Episode 126 | The “Nice” PT

What is up team, and welcome back to another episode on the ACL Athlete Podcast. You’re probably wondering, who this is, this is still Ravi. But I’ve lost my voice a little bit.  We are just going to get straight into it today — The “Nice” PT. I did an episode on the pro-team surgeon. Now, we’re diving into the nice PT and what is the nice PT you ask? Exactly that, the nice PT. My PT is nice. The number one thing that I hear whenever I ask ACLers about their PT experience is when they are saying they feel lost, or maybe they are stuck, or not sure exactly why it is that they’re not progressing. And they’ll typically say, well, I like my PT, they’re nice. And it’s the trap. The nice PT trap that I always say. 

And it’s just one of those things where it can be really tough to navigate this process as a whole. You’re trying to move forward. You’re hoping the person you’re working with is going to guide you and get you to that end goal. At the end of the day, you don’t want to be doing any of this. You just want to trust that person. They’re giving you the right things and you’re moving along. But as we know ACL rehab is very complex, and the person who is guiding you is a huge player in this process.

Usually, this is your physical therapist who is walking alongside you with helping you with rehabbing from the, maybe post-injury to post-surgery to the ongoing phases. It could be another healthcare provider. This is catching all these people who would potentially serve this role, whether it’s the physical therapist, athletic trainer, or some sort of other rehab professional. But this is the main thing that we see, is that these professions naturally will self-select to being very nice people, very extroverted type, outgoing type personalities, easy to talk to, easy to converse with, easy to just connect with. And so these are things that can be tough because you start to build these relationships.

The human aspect of ACL rehab is no joke and super important. I have strong relationships with all of the ACLers that I work with. It’s just something that comes along with the process. But the most important thing here is making sure that that matches up with the quality of the rehab that you’re getting as well. And I think this is where it can get tough is that you enter this system and maybe this rehab clinic and work with this physical therapist and everything is coasting along and you don’t know what you don’t know. This is also something that’s just the nature of doing something like ACL rehab.

A lot of times people are just like, all right, physical therapy is like this everywhere. I’m doing my thing. I don’t want to search for things. My search recommended this. Maybe I searched out a few things and this is the place I’m going to go. But then you may run into this problem where you start to realize, all right, I have a good relationship with this person, but are they really good at ACL rehab or trying to help me move along in this process? And I get the thing that is always tough about when people get to these crossroads of, hey, maybe I need to switch, or this is not serving me anymore, but this person is nice.

There are other factors that play into it, the relationship being the most important. But then also, maybe it’s just easier to stay, maybe you have insurance visits available. It’s kind of down the road. It’s easier for you to stay in this clinic. It’s “good enough,” they know your history, maybe. You started with them post-op, so then therefore they know where you’ve come from. And so it feels comfortable knowing, all right, I’ve been here. They’re the people who have helped me so far. But I do think that depending on where the skillset is and that quality it can run its course.

And what happens is, is that if there’s a good relationship, it keeps people pulled into the rehab process that they’re currently going through. And I think that’s the trap that I’m trying to allude to here, is that it makes it harder to step away when you need to. That’s where you want to make sure you can audit this process for yourself to make sure, okay, they are the nice PT, but how can I also make sure that I’m getting what I need for myself and being my own advocate? And that’s what I want to talk to you about with our three-step process to make sure that you can at least filter through this. If you are stuck with a nice PT, that’s awesome. I hope you have an amazing relationship with your physical therapist. But I also want to make sure that you’re also getting the quality rehab that you need. Because what happens is that people get stuck and then they are 3, 6, 9 months in and they’re still kind of spinning their wheels. 

Let’s go through this three-step process that I’m sure some of you have heard in the past, but it’s a good way to filter through to know, do you stay with this person or do you not? Number one is testing. Are they testing you? Are you getting numbers that are objective for your quad strength? Hamstring strength? And at this point in the physical therapy process, there’s not really a good reason to say no. Every single clinic and every single PT should be testing this if you are an ACLer, and you are moving along in this process whether that’s referring you out to certain places or having some sort of way to measure this.

And this is not just kicking into their hand, it’s not just doing a single leg to a box, it’s actually kicking into something, whether it’s a three to five repetition maximum of a single-leg leg press, leg curl, leg extension, or maybe it’s a handheld dynamometer, ideally an isokinetic machine. Any of those options are available, but we need those measures. And then there’s other things along in this process from your range of motion to power production to jumping ability, cutting ability, your capacity of being able to do certain movements. There are a bunch of different ways to add testing to this process. It’s just making sure that that’s being done and being objectively measured.

