury, five to six BJJ classes, three to five fitness conditioning with kettlebells and kickboxing and ideally she was wanting to now go and watch two to three BJJ classes per week and then potentially do anywhere from five to six workout sessions per week. Her schedule shifted from doing BJJ solely and some fitness conditioning to being able to still go to BJJ classes. But also being able to do and focus on her rehab and other workout-based movements. The goal that she had was to return to competition in BJJ and the podium. Those were her main goals.

And one of the things I want to talk about here is her timeline. Obviously, now it’s March of 2023. One of the things I want to talk about is how 2022 looks for her and what was that whole process and journey. We’ll talk a little bit about the timeline, but more so about the roadblocks that she dealt with along the way. It wasn’t just as smooth, like, okay, she hit this restore, block with us, and then rebuild and then return, and then she was back. It was more so of like, okay, the early phases had its challenges; mid-mid stages had its challenges; and even the late stages had its challenges. We didn’t connect initially until a month later. Two months after her surgery and wanting more specific ACL-specific guidance and help. Because she just felt like she wasn’t really getting that necessarily from where she was at. And she wanted someone who was a little bit more focused on this area, especially given the re-injury rates as well as like just needing more of a dialed-in program and guidance. 

We worked together and in the early stages what we ended up focusing on, which you guys know of, is the quiet knee and rebuilding some strength and some other positions. And the biggest things that we had challenges with were actually knee extension range. How many of you are probably shaking your head at this point? Yep, that’s me. Knee extension can be really tough to get back depending on the surgery, and how your body responds. And it could be troublesome even in the mid to late stages if we don’t work on it. And so knee extension was a big tough issue with Rebecca early on and even into the mid stages. And so for her, we worked a lot on that. And then the other thing was also getting her flexion range back. So trying to get that heel towards your butt. And especially with a sport like BJJ, we need to make sure we’re comfortable being able to sit onto our heels and get into that deep knee flexion. Because a lot of times you’re going to be in that position where you need it. 

Into the mid-stages, two of the things that we dealt a good bit with were still that extension and still working on the heel to butt. And then some other thing that actually came into the mid-stages was patellar catching. Her patella would clunk at this certain position of her extension and then we had to work on that. And then donor site issues. She had a quad tendon and we started to realize there were some issues that she was arising from the lack of extension and also the donor site-related discomfort. Over time, we progressed and worked on this. She stayed super consistent and eventually, we got there. We got there, which is huge. And that’s the biggest piece here is staying consistent and laying down those bricks as we talk about and keep working on those. Because if we just focus on those for a short period of time in these situations, especially the range of motion, we’re typically not going to get it. But this is where we got to chip away slowly, our daily breaks, one after another. And eventually, this hopefully lays into place. And if not, then that’s where there need to be assessments to see, if is there something else going on. Otherwise, we continue to just keep working on it. 

And so then she does her early and mid stages. Then some of the roadblocks that we dealt with that were interesting were actually in her later stages. Eight to nine months post-op, she started getting this weird clunking in August. And we worked around it, tried to make sure that the knee was okay, still working on, progressing on some strength and just keeping an eye on the clunking. That reduced down a little bit. And then the next month, which would’ve been September 2022, she got a grumpy knee, woke up, swollen, hard to extend, and even walk on the knee. And you’re like, man, all right, if she’s at like 9 to 10 months and this is what she’s dealing with, yeah, it happens. It happens more than you guys think, and it doesn’t mean that it’s okay. But it does mean that something aggravated the knee and we got to make sure that we adapt the program to make sure we get back on track. 

One of the things that she said that I wanted to note here is that I’m a bit worried about it since it’s a decent amount of pain walking on it right now. And this is totally normal, especially when your expectation is, I hope I’m in the clear, once I’m in those late stages, to be able to make sure I don’t have these like flare-ups or issues. When in reality, it still can happen. And there’s plenty of ACLers we work with where they might have pushed too hot out of the gate or maybe just something came up in the late stages and the knee can act up and get grumpy.

