Episode 227 | Why The Best Surgeon Can’t Save You From Bad ACL Rehab

What is up team? And welcome back to another episode on the ACL Athlete Podcast. At this point, I’ve talked with thousands of ACLers over the years. And one thing that I always ask in conversations, especially with ACLers when they’re looking to work with our team. Whether they are dealing with just some problems going on, we dive into some of the details.

One of the things I always ask is about the surgeon and their physical therapist that they’re working with. And oftentimes when they talk about the surgeon, there tends to be a little bit more effort in finding this professional. There’s almost like this level of like, I’m proud that I found this particular professional based on their experience, or maybe this particular achievements they have, or associations. And with this, they typically have maybe reached out to other people who have had ACL injuries, maybe medical professionals that they know. There tends to be just a bit more effort, if you will, in finding this professional. They’ve looked at those online reviews, they’ve consulted multiple surgeons, maybe. And they’ve done their homework. They are noted as the best surgeons in the city (I hear this a lot). I hear they’re the go-to surgeon for this particular procedure for ACL. They’re the “pro team” surgeon for this particular pro team, local to you, and they do all the pro-athletes around. 

Or they did X athlete’s ACL surgery. And don’t get me wrong, I was even a sucker for this. I went to a surgeon who was specifically associated in the town that I was in, for college, and that surgeon, for my second ACL, did the UG football team surgeries, specifically for their ACLs. And guess what, in hindsight, his technique for getting my hamstring graft was not great. When I look at all the different ways to harvest hamstring grafts, now that I am beyond that, I’m beyond my undergrad. I’ve done my physical therapy education, and I’ve dove into the ACL world. I’m very familiar with this because I can compare two different ACLs with the same graft type, but two different surgeons.

I have my high school ACL injury, had a graft that was taken from my hamstring. I don’t have any donor site-related pain. I do have some weakness in my hamstrings that can come and go. But then with my second one, I had a hamstring graft, but the incision point is not super solid. They went in where the crease of my inner knee is, and that created some scar tissue, which created some hamstring issues. Honestly, I could still ebb and flow with that, I notice even today. 

Now, does it influence the performance of my hamstrings? Still, the same as the other side of the weakness can ebb and flow. I have to make sure I keep strengthening my hamstrings. It’s easier to strain, if you will, because I am essentially lacking a muscle group; after all, that tendon is taken. So that muscle is not just regenerated by nature. It tends to atrophy. It may attach to other muscle groups. But with that said, with a hamstring graft, it’s still not fully understood what happens, but a lot of times it atrophies and goes away.

Now, with that said, the procedure on the second one, I just noticed it, it just feels funny. Sometimes it makes me hesitate with certain movements when I’m doing strength work. With that said, this was the best surgeon. This was associated with the best athletes, the top-tier team, D-1 college. And I would say that the technique that was utilized was not very optimal, and this is my personal opinion. That was maybe his training, maybe it was just a one-off thing. But in my opinion, based on this and knowing this space, I think that that wasn’t great, but I thought he was the best.

While there may be some associations with big names, “the best” still needs to be clearly defined, and that’s important here. And I don’t think it’s what they’re associated with directly that automatically gives them a pass. It’s who they are and vetting these people and their experience. Their bedside manner, being a human, first of all, to be honest, and the volume of ACLs that they do in a year, weekly, monthly; the graft types that they do and what they’re experts at, the outcomes that they get, if you’re able to gather this information. But especially knowing what their testing process looks like, what does their protocol look like? Because every surgeon has a protocol. Their criteria for running or for getting cleared to go play sports again.

What is their perspective on good rehab? Do they believe in good physical therapy? Some don’t even care for it and don’t believe in it. You’ll get answers across the board. And while it may seem like you are trying to interrogate or interview this surgeon, these are things that are important because y’all like, this is such a big procedure. We don’t need to worry about hurting their feelings or their ego is involved. We should just assume that they’re the professional who is right for you. We still need to do our due diligence. 

And so that’s just some side points I want to make here of what’s important, because sometimes we almost let these accolades or these particular associations automatically put this person in the best category just ’cause they’re associated with this team or because they’ve done X person’s surgery. And the interesting thing is that these ACLers, a lot of times,  sometimes they’ll travel outta state or they’ll go hours and hours and hours away for the “best” surgeon. They’ve done their due diligence. And don’t get me wrong, sometimes this is the case, and you do line up the best surgeon, which is awesome, and it’s just such a breath of relief, if you will, whenever there is a good surgeon to work with, and there are a lot of them out there. There are also a lot of difficult ones to work with locally here in Atlanta, and also all around the world. If you found a good one, more power to you, and that is an important step. I’m not saying don’t do that, but vetting them appropriately and making sure you do your due diligence with any member of this team is important. I would do the same. And I did do this for my hip. I didn’t necessarily do that for my two ACLs because I was young, and I didn’t have a lot of information available. I just kind of went to whoever heard what I did, and then I just went with it. But now that I know better, I try to make sure that we have the right people on our team. 

