Episode 45 | Choosing the Right Environment for ACL Rehab

What’s up ACL Athletes, and welcome back to another episode on the ACL Athlete Podcast. Today, we’re talking about choosing the right environment for ACL rehab. But first, a story – you guys know I love James Clear and his book “Atomic Habits,” and a lot of his writing. Well, in one of the chapters in Atomic Habits, he talks about the environment. And he uses this example from this other book by Jared Diamond, which is “Guns, Germs and Steel.” And he talks about agriculture and its development and growth over time. He starts with talking about the axes of America and Africa versus Europe and Asia. I want you to imagine South America to North America, just how north and south it is versus if you think about Europe to Asia. It’s more of an east-to-west, based on the geography, based on the way the landscape of the land itself. And then Africa is kind of one of those north-to-south as well. And this is important because of the environment that he’s talking about. 

From Canada to Florida, for example, north to south is very different in terms of its climate, and the way that you can grow agriculture. And so what they found was that agriculture was easier to develop and grow from Europe to Asia, those east-to-west lines. And the benefit of that is because of the same latitude, which generally shared similar climates, amounts of sunlight, rainfall, and changes in season. This allowed agriculture to spread two to three times faster in these areas when agriculture was developing and cities were developing, and this had a compounding effect for more population growth early on and newer technologies in these areas that had a better boost from agriculture. 

And one of the things that he stresses is that no matter how amazing of a farmer you are in Florida, for example, that if you’re growing oranges in Canada during the winter, it’s going to be very difficult. And it goes back to the whole environment that no matter how good you are, in some sense, your environment is really going to dictate a lot of the outcomes that you produce. At the end, he talks about if you want to maximize your odds of success, then you need to operate in an environment that accelerates your results rather than hinders them. And sure, the motivation is a big piece to this. But at the end of the day, your environment will win.

How is this related to ACL rehab? Before we jump straight into that, I want to talk about just being a product of your environment. And we hear about this all the time. You become the average of the five closest people you’re around; You want to lose weight, but you have a bunch of sweets at home; you want to get stronger, but you don’t have access to a gym or any weights. It’s going to be difficult to do any of those things whenever, maybe you have bad people around you. You’re not going to necessarily become the best person because of the community you’re surrounding yourself with. Or maybe it’s you do want to lose that weight, but your home has so much sweets and junk food. That it might be really hard for you to be able to lose that weight because you always have chocolate chip cookies on the dinner table. Or, if you want to get stronger, then it’s going to be difficult. You’re only going to maximize so much of your body weight before you reach a threshold and can’t really get as strong. You’re just working on endurance and work capacity, but you’re not going to be able to increase your ability to push more force or produce more force without more weight. 

And so one of the things that he talks about with trying to cultivate a better environment, there are three steps. Step one is to automate good decisions. If you want to, let’s say, lose weight and eat less then buy smaller plates. And there were studies done that showed people who buy smaller plates lose more weight because the intake of calories is less and their plate looks fuller because it’s smaller. Another example is procrastination. Being able to use software to block social media apps that might cause us to not get work done, or maybe get our rehab in, or go to the gym, or whatever it might be. But we can use apps to be able to block access to these apps, for example. If we take this over to ACL rehab, we are looking at, potentially you can set timers of when you need to do some range of motion work. Maybe you have a blocked meeting in your calendar for your rehab work that you need to do at home or maybe going to the gym. And then if we talk about 0.2, he talks about getting in a flow. This might you’re struggling with your rehab. This could be also related to someone who’s struggling going to the gym, struggling to lose weight, all of these things that we want to try and have good behaviors or good outcomes. But our environment is going to be really important to get into that flow and to get that outcome that we want.

If you want to eat more fruit, put them in a bowl where you’ll see it. That’s one of the things that he will talk about in his book. If we talk about this with ACL rehab, one of the examples that you could think about is putting your bands or putting your weight in the middle of the room; you’re not going to miss it. If you have a kettlebell or you have your stretch band that you’re trying to do for a range of motion work, let’s say you’re working from home, just put that thing on your desk or right next to you. And at some point, you have to look at it and it’s going to be hard for you to not do something when you’re looking at it.

