Episode 163 | Who Should Clear You to Start Running in ACL Rehab?

I am excited to dive into this episode today. Welcome everyone to the ACL Athlete Podcast. We are going to be talking about who should clear you to start running in ACL rehab. Just imagine this, you’re three months post-op ACL. You’ve got a checkup with your surgeon. They see you for 5, maybe 10 minutes, check your knee on the table, do the Lachman test where they pull it back and forth to test the ligament, maybe an air squat, kicking into their hands to assess strength. Then they say, look strong and good. You can start running. I’ll see you in three months. They’ve been cleared to start running. 

And when I said strength, I put in the “air” because kicking into someone’s hand where your person’s hand is on the top of their thigh. And then typically the other hand to resist is at the ankle of the ACLer. They’re told to kick out to test your quad strength. There’s no testing going on. It’s just to see, can you kick into their hand? That’s the only thing that’s happening is no test of strength. Let’s be clear here. 

To follow this through, they’ve been cleared, they’re ready to start running based on the surgeon. They’ve hit the timeline. They’ve had that 5 to 10-minute checkup. I’ve had countless athletes who go and see their surgeon and this is what happens. It happens more than it doesn’t. This is 50%, 51% and I would argue almost 60% to 75% of what we see is what happens here. This is not all of course, but it happens more than it doesn’t as I had just mentioned. 

I had a call with an athlete recently where he mentioned his surgeon just cleared him to start running. I asked based on what? He said nothing… but time in the protocol. He’s like you’re at three months, you look good. The protocol says you’re good to start running, so let’s do the thing. You started trying to run. And he was dealing with pain and started to limp. The problem here isn’t that it was the surgeon who cleared him, it was what reasoning was used to clear him to start running, basically nothing, but time and what the protocol says. 

Let’s also just look at the time of that protocol and its creation. It’s very unlikely that it was within 2020 and beyond, even though it’s 2024. It’s not uncommon to look at the dates on these protocols if they have them. And they will say 2003, 2008. It’s laughable to be honest because we have learned so much about ACL rehab and the things that we need to be hitting—I would hope so. That if things are not updated with such a major reconstructive surgery with such a high reinjury risk, if we’re not looking at this thing, can we not have someone in the practice looking at this thing and being like—is this thing up-to-date? What are we using to base this protocol on? What’s the factual information? What is the researchers who are crushing with his ACL rehab stuff what do they say in terms of their criteria for return to running or for return to sport? Whatever it is. Why don’t we have some sort of fact check every year about this, instead of looking at the 2003 protocol that the surgeon is still basing their clearance on, which is typically just time, because maybe that’s what they learn or they’re like, ah, it’s good enough timeframe. The way people just have concrete answers. I don’t think that’s healthy. This is the thing that can get people into trouble. 

And so what I don’t want to sound like, which I probably do is sound like a broken record. But for every one person, I hear that does get testing performed, there’s probably nine other people that haven’t. This isn’t pointing fingers directly at just the surgeon, is the whole system and all the professionals involved who aren’t doing their due diligence. The thing that I want to pose to you is imagine this: Your driver’s license you’re getting because you just turned 16. You got it. No written tests, no practical tests, just because you’re 16 based on the calendar. 

How terrible would that be for the teenager who never operated a car and then just magically crossed that date to do it. And the other thing too, is that could you imagine being also the drivers on the road? And being like, oh, all these 16 year olds who hit their birthdate are now able to drive. They didn’t get tested. There was no process to be able to make sure that they can operate a car appropriately and safely. It’s just like they’ve hit a calendar point and we’re good. That would be awful. And it’s probably because it would lead to death because there will be car wrecks. And so therefore, whenever someone starts running, you’re probably not going to die, but it’s likely that you are just going to be dealing with the repercussions of not being ready for it. 

And the thing is that when we get our driver’s test, either there’s a written test or there’s a practical component to it. This is the thing that’s important here that we assess and make sure readiness is there. That’s key here. We got to make sure the readiness is there. You show the appropriate preparation and then therefore that crosses potentially this line where you could start to run. And this is honestly exactly what happens is that we got the time that sneaks up and then they’re like, okay, you’re good. Now you might be like, okay, Ravi, it really is just running. But let’s take a second to think about the domino effect here and the sequence of events. Someone has been inappropriately told they can start running. They do. They start experiencing problems. They might have pain. They might have swelling. They might have stiffness. Maybe they start limping. Maybe they have a combination of all of these things and likely so. But they’ve been cleared, so they almost feel crazy thinking something’s wrong. So they carry on. This impacts their strength numbers, this impacts their compensation patterns, this impacts the athlete getting into more dynamic movements that are more demanding that need typically running as a prerequisite. Not to mention they’re dealing with a grumpy knee. It could be a few weeks, it could be months, it could be even years. 

