Episode 236 | Running Optional: Redefining Milestones in ACL Rehab

What is up team? Getting straight into it for today. Running is a very common milestone for most ACLers in this process. And something we as PTs, as performance coaches, want our athletes to hit. Very often, we are talking about running and what the criteria are to fit running, and then we are looking to aim for that. Blending not only the time pieces, but then more importantly, the criteria to make sure you are ready. You aren’t just ready to drive because you’re 16, for example. You’re ready to drive because you’ve passed a test. You’ve done a practical for it, and you have also checked off the box of hitting the appropriate age as well. Super, super important here. 

Running is after the honeymoon period, what I call that post-op process, where you are getting your range of motion back, and the pain and swelling are hopefully going down. You’re getting a little bit more strength back. You’re getting off your crutches. You’re getting back to your normal lives. You feel like it doesn’t feel like you are pushing your maximum effort to be able to get up and down stairs, get into bed, be able to take a shower without feeling like all is lost in the world, and will I ever get back to a normal shower? You are beyond this process where you see those day-to-day progressions and usually in the positive direction because of the early part of ACL rehab, where you are restricted to the post-op. You can only do so much, and there’s just more milestones hitting back to back to back because of how restricted you are post-op. So that’s our honeymoon process, where we see hitting those milestones. Life becomes a little bit more normalized, if you will. 

And after that, let’s say it’s after the first 4, 6, 8 weeks that you are starting to track on with the road ahead. And the next milestone we’re typically setting our sights on is running. The big thing about it is opens up the door to more dynamic type work and athletic things we want to get back to doing in ACL rehab. If we want to start cutting and being able to jump in space, well, guess what? We need to be able to start running to do so. And when I say jump in space, I mean you are covering ground over a field, and you are doing jumping activities as you are running. So that’s a more locomotor-based dynamic movement, from a technical sense. But with that said, running is going to help open up that door to do more of those things.

But if we haven’t run yet, then therefore, it’s going to be a little bit harder for us to get to those things because we need to be able to crawl first and then walk, and then be able to run before we make too many big jumps. So that’s going to be super important with this. With that said, we also have some people who are going through this process, who injured their ACL, who had surgery. Maybe they didn’t have surgery. But with that said, they’re rehabbing to get back to things that couldn’t care less about running. It’s not a goal for them specifically. And while we typically think of the high school athlete, the college athlete, the pro athlete who’s on the field or on the court, which, yes, this happens to a lot of them, that is what typically ACL rehab is printed with through the media, through what we expect and hear about, who has typically running a part of their sports. They’re playing football, if they’re playing basketball, lacrosse, or soccer. All these field and court-based sports are going to have running as a component to them. Now we can get nuance into sprinting versus running versus like plopping along, if you will, like a lineman. They’re not going to be running for long distances. And it might be five seconds, it might be 10 seconds, but it’s not long. But running as a prerequisite, as something that is just going to be natural as a part of their practices and a part of their sport. But the thing is that this also happens to a lot of folks who don’t need to run or care for it.

Let’s take for example, the skier. We have a lot of skiers who are like, I couldn’t care less about running. I want to get back on my skis. Therefore, they don’t have running as a goal. While you could say, yeah, hiking and running, there could be some relationship there. Not really, if you just want to go hike and take steps, like you are going to keep a foot on the ground at all times, more than likely. And running is defined as the difference between walking and running is actually, there are times where you’re airborne, where there is no foot on the ground. When walking, you have a foot in contact at all times. There is no airborne phase with walking. I bet you guys didn’t know that. That’s also how they do the speed walking versus running in the Olympics. And they’re always looking out for do they get airborne or not. 

But with that said, we have skiers, yeah, hikers, we have people who do juujitsu. Yeah, maybe they don’t care to run. It could be a part of their conditioning. You also don’t necessarily need to run to play the sport. Cycling, of course, you’re on a bike, and there’s plenty of other people who injure their ACL doing other things that may not need running as a part of their life or their sport. 

So, should we care about getting these people back to running if it’s not their goal? The question here is nuanced, to be completely honest with you. Let me break this down a little bit more in detail. In my opinion, I think that this goal, with not wanting to run or not caring to run, just allows more flexibility to work on strength longer and not rush into running, which can add a layer of complexity to the game plan when we introduce running. Knees can be pretty sensitive to running, it’s impact-related stress, and it just depends on the timing of when that is integrated. The criteria that are met. And running does muddy up the water a little bit with dispersing your time and just the way that the knee is stressed and the way that we’re just going to allocate the structure of it all. I’m not saying that we can’t do it all. Of course, we have most ACLers who are doing this. But I’m also speaking to the people who might not be time sensitive for this, but then also the people who just don’t care about this. And that’s the thing that we want to factor into this as we are thinking about running or maybe not running in this process.

