Episode 28 | The ACL Injury Journey – Part 2

What’s up ACL Athletes, and today we are continuing part two of the ACL injury journey. If you haven’t listened to part one, stop, go back, listen to it, and then come to this one. Because it’s going to be really important to help bridge that piece, if you will, to be able to know what we’re doing today and get a good overview of this process.

In part one, we started with the ACL injury journey. I want to make sure that I give credit where credit is due. This goes to British Journal of Sports Medicine authors: Connor Gleadhill and Christian Barton. I’m going to put the link of this in the show notes so where you can access the two graphics that talk about the treatment decision and then the rehab explained. You could also Google BJSM and look for the ACL injury journey, and I am sure that that will pop up for you. This was something that was published in December 2020, so it is very recent to the current date of this podcast being recorded. As I’ve looked through this and with the experience that I have and the things that I’ve read, this is really an awesome resource that I think a lot of you who are going through this process can really use to be able to help get more of, if you will, like a forest through the leaves type perspective here, and not just get too caught up in these minor details. Again, this is not medical advice, it’s educational, so use this as a guide for yourself or for someone that you’re working with.

In part one, we covered the ACL injury, gathering your team, beginning the rehab process, and then the shared treatment decision, considering factors and questions to ask yourself. Today, we’re diving into part two, which is the phases in rehab or the rehab explained, if you will. So whether you have surgery or not, rehab will be the essential piece here for getting your knee back to normal function, preventing a further knee injury, and you’re talking about the long-term quality of life. And I think that’s something that can get missed often is thinking in the short term of, okay, how can I get back on the field or how can I do this? Rather than also considering what is my long-term implications if I decide to have this graft, or if I rush the surgery or maybe there are some other complications with it. That’s why you need to have all the pieces and the information to make the best decision. 

Let’s talk about the rehab program itself. It should be individualized. It shouldn’t be this cookie-cutter program or protocol that everyone is being pushed through. It should be criteria-driven. Time is a piece of this, but don’t let time alone be the determinant of moving forward. The criterion approach is more so you’re adding time into this, as well as these other things that are very objective and that you can easily measure. That is maybe your range of motion, your quad strength, hamstring strength, your hop testing ability, maybe your agilities that are being measured. There are a lot of pieces in this that are more criterion-driven if you will. And what helps is to break this down phase by phase, which we will do a little bit later. But with some of the other pieces that it talks about is making it variable. So that means having some rest days and some weeks because this is a long process. So that’s where working with a coach and a PT will be very helpful so that they can balance these things and not going hard every single day. I made that mistake myself where I tried to push way too hard and my knee blew up during the ACL rehab process. This is something just to factor in and making sure you have that conversation. 

And then the last piece that it talks about is being social and enjoyable. This is tough because ACL rehab itself can be almost a little isolating, but do as best as you can to make it social. If you know someone else going through the process, maybe you’re in a clinic that has someone else who is rehabbing, maybe you could just have someone else who is working out that you can also take time during that same time to do your own rehab. But just try to make it as enjoyable as possible, even though I know it can get boring. These are things that a rehab program should help to do as you are moving forward. 

Now, they break this down into three phases, which I really like. The early stages and technically starts in the previous episode we talked about prehab. This is where this rehab approach itself starts. So you have the prehab if you will. Let’s say you decide to have surgery, then you kind of start that process all over again because you’re going to start working on your range of motion, you’re going to work on your quads, get the swelling and pain down, get the walking better, start strengthening. And that’s what is kind of the early stages here. Whether that’s post-injury or even post-surgery, the thing that’s beneficial about having prehab is that you move through this more seamlessly. And it also shows with research that people who have prehab will have better outcomes in the long term. These are the early phases.

If we shift towards the mid stages, we’re focusing on single-leg balance, a lot of strengthening, strengthening of individual muscle groups to make sure that we can get to that 90% limb symmetry index, or getting as close to 90% as possible compared to the uninjured side. Honestly, the aim should be anywhere from 95% to 105% to 110% because we know that the uninjured side can also decrease in strength. So that might throw the numbers off. And then we’re looking at returning to running, so having a gradual progression with that. And then when we start looking at the late stages, we continue to build on strength. We’re looking at jumping, landing, change of direction, agility, and starting to add in stuff with the sports environment practice. And hopefully, eventually, going to return to sport, that’s the end goal here. This is broken down really well. It doesn’t mean that it has to be in these specific boxes because some of this stuff can start earlier. But it’s going to come back to who you’re working with. 