You think I’m kidding here, but we’ve had people reach out 6 months out, 8 months out, 12 months out, or literally years out, not running because of issues like this. That could have been addressed if they had just had appropriate criteria and more of a team-based approach to this decision-making process. And while you might say my surgeon and PT are nice. Nice doesn’t mean that they know what they’re doing and are up-to-date. It’s the thing that I honestly find so funny because we do not get into physical therapy to make a lot of money, we do not. If you look at how much we were paid 20, 30 years ago, versus what we’re paid today, is very marginally not different, whatsoever. There’s very little change. And especially going from a bachelor’s to a master’s to a doctorate. There’s not a lot of shift except for the increased student debt. And so we don’t get into physical therapy because we want to make a ton of money. We get into it—typically if you ask most PT students, they’re like, I want to help people. I want to be able to connect with my patients. I want to be able to have movement as a part of my practice and what I do. That’s a very common thing that people in the physical therapy world, especially the students you will hear. And so the thing is that more likely than not, you’re going to have a nice physical therapist. 

We’re also oriented people. We love to talk to people in most cases where people facing for the most part. If you are a person who doesn’t like people, it doesn’t like talking, introverted which doesn’t mean that’s a bad thing, you’re less likely to pick a physical therapy profession because it’s just not self-selecting to that. You have to be a little bit more outward-facing and typically these humans are nice, in general. You’re going to find a nice PT versus a not-nice PT. And so that’s the thing that I want to mention here is that just because they’re nice doesn’t mean that they’re really good at what they do. 

Now I’m going to say something a bit more aggressive here. Why? I’ve just been feeling really spicy lately, so I don’t really care. This is where we have to stay in our lane as our profession and professionals. If you haven’t truly tested the athlete, seen their numbers, and known the ins and outs of what they’ve been doing, you have no business giving recommendations on what they can do, when they can do it. And this goes to any surgeon, ortho, physical therapists, athletic trainers, coaches, mom, dad, whoever, come at me. This doesn’t make sense for someone to make these decisions based on basically lack of information. And just because you’re constrained to a 5 to 10-minute visit, it doesn’t give you the authority to do that in my opinion. 

This is something that I think is a big gap that we need to readdress from a system standpoint because we need to make sure all of the players are involved. Or at least the person who is fully aware of what the numbers look like, what their criteria is for that, which is probably a problem in and of itself is that we can agree on this. But we do know that there needs to be some sort of objective measures to be able to know, if this person is ready, outside of time. Time alone is not going to do the thing. We know we need to measure things like range of motion, quad strength, hamstring strength, plyometric ability. And there’s other things that we can list here, but we need to make sure that this person is prepared and ready for the thing we’re going to ask them to do. And so this is where the person or the team who is involved with this need to know what those numbers stand, what has this athlete been doing. 

If we just say, all right, at three or four months, you can start running. But all they’ve been doing is like air squats and heel slides. Do you think this athlete is going to be ready to start running, the demands of running and what that is? Definitely not. But if you don’t ask you don’t know, then there’s no reason for you to give advice on that. That’s just like a blind recommendation that doesn’t make any sense. 

One of the things I always ask my athletes to do is when you leave a visit, whether it’s with your physical therapist, with your surgeon, whether it’s with a coach, whoever gives you advice on certain things, always ask why, or be able to explain exactly what it is that advice was derived from. This is the thing that’s always the light bulb moment that I love is that we’re working with athletes and they go see their surgeon and the surgeon tells them they can start running. And then I’ll start asking questions. I’ll be like, well, how long did you see your surgeon for? And they were like, we’ll five minutes. I was like, okay, what did they do? And they’re like, well, they checked my range of motion. They did that test where they checked the ligament, kicked into his hand and this is typically the most run-in-the-mill type situation. They’re like, yeah, you’re good. I’ll see you in three months. You can start running now. Just don’t go too crazy with it. And I’m like, cool. That’s great. 

And then it’s an uphill battle because especially if you’ve got an athlete who isn’t as in tuned in with the process and is very aggressive with the rehab or wants to get back to running if that’s a big goal. Oh, man, trying to walk that back is really hard. And so then therefore it’s just something that is blind advice with just a system-based issue and a protocol versus being something that is more oriented to the information, the data, and what they’ve been doing. 

