In this episode, we cover an opportunity cost regarding ACL rehab. We focus on sharing a special athlete win, return to performance criteria, return to performance testing, and finally, an audit of your own ACL process.
What’s up team? Coming at you this week with another ACL Athlete Win. This is Athlete Wins 3.0, so I’ll do this periodically for some athlete wins that I want to highlight, as well as this process can just be long. And a lot of times it’s just a feeling of a grind mode and sometimes it’s hard to see an end in sight. I like to share some stories from some of my athletes and see how they’re doing, especially some wins, especially when they get cleared. So that’s what today’s focus is on. And we could all use a little bit of positivity in our day, in our week, in our world. So that’s what today is all about.
Let me introduce you to Stella. Stella is 13. Yeah, I said 13, one, three. And she tore her ACL last June playing soccer. And she had surgery and I started to work with her in August of 2021. Stella’s dad first reached out to me at the end of last summer in frustration. He was saying the same things that I hear from a lot of parents and a lot of athletes, and a lot of you who are going through this process will feel at times. And it’s doing the same things over and over. And for him specifically and Stella’s experience, the same things over and over at this previous PT clinic after two months with not really much progress. And you take a 13-year-old when they’re doing the same thing over and over and over and not seeing much progress that’s going to get them to burn out and not buy into the process that much. And it’s just a lot of time and a lot of opportunity costs. He reached out to me. We met with him and Stella, and we got a game plan in place and we kicked things off. And let’s just fast forward to just a few weeks ago where Stella just graduated from her ACL rehab. She did her return to performance clearing and testing the battery. She passed all of her criteria just in time for volleyball tryouts.
For any ACL athlete, we are super strict here with our company to make sure we meet specific return-to-play criteria, especially for our youth athletes. What we know is that, especially for re-injury rates for ACL, they’re at an all-time high. But they’re especially at an all-time high for youth athletes. And some of this is also to play into their exposure. Sure, they’re young, but that also means that they’ll likely have chances to go and play sports or to play with their friends or be outside doing something a little bit more agile compared to your older populations. So that’s something to consider is that that’s why there’s also an increased risk for re-injury purely to exposure, but then also because of all these other pieces that play into our ACL rehab process. So that’s why we got to make sure we do a really good job and that we’re going to make sure we could reduce the risk as much as possible and get them ready for their sport or activity.
And for Stella, that was volleyball. When we first met, one of the main things we talked about are goals. We talked about short-term goals, we talked about long-term goals, and her main goal was she wanted to try out for the volleyball team at the end of spring, and that’s what we set our sights on. We made sure to reverse engineer the demands of volleyball, which is different from just, hey, you’re cleared to go. We got to make sure that she is ready for that sport. We’re thinking about the different jumping, cutting, the ability to produce strength, to be powerful. There are a lot of pieces that play into this. We want to make sure the deficits that we see within ACL rehab, that we are closing the gap on that and getting things as high and as symmetrical as possible. But then also making sure that her body is well prepared to handle any of the stressors related to the sport of volleyball. And therefore, after talking about maybe soccer or track or any of the other things that we had also discussed. And so we target her specific qualities through different phases of her ACL process.
By qualities, we mean think about physical attributes. We’re thinking about whether that’s the range of motion or work capacity or endurance, which is what a lot of people think of that as her max strength, her plyometrics, reactive strength, deceleration ability, change of direction, ability, and psychological readiness. Within each of these little buckets, there’s going to be little pieces or KPIs, as we call them, key performance indicators that we are measuring and we are tracking over time. And we do this with not only our in-person athletes but with our remote athletes as well. And these KPIs and criteria are going to be so key to making sure that we are getting them ready. Not only from these deficits or these issues that can arise from ACL rehab, but then also making sure that they’re at their best and they’re as prepared as possible for the sport or activities that they want to take on.
Some of the training will be different for someone who, let’s say want to run a half or a full marathon in nine months versus they want to go on and play soccer versus volleyball versus something like gymnastics. Those are all going to have different demands on our bodies. And you think about the athleticism that we need to show within those and the things that stack up to provide that said athleticism. One of the things that I want to share is just some of her return to performance accomplishments. When I say return to performance, we have this continuum along the process. And when you get into the mid to later stages, we go into this return to practice and then we go to a return to sport and then return to performance.