And so what we did was we calmed it down. We focused on regressing a little bit with programming. We put in some stuff that felt good. And we slowly built it back up. And so that was the big goal. It was more so to know, okay, this isn’t the time to freak out. There’s nothing wrong. We’ve been progressing as we have been and has been totally fine. And then we just got to put some pieces in play and adaptive programming to make sure we feel good. We’re still working on strength and the goals that we have, but also not pushing into that aggravation or making the knee more grumpy. We just want to restore those baselines that we had. And we did, and over time, that improved. And then over a little over a month later, we had already gotten back to that baseline. It actually happened again. She got her extension back and was back to normal baseline numbers. And it happened again. This time, there wasn’t anything previous to it that aggravated it. It just happened. And instead of stopping, we adapted again. This time it went away in five days. And we eased back into her programming a bit faster because she was able to return back to that baseline faster.

So that was September, October, and now we’re sitting on November 22, and her grumpy knee again kicks in. And this time, it went away in three days. The big take home here isn’t that we were just doing something to aggravate it because really we were tracking the programming, we were tracking the symptoms, we were tracking her progressions with testing and also with her strength measurements and things were going just fine. The thing is sometimes the knee can be unpredictable. And this is where we have to make sure we have an adaptable program and we can pivot whenever we need to. When this last grumpy knee episode happened in November and it went away in three days, this was so key. And the big takeaway here is that Rebecca didn’t freak out. We communicated and she knew that this was something that we had managed in the past. It felt familiar.

What I usually tell people is to pretend you’re driving on this road, you’re trying to get to this destination. And what we have to do is potentially take a detour. The detour can either be long or it could be very short. Now, in some situations, we tend to make it long just because we might shut down, or we might stop doing everything. And it can actually drag out the detour and get off the road a lot longer than we want to. Or we can use these principles that we come back to and communicate and adjust the programming. And we could take a small detour. It might just be getting off the interstate to be able to get some gas and get right back on. And that’s how we frame this. That was the goal to make sure that we just took that small detour. We gave Rebecca the self-management tools to know, okay, let’s not freak out. This is something that we’ve seen before and we know what your knee responds best to. 

And we put those pieces in play. It went away in three days versus us dragging this out for weeks and weeks and weeks. And it being this consistent problem or constant problem over time we were dealing with. And that was actually the last time we had to deal with it. It’s something that happens in this process. I can’t tell you why, she can’t tell you why, I don’t think anyone can tell you why, but it happens. And that’s the transparency I want to show in working with our athletes: there’s not always going to be a rhyme and a reason. Sure, we would love to deduce that from the testing from the training, or from daily life activities. But you’re dealing with the human body and you’re dealing with something that isn’t always as easy to reduce and simplify to this is what it was. And sometimes we just need to make sure we set and stick to our principles and adapt things as we need to, and know that things are going to be okay and that’s what’s going to be key. And more often than not, usually, we get right back onto the interstate and we get right back on the path. 

And a message I want to point out is a message that she sent three weeks before that actually happened. And this is just more of like keeping the goals in mind and what you’re aiming for. And she said, “Yes, I recently saw that there’s a local BJJ tournament scheduled for late March of 2023, and it has me pretty motivated to potentially shoot for that as a goal to get back to competing. That’d be 16 months post-op.” This is pretty cool from a time standpoint because as we round out this episode here soon, this will shine and show, okay, wow. The future pacing of it and the aim of her goals. Let’s fast forward to her criteria and getting past recently. On March 10, she did some strength testing, which was freaking awesome. She hit 3.9 on her uninvolved side for her quadriceps peak torque to body weight. Typically, our goal is 3.0 of torque to body weight for our athletes. And she hit this at 3.9 on her uninvolved side and 3.7 on her involved side. That is absolutely killer. 

And then when we looked at the hamstring quad ratio, it was two-thirds, which was the target we always aim for. Her drop jump and reactive strength index were above 2.3. We looked at her 5-0-5 and penultimate foot contact quality. Those all look super solid from the quantitative and qualitative standpoint. And then her ACLRSI, which is something that measures psychological readiness. We want this above 70, and she was at 96. And the highest you could score is 100. And sometimes when we get hundreds, we’re just like, did you really fill this out? But when you hit a 96 or above that range that we’re looking for, there’s some honesty that you can tell, okay, what was it that might have been short on those four points? And whenever you’re returning to sport, very rarely do you ever really check a hundred because you still need to do your sport to be able to really hit that 100 mark. And then there’s the sport-specific work and progressions we worked on. There’s a control-to-chaos continuum, which is basically thinking about being in a closed environment to an open environment of your sport.

