Episode 183 | Do You Feel Behind In Your ACL Rehab? – Part 1

What is up guys and welcome back to another episode on the ACL Athlete Podcast. Today, we’re answering the question and the topic: Do You Feel Behind In Your ACL Rehab? – Part One. We are going to have a two-part series here, where we dive into this question: Do you feel behind in your ACL rehab? Now, this is something that I honestly can’t believe, I haven’t done an episode or a series on this, so we’re going to be tackling this. I think this comes at a really good time with recent talks with different ACLers, whether it’s on a consultation basis and even some of our athletes who are having this notion of feeling behind just kind of bleed into their process. This could also be with just some different parents we’re talking with, if it’s a younger athlete. It happens with most courses of action, if you will, when you’re dealing with ACL rehab. 

This is definitely a big feeling for ACLers who are just going through this process, feeling “behind” with the timeline and where they’re at. Because they are not making progress or maybe they have been communicated at some point, they are ahead of schedule, if you will, are doing well above the average, which we also hear, which can be a dangerous place to be as well. This is something that we need to dive into and make sure we cover because it is such a foundational piece of this process. I’m excited to talk about this and that’s why we’re breaking this up into two parts because I want to make sure we do our due diligence to talk through this, give some really actionable takeaways. I’m really excited for this series. 

This really did kickstart with this conversation with a specific athlete. She is non-operative and she has been doing really great work for five months, being post-injury. Her orthopedic doc, who is a non-operative orthopedic, told her she was behind. This was a recent evaluation that she had and she says she left the session feeling super upset, especially since she’s done her research and has been working really hard in her rehab. We broke down where she is, some of her numbers, what’s being done in terms of her rehab. She is now doing some running and some jumping and some entry-level change of direction. Her biggest goal is to get back to skiing next season. And then I asked, what is it that the doc is basing this, “You are behind off of.” It’s always so interesting whenever there’s such a strong opinion or statement made, and it was all based on a super short visit and it was off of just testing her knee on the table. She had a little bit of swelling and still has some limits with deep knee flexion when she’s squatting, so coming out of that position, but no instability. She’s doing all these things now, being five months post-op, without an ACL. She has no instability. I was like, how is this justified as behind, based on what litmus? Especially with non-operative of all things. There isn’t this magical timeline of all right, you’ll be back to doing this thing at this time point, like their estimations, if you will, but non-op is even just a crazy world in and of itself. You might have a little bit more predictability with post-op, non-operative there’s so much variance in it, based on the injury and all the other concomitant injuries, the associated injuries, if you will, in addition to the ACL. That’s going to play such a huge factor into this, not to mention all the human factors of where this person is in life. What is their work? What is their habits coming into this injury? What are their habits after wards? All these things are going to play so much into the way the knee responds. There’s a lot of it that is a little bit out of the athlete’s control. Because we’re dealing with the human body, we can’t control these things completely. 

People who have their ACL’s healed; some people who don’t have their ACLs healed. And they all can do, okay, depending on their status and the way that their knee handles this stuff. But this is something that is just crazy to me, that someone was like, yeah, you’re behind. I was like, on what basis? And honestly, the thing that really just pissed me off was that, what this doc told her, she was not going to be the same ever again. If that tells you anything about this doc, it’s just not a good doc. But it’s interesting because this happens all the time. Now, it can be to the same degree, whether it’s off of no basis, it’s off of someone who has terrible bedside manner, who literally put someone down instead of build them up, which is just bizarre to me in the healthcare space. But the other thing too is that, even with most of this process, time is going to be such a staple conversation along, with everything that is discussed. Especially if they’re not as much up-to-date or maybe they do just go based on 3, 6, 9 months. If we’re lucky it’s 9 months or 12 months. Sometimes it’s not even mentioned that and it’s just like, all right, six months or three months. It’s crazy. I literally just talked to somebody they’re 4 months and their surgeon said you don’t need PT anymore. They’re still dealing with swelling and a lot of other issues. They have been told to stop going to PT because it’s no longer needed. Just figure out the rest of it on your own, which is really crazy to me, that people are communicated these things. 