For example, when I work with my athletes, we start working on drills for running pretty early on, whether that’s marching or wall-related drills for acceleration. We start working on some deceleration things of that nature earlier than you would think. But this doesn’t have to be in these perfect little boxes of early, mid, and late. But just know that we do need to build the foundation, the range, the quads, the gait, decrease their swelling and pain, what we call the quiet knee, and being able to move forward. Don’t try to rush this process. And I think this does a really good job of laying out the framework of what those early, mid, and late stages might look like. If you do this right, you have a lower chance of re-injury, better long-term outcomes, and a lower rate of osteoarthritis later. There are a lot of things during this rehab process that can put you at more risk, but if you make sure you’re following a criterion-driven approach and you’re checking these boxes and you’re getting assessed and tested frequently, then that is going to set you up for the best chances for re-injury and risk of osteoarthritis or other complications later. 

And then this talks about the return to play decision-making process. And I’m going to start with a statistic because I feel like people really need to hear this. But most people don’t end up returning to that same level of sport as before. It’s only 56% of people. We continue to see that over and over and over again. You want to really know why that is: poor rehab. Not sticking to a program, not having an individualized plan, and working with someone who does not know what they’re doing. And you have to remember, this process isn’t an ankle sprain, it’s not just some shoulder pain. This is a pretty serious thing so you need the best to be able to recover. That’s making sure you have an individualized program, a really good PT, or a coach to help guide you in this process. And making sure you have that team that we talked about in the earlier process to guide you along this process. If you get that gut feeling that it’s not working out, then you have to check that and make sure that you pivot to something else and not just something that is comfortable for you. And it might mean also having to pay a little bit more. But your long-term health is what we’re talking about. It’s not just some object like an iPhone, we’re talking about the long-term health of your knee and also getting back to something that you love.

We’re going to jump to the questions to consider for this from the return to sport and play decision-making. Do you feel confident and ready to return? This should be assessed by the physical therapist you’re working with. There are different patient-reported outcome measures that can be used. I personally use with my athletes the ACL RSI, which you as an athlete going through this process can use. If your PT is not using it, ask them about it. If they’re just writing it off, then use it yourself. Ask yourself these questions, answer them, and grade yourself. Question number two: Have you cleared all rehab criteria? This comes back to that criterion-driven approach. What is exactly those different pieces that are used, maybe phase by phase, and even at the end to decide to return to sport. And then this leads to the last question: Have you passed the testing battery? This essentially means, have you been put through with different return to sport testing, whether that is different plyometrics and jumping tests, whether that is checking out your range of motion. Have you had strength testing, and are you even close to that 90% of limb symmetry index?

The statistic that they use here is that 24% of the re-injury risk can be mitigated better by a proper return to sport testing. So what we know is that, in rehab, in ACL, return to sport, we’re pretty bad at testing. People don’t usually test strength and they will blame it on equipment, but now there are so many cost-effective approaches to be able to test your strength, and it really can’t be used as an excuse anymore. This is something that we need to make sure we keep at the forefront. If you’re at the end of this process, if you are about to return to a higher level sport, in all honesty, anyone who is going through this ACL process needs to be tested. That should be a concrete thing, and they need to hit these certain criteria. If they do not, and if you do not, then I would have hesitation with returning back on the field until you make sure you hit all these different criteria. And you’re putting yourself at a 24% re-injury risk. So that’s one in four people who do not pass these tests will go on to have another injury. If you think about this process, it is just not worth it. You might as well take a little extra time to work on these things because typically, time sensitivity is not in most people’s decision-making process. Sure, you want to get back to sports, but not very many people are in time constraints to have to have the surgery and then return to sports within, let’s say nine months.

