Episode 224 | The Real Price of Waiting: Opportunity Cost in ACL Rehab

What is up team? And welcome back to another episode on the ACL Athlete Podcast. Today, we are talking about opportunity cost, and I want to bring in some real-life examples that have taken place over the past week. I think this will help just evaluate opportunity cost, and we’ll break that down here in a second. But knowing that, every decision that is made has a trade-off. And this isn’t life in general. We have a trade-off between any decision that we make. And with opportunity costs, some simple examples: time is a great one. 

Time you spend one hour watching Netflix, the opportunity cost of that is you could have spent that, doing exercise, you could have been reading, you could have been working on other stuff, studying, whatever that may be for the context of your own life. A money example could be, you buy a $50 shirt. The opportunity cost of that is that you can’t spend that 50 on a concert ticket or maybe save it or invest it for something else. And that’s assuming you don’t have that $50 available elsewhere to utilize. A work example could be a college student taking a part-time job that pays maybe $15 per hour. The opportunity cost, well, that could be time that could be spent studying, which might lead to better grades or maybe future opportunities if they were to go all in on that. Of course, there’s the flip side to these things as well, but as we know, there’s always opportunity costs with anything that we do.

And the thing that I want to talk about today is just dive in specifically on how this relates to ACL rehab, because I think this is something that I just wanted to share these conversations that I had in this past week. And I talked to a lot of ACLers every single week. A lot of people are going through ACL rehab, whether it’s working with our team, whether it is through social media, mediums, email comments, or consultations that I have, I am very well in the know of working with people all over the world. This is something that I get to pull unique information from because of people reaching out and wanting either help with their ACL rehab, or they just want to share. This will be full transparency of talking with some of these people who have, may have started working with us, or may have just wanted some help, or just some sort of feedback based on their specific situation, or just needing a consultation. And don’t get me wrong here, I’m not here to just have a pity party. I’m not here to just say like, everything’s wrong with this space. And I do understand that people who are probably reaching out are less likely to be crushing it. Because if they are, then they probably have a solid process, or maybe they have some really good guidance with it. Or maybe they haven’t hit a crossroad yet where that might matter more, where that guidance or expertise might matter more, and they’re just kind of moving along the process. The people who I’m sharing here, obviously, people who are dealing with issues and problems, which is, of course, we know through this process a lot, and the majority are dealing with it, then are not right.

I was thinking about this after having a conversation today with an ACLer, and it just felt the need to share what I hear all the time. But I just want to share what has happened in the past week of just what I hear. I want to share what this ACLer told me and all these other ACLers, with the understanding of what is that they’re dealing with? And then also, what are the implications of their situation?

For example, if they stay on this road, what does that look like? And why am I doing this? Because many of you listening are likely in situations similar to these people. And if you’re not, that’s awesome. I hope that you have the best guidance, the best care, the most individualized plan, the best testing, and you are set. You are in the best hands. That is awesome. But that is the rare few of ACLers. And we are not talking about professional athletes, we’re not talking about the top-tier D1 collegiate athletes. We are talking about the majority of human beings who are on this earth, dealing with ACL injuries. This could be the 14-year-old who tore ACL playing soccer, or it could be the 45-year-old who’s trying to get back to skiing. And not all the amazing resources are available based on, maybe it’s finances, insurance, maybe it’s geography. There are a lot of factors that play into someone’s care, and that is something that is going to be important as we move forward in this conversation.

And because many of you are listening who are going to find yourselves in this, I just want you to be able to potentially see that, and then what that could potentially matter in the future, or maybe currently, with where you are, and just the opportunity cost. And maybe just what it is from this ACLer’s lens of what they’re feeling, and maybe this ignites something in you to do something about your case.

I just want to make sure that these implications are just a byproduct, more so, of what poor guidance creates. Unfortunately, it’s just people falling through the cracks. It is just these situations where it’s a system thing, or maybe it’s a geography thing, as I shared, a combination. But at the end of the day, what this ends up coming back to is just very poor guidance based on the healthcare system. It’s not just in the U.S., it’s all over the world. Socialized medicine has its cons as well, which I’ll share. But the one thing that I do want to share is basically what opportunity cost is. 

