Episode 39 | The A-B-Z Framework for ACL Rehab

What’s up guys, and welcome back to another episode. Feeling a little sleep-deprived today, stayed up last night watching the Atlanta Braves play for the first game of the World Series, which was awesome because we won. But that is not very conducive for working the next day and recording a podcast, but we’re here. The last time the Braves were in the World Series was when I was seven, so totally worth it. Anyway, we will see what happens. But hopefully,  we come out in the end. 

Now, for what you guys are here for today, which is the A-B-Z framework for ACL rehab. That is A-B-Z, Z as in zebra framework. What led me to this is I’ve been thinking a lot more about frameworks and models recently with just ACL rehab and thinking and learning. Because I’m constantly learning and trying to figure out how can I take all of these information that I’m learning from other professionals. And deep diving into different areas regarding ACL rehab and training and performance and creating frameworks around these to help understand them more. Frameworks help to understand difficult concepts, to remove errors within a system, and to produce as much consistent results as possible. And the goal is to constantly refine that and to make sure that we are using a model that is up-to-date or of best-practicing concepts. This is one that I want to talk about because I think it can be really helpful for your ACL rehab, whether you are a clinician or an athlete. This framework can help to visualize and understand very simply how to navigate this process. 

I first heard about it from Gareth Sanford on the Pacey Performance Podcast. He talks about this concept from Shaan Puri, who is a startup guy, an entrepreneur, a big following, very interesting guy. He talks about this A-B-Z framework. It got me thinking a lot about ACL rehab and how it can be so overwhelming for the clinician and for the athlete, for you guys to have to juggle so much and so much to do depending on where you’re at in the process; whether you’re just injured or you’re potentially going to have surgery. Maybe you’re doing it conservatively or maybe you are looking at two months, six months, maybe you’re 5 to 10 years out and you’re like, what should I do next? Or, how to navigate this long journey, if you will. And what exactly is it that’s important to prioritize right this second based on the goal that you want to get back to? And that’s going to be different for someone who’s a gymnast versus someone who is a soccer athlete versus a mom who is trying to play with her kids out in the yard versus someone who maybe just wants to run. There’s going to be so many different factors that play into this.

And with ACL rehab, it can get very confusing and really very overwhelming. Some buckets can get missed, in terms of how to maximize this process from the initial injury all the way to the end goal. One of the things that we see with this is that re-injury rates are so high. When we’re talking about one in four people going to have a second injury, that’s a little concerning. We don’t want that re-injury risk score at a 25 percent-ish chance of that happening again. How can we maximize this process as much as possible to make sure we move the needle forward and to be able to reduce our risk of re-injury? And ultimately, just get back to the goals that you have set. That’s why we’re here. No one wants to be in this ACL rehab process, but how can we get to that end goal? And that’s where this A-B-Z framework comes into play. And what happens is, is that too many people get caught up in the how. How do I go from A to B to C to D to E to F, all the way to Z, to get to the end goal?

But when we focus on each of these different pieces, then it can get really overwhelming really quickly. And depending on where you’re at in this phase and in this process, goals are going to be different. And there’s going to be different focuses and different things that you need to be doing. When we’re at A, which is where we’re currently at, and we’re worried about how we’re going to get back to running or jumping or whatever it is, that’s not helpful. Because we want to know how do we get to B, which is maybe, how can I start walking again. Taking the small steps instead of looking forward to these bigger steps to make this process a little simpler, a little more digestible, and something that we can conquer and do in bite-sized pieces.

If we break down this A-B-Z framework, you can think of it as a big-picture view and then also what is going to be the next step. The thing that Shaan Puri always says is, “All you need is A, B, Z. You don’t need the other stuff. You just need A, B, and Z.” A is where you are now, B is the next small step and Z is the end goal: the vision, the dream, the north star, whatever that is for you, that’s the end goal. And some of this may sound familiar. I talked about this in a similar degree with my self-assessment episode where we talked about going from A to B, and we dug deep behind the why of that. And what are the primary drivers? The emotion, digging a little deeper into those different pieces of why it’s important. And this one I want you to think about, more so the importance of this next small step. And if you take a big piece from this, it’s what is the next small step that I need to take in order to move forward? And it creates a beautiful visual for you to help simplify and ease this process and by ease, you know what I mean. It still sucks and it’s hard and difficult. But it’s one of those where it can help to get all of these anxieties and fears that we typically feel when we’re like, oh man, I’m this far along. You know, I should be at this in two or three months. It’s good to set our sights on that. But let’s kind of even reduce that down to something even smaller to see if it can be helpful for us to set our target on something that is more manageable, and something that we can take care of and really see more progress, if you will, because our target is set so small.

