Episode 248 | Stop “Easing Into It”: The Framework to Make Return to Sport Less Scary in ACL Rehab

What is up team? And welcome back to another episode on the ACL Athlete Podcast. I was checking in with one of my ACLers, and she’s been working on getting herself more exposed to her sport, specifically roller derby. And it’s a very physical sport if you guys have not tuned into it. We’ve had many roller derby athletes come through and work with them through different parts of this process. And they’re super tough humans. And it’s something that is fun to work with these athletes. We always enjoy them. 

It’s one of these sports where there’s contact, there’s falling, and there’s a lot of things that these athletes have to react to within doing roller derby itself. This includes putting yourself into some positions that can be awkward. Not the most ideal feeling after someone tears their ACL, for example. Falling and putting yourself into these low positions really demands the knee a lot. It’s just a lot after an ACL injury and after going through this process and this surgery.

One thing that I wanted to share today, based on the specific check-in with this athlete. She said we had informal practice at the park today. I took the opportunity to try crashing onto the grass. She sent a video of herself hitting a bunch of different falls into the grass, from concrete into the grass, like some really padded grass. At least I hope it was for you. But it was a pretty cool thing to be able to see and see the video of her hitting some speed and different positions to fall into it and essentially getting used to it. And she said it actually did feel fine, though. It was one of the things that just some note from behind was one of the things that she felt a lot of hesitation with. But she did say it actually felt fine, no knee pain or anything. I’m still scared of falling unexpectedly, but maybe a little less scared than before.

This was something that I was like, man, just so simply and beautifully put, a little less scared than before. Bingo. As we navigate the ACL process, it’s your rehab team, your physical therapist, your coach’s job to help guide this process and make it “less scary.” As she said, I like to use the dimmer switch analogy along with this to help visualize it. Instead of it feeling like this on and off switch, where it’s just Hhy, just go do it. It’s this dimmer switch for us to gradually build up, instead of it being from on and off, it is gradually going from the light being off to slowly brightening up. It’s a gradual process, and you can adjust up and down. You can think about a dial on the radio; being able to adjust the volume right to adjust the dial, or the intensity, or the amount. Those are things that can be really helpful in ACL rehab. I think it gets underutilized how much we should actually put this into play.

I think one of the things, I just wanna be a little transparent here, is that there are some. PTs who just don’t get it in some of this. They think that it is an easy jump back into things after they’ve tested, and that’s if they properly tested and did the right testing. And this comes back to something I’ve talked about before, which is clearance versus readiness.  In ACL rehab, a lot of times you’ll even hear us talk about doing tests. Tests are helpful proxies to be able to compare them to themselves, to the uninvolved side, to normative data, to be able to see what the research shows is valuable for athletes to get back to doing certain sports and activities. It reduces the risk of injury. It also allows us to know are their bodies are ready for it? And we use this based on the research and data that shows if you hit these certain thresholds, then you are less likely to tear your ACL again. If you do not, then we have a higher chance of re-tearing. We are trying to get you back to high performance while minimizing the risk of re-injury as much as possible.

I always tell our ACLers make this your last ACL. Our job is to make sure that this is your last ACL injury surgery that you have to go through. I know anyone listening you want that. Just as much as anybody to make sure it’s your last and do this. I think sometimes with sports there’s this kind of vague unknown, if you will, of okay, yeah, you’ll return to sports. Let’s throw in soccer, basketball, football, lacrosse, all kinds of organized sports where we could potentially see ACLs being torn, soccer, of course, or football. And then there’s other sports like skiing, and you’ve got something like roller derby, and you’ve got other different activities that people do where the ACL is also at risk.

I think that there’s almost this perception that it is just easy to jump back into it once you’ve cleared these tests. But in reality, there’s clearance, which these tests do show if you hit the right thresholds. But then there’s a different side of this, which I’ve talked about, which is readiness. It’s making sure your body is prepared for the demands of the sport and activity that you are trying to get back and do. It’s not just about doing one repetition; it’s about making sure that you can do multiple repetitions without the concern of your knee being able to hold up. I think that this is going to be a very important thing in ACL rehab, and especially as we get into these mid and late stages, where some of this exposure might start to happen, where you might start to get back on skates, or you might be dribbling with a soccer ball, or you might be dribbling around with a basketball, or running some routes on the field for football or ultimate, or getting on your skis.  These are all things that layer into this process. I think sometimes what can be missed is that it’s just like a jump right back into it, and it’s oh, you’ve cleared it, but we actually need to make this process gradual. I think going through this myself has just highlighted things as well. I resonate so much with athletes who are sharing, returning to a sport and the fear around it, and just the anxiety and the fear of re-injury, and just that feeling. I think it’s something that is hard to really explain unless you’ve gone through it. This is not to take away from any of my PT friends or people who are working with ACLers who haven’t gone through it. But I just have a unique perspective, having done this twice. And my goal is to always share these things because I do have that unique perspective, and with this injury, there is something that is just challenging about it, especially getting back to sport. It’s a whole journey. Even getting to that point where you’re starting to introduce it and getting into the midst of it. But then when you’re doing it, there’s always this kind of ah, feel to it to some degree. 

