Episode 131 | Self-Audit for Movement Compensations in ACL Rehab Without Fancy Tools

What’s up team? Welcome back to another episode on the ACL Athlete Podcast. Today, we are talking about Self-audit for Movement Compensations in ACL Rehab Without Fancy Tools. I know that’s a little bit of a mouthful. But basically, we’re going through and we’re gonna talk through how you can audit yourself with any type of movement compensations that can come along, without needing all these fancy tools like you hear about. Whether this detailed video analysis can be helpful, or force plates or strength dynamometers, and all of these different things that limit or create barriers for you to move forward, or to know how to intervene a little bit faster.

I’m going to share a couple of ideas that have helped drastically with our ACLers. And basically, something that you can use to make sure you’re keeping things in check. Because movement compensations are so common in this process, I want to share how we can tackle those. But first, I want to dive into compensations a little bit and talk about some background. If you caught the last episode, your uninjured side hurts, why? We talked a lot about movement compensations in terms of the post-injury and post-op, and how other things need to pick up the slack in order to basically just complete a task. Other things are doing more, or maybe you are using different muscle groups now that you are back to “normal.” But now your body’s just figuring out ways to do it around loading the actual side that you need to load. And you could check that out first as it tees up pretty well for this specific episode for us to be able to self-audit this process. 

Compensations will occur with any ACL rehab. There’s not a single person, not even the best pro athletes exist without compensating to some degree, especially if they injure or post-op. It just comes with the territory because you have injured something and you are going to create a decrease in range of motion and strength and add pain and swelling. It happens. Then, it’s a matter of your body doing its thing, while rehab is providing the right guidance and programming to clear up the deficits and get you back to the same as before. And honestly, you should be better than before if it’s really good rehab and performance training.

Studies in the past have shown compensation can continue for months to years after. From hip and ankle strategies to avoid loading your quads with knee-dominant type movements. Let’s take for example, squats or lunges to something like running with decreased knee flexion due to quad strength, torso lean with the change of direction and agility, a lack of knee bend, or relying too much on the uninvolved side when you’re going to cut. The penultimate and antepenultimate step as we call them in performance. And I have shared this study and understanding of inter versus intralimb compensations before. But I want to talk about it briefly, and then we can get into the practical self-audit that you can use.

Understanding compensations, there’s interlimb and intralimb compensations. Interlimb compensation is a shift from the ACL side to the uninvolved side. If the left side is the ACL side where you’ve injured it or your post-op, then that’s your left side, and then your uninvolved is your right. You are shifting to the right side, and that’s an interlimb compensation. An example is a squat shift from one side to the other. Left side going to the right side when you go to lower down. In terms of intralimb compensation, that is a shift from one joint strategy or muscle group to another. For example, a squat shift from knees forward to a hip strategy where your butt is going back. Maybe it’s less about left versus right, but it’s more about using a different strategy instead of laying your knees moving forward. You’re shooting your butt back because you’re avoiding loading your knees. 

There’s a huge study on this, which is I think one of the coolest ACL studies that exist. And it showcases exactly this. I did a whole episode of it in episode 78. However, the study is compensatory strategies that reduced knee extensor demand during a bilateral squat change from three to five months following anterior cruciate ligament reconstruction. Susan Sigward, 2018 — Susan Sigward is a boss and she is awesome, doing incredible research in the ACL space. Thank you if you ever listen to this. But this is a really cool study. In the results, they showed when athletes squat go from a combined interlimb and intralimb to just an intralimb compensation from the three- to five-month mark in tested patients.

Let’s use our example as before. The person had a left ACL. Before they were shifting to the right side and also into different joints and muscle groups. And that was what was happening before. And then they got to the three- to five-month mark after doing some rehab and hopefully strength training and building things up. They started to notice more intralimb compensation. So instead, the squat shifted back to a normal neutral squat. But instead, they were shifting towards their ankle or their calves and into their glutes and hamstrings as a hip strategy. They were loading just different muscle groups on that same ACL side versus to the right. 

