Episode 245 | The Rehab Gap No One Talks About (But Every ACLer Feels)

Let’s start off with this. You guys deserve a shorter episode. Let’s try to accomplish this. One of the things that I want to talk about today is the assumption in the ACL space that I really want to tackle and share with y’all today. It’s this gap that exists anywhere from ACLer being around the three-month or six-month mark to the end of ACL rehab, the process itself. Let’s just use the nine to 12-month for reference, even though we know it could be shorter for some, it could be longer for more of these ACLers. But let’s say you’re someone who is sitting at the three-month mark working towards nine to 12 months, or maybe someone who is around six months to the nine to 12-month mark.

Now, understand that this is a spectrum. You could be someone at the two-month mark. It could be someone at the four-month mark. It could be someone at the eight-month mark when this happens. It happens most of the time. What I’m talking about here is that your in-person physio, physical therapy, and rehab frequency decreases.

Here in the States, what typically happens is that it could be when you’re starting out post-op, for example, you could be going to in-person physio anywhere from two to three times per week. Over time, it decreases to two times per week or one time per week. Eventually, it starts to space out or get staggered every two weeks, every three weeks, every four weeks. It just depends on the insurance, the physical therapist themselves, and the setting itself. There’s a lot of factors that play into it. And don’t worry, for you international folks who don’t have insurance, I will be speaking on your behalf because I can pull from a lot of this information based on ACLers we’ve worked with internationally as well.

But the thing that I want to touch on is, why does this happen? Why does it decrease in frequency occur? You start to run out of insurance visits or healthcare assistance for those physical therapy visits, your PT says you don’t need to come in as much because it’s just naturally what they do. What you’ll see is typically a higher frequency post-op or in the acute part of the process, and then that will slowly start to reduce as time goes on, as you’re working with the physical therapist and during the rehab process itself.

And then there’s the skillset and/or the environment has its own limitations. Their skillset, the physical therapist is not served or not built up to help you as much as it did in the early stages, maybe, and in mid and late stages, their skillset is not nearly as solid, if you will. When we go to physical therapy school and we learn about rehabbing ACLs, we don’t focus a lot on ACLs. We also don’t focus a lot on what it looks like for good strength and conditioning and exercise prescription. At the end of the day, for the first eight to 12 weeks, you are constrained by the surgery. It’s easier to be able to give you certain exercises, especially, let’s say, the first week or two. You can’t do that much. Therefore, here’s only a limited list or menu of things that we can pull from. But, as time goes on, you have more variables to account for. The menu needs to get bigger. But we need to be strategic about the way that we are cooking the meal, as a whole. That’s where sometimes the PTs themselves can’t necessarily serve ACLers in the mid and late stages due to the skillset itself. 

The other piece of this, too, is that the clinic that they are in is not appropriate for what you need. There are so many clinics around here that are in boxes, and they only have weights that go up to maybe 10 pounds, and they may have a leg press, if you’re lucky. They always have those trampolines. They have a Bosu ball. You’re working on balance stuff. They, of course, have treatment tables and treatment rooms. But usually what gets shafted in a lot of these places because due to space, and also the pricing is just equipment. You might not have heavier weights. You also might not have an open space to be able to run, jump, and cut besides jumping on a box. Which is typically what a lot of physical therapists will revert to is box jumps, which is not even a plyometric. Therefore, that is something that can be limiting within the environment itself. That can also dictate—well, you can’t keep coming here three times a week. It doesn’t make sense because this is also limited, so let’s reduce this down. You go and do some stuff at the gym on your own, and then you come and see me periodically. 

Now, why does this happen, and who does this happen to, more importantly? Majority of ACLers after having so many calls with AERs, this tends to be the place where AClers are in this rock and hard place. They’re not post-op, but they are also not close to returning fully back to a sport or activity. They’re in the middle—this chasm, if you will. This gray area where they don’t have the structure and the sport they truly need due to these constraints that add shared and are also led to do a lot of it on their own while using what they get from those infrequent PT visits. It makes it hard for you, especially because you’re left hanging on hoping that you’ll get there. This is what the PT has structured. So yeah, the infrequent visits like being out on my own. You as a person feel like, oh I’m getting some autonomy. I’m good. That means I’m progressing along and that means I don’t need to go PT as much. Therefore, that’s this false sense of feeling like you’re getting there. And especially with those infrequent check-ins, you’re like, okay I’m doing my workouts, I’ll go see the PT and then we’ll repeat. And for a lot of my international folks, it might be every two to four weeks based on your healthcare structure. This same exact scenario actually applies because you’re still getting the spacing between the visits and depending on the individualized planning, training, all those things. You’re still dealing with the same issue. It reduces as time goes on, but the frequency is very low. 

