Episode 250 | From Hopeless to Hopeful: The Mindset Shift After Another ACL Tear

What is up team? And welcome back to another episode on the ACL Athlete Podcast. Today is episode 250 (two-five-zero), which is pretty wild. So that means we have been at it straight for 250 weeks with podcast episodes. Have I missed a single week? And I will say, very proud moment to hit this milestone, and it’s something that we are not going to slow down with. I love doing this podcast. I love hearing from you guys. I love the messages that we get about this. The goal of this is to educate ACLers, clinicians, coaches to be able to take matters into their own hands, to be able to feel educated, and to be able to make better decisions around their own care. I think that’s so important with this. 

I’m going to try and hit this episode a little differently because we did have a question/topic submitted. If you guys don’t know, you can submit a topic or a question. If you go to the show notes, there’s a form that you can fill out, basically put your name, and then also be able to submit a question. And from there, what we’re able to do is tee this up and answer the question. Today, what I want to do is answer one particular thing that someone submitted that I feel is very timely. 

I’m just going to let you guys know a little preview. I’m feeling a little fired up. We are dealing with our insurance stuff because it’s the end of the year is an absolute nightmare. If you live in the States and you’re dealing with any type of insurance-related renewals. It is open enrollment right now. It is absolutely awful. For some reason, there have also been a lot of people who, you get into these weird seasons where it just feels like no one is really wanting to do their job to 100%. I’m feeling all types of ways right now about this because I just feel like, you just got to show up, you got to do your job, you got to give people the most out of this. I was raised by immigrant parents who immigrated here, who had a really hard story to get here and build their lives. I think it’s just important to pay that forward. It’s just something that I want to share with you guys today about this topic, so you’re going to hear me probably go in on this one. If you’re not here to listen to a topic like this, then you can, of course, skip it if you want, but I promise it’ll be well worth the listen.

Let’s just go ahead and dive into it. I want to basically just share what this athlete had asked, and it was: Can you speak on multiple ACL injuries and surgeries? I know you have had two ACL surgeries, and I just tore my ACL last month, my other ACL. I’m about to go through surgery again. My left ACL meniscus surgery was in 2023, and my right ACL surgery will be next month here in 2025. My surgeon said I am anatomically prone to knee injuries because I naturally hyperextend and have knock knees. I have a lot of thoughts here, but I’m going to hold them. It is hard not to feel defeated emotionally after putting so much effort and time into recovering from the first surgery. 

From anecdotal stories, a second ACL injury is common. Why is that? Any silver linings here? And I will say that while second ACL injuries are common, it should not be accepted. That doesn’t mean that we’re okay with that. We need to continue to ask questions and push back until it becomes uncommon; that’s point number one. 

And now following this, I just want to say I’m sorry to this athlete, so I hope you’re listening to this. I’m really sorry. This sucks. To any of you who have had to do this more than once, it’s already more than enough to do it once. And for those of you who have torn it once, I’m sorry too. It sucks. But twice? It sucks. And then we talk about those who do it three times, four times, they tear it, it really sucks. There’s no other way to say it, to be honest. I feel like I’m coming from a place of just personally experiencing this injury. I feel so connected when I have conversations with the ACLers who are going through this, that I just feel it in my bones so much because I’ve gone through this myself twice. I always tell people that once you tear your ACL the third time, you really do reconsider doing the same activities in sports altogether. You just do. It’s just the natural byproduct of this injury and how hard it is. When you have your first ACL, you’re like, okay, I can do this. I’m back. Maybe it was just a fluke when you had your second one. You’re like, okay, I’ve got enough in the tank to do this.

When you get to that third tier, it really changes the trajectory of the things that you do from there on out. And that’s just the reality of the way that this injury is. Now, some people are striving after crazy feats like being in the Olympics or doing these milestones that they are so driven to do, like someone who grew up skiing and they’ve torn their ACL three times and they’re absolutely obsessed and they’re just like, I can’t be who I am without skiing. They may reconsider how much they do in the terrain and the frequency. I get it. It might be something that they’re just like, whatever, I don’t care. It’s worth it for me to get there. But just know that it is challenging whenever you hit those certain time points. 

