Episode 178 | Is Manual Therapy Needed for ACL Rehab?

What is a team and welcome back to another episode on the ACL Athlete Podcast. Today, we are answering the question: Is manual therapy needed for ACL rehab? And one of the things I want to do today is keep today super short, because previous episodes I’ve gotten a little lengthy on you guys. We’re going to try and keep this very concise to the points. You can enjoy this on probably 1.5 or 2X speed, or if you’re really spicy, you might do 2.5 or 3. But we are going to dive into this question today: manual therapy isn’t needed. 

Manual therapy to define this in a very basic sense, basically anything where the rehab provider you’re working with, your physical therapist or athletic trainer, might be a chiropractor, whoever is working with you in your ACL rehab. They put their hands on you to manipulate the knee joint, the knee cap, basically working on range of motion, flexion or extension, maybe a some rotation there. Maybe it is something where they are working on soft tissues around the area. It could be the hamstrings, it could be the quads, it could be the glutes, calves, you name it. But it’s essentially just hands-on work. Some people will refer to it as massaging. There could be some more rhyme and reason to it. Physical therapy, basically it is called manual therapy. 

And so then therefore this is something that relates to ACL rehab in a sense, especially more prevalent in the post-op and especially post-injury where the knee is a bit more restricted and needs some assistance if you will, some passive assistance. Because we are guarded with it. So then therefore it just feels like there needs to be some manipulation of the joint. And especially a lot of you listening to this probably feel this, especially when you are post-op. This is when you’re needing some type of assistance because you feel pain in the joint and you’re a little guarded and you’re also worried about this brand new ACL that you have and especially bending the knee feels really difficult. You’re scared you’re going to pop something or the ACL is going to do something. Just so you know you’re totally fine—that thing is locked in there and anchored in there. But it feels that way because you have had a major reconstruction or even after the injury, you’ve had a major injury to the joint. Your body is doing its thing to protect the joint. It’s in this like acute inflammatory phase. But the thing is, is that we need to get the knee to move a little bit so then that way you don’t get locked up. So that way you can restore your range of motion, get the quads going, all the things. 

What is very common in this process is once you are post-injury or post-op, you will see your physical therapist in person and they will start to assist you with, especially some range of motion pieces. Now there could be some caveats here. If you have a meniscus repair and you might have some sort of restriction there, or maybe some sort of other procedure. But let’s talk about just basic ACL reconstruction that most people get usually are able to extend and flex a leg as they need to. Even with a meniscus repair up to 90 degrees is usually at least. The most conservative baseline that we’ll see with most surgeons. Basically, you got to get the thing moving. And so yeah, when you show up to physical therapy, your PT is typically going to help assist you to move that knee. You’re going to potentially take off the brace if you have one. And then the goal is going to be start working on some quad sets, getting the quads going, getting some flexion, some heel slides probably in some sort. And this is something where your physical therapist might assist with the hands-on work—range of motion here.

The thing that we will often get the question about and some skepticism—which is fair from ACLers who are interested in working with us remotely. They’re like, how are you going to be able to move my knee? Especially in this post-op or post-injury process. And these ACLers, especially who are very stuck on this end up being the ones who have potentially gone through their rehab process for maybe even, let’s say a few weeks, if not like a month or two months. We’ve seen this up to six months and beyond where people are still working on range of motion pieces, or maybe it’s just a part of the philosophy of the physical therapist and their clinic. This is the one where people are potentially just guarded in the sense of, “Well, you know, I’m used to this manual therapy and how are you going to manipulate my leg?” And especially if that provider has had a very strong stance on utilizing it in your sessions. And they’re going to be working on typically your range of motion passively. They might be doing some soft tissue work around the musculature, whether it is the hamstrings and the quads, maybe the calf. Those are usually some areas you’re working on. 

I could also ask the question about this if that’s worth the time that’s being directed for it for this session. Or maybe they bill manual therapy as a code and they have it as the standard that everyone gets. This is something that you guys think might not happen, but it happens a lot. And we are in the landscape of healthcare, we are in the landscape of insurance, we are in the landscape of coding and billing and time per units, so therefore reimbursement is going to be dictated based on the codes that you are putting in. Therefore, there are clinics that have standard procedures of, “Hey, you’re going to do manual therapy for X amount of minutes,” so we can make sure we build this and it’s justifiable enough medically to be like, “Yeah, that’s going to be a part of your plan.” People just almost get into that process and even physical therapists because that’s just what the norm is. But I’m not saying the norm is good. 

