Episode 33 | Choosing the Right PT for ACL Rehab – Part 2

What’s up guys, we are going to waste no time. We’re going to dive straight into part two of choosing the right PT or rehab professional for your ACL rehab. If you did not listen to part one, please do me a favor and go back and listen to it. Because this part two really builds on part one and it really sets the stage for this specific episode. We are continuing that conversation, and this episode is really going to make you reflect. If you’re a rehab professional, it is going to make you reflect and really think about the things that you are doing. Or, if you’re an ACL athlete, the things that you are getting in return, and the rehab professional that you’re working with or choose to work with. I really hope that this equips you to be able to move forward, reflect, and make sure that you get the best care that you can. And now, without further ado, we’re bumping into part two. 

The next question to ask your rehab professional is, how do they know when to progress? Is it the protocol? Do they use milestones/criteria? Is it just when the range of motion is sufficient? Maybe you kick into their hand, as an MMT, as what we call it, manual muscle test. And they’re like, “Oh yeah, you feel strong. Let’s move on to the next thing.” Or, is this actually tested via isokinetic testing? Is it used maybe when you’re doing some single-leg test or leg extension or leg curl machine? How do you know when to progress into, let’s say, for example, running and into plyometrics and into getting onto the field? How do we know we’re in that phase? 

And so hopefully, criteria should be driving that. If they’re using time alone, run. If they’re like three months, we’ll be running, don’t do it. There needs to be progressions to that and ways that they measure it. And then this goes into testing. What type of testing do you do? And this could be for a return to sport. I think it’s very crucial for return to running any of the bigger milestones, especially when you’re about to put more demand on the knee and the body. We need to make sure that that knee is responding well and we do that through testing. And so there are specific criteria that we use to be able to make sure that we’re getting ready for that.

And let’s say for example, for return to sport, we’re looking at clinical tests like the range of motions, swelling, and things of that nature. We’re looking at, how it compares to the other side, or what we call our limb symmetry index. And to me, you should be aiming for 95% of the uninjured side. That’s just for me, a bare minimum. We try to get there as much as we can as we’re going through this process. How do they measure your psychological readiness? Do they know anything about your peak torque-to-body weight ratio? What about the quad-to-hamstring ratio? Do they do any specific hop testing or are they able to look at your rate of force development? There’s a whole list of things that you can look at to see, okay, they know what they were talking about versus they’re just you’re at six months. The doc said you’re cleared and you kicked into my hand and you ran out of insurance visits. That is not going to be sufficient.

One of the other things is time until clearance. We use time a lot in ACL rehab, which is just one of those objective markers. But it should be in combination with more of these other specific things that are to you, like your strength and your power and your range, and your ability to move around. Those are things that will be more important. In terms of time, we know from the research, nine months is the cutoff for return to sport. If they tell you that you’ll be cleared and returned to the sport in anything less, typically you’ll hear six months, you need to run. You need to go and find someone else who says at least nine months. Because at this point it’s pretty clear and that is a non-negotiable for me, and that happens day one with any of my athletes that I work with. You are going to wait at least nine months before you are playing in a competitive sport. 

Another good one to ask is what their opinion on leg extensions are. This is one of those things that I have gone back and forth a lot. But now it is very evident and very clear that leg extensions are incredibly beneficial for the ACL rehab process, mainly because the quads get so deconditioned and atrophied. One of the main markers that we’re using is that can we get that quad back to the same size strength, and power as before, especially compared to the other side. That’s one of those things that leg extensions can really help with, especially isolating and regaining strength in the quadriceps, which tends to be one of those things that is a pretty big risk factor for a re-injury. If they say no-go on leg extensions throughout the entire process, like, oh, it’ll tear your ACL, it’ll stretch your graft, run, because that is not what is up to current date and research. And if they’re in the know at all about more current stuff, then they will incorporate that. And maybe it’s something where they’ll incorporate that, not necessarily right after surgery. But it could be something that they start maybe four to eight weeks after. Some of that comes down to the philosophy and access to equipment and comfort. With my athletes, we start some form and variation of this immediately post-surgery, because we want to get those quads going. A quick, easy one to gauge their experience on ACL rehab, do they support doing knee extensions during ACL rehab?

Next up is communication with the team. And are you at the center of all of this? Do you talk to my surgeon? What about my family? What about my strength coach or my performance coach? Do you talk to essentially anyone who needs to be on the same page in this situation for you to get the best care and outcome that you need? And this shouldn’t be something of an inconvenience for the rehab professional you’re working with. I literally just had a call last night with another physical therapist who is passing off one of their clients to me. And we talked about where she’s at, what’s going on and what does that look like next. And it was me and him working together with this athlete so she can get back to downhill skiing. And it’s one of those things where, If you can collaborate and make sure that everyone is on the same team and on the same page, it can do a tremendous benefit to the athlete for you, to make sure that you have the best outcome. 