And then you have non-contact to contact-based drilling, you have volume and intensity progressions, and then you have the difficulty of the opponents that you’re going to face as well. This all being specifically tailored to BJJ and making sure that she was getting very familiar with the sport and not only feeling physically and mentally ready but also making sure the sport-specific drills were also supplementing that. And now the real reason why you guys are here is the ACL win. 

This past weekend she competed in a tournament and here’s what she posted in our ACL Athlete community. My ACL injury was in July of 2021 at a jujitsu tournament, and surgery was in November of 2021. It was a long rehab journey with 14 months of coaching from Dr. Ravi, to not just get back to baseline, but way stronger than I was before. The end goal for me throughout this entire journey was returning back to the jujitsu competition. And today, I was able to accomplish that. I competed in a local tournament against one other female opponent in Gi and No-Gi divisions and moved up a weight division. Since it’s a struggle to find women my rank and size in a largely male-dominated sport. I lost my first Gi match by points, but after shaking that anxiety off, was able to come back and win my second by points and third with a submission choke. Badass. My no-Gi matches. I went out and dominated with two wins against the points match and then armbar submission. I didn’t have a huge expectation on myself going in but came home with double gold. Those wins feel pretty amazing after all these months of work. When people ask, why do we do this? Why does the ACL athlete exist? This is it. This is for the people like Rebecca, where you put in the work. You have had so much time away from the thing you love to do so much, and it’s not been an easy journey. As you guys have seen, there have been tons of roadblocks along the way. And she still put in the work and didn’t act like a victim in this process. And she was able to come out on the other side. And here she is winning a tournament with her first competition back. 

And I want to come back to something that’s important that I saw with her that I want to highlight. And she kept coming back to her why. With some of our check-ins, periodically we will ask athletes to come back to, why are you here? Why do you care? Why are you doing this? What makes you want to like to do your ACL rehab? What makes you want to do your sport or your activity? Why? And then dive a little bit deeper.

And so back in January of 2022, when she and I first started. One of the things that she mentioned in her why was the way that she was talking to herself and how it impacted her mindset. And one of the things she wanted to correct was making an effort to not call my left knee my bad knee. Keeping in perspective the length of this recovery process and trying not to get too down when I struggle with certain exercises, instead I aim for small incremental improvements. That is the small wins in action and that is how you speak to yourself in action. Just key things here and we always tell our ACLers not to call their ACL side or whatever the side is that has been injured or operated on their bad side. You do not want to have these negative connotations towards your knee. It is something that you want to refer to as your recovering knee or the operating knee or something a bit more positive, if you will, or literally just call it the left knee or the right knee. But something that you want to make sure you restrain from is using it as a bad knee.

And that terminology is so key. And even if we highlight things from the past of James Clear’s work of identity. Identity is so key in creating good habits. If we want to make sure we’re building back as best as we can, then even using the bad knee as an example, is something we want to not do. And she killed it. She was the person who actually put that in play. She also was aiming for small wins, which are so key in this process. And then to fast forward to January of this past year of 2023, this is what she said when she was asked about her why and why she’s doing all this, to reconnect with it. I want to return to BJJ competition better and stronger than pre-injury. Chase down some world medals in the master’s divisions, and inspire my daughter and young women in a predominantly male sport. I also want full confidence in what I can train to accomplish and the adventures I can set out to do without any doubts or thoughts about physical limitations due to my prior knee injury. Wow. It’s just killer. It’s awesome to hear whenever people really can build in, not only just, all right, I’m going to do the rehab, but when they can actually build in the mindset pieces. It’s a big part of why she has seen the success she has, despite her roadblocks along the way. 

The other thing that I will highlight about her is that she continued to do some coaching and drilling in her sport as soon as she could. She wanted to keep her involvement in it, which allowed her to stay sharp. It also allows her to stay involved in the process and not miss the sport nearly as much because she’s still staying present with it. So that’s also key. Don’t feel you have to completely shut down and be involved as much as you can, especially if there’s a community around it or a team around it. See, if you could just stay involved with the process as much as it feels healthy to do so. 

