Episode 157 | The 4 Guiding Principles For Returning to Sport After ACL Injury – Part 2

What is up team? And welcome back to another episode on the ACL Athlete Podcast. We are diving into part 2 of the 4 guiding principles for returning to sport after ACL injury. Last week, we talked about part 1, where we dove into specifically – just kind of the background and setting the stage for this part 2. But especially diving into the pieces around these 4 different guiding principles: number one being physical preparation; number two being psychological; readiness; number three being graded exposure and number four being load management. 

Today in part 2, I want to talk a little bit more about objective measures related to this and how these can play a role, basically, how can we assess these 4 different guiding principles and breaking these down a little bit further. And giving you guys just some examples of how this can be and knowing that this can vary professional/uprofessional. You might go to one physical therapist and they may not have very much related to these different buckets. And then there are some that have heavyweight towards these different buckets and areas. And maybe include certain tests and don’t think some tests are important.

And there is a certain threshold, if you will, where there’s a bare minimum, that these things should be included and discussed, especially depending on the professional you’re working with and what is kind of the length of care that you’re with them. And what does that kind of define, done point with them? But let’s say we are rolling with the rehab provider and the professional who is going to help make a decision on you getting back to your sport and return to performance. 

Well, these are 4 of the guiding principles we use as a team, and that helps to anchor us as we are looking forward in this process. Of course, physical preparation being one of the big ones here, but we’re going to dive into these 4 different areas and knowing that these are the things that we look at. Some examples of some of these things we look at, and then that way you have an understanding of really what is behind the scenes. 

When we’re working with our athletes, it’s not just like, all right, here’s a program. We hope that this kind of moves the needle for them. We have so much, that is the background of this based on science, research, data, anecdote, all the things that come together to help provide essentially professional opinions and building out these programs for our athletes. I think it’s important for us to be able to dissect these things and understand, okay, well, what are our driving principles here and what is going to be the biggest thing that we want to make sure we wait really heavily? And maybe there’s some things that aren’t as important based on your return to sport process and things you’re trying to get back to. Compared to someone who might be getting back to a very high-level cutting and pivoting spore or something, that’s going to require a lot more demand from a physical preparedness standpoint. 

Well, these have to be even more and more dialed in. But we got to make sure we set our athletes up for success. No matter if they are trying to get back to playing with their kids, going to ski, doing jujitsu, being able to get back on the soccer field or play handball or play pickleball. We got to make sure our athletes are ready. And then that way, when they decide to do something, they are prepared for it. We have kind of this lens that we can look through to make sure that they are ready. 

Let’s dive into some of the different ways that we can objectively look at this, some subjective pieces here, but just want to make sure we break down these different areas so you guys have a very good understanding of, all right, well, if I’m in this domain, what is it that I’m looking for? What is it that I’m maybe teasing out with my own physical therapist or coach that I’m working with to see, are they even looking at this stuff? Or is this something where they’re just like bare minimum, let’s move you along based on time. Here’s some exercises, here’s an MMT where you push on their hand and that strength testing, which is not. These are things to help you just identify and correct your gut, if you will, or fine tune your gut. 

Let’s dive into first, physical preparation. This is our main domain which we work with, where we are trying to get this athlete prepared as possible on the physical aspects. The buckets to consider here are symptom profile. How’s your pain and swelling, doing your range of motion, donor site, how’s that coming along if you did get a donor site taken or a graph taken from that donor site, functional movements and motor skill, looking at strength in isolation in particular groups, of course, quads and hamstrings being big ones here, how does that look into integrated-type movements. Looking at maybe squat, deadlift, other compound movements, a single-leg leg press. But these are just examples of ways that we are going to be testing to see, okay, how does their strength look in isolation? What about in an integration? You got the multi-joint exercises and then you got the isolated exercise. 

So that might be with a leg extension, leg curl. Ideally, isokinetic or isometric testing is involved in your process to get the best accuracy of that. We’re looking at rate of force or your power development. Being able to see how explosive you are at a specific muscle group and joint, and then maybe globally as well. And then we’re looking at some areas of reactive and elastic strength. This is something where we’re thinking about kind of like that bounciness, that ability to react really quickly. And this is something that comes back to what we call our stretch shortening cycle. This is something where our bodies go through a rapid stretch and it expresses energy that is going to be elastic in nature, and that’s going to help to essentially run, jump, cut, all the things that we think a little bit more dynamically that happens very quickly.So that’s what reactive and elastic strength is testing. And there’s ways to measure all these things. Some easier than others based on technology and what we have today. 