Because what happens is, is that the surgeon thinks you’re cleared at six months and then the PT runs out of visits with insurance. And so then you get let go after three months. But you’re given some paper that teaches you to try and do these few jumping exercises that are just complete BS. And then you have your coach who’s just like, yo, when are you coming back? Your surgeon’s cleared to you. You’re done with physical therapy. But it’s just a bunch of miscommunication all around. But instead, if everyone can kind of just be on the same page, that would be incredible. And it’s just as simple as getting permission from you, as the patient, to be able to communicate via your surgeon and the PT. And it could be something so simple as an email or a quick phone call, or even if it’s so difficult to coordinate, maybe you as the patient, it’s something that you have to do just for the sake of your own care. Hopefully, that is not the case and whoever you are working with is willing to do that with whoever. So communication is an incredibly big piece here.

The mental aspect, so I’ve talked about this a lot. It’s just as important as the physical recovery in ACL rehab. Do they assess this and how do they assess it? This is typically done via patient-reported outcome measures. The one that I use a lot is ACL RSI (ACL Return to Sport After Injury). And this is a very simple way to assess this through a questionnaire. This is one that I think is important and is a part of this entire list of things that should be assessed. It will also let you know that your PT is in the know that there is also a mental component, and it’s also something that’s tested in the research. 

Now, some bonus questions. Is the clinic set up for you to get the most out of rehab and more importantly what you need? And this is something more so to ask yourself and to see, Is this clinic going to set me up for success? And the end goal of what I want? You can typically tell by walking in it’s this weird, ugly carpet. They’ve got tables everywhere, they have maybe one little setup of some weight machines, and then dumbbells that maybe go up to 10 pounds. We need overload stress and strength training in ACL rehab. It’s the biggest thing that’s missing in general is people don’t build up their strength and their size and their power back like they should. And it should essentially translate into just training. It should look like strength and conditioning at some point pretty soon in the rehab process. A lot of my clients get really surprised whenever they’re like, oh wow, I’m doing like squats and deadlifts and things like that as soon as possible. But it’s what’s needed. Is the clinic going to cater to that? Is the philosophy of the physical therapist or rehab professional you’re working with going to set you up for that? And is the clinic set up to facilitate that? Are you in the environment to do that? 

Now, this isn’t to say that a clinic with just those small weights and everything can’t get the job done. Because sometimes you’re in a town or a country or wherever it is that you are, where you just don’t have access to equipment. So that’s where you got to get creative and hopefully the rehab professional you’re working with is still making that happen. There are tons of things you can do with just wall work where you’re doing wall squats or even heels against the wall and squatting down. There are tons of ways to do this. But there needs to be external weight to be able to challenge you and to make sure you get back to a certain strength and power level that we’re looking for. Does the clinic set you up for that? 

Another question is, how often will I be spending time with you? This is going to go based on your own training, experience level, and comfort. You want to figure out, am I going to spend time with the physical therapist that I’m working with? Is there value being created during that time when we’re working one-on-one to make sure you’re getting the best care? If you are very independent and you understand these things, from a training aspect, then maybe you could be a little bit more autonomous with these things. But typically, I see, time spent with your rehab professional or at least clear communication on the expectations and being coached through it, then that is something to account for, as you’re moving forward with rehab. What you will see is typically you come in early, the evals, and there’s a little bit more time spent with the patient. And then as things kind of get pushed off, time with the rehab professional starts to slip away and you maybe get pawned off to a technician or an aide, maybe as a trainer. This really just depends and it depends on your comfort level, as well as do you still feel like you’re getting value out of it, or are you wishing that you had more time because you have no idea what’s happening. And you’re really not making any progress like you’d like to.

All right, guys, so these are the main buckets for asking your rehab professional or PT, whoever you’re working with. If you’re trying to interview them, try to figure some of these things out and just know it is never too late in the process to pivot or decide to do something else. Because it all comes back to the best decision, the best outcome for you and your health.

And last but not least, I just wanted to give you something advice based on my own experiences, as well as just talking to other athletes and just being in the field. And one of the things that I want you to think about is just don’t settle for what’s down the street: it’s convenient, it’s great, it’s on the way from work or from school. It’s maybe taking your insurance and it’s unlimited visits. But if the rehab sucks and the professional you’re working with doesn’t know anything about ACLs or what to do, then the number of visits doesn’t really matter. You could be there for two years and not get any better because it’s just bad rehab. Don’t just settle for what’s down the street. 

Another piece of advice is to balance on pads and BOSU balls, they have their place. But if you’re doing that for a lot of rehabs and it fuels hard and all of that’s being progressed is, okay, now you’re doing single leg catching something. But there is not a primary focus on strength. And let’s just make this clear: balancing on pads and BOSU balls is not a strength movement; it is proprioceptive. And if we are moving the ground underneath us, then that would be in question because we’re actually not facilitating proprioceptive benefits. That is another podcast. But balancing on pads, BOSU balls, they have their place. But just know that if those are the things that are hard and you’re not truly strength training on both legs and a single leg, very consistently and progressively, then that is one thing that I want you to question. I see a lot of times where people think that those things are what are going to protect your ACL and make you better when it’s going to potentially be helpful. But if we’re talking about a big piece of the pie here, that’s a very small piece of it. Making sure that what is hard is very much questioned and that balance pads aren’t going to get you back on the field. That’s a word of advice when evaluating the care and the rehab that you are getting. Again, not knocking it, just saying it’s a small piece of the puzzle.