But then, when I go to ask these same ACLers about their physical therapist, the practice, and where they go, there’s less research, and it ends up being based on two factors more than anything. 

Number one, what accepts their insurance? Number two, what is the closest to work, school, home/what is most convenient? There may be another part that plays into this. What are their times they’re open to schedule you? I know for high schoolers, sometimes they have to go after school, and if a PT clinic closes at four o’clock, that doesn’t create a lot of time available. Often, there will be offset PTs who will work at clinics, especially insurance-based or even out-of-network, that will stay open until six or seven to be able to see these late high school athletes or people getting off work who can’t make it in earlier. Therefore, that does influence the decisions, right? What accepts their insurance, and typically, convenience, and sadly. As if all physical therapists experience their clinics, the rehab itself, or ACL rehab, is the same across all physical therapists, but it’s not. I’m not saying everyone falls into this category, but this is very, very common from ACLers we talk to.

And of course, I totally get it. People who are reaching out are probably people who are dealing with problems, versus people who are like, I’m crushing it, and I’m going to reach out to Ravi. It’s not necessarily the case, but knowing the landscape of ACL rehab, the way our medical system is, the way insurance is, the way our physical therapy education is, and just knowing this process personally, but professionally, that this often happens. And especially as I had shared after talking with so many different ACLers through this process, there’s always a common theme of seeking out the best surgeon or doing some homework there. When it comes to physical therapy, it ends up being a matter of two factors: what’s convenient and what insurance will cover.

For people I’m talking to, they are typically in three main situations that many are in, going from the worst to the best case scenario here. I’m just going to list these. The worst is a very bad surgeon and a very bad physical therapist. That is not a good, good situation to be in. The next worst case is a good surgeon and a bad physical therapist. This is, to me, the next worst. A better case is a bad surgeon and a good PT. And when I say bad, I mean I recognize that I might be a little biased here again. But when I say bad, it means that they do just an average job. They’re not the best, they’re not the go-to that has been recommended. They get the graft, they put it in there, and they have done their due diligence on what the procedure needs. But maybe they didn’t have the best bedside manner, maybe they didn’t explain anything, maybe it was just like a very average procedure. And so that’s better in my personal opinion, and I’ll share why with a bad surgeon versus a good PT.

And then the best case scenario, of course, is going to be the best surgeon and the best PT. In this case, even with a very hard ACL rehab process, you’re not going to feel lost, you’re not going to feel directionless, you’re not going to lack trust. You’re in a good spot because you’ve got the best surgeon. You’ve created a really solid team with that surgeon, but also a very good physical therapist that you have sought out and are working with. Your GPS system is dialed in. You have this team to help guide you through this process. But more often than not, most ACLers are not in this best case scenario, given the way rehab education is.

As I had shared, the majority of physical therapists in outpatient orthopedics are not ACL experts, and most clinics are not designed to help ACLers get back to full sport and performance. My point here to share is that these ACLers often do a lot of work to find the best surgeon, then settle for their physical therapy based on convenience. And again, not everyone, but this is just something that I consistently see, and this creates a difficult ACL rehab. The tough part about this is that they don’t realize it until they’re months in and after post-op, because even the worst PT can help someone post-op, just by nature of how the initial post-op process can go, and just the constraints or the limitations of it. You’re more likely to see progress than not. You’re likely to improve your pain from that baseline post-op because you’re going to have that sharp pain that will eventually improve compared to the first day or two post-op. You’re likely to improve some range of motion, even if it’s 40, 50 degrees. You’re going to go from a straight knee to some bending, and then you’re going to probably eventually get off of two crutches to one crutch, to no crutch. You’re going to see milestones in progress regardless of even generic rehab because of just the natural healing process and because of how limited you become post-op, and then you start to heal, you start to do some movement. And therefore, you’re going to improve in this process early on.

