Episode 114 | The Most Important Phase of ACL Rehab

What is up team? Welcome back to another episode on the ACL Athlete Podcast. Today is episode 114, and we are talking all things the most important phase of ACL rehab. And I know a lot of you are probably on the edge of your seat. You clicked in this episode, you’re like, all right, I’m going to get ahead of this. What is the most important phase in this process in ACL rehab, in return to performance, in the ACL journey? What is the most important phase? 

Well, what do you think? It is based on previous podcast episodes if you’ve listened before. Is it prehab? Is it post-op? Is it early? Is it mid? Is it late stages? What do you think? Yeah, you guessed it. They’re all important in their own different way. I am so sorry. I could not give you guys the answer to that. But you knew what you were walking right into.

And I think today, I want to share with you why that is, that each of these phases is important in this process. Sure, some might have a little bit more weight than others, depending on the timing and for different reasons. But I want to really share how to think about this, and that way it helps to frame, okay, like what is it I need to approach this with, the type of mindset and the importance of certain movements.

And I think the best way to really think about how this process evolves is really to think about building a house. Imagine you are someone who is a homeowner or just purchased a lot and you’re about to build a house on a foundation. And this is the same question to ask if you’re asking your contractor or the builder be like, “Hey, what’s the most important part of building the house?” Well, you get multiple answers from multiple different contractors. But I think that they would probably say, we need to make sure we have a game plan, and we need to make sure that blueprint is there and that we are going to make sure that we build this in different phases. But each phase builds on top of the other. But let’s say you did pose the question to your contractor or the builder. What phase of the building is most important? Well, they’re probably going to explain why each phase has its own importance building on top of another. 

And then let’s say, for example, you want to speed it up. Or maybe you’re like, hey, what if we just speed up this phase, or we maybe cut a corner that could be just a little easier to do? Well, what would the end result be? Something that you probably aren’t going to be happy with. And usually, whenever you try to rush something or cut a corner, there’s usually some details lost in that process. So that’s one thing I want you to think about with your ACL rehab. In a nutshell, it is very similar to building a house. And I talk a lot about building your foundation in ACL rehab. That’s going to be the base of this process that is from which everything else will be built upon. And I believe truly that this foundational phase or the early phase, or what we call the restore phase in our athlete programming, typically in that first six to eight-week timeframe, post-op, or let’s say even post-injury, can make or break how the rest of your ACL process goes.

And I mean that a lot because after this point, working with hundreds of ACLers going through it myself twice, working with people remotely, in-person as a team, these are pieces that we consistently see across the board. The people who own the first six to eight weeks have a much smoother process throughout the mid and late stages, versus the people who maybe for some reason, they had poor guidance with the early phases, or maybe they just slacked off. There’s some people we talked to who they’re like, yeah, I just didn’t take it that seriously. Or maybe you weren’t educated well, or maybe you’re like, oh, this is a piece of cake. I’ve gotten my knee to move a little bit. But really, we know how hard it is post-op with the pain, and the swelling. And just all the different pieces and making sure that we hit those phase one goals, getting the knee quiet, calming it down, starting to build up some foundational strength pieces, are going to be so key in this process. And what happens is, is that if we slack off or get poor guidance not really hitting these certain criteria, you pay for it later.

We see this day in and day out with any athletes, especially if people come to us later in the process. We see this when they haven’t hit those particular buckets that they need to. And it could have happened for multiple reasons. But with that said, that makes it inevitably harder for the rest of their process. Why? Well, let’s say, for example, you don’t get your full extension or your quads do stay weak. Maybe you’re continuing to deal with pain and swelling, all pretty normal things to deal with until you start getting later and later and later in the process. Then at some point, these criteria should be hit and we should have the knee quiet and building on your strength and power and so on. And so when you don’t have those pieces, it’s like building that house, or it’s like building the pyramid where you don’t have a solid foundation to build on. And then the rest of the building process is going to be pretty rough if that’s the case. 

And sure, we cannot control certain things like… if we’re talking about the building. Let’s say for example it rains, or there’s a crack in the foundation, or there might be a default in some of the material, it happens and things are not going to go perfectly according to the plan or to the protocol, whatever that may be. But there needs to be some backup plans and some adjustments that are put in place to pivot and to be able to fix it and adjust. And that’s what’s mainly key here and then we keep adapting. Timelines are adapted, phases are adapted, and the blueprint is adapted. And you might even have some extra checkpoints along the way, but that’s pretty normal. It happens with building, it happens with ACL rehab. So all of these phases are really important.

