Episode 144 | 20 Red Flags To Consider in Your ACL Rehab – Part 1

What is up team? Episode 144: 20 Red Flags to Consider in Your ACL Rehab. This one’s going to be short to the point. It’s focused on the red flags that you’ll often observe working with a surgeon or rehab provider, anyone who is at the helm of your care, and just things to look out for. These are not things that are just concrete, solid like you hear one of these things and you run. Although, I will point out that there are certain ones that I’m going to put stars designated to them to the level of red flag importance, if you will. 

Basically, tell me you aren’t up to date with ACL rehab without telling me you’re not up to date with ACL rehab. These are just things that you can almost infer to some degree. Now, you might have to dig in a little deeper. Before I go any further, give the person a chance, ask them why, and ask good questions. And then if you start to see a trend or certain things that are continuing to pop up, then it’s a matter of like, all right, I need to make a decision for my ACL rehab and for my care for the long-term. 

But these are the things that I consistently hear I see the things that we preach against because it just stands for all the things that are not going to help you. And so these are things that I just want to make sure we touch on, things that you can look at and make your estimation and guess and follow your gut of like, alright, am I with the right person? And maybe it’s just something for right now. But this is something to assess early on, and as you’re vetting the professionals you’re working with. And just knowing, am I able to trust this person that I’m with? Why does this matter so much? Because this person is your GPS, they’re your guide, they’re the people who are going to be in control of a lot of the things that you’re probably going to be dealing with mentally as well. Because you’re going to have a lot of comfort knowing that you’re with the right person. Imagine getting into your car and you type in the destination you need to go to and you trust that GPS with all certainty, right? We type it into Google, we know that it is going to get us there. It’s going to do different calculations to take into account all the things that we need to. 

Now, imagine you’re with your ACL rehab provider and you’re like, all right, I’m trying to get from point A to point B, but it’s not very clear. There are certain things where you’re just like, well, we may take this route, we may go this route, but there’s no rhyme or reason and it’s not dialed in. It’s just very vague and it’s what’s done for everyone. Let’s just get straight into this because I hope that this can help highlight some things that some of you might be struggling with, with your provider that’s within your care.

Number one: You’re not asked about your goals. The person doesn’t know what you want to get back to, or the end goal. To me, that is a red flag. It’s like, well, what are we aiming towards? What’s our next point, and especially the end goal, if we just don’t know what we’re aiming at? I think that this is something important to be able to dial in. And if they just breeze over this, in my opinion, that’s a red flag. It’s important for us to know what our athletes want to get back to. What’s the thing that drives them? We’re going to aim a lot of the things that we do and the things that we discuss around the thing that they want to get back to. And it’s going to get more and more specific as we go, so we need to know what those goals are.

Number two: Prehab is not important. Research shows us prehab is important, so this is something that tells me you’re not really in the know of the literature. 

Number three: You’re pawned off to a student or a tech for most of your rehab. Look, I get it, our healthcare system is designed a certain way. You might have to work with someone else while you’re a physical therapist, and your rehab provider might also have to navigate and work with other people. There are certain models that support this well, and there are certain models that almost abuse the system of using students or technicians, people. And I’m not saying that these people are not equipped to be able to do it, but the thing is, is like you want to make sure you have the trained professional to help you in this because this isn’t just some hamstring strain or shoulder pain. This is something that has a high risk of re-injury. You want to make sure that you also have your physical therapist and the person who’s guiding you in the know and involved in your care versus just pawned off to somebody else. 

It’s hard to communicate with your provider. This is a star for me. If you can’t communicate with your provider, that is a big red flag. This is something that has to be clear communication. There’s not a single athlete we work with where there’s not a clear open line of communication. Full transparency, being able to dive into all the details, being able to share kind of the things that our athletes are feeling is very important to us because we’re going to dial in our plan and our programming to make sure it is meeting them where they’re at.

If they are burned out or if they are maybe feeling depressed, this is something that we need to know or at least be able to have a conversation around in order to adjust things. Or maybe they’re frustrated or maybe they’re having a blast and we need to ramp things up even more. These are all things that your provider needs to be in the know for so communication is really key.

Number five: They use a time-based protocol as their only guide. This is a star-based item. While protocols are a part of the process, a lot of times surgeons will give their physical therapists or rehab providers a protocol that they have designed. And some of these protocols are super outdated. A lot of them are usually based on time, in four weeks you do this, in eight weeks you do this., at six months you do this. While time can be helpful, don’t get me wrong, it’s important that protocols are not really based on time, they’re based on time plus criteria. There needs to be other things that go alongside this in order to move forward what we call a criterion-based protocol versus a time-based protocol. And that’s the really important thing is that there are criteria to meet to move forward. Not just because time passes, but because time can pass. But let’s say, for example, someone’s, you know, taking a year in school. Well, time can pass for a year, and then do they just move on, or is it because they’ve met the criteria to move forward into the next grade or into their major or into the next set of things that they need to meet, right? This is something that’s important is that we’re not just using a protocol as the only guide, especially if it’s based on time and fitting people into these perfect boxes. This leads me to the next point. 