Opportunity cost is the loss of potential gain from other alternatives when another alternative is chosen. You pick one thing at the cost of another thing, and that happens with any choice that we make, for the most part. The potential benefits you lose out on when you choose the other option over the other. I shared some general examples. I’ll share some specific ACL examples because I think that this can be helpful to help anchor this a little bit. But even something like skipping your rehab sessions or not documenting your progress, not filling out your workouts, not showing up to the sessions, or doing the days outside of maybe if you’re in person, the opportunity cost is, of course, to have delayed progress, longer recovery timeline, and a risk of re-injury, due to not progressing the way you need to. 

Here we’re not focused on sugarcoating anything. We’re here to call a spade to spade and to share what these things look like, because these are the realities of what happens in ACL rehab. Skipping rehab sessions is going to be more so based on your own personal, just dedication to it. I’m sorry if it’s bad rehab or you just don’t feel like you’re getting value out of it, then that comes back around to poor guidance. But if it’s on you and you can control it and you do it, then that’s one thing. But if it’s on someone else that you are relying on, then this is the most important thing; whether it’s evaluating yourself or evaluating the work person or team you’re working with. 

Another example here is choosing a general PT over a rehab specialist who focuses on ACL rehab. Now, don’t get me wrong, the majority of physical therapists are generalists. We get out of school and we are able to treat everything, but we are not experts at anything. We don’t necessarily go to the specialized track to focus on ACL. There are, of course, different areas like residencies that people can do—sports and ortho and cardiopulmonary, neuro, all these different lanes, but it’s not required. It’s not required like most medical doctors, for example, where they have to go to a residency and potentially a fellowship afterwards. 

With PT here in the States, it is a three-year doctorate, and then we take a licensure exam, and then we can treat everything. Therefore, it’s based on our jobs or what area we go into. But most clinics that treat ACLs would be a general orthopedic clinic, or maybe they are a “sports” clinic. A lot of times, it’s a marketing thing. But with that said, we are able to treat all the things; therefore, we are not very good at anything specific unless the person starts to specialize in shoulders, in knees, in ACLS, in pelvic floor rehab, post-partum mothers, and being able to work with CrossFit athletes. So that’s where it happens. But in the majority of cases with physical therapy, this is something where most ortho clinics, most physical therapists can treat a bunch of different things, but typically not very specialized in it. This is one thing that is going to be very important here, but I do understand that specialists are not available everywhere. Sometimes we need to go to just whatever the general PT or ortho is, to be able to do that. 

I think the thing that’s important here is that for your ACL surgery, you’re not just going to go to a general ortho who does all the surgeries. You may if you didn’t do a ton of research, and you know that’s something that could be challenging in hindsight. But most people will look and be like, okay, this person is an orthopedic surgeon who specializes in ACLs, or they do knees, and they have the reps with it. Now, your geography might be a little limited here, but that’s the same thing here with being able to find the right physical therapist or physio with this. We want to make sure that you can find a good specialist with this. The opportunity cost here comes back to the rehab-specific example. If you go to a general PT versus a rehab specialist, the thing is that you’re just going to get less individualized ACL-specific programming and just guidance.

They will miss out on the advanced testing that might be in play, any of the return to sport progressions that might be a factor within your specific ACL rehab, and just honestly, the higher level of care and the expertise to know when something comes up versus not. They’re looking out for roadblocks that are ahead, that you may never know about because they are always ahead on these things, because they can see, okay, this is where you are, this is where we’re heading. And they may look for these potential roadblocks. 

For example, we have an athlete going on a trip here soon. We’re not trying to break down all these things of like, hey, watch out for this and this issue and this issue. We’re just trying to reorganize the plan a little bit for this trip, so then therefore their knee tolerates it well. And that way, when they come back, they can continue in the process while they’re away, doing some things as well. Versus knowing that this knee can react during the trip, and then therefore they come back, and now we have to take a step back. It’s just looking out for potential problems that are coming that we know based on our experience and expertise in working with this population. That’s going to be key is being able to have a gut of understanding what to expect, and also the specifics and the different criteria and checkpoints along the way.