And when we talk about, let’s say, the mid to late stages are just as important as well. I wish I could say like, ah, early is where it’s going to be the most important. But each of these, if we were to bucket these separately, they’re also important because they build upon each other. And it’s one thing to have that cool foundation. But let’s talk about the rest of the house. Well, we need to make sure that it’s built up, the walls are built up really well, that if there’s multiple levels, that those are built up and in the right places. And then you also talk about the roof, how is this thing going to finish? How is this thing going to protect and have a cover-over? And then also, what’s going to be the internal infrastructure of the house itself as well. So those are all the main key pieces, but we have to make sure we start with a good foundation. 

And I think what’s interesting is that in most situations, “people will get the care to build that foundation,” if you will. And I put that in air quotes as I’m talking here because it depends on the physical therapy or the physio you get and the care that you get. But it’s typically what most PT covers, it’s the post-op phases, it’s the early phase, it’s where insurance will kick in, or the healthcare system that you’re using can help kick in, hopefully. But that’s where most people will have some sort of attention and direct care. Not saying it’s great, but that’s where it is. What’s tough is that even though that initial phase or that foundational phase, the restore phase, the post-op phase where you are working with someone, where we are trying to get the knee to get straight and to bend and to calm down and to start working on strength and potentially even getting into running, there’s so much skill involved in helping to guide an athlete through those mid to late stages. 

If you want to put this perfectly into a calendar, let’s say, zero to nine months is your timeframe here. Let’s just say that the first couple of months or even the first three months are the early phases. You’ve got your mid phases, which are three to six months, and then six months to nine months are your late phases. That’s just perfect to make our brains grasp the timeline. What does this look like if it was in a perfect world? And so this can help to frame, okay, most athletes that we do see end up getting coverage somewhere in that two to three-month mark. And then after that, it could be a little bit of a crab shoot to see do they continue to get coverage. Has the skill set of the provider exceeded what is needed for rehab? Is it just not the care that the person’s getting? Then you need to pivot to something else outside of something basic. And so that’s the thing that could be tough, is that with not only the early phases being skilled and needing to be skilled, that’s what’s more provided and available versus those mid to late stages in ACL rehab to truly progress athletes to more demanding training and activities that they’re wanting to get back to. That’s where the true skillset, if you will, from a program design and coaching and navigating and building up strength and muscle and power and the ability to run, jump, cut, all these different pieces. That’s where all that does become really important.

But often, it’s whenever that insurance or the help and the guidance can run out. It puts people in a tough place. What do we do? We turn to maybe some more affordable options or ones that are free, or what the protocol says. Or maybe the physio you’re with was like, hey, here and do this program. Don’t do that program, especially if there’s no specific individualization for you. Actually, follow something that is more specific to you. If you need help in that direction, then please reach out because we can help guide you in that direction or provide resources. But with that said, this is where the gap if you will, can exist in terms of this ACL rehab process.

The guidance is lost. There needs to be more skillset behind it. And the thing that is also tough with this is that you’re likely getting into the things that you want to do, the things that are more demanding on your body. And the thing that you probably likely were to tear your ACL doing and likely did doing versus that early phase stuff. While the early phases are important, the mid and late stages are just as important. But it’s where we probably don’t get as much of the support. And there’s a number of factors to that from insurance to potentially the limitation of the skillset of who you’re working with. And that’s just the reality of where we are in this space. And I do hope, and I see this progressing over time. But we’re still there just because of the way the model is built. But it’s like a pyramid and we have to have that base first before we can build on top of it. Reframing this to ACL rehab you can’t just skip to a high-level cutting or jumping without a good base of range and mobility, some good work capacity, some strength, and some power. And then making sure all your muscles and all the criteria that you’re hitting are hitting the objectives that we want to in order to build you up to those higher level things.

To answer the question of what is the most important phase of ACL, I know I mentioned it earlier, but they are all important in their own different way. My advice to you is to listen as you want to figure out which one it is, don’t underestimate the post-op phase. Don’t underestimate it. It will make or break the rest of the process for you and how smooth it can potentially be. And this is after seeing so many people, working through this or trying to skip through it and assume like, oh, let me just get to some of the strength stuff. But if you don’t have those prerequisites, man, it’s like trying to do dividing and multiplying and then algebra and then calculus and things of that nature. But you don’t really know how to add or subtract. You need to know how to do those foundational basics first in order to move along the continuum. It’s how our schooling goes, it’s how building a home goes. And this ACL rehab process is no different. No matter how much time passes. You can’t build a house just because we’re four months into the project, but we don’t have a foundation yet. We still have to start with where we’re at, meet the checkpoints, and then move forward.