It might be something where you lay your workout clothes on your bed and that could be the night before, it could be the morning of. And then that way before you get into bed, the next day, you see those workout clothes or just put them somewhere visible. And then that way it allows you to get into a flow and know, okay, I’m going to finish this. Put my workout clothes on. It removes that barrier and allows you to get into a flow. 

The third piece he talks about is subtracting negative influences. If the junk food’s out, put the food away, put it in your cabinet, put it in like a high cabinet so it’s difficult for you to access. Same thing here. A lot of times it could be something for ACL rehab where you just want to do something else instead, like watch TV, be on social media, whatever it is. Maybe you hide the remote or you take your phone and you put it out of sight, so then that way you know it’s time for you to be able to do your rehab or go to the gym, or whatever that might be. To be able to subtract any negative influence that would impact your environment and behavior that you want to do.

And now I want to shift gears here and talk specifically about the environment in ACL rehab. And we’re going to talk first about the goals of what it is we’re trying to achieve, and then thinking about how your environment is going to really influence that. With this, I want you to think about the goals in ACL rehab. One of the biggest buckets that we’re attacking is strength. We need to get stronger. Typically, our leg gets weaker because of the surgery or the injury. And then we’re trying to catch up with our other unoperated limb or uninjured limb. And then we’re trying to get both of them pretty much as strong as we can. We know that that is such a huge predictor and a huge factor related to good outcomes for ACL rehab, for osteoarthritis down the road, and for re-injury rates to be decreased.

We know that strength is a big piece of this. What do we need to get stronger? Weights are going to be a big piece of this. It’s an incredibly difficult task to get stronger without having some ability to have heavier weights to increase force production in your body. And when we think about the forces that your body goes through with different activities, let’s say for running, it could be two and a half times your body weight at the knee itself. It can experience anywhere from five to six times body weight. Sprinting is more than that, and jumping is even more than that. You’re talking about 10 times your body weight, if not more. And it’s always going to vary by degree and intensity and how much and all of these things. But if you think about those forces that are going through your body, you need to get the body ready to be able to handle those forces. And how do we do that? Through lifting and through overloading with weights. We need to be as strong as we can, as it’s our base for ACL rehab in progress. And that’s where we also tie all these outcome measures of good function and return to sport. And this is where our environment is going to be so important.

And so what I want you to think about is that if you’re an ACL athlete, or even if you’re a clinician listening to this, think about your PT clinic and think about what it has, the environment itself. I’m just going to paint you guys a picture because this is probably the most typical PT clinic look. When I say PT, meaning physical therapy, physio. It’s typically you walk in, there’s some ugly carpet, some beige walls. There’s dumbbells on this pyramid set. It can be anywhere from 10 to maybe if you’re lucky, 20 pounds. There’s a few machines. There’s definitely a bike in there. There is probably this trampoline and then there’s a physioball, that big ball that you see, some balance boards. But you don’t really see any dumbbells that are past 20 pounds, heavier weights like barbells or trap bars, or anything that we’re going to see that’s really going to truly strengthen our body. 

Sure, in those initial phases, we can see that there is going to be some use of those things. But then after you get out of those initial phases in ACL rehab, we need more. It’s just the reality of it. And if we take aside the PT that you’re working with, let’s say they’re the best PT that you’re working with, it’s just like that farmer in Florida, except they’re now in Canada, trying to plant oranges in the winter. It’s just not going to be easy to do that. And then you have to ask yourself the question: if you’re an ACL athlete, is this environment going to give me the best outcome to get me back to what I want to do? And if one of the main goals is to get stronger, then we need to figure out, how can I create an environment that is going to support me in getting stronger and getting back to full return to sport.

If this clinic that I just described is what you expect to do all of your rehabbing and expect to get the full return to sport and performance in nine months, it’s going to be tough. Is it possible? Oh, absolutely. But it’s going to be tough. And that’s where having a very skilled physical therapist who has specialized in this area will be able to help guide you in all of this. But it is very difficult to get people stronger when the maximum weight in the clinic is 20 pounds of dumbbells. I use this as an analogy. It’s like having a Ferrari, but you’re stuck in Atlanta traffic. Atlanta traffic sucks, or you can think about New York traffic. No matter how much capacity or how much ability that Ferrari has, if you’re stuck in traffic in Atlanta or New York, or you’re in these like downtown areas where it’s very boxed up, no matter what that potential is never going to be filled because of the environment that that car is in.