With this space, I think it’s just tough because time is going to influence so much of the decisions, in terms of where you are, and then that’s going to align with you feeling potentially behind because it was communicated. If you are in this ACL rehab process, unless it’s literally days after your injury or maybe even surgery, there is a very strong chance that you have had this cross your mind, or maybe even communicated to you about possibly feeling or being behind. The orthopedic surgeon has a strong influence on this and so does your physical therapist or athletic trainer, whoever is a part of your ACL team and is very involved in helping to navigate or construct this process. A lot of it comes back to their philosophy, their education, their experiences, keeping up-to-date on things or the lack thereof, etc. There are a lot of things that influence what someone is basing their opinion off of. Even for myself, there are so many different pieces that play into what I will share my opinion of. But I make sure it’s rooted in things that are really important like what are principles, what does the science say, what does the research say, what are things that are coming out that are newer to keep myself up to date if I’m in this space, what are experiences both personal, what about experiences with working with so many of these athletes, what about the education that I’ve gained from all this and knowing about the human body and anatomy and physiology and biomechanics, all the things that play into this and just having that experience—the unfortunate but also fortunate experience of having two ACL injuries. I can pull from a lot of different perspectives that I am fortunate to have learned from and I’ve worked really hard to gain this experience. This is something that I think a lot of professionals, depending on their setting as well, there can be some limitations and then therefore, maybe it’s just what they learned that it’s like, all right, this is a timeline, this is a protocol and this is how we do it. 

I find that this comes from all the different professionals. Anyone who bases things off of protocols or time-based progressions, as I mentioned. It’s not just like, it’s just the surgeon or just the PT or just the coach or the trainer or whoever it is. It could be any professional. It’s just a matter of like, what is it that their background is, and that is going to influence thing. The thing that I do want to share with this is that when you are a part of the medical team and depending on your experiences and beliefs and things of that nature there can almost feel like there’s this hierarchy or this authority figure. A lot of times the surgeon can be in that seat. It could potentially be your PT or your coach or whoever that is. But there is this common feeling of like, all right, well, the surgeons at the top and the PT maybe is below them and it’s kind of this hierarchy model and I hate it, but it’s just what exists in this space. I don’t know if it’s just this, you’re in this fancy medical facility and they’re doing this expensive, very serious operation. And then, therefore, their expertise and level is higher than anyone else. I’m not trying to throw any shade or anything. It’s just like the nature of what this process is because it’s funny. 

There are so many times where people come in and they trust you and they’re like, yeah, I’ve put my full trust in anything that you say, which you don’t do that blindly. But you’ve earned that respect and trust. But then for some reason, they’re getting some sort of negative information or maybe not helpful information from their surgeon. And they’re like, oh, well, I got to go check on my surgeon or I got to go check with this. It’s okay to do that. I think that that’s totally fair and it should be on the same team. But sometimes it’s crazy whenever they’re also saying, oh, like, this is… It doesn’t make sense. It’s not on the basis of anything. It’s just something that they said and there’s no backing to it. 

I’m going to get off of this little tangent here, and we’re going to redirect back to this conversation. I did want to share that because I think it is important to kind of understand, why do we put so much weight into this? And yeah, they did the surgery. But there is some things that could be just very challenging based on the experiences and what they’re seeing and what information they’re pulling in to make their decisions on. Yeah, your ACL is torn and there’s some other things based on the MRI and the x-ray and your clinical testing that shows, yeah, we need to do this surgery. This is the proper graft for you. But then when it comes to rehab and when it comes to return to running, return to doing any type of agility, jumping, returning to sport and things of that nature, it should be a team-based approach. But the thing that’s always interesting to me is that the surgeon or professional is sometimes making the decision based on five minutes. It literally sees you, you’re walking, you might do an air squat. They check your ACL with the Lachman test. And then they’re like, all right, how are things going at PT and then you’re on your way. We’ll see you in another three months, if it seems like it’s the right timeline. It’s just challenging because then it’s a little bit of an uphill battle. This is where I want to just pay careful attention to who are these voices that are coming into this and what are the basis that they are making these decisions off of. 