Planning: Is there an actual game plan? Do you know short-term and long-term what your goals are? Do they know that? And is that being accounted for as you’re going through your rehab process? Do you know where you’re going? Do you know how you’re going to get there? Just like a GPS. Is there a good and challenging program that you’re doing, whether you are at your physical therapy or maybe you’re at the gym? But is there something that is continuously being updated and programmed to make it challenging to move you along in this process? And do you leave your sessions fatigued, feeling like you’ve worked hard, you’ve sweat? Make sure that you are continuously doing that as you build and work through your ACL rehab because it should look like a strength and conditioning program. Sure, it’s scaled to certain parts of the continuum and where you are, but overall it should look like just good training. And so that’s something that’ll be really important with the planning and the programming that you’re doing. 

And then lastly, the support. Usually, this is something that’s there, it just varies in degree. Are they addressing your questions and concerns? Are you getting the coaching and feedback you need to make sure you’re moving well? Those are pieces that are going to be really key to make sure, okay, am I having those touch points? Am I making sure that my ACL rehab is going well? Not only just doing the things, but doing them well. And so you got to make sure that you have the support pieces. And probably most cases, people feel like they’ve got that aspect because they at least have some touch points with their PT. The biggest thing is going to be the testing and then more of a doubting game plan to know, all right, this is my roadmap, this is what I’m doing, this is where I’m heading, and is very clear with objectives and goals to hit. And those are the things that you can audit your process along with that communication piece of like, all right, cool, they’re nice. Go for the nice PT. I am all for it. And I’m not here suggesting you leave your PT. But I am here to tell you to audit that process, especially if you get trapped by this nice PT, feeling and making sure that it is lining up while also getting you back to what you need to be doing. And you’re having the big buckets and the big anchor points of testing, planning, and support that’s there.

The reason I’m bringing this up is because, at the end of the day, everyone is busy. There’s a lot of moving pieces, there’s a lot of volumes that are being handled, especially in traditional outpatient orthopedic physical therapy clinics. Whenever I’m talking to athletes all the time, whenever I’m asking them how many people their PT is working with at one time, it can range anywhere from two to even six, which is just bizarre to me. If it’s literally just them moving around doing the same stuff. That’s not going to be very individualized and it’s going to be hard to coach somebody. So there’s times and places where that could be valuable and done right, but in most places, they’re not equipped and skilled to be able to do that.

Therefore, we have to make sure, okay, can you advocate for yourself because you are trying to get to this end goal? And you can’t rely on the system to get you there. Because if we did, then our re-injury rates would be much lower. And so what I’m saying here is that you have to be your own advocate and understand that not all physical therapy is created the same. We have physical therapists who are nice because it’s the profession that self-selects to be nice. That’s even harder to work with when you’re talking about ACL rehab because you’re looking for a more specialized skillset and not just this general like hamstring strain rehab. We have to make sure that the person is able to do the rehab well, to be able to guide the person, and to make sure that there are the communication pieces that we’re hoping that they have.

And if it’s not there, and sometimes it’s having that hard conversation when your gut is telling you it’s time and it’s no longer meeting what you need. And it’s an opportunity cost, and that is totally okay. And they will likely probably know that, too. They’ve probably known that this has run its course. You’ve gotten stuck or you’re no longer progressing, and that’s totally fine. And so that’s where just having a conversation and respectfully letting them know, hey, these are the concerns. You can communicate about them. Maybe they get addressed and maybe they just didn’t know. But if that continues to be the cycle, then it is something that they will also know and they should respect.

Every physical therapist that you will talk to will know their bandwidth and know where they’re good at and where they’re not good at. And if it’s kind of run its course, then they should be okay with knowing, all right, it’s time to pass the torch or allow this person to move forward instead of feeling in this trap like, all right, you got insurance visits and we have a good relationship. But are you actually moving forward with your rehab and the goals that you have? And that’s what’s most important. While communication is very key and that nice PT is awesome, keep that. But just make sure that that aligns well with the quality control of the testing and the planning and the true support that you need to make sure that this nice PT isn’t the only reason you stay, but you’re also getting that quality and getting to the outcomes for your ACL rehab.

And I’m probably going to get canceled by my PT friends. But this is something that I wanted to basically bring up to all my ACLers because it’s something that’s super important and something that happens way more than you think in these conversations. And I’m like, well, what kind of gives? And it ends up being because of that nice PT and relationship. And I just always want to call it what it is. And that’s my goal with this podcast, is to bring transparency to the space. Where are the gaps? What are the blind spots? And this is one of those blind spots that I see way more often than we think. And I just want you guys to be as equipped as possible. 

That’s going to be it for today, guys. Thank you so much for listening. This is your host, Ravi Patel, signing off.