Episode 192 | Cleared But Not Ready: Understanding the Difference in Medical vs. Physical Clearance in ACL Rehab

We’re jumping straight into it today. This is all about reframing this term clearance or graduated. We’re going to specifically focus on clearance because that’s the one that is usually used in this process. But I think it’s important for many ACLers because they will face the situation where they get cleared or they’ve graduated ACL rehab. Maybe you just kind of finish because you finished your insurance and your visits, or maybe it’s just the value wasn’t there. Maybe you didn’t even get to this point. But a lot of times people are trying to chase this getting cleared or graduated in ACL rehab. 

Let’s try to address this particular idea and this concept that a lot of you will face. This can come from the surgeon or a physical therapist, maybe an athletic trainer, or a combination of these stakeholders where you will get cleared or you’ve graduated ACL rehab. But usually in most cases, the way it’s done, it’s the surgeon who ACLers look towards. I’m not quite sure why it’s the surgeon’s decision that weighs the most. Mostly, because they’re assumed “at the top of the totem pole,” or of this hierarchy. They did the surgery, they’re the ones you talk to probably initially, because a lot of people don’t connect with their physical therapist until after. But with that said they are the ones who are helping to navigate some of these decisions of the surgery. They’re doing this major expensive surgery. It seems very important, which it is. And so they’re in this position of authority. They’re a medical doctor.

The PT or the rehab professional also is in a position of authority. But for some reason, it’s presented as this hierarchy. It doesn’t seem as high as the surgeon. It’s a house being built and there’s a project manager and then there’s all the contractors and people coming through. But in all honesty, it’s not like that. There needs to be basically multi-project managers within this. They are working together as a team in order to decide what is the right path. There’s checks and balances within this. But for some reason, it almost seems the surgeon can dictate a little bit of this project management. But this is where it can be challenging for a number of reasons.

Number one thing is that people will take the surgeon’s advice at face value; especially if they have some type of reputation for a pro sports team or worked with this particular athlete. And I get it, ACLers are unfamiliar with this process so you’re looking for guidance. And most importantly, to be cleared and done with this process. No one wants to stay in at longer than they need to. You are trusting this medical professional to be able to help guide you, to give you appropriate advice on what to do. This is something that you want help with and we don’t know any better because it might be our first time. It might be even our second time. But we are trusting this person who has gone through and have been educated on this and trained on this to be able to help give us really solid advice on this. And while this is something that is important to take into consideration their information that is provided,  this is something that we need to make sure we factor into the entire decision-making process. 

What I want to do is share a story. I had an ACL who is six-ish months post-op get “cleared” by their surgeon. Now, prior to the six-month visit, we had this discussion, the work that still needs to be done for this athlete, they are not at a point of clearance. Also, it’s a nine to 12 month process for us, especially getting back this athlete to playing a higher level of cutting and pivoting sport. They knew that there was some time left, but they went to the surgeon visit and the surgeon said, you are good to go. You’re cleared. You don’t need to come back and see me. This is the same song and dance we hear from so many athletes all of the time. It might be six months, it might be even at the nine-month mark. This particular athlete came back and said, yeah, the surgeon said I could do all the things now. I always asked my athletes when they’re—especially as this discrepancy between what we’ve been talking about, where they’re at and what the timeline and their roadmap looks like versus what some other professional surgeon, and maybe it’s another professional involved says, their timeline and what that process looks like as well. I always ask my athletes: How much time did this person spend with you? What did they do? What did they make this decision based off, ultimately that bias that they’re giving you? Also, I asked them, how do you feel you are based on being cleared and their perception of where they are from zero to 100%? Often this doesn’t align. Sure enough, when I asked this athlete, it was five minutes, tested my knee via a Lachman’s test. This is where everyone knows the surgeon will grab the top of the thigh. They will grab right underneath the knee cap with their hand, and they will pull this knee back and forth to test the integrity of the ACL ligament. A lot of times they will say the ACL is strong. And it’s like, yeah, the ACL has an end feel. Sure, it’s there. You can’t tell if the ACL is stronger, not to be completely honest. You need an MRI, you would need so much more detail to know if the ACL, the thickness of it and even then the composition of it is not truly there. We know the ACL can take up to two years to heal. So then therefore us doing a physical Lachman’s test only tells us that the ACL is present and maybe a little bit of translation or the laxity of that ligament. But other than that, to be honest, you can not know if the ACL is “strong.” This Lachman test just lets us know, is there an end feel? And is that ACL present? And maybe a little bit of laxity, especially if we compare side to side. They will move it around. You might test some extensions, some flexion on the table. And then the surgeon will potentially do a squat, maybe a single leg squat. I remember, whenever I had my conversations with my surgeons for “clearance.” There was no testing. It was literally five minutes and there was nothing else done. For my first ACL, I had no testing. And so this is something that is bizarre and almost makes me think about, my second ACL tear. With that said, this is all based on a five minute exam, maybe 10 minutes, if you’re lucky. 