But the thing is that it is hard to know how good you could improve because of the rehab you may be getting. That’s how it can be challenging, because it’s not until hindsight that maybe some of this can be noticed. And when I’m looking at the surgeon and the PT, and I’m not saying like, it is this one versus the other. The goal here is to get the best of both.  But I’ve seen in many situations, even for our team, where ACL surgeries haven’t necessarily gone the best, or their surgeons aren’t very helpful in the process. They do the surgery, and then they brush their hands off, and they’re like, hey, I’ve done my job. Now it’s the physical therapist’s job, which is, it’s easier to fail on the physical therapist than on the surgeon. Because the things that we are dictating after an ACL surgery are going to be more the physical and functional abilities. And that’s going to be more of the physical therapist’s job than the surgeon’s. 

Therefore, when I look at this, I’m also thinking, okay, well, if I’m looking at the ACL rehab process. A lot of times, I like to come back to some examples, especially referencing building a home. To me, is like hiring an expert architect. You’ve done all the research, you’ve found the best architect to design your dream home, and then just finding a generic, cheap builder to build your home. You find the best designer, but then you went a little bit off the side route with the generic chief builder. And then some other example that comes to mind is the director. They’re an amazing director, but then the editor’s generic. An incredible financial planner, but your CPA is not great. They’re average. A brilliant branding expert, but then you’re building a generic website. Many of these cases, you could still get a good quality outcome if the second professional mentioned was incredibly skilled. But could you imagine the product if both were amazing? And usually, for an amazing product and amazing outcome, the team in general is all around really good. It’s very rare that one person’s bad, one person’s good, and they create an amazing product or an amazing service. 

That’s the point I’m getting at here is to take the time to make sure your ACL team is quality and it is legit. Put as much, if not more, stock in your physical therapist and the coach you’re working with. And I promise you, this person will make or break how your rehab goes. The surgeon would have to botch the surgery to be completely honest, for an incredibly skilled PT to not be able to do their job in getting you back to what you would like to do. 

Guys, we’ve seen some not-so-great things from surgical procedures. And we can make it happen. And I’m not saying it’s all that we can fix. There are certain times where we have to refer back to the surgeon because the knee doesn’t heal properly. There’s a cyclops scar tissue, a tibial button or screw issue. People are dealing with things that just the body doesn’t take very well. And that’s not necessarily the surgeon’s fault. It’s not the PT’s fault, it is just the biological process of healing, and that human, and it just didn’t work out the way it did. Yeah, we gotta refer him back. We gotta get some help from the surgeon. And it might be that surgeon, it may be a different surgeon. With that said, we can’t fix everything, but I promise you a very average surgery with a very good physical therapist will very much influence a strong outcome for your ACL rehab. And it will give you more of a sigh of relief to know that you are guided by somebody through the day-to-day, and they know what they’re doing. That is something that I’ve been trying to think about recently because. I’ve been getting some challenging cases, even myself, of people with just not great surgical experiences. Maybe very subpar experiences. Maybe the technique is super old. Therefore, what do we do with this? How do you communicate this to the athlete? What do we do about the rehab process?

And a lot of times, what I find is that they’re also just going to a very generic physical therapist. Therefore, they’re getting the typical starter kit of quad sets, straight leg raises, four-way hip, doing some air squats, maybe getting some lighter weights, doing some lunges, step-ups, and then maybe they’re doing an agility ladder and maybe some box jumps. And then they’re progressing things based on time. There’s no testing. And the thing is that that makes things just so, so challenging in this process because it’s just not the way that it should be done. And it needs to be done through criteria, through making sure that it is individualized to you, and we can’t give you the starter pack ACL rehab exercises. Everyone is getting it right. One thing I’ve been trying to utilize is a rating scale for different things. I think that this is the perfect situation for it. 

One way to look at this is if you had to rank your surgeon from zero to 10 in terms of your overall experience, from their bedside manner, guidance, and surgical outcomes so far, what would you rank them? And if it’s not a zero. And if it’s not a 10, why not? What do they need to hit a 10? Now, do the same for your physical therapist, coach, whoever you’re working with from a rehab standpoint, go from zero to 10. What would you rank them? And if it is not a 10, why not? More importantly, if it’s not above a seven or an eight, that’s a red flag, especially for ACL rehab y’all. I think that there should be a high level of expectation, no matter the care that you are getting, but especially for something like this with such a high re-injury rate, with such a high risk of not getting back to what you want to do, long-term knee health. Maybe having to put off a total knee replacement to having it sooner because of osteoarthritis progression. All these things matter, y’all. I think that if you are ranking yours less than an eight, that needs to change. What I find is that many people would rank their surgeon high and their PT lower. Why is that? And then it comes back to the initial time taken to vet them and finding the right professional, or a matter of convenience. And don’t get me wrong, I get it in most situations. Physical therapy comes after, while prehab is awesome. Hopefully, you get in there, you can find the right PT before you have the surgery. What ends up happening a lot of times is that people don’t get introduced to their physical therapist until after the surgery is done, in most cases. Therefore, they just kind of like, all right, this is good enough. They’re a professional, they’ve had an education, and so they just go through it. And then once you’re kind of in it, you’re in it. Therefore, they don’t want to just switch up the midpoint. And it’s also harder to figure out whether they’re good or not whenever you’re so early post-op, because that’s the last thing you’re worried about doing.

