Episode 221 | How to Build Your ACL Athlete Dashboard – Measure What Matters

What is up, team? Welcome back to another episode of the ACL Athlete Podcast. I’m not going to lie; I’m pretty fired up for today’s episode. We’re going to get into it. Today is all focused on this particular quote: What gets measured, gets managed. You might’ve heard me say this in the past in different podcasts because testing is so important.

Also, talking about the quote of “test, don’t guess.” It all falls in line with this, but we’re going to focus on this particular one: What gets measured gets managed. “Progress,” typically in ACL rehab, is often based on a timeline or protocol in most cases. If you look at the general landscape of this space, most of the time, that’s what things are based on. It’s what we hear from different ACLers; that’s what I went through. It’s what’s happening in the PT community, in the surgical community across the world. It’s not just one region. And of course, there are different areas, different clinics, different practices that might use different guides, such as criteria or data or both.

And instead, what we’re typically seeing is it’s timeline driven, aka a protocol. And so that’s what progress is measured by. And “progress” I’m using here  because it’s really hard to say that the timeline or a protocol is really progress. It’s honestly just a measurement of time, which isn’t truly telling you anything. Someone can go to school, and a whole year could pass, and they could do nothing. That doesn’t necessarily mean they get to go to the next grade or graduate. But the time has passed, “the protocol” or the classes they’re going to should have been taken. The thing is that it doesn’t necessarily mean progress. It’s just the passage of time, more than anything. And without objective measures, you’re flying blind, leaving it to guess. And that’s the biggest thing that I want us to just dive into, and I want to focus on the importance of this quote, and it’s going to help unlock a lot of things of what we talk about, but mostly principles related to ACL rehab. As it’s such a foundational piece, I cannot stress this enough. 

Testing, measuring is such a foundational piece of this process, and any good ACL rehab professional, surgeon, anyone is going to be measuring these things. Maybe as a team, certain people are taking certain things and measuring them, but that’s what good ACL rehab is. If you’re not getting that, then to be frank here, you’re not getting good ACL rehab. And the purpose of what this podcast represents is to make sure to provide a signal within the noise. Y’all, there’s so much information out there, so much. I’m not here to say I know better and everyone else is wrong. That is not my point here. My point here is to share information that is backed by research, backed by evidence that is showing, okay, what is the totality of the evidence? And it’s not just my personal hearsay of like, this is what I’ve seen. The foundation of this is using evidence to guide direction, and what’s working, what’s not working. And then of course, yes, tackling some of the anecdote or personal experiences, whether that’s my own ACL injuries, whether that is from a clinical standpoint, from a performance coaching standpoint, seeing this landscape. And also just talking to, at this point, thousands of ACLers and consulting with hundreds, and so many different people in this process, and also working with professionals in this space, like mentoring people and talking to other PTs, PTs reaching out to us, surgeons, reaching out. This is stuff that we see all across. And so this is something that I want to make sure is just shared and openly shared, because it’s one thing if we don’t know and you don’t know what you don’t know. And that’s the thing that’s so challenging about so many different avenues of life and different categories, if you will, from finances to health to stress to all the different things. We don’t know what we don’t know. But in this space, once we do know, we have to do better. 

That’s my goal with this is for me to share this information on a foundation of evidence, but then also pulling from anecdote and what we see, and also giving my take on things. Because I do believe that I have something to say in this space, because I have spent, honestly, a lot of my life so focused on this. This is something that I’m basically positioning. Listen to me, guys, but also please do your research, and I’m going to make the case for why this is so important and why things need to be measured. The right things need to be measured because then that’s going to lead to a successful ACL rehab. 

This quote: What gets measured, gets managed by Peter Drucker. He’s a renowned Austrian management consultant and educator, and author. He’s known as the father of Modern Management. He believed in the importance of defining clear goals, measuring performance effectively, and managing it. And managing it objectively. And does any of this sound familiar to some of the things that we do in ACL rehab, or want to do, but also for anyone that honestly needs to meet a goal? To be able to get to some sort of deadline and accomplish some sort of objective, some sort of goal, whether it’s personal, business, professional, you name it. We’re going to do these things. We’re going to define the clear goals. We’re going to measure performance effectively. We’re going to make sure we manage it objectively. That’s a part of SMART goals. The classic, like being able to measure it, is a part of that. That is something that’s going to be important. 

In his work, he focused on the need for measurable objectives to improve performance. One of the quotes, in addition to this, is that if you can’t measure it, you can’t improve it. That’s the thing that really does hit home here. If you can’t measure it, you can’t improve it. Now, while you can feel like you’re improving it. If you can’t measure it at the end of the day, like you really can’t improve it, because you don’t know where it sits. You don’t know where it exists on the continuum.

