Episode 174 | Can You Accelerate the ACL Rehab Process? – Part 2

What is up team and welcome back to another episode on the ACL Athlete Podcast. So today we are continuing the conversation and this series answering the question: Can you accelerate the ACL rehab process? In part one, if you haven’t listened to that yet, please go back and listen to that. As it’s important to help tee up this episode we’re going to do today to create some context, to help understand where people are coming from. We talked mostly about, the position from the ACL or a supporting role like a parent or coach, someone else who is involved in the process, but especially from the lens of the ACL athlete themselves. And then from the lens, also from the companies and the surgeons and the PTs, the coaches, the people who claim they can get you back to sport faster. Because we’re always trying to move faster in an instant-type society or instant gratification, being able to access things, being able to get answers very quickly, being able to expedite if you will. Why not do that with ACL rehab process. Can we do that? 

And so that’s the thing that a lot of people are looking for and there’s a lot of marketing and there’s a lot of just trying to seek out sources to be able to potentially speed this process up. And so we talked all about that in episode one and from the lens of these different people, especially not to blame the ACLer especially if that’s you listening and you’re like, well, yeah, I’m trying to speed this up. How can I get back to doing the thing that I want to do? And I don’t blame you at all. If there is some sort of way to do that, let’s do it. 

The part for today that I want to focus on is actually answering this question now that we’ve given a little bit of background, right? If you have listened to episode one, you probably already know my answer. If you follow me, you know my answer probably. But I want to elaborate on this to give some context and to give you guys some understanding as to why you can’t speed this process up. And so, yep, that’s my answer. Can we accelerate ACL rehab? And most importantly, returning to sport faster? No, that’s basically where we stand.Based on May of 2024, this is where we are in terms of the landscape of ACL rehab. And my opinion on this can always change just as you guys know, more research can come out, technology can advance. There are things that can be a little crazy with the way technologies and advancing, especially with AI and things. Obviously with ACL is probably not going to play a role, but with that said, it’s going at lightning speeds. 

And so with that said, there are things that could come out potentially new discoveries that may might change my mind and I hope so. If there’s a way that we can make this process—three months, that’d be awesome because then therefore, a lot of people would be happier. It would be easier to do this. Could you imagine someone who gets pregnant and you cut the 9-month time span into four and a half months, that would be a game changer. So anyone will be happy to be able to do that. With that said, though, with where we currently stand in 2024, we are currently in a place where my answer stands as can we accelerate the ACL rehab process and most importantly, really getting back to sport—no. 

The thing is, I often compare this to baking a cake in a sense. You can’t just turn up double the amount of heat and cook it at two times faster. That’s just not the case. You want to bake a cake, and let’s say you put it at 350 and it takes 45 minutes. Well, if you put it at 700, it’s not like it’s going to take 22.5 minutes to be able to cook the cake. It just doesn’t work that way. And that’s the way the human body in all honesty works in a very simplified and reductionist-type view. It’s just so complex. Our human bodies and biologies just can’t do things faster like that, even though we are getting better with medicine and technology. This is where it’s just something that we have to let us do its thing. And with the current state of where we’re at.

Let’s dive a little bit deeper because there are three things that really, really want to hit on, in terms of laying out why we can’t currently, as we stand today, accelerate this process. Number one and most important—is what does the data and the research say? If we just go based on anecdote, there are a lot of things that can lead us to think, oh, well, yeah sure, we could do that. And we might get lucky with that, but what does the comprehensive scientific method and the process itself show us? Research shows us many reasons why it’s a bad idea to rush back from a time standpoint, from increased reinjury rates, poor performance, strength, deficits, fear of reinjury, etc. There is an entire list of things that plays into when we rushed back to playing the thing or doing the thing that we want to do, especially if it is a higher level cutting and pivoting sport. This is something where we are at an increased risk of reinjury and also our performance is not typically that great because we haven’t rebuilt to the place that we need to be. And there’s just issues and there’s a lot of mental pieces that also align with this as well. 

And there’s one that really sticks out is by Grindem et al in 2016. It says for every month, that return to sport is delayed until 9 months after ACL reconstruction, the rate of reinjury for your knee is reduced by 51%, for every month. So that’s a very, very big deal because I’m going to take 51% for every month that is reduced up until 9 months. We use 9 months as this cutoff, because this is where a lot of the research lands in terms of this threshold if you will. We know that an athlete can be in a good place in terms of just purely from a time standpoint, that’s not factoring in all the other criteria. It’s just accounting for time: 9 months. 