Another thing, I get a lot of athletes who say my PT is just nice, they’re very nice. I’m like, that’s great! My mom-in-law is incredibly nice. She’s an incredible human. I don’t want her doing my ACL rehab. If you are just staying with your PT because they’re nice, but the rehab is terrible, then you need to reevaluate that. You can get nice a lot of places. You guys can go and grab a beer or get some lunch or something. But maybe just pivot to another PT if you’re not getting good rehab, or maybe to a very good strength coach who is experienced and understands this. 

Another piece of advice, listen to your gut. If you feel like you’re getting poor care, you probably are. Don’t let this go on too long. I just talked to someone the other day, where she is into her 10th week doing the same exact routine exercises, as her first-week post-op. Exact the same thing, no changes in weight, no changes in movements, it’s literally the same exact thing. That’s bad rehab. Listen to your gut. And if it seems like it’s not going well, especially after it goes for longer than you would like, there needs to be a pivot, there needs to be another option created or a conversation to be had. Just ask questions, as I mentioned earlier, before instigating. And then once you get clarification on that, you can make a decision based on the information that you gathered. 

Another point is just don’t leave it always up to insurance. And I understand that this is something that needs some financial resources as well. And it depends on where you’re at with this and this whole process. A lot of times some other options can be more cost-effective, especially whenever you’re talking about the outcome that you were looking for. This might mean that you have to invest more from a time standpoint, whether that’s driving or even just being at the clinic, or maybe it is financial you have to pay out of pocket or pay the difference of something. But it might be worth it to get what your need from your ACL rehab. 

And now a lot of clinics and people who specialize in this area, are starting to do packages for people with ACL rehab. That way insurance is not dictating the outcome, and people can just get better care. And just know there are other options out there. It’s not just what is local to me. Now, it comes down to you as the person or the person who is doing the rehab and what they need. They may need something more in person. But a lot of times what I see is that people can really do this on their own. I have an athlete right now who is 13. Sure, she lives local to the Atlanta area. But it’s not like we’re meeting all the time and she does a lot of her remote work. And then we come together and I coach her. And there are videos associated with that that help to be able to make sure that she’s doing her rehab appropriately. Because her dad got so pissed off with the clinic that they were going to because she was doing the same thing over and over and over. And they were setting her up for failure and it hit him so personally. Because he’s had two ACL tears and he didn’t do his rehab well and he’s paying for it now, being in his 40s. Just know you don’t have to be stuck with what’s right next to you or in your city. There are plenty of remote options as well. And guess what? Most of the people that I work with, I have never seen them in person. We have never met, but I’ve talked to them and we have such a strong relationship.

And it’s because of technology that we can make sure that they are rehabbing appropriately. We have check-ins. We progressed our program week to week. We do testing. And all of this stuff can be done wherever you are. If you need help, you need a direction to go in, and you feel like your rehab is going very badly and very poorly, and you don’t know what to do, then please just reach out, if anything can point you in the right direction. Email me at ravi@theaclathlete.com. Just send me an email. Just say, hey, I heard the podcast. Really wanted to reach out and just kind of see what the next steps would be in order to potentially have a better option. Or, maybe I can find someone local to me and you know somebody. I would love to put you in touch with them just to make sure that you have the best outcome for your ACL rehab.

The last point here is, if you are a PT or a rehab professional listening to this episode and some of these points that I had made are against essentially the rehab professional itself and how we kind of fall short. And I say we because I am a part of this profession. And so this is something that I ask you to ask yourself, why it is maybe that something might have bothered you or felt triggered by and reflect on it. And see, is it something that you can improve on or maybe have the answer to by doing some further research? If you need information, feel free to message me. I send so many resources and things like that. And I’m in the process of building some things out for clinicians as well. 

But if you’re saying, Ravi, I don’t see a lot of ACLs, or I don’t have access to this equipment, or I just don’t have time to keep up, then it becomes the decision of, well, maybe I need to pass this to another clinic, another PT. Maybe I need to take a course to make sure I’m up to date on these things. There are plenty of things out there. Maybe you can ask your clinic director or maybe somewhere local to have access to more equipment, instead of getting the next dry needling course, or you know this massage course or manipulation course. Invest time into critical thinking, and especially if you are seeing a lot of ACL athletes, then I highly suggest putting on top of that list. Learning from other people who are very skilled and who know about this area. If anything, just figure out, go and work with some strength and conditioning coaches to see how they analyze movement, and how they coach people, and that will help so much tremendously, in just the ACL rehab process itself. 

At the end of the day, my focus is on working with ACL athletes to better their outcomes, and being able to help to shift this whole perspective of re-injury rates being so high, and that we can do something about these re-injury rates. And the main reason right now is because we have poor rehab for ACL. All right guys, that does it for part two of this episode of choosing the right PT for ACL rehab. If you didn’t listen to part one, please go and do that, as it’ll be very important to put these two together. And just to make sure that you can make the best decision for your care and for your health.

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