Basically, the athlete is avoiding the ACL reconstructed knee and is trying to compensate to complete the task. And with this, there’s an intralimb compensation that can take place with just a three- to five-degree change at the knee with no change at the hip or the ankle. This can occur by the patient shifting their center of pressure minimally to different parts of the foot, changing the force vector and moment arm through the knee joint. It’s crazy! You can’t notice it to the naked eye, really, but then that’s something where, okay, they’re feeling it probably in different places. And if you ask them that, it can be likely. But this study showed visually you can’t really notice. Who’s going to really notice a three- to five-degree change with a squat at the knee? Not a ton. They were able to just shift the pressure in order to change the vectors at the moment arms in order to activate certain strategies and muscle groups. 

The human body is crazy, super crazy. And I want to share this helpful framework to help combat some of these compensation strategies. This is not the self-audit just yet, but it is 100% worth repeating. And this is something most important that I’ve learned from Eric Mira, who is an amazing mentor to me. And I’ve learned so much from him and a lot of other really smart humans out there. But it’s basically improving local tolerance, then capacity, then movement strategy, and going from local to global. So instead of really focusing on a big movement, like a squat or a deadlift, let’s focus a little bit more locally. Like maybe looking at the knee itself and knee extension to work on your quads or knee flexion to work on your hamstrings, that’s local. And then we’re moving towards global where it’s a little bit more of a compound movement. And then what we’re working on is the tolerance of that joint and position and movement. Then we’re building up the capacity of it, that ceiling, and then the rate of how quickly we can get up to that ceiling.

The constraints-led coaching and movements can really help this. It helps us to really just constrain down the task, maybe it’s the environment, maybe it is the person itself. But it all comes together to help constrain the whole total system and the movement you want and reduce it down to where all you get is what you want. A knee extension machine is constrained down to literally only using your knee extension and your quads. There’s no way to really do much else. And when you open that up to other movements like a squat or a split squat, you have more options available. It’s less constrained because other joints are moving and there’s more degrees of freedom to move. You can recruit different muscles. If we lack quad strength, we need an isolated knee extension movement of some sort, and the only way to do it is to do the knee extension, which is to fully isolate your quad. That’s the importance of building capacity. 

As I mentioned, if the function is attempted before building the capacity, new strategies will emerge if given enough time. Those strategies can still stick even if that capacity is restored later because it’s a new option that has been built. Working within a task within the capacity early is fine. The rule that is important here is that: only do as much as the quads can take through all the phases. To expand on the example, if someone shifts away with a squat, do I think that it is a capacity or strength issue? Or do I think that is a movement strategy issue? And basically, you want to think that is a capacity issue before you think it’s a movement strategy issue. If there is not enough capacity, you have to start there. And then from there, if there is enough capacity, then you address the movement strategy. 

Basically, address the strength first, and then the motor control, the skill, and the movement strategy. If you tackle the movement strategy, but they don’t have the requisite range or strength to do it, then you’re not going to get it anyway because it doesn’t have the requisite there. It’s like trying to multiply and divide before you can add and subtract. There’s no way that you can multiply and divide without knowing how to add and subtract first. This is where criteria are so valuable. And so this is where this framework can be helpful, is to go from local to global, to build tolerance, then capacity, then rate, and thinking it is a capacity issue before it’s a movement strategy issue. Build up that local place first. And I guarantee you that when you start to introduce the new movement or the strategy, you can constrain it to get a little bit more of what you want with different coaching cues and positions and potentially tempo and whatnot if that capacity is there. So that is going to be key. 

Now, why you’re here? Onto the self-audit, and then that way we can dive in and you guys can take this practically on. I’m going to start with kinematics and kinetics. Kinematics is your shapes and positions and kinetics are going to be the forces involved. Kinematics will impact your kinetics. Your shapes and positions will impact the forces involved in the muscle groups recruited. I can’t say with a hundred percent, but this is the biomechanics of the human body and how physics interplays with this. And this is all involved with moments and torque and lever arms and movement strategies, etc.