Young athletes who returned to sport before 9months after an ACL reconstruction have a rate of new injury seven times that of those who delay return. So basically we are saying that you have a 7X likelihood of reinjury in 9 months or before 9 months, if you will, if you return to play. This is by Beischer et al in 2020, that’s a study that was done in young athletes. And while a lot of the research does focus on more of younger athletes, active athletes, that’s where we pulled this from. Because it just goes without saying like, you know, with a lot of the sports, athletes will tear their ACL, especially if you’re talking about higher level jumping, cutting, and pivoting, soccer, basketball, football, things in that nature, especially when there’s contact involved as well. There’s a whole lot of sports that have ACL injuries as a part of this. But those are ones, especially when it’s demanding a lot from the knee, the lower body, ally reactivity contact in the sports. Those are ones with higher rates of reinjury and ACL tears in general. 

Therefore, this is something that’s saying research—and guys I could share tons of articles on this. I’m not going to bore this podcast with this. But with that said, the overwhelming majority of research shows that basically up until 9 months for right this point right now is a safe point for us. When we are told, we can get you back in 6 months based on what information. Is it just based on a it’s promising you something that is something that you want to hear? I can get you there in 6 months, but the research doesn’t align with that notion of 6 months. If you guys can send me something that shows taking the whole body of research and saying, “Hey, 6 months is good. I’ll jump on board with it.” But I feel like this is something that you see very, very repeatedly that 9 months is a very good threshold for us. And it’s not just like 9 months is just this magical threshold, and I’ll talk about that here in a second, why that plays a big role. But it’s just something that we noticed in the research that that’s a threshold that we see where reinjury rates and performance improves and reinjury rates are better. This is something that we want to factor in is, what does the evidence show us? 

I want to talk about the ACL ligamentization process. This is basically, when the ACL turns from a tendon that goes into the knee at the reconstruction to a ligament. I’m talking about an ACL reconstruction, as I had mentioned previously, that’s the focus of this, can you accelerate ACL rehab process? Is based on what majority of people who go through, which is an ACL reconstruction. They get a new ligament put for their new ACL. This takes a minute to go from a tendon to a ligament. And to remind you guys, a tendon attaches a muscle to bone, a ligament taches bone to bone. The native ACL attaches bone to bone. It attaches the femur, your thighbone to your lower leg bone, your tibia. And the thing is, is that when you get a new ACL, as we currently stand with the way that new graft is put in there, it’s a tendon.
It’s either taken from yourself, which is usually the big 3; you have your quad tendon, your patellar tendon, or your hamstring tendon, or it’s a cadaver. And it’s usually pulled from one of those 3; it could be an Achilles tendon. I’ve seen some other tendons used as well. But with that said, it’s still a tendon, right? For this process to unfold is called ligamentization. Basically, we are turning that thing from a tendon and into a ligament. We needed it to be an ACL ligament to do its thing, to naturally reduce the restraint of interior translation of the knees and rotational forces, what the native ACL did. And we find when you look at the research that threshold for it to get to a place where that ligament is good enough or that tendon changes into a ligament is somewhere around the 9-month threshold, but can continue to happen over the course of 2-plus years. Studies such as Claes et al 2011, Groningen 2012 and Yao 2021. These are all studies looking at ACL ligamentization process and is going through different phases of healing. We are talking about normal healing process, just like anything else in the body. There’s an inflammatory or this early phase, there’s a proliferation phase, remodeling phase and a maturation phase. This is all basic. I remember in exercise physiology when we’re learning tissue healing, these are the basic phases of what tissues go through in our body in order to turn over and heal. When you get a cut, that’s what happens. It goes through an inflammatory phase, it goes through proliferation, remodeling, maturation phase, anything in your body for the most part does this. 

The ACL is no different when it’s going through a ligamentous. process. It’s actually at its weakest from 3 to 6 months-ish. There’s some give or take here based on the research. But basically what you can imagine is that when this ACL goes in is actually at its strongest as a tendon, and then it drops in his tensile strength and its strength overall. Because it’s being broken down by the body and it’s going through that healing process and being turned over into a ligament. What happens is, it starts at a very, very high tensile strength and then it comes down and then it drops really low. And then it starts to come back up, slowly over time, but that’s over the periods of months. It’s not weeks, it’s not the short time span; it’s over months and months and months. They have measured this over the span of a couple years and some of these studies. Showing that the healing can go beyond a year into 2 years and onward. It shows that closer to that 9-month threshold is whenever it starts to get to a good remodeling and mature phase of the ACL—some variations of course, within the studies. 

