Episode 4 | Back to the Basics

Welcome back everyone to the ACL Athlete Podcast. Today is episode number four. And we’re talking about getting back to the basics in ACL rehab. This topic has stemmed from conversations with multiple physical therapists and just talking about the current landscape in ACL rehab in some of the shortcomings with it.

And I had a conversation with an athlete yesterday that really brought this full circle and she is five months post-op ACL. She’s a big runner, wants to get back to being able to do that and to play some recreational sports like soccer and tennis. So she decided to have her surgery so she could have those cutting motions and some more stability in her knee.

 She has been cleared after five months to go back to doing those things. Now, the question I asked her was her testing and, what did they do? And she said that the only strength testing she had was that someone pressed their hand against her shin and she had to just kick out and that was it.

So she did a manual muscle test, which is what we call ’em in physical therapy, an MMT. And they basically said her strength was good and she’s ready to go. So I asked her, does she do any running or cutting or jumping? And that was the thing that she was so surprised about– she never did any of that stuff. Not in her testing or even in her rehab. We’re talking about five months of rehab two times to three times a week. 

 As we progressed along in the conversation, I asked her what her confidence level in her knee is. And she said it’s about 50, 60%. And she was cleared for return to sport essentially. She could go out, she’d go play soccer, she could go run, whatever it is. Now that’s a huge problem for many different reasons that we won’t dive into too much but the biggest thing I see here is that there’s a very hard distinction here between deciding, okay a healthcare professional, multiple healthcare professionals, have told me that I’m good to go so I should be good to go, and an internal battle of only feeling 50 or 60% ready. There starts to become this internal struggle: is this just a mental thing? Is my knee actually good? And the thing — are we just going to trust the person who we hope is guiding us in the right path? That’s really tough. So then there’s this like internal battle of okay, let’s just get over it and I think it’s a huge player on why re-injury rates are so high. We create this system where we allow a patient to trust the medical process and the healthcare process, we guide them along this path and we don’t set them up for success.

We’re essentially setting them up for failure. And while we can pick apart return to play testing and all these different pieces that we definitely need to be better at, I think the big takeaway here is that the rehab itself really failed this person. Being five months out, she should have been exposed to more running and more load absorption and plyometrics and change of direction.

Now it’s all dependent on where the person is, but when she’s talking about the things that she did in her therapy, she was doing straight leg raises and some air squats and clamshells and just things that should have been done maybe in the first week to a few weeks, but then it should move on from there. There should be some progression towards her care.

And so today that’s why I just wanted to talk about why getting back to the basics is so important. So whether you’re a physical therapist or you’re a patient who is going through this right now, this is just something to think about. As your progressing in the care of a ACL rehab, make sure that these buckets are being hit.

For example, making sure that range of motion gets restored. Make sure you get full extension compared to the other side and that your getting your flexion back as that progresses with pain and swelling. As those things minimize, you’re progressing towards strength. Strength should be such a huge emphasis in ACL rehab, in rehab in general, because it sets the foundation of things going forward.

 Strength is a precursor to power. It’s a precursor to so many different movements that you need as an athlete. So you’re talking about the hamstrings and the glutes and the calves and especially the quads. The quadriceps , as Eric Mira says, are king .They are super important because that is what’s going to help with the reduction in a future risk of injury.

So there should be a huge focus here and I think the thing that can get caught off guard is that there are these novel tasks that can get introduced such as standing on a Boso ball and doing an air squat with tagging like a light. Now, don’t get me wrong. There can be places for this stuff, but if you’re not loading up the leg with heavy weights and doing it on both legs and single leg in a variety of ways, then it’s missing the boat here because you’re always going to fall short of some of these tests. Strength is the biggest issue when it comes to return to sport and getting back on the field.

There needs to be a huge emphasis here on strength, if you can’t tell already. And then there needs to be a progression of power– being able to use that force that you develop and use it quickly and being able to absorb it really well. And that’s where med ball type exercises and plyometrics can come in to be able to show these different expressions of force, using them at different speeds. That’s going to be very imperative for anyone who is trying to be an athlete and coming back from ACL injury. And guess what, that’s everyone. Any single person who is going through this process should be challenged in some sort of way, from a strength and power focus. 

Then, looking at change of direction and more of the cutting and acceleration/ deceleration type movements– these things need to be incorporated. It doesn’t need to be this sheet of paper where they get cleared and it’s like, Hey, make sure you do this and then you’re good to go. This needs to be in a controlled environment and ideally being seen by the eyes of someone who is a professional to be able to give feedback. Now, if that’s on video, that’s okay. Be that’s better than just not visiting it at all. 

Creating progressions for these different aspects or buckets, is important to be able to make sure that they’re moving forward in the way that they need to and that they’re fully confident to go back to whatever it is, whether it’s soccer or tennis or running, or a trail hike. We want to make sure that we bridge that gap to make sure that the confidence is there and consistently reassessing along the way.

The biggest thing that I encourage for this is in the ACL rehab process. And this goes for any rehab in general. Whenever something is being done, whether it’s an exercise or some sort of modality or anything of that nature, there needs to be the question of why that implement is there. What is it serving? What is its purpose? If I’m doing a barbell split squat, what is the intent behind that movement to get this person to the next phase of where they need to go? How does that relate to their goal? And the same thing goes for standing on a balance pad, doing squats and anything that you might see on social media. Is it serving a purpose? If it is, and you can ask why and answer that then, great. But I’ll tell you this one thing, you’re not gonna create peak force by anything on a balance pad or a Bosu ball so just throw it away or make it very small percentage of what you’re doing in your rehab. 

But the main takeaway here is to focus on the basic principles that are needed to improve your range of motion, your strength, your power, to be able to get on a field and cut and change directions or being able to express force fast. These are things that need to be thought about. If I had to say anything, that should be the main focus, it should be strength. And if we’re attacking one muscle group, it’s the quadriceps, but any good program is going to attack this as a whole. And it’s going to create a bridge to make this process as easy as possible.

Now that doesn’t mean there won’t be setbacks. There won’t be changes. There might be things that need to be adapted and that’s okay. But that’s where trusting someone who can guide you on this process is important. And talking to this athlete, I almost felt embarrassed about what she had to go through and where she’s at.

So this is just something that has come to the front of mind that I just want talk about today on this podcast. There are really cool novel exercises to do out there, but you really can’t beat the basics. There’s a reason why they’ve been here for so long and they’ve stood the test of time.

Make sure that your plan or the plan that you’re creating for someone is addressing these issues. And if you don’t feel that it is, then that’s where you either try to find additional help, whether that’s finding someone in your local network who does have a better grasp of this, or connecting with someone online, to be able to figure out what would be the best solution to get you to where you want to be.

So that’s it today, guys, for this episode. I just wanted to talk about the basics and emphasize that your making sure that it is in your rehab program, as you’re pushing forward to get back to the things that you’d love to do. So that’s a wrap. Thank you guys all so much for listening to the ACL athlete podcast.