The way that I see this is like you’re doing the hardest hike of your life and then you get, 50% there, maybe two thirds of the way there. And then, the guide looks at you and you’re good on your own now; therefore they let you go. Or maybe as you sum it up, they’ll see you periodically and be like, okay, cool. Yeah, you’re good. The thing is you’re actually going to be engaging in the hardest part of the process. And that is my argument here that I share with people is that this actually is where you need more guidance than ever. And don’t get me wrong, every stage, every phase of ACL rehab needs the guidance itself. But I think with any hard journey, you’re going to need that regardless of the stage you’re on, in terms of the journey itself, we need the guidance.

I think that this becomes challenging in this because as you get further in ACL rehab, while you might not be constrained by the surgery or on crutches or can’t drive your car anymore or take stairs, there’s still all of these things we need to work on. Maybe it’s still range of motion. maybe it’s flexibility, maybe it is specific strength in certain areas, certain muscle size. It might be positions, it might be being able to develop power in a particular movement, it might be being able to be very elastic or bouncy, it might be being dynamic on your feet. There are so many physical qualities, and we’re not even talking about the mental side of it. The physical qualities that it takes to develop in ACL rehab it just takes time. There’s a lot of moving pieces, especially when you open up the dynamic components. It’s not just jumping, it’s being able to run in spaces, being able to cut, being able to react, being able to make sure that you have the movement profile you need to get back to what you want to do. We need to still balance that with still regaining the proper strength because you’re not all the way there, as well as the power because that lags behind. There are so many other variables we have to factor into this versus the early parts of the process. I would make the argument that you need guidance more than ever in the mid to late stages, even though the early parts are hard. It’s going to be a little bit more constrained by the surgery itself and what you can do. 

Here’s where the reduced frequency does work. I do want to share that because I think it’s important. When there’s a very robust plan and system in play, basically the model that you are in. It’s typically the clinic model, usually not the healthcare model, unfortunately, maybe. But really it’s the model of the specific physical therapy clinic is designed naturally to have this built in. Not as a byproduct of reduced insurance or healthcare coverage, though, I think that’s a very important point here. Because when frequency is reduced, I share with you guys the reasons why it typically gets reduced. It’s not because you’re just doing so well and they’re like, we don’t need to see you anymore. It’s usually because of skillset or environment, usually a lot of times is healthcare coverage. We don’t need to see you as much because we’re not getting paid as much. And we don’t have as many visits to spare; therefore, they have to space things out while still trying to help you some. But at the end of the day, it’s not serving you because the frequency and what you get in between is not serving what you need. 

Again, where it does work, where the model is designed specifically for this, not because of reduced insurance or healthcare coverage. It might be a structured ACL bridge program. I’ve seen this in certain clinics, certain performance centers that do this so well. It’s awesome because as soon as someone graduates a certain point of their physical therapy, maybe at six months, they start a bridge program where they’re in group-based programs. Or maybe it is individualized and it’s more of a strength coach or a personal trainer taking you through that. There are ways for this to be structured, and I’ve helped other professionals structure different bridge programs for them to incorporate.

It might be a solid remote-based support model that compliments the in-person. You go in-person periodically, and then you have a remote-based model that you are having a structured workout. You are having communication outside of that. And you’re able to make sure that is still guiding the path in between the in-person frequency. Or maybe you’re just in very few models where the model and system for in-person is so well built out that you have objective testing when you come back in, you have a very detailed program built out and support in between the next visit. You may be in that very few where that exists. 

To be completely honest, I’ve been in this space, I have a lot of friends in this space. I’m very familiar with the physical therapy landscape here and also in other countries. What I just shared is the minority. We’re talking about maybe 3% to 5% of PT clinics that actually have this structured and built out. Otherwise, you’re dealing with the typical insurance-based frequency and it gets spaced out based on the amount of visits you have, or it’s going to be maybe every two to four weeks based on maybe the international healthcare that you have. This is going to be very different, but again, if it’s intentionally structured for ACL, you’re in the very small minority. And before you say yours does it. It’s not the same as seeing you every two to four weeks, checking in, going over a few exercise, and then you do that for two to four weeks—it’s different. And that’s the thing that I probably see most people are dealing with is this false sense of a legit PT and a plan. It’s keeping you from making the progress you want to have and more importantly, the clarity you need in this process to get the rest of the way there. 

You’re like, cool, Ravi. You’ve complained about this for about 13 minutes. You said it was going to be a shorter episode, and here I am talking away. What can I do about it? Let’s make this quick practical so we can walk away and you’re set up for what’s ahead. You want to audit this and I’m going to tell you what I tell my ACLers I’m consulting with how to go about doing it. 