For someone to walk into their sport and just be like, I have no fear. I’m fully there. I’m confident. No worries at all. Step onto the field or the court or whatever activity with no anxiety or fear. I believe that they’re either faking it or they just haven’t been educated very well, to be completely honest. This is something that really does make a difference in making sure that we understand how an ACLer’s feeling and that fear is real, especially if the injury is exactly the sport you’re trying to get back to. Meaning, if you want to get back to skiing and you tore your ACL skiing, getting on skis is going to be a little bit more daunting. Versus, we have people who might tear their ACL skiing, but they don’t really care to ski that much. They actually want to go play soccer. And while soccer is actually a higher risk sport, in general, for ACL tears. Skiing, yes, there are a lot of skiers who tear their ACL, is one where there’s a collision-based or the bindings don’t release. And usually there’s some sort of specific accident with skiing. I think that this is something that is really important. Did you injure it during the sport itself when you’re trying to get back to it? Or, was it some other activity, but then the other sport is the main goal you’re trying to get back to? That is a very important caveat in this process and the buildup to getting back to sport. 

As I shared earlier, it can often be viewed as a light switch, especially by surgeons. You hit these tests or you hit this certain time point, six months, nine months, whatever it might be. They’re like, okay, cool, you’re cleared. And it’s always the classic table test, five to 10 minutes maybe if you’re lucky. And then they’re like, all right, cool. Ease into it. I’m having conversations with my athletes around here, and their surgeons are like, cool, just ease into it. Or I think you can do this. And there wasn’t any testing done or any analysis of how the athlete moved. It was in this small box of a medical office, and they did a Lachman test. They did a pivot shift. They asked the athlete, Hey, how are you doing? And it was like, five minutes. And then they’re like, cool. You’re good to go. It is just crazy to me. One thing that I’m just going to add as a caveat, if any advice is given, especially to run, jump, cut, anything like that in ACL rehab, and the provider only saw you for five to 10 minutes, I promise you they did not gather enough information to make that decision. I promise you. It takes at least an hour for us to make sure that we can get enough data to be able to capture your strength, your range of motion, your plyometric ability, your ability to do some capacity testing. All these metrics that we’re looking at, you’re not going to be able to accomplish this even if you’re the most efficient surgeon in the world in under 15 to 20 minutes, I promise you.

This is what’s crazy to me sometimes, as a tangent, of course, as I’m going on, that decisions are made based on this. I think that instead of it being this light switch because of, oh you’ve seen me at nine months, and this is all I can do. Yeah, you’re cleared, good to go. Instead, I just wish that there was just like a little bit more communication around, yes, you still have this much to do. These are the numbers that we still need to hit. This is what this process is going to look like. You still need to follow your physical therapist or find someone who specializes in this because this is what’s going to be really important. And then a lot of times, surgeons fade into the abyss, and then athletes try to get back to sport. And guess what? If you reinjure it, a lot of times people don’t go back to the same surgeon; therefore, that surgeon never knows if you reinjured it or not.

I’m going off on such a far tangent, but it’s just something that I have been feeling as of recent with just some athletes that I’ve been seeing recently, where the guidance and the advice that’s given is just really off cue, of like where they truly are. And then what we have to do at the ACL Ahlete is reeducate and help get them back on course because then, therefore, they’re like, okay, this all makes sense. This is the data, this is what this looks like. This is where I’ve been, and this is where we’re going. This is how this is going to look. 

And that’s the main thing here, is that we just want this not necessarily to feel like a light switch. As this ACLer described it and put it so simply is it encompasses the way that we essentially approach our return to performance, return to performance is making things “less scary” versus that light switch. In reality, it’s a process, especially if that’s the way you injured it, as I shared. It’s a physical recovery and injury, emotionally, but especially a high psychological injury too. And I think people see that in hindsight more so than like when they’re in it. Especially when you’re months and months in it, and especially when you’ve had some setbacks and whatnot, and during this recovery. I think that it’s really important to be able to address the mental and psychological side that often goes overlooked, because what we see is typically the physical. But this is where checking in with our athletes, knowing where they’re sitting, and understanding how they’re feeling about this next phase or getting back into certain parts of their sport. How are they feeling? And that’s really important to us. 

