Episode 181 | The #1 Red Flag To Look Out For In Your ACL Rehab

I’m diving straight into it today. I am not feeling my best as you could probably tell from my voice, but the show must go on and we’re here. Bear with me with my mucusy, sick, little voice, if you can just for this episode because I do want to get this point across because I think it’s important. The episode title is the number one red flag to look out for in your ACL rehab. Now, I’m going to try and do my best to keep this short and sweet, especially since you guys have had longer episodes recently, so let’s just get into it.

I hear so many stories of athletes and people’s rehabs, with consult calls and people reaching out and whatnot. I feel like I have a good lay of the land of how people do in this process and what their rehab looks like in different parts of the world. Here in the U.S., you talk about different regions of the world, we’ve seen it all. They’re dealing with problems. One of the things that’s always interesting with these problems, it’s not always everyone. But there is something interesting with people who have these problems and when we ask, well, have you had any assessments done? Have you had any testing done? Especially when they’re like, I don’t feel like I can still jump yet or run or any of this stuff. And they’re like, well, have you had any testing done? And they’re like, well, what kind of testing? And we’re like, well, have they checked out your strength? We’re not even talking about a few months out, we’re talking about months and months out, like six months, nine months out, even years out. This stuff that we ask people when they’re like, well, not really. What does that mean? 

This goes into the topic of today, which is the number one red flag to look out for, which is not your range of motion testing, it’s not hop testing, it’s not agility testing, it’s not your, PT doing manual therapy on you. Are they doing these like fancy little flashing lights with you, are they doing cutting drills with you, all this stuff. The number one red flag to look out for is if you are not getting strength testing, that is a very hard, concrete thing for us. As rehab providers, as performance coaches, especially working with ACLers, I cannot imagine something that is more needed in this space than strength testing. 

It’s one of the things that I will ask people: Have you had this strength testing done? They’re literally looking at me and they’re telling me, Hey, I don’t know what you’re talking about. And they’re like, what is that? And they’re like, well, I did this thing like I kicked into someone’s hand and they said I was strong or they tested my ACL and it was strong. Or, yeah, we did the squat assessment and they looked at my squat and it looked strong, or we did this leg press assessment. Those are somewhat of assessments and we’re not going to get into the weeds of those. But when we talk about strength testing, truly in this ACL rehab process, and even in performance, we’re looking here to make sure that this is particular to, especially your quads and hamstrings. The thing that I think I’m almost more worried about is that when people ask me, what is that? And they’re kind of questioning or they’re like, I think so. Maybe not. If I have to explain what strength testing is to them, then they probably haven’t had it. Because any one of our athletes, if you ask them what strength testing is, they would in a heartbeat know, oh, I know what strength testing is. I’ve had that done at this time point, or this is what we assessed. With any good physical therapist or performance coach, you’re going to know, it’s communicated to the athletes. If athletes are not aware of, okay,am I being strength tested? You’re likely to just not having it done so that’s already a red flag. 

When we talk about strength testing specifically, I’m talking about the isolation of your quadriceps muscle and your hamstring muscle. The only joint that is moving is your knee joint. And the only thing that is working for your quads, you’re doing a knee extension-based exercise. This is something where you are testing out your quadriceps and your knee extensor mechanism. So that’s essentially think about, what is the thing that makes your leg go straight. Your quad muscle is the thing that’s going to do that. You need that isolated and tested and having an objective measure associated with that. The same thing that happens when you bend your knee or bring your heel towards your butt, that’s going to be testing out your hamstring muscle group. 

These two are so important in terms of relating to not only performance after an ACL injury, but then also the risk of reinjury, super significant relationship between strength deficits and these muscle groups. The way that we look at this is through gold standard testing, which is isokinetic machine. Now, these can be hard to access sometimes. Sometimes it’s locked down by universities, or hospital systems, or certain clinics that have certain red tape around it. There some places that are awesome and they allow athletes to come in for a fee. But this is something that these machines are 50K plus. This is something that’s really expensive and most physical therapy clinics don’t have them. I would probably venture to guess that maybe 1% to 2% of worldwide clinics, in general, might have these machines. That’s a very small percentage compared to how many ACL injuries we actually see around the globe. 

