Episode 56 | Setting Expectations In ACL Rehab

What is up guys, and welcome back to another episode on the ACL Athlete Podcast. I’ve got my coffee ready. The blower outside is going as it is always on par. Now, it’s time to get into this episode, and just want to say thank you, guys, for hanging out with me for whatever time this takes, and any other episodes that you decide to spend your time with me. I really appreciate it. Let’s dive into episode 56, which is setting expectations in ACL rehab. I did an episode before on expectations versus reality. And we talked a little bit about some of these in ACL rehab. Today, I want to dive deeper, specifically on expectations in this process, and focus this episode on that for you, ACL athletes. 

As we’ve talked about in the past, mindset really is everything in life. But especially in this process because it is so long and we do have to take on things that we’re not used to, whether it’s physical as well as the mental piece which we know is way harder in this process. And a lot of this comes down to our expectations. Now, sure, we’re going to have hiccups and issues along the road that are physical and that obviously impacts our mental state. But a lot of this stuff is based on expectations and more so of how we handle it. And that’s where I want to focus today on because our expectations determine our satisfaction, the outcome of what we think and feel about a certain situation.

And we’ve done this all across our lives. Think about it. In school, we’d often say we failed a test to manage our expectations if we actually did. I remember there were plenty of tests where I was like, I think I did well. But internally, when you’re talking to your friends and you’re like, yeah, I probably failed it. I feel like I didn’t study that well. And then all of a sudden, you get the test and you did well. We do this all the time, and that’s just to make sure that the blow doesn’t hurt us. Same thing with maybe a job interview. Often we’ll write it off. Maybe we critique what didn’t go so well and we don’t want to get our hopes up. And that’s managing our expectations for our own pride and our own ego. And a lot of this comes back to mindset. 

And if there’s a book I can recommend to you guys. I remember reading this years ago called “Mindset” by Carol Dweck. It is just a phenomenal read on how people can sit into this negative or kind of like a fixed mindset or a positive growth mindset. And it’s all about managing expectations and the way that you view things, which really does impact a lot of how we perceive and carry out actions. Now with these examples, I’m not saying to do this in your ACL rehab. I don’t want you to think, “Ah, it’s gonna suck. I’m gonna fail it.” That’s not the mindset that you want to take in this or the expectations to set similar to those school or job interviews that we may do. But it is managing our expectations properly and making sure that there’s not a mismatch between those and the outcomes that actually do happen. The difference between those two the expectation versus the actual outcome can make a huge impact on the way you move forward or attack a certain problem. 

One simple example I want to give you is, if a surgeon or maybe the physical therapist you’re working with, or maybe you read something online or a friend told you that maybe you’ll be running in three months. You often see this in like protocols. And I will hear it all the time from athletes who go and see their surgeons or someone who is following a strict protocol and it’s like, okay, three months hits, you should be running. And then I’ll often hear where they should be returning to sport at six months. It’s still out there and it’s very common to hear it. Although we have so much research to refute that. But with that said, we have these timelines in our head, and that’s how we kind of operate in this ACL rehab process. I wish it could be different and it could be more of a criteria-based approach where you’re like, okay, instead of it being time-based, the protocol is literally, time can be a factor. But it ends up being something where we anchor it to other things that are more objective. Time is kind of arbitrary in this, and humans are very different based on genetics and gender, injury history, and so many other factors. That time isn’t just going to be the only thing that’s going to solidify this process; which is why criteria is so important to progress forward.

When we’re talking about this expectation that might be set from someone telling you this or a surgeon at three months you’re running, six months you return to sport and you don’t, what do you think that that does for you mentally? Think about it. If you hit three months and you’re not running, what do you feel like? A failure. You feel like I’m not progressing well. And maybe one of your other friends is doing so and they’re running at two and a half months and you’re not. Then you start looking at things of like, oh man, well maybe I’m running behind, or, that’s the thing that I feel, I hear the most from athletes, is they feel behind in this process. And that bothers me because I think it comes from where we get our expectations from. And I’d argue that managing expectations is probably the most important thing in this ACL rehab process. It grounds our mindset; our mindset impacts our actions. If we’re going to do some exercises or just skip it. if we understand our direction and the expectations of that, then we’ll be motivated to work hard. If we don’t, or we feel like we’re spinning our wheels or driving kind of blind, then why bother doing it.

