Episode 134 | “Graduating PT” for ACL Rehab

What is up guys, and welcome back to another episode on the ACL Athlete Podcast. I’ll tell you what, it’s freaking hot here in Atlanta, Georgia. I hope that you guys are staying quite cool. I don’t know what we did before without AC. I’ll be honest, I grew up in southeast Georgia, so you think I would be used to the heat and the humidity. I kind of am, but not really. Anyway, thank God for the AC, seriously.

If you are a new listener today, welcome to the podcast. Thanks for listening. If you are a longtime listener, I appreciate you more than you know. Let’s get into it today, guys, “graduating PT” for ACL rehab. And I have graduating PT in quotations because that’s the finger quotes, if you will, for ACL rehab. And let’s just dive into it and talk about it.

This is something I get from ACLers all the time — I’ve graduated PT. It might be on a phone call, it might be a message that I get where they’re like, “Hey, I’ve graduated PT.” Can I do this? Or, I feel like I’m not all the way there, but I’ve graduated from PT. What’s missing here? I want to elaborate on this specific statement, what this means, and how we can make sure that we understand what’s going on when you’ve ” graduated PT.”

A lot of times these people who graduate PT fall into two camps of thinking. They think they’re done because they’ve actually graduated. They feel like they have been cleared and they’re done. They don’t really need any more rehab because that has been fulfilled because they’ve been told they graduated or they know that they’re not graduated or done. But even though, they have “been told” they’ve graduated, they still can’t do the things they want to do — activities, sports, running, jumping, stuff that’s a little bit more higher demanding maybe. Or, they notice deficits like range of motion, especially strength, that’s probably the number one thing that we see people have problems with later. And then pain, swelling, you name it. 

Now, I know this can be a tough thing to delineate because the term graduated makes you feel like you’re done. Just like graduating from high school, from college, from university, that chapter is complete. I’ve met the right criteria. I’ve tested appropriately. I have met the grades that I need to, and I am graduating on the next. However, this is often a false sense of truly being done when you’re not, especially in regard to ACL rehab. And let me tell you why. 

First, don’t get me wrong, we use it with the athletes that get cleared from us. We’ll say, you’ve graduated, congrats, you’re cleared, or whatever that might be in the moment to be able to share like, “Hey, you have completed X, Y, and Z” to make sure that you can be able to do this. And that’s actually because they have actually graduated and they are “done.” They’ve been properly tested and are cleared based on their goals in the ACL rehab process and our return-to-performance criteria.

Now, what is important to understand is what is meant when someone says they’ve graduated PT. What is that based on? And that’s going to be the biggest question I’m asking here. Because if you’re someone who’s been told you’ve graduated PT, you’re done or off you go. Well, let’s dig into what is that based on. Is it because you’ve run out of insurance visits? Is it because they can no longer help you improve based on where you’re currently at? Maybe you’re stuck, maybe you’ve plateaued, maybe the skill set of the professional can no longer serve you, maybe the professional left, and then they’re just like, “Hey, you’ve graduated. You’re good to go.” 

A lot of times it ends up coming back to more than anything, your insurance visits or your physio visits available. The last thing is, or is it because you’ve actually passed all the proper testing, as I alluded to before, and met the criteria to be fully cleared. Then, it actually means you’ve actually graduated. So that’s the thing that we actually need to make sure we delineate. Well, what is this based on? 

My wish is that the PT or who you’re working with would actually tell you, “Hey, our work together has come to an end” and explicitly say, here’s why. Instead of using necessarily the term graduated. Or if they do, they need to attach that to it. Here’s all the context around why you graduated from this physical therapy process with me. And in many scenarios, especially here in the States, is that insurance visits will impact the range and the link of coverage. Your graduation from PT is mostly based on that versus you truly being ready or cleared. While I don’t love using time, it actually can be a decent proxy for understanding this whole graduating concept. 

Let’s say it’s been three to four months since post-op and your PT graduated you. You’re likely just being released due to the insurance visits that were available, and those have all been used up. I will also say that this is often the timeframe when people do run out of their visits. They do end up having to get discharged. In PT terms, they might say graduate. 

Now, if you’ve been with them for six to nine months, maybe beyond that, then maybe graduation actually carries its weight and is more accurate to the actual term itself. But again, this all comes back more so to what the testing was done, and what criteria were passed. Because time alone will not define whether you “graduate.” But it does serve as a good proxy to know, okay, is it truly… if you’re not at nine months realistically, or even close to that, then you didn’t really graduate. They just couldn’t continue to provide services for some sort of reason. 