This is also not saying that every single physical therapist and every single clinic is doing this, but there are a lot of them that are doing this. Why I’m bringing this up, is because sometimes it just doesn’t add up to the time that is being spent. This is all about opportunity costs at the end of the day. Should we spend a lot of time working on this range of motion? Or should we be focusing on some things that are maybe more active and maybe more things that maybe you can do at home? Maybe things that you need a little bit more of an eye with, or maybe you need some more guidance with. It may be some things that are just more exercise-based in nature. 

We just literally had an athlete start working with us. When I asked her how her PT was before? She mentioned that she would walk into the clinic, she would literally do almost an hour’s worth of hands-on work—range of motion, some massage work and then she would walk out. No exercises, no active thing for her to do and now this is an extreme example. But it’s really common for this to be a part of the treatment session, especially earlier in the ACL rehab process. And again, nothing wrong with this. This is something that can have some value and carry over to it. The biggest question that we’re asking here: is it needed? Is it wanted? Maybe you like it. But is it needed and is it a must for a successful outcome of ACL rehab? One of the things that I do want to share with you is my stance on this as both a clinician and an ACLer going through this process; especially when we’re talking about the range of motion and the patellar mobility. 

First as an ACLer with my two ACL experiences, I had my PT helped me with moving my knee post-op. It was great. I felt confidence with allowing that person to help me for the initial piece of it. It gave me some comfort. It was almost similar to some degree as the CPM machine. It’s funny for my first ACL I did not get any CPM machine. And my second one, I did get a CPM machine. And for my second one, I got a little rely on the CPM machine. I was like, oh, 

Here’s the thing that was so interesting was I got to rely on it. It was a problem and it was all passive work, especially if your physical therapist or you’re in a CPM machine. This is all passive work. Initially, we’re talking guys like maybe for the first week or two, and of course this varies per person. But passive work should slowly phase out. But when I say slowly, like within a few weeks at most. This is something that we’re wanting to make sure that you’re not just passively rolling along. There’s active work that is at least combined with the passive work even if it goes beyond that. And the thing with me as an ACLer is that I actually had some delays in my range of motion because I got to rely on my physical therapist, helping me with some of the passive work and with my CPM. This is where I think manual therapy could be a double-edged sword initial entry into it. This is something that can be helpful to help with the fears of maybe moving the knee around, which I think is the main thing that a lot of people deal with. And then it’s a matter of almost getting too reliant on the passive work, where there’s not enough active work that you’re doing. And then you’re hoping that your range of motion will come along with the passive work. 

And what I mean by the passive work here is that it’s basically don’t think about any muscles working. You’re just using either gravity or someone else, or maybe you’re using a strap to be able to help assist it. And then no muscles are really engaging to be able to do the active pieces. So that’s what we call the passive range of motion versus the active range of motion. This is really interesting because, at the end of the day, we need the active to match the passive and we need the passive to match the uninjured side. There’s these pieces or these heuristics, if you will, that help guide us and getting our range of motion back. But the thing is, if we just rely on the passive pieces, it can make it difficult to get the active components if it’s not embedded in there as well. 

As a PT for my in-person ACLer, I might help them with the first session or so, but you can literally ask any of them. That’s pretty much it. After that, I show them what they need to be doing at home. And we focus our efforts on other areas that are more exercise-based and active. To me that is worth our time together because I can teach you strategies to be on top of that on your own. You can be at home, working on this stuff with so many different strategies to work on range of motion, passively and actively, which is awesome and I love because that puts you in control of the process. This is something that I want to make sure that we do educate our athletes as best as possible. This also allows us to focus our time on other areas that we might want to target together. They have that accountability and focus on things outside of our sessions. 

Even then, let’s say you are getting physical therapy three times a week and you get an hour for it. That’s usually the higher end of it—three times a week. You go there for an hour. If you spend 20 to 30 minutes of each of those sessions doing manual therapy work, I think that is a huge miss to be completely honest. Unless there is some small or certain situations where you might fit into where that makes sense. But for the majority of ACLers, that’s a huge opportunity cost. It’s something where, “Is this something that’s worth the time that you’re going into there?” When you could be working on probably 90 to 95% of that work you’re doing there at home. Why can’t we focus a little bit more on some other areas where you can really reap the benefits of being in-person and being able to get that work with that person you’re working with. 