The systematic review from JSM in 2011, that was the one by Claes. The ligamentous creation process and anterior cruciate ligament reconstruction. They looked at four different biopsy studies. On the patellar tendon and hamstring autograft reconstructions, it showed maturation of the graft as determined by mainly what they looked at was the vascularity and cellularity of the ACL. It wasn’t complete until 12 months at the earliest. This one’s even referencing, “Hey, it didn’t even get there until 12 months,” showed that the healing continued to 2 years and after that. This is something that’s really important because you can’t rush biology. Take all the PRP shots, do all the things that we have in regenerative medicine. We currently don’t have something yet that shows, “Hey, we could speed this up when we do an ACL reconstruction.” This is something that’s important to consider because even if you feel like a million bucks, you pass all your criteria and you’re at 5 months postop, let’s say you just are that certain percent that you just crushed it. 

We’ve had certain athletes who have done this and they’re like, “Hey, I’m ready to go. I feel good.” It’s one of those things where we have to be very careful because they feel amazing, but that ligament is still in a very vulnerable place. And so then therefore, even though physically, they feel ready, they go to do something that demands that ACL on is still weak and not doing its job. Guess what? It’s going to tear again. Because it is not matured enough to a point where it needs to do its job. And so this is another nail in the coffin, if you will, why we can’t accelerate the ACL rehab process because this ACL needs to go through ligamentization process. 

And then lastly here, I’m going to mention is this injury is one of the hardest injuries that come back from outside of something super traumatic like a spinal cord injury. Something very accident based in terms of multiple crush injuries and things of that nature. We’re talking about, if you are playing a sport, what is one of the most difficult injuries to come back from? ACL is one of the hardest ones in my personal opinion based on my personal experiences. And over 10-plus different injuries that I’ve dealt with, from a broken ankle to some hip issues where I’ve got bony growth to shoulder dislocations, ACL still take the cake on all that. Because it is just so difficult and it’s not even just the grueling pain, if you will, of the injury itself, it sucks. But with that said, that’s not even what I remember, it’s the long recovery process going through it. You have to get the surgery. Do you feel like you’re rebuilding from the ground up and that’s truly what this injury is. And any of you who are going through this, you feel this. You have the injury, your quad shrinks up and your legs that you’ve worked so hard of has shrunk to a hotdog, and then you go and have a surgery probably, and it shrinks up again. And then you’re immobile. It really breaks you down to be completely honest on that side because you are limited, you can’t really do much. For some reason, our bodies do something really weird whenever this ACL injury happens. zbecause it is not just a knee joint issue, it is a nervous system issue that we’re still learning about where there’s changes in the spinal cord, there’s changes in the brain. And there’s something about the disconnect of the nervous system to the muscle. For some reason, it just shuts the knee down and shuts the quad down. And so we’re still trying to figure this out and we’re still trying to understand how can we build these athletes back up better. 

But the thing that I do know from personal experience, but also working with athletes, going through this through a variety of the first tear to third and fourth tears, which is terrible but it happens. And the thing is you are building from the ground up after this injury. This injury takes so much away from our athletic and physical abilities due to the nature of the injury and how the body, the knee, the quad and surrounding tissues respond. A bit of strength and conditioning coach and in this space for 10-plus years now, we don’t magically just gain muscle and get strong and get athletic, especially with an injury like this—it takes time. It is even more complicated with an ACL injury. And I was saying that even outside of an injury. It takes time to get athletic and strong and gain muscle. Now you complicate that with an ACL injury because there’s that nervous system changes, I had mentioned. The brain and spinal cord have some changes. We have to respect the healing process and also rebuild back. That’s one of our main phases. 

After we get over restore phase, we have a rebuild phase, which is a very big phase for our athletes. And we walk them through these different phases and different criteria they need to meet. But we spend a lot of time in this rebuilding process. This is something that we are trying to really focus on to get them to return back to their things, which is our next phase. And so that is something that is not just range of motion or just quad strength, it’s all the things to be mobile, is to get them back to being super strong, explosive, reactive, making sure we can run, jump, cut, sprint. And these all are progressions within each other. You can’t just go sprint if you can’t run. You can’t really cut very well if your pylometric abilities and your jumping abilities aren’t great yet. There are all these prerequisites that we have to have. Because if you don’t have the strength, well, guess what? You can’t really run, jump or cut really well or sprint. We have to build all these things up over a period of time. And the strength piece is the hardest piece for most people, especially people who get autografts because there have been more tissue damage to their knee. And so then therefore, this is something that just takes some time. Even in healthy untrained humans, it takes a minute if there’s no base that has been built yet. So that is something that you have to factor into this process is that it’s not just something, no matter at what advantages you have or base you have, you look at the most elite of elite of elite athletes, and you look at the timing of what it takes to get back from an ACL reconstruction and getting back to feeling 100%. 