These are the things also from that reactive and elastic piece, what we’re looking at in terms of the on-field movements. So think about locomotor and type. So looking at those qualities, such as the running, jumping, cutting. Being able to decelerate, accelerate top speed type stuff. We’re looking at all of these aspects especially in the later stages of our development. And so these are some of the buckets, some other ones that could be included as conditioning, looking at sport exposure. But when we’re looking at physical preparation for our athlete, we’re not trying to mimic all their specific exercises that they do in their sport. We’re not trying to mimic all the different positions and  some functional things that people try to carry over into their training. We’re trying to get this athlete as prepared as possible from all these different domains and then let the sport specific work do its job and its particular training. 

This is where it’s going to be really key in terms of when we look at KPIs (key performance indicators). We’re looking at qualitative pieces. This could be something where it’s not necessarily truly objective, but we are looking at things within a certain range. When we look at this, we’re looking at the different shapes and positions the athletes will get into, what do those patterns look like as they start to express themselves, especially at higher intensities. This is where our coaches really comes into play and how we look at people and their movement. It’s a very underrated measure, in my opinion. Sometimes things almost get too objective, data-driven, which is important. Don’t get me wrong. But I think being able to use our gut here and be able to use our eyes is very helpful, especially if you’re a trained coach and rehab professional, because you can see what it is that they’re doing and it shows by what they’re also feeling and presenting with. 

If an athlete is shifting to one side or maybe they’re overloading their  unoperated side, when they’re going to decelerate, well, that could be because of a quad strength issue on the ACL operated side. It could be a knee pain issue, it could be a lack of flexion range of motion issue, it could be something where they just can’t produce force quickly. Maybe they’re just apprehensive so they’re loading that other side because they feel really confident and strong on it. Lot of different areas that we can dissect here, but this is where testing and assessments plays a huge role in making sure we can assess these different areas. Otherwise, we’re kind of operating blindly a little bit. 

This is where that coaches could be really helpful to look at the movements and notice the “normal” range that we’re looking for and then what is it that we see that is outside of that normal range. So that might be shifting to the opposite side, it might be shooting to the same side. But maybe in the hip or the ankle, or maybe it’s in their torso and trunk. How do their shin angles look? And with the given tasks that we’re giving them? How about what they’re doing when we do a deceleration-based task, a single-leg plyometric. We got to make sure we’re assessing side to side and seeing, okay, is this athlete moving really funky from one side to the other. And what story does this tell us and how do we continue to dissect that and make sure that this athlete isn’t compensating in a very non-productive way. 

And then we’re looking at the true quantitative KPIs. We’ve got this as an actual objective measures. We have to make sure we always measure these consistently and when they’re also relevant to the process. This is going back to our buckets that I had mentioned before. We have to identify the appropriate KPIs. It might be something where you’re aiming for  90% to 95% symmetry for your quads. And especially if we’re talking about getting back to return to sport, we are looking for 90%, we like 95% or higher for our symmetry. And making sure we also anchor that normalized to their body weight, which would be 3.0 Newton meters/kg. So that is something that we look for with all of our athletes as a threshold, and is a heavy weight, especially for our quads, to make sure that athletes meet or get close to this. 

We are looking for rate of force development. It could be something where we are looking at their isokinetic tests and we’re looking at the graph. Is there a very sharp peak, if you will, or rapid point where they get to that peak force. And we’re able to see that versus it takes a really, really long time for them to hit that peak or it drops off. We’re trying to make sure that they can recruit that muscle as much as they can as quickly as they can. So that’s something that we’re looking at and putting data around that. Maybe we are looking at their reactive strength and we’re looking at their reactive strength index for a drop jump. Maybe they have a good bounciness for one side versus the other. Maybe we look at a single leg as well with a drop jump versus a counter movement jump. These are all pieces that we would be looking at to be able to create a profile for our athletes, especially from the physical preparation standpoint and seeing where are they at, where did they sit on this continuum compared to themselves, compared to normative data, what the research shows that is a good threshold for return to sport. 

These are all things that we’re looking at and making sure that this athlete is ready as possible. Some other areas we could look at, is conditioning tests. Are they meeting the certain normative data that we’re aiming for, for their particular sport and for this athlete and age. Maybe we’re looking at their specific sport itself and the integration of that — which we talk about a little bit later with their graded exposure. But this falls into that physical preparation and making sure they have exposure to their particular sport. But there are different ways for us to be able to just dial in different sets of tests and KPIs associated with physical preparedness. We don’t want to just — be like, all right, these are some things that we think will look good from a performance standpoint. We want to anchor this to the science, we want to anchor it to the research, we want to anchor it to the principles that we know and making sure that the data aligns with how this athlete is feeling physically. 

Then, we roll into our psychological readiness. We’re looking at, how the athlete is doing is huge, huge, huge for us. We want to make sure we can ask them 0% to 100%, how confident do you feel? And then sometimes I’ll ask my athletes if the sport was literally right here in front of you going 100% full speed, how ready are you to take that on 05 to 100%? And then if it’s less than 100%, I asked them, what do you feel like is needed to get you the rest of the way there? Of course, if that the athlete is at 20%, 80%, there’s a lot still to fill up. But especially as we near the mid to late stages and return to sport, athletes might say 90%. And then I asked them, what’s the 10%? Sometimes there’s these like certain positions or feelings, especially within their sport they’re not feeling good with. Or sometimes it’s just, I just need some time to be able to do the thing, like play my sport and then I’ll feel super ready, which I really relate to because that’s something that I felt while I was going through the process. 

