Episode 51 | Test Don’t Guess

What’s up guys, and welcome back to another episode on the ACL Athlete Podcast. Today’s episode number 51, and we are starting off with a question. I’m going to ask you a question, and I want you to think about it as we go through this episode.

Let’s say you bought a car recently and something breaks down. Let’s say, for example, the axle which is what connects the wheel to the car itself. It’s essentially what you turn and what the wheel sits on, and so that’s been broken. Now, you need to get it fixed. You take it to the mechanic. The mechanic changes the parts, they change the axle, and then he says it’s good to go. He did not test it. He didn’t take it out for a test drive. He didn’t put it on the track to see if it drives okay and turns okay. He just changed the part out. Now, would you get into that car and would you drive it, would you take it into Atlanta traffic and have to bounce around? Or, would you take it to a racetrack and would you max it out? Would you drive it? And that’s something that I want you to think about as we go into this episode today. 

This leads me to a recent conversation I had with one of my athletes regarding a follow-up with their surgeon. The backstory of this athlete is that she is young and active. It’s not her first ACL reconstruction. The most recent one that she had was back in May of 2021. It puts her roughly at around eight months out from this point, as this podcast is being recorded. Her goals are to get back to running, biking, hiking, backpacking, skiing, and soccer. Most of which she’s already doing; skiing and soccer she is not directly doing and competing. But she is doing the majority of these things at eight months. She just had her six-month check-in with her surgeon, so technically it was her eighth month. But this is kind of the check mark that a lot of surgeons will have after their ACL reconstruction is at the six-month mark. She’s technically eight months out from her surgery. She goes in to see the surgeon. The surgeon takes X-rays. He checks the ACL via some hand tests, so he does the Lachman test, the pivot shift test, and then he checks her knee flexion range of motion on the table and then watches her walk.

Those were the only things that were done in this six-month check-in. After he does this and talks with the athlete, he mentions that he’s impressed with her strength and that everything feels and looks good. He told her that he would be comfortable with her skiing due to her history of being an advanced skier and suggested easing into it. And then at 12 months, do whatever she wanted in terms of skiing on the terrain or intensity. He gave her guidance on, okay, you’re good to go skiing, essentially cleared her for that.

My question for you is, is there anything missing? A five-minute table exam, a couple of questions, then he clears her for skiing. When I asked this athlete her thoughts, she says she was a little skeptical due to him saying earlier when she was at three months that she could go rock climbing. And so then that was one thing. The follow-up to this is that after this meeting with a surgeon, she had said she wasn’t planning on skiing this year. And then now it’s on her mind to potentially doing it. Now, there’s all this excitement around it and the potential to start skiing again. Then she asked me what my thoughts were, based on the surgeon’s advice and conversation. 

My follow-up question was, what objective measures and testing did he use to be able to give you this advice? To essentially clear you for skiing, did he see you squat? Did he take any objective strength measures of your quadriceps or your hamstrings? Was there any hop testing done? Did he see you do any type of lateral agility work? Any type of dynamic movements? Things that you would probably need to be able to clear in order to go skiing or do something of that intensity. And so essentially, what is he basing the guidance off of? That’s when she told me that he didn’t even see her squat, not even get into a just general controlled squat position in order to see what that looks like, or how she might look when she does it, anything of that nature. And that is just a drop in the bucket of testing. As a follow-up to that, I asked her, what are your thoughts based on what he said you can do versus what he saw and tested when he saw you in person?

From a clinical standpoint, when you take what he did in person and then told you you can go and do this. And she was like, it didn’t match up whatsoever. Bingo! And now here’s this athlete getting super excited to go skiing again when a surgeon gives this blanket response of clearing them to be able to go ski. When there has been no communication about the testing or any type of information about where she stands in terms of her training or her objective measures or anything of that nature. It was essentially we’re at six months, yeah, you look good on the table. You’re good to rock and roll. It was clearance based on time alone and just a few tests that were static in nature and not taxing whatsoever. When we look at the problem here, some of this is time, finances, resources. When we break it down, it comes back to a volume and a revenue-driven healthcare system.

And one of my goals this year is to not be so hard on this, but it’s also a big problem. And today is just not the day for me to say, the healthcare system is on a positive trajectory because it’s really not. And ultimately, at the end of the day, my goal is to serve you ACL athletes and to make sure that you have the best care and the best education. And to know how you can make sure this is your only ACL tear and that you have a better future for your knee and for your health and for your life. And to essentially reclaim the life that you want and be confident in your knee. And this is something that is just important to highlight because we need to know where the source of all this is. Because it’s creating a system that is causing athletes to be served very poorly. And then what happens is, is that if the healthcare system is driven by revenue and volume, which means lots of money. And the more numbers we see, the more money we gain. That surgeons have limited time to see athletes and have to give information or an answer based on limited information.