Here are some caveats to this that I do want to make sure I share. Measuring the wrong thing can lead to mismanagement. And honestly, in the space of ACL rehab, two things: it can lead to worse performance, and it can lead to re-injury. And at the end of the day, those are the two biggest problems that we are facing in this space of ACL rehab. The worst return to sport and return to performance rates, and having the worst re-injury rates. ACL re-injuries are one of the highest re-injury rates of any type of injury that exists. And my point here is to call a spade to spade because I see it so much. And these are red flags is where either things don’t get measured, which is very common, or the wrong things are getting measured, and that leads to mismanagement. And it’s almost like this feeling of being overly confident because we are measuring the wrong things. And now everyone can have their own battery of tests and their own process of measuring. But at this point, guys, there is a pretty strong consensus of what exists that is based on the research that shows, hey, this is going to help with the re-injury rates. This is all also going to help with performance. And so that’s where we need to just have our due diligence. 

We learn things in school, that stuff’s outdated. And so sadly, that stuff needs to get updated. Now, when I’m talking about measuring the wrong things, I’m saying things like MMTs (manual muscle tests). That’s where someone “measures” strength by kicking someone’s hand. This is the most classic thing ever. We’ll see this with surgeons. We’ll see this with PTs. We’ll see this with athletic trainers, coaches. Basically, they are testing each leg to see, all right, let’s resist while you’re seated on a table, putting their hand on your ankle, and then one hand on the top of your thigh, and then just saying, kick out into my hand.

And the thing is, is that these MMTs or manual muscle tests don’t actually test strength. I wish that they would get reworded. Honestly, I wish it was just like, Hey, this muscle is active, and that’s about it. But other than that, it’s not giving us a measure of strength because we don’t have any objective way to measure it. Even though there’s a scale of zero to five, it’s based on subjective feel. It’s like me picking you up and saying, this is how much you weigh. It’s just based on my strength and also your size. That’s going to be a factor in that. Other things that are typically measured, if you will, is going to be time. That’s something that is constantly used in ACL rehab. I’m not here to say time is bad. We use time. But we use it in a healthy sense of ranges, being able to strategize based on short and long-term goals, and also understanding that it’s time plus criteria, not just time alone, but is criteria-driven based on the research. We’re going to use those two effectively to help map things out for each of our ACLers. That’s what’s going to be important here. 

Another thing that comes up—hop test. The most classic “return” to sport test. We will have athletes who are like, yeah, I did some hop testing and you know, I passed the hop test. I’ve had athletes here. There’s a surgeon who is popular here, and they do return to sports testing. Guess what it is? It’s just a horizontal hop test. They’ll do a triple hop, they’ll do a crossover hop, they’ll do a single-leg hop. And while there is some previous evidence showing that it can help with re-injury rates, when you dig into the details of hop tests, especially the horizontal hop test. I’m not saying it’s all bad. I’ll even have athletes periodically do this. But with that said, it depends on what we’re using the test for. And the sad thing with hop test is that it’s usually measured by the distance and the symmetry, and that is the wrong way to test the hop test.

Now, while there’s a large discrepancy, does that tell you something? Sure. But a lot of times, what we see now when we look at the total of the research with the hop test is that athletes can cheat this well. And our bodies are incredible at being able to cheat things, and it could be even to the naked eye. But with the hop test, what we typically see is that the athlete—you’ll do the hop test on one leg. You’ll have that uninvolved side be the anchor or that comparison you’re aiming for. The involved side is going to do the test, or the ACLer’s side, is going to do the test, and then they get within 80 or 90%. And typically, the cut-offs have been like 90% symmetry, and you’re like, okay, cool. You can get within the same distance or close enough.

But the way or the strategy, or the quality of it is so different. The athlete might use their knee and bend at the knee and use their quad, and not bend at the trunk, using a knee strategy. While the involved side, hip strategy, literally, the hips pop back. Their shin is vertical. They’re using barely any quad. And when you look at Kotsifaki’s research, which has been recent, she compares hop tests. She also looks at vertical jump testing, and it’s crazy, y’all. There is actually not very much contribution when you look at the hop test on the knee. And so then therefore, yes, in landing there is more contribution, but we’re not measuring the landing piece, we’re measuring only the symmetry. What we’re testing is off. And so that’s “return to sport testing.” And then don’t get me started on how that is not necessarily related to all the the physical demands of what sport or activities are gonna test you with.

Some horizontal hop test forward isn’t going to be the thing that’s like, oh yeah, this person’s ready to go. It’s like we need to make sure we have a full battery of dynamic tests, jumping, running, cutting, being able to decelerate, to accelerate, to sprint. We need to test all these things through a battery to make sure this athlete’s ready to go, in addition to all the other stuff—-range of motion, strength, etc.

