Episode 55 | Time at PT vs. Home for ACL Rehab

What’s up guys, and welcome back to another episode on the ACL Athlete Podcast. Today is episode number 55, and we are talking about Time at PT versus at Home For ACL Rehab.

And one thing I want to dive into here is the common model that we see here in the States–PT, meaning physio or physical therapy, where you’re going into the clinic and you’re doing whatever is on the agenda. Most of the time after an ACL injury, especially after surgery, people are going anywhere from two to three times per week. That is the typical cadence that you’ll see anywhere from 8 to 12 weeks. And now there’s a lot of, it depends that comes down on this.

But insurance will be the main factor, as well as the cadence that you set up with the physical therapist and what they think you need. And so that will factor in a lot. And then you’ll be given an HEP program which is a home exercise program, essentially some things you need to be doing whenever you’re not at physical therapy.

And most places do this or should be doing this, and that’s something that you’ll need to complete at home. The question that I often get is: What should I be doing at home versus at physical therapy? And this is a pretty loaded question because it’s going to depend on a lot of factors. 

First, is going to depend a lot on what you’re doing in physical therapy, honestly, and how often you’re going. Now, I’m going to do some generalizing here because of what is often seen. But in terms of physical therapy, one of the things that’s going to really depend is what phase you’re at in this process. Are you post-injury? Are you post-op? Are you kind of in the mid stages?

Let’s say you’re out of the initial one to two to three months of rehab and you’re getting into more mid stages, or maybe it’s even later, maybe you’re six months post-op. All of that will depend honestly on what you’re doing in physical therapy. But with that said, what you will typically see is that some PTs and some physical therapy clinics will do a lot of massage and soft tissue work. So that might be, I don’t know, cupping or kneeling or manual therapy type stuff, which it can have its place. So just like take it for what it’s worth.

But to me, I think it’s overly done and I think that that is a significant time cost in terms of what could be happening, especially when we’re talking about strengthening and working on other additional movements. If you see me in the clinic with most of my athletes, we’re never doing soft tissue. We are focusing on movement because that is the end goal. And because if there’s something from a soft tissue standpoint, I just get them to do it on their own. And it’s not really as much about the modality or the method, it’s just about, all right, how can we relax some tissues here or some muscles, and that’s something that I would rather an athlete do at home, and not focus on our time spent in physical therapy together. But you’ll see this a lot.

I talk to a bunch of athletes. When I ask them what they’re doing, because they’re saying I’m not making progress, I ask what they’re doing in physical therapy. It’s either they’re doing a lot of stuff on the table or they are not really getting exercises that are meeting them where they’re at, in order to progress them forward. While every physical therapist has their own treatment philosophy. If most of your session is just laying on the table and doing a lot of hands-on work or massaging, then you kind of need to find something else. Because that’s just not going to get you and it’s not going to move the needle in the direction that you want to. So that’s one part of physical therapy. Maybe it’s the soft tissue stuff, then you’ll get some general exercises. So that could be stuff on the table, or maybe it’s some machine-based stuff, or maybe you’re starting to actually load some muscles, which can be good.

And oftentimes when you look at physical therapy itself, it will be a mix of those two things to some degree, if you are getting it here in the States. But again, it is going to depend on the physical therapist, what they deem that you need, as well as where you’re at in the process. A lot of these will factor into this. If we talk about the HEP program or the home exercise program, that usually is feeding off of the things that you’re doing at physical therapy. It’s usually some of the movements or the exercises that you’re doing, which can be good. It just needs to be balanced and it needs to make sure that it’s kind of attacking all of the angles and filling all the gaps, if you will. And so when we come back to the question of what should I be doing at home? Well, it is going to depend on a lot of these things. Bust most importantly, it needs to be meeting you exactly where you’re at in your ACL rehab process. There needs to be a needs analysis done by your physical therapist and coach to know, okay, here is exactly where you’re at from testing; and to know, okay, here is the next step that we need to make to move you forward; and the specific phase that you’re at; and the goals that need to be met at the end of this phase.