And I talk to a lot of athletes on a weekly basis who struggle with this. If you’re feeling this way, you’re not alone. But let’s ask why. Because this process is just not like a normal injury. And because ACL injuries and rehab are probably the most complex things out there, aside from some traumatic stuff, of course, like spinal cord injuries. But you guys get me sports-related injuries like ACL is at the very top of complexity. And the thing that is also just very difficult that impacts our expectations, as well as culturally and things of that nature is our system. The system is designed across the world, whether it’s in the U.S. with insurance and a volume-based model, or even universal healthcare. They all have their own problems. The thing that is tough is that it is generalized to manage any and all things. Whenever you generalize those things, let’s say you’re going to get the same care for knee pain versus having an ACL surgery. Well, the process itself is going to be very different based on those two routes. And the thing is, is that even in the U.S., our insurance only gives us so much. And then it’s going to be difficult to manage that. Not to mention volume that makes things kind of speed along, if you will, then things fall through the cracks, including proper expectations and proper ways to rehab and test. And so I digress. 

Now, setting expectations. You guys know I always want you to have some sort of takeaway and some actionable items with any episode, always. I think that the world is super arbitrary. There’s a lot of abstract things in it. People will be like, yeah, go get stronger. Let’s figure out how. Here, I want to talk about setting expectations. And here are some for you to mentally prepare for. And that’s what is so important from the start of this process all the way to the finish, is being able to make sure you can manage those as best as possible. And so I’m going to walk you through what I experienced with my own two, as well as working with many ACL athletes who have gone through this process themselves. 

And you guys remember that image, right? It’s one where you have a graph on the left versus the right. And at the top, it says success, on the left one, it’s what people think it looks like in terms of this process, and it’s just this perfect straight line that’s linear and positive and is from point A to point B. And the one on the right is what it actually and really looks like, which is honestly just the way my life looks and all of our lives, is that it’s just this chaotic line that goes up, down, backwards, around. It might trend in a positive direction, but there are definitely some dips and some negatives to it. And that’s kind of what life is. And that’s essentially what the ACL rehab process looks like when you think about it. And anyone who’s gone through this, I don’t know anyone who’s just had the smoothest process, who just crushed it, never had a day where they were not feeling like they were progressing forward. There’s not been a single athlete that I’ve worked with who hasn’t had a hard mental day, or that they feel like they’ve had a setback in some sort of way. And this goes from the youth athlete all the way to the professional. No one is immune to this. This is why it’s so important to manage this and to set those. I’m going to dive into some expectations. I talked about this on Instagram a little bit. But I want to dive into this a little bit deeper because I think it’s good to hear it and also to process it, depending on where you are in this process. Or maybe you are someone who’s just supporting, or you’re a physical therapist or a friend or husband, sister, whatever it is, and you want to understand this process a little bit more. 

Well, let’s dive into some expectations for you to be able to see and think about as an ACL athlete. Expect it to be hard and long that’s what this process is. But I promise it’ll make you a better person. It’s hard to see in the moment but you will. At some point, look back and be like, wow, I’m a better person because of that. Not probably when your knee is grumpy, but whenever you feel physically fit and better, or even when you endure some sort of long hardship. I know that there have been plenty of times in my life where I was like I’ve been here before. And I know what this mental battle is, especially when it comes to some sort of physical ailment. That is something I’ve been here before and I know what it’s like and I know I will persevere and get through this.

This process is harder mentally than it is physically. I will take that to my deathbed. It really is, and it’s very, very hard to explain this to other people, especially someone who has not gone through this process. And I know as much as we try to explain it to someone who is supporting, that is very true. But what happens a lot of times is that people who have not gone through this process will see you start walking around normal, maybe doing some things and they’re like, oh, well that person’s kind of back to who they were. But internally, you’re like, I don’t feel a hundred percent of who I am physically or mentally. And so that’s going to be something that’s really tough in this process. And that’s where you have to make sure that you have things in place to address the mental side of things. And that might also be working with a trained professional or a therapist to work through that. Because that could create some frustration, it can create some anxiety, some depression, and some fear. And those were some of the things that I felt in the process. And I had to have the support of friends and family and even professionals to be able to help me to get through the process. And that’s okay, no one is too tough for it. I will tell you that, no one is too tough. And it will be better for you as well as just the people you’re around in your process, whenever you are making sure that you’re taking care of the mental side as well as the physical.

 It’s going to be a 9 to 12-month process. If you are post-op especially, it’s going to be at least nine months, or it should be. I’m going to argue that until research proves me wrong, but it’s pretty strong at this point. If your surgeon is telling you to return to sport in six months, I’m going to disagree. And you probably should go and find a different surgeon or at least a physical therapist who has a nine-month timeframe. But here’s the thing, when you cross the nine-month timeframe, it is not a magical time where you automatically are cleared and you’re good and everything’s healed and ready to go. It only serves as a proxy to provide time for healing and to get you back to a hundred percent with the proper training and physical development. We need time to rebuild muscle, we need time to rebuild strength and power, and the ability to do things on the field or court and do them very dynamically like you were before. That’s why the nine-month timeframe works out so well and the research really does support that. 