The why behind this is because you’re literally looking at a calendar as a progress bar. So that’s where these time-based protocols come in and what a lot of surgical centers and ortho offices look at NPT offices. They look at these protocols that are created. It’s for the first four weeks, you’re going to do this, next four weeks you’re going to do this and it gets thinner and thinner as you get into mid and late stages. Sometimes it looks like a paragraph or maybe it’s like a sheet of paper and it’s like, here’s your whole ACL rehab. Here you go. This is what is always interesting because it’s usually time-based versus criteria-based. Now those do exist, but those are fewer than what we typically see. This is something that we want to make sure we come back to those criteria that are measurable outside of just time. We’re looking at range of motion, we’re looking at strength of specific muscle groups, looking at power, looking at jumping, cutting abilities, psychological readiness. We’re looking at sports-specific readiness, all these different things that we’re going to be looking at to make sure like, all right, is this athlete progressing along in these different domains alongside time. Not just because you’re at three months or you’re at six months, and then therefore you get to do X. It’s just like the same thing with school. I use this a lot. But with school, you can’t just assume just because you are in this grade and you’ve been in it for three months or six months, it means that you can just automatically just move to the next grade just because you’ve showed up. You got to take tests, you got to be assessed in different domains. And that’s what’s going to allow that to make sense for you to progress and have the prerequisites to progress. It’s not just based on the calendar alone of a year. passing. But it’s because you’re also that time passing, you’re putting in the work, but then there’s also assessments on different areas that you need to be progressing in. 

These are things that I think are really important for us to make sure that we’re factoring into this process and thinking about, all right, if I’m feeling behind, what is it that is entering into this space and in my mind that is influencing that feeling of behind. To share some examples here, it might be running by 12 weeks. They feel behind. Doesn’t have full extensions by four weeks, then they’re behind. There’s a whole laundry list of things that we could say like, oh, they’re not at this point in the timeline, then they’re behind. And that’s the thing that we will often see and it is based on those protocols which most are often  arbitrary. They’re a little bit of a shot in the dark to be completely honest. When you ask potentially the surgical office or you have this PT office, whoever’s created it, a lot of times it’s just maybe from other existing protocols and then you find out where those protocols are from. And then you’re like, oh, well this was created in 1996 or 2001 or 2005 and it’s just crazy. The thing is we’ve learned so much, even in the past few years of ACL rehab that has changed what we do at the ACL Athlete. It’s crazy if these protocols aren’t constantly being updated and the good ortho clinic surgeons, the good PT practices and people who are with it and doing this are updating those all the time and reiterating those. We will often see sometimes, a patient or an athlete will have their surgery and the surgeon gives them their protocol. And then we’ll see in a date where it was last updated and it says like 2001, I kid you not. We’re just like, ah, how is this possible for such a high reinjury rate, for something that limits people from getting back to what they love to do from an activity level of just being physically healthy, mentally healthy, how is it that we’re not looking at this. Instead, maybe we’re pivoting to what’s the best graft type or technique to do for ACL rehab to prevent injuries when we need to have such a huge emphasis on the rehab because that’s honestly where the biggest gaps do exist. Because we know people who do a successful rehab, who tests really well, go back to their sports, and are less likely to injure their ACL. There’s no one that is going to have 100% protection against an ACL injury; not even the healthiest and healthiest of athletes. Therefore, there’s always a risk when you go in do activities and play sports. 