Number six: They use time itself to make decisions. So this goes in line with a protocol, but let’s use protocol aside. Maybe they’re just saying like, all right, the most classic one you will hear is at 12 weeks you’ll start running, usually based on the protocol. But this is also something that people will just assume. Maybe research has said, all right, at most points, people at 12 weeks will start running. Well, some studies show that they can start that, but that’s not the only thing. It’s like, well, what if they were on crutches for the first four weeks? Do they get the same timeline as the person who was not on crutches? What about their quad strength? What about the range of motion? What about their ability to do light hops and tolerate those things? What about their hamstring strength?

All these things that we need to consider. If we just assume that at 12 weeks, it’s a set point of like, all right, you should start running. Well, it’s actually a range and that would be my suggestion here is that we even give our athletes ranges, but this is always based and anchored on certain boundaries. We have where they’re testing currently, what our next milestones and goals are, and then the criteria for that. And then we have an idea of usually the time it takes to do that. And we never set a hard set on this, it’s a range. And it will always be adapted from week to week. It’s not something that is just set, all right at 12 weeks you’re gonna start running. If you’re using time as decisions alone, that’s going to be a problem. They say that all ACL rehab is the same. It’s not. Everyone’s different. We can’t treat all ACL rehab the same. There’s not a single ACL I’ve had that is the same. as another person, not a single one. 

They use MMT as a strength test. Three stars next to this one. This is a red flag in a heartbeat. If someone tells you that they tested your strength by putting their hand on your thigh and then putting their other hand on your shin at your ankle and you kick into it and they say that is a strength test and your strength looks good — big red flag. It means that they don’t know what they’re talking about because MMTs are not a strength test. It’s used to see if the muscle is active and it was created during the polio epidemic. And we have taken that a little too far in the rehab space. But this is probably one of the biggest things that you will see that people will do to justify strength. But really it’s just a matter of the person kicking into that professional’s hand and the resistance that’s being applied, as well as how strong that professional is. How do we grade that? That’s like kind of picking you up and trying to guess your weight. We wouldn’t really know. It’s just an estimation, but it’s not really objective. You have to step on a scale to really know what your weight is. 

They say that zero-degree extension is fine. In most situations, people get into hyperextension, now this will vary from person to person, but this is where your unoperated side will be your baseline. Let’s say you get into an excessive amount of extension. Let’s say you get into minus fifteen degrees. Maybe we don’t need to get all the way there, but maybe we get to minus five to minus ten. In the majority of cases, when you look at normative data and people’s movement, if you look at the way people stand, if you assess their knees, they’re going to have some hyperextension. It’s normal. Same thing with our elbows. Try to lock your elbow out. It hyperextends a little bit. Our knee acts in a similar-ish way. We want to make sure that we can get past that. People who don’t get that to that same extension end up struggling with some quad-related issues. The kinematics of the joint changes at the knee are a little different and stress is going into different areas, articular cartilage.

If someone says zero degrees extension is fine, I would disagree. And I would also be like, well, my other knee also goes into minus 10 degrees extension. Maybe we aim for that. 

Number 10: The return-to-sport testing is just hop testing (red flag). Not really great, especially if it’s horizontal hop testing, if it’s a single-leg hop test, if it’s a crossover hop test if it is a hop test for time. All these things, yes, we can watch the strategy of the hop test and see if there is a gross difference. But outside of that, research has already told us that the knee doesn’t really contribute to those, and athletes can just strategize around it and compensate. We can essentially get to the same distance within 90 percent of symmetry, but they are not able to do it the same way. Horizontal hop testing actually is more related to hip and ankle versus a vertical test is actually more indicative of knee function and quad function. This is something that basically if your provider is in the know, they may use a hop test and sometimes I’ll just see how people perform a triple hop and see if there’s a gross difference, as well as if are they doing a hip versus knee strategy. But I’m not putting a ton of weight on that. I’m looking more into drop jumps and vertical jumps. That’s going to help us to see how much contribution is in the knee, as well as their reactive strength index, which is something that helps us to know their plyometric ability and their ability to reverse eccentric strength into concentric strength. This is something that is just a little bit of a highlight. For hop testing if that is their only way to “return” to sport testing.

All right team that’s going to be it for part one today. Next week tune in to part two to cover the other 10 red flags to consider in your ACL rehab. Until next time, this is your host. Ravi Patel, signing off.