One thing I want to share is that, yeah, I tore my first ACL non-contact playing football at the end of my sophomore year of high school in the spring. I was nearing the end of the year. I essentially had to miss my entire junior year because there were delays in my surgery and insurance, and then there were delays in my ACL process. The guidance was here and there in terms of the way it was. It was something where when I came back to football to play my senior season, I was still nervous. Even though I had been working out super hard and training, it’s just different now. I will say I didn’t get much guidance as I shared, jumping back into this football itself. There wasn’t this like seamless progression necessarily of like, all right, this is where you’re going to start for the first two weeks, and progress from here. It was like cold turkey, jump into it, and I was just told, you’re good. I didn’t have someone to help guide me to make it less scary.

And at times, it did feel like too much. But that’s where having that good guidance and a plan comes into play. It’s a gradual process to make it less scary. Eventually, you see the scale tip the other way, if you will, from scary to less scary, to also more confidence and more confidence in your body, in your knee, mentally growing more and more through graded exposure. And this is where having a framework specific to you is going to be so key. People often overlook. This thinking is the end, or they just ease into it. That’s the biggest thing that we hear. They were told to just ease into jumping, running, cutting, and that’s maybe the limitations of insurance. Maybe it’s the limitations or skillset of the surgeon or the PT. I’m not expecting the surgeon to give you that advice. They didn’t train for that stuff. They were trained how to do the procedure. Physical therapists, to be honest, in school, we didn’t learn anything beyond much of the first 12 weeks of ACL rehab. We may be able to give you more exercises. But, in reality, our exercise prescription in school was not super great. The way that I learned this, I was a strength and conditioning coach before a physical therapist. I learned so much during that and worked with athletes, coached athletes, watched movement, group classes, all the things, and that helped me to build a repertoire of understanding movement, and then taking my strength and conditioning foundation and then integrating that into physical therapy. And that’s what’s led me to the ACL route, especially because there’s so much strength and conditioning that is going to be involved in this process to get you back to high performance. And that’s going to be so important for us.

And making sure that we’re not just easing into this and just being able to actually give structure, create some sort of framework. And I’ve touched on this before in a podcast, but I’m going to break it down briefly here to give you guys actual, practical advice. I’m going to share a little bit of our return-to-performance framework. You can catch a previous episode where I share the three-step process, but essentially, we’re looking at this continuum. If you think about three different blocks, if you will. The first one is return to participation, the next one is return to sport, and then return to performance. 

Participation is you starting to get involved with the sport now. It could be solo drills, high control, and then slowly moving towards a process of returning to sport, which might be more like a modified version of less intensity, less volume, or minutes based on that. And then return to performance is typically unrestricted. That is where you’re doing the thing; you are full speed ahead. Maybe there’s a little modification, but we see this as you’re unrestricted and you’re doing it. Within return to participation, there’s three different progressions we actually look at. This is just something I personally built out, which is when you think about participating in your sport. There’s non-contact modification, again, depending on the sport you’re playing, contact modification, and then full integration, getting back into the thing. And then return to sport is modified sport and activity, exposure, and then return to performance is unrestricted performance, as I shared. 

Now, there are certain heuristics that we can manipulate, whether it’s like intensity from low to high, the volume low to high, minutes from less to more, the conditioning aspect of being more general or aerobic, typically to more position-specific. There could be a number of bodies or players. It could be zero, two, it could be one V one to multiple. It could be non-contact to contact. It could be controlled-type play, where it’s very predictable and you know what you’re doing, versus very reactive and chaotic. That’s probably more scrimmage-like in a sense.

And then terrain. Let’s take something like hiking, skiing, or mountain biking. The terrain, the altitude, the degree of difficulty is all going to layer into how we get people used to things. Again, when you get back on skis, you’re not just gonna get back on skis and go down a double black diamond. Sure, you could, but at the same time, why do it, especially if that’s the way you injured it? And I promise that for most people we’ve worked with a lot of skiers, there’s a lot of anxiety getting back on the skis. Even though you might’ve been skiing for 30 years, 40 years, 50 years, you want to get back on them, but you also want to build that up progressively.

We have practical progressions that we utilize from some different levels that may be as non-contact drills, one-on-one small group, doing some small-sided games, manipulating some contact within there if it’s involved, scrimmaging, and then returning to sport, returning performance. 