This is where the focus needs to lie. This is something that I want to dig into—where does this feeling of being behind come from? Where does it come from? I’ve shared some thoughts around this, but I want to dig in deeper on this because I think it will be helpful for you, especially if you’re someone experiencing feeling behind. Well, where is this voice coming from? This can often come from unrealistic expectations you have for yourself in this process versus the reality of it. I’ve talked about this on multiple different podcasts about expectations versus reality, because it really does impact so much of what we do, our actions and especially if that expectation does not match up to the reality. Especially if it misses, then we’re bummed as humans and it really impacts us in a negative way. This is one of the things that we need to make sure we check. But usually there are certain factors that are feeding into these expectations versus the reality that we do have. Let’s dig into those. Whether that is your ACL team or the person associated with it. Is it a narrative that is often communicated by maybe your surgeon, maybe it’s an assistant there, maybe it’s a physical therapist, maybe it’s an athletic trainer, a coach, think about anyone who is on the ACL team to help you move the needle. Is this someone that is potentially putting a narrative that’s you’re behind or you’re not caught up, to where you need to be, based on the protocol or based on this certain time point. And usually something time-based is what they have in their head. Or maybe it’s another supporting role. Maybe it’s a supporting role, a parent, partner, agent, sport coach. These types of roles can also play into maybe that expectation versus reality and putting pressure on yourself without even knowing it. I know a lot of younger athletes they have parents who are vicariously living through them, trying to get them back to basketball and thinking they’re going to be the next phenomenon in their sport. 

This is something that we need to check and make sure what are these voices that are coming in, that are influencing potentially the expectation and this timeline and this feeling of feeling behind. Is it comparison? It might be a friend, it might be a teammate, it might be Bertha, your PT clinic, it might be a pro-athlete story that you heard that they got back in four months. People always reference the Adrian Peterson story here and he got back really quick. He’s also 0.00001% of athletes in terms of genetics and their nature of who they are as humans. The Olympics is going on and I mean, these are people who are cut from a different cloth. Man, they’re built differently. Their genetics are different and they’re at the Olympics for a reason. And they might have recoveries that are different. This is something that I think is really important. I love that I’m seeing more and more pro-athlete stories where it’s going the other end where they’re waiting 9 months, they’re waiting 12 months. They might wait even longer because they’re not feeling ready. These are things that we want to align with better versus the athlete who got back in four months, because it’s just not realistic. It’s just really not. In the current state of ACL, we can’t do that unless there are significant risks, and that needs to be converse with the athletes and associated with those risk and reward of things. 

But with said, pro-athlete stories could be playing into this. I know that if you have a certain idol and this happened to them, then this might be something that plays into it. Social media can be very dangerous, maybe it’s Facebook groups, Reddit. I know all of you listening, you guys kind of peer into one of those categories and you see that. I know that the groups can feel like you’re not alone, but you have to be really careful. Because a lot of times what happens is in these groups, the people who have this success stories, they might come back and share. But then those people kind of kick that stuff in the dust, they’re gone there. They’re ready to move on. No one wants to just live in the ACL world and constantly do that. Now, this is not everyone, but I would say a good majority of people who are done with this and move on and go back to their sport activities. They’re not hanging around in these groups as much because they’re not dealing with problems. People are usually in these places because they’re dealing with problems and wanting to find other people who relate to this and can communicate with it and maybe find solutions to their problems. It’s what makes people move. And that’s why groups are so valuable and there’s nothing wrong with them. You have to be careful because comparison can really play into this. 

I’ve literally had an athlete who is like, I feel like I got the wrong graft. And I was like, why? And they’re like, well, you know, I was reading in these groups where people had these experiences with my graft and it didn’t sound so positive. And that’s dangerous because that puts a negative kind of thought virus in your head of like, oh man, did I make a mistake? In reality, people anecdotally speaking their own experiences. But then there’s these whole other group of people who are crushing it with the same graft type, that just aren’t speaking into it because they’re gone. This is something that you need to think about in terms of these voices that potentially play into this. Or, the last thing that I’ll say is maybe it is yourself. Especially for the type A folks or people who have a lot of time-sensitive goals, you have something to get to and you only have maybe seven or eight months to get to it. Maybe it’s 9 months and it’s literally atime-sensitive thing. Maybe this is the only shot you got, or maybe you paid for it and you can’t get your refund. There are a lot of things that can create pressure on yourself. Especially if you are one of those high performance people, then you’re like, well, I can do this. But you also know that you are having to work against your body, which has its own timetable of healing and recovering and adapting in a complex injury like ACL. This is something that can be self-created. It’s feeling like it’s a race against the calendar, against the time for that particular goal and often influenced by seeing a protocol. This could be based on the professional you’re working with.