For number one, practically, how do you look at this? How’s your form? Does it pass the eye test? Could I or a good performance physical therapist or coach look at you and not notice any compensations to the naked eye? And just know this is a range, as I had mentioned. There is something where there’s variation to some degree in motor control and strategies. But it needs to look fairly consistent with repetitions that are executed versus this complete perfection because you shifted just an inch or something. We have to make sure that the average stays the same, but maybe there are a few pieces that might shift a little. But this is where it should look pretty pristine, for the most part. But it needs to look consistent, right? That’s the goal that we’re aiming for, especially with the visual and the kinematics of it. The kinetics, the forces, will be impacted by the kinematics which is where it will influence what your lever arms are, the internal and external moments based on gravity and ground reaction forces, and therefore the muscles you feel working.

I know that’s a lot of like technical jargon. But basically, this boils down to me, for the self-audit, is what are you feeling? Those forces are going to influence the muscle groups that are creating the movement at the joints so what do you feel? Motor control and strategies play into this, for sure, to a variety of degrees. But if you’re executing the movement appropriately, and you’re doing it based on the intent and the goal, it should look a certain way consistently and it should feel a certain way consistently. Let’s get even more practical here. How do you look and what do you feel? Those are the two audit questions that you’re going to ask yourself to make sure you’re doing as much as you can in your own realm to make sure that compensations are constantly just a part of this process.

The look allows us to assess shapes, positions, and forms. How can we do this via your coach or your physical therapist in person? Hopefully, they’re looking at this, but they’re not always looking at it or the video. For every athlete I see in the clinic or even with our team remotely, we use a ton of videos, ton. Because it’s just such a great snapshot to slow things down, show any compensations, show the form, your positions, and shapes that we want to be in, that kinematic position that we are looking at through this entire process. It’s a way for you to do this on your own is basically to record a video of yourself doing the exercises and movements. 

Does this match up to what’s the ideal shapes and positions for the movement? If you are doing a split squat, for example, with a four-knee bias, let your knee go past your toes to emphasize the quads. But you’re actually in reality, keeping your shin vertical and bending over at your torso, guess what? You’re going to feel more glutes and hamstrings. It’s just the way that our lever arms work and your body figures out how to do the movement good enough, to seem like it feels familiar. But you’re actually doing it super differently because of the way that the moment arms are and the way that you are essentially compensating.

But you can clean this up by potentially changing the visual first or the positioning to hopefully elicit the muscles in the right positions, and that’ll therefore allow you to feel the right places ideally. If you can focus on allowing your knee to push forward past your toes in a more vertical torso, this is going to create a bigger moment arm to allow the quads to work and get what we’re aiming for. But if you are bending at the torso and keeping your shin vertical, you are not going to get as much quad as you’re hoping to. Even though it seems like a single-leg movement, like a split squat or a quad-based movement, in reality, your body’s just working around using the glutes and hamstrings to do the work. But you might not know that because you might be assuming that you’re doing it right. 

But then you see it on video and you’re like, oh wow, my shin is actually super vertical, or I’m doing this weird hitching thing at my hip, which is what we see a lot with ACLers who don’t want to go into that knee forward position. Or maybe you do see that’s going forward and you’re getting the knee past your toes, guess what? That’s awesome and it’s something that we’re going to want to make sure we build into progressively. But you can see this with video and something we can often correct with athletes. When people ask about our remote coaching, they’re like, well, you don’t see people in person. I feel like you need to put your hands on you. No, in all honesty, I rarely any of my in-person athletes, I don’t even really touch them. That sounds weird, but I don’t put my hands on them in order to move things around that much. Initially, at the first eval, assess the joint or whatever that might be, but we don’t really put our hands on anybody much at all. 

And if you are with a physical therapist where you’re like, oh, you need a lot of hands-on work and all this stuff, I almost question their approach to helping you get involved in this process and also what they’re going based off of. Because at the end of the day, you need to do the work and maybe outside of some range of motion that you passively need to move. You’re doing all the work, that’s the only way you’re going to actually build and progress. And especially since you’re going to be going home and doing that anyways, we use so much video to give our athletes video analysis feedback and they’re like, wow, I’ve learned so much from being able to see myself on video and for the coaches to provide feedback.