Now, for us here at the ACL athlete, we want ACLers to have the capacity to run, the ability to run, and not feel foreign or not sure if they can do it or not. We do not want you to leave working with us without knowing that you can physically go and run if you need to, or sprint. It is a general life skill, and we want to make sure you are an athletic weapon when you leave here, whether you care to run or not. We are going to give you the preparation and the physical abilities to do that and prep you for this. Now, whether you choose to go run after you finish up with us is going to be up to you, but we just want to make sure that you have the ability to do so. And I tell these specific athletes who don’t care for it that we’re not here to make you into a runner. Even for the athletes who are going into different sports, like we’re not here to have you go and run three, five miles at a time. Why would we do that? That’s not specific to your sport. It’s not going to get you any better at that. But yes, we want to build up a base of these things if you’re going to have running as a part of your sport. It’s something that isn’t specific to it, so we don’t need you out there becoming a 5K runner, a 10K runner, unless it is your goal to get back to doing so. And we have people who want to run 5Ks, 10Ks, half marathons, full marathons, and ultras. So then yes, we are going to be catering and individualizing the plan to those people.

We want to make sure you are prepared for this and especially prepared for life. And I think that is important from a training and health standpoint, that you are prepared for what life demands of you, and that could be in different seasons. And if you need to run to get out of the rain, you can do it. You need to chase someone who has stolen your purse; for example, you can do it. Run after your kid before they run into the street. Trust me, I get it. You need to react and be able to run quickly, or maybe it is legit running from your life, or running for your life. That’s how that should be said. You could be running from your life, too. That tends to happen to people, but you are running for your life. We don’t know the circumstances that we will have in our lives. You just never know, and we want to make sure you are prepared to do so when that time comes. 

In these types of situations, what we do for our ACLers we just build up a base. We want to capacity to run, and that’s it. Again, not making you into some big runner, but just making sure you have enough ability to run more than five seconds, for example. But being able to do that without the knee responding poorly, being able to have it stressed without it responding poorly. And then what that is going to do is just make sure that the knee is tolerating the impact and knowing that you can check that box and do it, but then also opens up that door, as I mentioned earlier, to more dynamic things like sprinting, jumping in space, those locomotor-based jumping movements, and then cutting. To cut, yes, you can make a step and cut. But in reality, when people are cutting, they’re going to be running in space when they cut. Therefore, we want to make sure that you can do the running, but then also open up the door to more jumpy, athletic-type dynamic things, as we call it.

And what I find in this ACL rehab process is that physical therapists and surgeons often feel inclined, or maybe they just kind of get giddy and excited, and they often feel inclined to get their ACLers to start running, especially at a set time point. And this is the big news—no, no in this process is that we don’t run just solely on time. We don’t make decisions at all based on time with the ACL athlete. And you should never make decisions solely based on time at all in ACL rehab. That is a very confident rule of thumb for us, and it should be for you. Time alone is not going to dictate anything. But we use time plus criteria—what’s the range of motion? What’s the strength? What’s the jumping abilities? Psychologically, where are you testing out at? Where are all these different buckets we’re looking at to make sure we are prioritizing the right buckets and filling the right ones up, especially to be prepared to run or do a set task or activity. We need to make sure those prerequisites are checked. Therefore, the thing that we see is that when I ask some of these people about their goals, they say they hate running. I’m like, why were they forced to start running, especially at an arbitrary time point, like three months, which is so common to hear. I often think that this is more of a surgeon or a PT having that milestone in their head. And again, don’t get me wrong. With most ACLers, we are going to get them back to running and doing this thing, and maybe there is more time sensitivity to it. But with that said, it’s also a very gray area. And oftentimes, it’s just this automatically programmed time point in their head. And they’re pushing it on the ACLer to start running at three months, versus it being more ACLer-driven, which this process should be. We’re here to guide you, but your goals and what you want is what is going to drive the way that we design things and build this thing out and structure it. That is how this should be driven is from the ACLer at the center versus you coming in, and we’re like, all right, you have to hit it at this point.