You go look at most stories and most people are taking 9-plus months, if not a year to get back to the thing. Of course, you look at them and they have the best resources possible at their disposal. And for most of us, we don’t have all these resources. We just get to work with the medical system that is close to us and what we have that is convenient in a sense, and maybe what our medical system or insurance provides. This is where we do have to potentially step outside of what that is in order to make sure we get the best care. But then of course, that comes at a cost and an investment, but it is worth it to make sure that we get the best outcome possible. And also more importantly, people don’t evaluate what is the cost of another injury. Not only from a financial aspect, but what about biologically, physically, what is the cost of that? But more importantly, mentally, right? What is the cost of that? What would you pay for your chances to be reduced at the maximum to make sure you can go back and do what you love to do within ACL injury and making sure that you are as best protected and know that you met the right criteria. That’s something that I think you can almost not account for a certain amount of money, if you will, based on the mental aspects, especially of another reinjury. And take that from someone who has injured his ACL twice. This is something that is brutal and it can be tough to deal with. This is why I am really trying to hammer home and share with you guys that this isn’t something that you can shortcut. And there’s nothing to this. If you have worked hard for anything in your life, ask yourself, was there any shortcut to it? To be completely honest. 

When I think about this business, what I’ve been able to build with this and what I’ve been able to share with people, there was no shortcut. There was no roadmap for it. It’s like you figure it out and you’re trying to find some direction with it. But what I do know is that there wasn’t no easy route to get here. It was something that was very difficult. I look at playing sports. I look at this ACL recovery. All of it was hard work. There were no shortcuts to it. It was just honestly really good rehab and strength and conditioning. Doing the basics really, really, really well over a long period of time, having something to work towards and achieving the appropriate KPIs and criteria to do that. 

I think the 9 months serves as a great proxy to get back to that spot without rushing or skipping over the steps. And now walking hundreds of athletes through this, I feel very confident in this. When I think about trying to rebuild athletes and trying to get them from this post-operative phase into this rebuilding phase, it is a process and it takes a lot of patience, it takes a lot of energy, a lot from you. It’s something that takes a long time to be able to do that. And so this is something that I think is really important to consider during this process and knowing what you’re signing up for and the expectations of this. 

The last thing that I do want to touch on is, are there athletes who go back earlier than 9 months? Sure. I’ve had athletes who have done that before and it’s conversations around this. Now it just depends because there are gray area around navigating this process. That doesn’t necessarily mean you get a green light just because you check off all your criteria. There’s a lot of things that factor into this based on their goals, what’s at stake. It’s a risk-reward analysis at the end of the day. And so the thing is when these athletes go back to 9 months, and these are the things that they are considering for a number of reasons. It could be due to the poor rehab, no testing and poor guidance and misinformation. To be completely honest, this is the most common. Also my belief, why we have the reinjury rates that we have for ACL rehab because I think that we do have poor guidance in this space, poor information, no testing. When you look at most athletes who are coming out of this, even here locally in Atlanta, to be completely honest. If I did a survey, I would probably venture to guess that 80% of athletes are not getting strict criteria, guidance, or testing that they need to in order to reduce their reinjury risk. It’s just like, “Hey, like I go to my surgeon, they test out my ACL. They say I’m strong.” And I’ve done my therapy for the time being and you feel good enough. And then guess what, it happens again. A lot of it is because of a system issue. And I think that that is a very big reason for the ACL reinjury rates we have. And it’s one of the reasons why people go on to do it earlier than 9 months because of the poor guidance and misinformation. Along with this could be due to a lack of resources, it could be insurance or coverage, medical system, socioeconomic status, geography, equipment, etc. This plays into the previous factor that I had mentioned leads to poor rehab, testing and misguidance. It could be because they assess the risk- reward as I had mentioned earlier, and they live in that gray area of the return to performance criteria and their goals. And they’re okay with that. At the end of the day, we can educate folks and then it is up to them to make that decision ultimately. Or, it could be because they have a dream on the line. They’re like, I don’t care. This is something that I want to do because there’s the World Cup coming up. Or, this is something because I put my cleats up for the last time. I just want to go play in this game. I know I’m putting my knee at risk for other stuff, but it is totally worth it. And so that is a conversation to have with the athlete and all the other stakeholders. But there’s a lot of factors to weigh into the decision of getting back to the thing. It really is important to have this in your own context and with your own stakeholders in conversation and making sure that everyone is on the same page. Most importantly, from this episode, no, this process can be accelerated even with the most perfect, perfect, perfect program, single exercise or coaching. Honestly, if you sought out the best ACL coach, by the way and you get ACL coach is going to tell you you’re not going to be able to accelerate it. The thing is that if someone is telling you that they can, then I would question their knowledge of the space and being able to actually guide you through the ACL rehab process, because they’re actually telling you something that isn’t proven by any means other than marketing and maybe business, to be completely honest. To put simply we just can’t speed up biology right now, based on our current information and body of knowledge. That alone should be the number one reason, the accelerated programs don’t work. 