My point here is that hop test will be used, and they’ll be like, okay, 90%. You’re great, you’re good to go. And that’s what we’ll typically see in MMT. They’re time-based. Maybe they’re six months or nine months, and then hop tests. They have passed their hop test. Cool, you graduated, you’re good to go.

We’ve seen this from the surgical side. We’ve also seen this from the physical therapist side all the time and it still happens. I can guarantee majority of clinics are still doing this. And this leads to the overly simplified “clearance.” What’s worse about this is the overly confident ACLer who just wasn’t tested on the right things. And honestly, this scares me the most because I know in that person’s gut, they’re like, I don’t feel ready. They’re like, I don’t know that I’m like really ready for all this stuff. Like ready to go and like get on a soccer field again to be able to go ski again, to be able to get back on the mats for MMA. I know that within them, they don’t feel like that’s there. But at the same time, their rehab professionals and their team have told them, hey, like you’re good to go based on these tests. So for them, they’re like, well, I guess I’m ready. Maybe it’s just a confidence thing. Ensure there are situations like that. Don’t get me wrong. 

But with that said, this is something I see way too often, where that person goes and they go to play their sport. They’re not even given guidance or recommendations on how to reintegrate back. And they’re under-prepared. They’ve been tested on not the right stuff, and then they’re not even given any type of progression back into it. And guess what? The re-injury happens, or they’re like, I can’t perform the same way that I did before. I’m going to give this up, and it makes me so sad. And this is probably the one that makes me the most scared, which is the overly confident ACLer, because they were tested incorrectly. And it’s almost worse than not being tested at all because then at least not being tested at all makes the person be like, well, my rehab wasn’t great. We didn’t do any testing. So then that can maybe create some curiosity of like, maybe I need to pursue more help and do more stuff. But the person who has been told based on the wrong stuff that they’re ready to go is the one that really breaks my heart, and that’s why I’m doing this episode, because I wanna make sure you guys have a clear understanding and also a practical way to tackle this.

Now, let’s dive into the practical ways of this, because we are focused on making sure that we can measure the right things. Now, the right things will be determined by just different parts of the process, because certain things are going to be a little bit more of a priority. But this simple heuristic is what’s going to help drive this. If you use this and if you’re a clinician or coach or surgeon listening to this, this heuristic, to be completely honest, will change the game. It really will. And that is this heuristic that I learned from Matt Jordan, an incredible PhD researcher and also a coach who’s doing amazing stuff in the field for us. That is the heuristic of three different parts. Determine what matters. Measure what matters. Change what matters. I’m going to repeat that. Determine what matters. Measure what matters. Change what matters. If you can nail this, then this is going to be an absolute game-changer. I’m going to go through each one.

Determine what matters: what quality or particular criteria are we looking to improve? Therefore, we are trying to pick out like what is the thing that is most important here. And then this helps us to create our KPI, or our key performance indicator, or criteria. And I’m going to use the example of peak isometric quad strength. Now, this could be several things. It could be pain management, it could be swelling, it could be extension range of motion, it could be maybe it’s a power development of the quadriceps, or a certain position. There are several things that we could peel back the layers and say, all right, this is what matters at this instant.

But as we know, quad strength is a big one. I’m going to roll with this one to keep it super simple. And this allows you guys to put this in play. So, determining what matters, the important quality that is going to be the example of peak isometric quad strength. Basically, how much force and torque can your quad produce on the ACL side versus the uninvolved side? That’s what we’re looking to improve. 

Now, measuring what matters. The thing that matters is the peak quadricep strength. Now we’re going to measure that thing that matters. What this means is, how are we testing the thing that matters? What test are we using? And this is going to be our method. Therefore, for example, with peak isometric quad strength, this can be a few different things. Now, there’s a gold standard, which is the isokinetic machine that’d be ideal in all situations, but guess what? It’s a very expensive machine. It’s not often that you find it all around, and sometimes access to it can be limited. But if you can find it, awesome, that’s the gold standard, and we would prefer that.

But guess what? If you don’t have that, we’ve got other ways to be able to get a proxy or an idea and measure this. That could be via a handheld dynamometer or a strain gauge, where you are pulling on that thing. You have an ankle strap. You’re seated just like a knee extension machine, but you’re fixed at either 90 or 60 degrees, and you’re kicking into this device that is connected with a chain or a strap, and is giving you an objective data point. It is saying how hard you kick out. And that might be in pounds, or it might be in force, or it may already calculate the torque based on whether you have the moment arm as well. This is going to give us and test and measure, all right, what is that thing that matters? And then if you don’t have that, guess what, we can use a knee extension machine to get an idea. 