As I shared, I’ve torn mine twice, one on each knee. Each led me to this particular path I’m on today. I don’t regret it happening by any means, but that still doesn’t change how hard it was. And how it influenced my knees and maybe, my knees in the future. I can do the things that I need to do. I could be athletic and move around. As you guys know, I also had a hip procedure on my left side. So there are a lot of layers to this. That is something that I know could be a factor in my future with the progression of osteoarthritis and just the health of my knees in general. Once you have an ACL injury, you are just in a different tier of just the way that knee will naturally progress over the course of time. This is just something that is important to share, but then also know that it is a matter of each person’s individual story, their trajectory. 

In terms of this question, I want to answer this first by starting with the re-injury rates. ACL re-injury rates are at 20% to 30% right now. If we take the general body of research, you can see some that are two to seven times more likely based on certain populations. You could have other re-injury rates based on how quickly they return and whatnot. But if we look across the research, 20% to 30% re-injury rates across ACL injuries. And 70% of ACL injuries are non-contact, meaning they were not directly hit. And as we know, if someone is directly hit, that is a contact-based injury. If someone is driving on the road and you’re driving on the road and they hit your car, you have a contact base injury with the car. If the car just breaks down without anyone touching you, you had a non-contact injury to the car. That was the car’s fault. Therefore, with this said, non-contact injuries for ACL are 70%. The  majority of ACL injuries are non-contact based where no one touches them. 

We’re like, okay, why does this happen? And I think this is something that we just need to make sure we understand because if we’re taking 20% to 30% of people, that’s roughly one in four people who tear their ACL. Will go on to have another ACL injury.  That’s something that’s really important here for us to factor into this. And this statistic is something that I also think about a lot. When I recently saw in surgery, when I was shadowing, the 15-year-old female athlete who was on her second ACL injury on the other side, her first was when she was 10, and this was the one who was also a soccer athlete, a competitive family that played sports year-round, never stopped. There are a lot of layers to this. But I always think about, I wonder what contributed to this and more so, why she re-injured it or re-injured the other side? That’s really important. And one caveat here is, for initial ACL injuries, it’s even more challenging to know for non-contact injuries what the factor is related to. And you’ll hear me talk about this here soon. But basically, even with re-injury rates, other factors layer into this. But with the first time ACL injuries, there’s a lot of challenges in finding out what exactly has caused it because I think there are multiple layers to this, and we know this based on the research. There’s no definitive, like this is why. 

Yeah, sure, people can blame like an athlete’s menstruation, for example, but there’s nothing concrete right now. I know there are studies that are potentially going to be in the works here to search for that, but I think we’re looking at the wrong stuff, to be completely honest. But I think it is something that we need to know, okay, what are the different factors that play into this? What are the ones that we can actually influence? What are the ones that we can’t influence? I think that those are important pieces here in terms of thinking about ACL injuries and in terms of the things that could be modified and might not be able to be modified.

But when we look at why, especially from the ACL re-injury standpoint, I think that’s where we make our most effective mark here, not on the first one. While we can do our best to train people and put them in the best positions for that first ACL, I do think that we can really leave a very strong mark on re-injury rates. 

I think the re-injury rates are very much due to two main things, if we just generalize it across the board. This is my personal take on these things. I think number one is that people are not properly getting tested before they get cleared or returning to their sport and activities. The majority of people are just getting cleared based on timelines still, or just not really good testing. We still see this pretty regularly. People walk into their surgeon’s office, and they’ll spend five to 10 minutes with a surgeon, probably five minutes. They’ll say, you’re good to go. They’ll do a table test, but there’s no formal, hey, this is the standard we need to reach. Outside of Hey, you’re at nine months. I can’t really do anything in this small office. You’re good from my end, which is very disheartening, but it is the reality of what is happening to the majority of people. If we take out professional sports, collegiate sports, which even happens in collegiate sports, a lot of times. But in general, if we just take most people, they’re not getting tracked through this whole process, and they’re not getting tested properly to be able to go back to sport. That’s the number one problem. If we can test, we can find problems. But the thing is that if we don’t test, we’ll never know what problems exist or what gaps exist, so people just assume they’re good, especially if a medical professional says that. 