I hit my 9-month mark and I was able to start playing my sport again. It didn’t take me until the 12-month mark until I felt fully confident and not thinking about my knee all the time. And so that’s something that can take time with the sport and with this process. And that’s why I like to ask my athletes that 0% to 100% percent scale because 100% anchors them to how I essentially was before. Therefore, we can get a good idea of what is that gap that’s still missing. And then there’s IKDC score, which is greater than 90. And then there is ACL RSI, which we want greater than 80, ideally 85 or 90 and above, is what we’re aiming for. I know the research shows 77 or greater — but these are different. Patient reported outcome measures to assess psychological readiness and get just a subjective response of how our athletes are doing. This psychological readiness is often overlooked, but good to get some sort of associated objective measure with this to know, all right, where is our athletes sitting? And then you can even dive in a little bit deeper on maybe some of the areas they don’t feel as confident with. 

Next up is graded exposure. This could be progressing different variables. This could be allowing non-contact versus contact. The number of athletes involved. It might be one-on-one non-contact, then it’s two V2, three V3, five V5, all going to be dependent on the particular sport. But then you can build in some contact with limited numbers, then build back up. Maybe you do one V1 to three V3, and then you don’t want to include contact just yet. And then maybe you include contact once they’ve built themselves up with more players and then bring it back down to one V1, three V3 and add in some contact. Because that’s going to be a perturbation or constraint to the exposure piece that is going to add a little bit of kind of throwing the athlete off and they might have a little hesitation, especially if their injury was based on some contact. There’s going to be some hesitation there. Therefore, if we can gradually expose this athlete back, that would be incredibly valuable for our athletes and making sure that they are confident as they build back up. 

We can progress based on the number of minutes. We could look at a type of intensity and gameplay or the activity style itself. If you’re a skier, am I be doing just greens for a certain period of time? If you’re a skier, it might be doing just greens for a certain period of time. If you’re a BJJ athlete, maybe it’s working on certain positions with your partner and what you’re feeling is comfortable with and having lower intensity and demand for that knee and lower body. 

The goal is to identify some different variables to dimmer switch this over time. Super key here: minutes, intensity, contact, number of bodies, positions, terrain, etc. There are a lot of different levers we can pull or switches that we can kind of dimmer switch over. But the goal is to make sure we have some of those that we track versus just sporadically being like, alright, here you go. We want to make sure that there is great exposure to that. 

Lastly, is going to be load management. And so this typically refers as the acute to chronic workload ratio. Few guiding lights here, but the main thing here is don’t get stuck on this particular ratio because it’s not perfect. There’s research that has kind of shown it’s not necessarily this perfect zone. We just want to make sure we understand. We’re just using a progressive ramp up and it’s not this huge spike in workload. So Tim Gaba’s research shows anywhere from point 0.8 to 1.3 is the sweet spot. Again, have some flexibility here not set in stone. Another role that’s often used is the 10% rule. At the end of the day, just don’t have huge spikes in your workload. This can be monitored via GPS monitoring system. It can be looked at with a simple RPE scale where we are measuring the intensity level and then the number of minutes for the total bout of activity. Maybe you multiply the RPE by the minutes and get the number, which is an arbitrary units. 

If you subjectively said the session was RPE 7/10, meaning 70% intensity and practiced for 60 minutes, you’d multiply 7 times 60, that’d be 420. And then that would be your total session “load” for that day. No units with this, it just gives you a number associated with it. You track this over time to manage the changes in sessions and the week, that’s through your acute load to the previous four weeks, which is chronic. Again, don’t get caught up in the minor details here. Goal is to watch for spikes and gradually building up the chronic workload to be higher. This allows the athlete to be as prepared as possible when we’re looking at these 4 different areas and just looking at making sure what comes their way, that they are prepared for that worst case scenario and best case scenario. 

We’ve not only assessed the subjective pieces, but also we have numbers to associate with, especially from the objective side, but also from the objective side. What I want to make sure here that is clear is that these 4 guiding principles can really help anchor us in terms of really helping to navigate this process: physical preparation, psychological readiness, graded exposure, and load management. Massive game changers and helping to manage our ACLers, getting them confidently back to sport. Most importantly, leaving no stone left unturned. We can’t leave this process up to chance. And so that is going to be so key to making sure we set our ACLers up for success. 

That is going to be it for today, guys. Appreciate you guys so much for listening, the support for the podcast, support for the mentorship. And we got so much more coming. Until next time, this is your host, Ravi Patel, signing off.