Now, this isn’t necessarily testing the peak strength of that quad, but we are getting an idea of the dynamic strength of that quad, and that’s okay. That at least gives us a proxy to understand. All right, well, my left side for five repetitions, I can do 50 pounds. That is going to be my ACL-operated side, and on my other side, the uninvolved side, I can do 100 pounds. Hey, that gives me at least a proxy and understanding I’m at 50%. At least let’s you know, all right, well, I do have a deficit here. But that allows us to at least get some sort of measurement, and the research shows that that can even help to give us an idea of quadricep strength. So that’s measuring what matters.

Now, we are going to change what matters. We went through to determine what matters and measure what matters. Now we’re going to change this thing that’s important to us. We’re going to prioritize and develop this important quality. Now, don’t get me wrong, I don’t want to get lost here, but we’re focusing on one here. There can be a few. But I would say after you have three, you’re kind of getting lost in this sauce there. You only need maybe 1, 2, 3 priorities, and that’s going to be it. Now, we might be having some tertiary things that might be developing and we do for our athletes, but at the end of the day, we’re like, we are picking our top three, and especially our one is going to be the most important thing that we are trying to tackle, and we are gonna prioritize that thing.

We’re going to try and change these things for the better because we’ve measured them. Going with this example, the other thing we need to know is we need to have a gold standard benchmark and just understand what is that threshold we’re trying to get to. This means normative data to help us know if we need to work on changing this quality that’s important and also relative to you. This will be based on the typical normative data for that person’s age, sports, activity, etc. Several factors play into this, as well as gender. And so the other thing that we’ll look at is also specific to the athlete, which is the limb aka the symmetry of it, from one leg to the other. And then we’re also going to look at that compared to their body weight. How heavy they are as a person and what their weight is, we’re going to see how the strength is relative to the amount of mass they need to move, the amount of weight they need to move. Because that’s going to be a huge factor.

If your quads are super weak and there is a higher body mass, then therefore, that’s going to be something that’s really tough because you don’t have enough strength to be able to control your body mass yet. So that’s gonna be something that’s really important, especially at high velocities and intensities like sports and activities.

We’re going to use those to understand this. Luckily, we have research that strongly supports these areas. For example, for running an important milestone in ACL rehab, you can range that anywhere from, even if we want to throw times on it. Three months to five months, six months. And it can range based on the person’s goals, also, like where they are. We’ve had people who start running early, and because they seem ready, they check all the boxes. We try to delay at least four to five months realistically for the majority of our athletes because we want to focus on getting strong, and we’ve got a lot of time to be able to still build up the running and other dynamic stuff. Why get in the way of that? 

But with that said, we are looking to try and get to at least 70% quadricep strength symmetry. And then, realistically, like what helps to anchor this even more is to get a 1.7 Nm/kg of body weight. So that’s essentially the torque to body weight. How much torque or strength can you produce in this quadricep relative to your own body weight? And so that’s going to help us to make sure we are running without as many compensations. We have adequate strength to tolerate the forces of running, and this is going to make sure that we have done our due diligence to be prepared for running.

Another example is going to be for return to performance or being “cleared” already. That number, if you will, for knowing you have at least that minimum threshold we see for helping people, that minimum threshold we see for helping people return to performance and reduce the likelihood of a re-injury. And that is going to be at least a 90% symmetry, or what we use a the ACL Athlete is 95% or above symmetry, and then our gold standard for the torque-to-body weight is going to be at least 3.0 Nm/kg body weight. Now, is this perfect to cross every single human being we work with? No. But at the end of the day, this is where the research shows, and we’re going to work hard to get close to this and hopefully beyond this. Several factors play into where athletes land in terms of their rehab and the timing and the work put in and setbacks, and whatnot. But this is the stuff that we’re aiming for. These are our target benchmarks. We’re gonna use these. And we’re aiming for, along with looking at the whole athlete in other areas. But this allows us to know, so when we come back to the idea of changing what matters, these specific benchmarks or CR exit criteria are going to be important ones for quad strength. If we’re aiming for these and not hitting that yet, well, guess what? That’s going to be us working on changing what matters, right?

Determine what matters. Measure what matters. Change what matters. Are you guys tired of hearing me say that? And that’s our continuous feedback loop through all of ACL rehab, where we revisit this entire process very regularly via serial testing. And that is something where we are just kind of regularly testing to make sure we assess and we’re coming back to like, all right, is this still thing still important? Are we determining what matters, and then are we getting measurements of this? And then, are we continuing to be able to be very surgical in our programming? And so this may be every week for certain things. This may be every four weeks, six weeks, based on where the athlete is in the journey and what we’re looking at.