Another piece this article talks about is if you do the non-operative approach, you could return sooner. Now again, comes back to those questions, your goals, how is your knee doing. But I’ve had people who decided not to have surgery. They do not have any episodes of giving out. They rehabbed it really, really well and got really strong and progressed appropriately. And they’re playing soccer now, or they’re playing football. Now, this is not everyone, but this could mean that you could get back to sports sooner than maybe nine months compared to the surgical process. But this is again going to depend on you, your situation, what the sports are, the goals and things of that nature.

And then if you do have surgery, there is a significantly lower risk associated with waiting at least nine months, and even better to wait longer than that with good training. And this is something that I preach, my role with any of my athletes is nine months. I know for me my own ACL injuries that it took me about a year to feel like myself again, and the research does support that. There is better time for their graft to heal. There is more time for you to get stronger, to acclimate better to the sport, and to utilize that time, instead of trying to rushing back. And what we will typically see is that because of insurance, people will get cleared from physical therapy after maybe three to four months. They’re not sure what to do. They’re just told to go and do some jumping and running. And then they go back to do whatever it is and they retear it. Or, maybe a surgeon will clear them at six months and then they’ll go back to the sport and that happens again. This is the problem with the insurance model and also using the time to dictate this, as opposed to using criteria that will give you very objective measures and things that will give you a hundred percent confidence in knowing that you did the best you could when you returned back to the sport.

The last piece of this article talks about ongoing injury risk reduction. If you have an ACL injury, you are more prone to have another one. It’s just the way that things work out. I am so sorry. I have had two of myself when I go out and play, that is something that I know that is at risk. But that’s where the training and the rehab and ongoing stuff that you’re doing is going to play a role in reducing that risk as much as possible. And so that’s where the strengthening and plyometrics, change of direction, agility, essentially exposure to the sport. And training for the sport is going to help you at best to reduce that risk as much as possible.

And there’s a saying at least two times or more per week. And there are even programs out there where some soccer clubs I know will use or different sports. But is the FIFA 11+, the netball new program, PEP program, ACTIVATE World Rugby Program. There’s a whole slew of them and now you can find other resources out there. But there needs to be something because as soon as you finish the rehab process and the training process, what happens is, is that people get away from training the legs as much, and then the strength decreases. And we see in the research that people do decrease in strength and their power ability and things of that nature if they don’t continue to work on it. And then that puts you at an increased risk. That is why an ongoing risk reduction program for injury is going to really help you and using the principles above will be really important. 

That’s it for today, guys. I just wanted to come on and talk about part two, to highlight the rehab process itself and how that can be navigated and organized to be able to make a better decision for yourself. Some big takeaways from this and overall from the ACL injury journey are to gather your team, begin prehab immediately, get that knee back to normal, and share treatment decision-making. We had those factors and the questions that ask yourself. We broke down the rehab phases into early, middle, and late. That led us to the return to play or sport decision-making process. And so there are questions there to ask yourself, which I highly recommend doing. If you can just have these three questions and continue to ask yourself as you’re getting closer to the end; if you can 100% confidently say, you are confident and that you have cleared all rehab criteria and you have passed the thorough testing battery; if you can say yes and confidently say that, then you are in a good place. If you cannot, then, I would ask yourself, how can I get to a place where I can be 100% confident in these questions? And if you’re looking for help in this, please reach out to me and I would love to point you in the right direction. 

The last piece of this is time. So wait at least nine months if you have surgery. If you do not have surgery, you might be able to come back earlier. But again, the classic line is, it depends. Then making sure that you are doing ongoing injury risk reduction, and making sure that you are adding that in after you complete your “ACL rehab” and return to sport to make sure you reduce the risk of future injury.

As a reminder, I’m picking one person each month to have a free strategy call. All you have to do is sign up for our newsletter, which is in the show notes below, and then leave a review. This takes not too long and it will help other people see this. I appreciate you guys who are doing this. I will also put the link for the ACL injury journey article in the show notes so you guys can see that. If you want to click on it and read through it, you can use this and have this in your corner as you’re going through this process. So that wraps things up for today, guys.

Thank you all so much for listening to the ACL Athlete Podcast. This is your host, Ravi Patel, signing on.