In this two-part series, we discuss the second half of the 20 red flags to consider in your ACL rehab. We cover ways to filter through the right environment, testing, programming, specific movements, knee extensions, and so much more. If you’re feeling like your rehab isn’t heading in the right direction, maybe it’s the guidance as opposed to the plan. Find out for yourself.
What is up team? Welcome back to part two. Now, we’re going to dive into the back 10 of the red flags to consider in your ACL rehab.
Here’s number 11: Your clinic only has weights up to 30 pounds. This is three stars for me. In my opinion, no matter how great the clinician is, if you don’t have the equipment available to overload your body, you’re not going to get stronger. No one gets stronger by just bodyweight movements continuously over time or even 20 or 30-pound movements. Sure, you’ll build up to that and this is relative to each person. But at the end of the day, you need heavier and heavier and heavier weights to get stronger. It’s the stimulus we need and the basic physiology and muscle hypertrophy when you think about strength gains. This is all the stuff that you have to load heavier in order to get stronger. Strength is the foundation of ACL rehab. If you don’t have it, it’s going to be a big problem and it’s a big relationship between re-injury and what the strength numbers are, especially for your quads. If your clinic only has weights up to 30 pounds, in my opinion, it might be something that is a short-term place to be. Otherwise, you have to get into a gym and you have to get to a place where it can load you better. You can’t rely just on that.
Number 12: You’re doing a lot of balance exercises. Balance exercises have their place, proprioception has their place, and we want to work on these things. But as we have learned over time, balance does not build strength necessarily. We’re looking to improve proprioception where our body is in space via balance exercises.
This leads to number 13, which is they’re using a BOSU ball a lot. A BOSU ball is basically that ball is like a half ball with a flat top. And then it’s blue and it is something where you stand. And it is very giving like a ball. You’re trying to focus on “balance.” And while sure, you can argue that you’re training balance and some stability there. When you actually look at the way that we use balance, we actually want our stability on the ground. And then we want to actually challenge our vestibular system and our vision in order to make sure that we’re upweighing some of our proprioception here. So that’s what’s going to be important is we’re trying to figure out, alright, well, how are we improving proprioception? Well, if we lose feel from the ground, that actually takes away, so then we’re relying on our other strategies of our vestibular system and our vision in order to balance. And that’s not what we’re trying to do. If we’re trying to build proprioception at the lower limb, we want to make sure we can feel the ground and then challenge our proprioception in different ways. Basically, the BOSU ball, if you want to use it here or there, that’s fine, but it should be 5 percent of your rehab. If you’re spending a lot of time on balance stuff, big red flags here.
Exercises are the same since day one and have not progressed. This is crazy how much I will hear this. Someone starts with a rehab provider and they’re three months in and they’re still doing air squats and straight leg raises. One of the guys that I’ve been working with, he finally got cleared. He’s playing soccer, skating, all the stuff. It’s amazing. He reached out a couple of years ago, actually, and then we finally connected and he was five months post op and he was still doing straight leg raises. No weight, straight leg raises at home. This guy was so strong and was not even being dosed appropriately. Basically, what I’m saying here is that if you are still doing the same exercises and have not progressed, that’s a red flag.
You don’t have any exercises outside of your rehab sessions. This is a three star for me. In my opinion, there’s a lot of time outside of rehab. Let’s say you even go to rehab three times a week, that’s three hours. Maybe a little more in your week unless you’re just absolutely getting crushed and working really hard like a training session, every single rehab session. There’s still stuff that you should be doing at home.
ACL rehab is something where you just can’t coast, especially depending on certain phases that you’re in. I would suggest that if there is not anything given outside of just what you’re doing in clinic, to me this is a red flag because you need to be doing stuff outside in order to continue to move the needle. This should be something that is structured.
This leads me to number 16, which is a laundry list of exercises with no structure. A lot of times people will reach out and say: Hey, like I’ve got 20 exercises and it takes me two to three hours to get through, or maybe they just don’t do it, or they skip around. We’ve seen all of it. There’s no rhyme and reason to the structure of it. They’ve just been told to do this. It’s not even really dosed appropriately, usually, it’s just a bunch of reps, and then there’s not an intensity that’s indicated. Therefore, we’re not really getting the stimulus we want. Also, depending on where we are in the ACL rehab process, it should look like a structured program. It should look like almost a gym training type program, where you’re like, alright, here’s day 1, here’s day 3, here’s day 5, here’s the things that I’m going to do in between, here’s the emphasis, here’s the rep set, here’s the way that I’m going to warm up, here’s my main lifts, here’s my accessory stuff. And then there’s going to be intensities associated that is hopefully building on the goals you’re trying to work towards.
While I understand you’re not going to get this perfectly dialed-in program potentially with your rehab, this is something that’s important. You have to be able to make sure that it’s more targeted. We’re not trying to shoot a shotgun if you will. We’re not just trying to cover as much ground as we can. We want to be a little bit more targeted. This is where having something like a sniper, if you will, being more focused, being more dialed in with your programming, and having a rhyme and reason is going to be really key versus trying to attack everything at once. It’s not going to be helpful. You want to make sure that there’s structure with it.