The next best is isometric testing. So that’s via a handheld dynamometer or some type of force gauge. So these are these little devices that you typically see people hook up to chains or to straps. And you’re kicking into it and it’s pushing out some sort of number, whether it’s on a screen, whether it’s on the device itself. You’re getting some sort of number, numerical value, usually in kilograms or pounds. And that is going to be something that is a raw number of how much force that is being produced through that force gauge or that handheld dynamometer. Then that’s going to be converted into torque, which is a calculation using your moment arm and all this stuff. But even if you just have that raw number, that’s great, because then you can still compare it to the other side. And then also if you get the other measurements. You can start getting the torque and then how that relates to your body weight, which is amazing in what we do with our athletes. This has really grown in popularity and it’s more accessible because it’s affordable. There’s units out there. You can get a crane scale. To do this for 30 to 50 bucks on Amazon. And then there’s these awesome units now, we use 10 deck as a team and it’s awesome. This is anywhere from 150 to 250 bucks. It’s mobile. You can bring it literally anywhere. It’s literally fits in your pocket and it’s something that’s so helpful that we can use. 

It’s just crazy to me whenever clinics are like, oh, well, we can’t afford that. And it’s like, you can’t afford. Something that is so drastically valuable in ACL rehab and other forms of rehab that is $200. When you have an ultrasound machine or an east end machine over in the corner, that’s probably collecting dust. That’s probably a $10,000 plus or more. Sometimes crazy to me, clinics will sometimes value. And I think sometimes they don’t know enough information or why is it that we would use this. But we’re in 2024 now and we know where ACL rehab is. We know the statistics. Now that we know better, we have to do better. And so you’re starting to see more clinics adopt some of these handheld dynamometers because it’s more affordable and is giving us data that is so valuable to inform our ACL rehab. 

Let’s say like, you don’t have access to isokinetic, you don’t have access to handle dynamometer. We have athletes in different parts of the world where they don’t have access to those things. They don’t have clinicians who have the equipment necessary. We have to use other forms as well, especially you think about lower socioeconomic countries. Like there is not access to all these bells and whistles or access to really good care based on geography. 

What’s the next best thing? It might be a repetition maximum of a knee extension and leg curl that is done a particular way. At least this gives us some sort of proxy or some sort of number for us to understand. How do we look side to side? But if we don’t have these measures, then you’re kind of operating blindly in terms of how your knee is doing and where your perception of where you’re at and even your rehab provider and your your surgical team, like their perception of where you are. Is not completely accurate unless they have all of this information and data in front of them. Because then you’re just kinda making a kind of a subjective. Well, You look fine. You’ve been progressing fine. But again, think about all these different areas that these people are looking at, especially if your surgeon is only seeing you for five minutes, every three months. They’re not going to gather a lot of information from that. They might test your knee and you might be on your way, but even for your physical therapist, right, they’re not testing and using numbers with that and using qualitative measures, alongside that with the objective measures, Then you’re kind of missing a big part of the puzzle. It’s almost like you’re only going 50% of the way there and you can’t be confident enough until you get the other 50%, which has to be the objective data. Now don’t go jumping down your physical therapist, throat. After listening to this episode, asking them why haven’t you strength tested me yet? 

The reason I’m saying this is that there could be a number of reasons why. But the thing is that this only kind of falls into the earlier post-op phase. Let’s say you’re four weeks out, maybe even like eight weeks out, maybe your PT has said. You know, we’re not there yet. because you’re just so early, post-op, there’s no sense of strength testing you because you’re still dealing with the early post-op like pain and swelling, and you’re still trying to get some other pieces in play. It doesn’t make sense for that to be tested just yet. And even for our own athletes, we might not put that in play until week 8 to maybe even 12. Depending on how their knee joint is responding, the type of graft that they got, all these different factors that play into, when do we actually start to strength test? And you can even go back to the previous episode where we talked about frequency of testing and the structure of testing to help give you a little bit more insight of that as well. 