This is the exact same thing for our remote athletes, we teach them the goals we’re aiming for, the range of motion targets, our milestones we’re aiming for and set up these goals and the movements. We give them the visuals, we give them the demos, all the things that they’re supposed to be feeling, queuing and executing on that. If you can follow those things, which majority of people can, then they don’t have any difference in outcomes compared to the people who are going in-person. They’ve just been educated and guided on it. We get to continue to monitor and measure that over time to see the progress or potentially 

The same thing goes for any type of soft tissue work. Instead of focusing our time on that in our sessions, we know strategies at home using a foam roller, lacrosse ball, tennis ball, massage gun, any other implements, all accomplish a very similar outcome. There’s nothing magical about our hands as much as a lot of us, physical therapists, would like to think there are. Pressing into someone’s tissue or muscles for relaxation compared to one of these objects. If you lined up 10 people and someone put their hands and did a massage on a certain area, did with a foam roller or a lacrosse ball or some massage gun, they’re probably going to feel some similar-ish benefits if the pressure is all equaled out here. It’s not the carry-over is going to be so drastic over days and weeks and months. It’s a very transient feeling to begin with anyways. This is something that we try to teach our athletes to have their own self- assistive work. That we would want to spend more time focusing on other areas and potentially plugging these types of things on a certain days or strategically placing them, to make sure that they’re able to chip away at it over time, actively. 

In terms of why I actually love this perspective of being more hands-off if you will, and active in our philosophy, in our approach, it more importantly shifts the locus of control the athlete who is feeling empowered in this process in a sense. It shifts from the provider to the athlete. Instead of relying on the provider to feel the safe place to move the knee or be reliant on doing the range of motion work passively, the athlete is in control of their process. They’re the ones who are given the responsibility to do the work. It creates autonomy and independence early on in the process. It includes them in the process. I think that it is something that really does promote the active piece of it. Because a lot of times, we can get so passive having things done to us. I think that there can be a huge carry-over with being able to allow the athlete, teach the athlete how to do this and spend our time wisely during our sessions, whether it’s in-person piece or whether you are working with ACLer remotely. This is something that I think we have to just be very strategic about—what is our lowest-hanging fruit? Is it worth our time here and is it something that we can teach the athlete to really do on their own and just continue to monitor the progress of it over time?

Now don’t get me wrong it can have its place. I’m not saying it’s bad. It’s just whenever we have athletes who are talking to us and I’m consulting with them, or they’re wanting some opinions and a lot of times I’ll hear, “Yeah, laying on the table for 30 to 40 minutes of the session or all I’m doing is stretches and range of motion work.” There’s so many other areas that are untapped and I almost feel like it’s a limitation of that physical therapist or their model that you’re not being served your best. I can’t think of many situations where majority of the time that should be your focus. 

Even with the ACLers who have such difficult range of motion. I’m talking about 70 degrees flexion they’re stuck at; plus 10 degrees of extension.I’ve seen them all. The thing is there are ways for us to still strategize things, to focus on the range of motion as a big priority. But then we can also move the needle on other areas, especially strengthening and being able to educate our athletes on doing other active pieces, just outside of the passive range of motion or manual therapy work that can be a part of ACL rehab. 

This is something that I just want you to view as a pie chart. A lot of times in the early post-op phases, this kind of manual therapy or assistance in range of motion can be anywhere from 505 to 70%, 80%. But what if we reduce that down in terms of how much of that pie that should be a part of your session, there’s a huge priority for you to work on. But what if you can allocate that time to something else with your rehab provider, where you can get a lot out of the strengthening pieces, positioning. Maybe you guys can throw in some conditioning work that can make you feel a little bit more like you’re working on some metabolic stuff, some energy system stuff. You’re able to go home on those other hours outside of the three hours that you’re only with your PT in person, to be able to go work on this range of motion pieces. Or, if you’re remotely, then you can build it out, however, is best for your schedule. You can also be able to utilize your training sessions and be very targeted with those.

This is just something that has come up and we get questions about this. I think one of the things is the reliance and the passive nature of what manual therapy can do. And knowing that really you shouldn’t be on the table all that much with ACL rehab. I think that there’s this notion of  “Yeah, we got to get on the table.” We’re going to do our quad sets or straight leg raises, our clam shells, our hip abduction, hip adduction—I’m naming all the basic post-op exercises that you’ll get, the starter kit, if you will, for ACL rehab. Not our starter kit, but most starter kits everywhere else. And the thing is that at some point in time, we do get to progress past that. I think what can happen is that we get funneled into this process and system where it is the routine, this is what we do. I think that time can be optimized better. 

The most important takeaway here is that there should never be a reliance on someone else, especially for hands-on work in this ACL rehab process. It’s something that I honestly get away from as quickly as I can with my athletes, especially in-person because they don’t need me for it. And guess what? They are able to get the range of motion back as they need to, being able to have their own self management strategies and being able to work on that stuff actively on their own. 

If you guys have any questions on this, you know where to find me. Send me a message on Instagram (ravipatel.dpt). You can send me an email. You can also send a message through the show notes below. Until next time team. This is your host, Ravi Patel signing off.