What I want you to think about is how can you change this. Is this something where you might have to not go to the clinic that’s right down the road or come home from work? Maybe it is, and maybe it’s something where it’s a little bit of a time cost. But if it’s beneficial to your knee and to your health, then that’s what’s going to be important. And you got to think about first, what is that environment that’s going to facilitate it. If not, then maybe it’s something where you talk to your physical therapist and be like, okay, well, if I’m trying to get stronger and do more of these higher demanding tasks, then is there some sort of continuation? Or, is there someone you can refer me to that you trust, like a strength and conditioning coach? 

And in reality, a strength and conditioning coach can pick this up pretty early and do really well with this process. I would argue that they know this process almost better, especially whenever you start getting into more of the loading phases, getting further away from the post-operative phases. And I completely understand, not everyone has access to the same resources. They’re not easily able to shift clinics. Maybe it’s insurance based, maybe it’s financial, maybe it’s not as difficult to get into a different gym. But there are options. And that’s what I want you guys to think about. And I want you to first take a step back and think about your environment and how is that going to influence your end result. 

And if you think that your environment is only going to serve you for a particular season of your ACL rehab, then that’s great. But you need to be able to start thinking, okay, well, what is it that I need to do? Do I need to get a gym membership? Every single one of my athletes has a gym membership. If not, they have a home gym. And that’s because we are working on strength and conditioning for them to get back to the sport or activity that they want to do. And I know that this was something that was really tough with Covid and lockdown. Maybe you don’t have access to the gym or maybe you don’t have weights available to you, then that is something where it is just your environment in general. Covid kind of shut things down, so then you do have to work with what you have. But if there are options to be able to pursue your own gym and being able to, maybe pursue a different physical therapy clinic that is going to support you in getting back to a full return to sport, then that is something to just think about. If you’re in the early phases, then maybe the whole bad carpet, beige walls, and everything will be fine. But then at some point, you have to start thinking, is this environment going to get me back to the things that I want to do?

And on the flip side of this, you can have an incredible physical therapy clinic. You can have all of the turf, you can have all of the weights. If you have a bad guide, whether that’s a physical therapist or athletic trainer, someone who is not really knowing what they’re doing. Or, they’re just kind of putting you on a balance ball and that’s kind of your rehab and your strengthening, if you will, then that could also be just as bad and could cater to the environment. Your environment might be great, but then you got to also think about the guide that’s along in this process. 

There are options, maybe you got to drive a little further. Maybe it’s something where you do something remotely and then you take membership into a gym. Maybe you invest in some weights that that membership would go towards and then you’re getting guided remotely, or maybe you have a relationship with a strength and conditioning coach. These are all the things that I just wanted to bring up in regard to the environment. 

One is how can you strategically change your environment and using these three different steps that James Clear talks about, to make sure you can get into automating good decisions, getting into a flow, subtracting negative influences, and then that way you make sure that you’re going to have the best outcomes in that way. And then just think about how the environment itself, especially for physical therapy, and as you get more into the training and strength and conditioning pieces, how are you going to get stronger? Is your clinic going to support you in doing this? And if not, what is the best alternative? And start thinking about that early.

Don’t let that happen. Get three months in and you’re like, okay, well, now what do I do? And you’re released from physical therapy. And something that’s really important to start evaluating early. I want to leave you guys with this quote: ” Life is a game. And if you want to guarantee better results over a sustained period of time, the best approach is to play the game in an environment that favors you.” Winners often win because their environment makes winning easier. 

Im going to reframe this. I’m going to replace the word life with ACL rehab. ACL rehab is a game. And if you want to guarantee better results over a sustained period of time, the best approach is to play the game in an environment that favors you. Winners often win because their environment makes winning easier. And this is something that I want you guys to take and think about. If you need help in choosing an environment that might be best for you, then reach out to me. Reach out to me on Instagram ravipatel.dpt, or send me an email at ravi@theACLathlete.com. I would love to help in any way that I can. And if it’s just even giving you some ideas of what it is that might be the next best steps, then please reach out. That’ll be it for today, guys. 

And by the way, look out on my Instagram next week, possibly Tuesday, might be a little something for you ACL athletes and clinicians out there. Keep an eye on that and it’ll be something really cool that’s coming. But other than that, we’re out for today. Thank you all so much for listening. This is your host, Ravi Patel, signing off.