Number one is to follow your gut. If you do notice in your gut it feels off, listen to that. Our guts do not steer us wrong. I promise you that. It might be early in your process. I’ve done episodes on, your insurance isn’t going to get you all the way there, or your current PT isn’t going to get you all the way there. Just know that if you’re in the traditional system, it’s probably not going to get you all the way there. It’s not designed for it. Therefore, follow your gut on what that looks like. Start to be proactive about it because it will eventually change. When you change, you have to have a game plan, whether that’s in-person, remote, both, whatever that is, you need to have some sort of game plan. Iisten to your gut here.

A simple way to audit and frame this is by asking yourself, number one, do I have objective testing and criteria that will guide each stage and block of this process? Not only the big parts of return to running, return to sport, but also what about within the process of getting off your crutches or being able to start to do jumping again, like there should be criteria in place to be able to progress athletes. You need to make sure that there’s at least very evident research backed objective testing in your process. Do I have that? 

Number two, do I have an individualized program that connects the dots from that testing and the criteria and is updated each and every week? I do not think that ACL programs that are set for four to six weeks really can do justice because of the volatility of this process. I just don’t think it happens. I think maybe 10% of people can get away with it. But I think because of just the variability in people’s knee responses, movements just the way that it is, that you have to have something that is consistently reviewed and updated every single week. Do I have an individualized program that connects the dots with testing and criteria and is updated each and every week?

Last question here, do I have an ACL expert guiding me through the steps, adjusting along the way, and adapting when the knee has had a setback, and answering any questions you may have? I think this is the make or break it guys. I think that if you have someone who knows this stuff inside and out, guiding you through this, supporting you through this, that will be the ultimate part of this process. Ultimately, you just never want to have a question or really question your ACL plan and process because having solid testing, a plan, and most importantly, you have that expert support each and every day. That’s going to be really important every week. It’s about having clarity and being to truly just exhale. Knowing someone’s got you. I think that’s really important here. You can just give it to them and you can allow them to steer the ship, be the GPS, versus feeling like you feel like you constantly need to be the GPS in this. That’s not your job. I always tell any ACLers I talk to, it is not your responsibility to program or do any of this. 

I’m sorry that the standard is so low that it has failed a lot of people, but you are not the one who is supposed to be figuring it out. It is your rehab professional who’s supposed to be guiding you and doing this for you and alongside you, bringing you along this, not just doing it to you. That’s really important here. But with this, if you can confidently say yes to these three questions about the objective testing, about the individualized planning and programming and the expert guidance, if you can say yes to those, you’re in amazing hands. I would say I would not even look back. I would not look elsewhere.

If not, that’s where I’d encourage seeking out proper care. Someone who knows this process inside and out where you can confidently say, I’m with the right person and team who knows this injury and trusting the game plan you have. After talking with thousands of ACL athletes at this point, living through two myself, I have so much information to pull from, and I try to share this every single week with you guys. I’ve seen both sides of this journey. I’ve seen the smooth recoveries, the ones that are less stressful, less anxiety. People are getting there. I’ve seen the ones that have really struggled. I’ve seen the ones who have gone on to reinjure. I’ve gone on to see multiple things occur, whether it is depression, anxiety, being able to not move anymore, excessive weight gain. I’ve seen the negative sides of this process and it hurts my heart about it. The thing is like the differences almost always comes down to whether these three boxes were confidently checked.

I don’t care who you work with. I just want you to make sure that you work with an expert who knows this stuff. We work with people all over remotely. We have plenty of people who we refer people to. It doesn’t matter. I just want to make sure that you’re set up for success and don’t feel like you are that person who had the struggling process. The one who is like looking back, being like, I wish I did that so different. Because right now you were able to make that change. I think that this is a really important call to action for you if you’re listening to this and your gut is telling you, then make the change. I think that is something that you don’t necessarily need to be piecing this together, and especially if your gut is telling you differently. Don’t fall for the one time per month PT or whatever frequency, if it’s especially lacking one of these three things. You cannot do this process without each of these three things, these three pillars, these are the ACL athlete process: test, plan and support and guide. Those are the things that are so pivotal, so foundational to this process, especially for such a hard recovery like ACL rehab. That’s what we anchor to in our ACL remote coaching, for our in-person here at the ACL Athletes. 

It’s the standard that every ACLer deserves, and it’s something that we are hoping to redefine and do in this space by influencing not only you guys listening, clinicians and coaches, people we mentor. But hoping to continue to make changes in this space as time goes on. I hope that this is helpful a little bit more of a hard-hitter, real conversation for you all. Sometimes these need to happen. I said it was going to be shorter, but here we are at 20 minutes. I’m going to round this one out. If you have any questions, you know where to find us. Otherwise, I will catch you guys next week. This is your host, Ravi Patel, signing off.