But with that said, we want to make sure that we are doing this testing and this is something where you basically want to communicate with your PT. And one thing that ust kind of comes to mind with this is that, you know, this is the, tell me you’re up to date without telling me you’re up to date. Talking about testing with you via one of these means whether it’s isokinetic, isometric or even a repetition maximum on isolated machine. And they’re discussing this stuff with you and assessing your strength. And how that is going to impact your rehab and your programming and your recovery. That’s amazing. That’s like telling me, what you’re doing without telling me, you know, what you’re doing. Now. While there are other areas we’d want to assess. I’d say that if you’re doing the strength testing with current day standards, Then they’re already, your physical therapist is already better than honestly, 95% of most physical therapists out there. I use this number very confidently because most clinics, I know aren’t testing and doing the strength testing, which hurts my heart so much because we still have a long way to go because for every one athletes tested nine other athletes are probably not getting tested.

This is changing over time, and I want to be optimistic about this, but as I know with the landscape and currently where we set. It’s still just outperforming these clinics that are kind of mill based clinics, pumping people in and out, they don’t have the time or, you know, they’re not educated on this stuff and they’re just like running people through. And so then what happens is that they just are like, all right, you’re good enough, just keep rolling. And this is where I have a problem with it because you can’t just treat this like another shoulder issue or  back pain. Like this is something that literally changes people’s lives. You talk about the youth athlete who tears his ACL twice. And had dreams of playing soccer. Well, he’s thinking about hanging his cleats up because he doesn’t want to do this again. You think about the skier who is obsessed with skiing. Loves it has grown up doing it. And then all of a sudden they’ve torn both ACLs, it could be at the same time, it could be at different ventures and a lot of it was coming back to poor testing and not doing good rehab. And this is something that maybe they’re like, you know, skiing’s not worth it anymore, but man, it gave them that visceral feeling. That was just amazing. It was just like they were on top of the clouds, on the mountain doing their thing, feeling like themselves. They’ve been doing this since they were a child. And that’s taken away from them and it’s not because of the injuries themselves, it was because they were just not served very well. And there are hundreds of accounts of this guys that I can just like literally line up and tell you timev after time, after time, after time of conversations, where people are just. Not tested. They’re not guided. They’re not given the right support and then they end up in these types of positions. It’s mostly just because, you know, it’s just a system thing and it’s a training thing. I hate that as something that.

As a profession we really need to do a lot better with. There are so many different systemic issues with this. And I know I’m going here on a tangent, but I feel very passionate about this and it really fires me up because I think. It’s just something that. It could make or break the difference in someone. Achieving their dream or achieving the happiness that they really care about that makes them feel like themselves, or it could send them down this spiral of depression and just not getting back to activity. You talk about the co-morbidities and metabolic diseases that come with just being inactive. And you think that these are extremes, but I’ve seen them. Over multiple occurrences; both for the positive and a lot of the negative. This is something that I want to really share openly because it’s a problem and the way that you can make sure that your rehab provider is not raising this red flag. Well, you screen them, you screen them prior to starting. And I get it A lot of times we don’t get the option to just like that our physio, like we do, get to vet our surgeon. You go to the surgical console and you kind of get a feel for it. But with physical therapy, you kinda all right, I’m starting my evaluation, I’m kick-starting my rehab. You’re just kind of in it. But what I tell people is that even when you go for your first session, second session, vet them. That’s your opportunity to do that. And yeah, maybe you’ll kind of get a little bit of a stare if you start asking them questions, but it’s your rightful duty to do so you shouldn’t just trust them blindly, don’t trust me, blindly ask me the questions and if I don’t have the responses, then I’ll make sure to get those for you. And that’s something that’s really important. I think that your rehab professionals should be able to answer those questions and be able to redirect and make sure that you are in good hands. Especially at the start of your care, you can trust them. This is something that, take those first few sessions, ask them those questions. We’ve got previous podcast episodes where we talk about, questions to ask your PT, to vet them so do that. Ask them, do they strength test and then how so? This tells me a lot about the provider without knowing anything else to be completely honest. 

If I  have someone who’s like, yeah, my physical therapists, I had a consult the other day with an athlete who started working with us. And she literally listed out her numbers of her torque output and her strength on both sides of her leg, her quads or hamstrings, and that was amazing. I was like, yeah, your PT provider was able to help you and get you. These numbers in is amazing. One of the things that she was struggling with was having a dialed in plan and all these things, but that still doesn’t negate the fact that her PT was with it enough to be able to stress test them. 