And then also, most importantly, the end goal which is what we are working towards and our reverse engineering to make sure your rehab and your training fulfills that, so you’re prepared for it. I’m going to share a story with you guys of an athlete that I just started working with. He’s five months post-op ACL. He was at another clinic before using his insurance. And he was getting really frustrated. He started out with two times per week and then slowly tapered to one time per week. And the thing that baffled me the most is the things that he was doing for so long, but check this out, his home exercise program for the past five months hasn’t really changed at all. Is that he was doing variations of straight-leg raises on the table, and that was it. And then they wanted to taper him down to one time per week. And the only thing at home he was doing was straight-leg raises.

This is a soccer athlete, someone who likes gymnastics as well as roller skating. And this is the kind of stress that we’re going to try and apply to this guy, in order to get him back to those sports and those forces that are going to really stress his joint and especially his knee. And you can’t blame the guy for being frustrated. He was not sure exactly what was going on, and there wasn’t a lot of transparency in this. But my point in saying this is that we need to make sure we’re meeting you where you’re at. And that means how often you’re being seen or what you’re doing outside of the clinic, as well as the right dosing of stress and recovery and to get you to the next point and ultimately to the end goal. 

When we’re talking about time in PT versus time at home, this is an important factor to consider in your ACL rehab process. It’s a conversation I have a lot with people who are working potentially with someone else. Or, maybe they’re not getting the outcomes that they want, or maybe it’s with my own athletes, and they all know this and they’re all very familiar with this because we set the expectation from the front, from the get-go. The overarching theme here is that the time that you put in at home is just as important, if not more than what you do in physical therapy. It just is. Just think about it. If you are going to physical therapy three times per week, that’s three hours of your week; if you’re going two times per week, that’s two hours, and then one time is one hour. If we were to take just even the maximum of, let’s say, three hours per week, unless you’re just magically gifted with way more time and way more frequency based on your resources, as well as the physical therapy and even the program and training you’re getting which is very rare. It’s a small percentage, and we’re talking about professional athletes as well as just unique situations.

Most of the time it’s two to three times per week, and then it kind of whittles down or it just runs out. If we’re looking at two to three hours within a whole week. A whole week has 168 hours so that brings us to less than 2% of your week is in physical therapy. Now insurance again, will dictate a lot of this, as well as your coverage as well as the physical therapist, and the clinic you’re at, will impact what you’re doing. But then we do need to really consider what you’re doing at home. And then there can be so much time at home. Because if you are doing, let’s say three times a week at physical therapy, that leaves another four days where you’re not doing physical therapy. Maybe those can be recovery days depending on what you’re doing at rehab, and you’re really trying to push the needle on things, depending on where you’re at. But let’s say you’re even two to three times a week, so then you’re looking at five to six days where you don’t really have physical therapy. Your home exercise program and the things that you’re doing at home will become that much more valuable and will be the thing that really moves the needle for you in your rehab.

The way I want you to think about this is to treat your ACL rehab like school. But now you are focused on the most important thing you’ve ever wanted to learn, do and pursue, and be super serious about. And when we think about this from learning a specific profession to a topic to a subject matter, we all know that if we just magically show up that we’re not just going to learn the material. Sure, if we participate and we pay attention, that’s good. But showing up is not going to be just good enough, it’s going to be something that’s going to help facilitate the process, get you introduced to it, ensure, and provide some of the resources. But at the end of the day, you have to take it upon yourself to truly learn the material, especially if it’s something that’s important to you. You’re going to go home, you’re going to do your homework, you’re going to study, you’re going to be consistent, and you get out what you put into it. 