And then as a physical therapist and as a coach coaching her, a few things I do want to touch on. Her compliance was insanely great. She always showed up even if it wasn’t the best day or workout or she was feeling sick. We would communicate about it or we would adjust things even when the knee was being grumpy. She would communicate and let us know she would do what she could. We adapted things and that does bleed into that communication piece, which is my second point, always communicating, always checking in as we need to, and was always open about how things were going, any feedback, and allowing us to just really adapt the program and keep the needle moving. It was a huge game changer in this process. And as I have said in the past, our three-step process anchors us: testing, planning, supporting, repeat. And we do this with all of our athletes. And this is the absolute key to having a really successful ACL rehab and getting back to your sport. And when our team discusses the athletes who get to this other side of ACL rehab to return to sports, to being back to themselves and the ones who don’t. And as the ones who really do show up, who put in the work, who provide the feedback, who communicate, they always do. More often than not, 10 out of 10 times, they will.

And that’s the thing that I want to highlight here, is that if you feel like you’re struggling and if you’re someone in this process that is not getting what they need. First, it comes back to the big points of like, all right, do you know where you are? What does the plan look like to help get you to the next checkpoint and to your goals? And are you truly being supported on that? That’s what’s really important to evaluate and have an honest conversation with yourself and with anyone involved in the process of, okay, how does this look? And this is the thing that I probably see with communicating with other ACLers, is that there’s usually a glaring hole in one of these pieces.

Your plan and support could be awesome, but if you don’t have testing, then that’s a big issue. You could have testing and support, but if the plan isn’t reflecting what you need to build towards, that’s a problem. And then testing and planning, that’s awesome, but you really need that guidance or the guardrails and GPS to make sure that you’re making progress and adapting the program as you go. I think that if Rebecca was just on some templated program and that hiccup happened in months 8, 10, and 11. And there were no adjustments being made, then who knows how long that would’ve lingered or what would’ve been the outcome of those things. But because we were communicating and guiding, we were able to adapt the program to be able to course correct and make sure that we keep building. 

And so as we round this episode out, what are some of our big takeaways from this episode? One is that no one’s journey is going to be perfect. It’s very unlikely to follow that typical nine-month timeline, especially if you want to come back at your absolute best better than before. Give that 9 to 12-month range. Sometimes it could take longer, especially if there are more hiccups. And also consider that she was non-weightbearing for six weeks. That immediately pushes the timeline a little bit longer just because six weeks, you’re not putting weight on it. For us to assume that we’re going to make up that time is something that I think is a bit of a misnomer in this process, that we assume that everyone starts the same on day one when really everyone’s got a different starting point and starting line. I think that is something to evaluate and understand from an expectation and time standpoint. 

The perfect plan doesn’t matter if you’re not consistent and you don’t communicate. Those are the keys. We could have two things that we ask people to do really, really well to be consistent or be compliant and to be able to communicate. Be a game changer with a really good physical therapist and coach. I promise you, you will make progress and I promise you you’ll get back to the things you want to do. Make sure that you’re working with someone who knows ACLs, who will test you, who will individualize a plan for you, and who will support you. That’s our three non-negotiables at the ACL Athlete: test, plan, support, repeat. 

And then lastly, I want to end with this message from Rebecca. Keep grinding! There’s an indescribable sense of accomplishment on the other side of all this work. As a two-time ACLer myself, I cannot agree more. It’s really hard when you’re in the meat of it and really trying to get through everything. But I promise you, you’ll be stronger, you will be better, and Rebecca is a great example of this. And if you’re someone listening to this and you’re not getting the support, if you are not clear on direction, then please just reach out to us. We’d love to kind of point you in the right direction. Happy to help in any way. You could always go to our website and send a contact form or whatever means you would like to reach out to us. We would just love to help you.

I do hope that this episode, Rebecca’s story, and every ACLer’s story that we’ve shared on this podcast is something that just encourages you. For you to even take the next step or just know, all right, I’m going to show up to rehab and put in more effort and really stick to the plan and make sure that I’m being supported in this. And just knowing that it’s not an endless journey, that there is actually light at the end of the tunnel, and that you can get there. It’s long, doesn’t get me wrong, but you can get there. And Rebecca is an example of this. Rebecca, if you’re listening, shout out to you. Thank you so much for being such an incredible athlete to work with. So proud of you. 

All right, team. I’m going to go before I shed a tear here. If you have any questions, you know where I am. You know how to reach me. This is your host, Ravi Patel, signing off.

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