Another example here could be focusing only on at-home exercises, which can be common with in-person PT.  And the frequency will definitely impact this if you’re going one time a week, two times a week, three times a week. At least two to three times a week, which can be an average, but for some people, it could be different based on the insurance that they have. Maybe you’re only doing home-banded exercises, or you’re doing straight-leg raises, and you’re 10 weeks out. You might not be getting into the gym. The opportunity cost of this might be that you’re sacrificing gains in your quad strength and your ability to potentially start doing some jumping and some running. And of course, the long-term stuff of more dynamic things like cutting and being able to sprint and just progressing, all of these things. That could be because you’re at 10 weeks out, and you’re doing stuff at home, and maybe in-person PT isn’t pushing you. But there’s an opportunity cost, all these things. This is important leading up to some of these that I’m going to share because I want to break this down and follow it up with the opportunity costs or the implications, more importantly, of what happens with these people if they stay on this path. 

Now, these are things that I have heard while talking with ACLers this past week. Number one is that this ACLer is four weeks post-op hamstring graft, and their physical therapist asked them to do a high-effort isometric hamstring curl. This is something that tweaked their hamstring, and it’s just something that I was like, man, why would they have this athlete do a four-week post-op hamstring isometric, especially in the position where they were fully extended, and then it tweaked their hamstring. I’ve got personal experience with two hamstring grafts and an ACL. With that said, this is something that I found so surprising that just an inexperienced physical therapist did something with this person when they should have allowed this to be a self-limiting type of exercise. They should have allowed the athlete to give them some criteria for low intensity. Yeah, we can get the hamstrings active, but how about let’s put you in a position versus you resist against my hand too early. There’s no reason to force this. There’s a lot of time left available to get the hamstring stronger, even with a hamstring graft. Implications and opportunity cost here is that this athlete has to take a step back with some of their hamstring rehab. This is also going to influence the way that they walk. This is going to influence the amount of strength that they gain over the period of the next four to eight weeks, if not longer, if they don’t manage this really well. This is important that this athlete gets some better guidance around being able to strengthen their hamstring and not doing something like this with an inexperienced physical therapist.

Number two, having the same program with no updates for three months to six months after post-op. This athlete, for three months, from month three to month six, had no updates in her ACL program from her physical therapist. Crucial to have updates every single week. I’m not saying every exercise needs to change, but there needs to be progressive overload, and there needs to be changes within those three months because those are the bread and butter of ACL rehab. After your post-op phases and building some foundational phases, man, we are building athleticism between months three and six if we’re looking at this as a typical ACL rehab. You can’t have the same program. And what does that mean, implications-wise? You push your ACL rehab for three months. To be honest, the same exercises are not going to get it done. There needs to be progressions, there needs to be loading progressions, there needs to be a variety of movement and exposure to different areas of athletic development and qualities that you can portray. This is delaying this athlete by three months, if not longer, because of not having a progressive, individualized program.

Number three, athletes are getting their visits canceled and moved because the clinic needs them for other patients. I can’t make this up. They literally had their visits canceled, and then she was asked to move some visits because the clinic needed availability for some other patients. And I was like, this is crazy. I’m like, who’s to prioritize her visits over this other patient or other patient visits? This just delays things. Time is the biggest thing here, is this person, and not to mention the day-to-day implications of, well, they’re going to slow down their progress, their updates are going be slower and they might be doing things that they were doing two weeks ago that should have been changed, at the next session. But guess what? The next session isn’t until two weeks later. We have wasted two weeks, and that could have been progressed further.

Next up is that they’re told they’ll get tested and never actually get tested at nine months out. They said that they were going to get some testing, and they waited and waited and still haven’t gotten testing. There are a lot of implications here from just knowing where you’re at from a strength standpoint and other different criteria that might be getting assessed. But it’s also like, where has your programming been directed? If you haven’t had testing, then you don’t know where your gaps are. You don’t know where your deficiencies are. Therefore, testing is going to help us to be able to know where this is at. It’s just like in school. If you take a standardized test, you’re going to know where your strengths and weaknesses are. Sure, there are flaws in the test, but with that said, you’re going to know if you’re strong in math, you’re going to know if you’re strong in English and writing, you’re going to know if you’re strong in being able to do something like history. Different pieces allow us to understand, like a grading scale, if you will, of weaknesses and gaps. Therefore, if we have not been tested, then this is a very big problem. Therefore, we need to make sure that this is being done. If the person isn’t getting that, then that’s a challenge here, because then there are implications of where they are and the direction. 