And we love it, it’s fun, it allows us to basically be with them in the clinic and for them to have that in their database for them to be able to continue to reference. And just to make sure, all right, is this video reflecting what my coach had said I need to change? It allows you to progress and make sure week-to-week session-to-session that you are progressing along, not only from doing the movements but doing them right and getting in the right positions and shapes. 

The same thing can be done literally with any movement from a range of motion extension type work to basic body weight squats, loaded double or single leg movements, to more dynamic where I suggest this is even more important, such as running, jumping, cutting, sports-specific stuff. Video is going to be so crucial. Record yourself and allow yourself to analyze, how does this look side to side? Am I compensating? 

I had an athlete the other day. She has been known for compensating. Her body just does not want to load into her knee sometimes, so then we have to make sure that we video. And she’s videoing herself to make sure she’s keeping an eye on, okay, how is this looking? Am I compensating? And we’re continuing to adapt the program to make sure that is a consistent thing she’s dealing with, especially once she gets into the dynamic stuff where that stuff is less noticeable but still happening.

You have to clean it up with the static and easier to judge stuff because that stuff is going to translate 100% into the dynamic pieces, where you add speed or velocity or increased stress. And then we haven’t even talked about the increased chaotic environment. Our bodies, if they’re doing it in a controlled space, they’re a hundred percent going to do it in an uncontrolled space. This allows us to assess how that physically looks to the naked eye, and in passing the eye test and allowing you to also be the judge of that. 

Next is going to be the feel: what you feel. How can we do this? This one is not as easy because we can’t look at the visual. It’s not as easy for the naked eye. Sure, we can let it inform where we should be feeling things. But at the end of the day, we feel what we feel. This is an internal report from the person who is subjective. We can’t see unless you have something like an EMG hooked up to a certain muscle group of how much activation there is. The intent has to be super key here, the intent. And we have to be super dialed in on the movement and the feel of it.

Ask yourself when you’re doing a certain exercise or movement: where do I feel it? If the goal of my split squat is to work on some quad strength when you do the injured side versus the uninjured side, do you feel the quads or do you feel the hamstrings and glutes? Maybe both. And then making sure that you really assess. If the goal of the movement is split squat with the quad strength and feeling the quads, then I need to make sure that I am manipulating the positions to do that. That’s going to be a more vertical torso and allowing the knee to drive a little bit past your toes. Because that’s going to create a moment arm that is going to require you to push and create knee extension torque that is going to work your quads. 

Otherwise, you’re just going to get into your hamstrings and glutes, and guess what? Compensating and strengthening those up versus the quad, which is the main goal and target of the movement anyway. This is where the feel is going to come into play. What are you feeling? 

Another example here is if I’m doing a squat to strengthen my quads, which is what a lot of people do. And you feel it in your hamstringing and glutes, you’re likely just using a hip strategy where you’re pushing your butt back and bending at your hips, to bring your torso forward and not working the quads as much. Are the quads working? Sure, they’re working some. But that feel and that position is going to help you assess that. 

Another example, I’ll have athletes do backward sled drags. If you are an athlete of mine, you have done this. They may have to do it for a few rounds, for maybe 50-ish feet, really focused on the quads. This is a great movement to do because it’s very self-limiting. And I’ll be even mean, and I will add BFR to it sometimes. But man, is it a killer combo? When you watch this, one thing that you’ll notice is that both legs are working. You’re just dragging a sled backward. You’re moving from point A to point B. It looks like it’s all jiving pretty well. It’s working to the naked eye. It looks good that they’re doing it evenly. And even athletes are like, oh, I feel fatigued at the end. It’ll take your breath, it’ll make you work hard, increase your heart rate. When I ask after, where do you feel it? Then sometimes I’ll follow up and ask, does it feel even side to side? And I’m not expecting it to be 50%-50%, even side to side, but roughly there. And I do expect the ACL side to be super fatigued and burning, especially because it’s a little bit more deconditioned than the uninjured side in most cases.

