Episode 156 | The 4 Guiding Principles For Returning to Sport After ACL Injury – Part 1

What is a team? Welcome back to another episode on the ACL Athlete Podcast. It’s a rainy day here in Atlanta. Prior to this, it was super cold, like north people cold, which we’re not used to here in the south. I’m glad that is over with. I have my coffee next to me and we’re talking the 4 guiding principles for returning to sport after ACL injury (part one). We’re going to dig into this, here in a minute. 

But before we do that, I did want to bring up our ACL Athlete Mentorship which is now open for enrollment for cohort two. We start on February 5th and we are closing enrollment next Wednesday, which is January 31st. This is something that has been a long time coming in terms of being able to help provide a solution in the space of ACL rehab and performance. Our goal is to bridge that gap. 

We want to make sure that this is based on principles, that you walk away from this understanding of how to take an ACLer from post-injury, whether they go down the surgical route, the non-surgical route. And being able to walk them through this process, not based on a protocol, not based on time, but base on criteria and framework that you can use along in your own process. Make it your own model and being able to develop all of the different pieces of an athlete’s program, from program design, exercise, prescription, making sure you can scale, progress and regress different movements, return to running framework from plyometrics to acceleration, deceleration, agility, speed development, all of these different pieces. We look at the movement compensations. What are the things you’re supposed to look for that look good? What about the things that don’t look good? And then troubleshooting those types of areas and giving you the tools that can help to identify those and also be able to help course correct for your athlete. 

And most importantly, making sure you understand how to test, being able to get your athletes back to their sport and feeling fully confident in that game plan. And that’s what we’re providing for you in this mentorship. If you are interested, you can get on the waitlist, which is in the show notes. That link is there. If you are wanting to get in on this cohort, we’ve got some spots left. So send me an email ravi@theaclathlete.com. That info is also in the show notes, but this is something that we are so freaking proud of and so excited to be able to release this to clinicians and coaches. And just make you feel more confident in your process and being able to get excited when an ACLer shows up and knowing I’ve got this, I could do the thing and we can get them back to what they want to do. So that’s our goal. If you have any questions, reach out. Otherwise, let’s dig into it. 

The 4 guiding principles for returning to sport after ACL injury – part one. This is something that is just taking a lot of the different pieces that we do in this process and trying to distill it down to four different areas. And as we approach, especially this return to sport, return performance process, we are looking at certain buckets or principles to make sure that we have done our due diligence to make sure this athlete is prepared and making sure our ACLer can step on the field core, get on their skis, get on the mat, whatever it is that they’re trying to get back to do, that they are fully prepared to be able to do that. 

When we break this down into the four guiding principles, we are looking at number one: physical preparation; number two: psychological readiness; number three: graded exposure; number four: load management. We’re about to break these different pieces down in part one here, as we are talkingwe are going to go into the details of this a little bit. And then in part two, we’re actually going to talk about, alright, cool, we know what these areas are, but how do we objectively measure it? How can we assign some sort of number? How can we make sure that we are falling in line with where we need to be as we’re moving our athletes along in this process, especially in those mid to late stages where there’s a lot more moving pieces? It can get a little confusing. How do we do that? We’re going to try and break this down very simply in this two-part series. 

For number one of these guiding principles: physical preparation. When we think about our main domain as rehab professionals, as strength and conditioning coaches, this is our area. This is the thing that we are trying to help prepare our athletes for because it’s the most we can impact. And it’s also what we just kind of train and do for. This is why we went and did our undergrad and our doctorate degrees and our certifications and the internships, all the things. These are the things that are the primary focus is physical preparation. 

The goal here is for us to make sure that we have the buckets. When I say buckets, these are just kind of different qualities or different domains that we are trying to fill up in order to make sure this athlete is as prepared as possible as they move closer and closer towards getting back to the “thing.” When I say getting back to the thing is their goal. It’s potentially getting back on the soccer field, it’s getting back on the mat for wrestling, it is being able able to get back on your skis. It’s your ACLers’ goal, it’s their dream, it’s the thing. So that’s what I’m referring to when I say the “thing.” Going back to the buckets here. When we look at different buckets, now, this isn’t comprehensive by any means, but this is based on you and what you assign as physical preparation. But we do know there are certain domains.