The second point is, did they have an individualized plan and programming to get them fully back and see it through? And I think that’s another big layer to this, because overall, physical therapy, physio, ACL rehab is very generic across the board. It’s the same thing across most protocols. It’s all time-based. People progress at different rates, mainly just because of what timelines exist. And they’re like, okay, at 12 weeks we do this, at this point we do this. And then we also have just a system-based issue. It’s not in the US but across the world where it is challenging for people to see this entire process through. You’re talking about a nine-to-12-month process, being able to have enough frequency of visits, but then also making sure that the skillset of the PT and the bandwidth that they’re working with can provide enough support during this to be able to make sure that they’re continuing to progress through it.

That’s the two things that I think from a re-injury standpoint. Poor testing, poor programming, and individualized planning are the two main layers of why people get injured again. And the thing is that if we had testing, we would see the gap. Therefore, we wouldn’t clear people to get back to sport and delay things and get it right. And the thing is that programming is going to be that thing that closes the gaps on this, to make sure that we can get people back to doing that and pass their appropriate tests to get them ready for sport. 

Now, don’t get me wrong, people can do these things really well and still get re-injured. It’s not like it’s 100% positive. If you test well and you do all the right stuff, you’ll be bulletproof and never get injured again. Anyone who says that is completely wrong because if you’re going to play sports or put yourself in traffic where you potentially could be injured again, then there’s always a likelihood. There’s never a 100% chance of prevention. It just doesn’t exist per sport because, by nature of sport, you are choosing to take your car into traffic. You don’t know what the roads are going to look like. You don’t know what a car can do in certain conditions. You also don’t know what other cars are going to do; therefore, we can’t predict that 100%.

Now, having worked with hundreds of ACLers at this point, our team as a whole has worked with so many. I do know that the rates are not 20% to 30%. If these two things are done right, regardless of sport, regardless of population, we should be in a single-digit re-injury rate if we were doing this right. And I believe that if in a perfect world, if we were testing individualized programming, monitoring athletes better, making sure that they’re not overdoing it like kids playing year-round sports, for example, where they get no rest or training, they’re just literally playing their sports and the same stress is over and over, for example. Then I think that we could get these re-injury rates down significantly. I believe that these factors play a big role in it.

An important part I want to address is what the surgeon said. That is something that I just, yeah, I’m going to share what that surgeon said, and then I’m going to give you my take. She said, my surgeon said I’m anatomically prone to knee injuries because I naturally hyperextend and have knock-kneed. It is hard not to feel defeated emotionally after putting so much effort and time into recovering from my first ACL surgery. If you’re listening and you have children in the car or around you and you’re listening out loud and don’t like cussing, then please mute it for a second because this is absolute bullshit. And I don’t cuss often on this, but this is something that just boils my blood because it’s just something that the surgeon cannot confidently say, this is why she tore her ACLs. No one can. I’ve seen some people who have the worst movement and knock knees that you would say in the world play sports for years and never tear their ACL.

There was actually a study done where they looked at valgus moments, and they tried to predict people who went on to tear their ACLs, and there was actually no relationship between the movement analysis video of the people who had valgus knock knees and the people who went on who tear their ACLs. There was zero relationship between the two. These were trained people who were looking at these videos, saying I think this person’s going to tear their ACL based on the way that their knees look. There’s no relationship, and that is consistent through the research. 

The thing is that there’s also the most robust athletes who play incredibly well, move well, glide when they move, and it just looks so smooth, you would never guess to tear it, and they tear it. With this, the surgeon had an opportunity to empower this athlete. They had this opportunity and gave this person hope, this human being. But instead, chose to blame something the athlete cannot control their genetics. How do you walk out of that for the second time and say, let’s do this. Let’s get after this ACL surgery, and I’m going to do it right. You don’t, you feel defeated.

What I would’ve loved to have asked is the surgeon, if I could talk to them and just ask, how did you come to this conclusion? Everyone’s knees hyperextend. That’s just natural anatomy if you look at normative values. Knock knees is actually something that, yes, there can be genetic components to it, and there can be certain Q angles. But the reality of it, there’s not really that much of a relationship compared to if we’re looking at dynamic valgus, if that’s your claim here, that is a strategy that people use. There’s no relationship between ACL injuries and dynamic valgus and knock knees. I’m just like, are you just making stuff up, or just pulling things from 1985, which is when you probably got trained on. 