Because some things are going to just take a little bit more time to develop with this. For example, quadricep strength isn’t going to jump 50% in two weeks. We’re going to need to take some time to train, put some stress in, recovery, and to see how that adaptation occurs. And giving this at least, maybe four to six weeks and seeing if we’re moving the needle on this.

The one thing I want to say is that we want to be careful what you measure, because you might end up managing only that, though. We’ve got to remember we’re working with a human being. We have to remember that they have life things that are going on, and we have to make sure that we can’t lose sight of the other important things. So that’s what’s going to be key here. Now, while we want to prioritize the top bottlenecks, the main goals, the things that we know are holding that person back, especially from day-to-day, all the way into more activity and sport-based. We don’t want to get so laser-focused that you forget everything else.

Yes, we care so much about quad strength, but we don’t want to forget about making sure that this person has full extension. We want to make sure that this person has the flexion needed, especially if they start running and sprinting, for example, because we need to make sure that the heel recovery, that the heel can go through that proper range of motion. We need to make sure that this person can show a positive shin angle, as they can drive the knee forward and tolerate positions, and make sure that their donor site, for example, isn’t something that’s limiting them. So that’s where your rehab provider, your guide, your coach, is the one who is determining all these things, but we can’t get laser-focused. And for us, we use a zoom in and zoom out approach throughout all of our rehab. We are always looking at, all right, what’s the next step? We use the A-B-C framework, where it’s like, all right, where’s the athlete? Where do they want to be? End goal.

Then B is that next step, and that’s in alignment with the person’s goals, as well as well as where they want to be at the end with that point Z. So that is something that is important to us to make sure, we want to be able to zoom in and zoom out. Of course, we have a time and place where we can get so laser-focused on something, but we want to make sure that we always revisit that zoom out approach as well.

Now, why is this so important? Why measure things? Why am I saying this quote? I’m going to share three things that are important here. It creates accountability when we measure the thing and making sure it gets managed. It’s going to create accountability for the athlete, for the rehab professional, the surgeon, the coach, and all stakeholders involved. It’s all right, well, are we looking at a thing that matters? And okay, if this thing’s not improving, well, let’s talk about this. Let’s have a conversation. Let’s not just assume it’s going to get better. Let’s change the game plan. 

Number two, it creates intentionality. As I said earlier, it allows us to be more surgical. It’s like, for me, the way I look at it is instead of taking a shotgun approach, seeing the spread of it and just kind of trying to tackle everything, we’re being more precise. We’re taking that cross hair, if you will, and we’re taking a sniper, and we’re like, all right, we’re being very intentional and we are having a very direct focus on these certain gaps that we’re seeing in these priorities. It drives our programming and the exercise selection, the rep sets, the design of the program, how we’re structuring your week, and factoring all those pieces in place, allowing us to just be as precise as possible and intentional.

Number three, it creates transparency. And all stakeholders, communications, and managing expectations. That’s the thing that’s important here, is that there’s transparency in where the athlete is where they want to be, and we are able to make sure that there is numbers associated so we’re not just guessing or being like, well, there’s stronger, but okay, cool. How much? Or they’re ready, but they’re not fully ready. It’s like, okay, but. Can we get some objectives here? Can we get more details around this? So it’s transparency of almost black and white, if you will. Of course, we work in a gray area, but it allows there to be more black and white. And so then that allows all these people to communicate between the athlete, coaches, rehab, professional surgeons, parents, you name it, whoever else is involved, agents.

And it also allows for management of expectations. And so that’s the other thing too, is that if the athlete is. Aiming to run at four months and they had, you know, a big trip for from months three to four, and they were walking around, they didn’t really have access to a gym. Guess what, if we test this thing and we’re able to say like, Hey, your quadriceps strength we were hoping to be at this point is not there yet.

We’re able anchor that to something because we’re like, we need you to be at 70% symmetry or 1.7 new meters per kg, and you’re still below that. Right. And all the other things show us that we’re not ready yet. And so that helps us to prove those points and to be able to manage expectations for this athlete versus being like, oh, well I’m at four months.

I should be running now. Right? And so the thing is, we gotta factor all these pieces in. So accountability, intentionality, transparency are three things that benefit from being able to. Measure these things and manage these things, right? And here are some parallels that I wanna share with you that’ll hopefully, and here are some parallels to hopefully help this hit home for you.

We can talk about finances. So if you’ve never tracked your spending, how do you know where your money goes? People who create a budget and track expenses tend to manage their finances better. It’s pretty black and white there. If you’re not measuring what you spend, it’s easy to overspend or to fail to hit the savings goal you might have.