For example, this could be related to their symptom management. How is their, overall symptom profile looking? How is their swelling, how is their pain, how is like things like stiffness feeling? The perception of symptoms, what is that feeling like? And can we manage those? We need to make sure that we are able to knock that out because that could be something that is a big bottleneck in the process. We got to make sure that we are attacking those, especially on the front end and any time it comes up in the mid to late stages. 

And then as we move along, I’m looking at some other buckets: range of motion, functional movements, strength (specifically quads and hamstrings). Those are always the two top priorities along with other areas, glutes, looking at the calves, the core, the lateral hip. There’s so many different areas that we are aiming for, especially for the lower body and the trunk. But when we look at this, we have to make sure, especially quads are number one, hamstrings being number two. 

We know that those are the major key players that get weak, especially if we’re talking about donor sites that are taken as well. But our quads try and get those things back up to speed. So strength is a big bucket to fill. When we’re looking at power, this is something that we want to also make sure that we’re improving. It’s cool if you have a lot of strength. But if you can’t recruit that very quickly or be explosive, then that’s going to make it very difficult, too. That’s where rate of force development and power comes in. Making sure that we are developing the ability to get to that ceiling as quickly as we can. 

And then there are other domains more dynamic if you will. Talking about running, jumping, cutting, sprinting, the conditioning aspects to make sure that the athlete has the energy systems built up to be prepared for the thing to. These are the physical domains or the physical preparation that we’re looking at and qualities we are trying to develop in order to make sure this athlete is getting as prepared as possible to get back to their goal. 

Our goal mainly here is to help ACLers become physically ready to take on the demands of their sport, of their activities, of their goals and life. We want to make sure that they are prepared for worst-case scenarios and making sure that they are equipped for the things that they want to do in life and don’t feel fearful or worried something’s going to happen. 

And that leads me to my next point, the guiding principle number two which is psychological readiness, huge, huge, huge factor in this process. One that gets overlooked all the time because there is such a physical component. Of course, there’s an injury that happens. Of course, the recovery, the rehab, your physical therapist isn’t working as much on the mindset pieces or the psychological aspects of this.It goes along for the ride. And this is something that we’re not trying to just go crazy over and spend all your time over because some athletes don’t need this. But there are plenty of people who need this. 

What I mean by psychological readiness is making sure as we continue in this process, that that is aligning with the physical preparation and that is aligning also with getting confident to get back to their sport and getting back to the things that they want to do. Huge risk factor for re-injury; huge risk factor for not returning the injury.

Toole et al in 2021 had shown 28% of people did not return to their sport due to fear of re-injury. Now there’s a lot of layers to this and I guarantee you, this number was probably a higher, but fear plays a huge role in this. We have to make sure that this is not something that athletes are dealing with as they are going back to doing their thing. Just know that it’s normal. It is normal for this to rear its head. It’s just a matter of making sure that that slowly comes down over time and then their confidence, and that aligns with their physical abilities goes up. This is one of those things where we need to make sure we are communicating with our athletes, making sure the dialogue is open and regularly checking in with your athlete.

With all my athletes with our team, we check in with our athletes every single week, all the time. And we’re trying to make sure that they are coming along. We’re not only checking in on like, how is their lifting going hard, the numbers looking, we’re also checking in and seeing, all right, where are they at mentally? Are they doing okay? Are they struggling with something?And these are the things where if you have a good relationship with your athlete, they will be open to telling you this. It’s crazy how much this brings the clinician and the coach to their athletes into such a good synergy because they feel open to communicating about those things. 

