Episode 230 | Undercooked > Overcooked: The Golden Rule of ACL Rehab

What is up team?  And welcome back to another episode on the ACL Athlete Podcast. I’m excited for today’s episode. This is a concept/idea I love to talk about. We talk a lot about this with our ACLers, we talk a lot about this with our mentees in our ACL mentorship, and we talk about this as a team because it is a very common theme in this process that we want to make sure stays front of mind. And to start this off, one of the things that is always important is for us to just understand why we’re going to bring this up in the first place. 

With ACL rehab, we’re always trying to find the sweet spot to load appropriately and to progress. And this can be a double-edged sword due to too little and you risk not progressing at all, due too much and you risk getting flared up and set back. What is the best strategy? Let me break this down with you with an analogy. 

I love to use this steak analogy. If you don’t like steaks or vegetarians, I’m sorry, I love steaks, but I promise you’ll get my point. Apply it to any type of thing that you could potentially cook too long, which is most things. If you are grilling a steak, for example, would you rather undercook it or overcook it? And I’ll give you a second to think about this answer. If you’re grilling a steak, would you rather undercook it or overcook it? And then why? Based on your answer. 

I hope that you picked undercooked, why? Because if you undercook it, I can always put it back on the grill and get it to the right temp. I can always do more. I can always add more temperature to it. But if I overcook it, it’s done. You’ve gone too far, can’t go back, and you’ll be sad eating a very tough, chewy, flavorless, overcooked steak.

My point here is that in ACL rehab, it’s always better to undercook than overcook. You can always do more, but doing too much too soon can set you back. And to me, it is not worth it, and let me explain why. This will be even more important for someone who is in the earlier stages of ACL rehab versus maybe mid or later in the process, because the knee is typically dealing with more symptoms and limitations. It’s fresh from the injury or the procedure; therefore, there’s just a lot more volatility from the symptom standpoint and just the overall limitations of the joint. You have less bandwidth or less to work with, so you can overcook it with even very basic things.

I did a podcast episode on straight-leg raises, and it’s crazy. You can overcook your leg by doing too many straight-leg raises or not doing them properly. And that’s just a note to say, just don’t do straight-leg raises. I’m just kidding. Do whatever your provider is telling you to do. If you are working with us, you’re probably not getting them. But with that said, that is something that is going to be important, is that early on, you are typically dealing with these symptoms and limitations. It’s the capacity to handle stress is lower for the knee overall. Plus, early on, psychologically, there’s also a lot of apprehension and anxiety that comes with ACL rehab. Because let’s be real, ACL rehab is a dance. There are times when the knee is leading the dance, and there are times when you’re leading it. Early on, it feels like you’re more at the mercy of the knee, and it is pulling you around dancing, so we need to be mindful of making sure we are approaching this very strategically and very methodically.

My default is always to undercook. If you are an athlete of mine, you have probably heard this many times because it is an important principle and something that we utilize, especially in rehab. Now, it could be a little different with performance, where someone is not dealing with an injury or pain, and we’re looking for high performance. But even with that said, if we’re introducing new stuff, we’re probably not going to go 100% all out on the gate and just cook the person to where they can’t walk the next day and do anything. But we have to be even more sensitive on this and let off the gas and, if anything, beyond the brakes a little bit more, especially with an early ACL.

We want to be very intentional about this. As I shared, my default is to always undercook. There’s always a safe starting point with any type of movement or quality I want to work on, for the most part. Meaning, we can always find a way to work on that extension, that flexion, the quad strength, the hamstring strength, power, foundational movements, and dynamic movements. There’s always some type of entry point and way to scale the movement to be able to work on it. And that’s just good rehab, good strength and conditioning, working with a good physical therapist who understands movement, exercise, and prescription so well. I’d rather have an exercise or a session on the easier side as we start, then progress from there. Because I can always make it harder or make it more challenging. I could always regress it too, but why give someone a harder version of it and they flare up or set them back when you could give them that win of doing something either a little easier or something that they accomplish and do well, and build off of that.