Return to practice is getting back used to the movements or even the positions, more of some controlled drills, non-contact into progressing into contact. And then there’s the return to sport where we are doing more actual game-type scenarios and increasing the intensity and the volume. And then we’re getting into the return to performance, which is actually a live match or competition or the event itself. And this is as we’ve used in the past, that slider scale or the dimmer switch to be able to progress through this continuum from a very controlled and closed environment to a very open and chaotic environment. And this is how we need to see this return to sport process and return to performance process which was a big focus for Stella. We had to expose her to a lot of volleyball positions as we were getting near the end of our return to sport and return phases.
Here are some of her accomplishments. She increased her thigh girth, so her muscle mass on the ACL side is actually 0.5 centimeters bigger than the ACL side. That’s either two things: one, her uninvolved side got smaller. Or, realistically based on our measurements, it didn’t get smaller. We actually got an increase in her thigh muscle mass by 0.5 centimeters on her ACL side, which is awesome. It is really difficult to be able to get an increased size after ACL injuries and surgeries. I know any of you listening are probably like my quad probably feels like a hot dog or looks like a hot dog. And I remember through both of mine, I felt like that. And it takes a long time to get that built back up. And Stella, she was able to get that to a point where her ACL side was bigger than her non-ACL side, which is a very big accomplishment.
And then let’s talk about some strengths. On her quadriceps for her knee extension, isometric peak torque, so essentially the LSI or the symmetry that we’re always aiming for is above 90. For my athletes, we’re always aiming for 95% to 100% or higher. We want to make sure that the ACL is at least within 95%, the ACL side, compared to the unoperated side in terms of strength and a lot of different measures. Luckily, that was the biggest thing where we had 101% symmetry. Her ACL side was slightly stronger than her uninvolved side. And I’m saying ACL side, we mean the involved side here.
And when we look at our hamstring strength, the peak torque was 98%. These are really great numbers. And it’s been awesome to see Stella progress with this in her strength, in her movements. And the other thing that you’ll commonly see is that if you look at symmetry, well, if you have one weak leg and then you compare it to another weak leg, then those numbers will be off. And so that’s why we always want to calculate the peak torque to body weight because that’ll be important as well. For her, on the involved side it was 3.04 and the uninvolved was 3.02. Our goal is to try to be above 2.5, typically for female athletes; usually, three is a very good number and we’re aiming for Newton-meters per kilogram of body weight. And so those are going to be measures that we try to track.
And this is one of the things that there is the luxury of having a handheld dynamometer to be able to test your strength. But the other pieces that we can still gather similar information is through simple like extension machine, curl machine, press machine, and other movements. These are only small pieces of the puzzle with Stella. We also looked at a bunch of other different measures. And I’m just highlighting this because it’s what should be provided, especially for any type of in-person-related work because it’s going to give us the objective numbers that we need.
And then looking at the drop jump RSI (reactive strength index) we just want to be above two here, and she was at a 2.3 and above. And then we look at the 505 tests. We look at the change of direction and deceleration ability, our ability to stop ourselves. And we look at something called the penultimate foot contact quality. And that means it’s the step right before you cut. And that’s going to give us some information on how our body moves, how we’re loading our knee, our quads, our entire body, and even our torso angle. These are all things we’re looking at, and we’re not necessarily telling the athlete: Hey, this is exactly how you need to do it. But we want to make sure that we coached this over time and that this shows through their different mechanics and movements. She really crushed it on this one to make sure that she’s not compensating with the unoperated side.
And then last but not least is measuring psychological readiness through the ACL RSI, which she got 90 out of 100. We just want above 77 to make sure that she’s good on this. Now, before we move forward with this, you might be wondering, am I doing everything that I can? I’m not doing any of this stuff. Or maybe you’re like, Ravi, you’re talking a lot of nonsense and I have no idea what any of this stuff is, then that’s okay. The thing that I’m saying here is that it’s going to be important to make sure that we’re getting measurements in these different physical areas of range of motion and strength and jumping ability and being able to cut and change direction. And there’s so many different ways to do it. And there’s a lot of ACL research that shows us ways we can objectively and reliably do this, which is very important, especially in this process due to the re-injury rates. While these values can be very helpful in these criteria, you don’t have to have all of them. And it’s all putting these different pieces of the puzzle together to make sure that we have tested the things that are important.