This is where we want to make sure that we dial in the psychological readiness, especially as this is getting closer and closer towards the goals of the athletes and making sure that that is in alignment with their physical preparation. And we’ll talk about some numbers as we get into part two. But this is something that is often overlooked, which is why I want to make sure I bring this up and it goes hand in hand with the physical preparation. And the thing that I do want to mention here for myself as I walk through this ACL rehab process twice now. This was the thing that took longer than the physical side.

I was cleared at 9 months, but I didn’t feel fully confident until 12 months, especially after that first ACL injury. This is something that you might hear some PTs, especially in the ACL world say. But this is truly not only just from what they might say from hearing your athletes or talking to their athletes. Anecdotally for myself, this is also something that feels pretty consistent. Getting towards that 12-month mark, especially if things are going along and you get to that 9, 10-month mark and you are feeling pretty good. You do get cleared. Now, again, this is based on what you get cleared by and what are those criteria. But with that said it takes time. And that psychological piece is lagging behind the physical piece and that’s okay. And this can range from early in the process, all the way to late in the process. 

You might be listening to this and you’re an ACLer, and you’re like 15 months out. You’re two years out and you’re still dealing with this. That’s totally fine. And it’s something that doesn’t get talked about super often. But look, guys, I’ve talked to hundreds of ACLers at this point, on the phone, consulted with them. We’ve worked with hundreds of ACLers. This is the thing where when we get on the phone, the mental side of this is such a huge thing. It’s something that gets overlooked. When people are going through this rehab process is check-in, check out, do the rehab, do the exercises, move along based on time. Even when you think about orthopedics, like not that your orthopedist is supposed to be this psychologist. It’s silly for us to examine a knee and just be like, all right, cool, you’re on what you’re on your way.

I think that there are things that get missed or fall through the cracks. I think we can’t leave this up to chance. And that’s why I’m talking about these principles, because if we can iron these out, man, we can set our athletes up for success. These are two that are super important, the physical preparation, psychological readiness. And when we look into the next two, we’ve got graded exposure and load management. 

Graded exposure in a nutshell, this is essentially gradually exposing you to the physical stressors in rehab and the training process. But this is also exposing you to your sport and your activity and to life, the athlete is trying to get back to. We are trying to make sure that the athlete is exposed to those things, sharing the gym and in our training. But then there’s more, if we can think about it as like a funnel, you start from a general standpoint and move more specific towards the thing. And so then therefore some of the interventions and some of the things that you’re doing mostly from the sport side, we’ll start to get a little bit more specific to the athlete. 

And a lot of that they’re getting through their sport, through their practices, through just going through some of the emotions of it and then slowly building it back up. This also means preparing for the tactical side of things, the technical side of things as well. This comes back to working with other stakeholders. This might be the coach for the team, or it might just be you and the athlete. Because they are either playing a less organized sport. Let’s say they’re in rec sports. They don’t necessarily have this team that they can go back to. They’re just playing pick-up soccer or maybe it’s activities that are a little bit more independent, like skiing, always a good example here. You’re not depending on other people or needing other bodies around you. It’s more so of just getting back on your skis and slowly progressing back. But there’s more to it than that. But graded exposure allows you to build up. Your body and your tissues to get prepared for those demands of the thing you’re trying to get back to, but also mentally keep things in check and allow you to build that up. 

So those are the ways that we can start to look at this, how can we use that dimmer switch analogy if you will, and be able to gradually expose ourselves back to the thing. Versus doing this on and off switch and just being like, all right, well, you’re cleared, you return to sport testing. Well, now you can just go play soccer. It does not work that way. I don’t care who says it does. It does not work that way. This is something that I guarantee you if you had an athlete who passed all the return to sport testing, and you threw them into a full-blown soccer match at full speed. They would start to freak out a little bit because they haven’t been exposed to it yet. There needs to be this graded return process from participation to sport to performance, which is our continuum we use and it’s something that has to be gradually exposed.