Protocols will give you anxiety because you’re not hitting the timelines perfectly. It’s okay. Protocols are trash to me, in most situations but more so, the protocols are based on time. That’s the thing that I want to make sure I stress here is that not all protocols are bad. It’s good to have some guides and it’s good to have some frameworks. But like anything, it needs to be based on criteria rather than time alone because time is really arbitrary. Everyone is different. We have different injuries, different graft types, different ages, genetics, did you have a meniscus repair, did you have a meniscectomy, did you have a very complicated injury with a fracture, is there bone bruising, did you have an injury history, other than that, that has made the knee more traumatic. There are so many individual differences that we have to take into account that a protocol isn’t going to fit everyone into that.

And the best way to really think about this process if you can really try to visualize it instead of time, is to use criteria and to think of it as school or like college and prerequisites. You’re not going to be able to get into your major until you meet the prerequisites to get there. And you can think about this for your ACL and phase-by-phase approach. If you need to move on to phase two, well, you have to make sure you have phase one knocked out. And that’s going to be getting the range of motion and getting proper quad control, gait, all of these things we talk about. But the same thing in school, you can go to college at any time, and then you can take your college prereqs. But the thing is you can be in school for a long time and still not hit those prerequisites and then be pushing off getting into your major. You can think about those as phases and making sure in order to proceed to phases three and four, well, we need to make sure we have English 101 knocked out. All these prerequisites for this specific major in order to move into the major. So that’s the same thing here maybe you think about, I need to make sure I have my range and certain adequate strength before I move into running and before I move into more dynamic type work, especially field or court-based dynamic work. These are things to think about instead of, all right, I hit six months and we’re good to go. I know that time is easy to anchor to for us, but I want you to think about how to change this mindset because that will help a lot. 

Range of motion, you’ll probably work on a range of motion past the first four to six weeks or what the protocol says, especially extension. Your protocol says, to begin running the program at 12 weeks. There’s a very strong chance it might take longer to run. I probably don’t have, most of my athletes run until four to five months. And my reasoning is, is that the demands of running are a lot on a newly reconstructed knee; it really is, its impact. There’s a lot of repetitive impact. And the process itself is typically nine months at a minimum. Why not just build the base up more with strength and other positions and running mechanics why rush the process? 

Unless you have a time that is sensitive to get back to, why rush it? And that way you can also let the knee heal and settle down a little bit more. And also allow it to progress running a bit more adequately, once you build a better base. And a lot of that is based on strength. Your extension is going to be so important. Get that back as soon as you can post-op or post-injury. A good rule of thumb is getting to the same as the other side, your uninjured side. Zero degrees or just straight is not going to cut it. You need hyperextension for us to be able to engage our quads, and we need to try and match the other side. Your quad is by far the most important muscle in this recovery, so you need to strengthen the hell out of it, like a lot. Along with your other muscles, including your soleus muscle, if you don’t know what that is, talk to your PT and see how you can strengthen that more. Because that plays a big role in jumping and running and is a huge second to the quadriceps and along with the hamstrings and glutes.

You’re going to think you’ve messed your knee up 25 different times; it’s very unlikely. But make sure, if you feel like there has been a scary situation, just ask the healthcare professional you’re working with. If it seems like there’s been a significant shift in something like that. But especially post-op, you’re going to feel like things are off. But as long as things don’t shift in a very dramatic way, you’re probably fine. And I’m also going to add to that, you going to hear some pops and some cracks. And you’re also going to think something’s wrong with your knee. As long as it is not clunking or huge shifts, or it impacts your function or becomes super painful, then I wouldn’t sweat it too much. And just know that with joint swelling and healing the dynamics of the joint itself change a little bit and how structures slide across each other. Just think about that whenever you’re feeling that. And especially to delineate if it’s impacting your true function and your ability to rehab. And also, is there pain present? But you’re going to feel like it’s going to be messed up. You’re probably good. At the end of the day, talk to your professional to make sure that you are good, if there is doubt. 

Everyone wants to ditch their crutches super fast, and I get it. I tried to do it, too. But if you don’t have the right requisite range, control of your quad, and the pain and swelling managed, then it might do more harm than good swinging your leg around. I’ve seen people who literally ditch their crutches and then they’ll start windmill kicking their leg around because they want to walk without the crutches. And so that’s something where I would highly suggest just finding a sweet spot here and making sure that there’s this very good progression. And if anything, stay on a single crutch a little bit longer. That way you can normalize the way that you walk. And then as these things come along, like your range and your quad control, that’s going to help a ton in terms of being able to get your gait normalized. 