These are things where we have to check ourselves a little bit. And the big thing here is that we have to have objective testing. What does their symmetry look like for their quads? What about for hamstrings? How does that look like normalize to their body weight? Are they 75% symmetry in their quads, but their Newton meters per kg is 1.2. Well, great. They’re not ready for running because of the research that we know, we probably need to hit somewhere around a 1.7 to 1.8 threshold relative to your body weight. And you would only know that if you tested the athlete’s strength. It’s a very strong correlation with running and mechanics and with symptoms and with all the things that trickled down to this. I’ve done a whole episode on strength testing and how the quads lack of strength leads to such a chain reaction of things that are problems down the road. 

This is something that we have to keep in check. We have to make sure that the range of motion is fully restored. There’s some knee flexion that’s involved, there’s some extension that’s involved whenever the body hits the ground, the foot hits the ground. And so then therefore, if we don’t have that prerequisite, guess what? We’re going to figure out a way to work around it. We’re going to shorten our stride a little bit. We’re going to not go through that cycle as much. We’re going to lean on the other side, we might have some trunk sway, some rotation. There’s so many things that can come into play to complete the task of running because you hit that threshold because the professional has told you to do so. So you’re like, I’d be crazy if I didn’t start trying it, because this is something I’ve been wanting to do, but you don’t have the prerequisites so then, therefore, it should have never been suggested in the first place. 

This also should mean that they’ve done running drills and some single-leg plyometrics where you’re working on that stretch-shortening cycle because the running forces are going to demand some of that. We got to make sure you’re prepared. If you’re going to run a full marathon, you got to make sure your body is prepared to build up to that mileage and it’s there when you go to run it. If you only been running two miles and you’re going to run 26.2 miles, God bless your soul. That’s not going to work because your body’s going to be like, what’s happening? I’ve not been trained for this. I’m not prepared for this. So preparation is key here. And then those who have the information can give you that guidance or recommendation for what is the next thing to do.

Now the intention with this podcast is to determine who should clear you. I know I sound like I’m always complaining, but this is the thing that we deal with in this space as we currently stand, in terms of just poor information and guidance. I’m here to try and help set the record straight as much as I can. And I’m not saying I have all the answers and I have the solutions, is just ways for you to feel educated and for you to have a better grasp of like, okay, this is what I’ve been told—how does this kind of play into this. And starting to make those light mold moments come to play just like my athletes when I’m like, how can they take away this much information to give you a green light to start running for 5 minutes of your time? I don’t care what I do for five minutes. I’m the fastest person possible to assess things. You can’t even test someone’s quad strength in five minutes, efficiently on one leg. So there’s no way that they have enough of that information unless it’s this like lucky college or private school or pro-level type situation. 

Well, in that case, you probably have 10 people that you can account for that’s going to help make this decision. The surgeon isn’t the only one that’s making that decision in these types of scenarios. And so this is where I want to make sure you understand, well, who should clear you? In my opinion, this is analyzing who is your ACL team and the stakeholders involved. This is where this first starts. Here are a few buckets and people who fall into each is not completely comprehensive, but this is most people. This can include sports medicine, whether it’s the physical therapist, orthopedic doc and team, athletic trainer, sports psych, family and friends, parents, and significant others can play a role in this. You have a sports performance, you have a strength coach, the sport coach. Others could be agents, sports science, management, or owners of a team or an organization. And the athlete is at the center of this. You as the athlete, ACLer is at the center of this. You are the one who gets to have input on this and the conversations, hopefully. Each athlete will be different based on their own context. And this will also create different stakeholders.

The college recreational athlete stakeholders might just be the ortho, PT and parents and sports coach. And then for the 28-year-old, who wants to just get back to skiing, it might just be the ortho and PT. This is something that we commonly see is just the surgeon’s office, whoever you are working with they’re your physical therapist and that’s it, especially in the typical insurance-based model. So then therefore these are the people who need to be involved in that decision-making process. It’s not one or the other. It just depends on how much weight they carry within knowing the information and being able to help you make this decision. 

I would say most of these folks, as I had mentioned, just have the surgeon and the physical therapist. So then therefore for your own situation, you have to assess your own stakeholders and who they are. A good way to look at this is who is, and has been involved in this process that has something at stake, who is capturing the qualitative and quantitative or the objective data to help me meet my criteria. And hopefully you have criteria. That’s probably the number one thing that we need to tackle. Write these people out and make sure when it time comes to be cleared for X, Y, and Z, or to move on to something, everyone is on the same page about it, about where you’re at and that makes sense. 