How do I use this with my athletes or maybe with some athletes that I chat with and do consults with? And one of the things we always start with is the end goal. And that’s that north star we talked about, the vision, the dream, the end goal we are trying to focus on with getting back from this ACL injury and let’s say, for return to sport or performance, what does that look like? And maybe for some people that’s soccer, that’s skiing, that is running around on a football field, or maybe it’s just running or playing in the yard with your kids. There’s so many different end goals that a lot of athletes look to. Okay, well let’s set our sights on that, that’s the end goal. This would be our Z in this A-B-Z framework. And then we’re going to look at, find where you currently are. So that is going to be your A in this A-B-Z framework. So that could be, if you are someone who is two months post-op and you’re struggling to get your extension back, you might be three months post-op and you’re trying to run, you might be, let’s say, seven months and you’re trying to get back to sports practice or participation, whatever that is. You need to find exactly where you’re at and try and define it. Sure, yeah, I’d say that time is not important in this process. Trust me it’s not important, but we still need to have some sort of reference and its criteria that we continue to utilize. But I just don’t want you to solely get dependent on time because your injury versus someone else’s or the surgery can be so different and impacting on your recovery.

But it still helps to give us a frame of reference of like, okay, you’re in this early stage, middle stage, maybe later to help frame, okay, where should things be heading. And then we’re looking at, okay, what is the next small step? We’re going to try and reduce this down as much as possible, to be able to make sure that we understand what this next small step is. So that’s going to be B. And before we get caught up in running or jumping or sports-specific skills, let’s focus on the B. So instead of E or R, or T, whatever it is, let’s focus on B. And because we can’t get two Z without making sure that we tackle B. It’s good to still see that big picture and make sure that B aligns with Z, but we still need to focus on this small step to move that needle.

An example from A to B might be focused on daily knee extension for a program in conjunction with the things that you’re already doing in the current phase. If you are that person who’s two months post-op maybe you need that knee extension program to really overhaul and get you into that next phase, which is maybe running, or maybe it’s just starting to introduce some deceleration work, whatever that might be. But knowing what that next step is to get that extension back, is going to be important for the person who is trying to run at three months post-op, maybe part B or step B is going to be starting on running mechanics and drills and some low-level plyometrics to build up your capacity for running. It’s not just, I’m going to go and run five miles. It’s okay, well, what is that bridge? Or, what is that small step to take to be able to get to that step B, which is working towards running? So then how can we get there? And right now on A, you’re having a hard time getting there, so how can we make that small step? And that B is going to get you towards Z, which is more the fieldwork.

Sorry guys, I know there’s a lot of letters, but hopefully, this is all making sense. And if we move to the person who is maybe seven months postop or post-injury and trying to get back to sports practice, maybe it’s having a breakdown of how that is going to look for them. So their step B is going to look like, maybe it’s a return to participation. So that might be individual non-contact sport-specific drills, it might be a very reduced amount of time or volume with that. Maybe it is the next step of one-on-one non-contact sport-specific drills. Maybe next it’s limited contact. Maybe next, it’s a team scrimmage, non-contact. There’s so much variation that you could play with, but this controlled the chaos of exposure. It’s this continuum that we’re trying to follow. And instead of it throwing you straight to the wolves, if you will, of like, okay, just go and practice, go and play in the games, you’re good to go. There needs to be this gradual progression and that’s where this small step B can be so helpful, instead of feeling like you’re just making the jump from A to Z.

You might wonder, how do you know what B is? Or even to know where you’re at with A. This is the hardest part about rehab and about just doing this entire process. Is being able to test and know where you’re at and to know what is the next step. And I think what is most difficult is that people really don’t know what that next thing is. And a lot of times this comes down to the rehab professional and they don’t lay this out clearly enough, or maybe it’s a protocol that is just too general and being followed. It’s something where it’s so mechanical, it’s time-based, it’s very general, like “Okay, here’s some of these exercises.” But there are no principles to really guide this process. And then when a rehab professional is like, oh, well the protocol says this, but the athlete in front of them is not exactly where the protocol says, which is typically based on time. It could throw them for a loop and then things get out of whack, or it’s more so that the plan gets very vague. It’s like, okay, well what’s the new exercise? Or maybe, here’s some sort of hopping activity as opposed to guiding this process based on principles. 