There’s such a psychological benefit to doing something like that because they’re like, ah, I did it right. And even if it’s easy—hey, they at least can check the box and be confident with it. And then guess what? You could just make it harder. We don’t need to make it hard and then step back. I’d rather make it easier and then add and make it harder. And that’s where working with someone who knows this stuff is going to be important. The problem is when we push too hard, too fast, and overcook, which could mean pain, swelling, stiffness, or maybe just a lot of soreness and fatigue. Then we just have to let time and biology do their thing. Then it’s the waiting game that could have been avoided by proper education, individualized planning and programming, and really solid coaching, and an unnecessary setback, in my opinion. This should not have occurred. Setbacks happen. But things like this should be avoided, and that’s where these types of details will be so key for you specifically.

And don’t get me wrong, this isn’t perfect. People can still have their setbacks, as I shared, because we do know that ACL rehab doesn’t just happen in a vacuum. People live their lives, and lives must go on. With that said, you have a better chance to control and titrate stress if we start more by undercooking and conservatively doing it, then turn up the dial on the volume and intensity too much. This is an important point. We don’t undercook and just stay there. We need to make sure what is being done is meeting the sufficient stimulus to get the adaptations we want. That’s where testing comes in to help us and to make sure we are meeting those specific demands or the stimulus that we need to get the objective changes that we are looking for. Maybe as qualitative instead of quantitative, but we’re seeing these things and we’re evaluating them as time goes on. But with that said, that’s how we are able to make sure that the stimulus is meeting it, so we can get the adaptation we want. The beauty is that we can continue to progress the movement or the stimulus to find more of that sweet spot.

Even if you start super easy, then you can progress it, and then eventually you will find that sweet spot, and then adapt as needed based on the athlete and their dose response relationship. You put in a dose, and you see what the response is back. Do they respond well? Do they respond okay? Do they respond poorly? Ideally, you avoid the poorly by being able to undershoot it or being able to undercook it, and then you can add a little bit more, make it more challenging. Symptoms ramping up. Let’s turn down the dial some, or maybe we just stay steady for a second and see if it normalizes. Everything is moving smoothly and progressing well. Let’s turn up the dial some and make it harder. Let’s see the dose response to this. 

Practically looking at this, undercooking is conservative loading that allows for the adaptation without flaring the tissues. For example, an athlete comes in with some soreness, reduces the volume by 20%, and reassesses the next day. Start with the easiest version of this dynamic task, and then progress up versus this really hard task to just show off like a hard exercise. Stay in a low rate of perceived exertion, RPE range, when introducing a complex, compound lift, if you will, or something that just might involve a little bit more exertion. We want to make sure that the athlete can own the positions before they push the intensity and be able to dial in some good capacity and volume.

Overcooking might be pushing past biological limits. That might be swelling, pain, irritation, or dealing with setbacks. Coaches push, heavy landings too soon. Athlete swells up, misses maybe one or two weeks, or they have to set back. A return to run milestone is hit, and there’s no parameters on running. Maybe they’re like, go run a mile now, and the knee swells up and is limping for days. Why not just allow this athlete to do a jog and then give them an easy jog progression interval right after that? Very short running in duration at a low intensity and then a walk ratio, instead of just going run steady. Because a mile at the end of the day is still probably a lot of stress on someone’s knee when they’re just getting back to running, and the impact on the knee.

The thing is, you can’t take back a flare-up. The body needs time to get back to baseline. Why not just progress it to the next challenging thing versus what feels good in the moment? ACL rehab is a slow-cooked process, y’all. It’s slow-cooked. That means we’ve got to play the long game. Don’t try to win it in one week or two weeks, or even in a month. We are trying to play the long game and get ourselves as solid as we can in an efficient way to the end. 