That’s something that tells me, okay, they do know enough with where we’re at in this state of ACL rehab, that they are strength testing people, which is amazing. Now I think that that is not most people coming in, which is usually a big problem that we see. So, um, if your provider says, no, they don’t strength tests (I don’t have a clear answer), they can’t directly answer how they do that. And when they do that red flag, red, red, red flag, not a yellow flag, red flag. Why is this important? Reinjury rates are so freaking high. Y’all. Whenever one in four to one in three athletes, go on to reinjure. That’s a problem. It’s a big problem. People are released back to sport or cleared usually based on time. And a lack of true objectivity is just like, all right, cool. 

You’re at like six months you’re at nine months. You kind of move fine. You did a table test. You did some hop testing. Cool. You’re good to go. But this has honestly led to increased reinjury rates. Big part of that is the lack of testing. Or the proper testing, right? Maybe they do hop testing or range of motion testing. Maybe they test a Lachman, but that’s not really testing your physical capacities to be completely honest. That’s a very bare minimum drop in the bucket of what truly testing should be for this ACL rehab process. It doesn’t matter if you’re the professional athlete, to the dad who just wants to run around in the yard with his kids. It doesn’t matter what level the criteria should be treated as the highest level, because that’s what you deserve. And so that’s what’s important to me; That’s what’s important to our team. 

The thing is that this usually shines a light on strength deficits with the testing, which is a major factor of the reinjury. 

If you never test it, you never really know it’s a problem. And I think that’s the thing is that people go along in this process and they feel okay, and maybe their rehab didn’t expose them to the right things. Or maybe they just never really tested themselves. It’s like them getting in their car and they’re just driving in their neighborhood. You don’t really test the limits of your car driving in your neighborhood. It’s going to operate fine. You’re going to really know how to test the limits of your car by going out on the highway, like a major interstate, a busy traffic area like those are things that you’re going to be able to test your car and see are the brakes working well? Does it accelerate well?  Can you like turn really well? It’s not going to be in your neighborhood. So that’s the other thing too, is that. You’re testing. might be dependent based on what you’re actually being tested on. So strain testing is really going to be very robust and is going to help you to know, all right, am I going to be ready for this interstate? It’s not the end all be all, but it is one of the main foundational pieces of this. 

To me, this honestly makes or breaks a lot of people’s rehab with strength testing, because if they’re being tested, they’re likely with a decent PT at the bare minimum. If they are not, then this is a huge red flag to me. And sadly for ACL rehab, the bar is just not set very high for this. 

Number one. What can you do? Number one, vet your PT, makes sure they, strength tests usually takes place around 12-ish weeks post-op and beyond in regular interval intervals. 

Number two. If you’ve never had your strength tested and you’re three to four months, post-op this is a red flag. I know you’re probably feeling comfortable with your healthcare. You’re probably like you like your PT. They’re nice. Everyone likes their PT. It’s rare that you don’t like your PT. We don’t get in it for the money I promise you that. And it’s a lot of work to find someone else outside of your current PT, because it’s just, just extra work man. What I’m doing right now is fine. But what I promise is worse is a second or maybe even third or maybe even fourth ACL injury. 

I hate to say that, but we’ve had people two, three ACL injuries in, and you know, there are multiple reasons why, but the thing is, is that that next injury is going to be worse than whatever discomfort you’re having to deal with right now, or whatever it feels fine for right now. You can choose the hard now or you can choose the hard later. Usually the hard later is always, always worse. You’d rather just get through that point right now and be on the path to where you need to be. And it’s one thing, if you don’t know. But after listening to this episode that I told you, I would do very short, but I got fired up. And here we are with a 20 minute plus episode again, I apologize. But. I love you guys. But it’s one thing if you don’t know, but after listening to this episode, you do know better now. Go and do the thing. Don’t tell yourself in three months, or like, you know, one time at this point, I’ll do it. Or once my insurance runs out, And that’s probably the number one thing that I see handcuffed people all the time. Your insurance handcuffs you because it’s your healthcare and what’s. Everyone is in different socioeconomic places and their coverage and support. So that doesn’t necessarily mean you need to dump it unless it’s being negligent or harmful to your recovery. Maybe you find something in addition to it to help guide you. Someone who’s an ACL expert. Someone who knows this stuff, there’s remote options that exist. 