We give you, of course, the criteria for it and what we can expect from a timing, just roughly, and we update that as we go range-wise, from a time range. But with that said, we want to build it to you versus us, make you fit it to our standards, or mostly our timeline, if you will, because that’s going to be important. Again, assuming your goal is not to run, then that has no relevance to any other goals as well. That’s the thing that is important here, is that I think almost PTs and surgeons, they just have these timelines already set up. Therefore, they’re just like, all right, we’re going to hit this running. And you’re usually going to do what they say.  In most situations, you’re not like, whoa, whoa, whoa. I don’t want to run. I don’t need to run. In some situations, maybe you might speak up, but you’re letting them lead the charge here. And they’re like, all right, it is three months in, and we’re going to start running, or even four or five months. The thing is, we need to make sure that it lines up with what you want as well. So that’s going to be important. 

The other point I do want to mention is that there’s no time sensitivity to this. While yes, it might not be a part of your goals. Maybe running is just the next step into doing those dynamic things, but you couldn’t care less. But there’s no time sensitivity to it. Now, do we just ignore it and just say, like, all right, we’ll run in like nine months. No, but like someone couldn’t care less if they run in three months, especially if there’s no time sensitivity, and they couldn’t care less at five months or seven months if that’s not something specific to them. But I always say, why rush? That is the biggest thing here is why rush trying to get into running, especially when we know it’s going to be a 9-to-12-month process. I get it if it’s something that you want to get back to doing, then yeah, we’re gonna prioritize it. And I’m not here to just say the three months is bad. It’s just more so that most people are not ready at three months, and you could put a lot more into the tank and get a lot more out in the long term by waiting a little bit longer, even four to five months to get stronger. We’ve had people who have been able to do it earlier, for example, and they’re crushing it. So that’s why we use criteria plus time to be able to make these decisions. But the biggest thing is, why rush this process? Outside of people who are super time sensitive, where they need to get back to a set time to be ready for something, then yeah, we might start integrating this earlier. 

For our ACLers, we’re still integrating a lot of dynamic tasks that will ingrain the pattern of running. We start working on these mechanics, like a marches wall, acceleration drills, like some three-position heel cycles. We worked this stuff in super early. We’re talking about weeks post-op, like we are working some of this stuff in and getting you there and progressing it based on how you’re doing and responding. Therefore, when people do get to running, they’re almost itching to run whenever we do clear them to start running and hit the criteria because they’ve already been working on this stuff. It’s almost like a second nature to them when they do start doing actual running and working on this.

But the thing is, we’re not pushing this off. We’re working on the prerequisites a lot leading up to it. But if there’s no time sensitivity or it’s not their goal, then why rush it? Let’s keep the main thing, the main thing, which is likely quad strength, just kidding. But in all seriousness, it’s probably quad strength. It’s always going to be your top priority in ACL rehab forever. Okay, maybe not forever, but for a long time. And yes, we can have running in the mix, but why rush it early, especially in this situation. And most importantly, I think the thing here to make sure to take home is let’s cater the game plan to you, to the athlete, the ACLer in front of us. Versus following the protocol from 2004 that says, let’s run at 12 weeks. This is meeting our ACLers where they’re at, fitting everything to their specific goals and plans. Versus the PT trying to fit them to a standard protocol that they expect everyone to go through at the same rate. And it just doesn’t happen in ACL rehab.

I do want to make sure that this is clear that if your goal isn’t to run or it is not a part of your goals, or maybe there’s not much time sensitivity, then I would almost push back on these timeframes that are typically given, and this is working with different ACLers through this process. Because also graft type is also going to weigh in a lot on this. If you have a hamstring versus a quad patellar allograft, you guys are all going to be cruising in your different lanes. You may also have other procedures that were done. Maybe you were non-weightbearing for four weeks; therefore, your timeline is going to be a little different. You were slower to begin with some of these things.

I think that these are just important factors to consider, so we can’t just blindly say 12 weeks or even maybe 16 weeks that you’re going to start running. When we don’t even know where you’re at week three because you’re in week two. Yes, we can have targets, and that’s what we provide for our ACLers to give you guys an idea. We try to aim for four to five months to be able to start running post-op. But we continue to update our ACLers every step of the way so they know what these milestones look like. The criteria stay clear for them, and then we are also adjusting things based on whether it’s within their goals, what they want. Is there time sensitivity? Is there not? All these things factor into making sure this is as dialed in as possible. 

I hope this helps y’all. I feel like I notice a lot of people who are just like, yeah, I’m just jumping into it. That’s what my PT said. And they’re like, I don’t care to run. I don’t ever wanna run, ever. And people feel strongly about running a lot of the time. It’s like, why push it if it’s not a goal? And why don’t we just kind of focus on some other areas that might move the needle and make your knee feel better earlier, and then integrate that stuff and make sure you can do it, and then keep the thing moving. I hope this helps y’all. If you have any questions, you know where to find us. Until next time, this is your host, Ravi Patel, signing off.