And then that leads me to the fourth principle, which is load management. For load management, this all comes back to balancing stress. When we think about the load that is the stress coming into your system. We want to make sure that we are balancing that appropriately, especially as you get into the later stages of this process. There’s a lot more to balance from the rehab side of things, the training side of things and of course the sport and activity-specific work. There’s a lot more of those moving pieces. Therefore, we have to have more of a grip on what that looks like from a stressor standpoint. 

The athletes also tend to be excited here. They’re not feeling kind of the lag behind of the early process. They’re feeling more like themselves. They’re feeling more physically competent, more mentally competent. Therefore, this can also lead to the athlete overdoing it if you’re not giving the appropriate constraints and boundaries around this. We want to make sure that we can provide this for our athletes because otherwise they will come out hot out of the gate. And then that will flare the knee up because it’s not used to it. You have to make sure that this is approached very strategically. 

The big thing here with load management… Tim Gabbit, huge researcher in the space of load. This is cool, the work that he’s done in terms of looking at specific numbers, but the goal here isn’t to focus on that, and sure there could be some  pushback on the range of the specific numbers. The idea here is more so the principle or the concept of load management. It’s making sure that we remove any big spikes in training and making sure that the athlete is adapting well to the stressors and recovering well. We want to make sure that the athlete is not underprepared. 

We don’t want to make sure it’s an overuse injury. We don’t want to make sure that we are preparing the athlete in that sweet spot. And a lot of this comes back to load management, especially as we handle the mid and especially the late stages. That is going to be such a key factor for our athletes in terms of making sure that as they are getting back on the field, on the court, on their skis, all the different things, even hiking, all the things that we would consider kind of less ACL stressor activities. All those things we still want to  make sure that we are managing that load and continuing to move the needle in the right direction. 

These are things when we are looking at athletes when we’re getting into the return to sport process, especially we need to take a step back and evaluate these 4 guiding principles. If we can confidently say we’ve “checked the box on these,” you’ve got a well-prepared athlete. They are physically prepared, they’re psychologically ready, they’ve had graded exposure to the thing and their load has been managed and their chronic load – the load that has been built up over, let’s say four weeks has been built up to the thing that they’re trying to get back to. Therefore, you can look at this and be like, man, this athlete is ready. They’re ready to rock. But the only key and knowing this though, truly is to have objective numbers and KPIs what we call (key performance indicators) to back this up. 

If you say you’re feeling strong, we have to make sure you have a number associated that is valid and reliable based on the research and science to show that this is something that backs it up right. This will lead to improved performance. And most importantly, reducing the risk of reinjury. If we can base that on the science, research, the data that we know, then therefore we can set our athletes up for success. We’re going to have objective measures to align with our subjective pieces. The conversations we’re having, what we’re seeing that doesn’t necessarily give us numbers, and making sure that those aligned together and meet the criteria we need for our athletes. That’s the goal here. 

And so that’s the thing that we are going to tackle in part two because we can’t leave this up to chance. That’s the key thing here. The reinjury rates are too high for ACLers so we have to make sure we do our due diligence and making sure that we align our subjective and objective measures, having key KPIs. To be able to tackle this and to make sure that the athlete is as prepared as possible in all the ways. 

In part two, we will talk about the objective measures and KPIs that play into managing these 4 guiding principles. You can make sure it aligns. Subjectively with what you’re hearing and making sure that that also aligns with what you’re seeing. And you can feel as confident as possible. Being able to get your athlete back to the thing. 

Tune in next week for part two where we dive into some of those objective measures. Before we sign off here, I do want to remind you of the ACL Athlete Mentorship enrollments are open for cohort two. If you want to be a part of this for some of the spots we have remaining, then reach out to me via email ravi@theaclathlete.com and I’ll send you more information. If you want to get on the waitlist, that is also a good way to get access to the information. But we are here to open the doors and continue to level up the ACL rehab game. If this is you, reach out to us. Otherwise, I will catch you guys in part two of this series. Hope you guys have a good rest of your day/week wherever you are listening to this. I appreciate y’all.