Episode 32 | Choosing the Right PT for ACL Rehab – Part 1

What is up guys, and welcome back to another episode on the ACL Athlete Podcast. First, I just wanted to say thank you to all of you who endured me last week in the Small Wins episode, where my throat did not make it very well. But here I am, we’re good. Feeling much better today. Also, a house is not being destroyed next door. We have some good peace and quiet for this monster episode that we have today. And also thank you to the people who sent me some posts and some of their little snapshots of their small wins. I had someone who sent me one that was really cool where she essentially had her history down and she journaled, and then she had this like little graph. And the graph would be these dots and these points of essentially her progress in her ACL rehab. It was all going in the right direction. Sure, she had some downs, but it was all progress. It’s like the same image of how you think things are supposed to go and it’s just like a straight line that goes up, as opposed to this big mess of a line that goes up, down, sideways, left, right. And then eventually, you kind of make your way up. But that’s typically how things go. She kind of drew this out, which I thought was really cool. So thank you. That was from Marie. But thank you for sending that and to all of you who have done that.

Now, let’s dive into part one of today’s episode. The episode that I have been wanting to do for quite some time now. I just wanted to be fresh one morning to do it, to give you guys all the tea on it. It is choosing the right PT or rehab professional for ACL rehab. And I have done an episode in the past of questions to ask your surgeon. This came up from a question from someone else where they weren’t really sure who to pick as their surgeon. It was a list of eight questions that essentially helped you to decide, “Okay, is this surgeon experienced to help vet them to know that they are the ones that you want in your corner to do your surgery.” Now, we are flipping that and now we’re going towards the rehab professional and essentially how you can pick the right one for your own care for ACL rehab. 

Now, you guys have heard me talk about re-injury rates in ACLs and they’re pretty high. It’s not the best statistic to shout out there, but re-injury rates are anywhere from 20% to 30%. A lot of this comes down to poor care and poor rehab. It’s one of those things where you may not be able to prevent the first ACL injury. But if you get the right care, you get the right rehab, then you sure as heck can reduce that risk of getting injured again. And this comes down to the care. And I get a lot of athletes who reach out and they’re like, I’m getting really bad rehab right now. I’ve been doing the same thing for 10 to 12 weeks. Maybe you’re years out and you never really recovered from your ACL injury or surgery. Maybe you had another re-injury which sucks. But it all comes down to probably bad care or rehab. And that really stems from working with a rehab professional or a clinic that really didn’t have your best interest at heart. If we’re going to be really honest and put that out there, that’s essentially what it is. It’s working with the wrong person to get the outcome that you want. But sometimes this may be just the system that they’re in. 

In the U.S., it’s one of those things where insurance and the healthcare system itself really dictate the way that things operate. But I have so many friends who are in the rehab realm who do it so well. The whole notion that it’s not doable to give good rehab for ACL is just not true. People are doing it and it ends up coming down to the clinic and the professional that you’re working with. I’ll be using PT or physical therapist a lot in this episode. A lot of you know this as physio as well. But just know that the term is essentially rehab professional. Anyone who is doing rehab, pt, physio, athletic trainer, athletic therapist, whoever is educated, trained, experienced, and qualified to do your ACL rehab. Not just Greg on IG who has all these ACL rehab or knee exercises. It’s a trained professional who knows about this stuff. 

You’re probably thinking, how do I know who is good versus not? I’m just trying to survive, bro, and I get this. I totally do. It’s very overwhelming to think about the surgeon, to think about the physical therapy. And for most people, it’s not in their realm of experience, whatsoever. You’re not just thinking, oh yeah, I’m very experienced in ACL rehab. This is why you turn to professionals to be able to help guide you on this. So this podcast, I’m hoping is going to help shed some light on helping you to figure that out. And to be able to ask the right questions, to be able to think through some of this stuff. As someone who I have gone through myself twice in ACL rehab and surgery. And also now treating a lot of athletes related to this. I work with surgeons who do surgeries on this, colleagues physios and athletic trainers, and strength coaches who are also along this process are specializing in this. This is taking all this information, hopefully distilling it down to how can you figure out the right rehab professional, PT, athletic trainer to work with. 

I know that sometimes proximity and location can be the biggest limitation here. Maybe it’s your PT clinic that’s closest down the road and is closest to work, or maybe it’s the athletic trainer for the club or for your team or school that you’re just kind of forced to work with, which I get. There are definitely a lot of limitations here. And maybe it’s also insurance. Insurance will only let you go to this one versus that one. And now what you’re starting to see is that a lot of physical therapists who really care about this are starting to branch off and do their own thing where they don’t even take insurance.