So as this relates to ACL rehab, it might be not tracking quad strength or you know, your jumping performance. It’s like guessing how much money you might have in the bank, right? Your decisions are kind of being made in the dark, taking medication without checking symptoms. Imagine, you know, you’re taking blood pressure meds, right?

and you’re taking these meds without ever checking your blood pressure. I. You never know if the medication is working or if it needs some adjustments. It’s kind of crazy ’cause my dad actually, our family has hypertension, um, genetically. And so my dad has actually been dealing with some things with this and his blood, blood tests have been showing certain things and his blood pressure’s been showing certain things.

Guess what? It never really did have any type of attention to it, so I had to kind of step in and, you know, talk with the doc and be like, Hey, like we’re seeing this deadly increase over time, like, what’s the game plan here? And so I couldn’t have come to the dock with that. If I didn’t have the proof of these readings, and that’s just the typical, like primary care overlooking some things, throwing some medication at it, hoping it helps instead of, you know, really dialing in the details and be like, all right, cool.

How can we make sure we get this medication down? So anyway, that’s a tangent healthcare system. But with that said, the objective data allowed me to have proof in saying like, Hey, this is where my dad’s blood pressure is. Like this is what we need to do potentially, in order to help this. Right. Of course, there are lifestyle things to improve, but with a genetic piece, there might be something where medication needs to be bumped up and the treatment. Otherwise, if we’re not measuring it, it becomes reactive instead of proactive, right? If we’re able to track the hypertension early, we can get in front of it based on lifestyle decisions and manage that a little bit better. Maybe more aerobic capacity work, maybe being able to take some supplements, being able to eat more whole foods, and managing stress.

things of that nature. And so we can be more proactive if we are able to measure that objectively. And the ACL tie-in here is you can’t manage rehab dosage or progress unless you’re tracking these things. Right? And so that’s like, maybe it’s the joint effusion, maybe it’s kind of like the fatigue, which we check with all our athletes through a questionnaire each week.

Maybe it’s their, um, energy levels, right? And the response to load. Maybe it’s their sleep, for example. So we’re, we’re measuring these things even from a subjective standpoint, trying to put some numbers on it. But from the blood pressure piece, that’s, that’s a really black and white situation. But if we didn’t measure it, how do we manage it?

The next example is studying without a Grade. A student studies hard for months, but never takes a test. They see a, don’t see a grade, they don’t get any feedback. And they may feel like they’re improving, but they don’t have any benchmarks to really know. It’s kind of all subjective. And they’re like, oh, okay.

Like I’m, I’m kind of learning this stuff, but there’s no test. Progress feels good, but it may not actually be real. And you might be just kind of like fooled by that. And so. The relationship with ACL here is that an athlete can quote unquote, feel strong, but still test, you know, 30, 40% weaker on one side.

This is such a classic thing we see in this space. Whenever I talk to people and they’re like, yeah, I feel, you know, pretty good. And I feel like the leg is getting, you know, pretty close within 10%. And then we go to test and there’s like a 50% deficit. Turns out they just were never pushed. They were never truly tested.

And the analogy I give with this often within this analogy is that, it’s kind of like, you know, you only took your car out in the neighborhood to drive, right? It’s like you can’t really. Test the degree of what the car can do in your neighborhood because it’s a neighborhood man, like you’re not gonna like hit the high speeds.

You’re not gonna really have to hit the brakes hard. It’s very predictable. It’s not high traffic. The thing is like when you take this thing out on the interstate here in Atlanta, you better be able to ready to like hit that brake really hard. You’re gonna be able to start hitting like eighties, nineties.

Right, so you’re really taking that car for a ride and really testing it out. And a lot of times athletes just don’t get to do that in rehab. And so then therefore they feel like they are better than they are because they’ve just never really taken it for, for the proper test drive, if you will. And they feel stronger than they are.

So subjective, confidence. Doesn’t replace the objective markers. It can help with alignment of that. But this is where it can get dangerous because going back to the thing of measuring the wrong things, or either the athlete is overly confident because they were told like, Hey, they’re good. But it was more subjective than it was truly objective.

Right. Alright, last one here. I know you guys are like, wow, Ravi, you’re really trying to hit this home. I’m trying to make a point here. I hope that this one helps. This one is very useful for us, but. Think about driving without a dashboard, driving a car without a speedometer.

You don’t have a gas gauge to know if your gas is full or empty or if you’re, you know, electric, like you don’t know how much battery’s left the check engine light, for example, if something’s going wrong in the, the engine, right? and you might be fine for a while. Until something breaks or you run outta gas or you’ve got speed limits that you’re trying to monitor, but you’re like, I don’t know what the number is.