And what you need to know is what’s the main goal of the phase you’re currently in, what you need to get to next, and how is that going to happen. That’s the A to B. And this should get tested and updated as you progress along the continuum. This A and B, if you will, will consistently change over time as long as you’re progressing. And the way that we continue to stay honest with ourselves is with objective testing and allowing criteria to drive our ACL rehab process. The way that we are driving each phase is by the outcomes that we decide for them. This is going to be dependent on your case, the PT you’re working with, and the potential protocol that you are using. But this should all end up being more so guided by the principles, and how we’re going to get to that end goal of that phase and then moving forward. 

For each of my athletes, they know what phase they’re currently in, what we’re working towards, and how we’re going to do just that. They should know the goals of these immediate next phases and also how we are going to get there. And that’s so important. I can’t stress this enough. If your PT or rehab professional can’t tell you that or what the game plan is or what this is going to look like, then honestly I suggest you find a new one. If you’re a rehab professional and are not able to really lay this out for someone who you are working with, then I suggest taking a step back and figuring out how can I structure this in a way, to be able to know what this athlete needs and how to meet those needs with the phase that they’re in and where they need to go.

Let me leave you with this last example. If you buy a house, would you trust the contractors and builders if they couldn’t communicate to you the full plan of how the house is going to be built? Think about it. You’re about to invest a lot of time, a lot of money, and a lot of energy into your new home, the one that you want, the one that you’ve been dreaming of. But if they can’t really tell you what phase one, phase two, phase three, all of these things look like and how do we know we are meeting the mark for each of the phases, and in order to meet into the next one, or go into the next one, then would you be okay with that? Would you just be like, yeah, it’ll get, it’ll just get done? We don’t really know what the plan is, but we’ll get there. No, no one would do that. Why would we do that? Why would we be okay with our rehab whenever a physical therapist or whoever you’re working with cannot really tell you what that is. What’s the plan, what’s that going to look like, how we’re going to execute it.

As an ACL athlete, this really shouldn’t be your job to create all of this and to guide it. That’s where the person in your corner who you’re working with is supposed to do that. You might not need all the specific details. Not all my athletes get all the details of everything that we do. Some just don’t care and some it’s just not really that relevant. If they ask, we completely talk about it. But the fact that we can be able to talk about it and know what that is, is important. But you should understand the overall process to know when it’ll be done roughly. And if you need to know more details, they could easily educate you and tell you about it. It’s not just a very vague answer. And if they say I don’t know, then at least that’s something that you can take as them being very honest, instead of them just making something up super vague. 

Talk to somebody today, where they talk to their therapist and they’re not really happy with the rehab that they’re getting. It seems just like a clinic that’s not going to set them up for success. And he said through the past three months, he’s been working with a physical therapist. He could not get any answer of, what is the next steps or what should I be working on specifically. Or, how do I end up getting back to volleyball? None of this was really educated or communicated to him. He was just like, they said, this is the protocol, this is what you follow, and then that’s kind of it. It was mostly just a time-based protocol. You guys know how I feel about that. But if someone was just like, “Hey, like this house. Yeah, you’ll get it built at some point. We’re not sure when it’s going to be finished.” We’re not really sure the material or what phase three really looks like. But we’ll be okay, we’ll be totally fine, we’ll get there, eventually. It’s just not going to work. I don’t see this being any different. And if anything, this is way more important than any house you’re going to buy. This is your health guys. This is your knee, this is the only knee that you get so take care of it. And your rehab should be no different in regards to any other thing we extrapolate this to. 

You guys know I’m a big fan of James Clear. He even talks about, don’t worry about all the steps, all of the things that can get overwhelming. He’s like, “focus on your next step.”Just accomplish the next step and move the needle forward. And y’all know how much of a fan I am about that. So that’s going to be it for today, guys. I wanted to come on here and talk about the A-B-Z as in zebra framework, where you are the small next step and the end goal. C, D, E, F, don’t worry about everything else, don’t worry about those letters in between. Make sure you’re just focused on where you are and the next step. Don’t worry about when I will jump, run, be at practice, be able to play with my teammates, and things like that. It’s good to ask those questions from time to time and to be able to gauge what your direction is and progress. But most importantly, being able to know what that next step is. The way you know that is by having a plan in place and someone to guide you. And so your PT should be able to communicate this to you when you ask. And maybe even know what the next step is, to be able to set your sides appropriately and you know that you have some direction. So think about this.

If you have any questions at all, please feel free to reach out. As always, guys, thank you so much for listening. This is your host, Ravi Patel, signing off.