Now to answer this question: who should clear you? It’s not just one person. It should be a collective decision based on your ACL team. And all the stakeholders. It really is the people who are seeing you through it, all the testing that you’re doing, getting that objective measures, making sure you hit every criteria of return to running to sports. Since those are two, obviously very big milestones, process and making sure you’re just meeting the demands of what that task. If we have athletes who want to go hiking, but they are not clear-cut criteria for hiking. We just kind of do a needs analysis of it. 

And we’re like, all right, can you do this, this, and this, has your capacity build up to this. This is what we typically see with hiking and based on the train of it. So then we’re just making sure that physical preparation is there. So you could take on the demands of it. And so then therefore we’re trying to make sure that you have met, set capacity and strength and criteria in order to make sure you feel ready enough to do that. 

And so we’re having that conversation with you about it and also risk reward of it. Is it worth it? If you have something else coming up pretty quickly. And this, my bug out the knee, when we need to make sure we meet the thing that’s coming up, that’s more important to you. So these are all conversations we have with our athletes to make sure that this is all weighed in and it’s very important to do that. This means everyone has to be on the same page and communicating. This means putting egos aside. There’s no hierarchy here and it is a team-based approach and focuses on the athlete in front of us. 

This is something that is always tough because with us, even like, you know, we do communicate with other stakeholders. Sometimes it’s just hard to communicate with other stakeholders and people are asking questions. Well, am I ready to do this? Or maybe the surgeon’s office or whoever they are working with is pretty disconnected. There’s not a lot of guidance. Just like I did the surgery. And now your physical therapist is responsible for the rest of it. It just depends on the involvement and what this looks like, which is important to determine. 

But a lot of times we end up having to make that decision. And I think rightfully so if I’m being completely honest, because we are in the throws of the athletes, being day in and day out, seeing what they’re doing in rehab, what they can do, what they can’t do, talking to them, being able to test subjectively, and this is also being done at the surgeon’s office. That’s awesome. 

We have surgeons around here in Atlanta who do an incredible job of this. And we communicate based on this. But this can be tough for the ones where it’s kind of a little bit silo-based and they’re kind of operating, are you check the box? You came for the visit. Your ACL is not torn. Keep moving. Protocol says this. Well, there needs to be a pause here because we need to make sure that you’re ready for it because this can be such a domino effect into the rest of your rehab. And you get back to the things that you want to do ultimately. 

When someone gives you an opinion, this is what I want you to take away here. Especially passing a big milestone or “clearance” to start doing something. Ask them why and based on what. If they haven’t measured your quad strength or your hamstring strength objectively, then I think you need to reevaluate that decision and that, you know, guidance and that advice you’ve been given as they are likely not up-to-date of the latest of what’s needed to make that decision. 

Point blank—if they haven’t measured it and they give you some sort of like you can start running, you can especially return to some high-level cutting and pivoting sport and your quad strength and your hamstring strength. At the minimum, there are other things that we would test, but that is at the minimum hasn’t been tested appropriately using a dynamometer for isometric strength or isokinetically, or even worst case scenario, one repetition maximum, or a three to five repetition maximum. And if they don’t have that information of what your symmetry is or normalized to your body weight, they have no business making that decision yet.

This is something that I want you to take away of knowing, if I get this info, if I’m told this, what do I do with it and how do I make this decision and make sure it’s the best in my health, in my journey. This is where knowing who is a part of that team and who is helping to make that decision and ultimately who is also collecting that information to make that decision for you or help you guide that. and get back to the thing and running is a big one that I often see miss I’ve talked about returning to sport and performance, but I think running is one that is like a door that opens, that opens up a lot for people. It’s one of the biggest milestones that people are looking towards after that post-op process, because you’re like, all right, if I’m running, I can start doing X, Y, and Z. I feel more like an athlete, which is what we’re trying to do with this. This is where it is very, very crucial to make sure we have a process. We question things and we know who our stakeholders are and whatever guidance and clearances we have, data and information to back that up. 

Who should clear you? It depends. It’s really based on your stakeholders and who is collecting that information. I hope this was helpful team. If you guys have any questions about this, if you’re like, I’m kind of confused, I’m kind of in a tough spot, reach out to us. We’re happy to help in any way that we can. But otherwise, I will catch you next week. This is your host, Ravi Patel, signing off.