And that’s the other thing that I think a lot of people will notice is that a limp will stick around for a bit. Then we have to ask why that happens. If that’s the case, go check out episode 49, which is, why do I walk with a limp? But with that said, it typically happens a lot because we’re just trying to walk and we have to relearn how to walk. And some of that also means we have to take it a little bit slower on crutches than we want to. Piggybacking off of this, go slow, especially in the early phases, and focus on the foundations. Don’t get too far ahead. Some of this stuff can get super repetitive. It can get monotonous and boring, like the range of motion work. A lot of my athletes will be like, how long do I have to do this? And it’s something where it’s a problem or it’s something you work on until it’s not a problem until you meet the criteria, essentially. 

If you do not have terminal knee extension and are able to get into hyperextension, we’re going to keep cranking on it and we’re going to keep working on it, and you’ll keep seeing it until that progresses. Unless we have some sort of issue in the way, then we need to get that addressed. And then make sure we continue to move forward. So that’s going to be really important. Go slow, don’t rush anything, and build the foundations. I call these the daily bricks. Lay down the daily brick. Make sure you create that foundation really solid before you get too far ahead. Are you guys still with me? We’re going to keep this going. 

The next one is you will likely have a setback. I had many in my ACL rehab process, my first one to second one, lots of setbacks and that’s okay. It’s going to happen. Some people have a smoother ride than others. I have one of my athletes who had an infection that got into the actual screw itself. They had to remove some of the hardware and he has had a really rough go at it. He really has. And he just wants to play soccer and he just wants to be active. And right now he is struggling because he had to get the hardware removed. He’s been dealing with some pains that are not typically normal, so it has been a process for him. And he was like, I wasn’t expecting any of this when I first decided to have surgery. And that’s where we had to pivot and we had to make sure that we kept the graft safe. And also to make sure that we had a game plan to continue to keep working. My suggestion to you is just to make sure you have a game plan to pivot to when that happens. Not if, when it happens, you need to make sure that the professional you’re working with, that there is a game plan to address and work around whatever happens. And sometimes that might be a little bit of time. Sometimes it might be just switching up movements or the way that you’re approaching things.

There will likely be very tough days, and that’s okay. Some days you might want to give up or be like, why am I doing this? Just focus on making it to the next day. Losing motivation often happens. It is just one of those things, especially early. And I find this for people who can get anywhere from like three to four or five months out depending on their progress. And that could be because they’ve just been in it for a bit and it can get a little bit boring at times because you’re just focusing on continuing to build strength while working on some other things. But you’re like man, I’ve been at this for a while now, and you just want to get to the end already. Just remember your why and what’s most important and why you’re doing it. It’s okay to feel burnout sometimes. Talk to your PT or coach and make sure there’s a game plan for that. And this is something that plays into the previous point. But it can very much happen. I’ve had plenty of athletes who can get to this point and a good coach or PT will be able to figure that out and know with communication. And even from a performance standpoint, when there might be time that there needs to be a break. I give the majority of my athletes breaks periodically through the process, especially when they’re starting to feel that kind of burnout feeling. And I’ll even tell them to get out of the gym. Don’t worry about any ACL rehab, just be active. And they come back and they’re ready to rock and roll. They oftentimes also have better numbers because they’re rested, they’re mentally better, and so then that creates better output. 

You need your support system, I’m going to say this again, you need your support system so lean on them. Your friends, family, teammates, coaches, rehab professionals is something that’s so essential and you’ll need to lean on them. Prioritize getting really, really strong, like really, really strong. And I promise this process will be much easier, especially getting your quadriceps strong in different kinds of ways. Recovery is just as important as rehab or training. This is where your body actually adapts and grows, so make sure to prioritize your recovery. You must have proper objective testing and clearance, and there are no exceptions. No human listening to this, no matter who you are, your goals, you should have proper objective testing. If you do not, find someone who does objective testing that is good, reliable and valid. And if you’re a surgeon or a physical therapist tells you: “Hey, you don’t need this.” I really suggest finding someone who does, I really do, because this is your health. You only want to do this once. Make sure that you do it at the best of your ability, and that means proper objective testing and meeting the proper criteria with that. 