This is something that is just really challenging because what I would love to have asked the surgeon is, did they have detailed and thorough ACL return to sport testing; including isolated quad capacity, hamstring capacity, and strength, jump testing, vertical/horizontal deceleration. Have we looked at what that looks like side to side? Do they compensate? Agility testing? This is what we do with every single one of our ACLers. We make sure that we are testing every single quality and athletic component possible to make sure that they’re ready to get back to what they need to do.

Next up, was there an appropriate reintegration from a return to practice, sport, and performance process with proper load management? Did we assess the psychological ability of this athlete? Was all this done? Or, was it just hey, you’re at nine months, six months, 12 months, and you’re cleared because you’re good here? This is the question that I’m curious about. I hope that whoever asks this question can answer these questions for me, because I would love to know the details, but I can almost guarantee you, based on what the surgeon had said about this, that there was no testing done. Knowing the relationship between saying these types of words and communicating this stuff about ACL injuries, and then also just the relationship typically between them, are they research-based? Are they testing? Are they doing all the right stuff? And probably not. The correlation is not very strong. 

With that said, when we look at ACL injuries, we look at risk factors. What are the things that could have contributed to this injury happening? I think that’s fair. There are so many things that we can’t really even pinpoint one single thing, rarely, unless of course it is a contact injury. As I said, then it’s going to be very obvious someone landed on your knee. That is the thing that tore your ACL. There’s nothing you could have done about it besides not showing up to the game or not being in the game at all. Some things are non-modifiable, such as the risk factors. We can’t change your age, we can’t change your sex or gender, we can’t change anatomic or morphological knee and lower limbs, like the way you biologically grow is the way you biologically grow. We are not going to change the way that your body goes through puberty and does that. Previous ACL injuries, you can’t change that once that happens. Your genetics, the things that make you who you are, your chromosomes, those are the things we can’t change. A menstrual cycle, we can’t change. Cough. This is not something that we need to go in and really focus on, in my personal opinion. Instead, what we need to focus on is modifiable factors: biomechanics, athletic quality, such as strength, power, fatigue, conditioning, rest, recovery, return to performance criteria, load management, timing of returning and doing these things, the graft itself, the surgical factors that contribute to it, access to lifting in the gym, nutrition, sleep, etc. These are all things that we can change, we can influence, and we know that people are more resilient, less prone to injury if they’re able to influence these particular things. Not if we track a menstrual cycle and see if someone is on the cycle, certain parts of it. There’s so much messiness with it. I know that there are things that may be correlated with it, but I think we’ll notice that. It’s a small piece of the pie compared to how much female athletes, for example, are not getting access to the same level of training and resources to be able to develop as they age. And then all of a sudden they’re playing sports year-round, especially soccer. They’re just forcing their body through these puberty-type phases, and it ends up being a lot of stress to the body, and they don’t have enough of a background or foundation and strength and conditioning, which we know is typically just the best injury prevention program or reducing the risk of things to come. 

Those are things that we want to look at and work on modifiable ones versus focusing on things like genetics, which are non-modifiable. We cannot change your cue angle. We cannot change when menstruation happens. We can’t change whether you hyperextend too much. So those are things that we can’t change. There are many more factors that I really didn’t list here because I’ll save you guys on this, but I think it’s important for us to understand, okay, what are these risk factors that potentially contribute to this?

The thing that stumps me is why does this surgeon have to pick the thing that would make this athlete just feel hopeless? And I’m sharing this because I have calls with athletes every week, consult calls, people wanting to work with us, people working with us. All sharing pretty negative medical narratives mentioned. Don’t get me wrong, there are positive ones in there too. By nature, with the way healthcare is and the way that, just the way the jargon and narratives can be, it’s easy for things to just be pointed as negative or almost transactional to be honest. And a lot of times, these medical narratives, many, they can’t really back up their claim. But it makes them find some sort of blame or scapegoat, and I’d rather people just say Hey, we really don’t know, but here are the things we can control and focus on. Versus blaming hyperextended knees or blaming the genetics of the athlete and their knock knees, for example. That’s an easy scapegoat, an easy way to blame things when in reality there’s no reality that. That can be proven. This is surgeons, this is PTs, this is athletic trainers. These are all kinds of medical professionals and coaches in this place. No one is excluded from this, but we do find that surgeons do have a lot of tendency to have the power in this process. They’re a part of the food chain, if you will, and it’s just the way that ACLers and people look in this process is like the ortho is the one who is the top of the food chain, It can make things really challenging from a physical therapist perspective and other people who are a part of this because of the power or the kind of like white coat feel that it carries with it.