As I had mentioned earlier, we don’t necessarily have to have this dynamometer or this isokinetic Biodex machine. That stuff is not required, although it could be great to get us some true values. There’s so many athletes that we work with remotely who might not be from a geographic location and don’t have access to this. And so then we have to work within whatever our environment gives us. We’re still able to get our symmetry numbers, we’re still able to see strength numbers, and we’re still able to calculate a lot of these things via video. And then we break these down for a lot of our athletes and give them feedback, as well as letting them know, okay, here’s our next training block to make sure that we are working and closing the gap on some of these numbers that might not be where we want them. If you are going to in-person, I challenge you guys to just ask your PT or coach or whoever you’re working with, what are the things that we’re measuring and how are we doing it. And then if you’re working remotely, then hopefully that that stuff is also being checked and tested and worked on to make sure you’re getting the most out of your program.
Circling back to my girl, Stella, this process isn’t easy for anyone. And any of you guys going through it right now, I know you guys feel it. And there’s the ups and downs, the non-linearity of it. It’s a lot and it’s definitely not easy for someone who’s 13 years old where she literally just wants to run around, jump try out for volleyball, uh, soccer later this year. Stella had setbacks. There were setbacks in this process. She pushed too hard sometimes. Her knee got a little grumpy and there were even times when Stella had plateaued a little bit with some of the things we were working on. But we had to make sure that we pivoted, we had conversations and we were communicating to continue to make progress and get her to the end goal. And there were many times when I had to tell Stella that she wasn’t ready to do something she wanted to do. It was not easy conversations and communicating that to someone who’s 13 sometimes can be a little difficult. But we have a great relationship as well with her parents, and she has an incredible support system, which makes a massive difference in this recovery.
Since it is a 9 to 12-month process, it’s being able to make sure that there is a game plan, it’s agile. There is testing involved to make sure that we are being true to ourselves. And at the core and foundation of all of it is communication. That was the biggest thing. And even though Stella had some of these issues in this process, like many of you are currently, Stella did not let that phase her.
She kept fighting, she kept working hard and now she’s cleared to rock and roll. She can go and play volleyball, she can go and play soccer. And as a coach and as a physical therapist, and someone who is so obsessed with this process, especially ACL rehab, these are the moments that I live for. These are the moments that our team lives for. So go, Stella, I wanted to hop on here to share this with you all as a sense of encouragement to you. This 13-year-old ACL athlete who never gave up kept laying down each brick, brick by brick, and now she’s playing volleyball.
If you guys want to see a picture of Stella, then you can go to the link in the show notes. It’s on Instagram and it’s this ACL athlete’s graduation day, which is just phenomenal. And I hope that this encourages and motivates a lot of you out there, especially any of you who are maybe in a setback or feeling like there’s a plateau or maybe you’re near the end, but it still feels like it’s a long shot. And so I hope that this helps to bring some positivity to that and that you will get there as long as you have a good game plan and a good coach and PT to help guide you there.
That is going to be the main thing. And then you just put in the work, make sure that the program is agile, you’re testing. And that was one of the other big pieces today, which is to show that testing is important. And we didn’t blindly follow time in order to make sure Stella was there. We made sure that we had numbers, numbers specific to ACL, numbers specific to Stella, and numbers specific to getting her ready for volleyball and ready for life. And that’s what’s really important.
If any of you need some help, need some guidance, feel lost, not sure what your next steps are, then the door is always open. Please reach out to our team. You can reach out to me at firstname.lastname@example.org. That information is also in the show notes, so reach out. That will do it for today, guys. Stay tuned for the coming weeks. We’ve got a lot of exciting content coming out, especially related to the podcast and to the company as well. And we are super pumped to get it out to all of you, that way you can have better resources and better information to help guide you on your ACL journey. Until next time, this is your host, Ravi Patel, signing off.
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