Now don’t get me wrong. We can get people moving and doing things sooner during the rehab process, if they hit the right criteria. Meaning, maybe they’re able to run a little bit faster, maybe it’s not at 3 or 4 months, maybe they’re able to start running at two and a half months. Because they’re crushing it, they had an allograft, their knee responded really well. They did prehab leading up to it. They were doing all the things like BFR from the get-go. There are a lot of things that people can put in place to make sure they set themselves up for success. And there’s some people who just respond better because of genetics or maybe just their body responded better to the surgery itself. And so maybe they start doing things a little bit faster during this rehab process. 

So yeah, we can move along in this continuum, as long as it’s not at the detriment of the athlete and they’re checking off the right boxes. But that doesn’t necessarily mean we release them to be free to go play a high level sport, especially going back to soccer and you’re a 16-year-old female athlete. That’s not something that we’re just going to be like, yeah, you’re looking good. So at 6 months, you’re good to go because the research still shows us the ACL is healing. We probably have some stuff to work on to be completely honest, even if not. The other thing is that we want to make sure that we allow that graft to ligamentize as long as it needs to and making sure that the reinjury rates is as reduced as possible of that risk. That’s the thing that I do want to make sure I share here because that doesn’t necessarily mean you can’t start doing things within your rehab like getting back to practices and things of that nature in a modified version, but in terms of doing the thing when it has high level cutting and pivoting, and especially if they’re a youth athlete. This is a ver. hard criteria for us. We’re going to make sure we’re at that 9 months. Because we’re also trying to think long term. It might be middle school or high school. What about college? What about like later on in life? What about when they’re 30 and 40 and 50, what’s at risk here? We’d need to do a risk-reward analysis of the short term, but we also need to do this for the long term, man. Like ACL injuries, you automatically are signing up for an increased risk of OA. That’s not by your own choice is just the nature of what the injury leads to. 

It’s just you can have an increased risk of osteoarthritis down the road, especially if you have a meniscus injury with it and a meniscectomy with it. And so this is something that we want to make sure we factor into. This is not only the short-term, but the long-term because there’s some athletes I know who have given their life to everything in this 8-year window of playing sports and they’ve had 3 or 4 ACL tears. I’m like, man, what is this going to look like whenever it’s 20 years down the road for you? And you have kids and you’re trying to run around with them and do the thing with them. I think these are all things to factor into this process. I truly think the sooner ACLer can understand these expectations that we can’t speed it up. There’s no reason to, and you’re at a risk if you do. If we can understand these expectations, the easier this process and this road can get, because then they’re not racing against time. You’re not fighting it. You’re not like, all right, I can get back in 6 months. You’re targeting a 9-month-ish threshold. And to be completely honest, I think it’s healthier for us to aim for a o1-year mark. And of course, 9 months is something that could be like a soft landing spot, because I do think that it really does take a year for athletes to get into this place where they feel like themselves playing like themselves, competing like themselves and it just takes time. I think it better sets us up for success if we set that expectation from the front end and as we continue through the ACL rehab process.

I hope that this was helpful team. I know I talked to a lot about this and in these different categories, but I think it’s important to elaborate on these particular areas. And there are some other things that I didn’t even mention, but these are the three things when we look at it that are really hard stands for, why it is that we can’t accelerate this process in may of 2024 and until evidence comes out to show differentlybased on an ACL reconstruction. This is where I’m going to stand. I hope that this was helpful for you guys to hear it and understand from the perspective of myself, but then also what does it look like in the landscape, what the research says, what is the ligamentization process look like, and also just rehabbing so many different athletes from this injury. This is what it does look like. Until next time team, this is your host, Ravi Patel, signing off.