And just honestly, just harder conversations to happen in those shorter windows and in just the confines of what a medical office is. These narratives tend to flow a lot from things like this. And it’s frustrating, and I’m saying this because  I’ve been in it, y’all. I’ve been in this space. You guys are probably listening.

You’re like, I’ve had a medical professional not speak well on my behalf. There’s probably plenty of you who have had surgeons who haven’t spoken to you very well, and I know that there are PTs and all the other medical professionals. There’s good and bad in everything, but it’s just frustrating and.

The thing is, there was a choice to give this person in front of you hope, and instead, you gave her reasons to feel hopeless due to things about her body. She can’t change. But I’m going to try and back off here because I’ve already complained enough about this. I just hope that y’all see this perspective and understand that, when something like this is shared with you, it’s often not the case, and it’s more so you just need to find a better provider.

And the thing that I want to share from here is, she asked about anecdotal stories, a second ACL injury is common. Why is that any silver lining here? I’ve already shared my thoughts about why I think additional injuries to the ACL happen and why they’re common. I really think poor testing, poor individualized programming, and not seeing people through it to the end to get to the proper criteria and thresholds is a big player in this.

People get cleared based on time; they go back to do the thing, and then they reinjure it again. That’s very common. And that’s probably the main thing that happens. And what we see a lot of times, and the horror stories of people, especially younger athletes getting cleared, at six months, maybe nine months without any testing, they go out and play their sport. They go to practice, they may have their first game, and they tear the other side, or the same side again, and it breaks my absolute heart. But the thing is that this is what I think layers into why it’s so common now, silver linings, which is, let’s try to bring this back around with some positive here.

If you’re someone who has had your first ACL or especially multiple this is where I think it is important. What can be the silver lining of this? And I always describe this as an ACL injury is an opportunity, whether it’s your first one, second one, third one, what opportunity? Some of that is for you to figure out, but let me share some insight on what you may get out of this, right? What’s the silver lining here? 

From a psychological, mental standpoint, you will gain some resilience. If you work through this process, I promise you’ll be more resilient and you’ll be able to cope with things better, especially things that physically and mentally happen to you. It’s just a byproduct because this process is hard.

Setting realistic expectations, you will have your expectations met and many that won’t be met based on what you think. Therefore, it gives you experience on trying to be more realistic with expectations. Motivation may look a little different. You may be pretty motivated, maybe first ACL, second ACL. I think you might be a more driven person because you’re like, I want to get back to that thing. I think you’ll look at that a little differently. You’ll have a lot more autonomy, especially if you’re doing things with a group, for example. There’s going to be things that you might be doing on your own a little bit, which also leads to some isolation. I don’t think isolation is necessarily bad, but I do think that it can be too much because if other people are still doing the thing and you’re on your own doing your ACL rehab process, then it could be challenging. But that’s where you can lean into community and connections, where you gain new relationships with providers, especially people going through this process with the shared trauma of it and also appreciating it. We have many ACLers who connect and lean on each other, which I think is incredible. The ACL Club, there are plenty of other outlets out there. Especially if people in your sports team, whatever it is, are able to connect with them and share that experience. I think that’s super huge. And you’d be able to create some connection with that.

Identity outside of the thing. I say the thing is what’s your main thing? I think there’s value in being able to look at your identity, especially if you are a soccer athlete, you are a skier, you are a volleyball player. That’s all you’ve known, especially if that’s you, and you’ve gone through college, even, early college and late college and after, and you’ve just been known for sports. That’s your thing. And all of a sudden, this thing gets taken away from you, what do you have? If you’ve been playing sports all your life, then it’s really hard. Then you have to figure out what else is my identity? And I think there’s a silver lining and beauty to that to find other things whenever the sport or that identity might not be just who you are. I think it’s so beautiful to be able to capture.