We do remote options. There are other in-person options. Options that exist. Maybe you just go touch base once a month with that person. Think about it in a sense of like, how can you build your team and make sure you’re as confident as possible in this process? Versus, I’m feeling like your insurance is the thing that is going to be the guide for you. Because I promise you if you use your insurance as the driver of this process, it is going to fall short. It is not going to get you to the end goal. If you start to build this around, what do I need? 

If your insurance happens to support what you need, then that’s great. But just know that your insurance, like, sometimes it covers certain physical therapy and others. it doesn’t, or maybe it’s up to a certain point. Or, yeah, it’s covering this PT, but the rehab you’re getting is just literally cookie cutter and it’s rinse repeat with everyone coming through. You’re not even working with the PT, you see them with two to three other people, you might get passed off to attack or a PT aide who is there, who’s probably got a high school degree or like going through college and they’re just running you through some exercises.  Are your goals important enough for you to be able to make that switch? And I understand people are in different positions, so I’m not to say like, Hey, you just need to bail and go pay out of pocket for something. 

I know everyone’s not in that position. But what I am saying here is that look out for this red flag, because it will put you on a path that is not promising. It can kind of almost give you this false sense of hope of like you’re doing better than you are. And really any single one of our athletes. 

If you ask any of our athletes, our team in general, we anchor to testing because it’s the only way to stay honest. With this process. It’s the only way to minimize reinjury and is also the best way to maximize performance. So when our athletes come back and they actually performed better than they did, pre-injury people are like, how do they do that? 

We use the numbers. We use our, you know, ability to program and to guide them with this process and coaching. But testing is such a huge piece of that, because then we can really connect that to their goals and make sure that whatever the demands of their goals are of what they want to get back to skiing jujitsu, whether it’s volleyball, being able to play soccer, any of the sports activities you can think of, we’ve worked with them. And the thing is that we’re reverse engineering to see how can we build out their programming and build this athlete back to being better than before, but then especially going beyond the demands of their sports. And then that way, when they step onto the field, they go to do a rock climb. When they go to get on their skis, that they feel better than they were before and feeling very confident in their body. Not only that, but they have been tested and they’re like, you know what? I know. Not only do I feel great, but I know objectives early. I’m on it. They feel confident knowing that if you look across the literature, my risk of reinjury is so low, which is also why. My team has felt confident for me to get back to this sport and do this thing without any hesitations. 

Big red flag here is if you’re not getting strength tested at some point, and you are three-plus months out from ACL rehab from surgery. And especially if you’re in six months and beyond, anywhere in that timeframe in all honesty, after that eight to 12 week window, post-op. If the conversation hasn’t opened up or you haven’t been tested at all—red flag. This is something that I would think about, I wouldn’t make any rash judgements, but ask questions. It might just be a pivot to be completely honest with you guys. And we’ve had athletes do that. And just know it doesn’t necessarily mean you’ve got to just jump ship unless your coverage depends on that. Maybe it’s something where you can look at a combined effort. We have a lot of athletes we work with where they’re getting in-person support, but then they want us to guide the process. 

So we’re doing remote coaching with them remotely, and we’re giving them everything that they need. And they’re getting the shrink testing and everything, whether it’s referring or we build that out for them. And then they are able to still have that in person. touchpoint as they need as well. If you need any help with this, if you’re an ACL or feeling loss, or you need guidance on this, we’re here to help. 

If you are looking for better care or if you’re just looking for someone close to you, we have an amazing network of people that we know. So please reach out to me, reach out to ravi@theaclathlete.com. Send me a message on Instagram, whatever that is. send us a message. And if it’s something where you need more support than that. Head to our website. We have one-on-one remote coaching. We would love to work with you. we work with people all over the world, different sports, different ages, different cases. We love this stuff and we would love to support any of you on that journey. Until next time team. This is your host, Ravi Patel, signing off.