And so then this is where there’s a gap. I know that we are talking so much about this term, graduating in physical therapy. You guys are like, come on Ravi, can you stop talking about this? But hear me out. The reason why I am focusing on this is one, because of the number of conversations I’ve had with people where they feel like they have achieved a certain level of completion. And while there may be some merit, you’re only maybe 30% to 50% there of this process.

The reason why I’m harping on this is that I don’t want people to have this false sense of illusion, which is what this feels like of being done, cleared –or putting you into this weird headspace of, “Well, if I graduated, I should be ready to go do whatever I want to do” when there’s a strong chance you’re not yet. I would argue that in 80% of ACL cases, and I think this is still a conservative estimation, people leave or get released by their physical therapy or physio or their rehab provider for ACL rehab much earlier than needed. And a lot of times this comes back to those factors I mentioned before.

A lot of times it’s the coverage more than anything, whether that is out of pocket, the insurance visits available, whatever that might be. So that’s what ends up happening. And so then this is where there needs to be an analysis of where you’re at in your goals. You need to make sure that you’re fully prepared for what you want to do and have been tested from range of motion to specific strength of your quads and hamstrings and other muscle groups to running, jumping, and cutting at the very least, to really truly say, “Hey, you’ve graduated and you’re cleared.”

This is where the gap typically sits for a lot of people, and it still needs to be filled in. Right now, it’s almost left for people to figure out once they do hit that three to four-month mark or their insurance visits run out. I just want to make sure that there is no mismatch in that perception of what you’ve been told versus what you think is going on.

If you fall into this bucket where you feel like you have “graduated PT.” You’ve been told by your provider. I had someone the other day who came in and said that they graduated PT. We tested their strength — 50% quad deficit. They have not graduated from PT,  they just ran out of insurance visits and they were left to their own. And so you were just discharged and terminated from PT. You weren’t really graduated because you didn’t really meet a certain fulfillment of what you needed to even get back to probably normal daily life stuff with the 50% deficit. If you have graduated from PT but still don’t feel like you’re quite yourself, listen to that.

In the majority of cases, people do need a lot more support and guidance post-PT given this process. Most of the ACLers who work with us, whether it’s remotely or in person, fall into that bucket a lot of the time. They’ve graduated their physical therapy or they’ve finished is what they’ll tell me, and then they’re only four months out and still can’t run without swelling or pain.

This is your call to action to make sure you have a clear plan and structure towards your goals, testing to confirm you’re moving forward, and support to make sure it’s custom to you and no details get missed. And this is what is going to be very important in this process, more than anything, understanding the expectations of this system of healthcare and insurance. The way that physio is just generally set up the skill sets of physio, the visits that’ll be available based on especially insurance if you’re in the States. This is just me sharing my experiences of talking to so many ACLers and working with them. Honestly, even just going through my process whenever insurance also didn’t cover me after a certain period of time, when I was really young in doing this.

My main point here is that I want to make sure that you guys are taken care of and there’s not this false sense of feeling like you should be ready or you’ve graduated and you’re still not there yet. And that’s okay. When we think about this process, even the best of the best athletes that we work with, it takes nine months at minimum. Nine months is because it’s basically a proxy of you… think about everything that you lose in this process, especially from range of motion to strength, to power, to the ability to run, jump, and cut. All the things that your knee and body should be able to do. You got to build all that stuff back up from the ground, honestly. It’s not that people just get right back to it immediately, and that’s why this process is what it is.

And so therefore, if we’re sitting at three months, four months, five months, there still needs to be work to be done in order to continue to fill in that gap and for you to be able to move forward. Not only from a performance standpoint, but also from a re-injury risk standpoint, and also the longevity of the health of your knee and your body. Because that’s what’s going to be important here.

If you are someone who falls into this bucket, my next suggestion is to find someone who actually understands this process, reach out to them, and see if you can work with them. And at least, get an evaluation, see where you’re at, and assess that from not only how you feel but also objectively. How can they measure your range of motion and your strength for your quads and hamstrings? What about other muscle groups? What else are they going to test? And then let’s see where you need to be based on the criteria that you need to pass. And especially based on the goals that you want to get back to. That’s what’s most important, is that we want to get you back to the thing, but we want to make sure you do the thing as well, or even better than you did before. Make sure you don’t re-injure again. And then make sure that you also can do this for a very long time because your knee is healthy and it’ll sustain you for you doing the thing.

I hope that this helps, guys. It is just something I wanted to tackle because of this misnomer of graduating PT and just understanding that there’s probably going to be more work to be done in most of these situations when you might be discharged or finished up your physical therapy.

If you have any questions, hit us up with a message, email, or anything that you need. We’re here for you, the ACL Athlete. Until next time, team, this is your host, Ravi Patel, signing off.