This next one might ruffle some feathers, but nah, I don’t really care. The PT clinic down the road might not cut it. Not all clinics and not all physical therapists are equipped to manage an ACL injury, literally and figuratively, about the equipment part. Some clinics literally just do not have the equipment there to be able to facilitate a proper ACL rehab recovery. Some do. And then it’s talking about skillset. So that’s the two big things here, the clinic itself, the environment as well as the PT and the skillset, and whether they’re fully equipped to be able to handle this. And I know that convenience is huge for humans. We’re all lazy. I’m lazy at times. And so being able to go down the road is great. But think about the things that you might go out of your way for good quality stuff, whether that’s the food or haircut. Maybe it’s going to a certain place or a restaurant because you love it and you know what you’re going to get. And you know every single time that you trust the haircut place, the hairstylist, the barber that you go to, maybe it’s a coffee shop where you’re like, man, the coffee is always on point every single time. The same thing here. This does not need to be any different, and especially when it comes to your health, don’t go the cheaper route, don’t go the convenient route. And make sure that you find what it is that is going to get you back to what you want to do. That’s going to be really important here. 

The other piece that I want to stress is that unless you have amazing insurance or health benefits, you’re probably going to need more than what it gives you. You probably are. A lot of times I’ll talk to people and they have 20 visits, 30 visits, 40 visits. That’s still not going to be enough, typically. And I hate it, and it’s the system we’re in. But other cost-effective options do exist. My suggestion is to find a great strength conditioning coach who understands how to build you up, properly from a strength and power standpoint, and then all the other more dynamic things. And that’s essentially how I operate with the majority of my athletes. Sure, I’m a physical therapist, but I am a strength and conditioning coach, and that’s the lens that I look at with all of my athletes. And sometimes I have to pull out the PT hat, which is totally fine. But this ACL rehab process needs to look more like a training process rather than sitting on a table and doing some exercises that can be associated with physical therapy. Make sure that you have that kind of network to go and even ask your physical therapist: “Hey, like, is there a trainer or a strength coach that you know that I know my insurance won’t get me all the way there? What can I do and how can I connect with this person?” Just make sure that you don’t do it alone. This process is way too complex to figure out on your own. And your health is so important to just figure out on your own. 

I’ve met folks 10, 20, 30 years out from their ACL surgeries, wishing they would have done it differently than the way they did, or just slacked off on the end part and they re-injured again and never got it taken care of. Definitely, take the initiative on it. You don’t want to be looking at this further out and be like, well, this is just what I have. You need a plan that is specific to you, that is agile and flexible along the way. It needs to be adaptable so that when there is a setback or maybe there is something that needs to change, you can do that. And you’re working with someone who is a knowledgeable physical therapist or coach to be able to guide you there. That is so crucial because this injury is not just a general injury. It’s very unique and you need someone who is experienced in this process, and not just someone who is nice or the PT clinic down the road. I don’t want nice. I want to achieve my goals, get back to who I am and have longevity with my health. And that needs to be someone that you find to bridge that gap for you. And if you need help, there’s remote coaching options that exist. And I don’t really care which one you pick, I just want you to make sure you have a good recovery. 

These are some expectations that I want you to kind of think about is advice/expectations that will help to form your mindset in this process. And as I’ve said before, mindset is everything. This will be driven by our expectations. If you look at this injury as an opportunity rather than a why me, it will help so much. And this can be an opportunity to build, as I’ve said before, from the ground up to become a better athlete. The opportunity to focus on maybe other areas of life and really evaluate your identity and purpose given with the downtime. There is some silver lining to this, and I know sometimes in the process it could be tough to see that. 

And the other thing that I’m going to suggest to you guys with this to keep just momentum going is to celebrate every single win, no matter how small or big, celebrate every single one. That’s where the expectations aligning with our mindset hitting these proper milestones and progressing along the path is going to be so important. And to make sure you celebrate your victories. 

I’m going to leave you with this because this has already been so long. If you work a job, you thought you were going to get $100 for it and you get $10 for it. You’re going to be mad, you’re going to be pissed, you’re going to be like, why did I do that? This is going to be the same thing. Expectations are everything. You need to make sure that you set them appropriately and make sure that you get educated on the process because it is very different. And a lot of the time, people have not experienced this before. So that’s why this podcast exists. I want to create proper expectations for you. That’s why this episode exists. And that’s why previous ones do, so you can be as informed about this. And so then that way this can ground your mindset, and then that way you can have the most successful ACL process that you can. 

So that’s going to be it for today, guys. If you have any questions, I’m always open to them. You can send me an email at ravi@theaclathlete.com. It’s also in the show notes below. Or you can send me a message on Instagram ravipatel.dpt. Hit me up with any questions, any thoughts about even the podcast, or if you need some guidance. Just let me know. That’s going to be it for today, guys.

Thank you guys for spending 30 minutes with me talking about setting expectations. And I hope that it was helpful. Until next week, my friends.