The other piece of this, to tie this in there, is that a surgeon cleared someone at nine months and said, Don’t do anything I wouldn’t do, which is just what does that mean? The guy was old based on what the ACLer had reported, and this is something that’s just interesting to me, because why do they clear this person at nine months without any testing? And then also they just said, they’re exhausted with their rehab because the person isn’t making any more progress. It doesn’t mean they’re ready. It doesn’t mean they’re cleared. Therefore, what should have been an alternative is finding this person a better option for rehab to continue moving the needle. This is where it makes it challenging, because then when we look at the testing process itself, this is something where there was an MMT done for the return to sport testing, if you will. And just saying like, all right, just keep working on it and progressing into it. This is what makes things challenging because then therefore, again, you don’t know where your deficits are. An MMT is pushing into someone’s hand, and that could be very challenging because it’s based on their strength, and it’s not based on an objective measurement.

With this in particular, there is a false sense of knowing where someone is or saying, Hey, you’re cleared. But then also just saying, don’t do anything I wouldn’t do with this person. This is just something that I don’t think applies to this case. Another person was trying to be funny, but there are a lot of implications with this in terms of just what this person can do. They don’t know, and what needs to be done is that this person needs to be tested, and then, therefore, at the end of the day, what is the biggest opportunity cost here is that this person can reinjure. And then, therefore, they may have to go through this process all over again. 

Seeing a PT every two weeks with a sheet of paper that’s printed out and a 30 to 45-minute session, but they only see them for maybe 10 or 15 minutes of the session. This is just delaying the progress. It’s not very individualized. There’s not much you can really do with only 10 to 15 minutes every two weeks, especially if it’s on a sheet of paper because there’s no progression to that unless they have a system that is dialed in, with proper progressions and communications in between that. Two weeks is essentially pushing this down. Two weeks, if not, exponentiating that or multiplying that, because two weeks isn’t just two weeks pushed down the road. It’s like that could have been tackled earlier on. This multiplies times two, times three, times four, times five over time. There’s a limitation in progress and a delay in the timing of getting back to things. 

Another athlete was told to bed rest for one week after their ACL reconstruction. No way, Jose, there’s no bed rest. Yes, there is “resting” after your surgery, but you’re still working on things—extension, flexion, being able to work the other limbs, making sure that you can try and tap into whatever is doable within days post-op. I want to see my athletes as early as possible, and we have every athlete ready to go day of surgery. Day of surgery and day one post-op, they are doing different exercises because that quad will atrophy, that knee will settle in, the extension will get difficult, and we want to make sure we maximize this process as much as possible. Bed rest for one week has implications of not only just getting off crutches and the strength atrophy and muscle atrophy here, but it’s just something that can delay things exponentially, just like the example before.

The next one is doing ACL rehab with only 20 insurance visits, and I hate that this is the reality of a lot of cases. But in reality, what this creates is that you have to either burn through those, depending on what they recommend. And some people don’t even push against this. Sometimes it’s like, Hey, the PT recommends three times a week. So guess what? You’re burning through this in six weeks. Sometimes, they don’t even know. They can’t track how many insurance visits you have, because they have so many patients. And then you’re out of visits, and then you are up for having to pay out of pocket, or find other options, or left to your own devices. Therefore, they’re trying to strategically space these out. This might be two times a week for a certain period. It might be one a week. But then, it just depends on the way that they can deliver the individualized care, if possible. If it’s the sheet of paper and one visit every week or every two weeks, that’s going to delay things. The 20 visits are your cage or your constraint. And I understand that that’s what your insurance might be, but we kind of need to think outside of this of like, okay, if I eliminate insurance, what are my options here? And then, therefore, you can make better decisions without being constrained to just insurance visits because we know insurance is not going to get us all the way there. And that’s the mentality you have to have with ACL rehab is that our healthcare system by itself will not get us all the way there unless you are in the top 1% pro-athlete, elite athletes in a certain system. For the most part, you’re going to still have to invest or do more work outside of what you’re typically given. Don’t let the insurance visits be the thing that limits you; therefore, you get subpar care and subpar progress.