When we take a step back to assess how the decision was made, we start to see how this misses the mark on such a huge decision. We are saying that you can start going to play the sports and activities. This is based on this five-minute exam. In situations like this, this is where we need to be detailed in clearance. This is my point of this podcast episode. This is a medical clinical clearance; it is not a return to sport clearance; it is not for all activities clearance. Meaning they tested the knee clinically in their environment, typically a very small room. It’s very basic and there’s no possible way for someone to clear someone for a high intent sport or activity by seeing them for five minutes in a small treatment room with a few table tests and maybe a mini squat or something. 

When we think about the degree of someone moves in terms of an activity, when we’re looking at on-field stuff, on-court stuff, when we’re thinking about even skiers, when we’re thinking about jujitsu athletes, when we’re thinking about athletes who are doing parkour-type stuff, handball, when we think about any of these sports.This is going to be something where this athlete needs to be able to be strong, be able to have range of motion and be able to move dynamically. Can we grab this from being on a table? Absolutely not. This is always something that needs to come back to what the professional is basing this advice and clearance on. If it’s via isolated objective strength measures, dynamic tasks, such as running, jumping, cutting, then yeah, I am all game for them to be able to give a little bit more advice on saying, hey, yeah, I think you’re cleared and this is what this return to sport or activity progression should look like. But this is basically just saying, hey, like you check out on the physical preparation checklist. Good surgeons will do this in conjunction with information from good rehab professionals, physical therapist, athletic trainer, strength and conditioning coaches. 

In most cases, when you think about a pro-athlete, when you think about even collegiate athletes, especially at division one, there is a whole host of people making this decision based on data and based on talking with the athlete and based on talking with all the stakeholders, all the professionals involved with the athlete being the center point, and maybe there’s a parent, maybe there’s other people and agent involved. But with that said, you think about this at the highest level. 

Now, if we bring this down to recreational high school, where there’s not as many resources because of course, we’re not at the collegiate or professional level, then therefore we don’t have as many stakeholders involved as in those domains. We also don’t have access to the technology, to the time, to the testing, to the focus on that. And we are based in this insurance-based system here in the States; other places is different from universal healthcare. And so there’s limitations within all of them. But with that said, most people who go through this injury are not going to have the glamor and all the bells and whistles for this. They’re not going to have the people to help look at all the data and be able to make this decision. With insurance and with most healthcare systems, they’re going off of volume and very bare information to make these decisions. And a lot of it is based on timelines and so that’s what makes this really challenging. And if this decision is on the five minute table test, it is only a medical clearance. If they’re like, hey, you’re good to go. You’re cleared. I will push back on this and say it’s only a medical clearance, not physical readiness and not clearance for return to sport. This is all going to be based on what they’re making their decision off of and they need to defend this.

If an athlete, if I clear them and if a surgeon clears them, we need to be able to defend why it is that I say you’re ready. It’s not just because, hey, you’re at nine months, like good to go. You put in your work. It’s great. You’ve been working at this, but show me and prove to me and earn the right to be cleared. It needs to be focused on data and it needs to be focused on understanding where the athlete is. Not only from that physical and objective standpoint, but also subjectively, how has the athlete doing when I’m checking in from their psychological side. We do some questionnaires, ACL RSI to check in on this stuff. It is going to be really important to be able to do this. I know our bias in ACL rehab process is to be done. We want to be done as athletes, we don’t want to be in this any longer than we need to, and to hear that clearance or graduated word, but it has to be based on legit information. We want to hear those things so then therefore, when we hear it, we’re excited, but we need to make sure it’s proven based on information that is legit; not that six or nine-month timeline and protocol. And that’s what a lot of these decisions are made off of. 

I do think this is a very big factor as to why reinjury rates are as high as they are. Underlying this is because there is not enough testing to be able to see where these athletes are. And sure it’s medical system limitations, but with that said, testing is not being done. And then also our appropriate programming and exercise prescription and helping these athletes get to these appropriate criteria that is proven in the research to reduce reinjury rates. I think that this is something that really does lead to reinjury rates because we just let people go, whether they don’t have a continuation of the plan, or clearances given whenever it shouldn’t be given or there needs to be more context of what type of clearance. 