Often what they will say, especially if it’s early on, is that they feel the uninjured side more. What’s going on here? It looks even, and they’re fatigued. But guess what? They are literally doing most of the work with the uninjured side, pulling most of the weight, literally. Then we have to revisit the goal of the movement and the intent — it’s to work the ACL side quad. This means we need intentional focus, that intent that I talked about on the pull with each step and potentially do less on the uninjured side. Or maybe lighten it up or change the movement altogether if it’s not tackling that goal. We wouldn’t have known this though without checking in on the field because visually it looked okay. And what this ends up looking like is that the athlete does the movement again. And when they go to pull, they might not pull as hard with their unoperated or uninjured side. 

And they try to really be intentful about pushing as hard as they can with the ACL injured or operated side. And that helps us to get a little bit more of a direct effect. But that’s because we revisited the goal. We made sure that the movement looked the way it needed to, the kinematics of it. And then we’re going to try and impact the kinetics of it by making sure that there’s a little bit more intent by the pressure and the drive of the side to side. And so that’s where when they finish, they’ll be like, all right, after that I felt it way more on my ACL side. And that’s because we changed up the intent. We were able to adjust this, but this was all based on how they felt after they did a rep that wasn’t as ideal.

Another example of this is the bike. If you’re working your legs on the bike, whether it’s an easy aerobic, coasting-type work, moderate or higher intensity like sprints, how’s the burn and feel side to side in doing it? I remember I would always burn more on my uninvolved side. I would finish the sprint and especially a series of sprints and I would just feel my unoperated side at the time really pump and blow up. It wasn’t doing all of the work, but it was definitely doing more of the work. I’d probably say anywhere from like 60% to 75% of the work. And then that’s where it was just fatiguing out because it was taking on more of the workload. And I wouldn’t have known that if I hadn’t asked or been intentional about doing more work with the A C L side versus the opposite. So that’s where feel and that burn and muscle work is going to play a big role.

With double-leg movements, you have to make sure it feels even-ish. I’m not saying perfect, but it needs to feel even-ish. If it doesn’t, then there’s definitely some compensations going on, or the movement is just not appropriate, or the weight. But likely it’s just the compensation that’s happening. That’s where it’s going to be important to make sure there’s an audit of this process to see, do I reduce the weight, the tempo, do I affect a few other pieces of pushing more on one side versus the other. But it should at the end of the day, feel fairly even side to side because we don’t want one side doing more than the other in most situations. This is especially important when the unoperated or uninjured side is doing more. That’s just going to further build that compensation that we’re trying to get out of. And then if we are looking at single-leg movements, you need to make sure side to side, it feels even-ish. Going back to the split-squad example, you want to make sure that when you finish the repetitions for each side, you are feeling a similar amount of burn and work side to side relative to each side, any single leg movement.

Or let’s say, for example, you hurt your bicep, your left bicep, and you’re doing bicep curls with the dumbbell. You want to make sure that when you are building it back up, that the intensity, the weight, the feel of it, you get that bicep pump. But you’re not just feeling it hardcore on one side, on your right side, that’s uninjured, and then your left side is just working, but not really. You want to feel that similar stimulus based on the weight that you decide, and the rep scheme as well. So that’s going to be really key, is to try to make sure it feels even-ish, side to side, especially with single-leg movements. 

In review, compensations are real. They become even more important with returning to the sport, especially higher level cutting and pivoting and jumping because there’s more reliance on the uninvolved side, which is why we see a lot of contralateral or opposite-side injuries. I’m a pure example of that. I tore my right and then I tore my left, and what happens is, is that if people don’t improve that capacity in the local area. The strength, and then build that backup and then make sure that your motor patterns and all the staff have been trained, then well, the other side might just continue to take on a little bit more. Maybe not, 90%, but maybe it’s 60%- 70%. And then over time, that accumulates and all it takes is that one moment. We need to make sure that both limbs are operating at full cylinder and full capacity so that way you’re not over-relying on one side or the other. 