It takes time for that to develop, for you to be able to see that. You’re ranking your PT lower. I want you to define it and, of course, see if there’s something that can be improved. And if not, then change it to where you can feel confident ranking it a nine or a 10. You deserve the absolute best, and sometimes we just don’t know what we don’t know. And that’s okay. And it’s a direct result of, you know, this being in hindsight that we’ve learned it. I think it’s okay to have some space for that because we don’t know what we don’t know. But once we do know better, we have to do better. If we don’t, the result is on us at that point. 

If you feel like you find yourself in this situation, I really hope that you advocate for yourself and make the change. Now, I promise you, in the first one to two weeks, if you’re with a very good professional, ACL rehab expert, someone who just knows this stuff, you’ll notice an immediate difference. You’ll exhale knowing you’ve got a solid GPS and an expert team navigating you on your ACL journey. And the biggest thing I would say is please just don’t look back three months from now, six months from now. Or heaven forbid, years out wishing you would’ve done it differently. You only get one body, two knees, give it your best shot now, not later, because you deserve good care.

I fully believe that elite care shouldn’t be just for pro or elite-level athletes. Everyone deserves it, no matter what level or status, and that is just good healthcare. Make sure each professional on your team isn’t an expert and is quality, and just make sure that you vet them and make sure you do your due diligence. Instead of there being this pie where it feels like 70% of the weight and the effort of searching was more for the surgeon, and maybe 30% was for the PT. I know in theory it could be a 50/50 thing here. But a lot of times, what I see is that there tends to be a lot more heavy weight towards the surgeon side. And then we almost kind of settle a little bit for the PT side, I know that this healthcare landscape, no matter what country you’re in, is very challenging. I’m not saying that this is just an easy pivot or change because I know that there are a lot of things to navigate and jump through. But I do think at the end of the day, if we can evaluate, am I getting the best care possible?

And if your answer is no, and you rank that zero to 10 lower than you feel like you should, then that’s when we need to evaluate and say, okay, what needs to change? Is it a conversation with the physical therapist? Is this conversation with a surgeon? Is it trying someone else out and seeing if this is a better fit?

And maybe that person was good for where you were in the early post-op, but maybe after that first six weeks or eight weeks, the value or expertise or their skillset diminishes, right? Everyone’s kind of got their area that they’re good with, and they’re not going to be masters of the whole thing, unless that is all that they do. That’s all they focus on. That’s all they see. Y’all. It’s really important to just make sure that you get good care. And I know I’m biased here, and you guys are probably like, wow, you’re beating a dead horse with this conversation. But I just continue to see this and I just want to make sure that if you’re listening to this and you’re early, especially I more, you’re planning your next steps.

That you’re able to just get good care, because I do believe that it can make the difference in the rest of your journey, but also just from how much this recovery takes a toll on you mentally. And when you don’t have good guidance and good care, it just makes it worse. There’s more anxiety, there’s more fear, there are unknowns.

And while some of that stuff exists, even with the best, I promise you that there is a difference in the perception of it and your direction and clarity around how you’re gonna get there. Because any good. An expert professional is going to share how that’s going to look and give you that plan and that roadmap.

So please do that. Please evaluate it. I promise you it will be so worth it to be able to make that change, even though it’s uncomfortable. Choosing that hard now versus the hard later will be totally worth it. It’s because you deserve care, and because of technology, now, it’s not like you have to go to this high-tech facility to get that.

There are many different ways from a remote or in-person standpoint to be able to access elite-level care and expertise. Reach out if you need any help. There are tons of people out there who are also doing great stuff, so make sure you make some moves if you feel like this is kind of pressed on you after listening to this episode. And if you have any questions, please reach out to us. Until next time, this is your host, Ravi Patel, signing off.