Most professionals use timelines, they test and they make these decisions off of very limited data, which is dangerous. Think about this: If you got in your car, you got into a rack where the fender was bent. The wheel was busted up. The axle that attaches to the wheel was bent as well as busted up. And then you went, had it repaired by a mechanic. When you went to pick it up, your mechanic showed you it’s good by just turning the steering wheel. No way I would drive that thing back on the highway. They would need to show me they’ve test drove it at different speeds, show me the new parts, the performance and the testing of it. Usually, there is a checklist that mechanics will go through, especially for a major accident like this, even for something basic. They will have things that they will need to check off to make sure that this has been done. And so it’s a checks and balances to make sure, hey, is this repaired? 

Of course, sure, if you go to certain places, they don’t have these standards or parameters, but if you are talking about a car that you could be risking getting into another wreck or an issue, or putting someone else at injury or at stake here. Then that is something that falls on you and you want to make sure that you protect yourself as well as other people to make sure this car checks out the way it does. And so then therefore, you’re going to make sure that what you’ve invested and the work that’s been put in, you’re going to make sure it’s tested and done appropriately before you drive the car again. And while I know ACL rehab is not a car and humans and cars are different because it’s mechanical versus weirdest this complex thing. It is similar in the sense of, we can’t just leave this up to blind trust. We can’t just trust the mechanic did it, and we’re good to go. We need to be convinced why they say it’s good to go just like the knee. And it can’t just be rotating the tire by saying like, all right, cool, you’re good to go. It’s no, it needs to be tested and it needs to be pressure tested, to be honest. We need to know that this thing can be able to keep up with the demands of driving on the highway, of changing different speeds, changing different lanes, being able to break when you need to. 

The same thing with our knee and our body is we need to make sure that it is pressure-tested to make sure it can handle all the different situations that we are going to have to navigate with it. Especially, if you’re going back to a higher level cutting and pivoting sport, or just something that is very demanding on the knee. We need to be proven why we’re physically and mentally ready, not just be an ACL ligament Lachman test. It is so much more than that. I think this is the thing that can kind of fool people sometimes because there’s this test of the ACL ligament and in our brains, we’re like, well, that’s the thing that got repaired. If that thing is there, the surgeon tests it, then yeah, that should be good to go. But in reality, that is a fraction of the stress that it will feel. While the surgeon is testing, is it there? Nothing else besides that and maybe a little bit of laxity. But other than that, you are not going to get the “strength” of that ACL by any handheld test. This is where I get it though. A lot of surgeons have their options and what they provide exhausted. 

When you think about the options that exist, it’s usually to do nothing. Maybe give some medication, to inject cut, and that’s mostly it, that’s the focus of their solutions. I’m not expecting it to be this hour long session where they watch everything and see you do that. That’s not their job to be completely honest. They were the ones who did the surgery so their goal is to make sure that the surgery was done right and the knee is healing. Would that be awesome that they can look at this and be able to assess these things? Great. But it’s not their job, as I had said. The issue I have is that clearance. And understanding it is not full clearance for anything. It is medical clearance, especially for the typical five to 10 minute exam that 90% of ACLers will get. 

Now this urgent is getting information from their sports science, from their physical therapists, from other stakeholders where they’re like, hey, I’ve got range of motion, I’ve got their strength testing, isolated, I have their dynamic profile. Looking at running, jumping, cutting, all these different metrics and numbers that they’re looking at, and they have particular criteria for you to hit, then awesome. I’ve got some surgeons here in Atlanta who do an amazing job of this. And one of the biggest things that they are having as a non-negotiable is strength, which aligns so much with the research, aligns so much with my bias and what our philosophy is, because we know this is such a big reinjury risk, so that’s awesome. But that is far and few between to be completely honest for most professionals. And so then that’s what makes this challenging to make a decision like this. And so what’s tough for us is that in this type of situation, we have to be the bad cop and help reset expectations when an athlete does get their hopes up. 

I’ve seen on multiple occasions where this athlete knows where they’re heading, we’ve talked about it and all of a sudden they go see their surgeon. The surgeon tells him something like, hey, you’re ready to go. Are you ready to do this? And it’s not based on anything. It’s just the timeline. And they leave and they’re like, yeah, this is awesome and I’m so excited. And I can do this. I have to bring them back to earth because it’s like, hey, you’re still only at 50% quad strength. I love that this surgeon did tell you this, but to be completely honest, there was no basis on this and so that’s what can be so challenging for us. Don’t get me wrong, I’m not here to just point fingers at the surgeon. I know I’m talking about this a lot. But PTs can quite be guilty of this, too. We are not the best at being able to navigate this stuff either. But what I do, see and hear about a lot with ACLers is that the surgeon because they have such unique position and this control in this process, as I had alluded to earlier.I want to offer most importantly, some solutions because you guys know me. I want to make it practical. This isn’t just, hey, complain about it and then preach it out to the world. It’s no, let’s do something about this. And that’s what this podcast is about and that’s what I am here to help do. 