The next one is a zero extension is fine. Zero extension is rarely ever fine except for hypermobile athletes, maybe those who are incredibly flexible. We want hyperextension matching the uninvolved side. That is typically our goal unless you are very, very hypermobile and you can get 15 to 20 degrees of extension and hyperextension. Otherwise, most people have anywhere from like five degrees minus to 10 degrees minus of hyperextension. We want that thing matching where you can do a heel pop sitting on your butt on a flat floor. The thing is, is that if you don’t get it, it’s going to have a little bit more pressure on your anterior knee. It is going to create your quads to be a little bit more on when you walk and are vertical. It’s going to implicate activation of your quads. Just think about trying to straighten out your tricep, but you can’t do the last 5% to 10% of it. You’re not going to feel that thing tense up like you do when it hyperextends, when you hyperextend your elbow. Our knees are meant to hyperextend or elbows are meant to hyperextend, so we need to get there. Zero is not okay. 

Another one is that the athlete was told never to ski again. This is sad to me because it’s like, okay, in what situation can someone ever say that? Of course, if you’ve had four or five ACLs, maybe that is a case to be like, Hey, this is not in your best interest. But with that said, I don’t believe in that. And the implications of that, honestly, are just very poor mental health for someone important to. 

You are told to only do passive range of motion. I cannot make this up, only passive range of motion. After you’ve been injured, you know you’re getting ready for surgery, and so this is something that I just talked to an athlete recently about, where their PT told them to do passive range of motion for flexion, not active, and then therefore it pushed her surgery off by three weeks. Some change, and it was frustrating for her because she had to get on the road with life. She’s got kids, it’s summer. And by poor guidance, this created this person had to push their surgery off because the surgeon would not do surgery. 

And then the last one I’m going to mention is rushing into surgery two weeks after an ACL, meniscus, and tibial plateau fracture. This person is now five weeks post-op and struggling bad. Their rehab isn’t great, the guidance isn’t great, but this person was told to rush into surgery two weeks later because the surgeon had availability. Let’s get this thing fixed. And the person was like, all right, cool. Let’s do it. And guess what? They had a trauma to the knee that was pretty aggressive. Then they had the surgery, which is another trauma. This person is dealing with so much swelling and not even in the knee, but around the different tissues, and they have a tibial plateau fracture. Guess what? Why did we not allow this thing to calm down a little bit? Give it six to eight weeks, I know that we’re trying to get a move on and whatnot, but the thing is, this person would’ve been better off, I guarantee you, if they would’ve had waited and then allowed the surgery to happen. Let some things heal from the injury, but they were rushed into surgery. The implications are swelling, delay in their progress post-op, and now they are dealing with work issues that are coming up that they cannot take off time for anymore. This is going to impact their next three to six months, if not longer. 

All these, why am I sharing this? It honestly hurts my heart, but this is the reality of ACL rehab and the landscape. And I know I’m pointing out the negatives here and the implications or the opportunity costs, but this is not uncommon. This is very common, and I’m sure some of you listening, you’re like, this is actually what I’m doing in PT. Or like, this is the scenario I’m in. And I’m not saying everything’s perfect, but the thing is like we have to make our changes. And the thing that’s important here is that with this, in particular, with your ACL rehab provider guide, your team. The thing about generalist physical therapists who don’t have experience with ACL is that it’s like asking a primary care physician to handle a cancer diagnosis case, make it make sense, it doesn’t. And that’s the thing that’s so challenging here, is that we need to make sure that who you are working with has the experience, can defend essentially why they’re doing what they’re doing, and then also to be able to lay out this roadmap in very clear detail for you, specific to your situation.

I think this is the thing that’s always challenging, is that, oh, what the protocol says. A protocol is not super helpful because it doesn’t individualize things. We need to have a guided roadmap with criteria, plus time to be able to help people with this process. And the thing is that this has negatively impacted each of these people, physically, mentally. Time has influenced a big piece of this because they have to delay things because of where they are and the structure of this, and the guidance that they got. 

And the last thing that I want to share here is that your ACL team is going to be the most important decision that you’ll ever make in this ACL rehab process. It’s more important than anything else that you’ll do. It’s going to be making sure, especially my own bias, is your physical therapist, aka your guide. They are your GPS. Your surgeon is not your GPS. The surgeon is going to go in there and they’re going to rebuild the ACL. They’re not the ones that is going to guide you through the rehab process. That is your physical therapist or your rehab provider’s job. And the thing that’s kind of crazy is that I see people spending weeks and months on end researching the best surgeon around them or the best graft type, even traveling far and wide, for them to get the best surgeon. And then they settle for the physical therapy clinic closest to them that takes their insurance. When in reality, this is the most important decision in all of your ACL rehab, I promise you, and I will go to my grave with this. I’m biased. I know, but I’ve seen it make or break the process. I’ve seen terrible surgeries with amazing rehab go well. I’ve seen amazing surgeries with amazing rehab go well. I’ve also seen where there have been. Poor rehab with amazing surgeries. Guess what? It doesn’t matter if this surgery was amazing; the poor rehab still broke the process. I think this is important here, is that I’m trying to share essentially the opportunity cost of everything that we make in terms of decisions in life, there is to your ACL rehab process. It is going to have implications on your physical and mental health, along with your timeline and the things that you want to get back to. 