The kinematics or the shapes and positions will drive the kinetics and the forces, and what’s being recruited to do the movements. Motor control and strategies will play into this and dictate what is recruited. But overall, it should feel fairly consistent, even though you might have to shift a little bit based on each repetition. Your self-audit is the most important here and the takeaway from this episode is going to be based on the intended goal of the movement. What are we trying to work on? What are we trying to improve? How does it look? Use the video to give yourself feedback on this and watch the video back. Is it what you’re matching up to aim to be? Make sure that it looks right. If your shin is vertical and you’re trying to get more quad work with a split squat, allow that shin to move forward with a positive angle. Let that knee move forward and keep your torso a little bit more vertical. 

I promise you, you’ll feel more quads. But if your goal is to do that and you’re not getting it, you won’t know it until you video it. Or maybe someone points it out outside of you doing it. How does it look video to help provide that self-audit? What do you feel? Use intent behind your movement to help drive a more even feel with two-legged movements similar to single-leg movements. Make sure it’s the proper muscle group and this comes back to the intended goal. Is it quads, or hamstrings? A certain pattern where specific muscle recruitment is important; a certain pattern where it’s not. But the pattern itself is more important. These are all going to play a role. We have to make sure we know what the intended goal is, and then also assess and see what am feeling. If I’m doing a backward sled drag my ACL side is feeling a lot less of the burn or work and my other side is, that’s a problem. We got to make sure we adjust the movement, the weight, the tempo, and the intent to make sure that we’re doing it well.

And sure, I might be simplifying this. Sure, there’s the technology that can help improve this a lot more. But my goal for you guys is to remove as many barriers as possible. Bring practical reality to the ACL space and help you to have tools that you’re not just creating more barriers. It’s not just like getting in the way and needing all these apps or needing to go in for this like 3D biomechanics analysis or these machines or force plates or whatnot. Those are all great and those are all the bells and whistles and it’s awesome. But at the end of the day, most ACLers are not being served on the basic level. 

How is it that we can intervene to make sure that you aren’t becoming just another number and that you are able to take matters into your own hands? This is going to help you if you can dial in the look and feel of the movements and audit yourself because compensations happen. So what is it that is so practical for you to implement as soon as you finish this episode to be like, all right, well, I’m trying to do this particular movement. And I know I can compare side to side, as well as look at maybe ideal positions on the internet on YouTube. There are so many resources performed if you will, or technique breakdowns. You can look at that and be like, all right, here’s my form, here’s how it compares against others. 

For our athletes, they get demo videos so they know what those are going to look like. They get cues to make sure they know what that position looks like. And then also maybe the feel of it, anything they need to execute the movement properly. And that’s going to be an absolute game changer along with the feel of what you’re feeling in the movement in order to really change your ACL rehab, and remove some of these compensations. And I believe can truly make a difference potentially to reduce the re-injury down the road. That’s going to be so key. I hope that this was helpful, team. This is something that I’ve been using for years, not only for myself but also after working with so many athletes, and ACLers. Being at UGA, working with different athletes, and seeing the way they move. There are so many different things that you pick up as a coach. And now being in this space for 10-plus years, this is something that I’ve slowly adopted. And just want to remove barriers so you guys can keep moving forward and be in control of the process. So that is going to be it for today, guys. Please put this to use.

If you have any questions, if you’re like, “Hey, I want Ravi’s feedback on this movement,” send it to me on Instagram. I’m totally game for it. Tag me in it. I’m going to help you out. I’m totally open to doing that. Our team, as a general is open to doing that. Please reach out if you need any help. If you have any other tips, happy to hear them. This as a team is very effective for us in terms of this population and just performance in general. That’s the lens we look through. That’s what we want to get you back to. And these are the things that are just low-hanging fruit that anybody can use as long as you got a phone and they’re intentional about the movement. 

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