I was this type of person and I pushed myself so hard. And then I actually had a setback and then I was behind and then I was rough on myself again. This is something that I want to warn you guys up because this is something that could be very challenging to get past, and it could influence the energy that you’re bringing into this and also not enjoying this process. I’m not saying it’s fun. I’m not saying you love the grind of having surgery and doing all these movements and feeling like this part-time job of rehab. But you’re doing it so you might as well make the most of it and also grow and enjoy this process, and use it as an opportunity to be a better person. Some of these things can really take away from that, especially if you feel behind; it sucks. 

I remember that feeling and it really was just bleeding into everything. I had to really check myself whenever I was feeling this way. Some honest checkpoints I want to have for you and share for you is, one, are you showing up and doing everything you can that’s within your control; the controllables. Versus the uncontrollables, the things you can’t control. Maybe how your knee responds to something from the surgery and it’s irritating. But if what you can control is the movements you do and the way that you are strategizing your day and your weeks with your rehab professional. This is something that you want to make sure you control and do; but if you’re doing that then awesome. 

Next is, are you getting expert ACL guidance and support? I can’t stress this enough guys. This is one of the things that is so key for you to have a little bit more peace of mind in this process, to know you have someone you trust, who is an expert, who knows ACL and is able to feel supported and heard and communicate, and know where you’re at and know where you’re headed. I feel like a lot of times, people feel lost in this process. And so that can play into that feeling of feeling buying because you don’t know where you’re at. It’s literally you get in your car, you don’t know where you are and you also don’t know where you’re going. You don’t really have a reference point of what it is to type into your GPS because you’re like, I don’t even know where I’m starting. Yeah, I feel a little bit out of control. I feel like I’m not going to get to where I need to go, because I don’t really have a clear outline of what that looks like. That’s where guidance dialed in with an expert is so key for this process.

 If you feel confident about these two things about being able to show up and control the controllables and doing what you can within that, you have good guidance and support that you trust, then honestly, you’re doing what you can and being guided to do so. You can’t be mad at yourself for that. The one thing with all of this is that I want you to take away is that you’re not behind. Let’s make this absolutely clear—you’re not behind. If you’re doing everything you can in your control, you’re having good guidance, then I think that those things are saying basically you’re showing up when you can and doing the work, putting it in and you’re having good guidance along the way. You’re having a path that is structured to you. What else more could you really ask for, in terms of controlling the controllables? This is something where if you can say, all right, I feel confident in those things, then this is something where I really want to be clear is that you’re not behind. Even for those of you who might not have the best guidance and you had to settle for a certain provider that is based on geography or maybe finances or whatever that might be. That is something that you have to see, you’re also not necessarily behind. It’s something that I think it’s more so, what needs to be communicated appropriately to you about where you are. But I think that’s the most important thing here is, if someone isn’t doing their due diligence or they’re not doing their rehab, not going to physical therapy, or they’re not doing their remote work or whatever that might be, then that is on them. Honestly, that could be playing into you being behind. 

There are athletes who truly are behind because they’re just being lazy and they’re not putting in the work. Or sometimes it’s tough because they’re just not doing the right work. And that’s why I said the guidance is really important because that is where that’s going to really help to make sure you’re being as efficient as possible. But with that said, for the most part, when people are like, I feel behind, but I’m doing everything that I can; you’re not behind. I think that’s the thing that I really want to stress. The thing that I want you to think about here is that, there’s track athletes, racing to the finish line. We’re watching the Olympics and you watched a 100-meter dash. They are all racing against time and against all of these other athletes to see who finishes first. The way that I want you to think about this is that you’re on a track by yourself. Now, it sounds lonely, but you’re running your own race. You’re running to beat yourself. You are not running against all these other athletes, especially from comparison. You’re just trying to improve yourself. You’re trying to move the needle. You’re trying to keep the momentum going, but you’re running your own race. And that’s something that we try to share with our athletes, is run your own race. Don’t let comparison steal the joy of this process. Comparison is the thief of joy. This is something that we want to make sure you’re running your own race and you’re not feeling behind. Everyone is going at their own speeds due to all the human variables and controllables, and uncontrollables that take place. What we can do is take a hundred athletes, same sport, same graft, same procedure, even same surgeon. And I promise you, there’s going to be a decent amount of variance between these athletes. Why? Because we’re human and there’s a lot of things that can vary person to person from age, gender, genetics, lifestyle, mindset, life phase that they’re in, all the stressors that they’re dealing with, socioeconomic status, the rehab itself and who is guiding them within that. And so much more than I didn’t even list. There’s so many variables that it would be this huge laundry list of different factors that play into this. When someone says you’re behind, what is this based off of? Is it a timeline? Is it a protocol? Did they even use anything concrete to truly assess you like range of motion, strength, etc.?