Four key principles I’ve talked about before: physically prepared, psychological readiness. We want that dialed in. We want graded exposure to the sport and activity, and we want to make sure that the load is being managed. We want to make sure it’s not an acute spike. You’re not going from, oh, I practice five, 10 minutes, and this practice to a full 60 to 75-minute practice. You’re not going from a game where you did five, 10 minutes of play to 60 minutes of play. There needs to be a gradual progression into that to make sure that you’re feeling fully ready. We use that control chaos continuum of going from high moderate control to moderate to high chaos, and it’s the continuum that we utilize. And these are things that are super important in this process that we break down for our mentees and our mentorship for our ACL athletes. We walk them through this and help them understand. This is where you are, and this is how we’re going to build this out. We are trying to make it super practical.

One of the things that I love to just do is ask my athletes to brain dump all the things possible they may do solo. And then maybe when they do team-based drills or one V one or two V two, and then contact small groups, scrimmages, etc., for us to just get a good idea of this. And then we will have them rank from easier to harder. And then this helps us to build out a progression to be like, okay, at least we got something to work with. Versus being like, yeah, go jump into practice. And this is always the messiest stuff because the coach isn’t always going to know, the parent isn’t always going to know if there’s a parent involved. The physical therapist, if you’re familiar with the sport, then maybe, but there are sports that you may not know the ins and outs of the drilling of the coach or what they do within it. I wouldn’t say that I am incredibly versed in roller derby in every single ins and outs of it. But this is where teaming up with your athlete, looking at other resources to make sure you create a structured framework and understanding, okay, this is low demand to high demand. And that’s for us to make sure we can create the safest entry point. And I promise you guys, with any sport, there’s a safe entry point. 

Basketball, you could literally be doing standing drills, seated drills. Lacrosse, you could throw a ball against the wall. There’s so many different things that we can do. Volleyball, you can volley with your coach, teammate, or you can be seated, standing, you can move forward and backside to side. There are so many different ways for us to be able to integrate it and have a safe entry point, and then also know what’s the next small step after that. And let’s say something feels a little too daunting. Let’s take a step back. Let’s regress it back. This is going to help us, especially for sports and activities that might be a little less obvious and maybe straightforward, because that could be challenging. Sometimes physical therapists feel like they need to know every sport, the ins and outs of every sport, and be able to recite the energy demands and the needs analysis of every single sport. There are so many sports out there that I’ve been exposed to while working with athletes all over the world. There’s handball. There are so many other different sports that I’m like, I didn’t really know that this existed or how it worked. And then athletes are like I want to get back to this and this is how I tore it. And then that’s where you go do your own research, watch the sport, read up on it. But then also ask the athlete to join you in the process to be able to create a framework together, and be able to understand how we can make this less scary. And that’s what I want the theme to be today. Not a light switch, a dimmer switch. How can we make return to performance less scary over time and slowly nudge that towards more and more confidence? Because every ACLer is going to feel some slight bit of fear, especially if that’s the way they injured it, if they’re getting back to it.

We would just want to make sure we understand: can we build out a process specific to them to make sure it’s less scary over time, and that they can ultimately get back to it, especially through that graded exposure? And being able to nudge their system themselves, their confidence is in the right direction? You’ll slowly start to see that scale tip from feeling that fear to slowly starting to feel that confidence really build. And that’s where gradually exposing them to this and having a process is so valuable.

I hope that this was helpful. I thought that this was just a good thing that this ACLer had shared with me, and it really sparked this idea to share with you guys, because I get the question a lot. I’ve been having a lot of these conversations with a lot of my ACLers and with younger ACLers and their parents when they’re nearing this process, and we’re trying to line this up to make sure we understand. Okay, what are we looking at? And I think this is even more important for maybe the ACLers who are longer in the process. They had some hiccups through this. They had some scar tissue cleanouts. They came from other places. It’s not the typical nine-to-12-month process; it’s also a quad tendon in some of these, so they’re even being delayed longer. The timeline is blurry for them, that they’re getting later in it, and they’re like I want to get back to this. We have to make sure we understand what that looks like, because as soon as you get out of that six-month, nine-month timeframe, and it’s not been the cleanest process overall, then it starts to be like, what does this look like? If we don’t have a process or a framework to come back to, to educate them, then they’re just gonna keep feeling lost. We want to make sure that you feel equipped and know this is where you are. This is what we’re working towards. This is the end goal, and this is how we’re going to get there. The GPS is what we’re trying to be here, and we’re trying to make it so specific to each of our ACLers.

If you guys are ever searching for help or you’re feeling lost in this process, we are here to help here at the ACL Athlete. If you want to reach out to us, our information is in the show notes. Find someone local. All I ask is that you just find someone who knows this process. When you ask questions that they have answers to, that you feel clarity around this and that they can guide you, because it will be the most important decision you make in ACL rehab. Until next time, team, this is your host, Ravi Patel, signing off.