I remember hearing this from one of my mentors that you can’t expect to bake a cake twice as fast by doubling the oven temperature. Even ovens can’t get up to 600, 700 degrees; some can. But with that said, it doesn’t mean that it’s going to bake the cake faster. Same thing here. We need to respect our human biology and the dose-response relationship. When we’re talking about where we want to be intentional about undercooking, early post ACL injury, early post ACL surgery, when there was a traumatic injury and damage to the knee, a complex ACL surgery with concomitant injuries and surgical processes as well. A sensitive knee with fluctuations in symptoms, especially with pain and swelling, non-operative ACL dynamic work. When we’re introducing dynamic work for our non-operative athletes, we’re being a little bit slower on the gas pedal. We’re trying to make sure that we don’t ramp it up too fast because they don’t have an ACL. We are going to try and make sure we are very intentional about the way we implement this and see the response back from the athlete.

When starting a new training block, aka new exercises and movements, we want to see how that feels on the joints, on the muscle groups, the body itself. How does it respond the next day? Introducing heavy loading, especially if it’s newer after this injury and surgery, introducing a lot of volume where they’re doing a lot of reps, introducing dynamic and impact-based tasks, as I went back to the running example, that is something that sometimes people ramp up too fast and their knee swells up. They haven’t been used to the impact, and they probably didn’t get any plyometric work prior to which you should before running. You should actually be jumping and working on that in a very strategic way before you start running. And this is important to get the knee ready for the demands of running and then especially for jumping as you progress. We want to make sure we progress these very strategically and not ramp it up too fast. 

The last piece I’ll mention is introducing complex tasks. When things are complex, we want to introduce them very slowly. We don’t want to just throw an athlete on a field with seven people and say, run around and react. Kick the soccer ball and play your sport. We want to make sure we go from simple to complex. We want graded exposure with this and make sure the athlete adapts appropriately to these and responds really well. A good rule of thumb here: goal is to find a tolerable volume and intensity you can handle and don’t pay for it the next day. Return to baseline ideally. Your symptoms or the way the knee feels like you feel like you’re back to baseline. That’s awesome. Use each exercise and session as a data point and see how it trends over time. That is something that is so huge. Don’t take one session for this big overlying theme. Instead, look at how each little session is a data point and see how that trends over time and your body responds to it. Even if you feel great that day, don’t take that as a pass to go hard. That has been something that has gotten athletes in trouble where they’re like, oh yeah, the run for a half a mile felt great, but then they decided to go on a mile or a mile and a half, and then they overloaded themselves. That wasn’t a part of the plan, but they felt good. And yeah, when your body is warmed up, it probably feels a little bit better. The thing is, you haven’t built up that capacity yet. We’d rather work on that a little bit more and slowly titrate that up. So that’s going to be super key here.

What you want to make sure is that you have earned the right to progress and do so, and build it up progressively. Just like that dimmer switch I utilize a lot, instead of this on and off switch of go hard, I’m slowly dimming it up or down, and then turning the dial up, turning the dial down, whatever relates to you. But that’s something that helps me in this process very much. I hope that you guys can utilize this because it is such a valuable thing working with so many ACLers. 

As we finish up here, it is better to undercook it versus overcook it on the side of undercooking early. You can always cook it more, aka, do more in the next session or the next week. Progress is non-linear, super important here, but unnecessary setbacks don’t have to be a part of the plan. This is where having a solid roadmap, individualized and adaptable programming and planning and expert ACL guidance is going to make all the difference in this. I’ve seen a lot of people who are just flaring up or just doing too much, maybe doing some of the same stuff. And maybe they will progress too fast. They’re pushing through pain, and they’re having swelling in the mid and late stages. By the way, if you’re mid and late stages and you’re dealing with swelling, it’s not normal. We need to stop normalizing that. It is normal for the knee to have a lot of pain and swelling. We don’t need to push through it. It means the knee is not tolerating the loads. We need to make sure we take a step back for us to make sure we feel really solid and be able to move forward two steps, one step back, two steps forward, and that’s going to make a huge difference here. But always to undercook, and then you could always cook it a little bit more.

I hope that this helps y’all. If anything, just remember the steak, remember the analogy, and take that with you as your themes in your ACL rehab sessions. Until next time, team, this is your host, Ravi Patel, signing off.