For the mid to late stages, that’s where people can have the least amount of support. But most of the skill that is probably needed from a physical therapy and strength and conditioning coach standpoint, that’s where it’s really key. Because we need to progress you into running and building up that capacity, hitting your max strength thresholds to build up your power and building up your explosiveness and then making sure that you’re a really strong reactive athlete and that you’re an explosive athlete, and that you are elastic. You can bounce around. Use your stretch-shortening cycle. You can operate at slow speeds and fast speeds. You can cut, you can run, you can jump. And not really feel stressed out about the knee. And those all build on top of each other. But that’s where having someone with a performance lens is going to help you so much. And that’s where you want to make sure you find those specific people that can do that. 

And this is truly where we probably see athletes and ACLers fall off the most. Is that either the early phases weren’t done well, or maybe they do and then they find that there’s a limitation in skillset, or maybe insurance runs out and then they’re stuck in this like mid phase. And they just do it on their own. But the thing is, no one should do this on their own. If it were to happen to me again, knock on wood, I would not do it alone myself. I would have someone else to help guide me in this process. And that’s just because we got to have someone who’s going to check our blind spots to make sure that we’re looking at this objectively and not just doing the things we want to. And then also just to think from an external perspective versus just biasing it towards our own.

And then the last thing I’ll mention here is that I will often get the question when is a good time to start working with us, the ACL Athlete or someone who’s just more specialized, a physical therapist focused on sports, or a strength conditioning coach, a performance coach, someone who knows movement really well, especially on the performance end of the spectrum. And for some reason, people really think that it’s the later stages, especially with us. They think that, oh, well, I’ll just do the basic stuff and then come and see you guys in the mid to late stages. And I get that because there can be more complexity. Maybe you have insurance coverage. And you’re like, I want to wait until I need to really utilize a skillset from someone like this in order to build up something like running, jumping, cutting, sports-specific stuff. And that makes sense. 

But let me ask you this: if you’ve got a hard hike ahead of you that you want to do, would you rather start a super hard hike yourself and then find a guide along the way? Or would you rather have a guide to help you navigate the unknown terrain and the path as soon as possible so you don’t wander or spend a ton of extra time or energy trying to figure it out? Would you rather have them at the start, or would you rather have them later in the process? And then you might have to almost like going back on the trail in order to get back on the right path. So that’s the thing to think about and put yourself into this position is, okay, well, when is the best time to start working with someone who knows more about this process? As soon as possible is always my answer. What ends up happening is that people will reach out and they’re like, oh yeah, I’ll come back later. Or maybe they’re like, yeah, this PT is fine. But what we see is if people come to us later and we’re starting with them at the three-month or six-month process, while it’s no problem and we love working with these ACLers. 

The earlier ends up being better because then we don’t have to backtrack on potentially hitting some of these criteria or KPIs. And having to start from a place where we would’ve needed to anyway. And it helps to just be able to be with someone who knows this process from the start versus having to pivot later in. But I know that everyone has a different situation, whether it’s financial, whether it’s time, whether it’s the insurance you have available, the healthcare. I’m not going to sit here and act like I know it’s an easy choice and there are a lot of factors to consider. But if you do have the option and you’re listening to this and you’re like, when can I intervene in this process? Do it sooner rather than later. And I promise you, you will thank yourself for it. And when you’re looking at this ACL rehab process and when you are trying to figure out, okay, what’s the most important, your current phase is always your most important phase. 

And the other thing to this is just think about it similar to building a house when you ask yourself: Should I focus on this part right now? Or should I just save my energy for later? Well, imagine that house and you’re building it, do you want that solid foundation? Do you want that next phase to be built up well? Do you want that roof to be built up well? How do you want that to look? And that is basically ACL rehab in a nutshell. You can’t speed up the process. If you do, you might cut some corners and you might end up not getting the result that you want. And it’s going to be huge to have a builder, if you will, or a contractor, someone specialized in guiding you from the start. It’ll just be a huge game changer because they will help to navigate that and to reduce as much time, as much stress, and to be able to make sure that you’re progressing along the way that you need to. 

And then one last note here. One thing that I’ve learned from mentors is that if you work on building a good, wide base and a foundation, the higher you can build. For example, if you’re building a pyramid and you build that thing out big and wide, to a certain degree, you’re going to be able to build that pyramid up higher than a very narrow base. Start from the beginning, build up that foundation as best as you can, build it wide, and then build up. And that’s going to be the key here. Each phase builds on top of another, the top being just as important as the bottom. But you have to start at the bottom and work your way up. 

If you guys have any questions, I’m always here for you. Until next time, this is your host, Ravi Patel, signing off.