Just to give you guys an example, and to finish up part one here. One of our coaches has an athlete who has absolutely crushed it, super freaking strong, has tested out really well through all of the gold standard resources and is ready to go and return to sport. They’re at 9 months, the athlete went to go see her surgeon and her surgeon saw her and said, wait, three more months. Wants to know the basis of waiting three more months to return to sport? Why the surgeon said that? Her air squat. Her air squat had her knees kind of come in a little bit, which is going to be knee valgus. This is typically demonized, depending on your background. But we know that there’s actually no relationship between knee valgus and ACL injury. This is something where the surgeon saw an air squat, probably a writhe, maybe two, given the minimal time and exposure, that they get with this athlete compared to their rehab providers. This athlete did this movement and all of a sudden this surgeon said, let’s wait three more months. We want to see this improve. Didn’t look at much of anything else, strength testing, any type of jump testing, any stuff that truly shows her ability as an athlete, to see her stats of the strength side to side and how she’s pushing out 3.5 Nm/kg bodyweight. We would crush for those numbers. That is absolutely insane from a strength standpoint for your quads. And yet the surgeon saw one or two air squats, and was like, no, we’re going to wait three more months. It’s wild the basis that these things are coming off of. 

What I want to do, and the goal of this podcast is really expose, honestly, it’s just to expose the space, is to educate you guys, allow you to see what exists and what I see as someone who has gone through this process, who works as a physical therapist, working with hundreds of these athletes. Our company running as working with tons of these athletes and then also working with other clinicians and coaches, hearing stories and consulting with different ACLers.  There’ve been a lot of reps, not only here in Atlanta, but all over the world. The thing is that we have been able to take in so much information and so much data that I feel very confident in the things that I’m saying. If 182 episodes don’t say that, then I don’t know what does. But the reason I’m sharing this with you guys is because it really frustrates me when I get on a call and these athletes are beating themselves up and you might be one of those athletes. I feel so much of this because it is something that I dealt with. If I had the right guidance, I wouldn’t have dealt with it. And that’s the thing that I want to make sure that is very clear here is that there are a lot of voices and a lot of opinions. Even if you are behind, it can be communicated in a way that is so uplifting and allowing us to build things up versus making you feel like you are not good enough or you’re just not doing the right stuff. They put the pressure back on you. It’s just not fair. 

I think that this is something that I struggled a lot with, and I want to make sure you guys do not do that because there are so many variables in play. If you can confidently say that you’re doing all that you can and you got good guidance, even if you don’t have the best guidance, if you’re doing everything that you can, then this is something to say, well, I’m literally putting my best foot forward. Feeling behind needs to come from some sort of very strong basis when someone says that. Not off of a 5-minute exam, not off of something where they’re looking at a protocol and they’re like, well, this is where most athletes are. But you’re not that athlete. Every ACL that I’ve seen is so different, even the same exact injuries, same exact sports, same exact grafts, every single athlete is going to progress so differently because so many different variables. 

Before I continue to just get fired up more and more, I’m going to break from this episode so we can take this energy into part two of next week. Please, listen to that episode. I know a lot of times when there’s a part one, maybe people don’t catch the part two. But I promise you guys, it will be so worth it. If you got any value from this episode today, please tune in next week for part two of feeling behind because I’m going to give you some practical strategies, some things to put into play that will help a ton, that is building off of this episode.

I’m going to sign off for now until next time. This is your host, Ravi Patel, signing off.