And that is one of my models. I just don’t take insurance because I don’t want the outcome of the athletes that I work with, to be dictated by insurance visits. As you’re trying to figure out or process who you want to work with, I know that there will be limitations. So that is just something to keep in mind from this aspect. Before we dive into the specific questions or areas to focus on and ask your rehab professional, I just want you to think about one thing. And that’s, as you’re going through this process, you’re trying to figure out the right surgeon, maybe you’re having surgery, so you’re trying to figure out the graft type. And then I know you people who are looking on Amazon for the best [?] unit and ice compression unit, the best shower caddies and things like that. You’re doing your research to figure out what those things are. I’d argue that the most important research that you should have at the top of your list should be the rehab professional you are trying to find and work with.

This goes hand in hand with the surgeon or the orthopedist you want to work with as well. But I would argue that rehab is at the very top because those are the people who are going to make or break your recovery, who you are going to spend the most time with. And I’m going to be completely honest, a lot of you settle for your rehab, but you shouldn’t. You get this internal feeling like this isn’t going the way it should, or I’m getting passed around like clockwork like a waiter coming around and you just need more than that. The way to look at this is almost just like doing a job interview. Before you go into your job interview, you’re going to do your research on the actual company itself, the position, and all the things about it. And you got to think this is your health. It’s more important than anything you could really invest in. When you are doing this, you’re trying to pick the best job, you interview them as much as they’re going to interview you. You figure out the philosophy, the beliefs, the culture, promotions, salary, PTO benefits, all of those things you’re going to figure out before you accept a job.

The same thing with your physical therapy, especially ACL rehab, this is something that you can do with the PT that you’re going to work with. And hopefully, you can meet prehab or right after you have the injury so you can establish that normal knee again. And then be able to get almost an idea of, “Okay, is this going to be the person I want to work with?” And if you can do that prehab, I highly recommend it and it should be required. But think of this as your initial interview. And you’re trying to figure out, “Okay, this is that person I want in my corner through this process.” And after you’re able to vet the person and know that this is the person, or maybe not, this shouldn’t be offended by that. And you should be able to pivot to the next place or the next option to make sure that at the end of the day, you get the best care. So you can get back to those things that you love to do that make you you, make you happy, and that you’re just not settling for the nice PT that is right down the road from you. 

Let’s dive into the different questions and different topics that you could talk to with the PT that you’re working with, to see if they’re the right person for your ACL rehab. And I’m going to give you some of these ideas of when to “run” or just literally leave and don’t work with this person and find someone else. But my first suggestion is to give them a chance and ask a bunch of questions. And then once you have that information, you could take that and then decide, is this where I’m going to be? Maybe I’ll just be here for a little bit and then move on to the next best thing. Or maybe you pivot and decide this is not going to work, and I can just tell.

Numero uno, the number of ACLs that they see or have seen. This is one of those things that can be a little tricky, especially if you’re working with someone who is newer to physical therapy. They just might not have seen as many in number because they are maybe new grads. But I’m also not going to say that someone who’s seen hundreds of ACLs automatically means that their rehab is better. Just because I’ve talked to many older PTs and they’ve been doing the exact same thing with their ACLs that they were 20, 30 years ago. And that’s just not going to work. They’re not doing knee extensions. They’re staying away from knees-over-toes type of work. The number of ACLs in and of itself is not something that’s just going to tell you to work with them or not. It’s just to figure out their experience with ACLs. Have they seen a lot recently? Are they diving into more of the literature about it? And hopefully, all of these things that we go through will give you a very good and comprehensive idea of, is this the person? But if you’re talking about the number of ACLs. Maybe you ask them about their opinion on the non-operative versus operative ACL approach. Maybe you’re someone who’s older who doesn’t have these big goals of trying to run, cut, and pivot in a competitive sport. Maybe they can guide you on trying to see if we do this non-operative option and see if you could just get by without having the surgery. 

Being able to ask them the number of ACLs, their opinion on non-operative versus operative, and maybe even the graft types, maybe they see a specific surgeon who sees hamstrings more so than patella, tendons, quads or cadavers. Just getting a gauge of their experience with those things. And one of the key buckets here is just their philosophy. What is their belief? What is their process? Do they believe in prehab? What are their progressions? Those are all things that are important, but what is their philosophy as a physical therapist, especially for ACL rehab as you move forward? Because you’re thinking, this isn’t four weeks. This is a 6, 9, 12-month process. What does that look like? Because that’s a lot of time. Maybe they’re like, oh, well we only do the protocol that the surgeon gives us, run because that is important. But it’s not the end-all-be-all. 

And as you guys have heard me say in the past, protocols are just a guide, they are framework, and not everyone fits perfectly into them. People are going to progress differently based on hundreds of factors that will dictate what you’re going to be doing in four weeks versus eight weeks versus six months. So that could be helpful. But if they’re like, we’re just going to follow the protocol, then I suggest you run. Or maybe you ask a question, well, what if this happens? Maybe I don’t hit three months and I can’t run yet, then what are we looking at? How do we know? And making sure that they’re focused on you, as the person, as an athlete, as the patient, to make sure that you are at the front and center of all this.