Let’s talk about practical solutions if you find yourself in this. If you’ve been given advice (i.e. return to running, or especially returning to sport and activities) especially when you have hit a certain milestone that is pretty big, especially the return to sport and activities. When you’ve been cleared or graduated, ask yourself: What was this based on? Does it make sense with what they looked at? Was there any strength testing done? Specifically having objective numbers for isolated quad and hamstring strength. Other measures are great as well and we would love to see that. But this is absolute bare minimum as a standard, no matter any ACLer procedure, goals, etc. Ask yourself. If this aligns with how you feel, if you say 0 to 100%. If you say 100% was pre-injury. Then, if you go to look at yourself now, and you’ve had this advice given you’re cleared for X. Ask yourself 0 to 100%, where do you feel like you’re at. And if you feel like you’re at 90% to 100%, then cool. Maybe that does align with it. And therefore you might be good to go as long as you have numbers to back that up. But let’s say you are cleared, but you only say you’re at 60%, 70%. That’s still a huge gap. Therefore we need to listen to this and be able to address this gap and understand why do I feel this gap. You inherently know it or not. 

When I talk to any of my athletes, even if they give me a number different than what I’m seeing. They know it. And the thing is that they just want to believe they are more than they are. I get it guys, I’ve been through this twice. And the thing is, I understand you want to be through this, you want to be more than where you’re at. I think the biggest thing is making sure we’re honest with ourselves because we owe it to ourselves and we do not want to do this again, make this the last ACL injury that you ever have. The way you do that is by doing this right. Not just following through whatever the step-by-steps are, that this traditional system has given us. This is where this podcast comes into play in being able to educate yourself and put this stuff in play. You need to have numbers to help back up this clearance. That is the thing that I want to really hit home here. Whether that’s your PT, rehab provider, strength coach, whatever that is or ask your surgeon and be like, hey, I don’t know that I necessarily agree with this. But even then, you could just let it be what it is. More so as, hey, is there a way for me to get strength tested? Is there a way for me to get isokinetic testing or get a dynamometer and be able to be referred somewhere. If they don’t know what you’re talking about, that is red flag number one. 

Number two is that they might say we don’t necessarily have the resources or I don’t know. And that’s okay. Then you’re left to your own devices of like what you need to do and tackle. But this is something that is worth a shot to ask your surgeon. This should have been something maybe vetted prior to even having the surgery, just to see what they believe. But with that said, most don’t necessarily do this. So that’s okay if yours doesn’t. You just need to know that this standard is not where it needs to be in terms of testing athletes and also where things need to be in terms of minimizing reinjury risk and getting you back to full performance. This is where we want to be able to ask the local PT,  strength coach, maybe it’s calling around to clinics or university settings. And being able to ask: Do they have access to testing equipment more specifically? 

Every major city for the most part has it. There’s lots of clinics that are starting to do this more and more, whether it’s with the dynamometer, with force plates, with isokinetic machine. But what you’re looking for is asking, hey, do you do ACL return to sport testing? Now, this is where this needs to get very specific. And most importantly, the number one thing, numero uno, specifically asking for isometric quad and hamstring strength testing. They’ll either have a dynamometer. This device that you are able to measure force with, and that is where you can test your knee extension and hamstring strength to be able to see what is the quad and hamstring strength looking like, from an objective standpoint. A cherry on top if the place has the isokinetic machine, that’s where you’re fixing this big machine. And you’re going to be kicking in and out of it. That’s awesome. The names of those are typically Kin-Com. The other ones are the Biodex and being able to look at a Cybex. Those are the brands that are usually rotating throughout. You can look at different university settings, a lot of sports science, actually in sport science have testing related to this. They’re doing research-related to this typically. You can try and find some new grad is looking to get data for an ACL subject and be able to try and get some information from that. But usually hospital systems, university systems, there’s somewhere in isokinetic machine, if not a local clinic has a dynamometer to be able to objectively measure your quad strength and hamstring strength. 