Number 17: After your initial post-op stage, you’re not loading into heavier weights. Let’s say you’ve gotten past all the quiet knee stuff, you can walk, you have a normal range of motion, your quads are firing now, but all you’re doing is just bodyweight stuff. And you don’t start getting into heavier weights and this can come back to that point of the clinic not having heavier weights so that’s a limiter in and of itself, or it could be just the skill set of the PT, or maybe it’s just something that they don’t believe in. But in order to get stronger you have to lift heavier, that’s just a basic rule of thumb. You can ask any weightlifter. You go and watch people who are really strong. They are usually not doing bodyweight stuff. They are doing stuff that is loading them very heavily. This is something that is a red flag to me in your ACL rehab because a lot of times what we are guilty of in the rehab space is that you are being underloaded. Therefore, it’s deconditioning you in a sense and then you’re wondering, well, why am I not making progress? You feel like you’re doing stuff because the rehab provider has given you the stuff, but it’s not enough stimulus to move the needle forward.
Number 18: They say knee extensions are bad or stretch the graft. Three stars next to this, five stars next to this. Tell me you’re not up to date with ACL rehab without telling me you’re not up to date. This is one of those. At this point, an open kinetic chain is another way of saying basically what knee extensions are. If your provider is saying, hey, these are not good or they stretch the graft, walking has actually been shown to stretch the graft more than doing a lighter load of open chain knee extensions. It’s the only movement that is going to target your quads in isolation. It’s very important for us to be able to work that in because our quads are the thing that suffers the most in our ACL rehab, so we gotta make sure that we have that dialed in. If you’re a rehab professional saying this, well, there’s tons of research now that has come out to essentially disprove this myth.
The other thing too is that, okay, sure, there’s merit. You don’t want to do a hard repetition maximum right after you just got a new ACL. It’s a progressive process just like anything else. You’re going to build up, you’re going to get acclimated to it and see how the knee’s doing as time goes on. But it is something that shows is massively beneficial for outcomes short and long-term for the ACL rehab process. It doesn’t stress your graft unless you are completely reckless with it.
Number 19: Clearance is based on time and not a battery of testing. I talked earlier about hop testing just being the person’s return to sports testing. Well, here, we are coming back to time. And mostly focused on clearance and return to sport. One, time is important, but less than nine months, in my opinion, has no weight in it. Just because of the research that it shows us unless the person has accepted the risk and reward of that. But in most situations, nine months is the minimum, working towards a year, unless research proves me otherwise at this time point. And then just not having a battery of tests. Maybe they do do the hop test and as I had mentioned the horizontal hop test only has very little merit.
The other thing is that we want to make sure we’re assessing for the different areas. Imagine again, like someone is graduating high school and the only thing that they may have gotten tested for is math, right? They don’t know how they do in English. They don’t know how they do in maybe history. All these other areas that are important, but they’ve only been tested in math. Well, let’s say, for example, this person just did the hop testing. That’s all they did was test math. But we need to make sure that we test all the other areas and all the other criteria. We need to make sure the range of motion is tested, strength is heavily tested, and the right test is valid and reliable. We need to make sure that we are assessing their capacity. We need to make sure we’re understanding and seeing where their power output is via test if that’s accessible for you. At least being able to look at their reactive strength index with some different drop jump and vertical testing. And then I think it’s important to also include change of direction testing. A 505 test, T-drill, 5-10-5 test.
There’s all these different tests that exist out there for us to see, all right, what does it look like strategy-wise, and how comfortable do they look when they do some of these movements? Because that is going to give us insight into how the knee is doing, and their confidence. And if we truly have a battery of tests that is objective, that way we have numbers associated with this. This is why the reactive strength index is so great to be able to get for our plyometrics and our jumping abilities to know, all right, well, maybe we have the strength, but do we actually have the ability to produce that and be able to load into our tendons and release that energy appropriately.
The last one that I’m going to mention here is number 20: You feel lost and have no clear direction. This is something that is actually very common that we hear. You just go along, you’re assuming that things are just going to plan and then you start to realize, man, I don’t really know where I’m going, or especially if you run into a road bump where you’re like, well, I’m supposed to “be running”, but I’m barely walking without a limp now. Or you’re dealing with just like certain problems in this process or you just feel like, well, what is my next target? And your provider or your ortho or whoever is helping to guide your care doesn’t really give you clear direction on that. This is something that I think is a red flag and one that you could put three stars next to because if you don’t know where you’re going, man, that is so frustrating. That makes you just feel really lost and it’s just something that you want to make sure you get in control of.
These are the 20 different red flags that you can look at. Are these all set in stone like I said? No, there are certain ones that really stick out more than the others, but these are good ideas for you to look into where you probably are and see if that will really get you to where you want to be. If these providers are showcasing some of these examples, this is something to just take that pause and just say, all right, is this something that I just do for now or is it something that I just need to get out?
And the other thing that I’ll mention is choosing what’s convenient and available versus what’s needed, as I talked about in the previous podcast. Make sure that you’re doing what you can for your care. I know some people are forced to be in a certain place with this, and I understand that. But if you have the ability to change, if you have the ability to make a shift, and you know that, and you feel that in your gut, do it. You’ll be better for it. These are the 20 red flags. If you guys have any questions, you know where to find me. I’m so sorry that this is not shorter than I expected because I just want to elaborate more versus just go down a list. Hopefully, this is helpful, especially if you’re starting to notice more and more of these things coming to life in your own care — make a change. Until next time team, this is your host Ravi Patel, signing off.
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