At the end of the day, no one wants to be in this. They just want to get back to their lives, activities, and be active. And so that’s going to be important here, is that it has so many implications to your physical and mental health. Your most important decision in ACL rehab is your rehab provider. They are the person who is going to guide you and be your GPS, not your surgeon, not your sports coach, not someone who’s on Reddit or Facebook group saying this was their best experience—do this—your physical therapist, physio, and your rehab provider. But they need to be vetted, and they need to be legit and know the stuff.

I stand by this more and more. The more I talk to people and have these conversations, what ends up happening is that they end up with a general clinician, a general physical therapist, their insurance limits them, and then they are stuck and handcuffed in this system that is not built for ACLers. This is challenging, even with the person with that 20-visit insurance. How can you expect them to get all the way there? With the way that it is structured in 20 weeks, let’s say one visit a week, let’s even be just like very conservative, and they go 30 weeks. That’s still not enough. And that’s spacing out visits a ton. And that’s assuming that the system that they have is built to manage someone well outside of the clinic, which is not in most insurance-based clinics’ structure. Therefore, it’s like that’s already putting the person at a disadvantage as opposed to what is the best-case scenario. They have support and individualized guidance every day, and maybe it is two times a week in person, three times a week, or maybe they don’t need it because they just need a plan and some asynchronous touchpoints outside of that. 

I think this is super important for us to peel back some layers on and to share with you because you have to take control of your process and make the changes if you feel as needed. Do not weigh, there’s an opportunity cost in doing so. Let me ask you this: What is the opportunity cost of staying exactly where you are at? Whether you’re staying at the same PT you’ve been with, maybe it’s the same surgeon, maybe it’s just the gym that you’re at, for example. There could be several factors in this, but what is the opportunity cost of staying exactly where you’re at? Imagine yourself three months from now, six months from now, a year from now, do you feel like where you are is going to get you on the path back to where you want to be? And if the answer is no, there needs to be a change. 

Some questions that I want you to ask yourself is: how much do I value this? The rehab, what we’re doing, the plan itself? What am I giving up now to have this? What am I giving up in the future to have this now? And the trade-offs that come to mind are typically like the financial pieces, because people are investing in this. If it’s insurance, there’s a feeling of feeling like the insurance should cover everything, but in reality, with the landscape, it’s not going to. Most people I talk to have a copay, and they’re paying out of pocket, and then that’s going to be something that needs to be evaluated. But what about time? What about work? What about just the things that you enjoy? And getting to just events, maybe it’s travel. But those are things that are going to be important to evaluate. And also just thinking about your mental health. This is such a big piece of knowing where you are at all times, where you’re going, and what that plan looks like, specific to you. 

The last thing I’ll share with you is that if your best friend came to you in this situation that you’re in, if you feel like you’re struggling, what advice would you give them based on this episode? Based on what you know about this, what would you share with them? Maybe it’s your brother, sister, parent, friend, best friend—what advice would you give them in this? Pause for a second. Take that in, answer it that way, and then use whatever you have just said. And go do the thing with that, and likely it is to make a change. If it’s not, then awesome. Keep rocking. More power to you to do that, and I’m fully in support of that. But if you feel like a change needs to be made, do it now. This is your permission to make the change. Make the jump. I promise you, in three to six months from now, if you do it and you find someone good at this, they will be able to get you there. And if not, they will be able to guide you to the right person who will get you there. But that’s going to be important in this process. I hope you guys can get some value out of this. I did not want to bring this into a negative vibe here, but just more to be transparent because this is the true reality of what is happening. I see this all the time. I hope that this was helpful. If you need anything, we work with people remotely all over. We are here to serve. We are helpful and also refer people to other places if they need some help. Please reach out. We want to be a resource here. Until next time, team, this is your host, Ravi Patel, signing off.