I’m just kind of going based on the feel of the speed of the car and everyone around me, right? Those measurements exist so you can manage the risks and make sure the function of the car is going. Through what it needs to do, essentially with what you’re giving it to do. Right? And so the way that this looks with ACL rehab, the tying it in is that the objective data in rehab is the dashboard.

It tells you if you’re ready to go full speed or if we need to make adjustments before a breakdown may happen, right? We use this all the time as a team. What’s the ACL athlete dashboard? Right. What’s on this dashboard? What are we managing? What are the things that we’re highlighting? What are the things that we need to prioritize on this?

And we teach through our ACL mentorship. Our clinicians and coaches like to build their own ACL athlete dashboard. And to get an idea of how we can manage the important KPIs on that dashboard, just like that speedometer, the gas gauge, the check engine light, and all the other things that we’re looking at for this particular athlete’s profile.

Testing for us is a part of the three-step ACL athlete process and our pillars, number one, is going to be testing. We’re going to make sure we have an anchor point of where this athlete is and at all times throughout the process, even if it’s through training, that’s giving us some. Indirect testing or embedded testing without athletes ever knowing it.

There’s so many of our athletes who are like, yeah, we’re just kind of moving along and we’re actually testing you without even knowing. And we’re like, Hey, go to failure on this. Or like, Hey, like show us a max repetition or open sets, or whatever it may be. And you know, if you’re listening to this, guess what?

That’s what we’re doing. We’re trying to test things out without you even knowing, knowing it, or it being a test week or a test day. So that’s something that we are wanting to make sure we provide and is. Such a huge piece of, of what we do in this process. Without it, you’re honestly living it, leaving it to chance.

Without it, you’re honestly leaving it to chance. And the thing I always come back to is why do we have a 20 to 30% re-injury rate? This is, in my opinion, one of the biggest parts of why they are the way this is. It’s because we are not testing really well, therefore, we’re not exposing the deficits.

Therefore, we’re sending athletes out when they’re underprepared and not ready. And so that’s the problem that we have. And of course ,there are a multitude of other factors that play into this, like the healthcare system, the insurance, the expertise of the professional X, Y, and Z. But at the end of the day, the testing will expose this.

It will poke holes in things, and if we’re doing the right testing, it’ll show the person’s not ready, even if the person doesn’t have the best rehab professional or whatever it may be. Even if you finish insurance visits. At least it gives you an honest, transparent perspective of where you are.

Therefore, it gives you a better opportunity to fix this gap versus going out there because you think you’re okay. Right? And so we need to make sure we measure and we measure. We need to. We have to make sure what gets measured gets managed, but it needs to be the right things, the right qualities that we’re looking at.

And my last note here as we wrap things up, just because the professional you’re working with, the team you’re working with has their masters, their doctorate or medical degree, or they sound smart, honestly, doesn’t mean that you can blindly trust they’re going to do it because. You can’t blindly trust that you’re going to do it to what’s the gold standard?

There’s a number of reasons why this plays into this, but this whole, you know, being high on the pedestal because they’re a professional and they sound smart and they’ve gotten their degree, doesn’t necessarily mean that they’re the best for this. Y’all, I’ve seen the craziest of craziest things with people who have doctorates and medical degrees.

And so y’all know this too, if you like really kind of think about it. Not everyone in the medical field is even health and fitness in general is a wild, wild west. I think about it all the time and often this is more so stemmed in terms of like what people do based in these professions or their degrees or experience.

It’s more so stemmed on what’s been done, to be completely honest, and also due to a system in time constraints. AKA not afforded enough time or the resources due to the healthcare system to get detailed enough and be thorough enough for you and to be up to date on things. We want to believe it’s the case, but in reality it’s not.

And I’ll share this last thing that helps to kind of hit this home is that we just had someone starting working with us remotely. Guess how many people she said were at the PT clinic that she was going to? And she’s been going to for quite some time, for one physical therapist. One physical therapist, she often counted 10 people to one pt.

Now obviously I heard some crazy stuff of like, you know, group stuff and like, you know, four or five, you know, but 10 to one is wild and honestly not. Uh, I’d, I’d almost que question the, the practice of that and the legality of that. But with that said, what I would like for you to imagine is if you get your taxes done and there’s one tax accountant bouncing around at 10 different tables, and you’re all there, you’re with your partner, you’re by yourself, whatever it is, and you’re just like, kinda like, wait, you’re like kind of going through some of the stuff and you’re like, okay, the, the tax account will be, be right back.

Like you’re, you’re waiting. Even if it’s four or five people, even if it’s three people, you kind of start to get frustrated. You kind of be like, I, I just kind of need someone to talk to me directly, answer my questions, even handle it for me. Right. Taxes is a little different because you know, you can kind of give that to somebody, but with that said, it still needs to be an active process, especially with this being the human body.