And that’s what’s really tough is that when you have a condensed amount of time, you can only do certain things. And then the athlete is looking for clearance or the next steps, or hey, can I do this now? And that comes back to, okay, well, what information do we have available? What you’ll often see, and this has been my own two ACL experiences myself, as well as talking to countless ACL athletes that I work with or even conversations. When they go to check in, typically it’s 5, maybe 10 minutes max. It’s some table tests to make sure the ACL is okay. And then there’s just some given suggestions based on typically time. That’s usually the main thing that – as long as the wounds are healed, the range of motion is coming along, the knee doesn’t feel lax, you’re good to go. You can progress onto whatever three months is typically running and then hopping, and then… at six months, depending on the surgeon will clear them for sport like this situation. And that’s where the problem can occur. And it’s based on very limited information. And if you take this specific example, it’s only maybe 5% to 10% of the entire athlete picture when you look at the physical demands of what she needs to be ready for.And it happens so often. This is typically the situation that I see most often and hear about. 

And it’s a big reason why re-injury rates are the way that they are and are so high because we don’t do proper testing and then that leads to potential clearance or the athlete just gets tired of it and then they just go back to whatever they were doing and then it happens again. And so this is where the goal is to create awareness around this to understand: Okay, what do I need to do in order to make sure I have checked all my boxes to make sure I have put myself in the best position possible? And when I’m chatting with athletes, and I was even talking to my wife about this, it’s really tough because the medical system is difficult to navigate. These injuries are so foreign to the majority of people who go through it. It’s hard to know what to expect. I have my check-ins with my surgeon at three months, six months. Typically, the time that we’ll use based on the research is a nine-month clearance of being able to go back to competitive sports; and there’s variation there. And I know this athlete at eight months. But it’s not necessarily the whole time thing that’s the issue. We are building towards skiing. The thing that’s difficult is the surgeon’s advice of what they can do and clearance for versus what they tested to know, is this athlete ready or not?

I think that’s the disconnect here of, what they know versus what they recommend the athlete doing. And what happens is, is that we follow this professional’s advice because they’re the surgeon. They did the surgery. Usually, a medical doctor is someone who’s seen at the top of the hierarchy, if you will, of the medical system. It’s a prestigious level to reach in terms of education. But that doesn’t necessarily mean that they’re just above everyone. It needs to be an even playing field and there’s a team-based approach in order to make the best decision for the athlete in front of us. For you ACL athletes, it needs to be a team-based decision, and that is going to be something that includes the physical therapist, the performance coach, the entire healthcare and performance side, as well as the supporting roles for the athlete with you as the athlete at the center of all of this.

And that’s where this whole test doesn’t guess comes from, is you don’t want to be guessing, you want to make sure you’re testing, especially objectively, to make sure that we are making the right decisions. And now hear me out, I’m not calling out surgeons here, this is just a call to action for everyone involved in the process. I have plenty of surgeons who have really good relationships with, where it’s a team approach as I just mentioned, where they ask about how the athlete’s doing in rehab, where they’re at. There’s objective testing played into it. And then their decision to clear the athlete for said sport or activity is based on team communication and these testing and objective measures to make sure that this athlete is ready.

It’s not just a blind, hey, you’ve hit the six-month mark. You look good on the table. I don’t know what else you’re doing, but you can go skiing now. And that’s just not going to cut a gang. So that’s where testing is very important and is going to be required for every single ACL athlete. That is my goal, is to make sure that every single ACL athlete has objective testing done and that it’s provided for you in some sort of shape, or capacity, and no one is exempt from this. No matter what sport you’re playing or the activity you’re getting back to, we need to have this for long-term health and outcomes, as well as reducing the risk of a second injury. And no matter who is telling you, no matter if they have 10 medical doctorates, no matter if they have the highest prestige in the world, even if it’s the President of the United States, you need to have ACL testing, objective testing in order to be cleared and to know where you’re at. That needs to be with range, strength, plyometrics, agility, psychological testing, as well as sport-specific testing if you are going back to a competitive sport. And that is going to be very crucial in order to mitigate the risk of having a second ACL injury. 

My advice to you as you move forward through your ACL journey, if you are told that you are cleared to do X activity, I want you to ask the professional you’re working with, how do you know that, what numbers are you basing that off of? Strength alone accounts for so many of the re-injuries. Is there strength testing that’s being done and can you give me a number besides kicking into my hand, to know, okay, what is this number that is for the quadriceps, for the hamstrings? Maybe even a leg press or knee extension, but that is something that is part of these criteria of making sure that you’re cleared to get back to any sport that we’re looking towards, including skiing. 

What I want you to do is to make sure to connect the dots between what they’re saying you can do, the advice they give you, their understanding of your actual physical capacity via testing, you use the testing to know, am I prepared for said sport or activity, and then also what you’ve been doing with training and rehab. If you haven’t gotten there yet, but you’ve been clear to go do a certain activity, then there’s still a gap there that we need to fill to make sure you are safe and ready to return to your activity or your sport. This can be the thing that makes the difference between having another ACL injury or not. It really does. And it comes back to testing and making sure we’re not guessing in this process, and that we’re connecting these dots to make sure you have the best outcome for your ACL, for your knee, for your health and longevity. So that’s going to be it for today, guys.

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