Do they have a belief in strength and conditioning with moving weights? This is a very big point in physical therapy for ACL. Do they believe in that? If they don’t, you should run. If they do, then that’s great rehab. How quickly post-op would you start doing physical therapy? If they say a few weeks, then that would be a question mark for me. If they say within a couple of days after having your surgery, then that to me is typically the best thing. There are not very many situations where I have a patient, no matter what the procedure is, where they can’t even start doing a little bit of rehab. And maybe that’s something that you guys cover in prehab that you just start doing to conserve insurance visits, then that makes sense.

If they’re just like, yeah, the surgeon says a few weeks. And this is just kind of what it is, I would kind of go the other way. Find someone else. How long do most ACLs stay in PT with you? I think this is a really good question and I think it’s something that should be asked, and that way you know your trajectory. What does it look like? Am I with you for three months? Is it six months? Is it four weeks? Typically, this comes down to the insurance and the cost situation. If people could, I know that they would come multiple times a week until they are good to go. But that is not the case unfortunately with healthcare. So that comes down to what is the game plan of using insurance visits? They should know the total number of insurance visits that you have. And also the worst-case scenario if the insurance runs out. But this needs to be mapped out. Just as we know, you need to be at the 9-month mark for a minimum at clear to return to sport. So then what does that look like with your insurance visits? Is it only going to last you for three months? Is it going to last you only six months? This needs to be discussed. 

I know a lot of times, what will happen is you have a certain amount of visits and then they’ll have to ask for authorization for more visits. But this needs to be gauged earlier rather than later, of okay, these are the total amount of visits. Here is a time span of, let’s say, six months or even nine months. Let’s see what this looks like to be able to spread this out. Maybe if you’ve covered a lot of ground and prehab, then you don’t need to see each other as much in that first two to four-week range. But maybe you didn’t see them and you’re seeing them post-surgery, which a lot of times is the case, then you need to be strategic and maybe that’s not three times a week, and that’s just maybe one or two times a week. And then, when it gets to those important phases, we opt for any and start utilizing more of those. But this is something to ask them.

One of the things that I think is underutilized so much is a good local relationship with a strength and conditioning coach or a performance coach who understands movement, who understands training, strength progressions, plyometrics, agility, and understands how to do that appropriately, as if someone did not know how to move at all. And that’s how this needs to be approached, is building from the ground back up, and not just like throwing you to the walls and being like, all right, we’re going to go sprint and then we’re going to go cut and all of those things. But that relationship can be so key. I have some local relationships with some strength and conditioning coaches who are so essential that I will pass off athletes, too. And even performance coaches to get more exposure back to their sport, let’s say, it’s soccer. I take them to a soccer-specific coach. They start to gain more exposure because you don’t want me coaching your soccer, but that gap needs to be bridged by exposure to the sport and exposure to higher stresses, especially in the mid to later stages of ACL rehab. So that relationship with another strength coach or performance coach can be really key to this. This is something that you can ask your physical therapist, maybe you could do your own research in the area. This one you have to be super careful with because a lot of people will say, “Yeah, I’m good at this,” especially if it means a new client. But this is again, where you vet the person and figure out, is this the right fit for me? Do they know what they are doing? And just know you always have the option to pivot or back out, especially when it comes to your health and your livelihood.

All right guys, that’s it for part one. Don’t miss part two because we are bringing the heat with more of these questions and some bonus advice at the end. Make sure to tune into that next week. 

In review, interview the professional to make sure it’s the right fit. Just like a job, you do not have to settle. A surgeon may even suggest one place. And a lot of times they have clinics associated with their surgery clinic, but that doesn’t always mean it’s the best. Make sure that you evaluate that. You do typically have the freedom to go anywhere you choose to in most situations. If you get a physical therapy script, at least in the U.S., you are able to go anywhere within state to be able to get that rehab. And then asking about the number of ACLs that they have seen or are seeing, the graft types that they have experienced, the operative versus non-operative rehab, and their approach to that.

Make sure that you ask them about their philosophy of treatment and progressions in ACL rehab in general. Do they have a strong strength and conditioning background, or at least understand that aspect of ACL rehab and being able to progress that way? Is it based on the criteria or is it based on a protocol? You want to look for someone who uses criteria to drive the rehab process rather than a protocol. You want to see how soon post-op you’ll be working together and what that plan looks like, how long in physical therapy you’ll be, and what that game plan looks like based on your insurance and based on the PTs themselves. 

And ultimately, getting back to whatever activities or sport that you want to and how to reverse engineer that to make sure you are supported. You have a plan that is customed to you to make sure that you can get there. But also thinking about what happens with insurance if it runs out. Do you get reauthorization for more visits? Let’s say that doesn’t work. What’s the next step? We discussed having other relationships with strength and conditioning coaches, and performance coaches, to be able to carry on maybe the second half of this ACL rehab or training process to make sure that you could still get to that end result and you just don’t fall off. Just stop doing everything and not feel supported by it. So that does it for part one of this episode.

Thank you all so much for listening. This is your host, Ravi Patel, signing off.