But she said it was 10 people to one. She said there was. An hour and a half of when she went in and did the rehab, actually, and only got a few minutes with the pt, she said a few minutes. The high school techs were the ones managing the rehab. It’s wild, and they were bouncing around multiple techs, being able to say like, Hey, here’s the next exercise.

Which is just crazy. And so while this isn’t always the case, it’s more common than you think with clinics having maybe one to three ratio or one to four ratio, it’s very rare in an insurance-based to be one-on-one for full-time. And this is what makes it challenging for. The professional and also for the a cer, to be honest, but especially the professional, to be able to allow for frequent testing.

And that’s due to limited time and bandwidth to be able to individualize a plan due to limited time and bandwidth. Plus, you know, you’re not gonna necessarily get a lot of units or coded for that for insurance and so. It’s all about maximizing time and for them to not burn themselves out, especially managing so many people.

And so it’s hard to, in individualize things. That’s where a protocol can quote unquote help them or just be like, all right, this is already done for me. I can at least give this to the person. This is getting them started on some stuff, but it’s not individualized for that provider to have any time to really focus on current concepts and updates in ACL rehab.

This is one that’s really important and this is due to the limited time they get potentially burned out or they’re just like, look, I’m like working and I’m taking notes and doing all this stuff that they don’t necessarily want to like be focusing on this stuff. Outside of that, they almost want to disconnect.

’cause burnout is really high in physical therapy and in this profession because of the way that it’s structured. And the thing that’s challenging is that. What we’re taught in school, number one, we’re taught to be generalists and treat everything. I told you guys, we spent maybe a few weeks on the knee and ACL rehab was really sad.

This was really, really sad for how much we covered in all of three years of a doctorate. ACL rehab was very slim. Very little in general, especially all we’ve talked about is post-op stuff. We didn’t really even talk about anything else. but we had to be able to treat everything. That’s what we go to school for.

And the other thing that’s challenging is that what’s taught in school is outdated. I. Now, not everywhere, but for the most part it’s going based on the board exam, which is stuff that’s like super outdated. Y’all like super outdated. And so for things that like really come to become outdated or to be more up to date, if you will, there’s a lot of work that has to happen.

And so these are factors that are playing into, you know, why the PT professional isn’t necessarily always an ACL specialist. It’s like assuming the primary care doctor can treat all the things like a neurological disease, like they can’t, they can give you maybe some general like idea of it based on knowledge, but you gotta go see a neurologist.

And then of course, if it’s a very, very specific thing, then you’re gonna go see a specialized neurologist for that thing, right? Same thing can be said about even orthopedics. Y’all like, you sure you’re gonna go to an orthopedic surgeon, but a lot of times you’re going to someone who. Does acls, they may do all the things, and I would say that’s not the orthopedic that you want.

In reality, maybe they focus on shoulder a certain procedure, and then acls cool. What is your volume? You know, what are your outcomes? Like all the things that you wanna normally ask someone to vet them. But at the end of the day, even orthopedic surgeons, unless they’re in a rural area, they’re gonna start specializing in certain areas because they want to get specialized in it.

It allows ’em to be experts in it. Um, and that’s something that, you know, allows them to be able to be focused on that thing and be better at it versus being general. Right? So that’s the same thing with physical therapy. It’s just challenging because we are taught to be generalists once we are licensed, which is.

Just kind of wild, right? And most clinics are treating everything. So with that said, it can make it really challenging and that’s why we can’t blindly trust. We have to vet the professional on our team and to round this out, what gets measured gets managed. This statement implies the metrics that get measured get prioritized, and that’s what I’m sharing here.

The scoreboard matters because it dictates how we play the game or rehab. In this case, you cannot afford to leave it to chance. And now with that said, I had such an intention to keep this super short, but this is the opposite of short. One of my longer episodes, I apologize, but I hope that you took a lot away from this and you were able to like really pull from this a lot of value.

And if you feel like this is something you’re not getting, and especially if you’re someone I would say eight to 12 weeks out and you feel like you’re not really getting that, then I would start to kind of consider like, okay, like. Asking questions and making sure like, when am I gonna get this? And making sure it’s doing the right stuff, right.

It’s not the MMT, it’s objectively measuring strength, objectively measuring other different criteria, and making sure that it’s not just the protocol or the timeline. Says at three months, you do this. We want some time. Plus something else. There needs to be something in addition to this to prove you’re ready to do that thing right?

And that’s how we are going to make a massive change in this space and be able to reduce the rate of injuries and be able to get people back to what they love most. And that’s the goal of what we’re doing here. I hope that this helps y’all. If you need anything, we’re here to help. Until next time, y’all, this is your host, Ravi Patel, signing off.