When you ask for ACL return to sport testing, the one thing I want you to be cautious of, as if all they do is hop testing. If you are just doing a single leg, horizontal hop test,  six meter hop test, crossover triple hop test. If you’re just like hopping on a single leg, horizontally, over some space that is not ACL return to sport testing. While you might get some information there, that is not what we would be looking for, in terms of trying to get an understanding of your strength profile and your movement profile. One other thing that we see in this space, whether it is at the surgeons office or in PT clinics, where people will have return to sport testing, and it’s just these hop tests and then they’re cleared. We literally just had an athlete who had a hop test done, and they were in the 90 percentiles for most of them, comparing side to side, for how far they could jump distance wise. And then when the strength was looked at, they were doing this testing at a different clinic for in-person, working with us remotely. And when we looked at their strength via isokinetic, there were only a 60% strength. But the PT at the in-person clinic had said, hey, you’re good to go with doing some of this stuff. But it didn’t make any sense because their strength wasn’t there yet. So there’s discrepancies in these different tests as well. But to keep this very tactical, your goal is to find a place that can isometrically test your quad strength and your hamstring strength and have objective numbers tied to that. Hopefully, you’ll be able to get some other jump testing and some cutting measures, but this are the bare minimum. 

Worst case scenario, which is still better than what most is happening, is capturing some objective strength numbers for your quads and hamstrings via the gym. You’re looking to try and hop on a leg press, leg extension, leg curl on those three machines. You’re aiming to do a three to five repetition maximum for a single leg and comparing each side to each other. And then therefore you do have a comparison side to side to see, all right, are these similar or not? And then therefore you can even associate a percentage or a symmetry to that. And be able to see. Cool, we need to make sure both legs are strong and making sure, especially the one you’re comparing to is strong. And then therefore we can use this as a proxy of strength, at least for isolated strength for your quads and hamstrings, if you don’t have access to these other means of a dynamometer or isokinetic machine. 

I’m fortunate to have some great resources and people here in Atlanta to help me with testing for isokinetic strength testing. For our remote athletes, we often have someone nearby. We can connect them with, to get them tested. For ours who have limits of geography, maybe finances, for example, we can still utilize the machines in the gym because that still gives us a decent proxy. But we are going to try and push for trying to get to some isometric or isokinetic testing, just to make sure we have even more of the gold standard assessments for quad and hamstring strength. We can assess all of these other things via remotely, very easily to be able to give our athletes the best chance for returning to their sport and their activities, and be able to give an accuracy of clearance. This is something that is just really important for this episode. 

My point here is if you’re making a big ACL decision, you need to have objective numbers to back it up, not just the table test and not just five minutes. That is a medical clearance and that’s it—bare minimum. And until someone can prove me otherwise—I’ve been through it, seen it, done it, heard about it over multiple occasions, multiple times, many different athletes. And the thing is just doesn’t make sense. But I know the perception is that his clearance to do the thing, but it’s not. You need to have physical and return to sport clearance via true testing, and that is different and should be thoroughly tested and assessed. We do not have time to leave it to chances ACL rehab process. This is where we get in trouble with  reinjury rates and poor long-term knee outcomes and health. We’re not going to do that. That’s not going to be you, you’ve listened to this podcast episode. I’ve rifted on this for 30 minutes and you’re like, Ravi, this could have been five minutes. But here I am, because I want to make sure it is clear to share the perspective that I see through so many different lenses, and to be able to call out the things that are out there. As I had mentioned, this is not just pointing the finger at surgeons. This is for every professional that is involved in helping ACLers. But more importantly, for you to be equipped as an ACLer to know, if I am given this and I know many of you shook your head and was like, yeah, this definitely was me and I’m still feeling lost and I still don’t feel like myself. Listen to that, get tested, be able to find someone who is an expert in this to guide you, to give you the roadmap and the plan that is structured and specific to you, and that’s what you deserve in this process. 

As the take home here, when you go into that six month or nine month visit, and they test you for 5 to 10 minutes. There is this clearance given whether it’s a surgeon, a physical therapist,  whoever the person is, if they clear you or say graduated, back that up. Otherwise, that is just a medical clearance. There needs to be more than just table testing, a single leg squat and five minutes. And that is going to be so key. And if we’re trying to change this narrative around reinjury rates, this is a very big place on where we can start and really make an impact. 

I hope that this was helpful team. I am hoping that if there are any surgeons listening, that we will be able to change this narrative. If you’re a physical therapist, rehab provider, listening, changing this narrative, to be able to help our ACLers. That is so important and giving ACLerzs the best shot in this process. And so the statistics don’t continue to rise. One day, we will be able to flip the script and be able to say, “Hey, we are doing better with this.” We’re actually seeing re-injury rates decreased. But we’re not there yet. So we’ve got work to do so. Hopefully, this was helpful to you all. Until next time team, this is your host, Ravi Patel, signing off.