There’s post-traumatic growth, like there’s trauma through this, and you’re going to be able to grow and be resilient, as I shared, and be able to learn from this. You are going to be able to deal with setbacks better. In my personal opinion, you’re going to have setbacks in this process. When things don’t go your way in life, you are going to be able to be like, I was here before. I still recall a lot of these things to this day of what I experienced versus what I may deal with day to day. Now, I pull from this a lot more than I would ever think, to be completely honest, and I’m appreciative of it.

Physically, you’re building from the ground up. Dial in better form. Strength, power, and coordination skills. You can come back better. And I think people sometimes think you can’t. We’ve had people on 1, 2, 3 ACLs, and they’ve come back and they’re like. I’m the strongest I’ve ever been. I’m the most confident I’ve ever been. I’m hitting more weight than I’ve ever done. I think that’s an opportunity, and that’s what this is. You can prioritize sleep, you can prioritize nutrition, stress management and recovery better. You can understand movement in your own body better, and you can have just a deeper appreciation of movement. And guess what? You’re going to take that with you from this process. We always tell our AClers, this is an opportunity for us to be able to teach you things about movement, nutrition, and just the way to manage flare-ups, or like pain and swelling, because this might not be the only time you deal with this through your lifetime. 

You’ve got to take this with you, and we’ve had people message us sharing. Oh, I used that traffic light feedback loop, I used a 24-hour feedback loop where I didn’t go to my doctor and just get meds. I ended up trying to manage this by titrating things slowly and using feedback loops, for example, or modifying movements, and we’re like, this is beautiful. This is exactly what it is. Don’t stop modifying and adapt to it. Those are things that we are trying to learn through this process. Building from the ground up, as I had said, do you want to be a better athlete? Here’s the opportunity to do that. I think that those are things that are really important with this, and it’s also okay during this. While those are some silver linings, it’s okay to still have days where it’s tough. It’s going to be hard. But if you can shift this mindset by looking at this injury as an opportunity, you might just notice that the tough days are a little bit easier to get through, and you may be a better human as a result of it.

A second ACL injury, third or fourth for that doesn’t define you; it refines you. I know that’s cheesy. You have more experience, more wisdom, more clarity that most never get, maybe for the first time, if it happens the second time. This round isn’t just about getting back; it’s about coming back better, stronger, smarter, and for good, hopefully. For those of you out there, it could be your first. This still applies, but especially for my re injuries. This one is for y’all. It’s an opportunity to dig in deeper, dive deeper, leave no stone left unturned. And most importantly, I want you to make sure that this is your last, and I know that’s all that you want. That’s what we tell any of our remote in-person athletes, any athletes we work with, we’re like, we’re going to make this your last ACL. And that’s our goal here. We’re going to leave no stone left unturned, and we are gonna come back stronger on the other side. And we’re going to do that through research-backed testing. We’re going to do this through individualized programming, mapping out a plan for you and making sure that you have expert guidance along the way. If you have those three things, y’all. You will make it through this process and you’ll be a better athlete for it. I promise you. 

The thing is, you need to find it. Don’t settle for okay, mediocre. Don’t leave it to chance. Do this as if it were your best friend, your partner, your kid —whoever it is. like. If they were in this process and they were asking you this question, what should I do? Tell them don’t stop at just being 80%. Find the best and pursue that, and make sure you get the best care possible. And just know that medicine is challenging. We’re going to have narratives that are pervasive in this place that it’s easy to beat you down, but when you find a medical provider who can lift you up, who can give you positive words and empowering, and to just know that we can get through this together, and that they’re there to be alongside you in this, that’s when you know you’re there. You have the right team, you have the right people with you. There’s so many incredible humans doing work. On the flip side, there’s also some challenging narratives out there. I would recommend that if you have those, be able to mute those, keep those out, and guard your gates. Make sure you don’t let those in, especially if it’s social media or social forums, but especially if it’s your medical team. There are ways to avoid that, and that’s by making sure you pick the right people in your corner alongside you the rest of the way.

I hope this helps y’all for episode 250. Just went on random tangents and talking about this, I want to talk about multiple retears. I think it’s something that a lot of you are probably listening to that have experience, and maybe some of you that’s just on your first one, this all still applies. But the thing is that I think it’s important for us to understand the landscape of this, what we can do to take control of this more than you think. I think that’s what’s important here. We want to make sure you feel educated and empowered to be your own advocate in this process, because I promise you no one else will.

Until next time, team, this is your host, Ravi Patel, signing off.