I remember deciding between two physical therapy schools of which one I wanted to go to. And one of the big things was finances, as well as some of the pros and cons in terms of specialties. One of my mentors told me, you get out what you put into it. And whenever I thought about this statement, it actually rang true to a lot of things that I have done in my life. And if you think about it yourself, this can be with any area of your life. And truly has shown up in my life in very positive ways in the things that I have put a lot of effort into. I want you to think about that in terms of the school analogy and treating your ACL rehab like this. Because there is going to be things that you need to do outside of just physical therapy and doing it at home to work hard, to really get the outcome that you want, especially to be confident in your knee and to get it strong and mobile and powerful. This stuff can’t all be accomplished at physical therapy. And so that’s where making sure that you have a good plan in place, and someone who is guiding you is going to be really important. That’s just like school. If you’re trying to learn something, you have a teacher there, as well as they have a plan and they’re guiding you. They’re giving you the guardrails in this process to learn, and you are applying yourself to make sure that you take care of your knee and make sure you have the best outcome in this process. 

And I know I’ll get this question, but different parts of the ACL process will have different demands. So that’s going to depend on what you’re doing and how much time it will take. These are anchored to the goals of each phase with each one building on top of another. You can’t truly move forward unless you pass the criteria to move on. 

And so an example of this would be the early phases of ACL rehab. We’re talking about fresh ACL or post-op, where you might need more frequency and more time since you’re working on the range of motion stuff and waking up your quads and getting your gait normalized and other muscles conditioned. We’re talking about stuff that might be a bit more daily. You guys have seen that before where it might be the heel slides and the knee extension work and quad sets; and sure those are good. And the thing that we need to keep in mind is that frequency is very important here. And we got to find the sweet spot, it’s a little bit of a dance with figuring out, okay, is this the right amount of dosage? But we want to make sure that we have a lot of frequency with this because it’s lower stress if you will.

Sure, the knee is healing, but we’re not stressing our muscles beyond the capacity of what they can handle. We’re just trying to focus on this phase, and that needs to be more input, more frequency, and working with our knee and making sure that it’s healing appropriately. And we’re building these foundational blocks. And these are lower-level movements, as we work through the initial phases and into the mid and later phases, it might be a little less frequency where you don’t have to work on stuff every single day and the intensity dial might be turned up a bit. You actually do need some adequate rest between sessions. So that’s where we’re working on more of max strength and power and maybe field works like a change of direction and plyometrics, to get a good balance of the adaptations that we want. And again, this will always come back to how often you’re going to physical therapy in person, as well as what your home exercise program is.

But with that said, a lot of the model and the structure, at least here in the States, is set up to just be a bit general. And as you start to maybe wean off of visits, there needs to be some sort of home program in place to make sure it compensates for it because you’re going to need more as the process goes on. And that’s going to be different days focused on different movements, as well as different physical qualities such as single-leg strength, power, rate of force development, change of direction, sprinting, and jumping. There’s so many different things that we need to get back. So that’s why this needs to be strategically done. And if we just wait on it being done at physical therapy, we’re probably going to be leaving some gaps. 

Where to address this? Is to make sure you’re communicating with your physical therapist, and making sure that there’s a plan in place to address, not only what you’re doing in rehab but also ask, how can I maximize this process at home? What can I be doing? And making sure that you balance it appropriately to make sure your knee is happy and progressing along like we need to. The difference between the athletes who crush it in this process and get back to a hundred percent and the difference in those who do not, they show up no matter how much things suck. They get it done and they work hard. They’re consistent, they communicate and they make sure that they are maximizing their time in the clinic as well as outside of the clinic. 

And if there’s anything that you can take away from this episode, it’s that if you can find a good balance in making sure that PT in the clinic is not the only thing that you’re doing, and you find the right plan, and you make sure that you are executing it as best as you can, then that’s all you could really ask for in this process. If you feel like you were relying heavily on just going into the clinic to get the results, then there is a good chance that you’re leaving some stuff on the table. It’s just inevitable with the frequency and the way that is built, as well as the time that we have at home. We want to maximize time and the return on your investment in order to make sure we are not wasting time and dragging out this process longer than it needs to. And we know that this process is already long as it is. 

That is my takeaway for today for you guys. Make sure that you maximize time and make sure you have the right game plan in in-clinic and out-of-clinic. Ask the questions, and make sure you’re informed. If not, get educated on it. If you guys have any questions, as always, feel free to reach out. That’s going to do it for today, guys.

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