Episode 89 | How Often Should ACLers Get Tested?

What is up team? Getting right into the episode today: How Often Should ACLers Get Tested? This is a great question, and it will look very different based on the athlete and their specific situation. You might be sitting at post-op, maybe pre-op in that prehab phase, or maybe you are a few months out or even a few years out. And this might look a little different based on your specific context. But this will all be dependent on the timing of the ACL injury, the surgery, or maybe the non-operative part of where you’re at concomitant injuries.

Other things that had happened, like a meniscus tear or MCL tear, or maybe a bone bruising or a fracture. All those things play into it. The graft type, meniscus repairs, post-op complications, phase of rehab, access to equipment, of course, etc. Lots of factors, and that’s not even all of them. With that said, we do have some general rules we follow here at the ACL Athlete with our team and with our athletes.

First, I think it’s important to break down why testing is important. This gives value to its implementation and the planning for it. And we’re not short of any reasons: re-injury rates, return to sports numbers, and even long-term health outcomes. We know that these have been studied in the research based on specific numbers and our performance in our rehab, especially as we come through their process towards the end. And what do those numbers stand up against versus the gold standard? More practically speaking here, it gives us qualitative information. The things that we see that doesn’t necessarily have a number associated. 

Let’s say, for example, a squat shift, unless you have really cool technology or force plates, you can’t always track that. Or let’s say a change of direction task where you’re doing a 180-degree turn and we’re analyzing that via video. Well, we can give qualitative feedback on that to better complete positions that we’re looking for versus compensating. And then there’s the quantitative or the objective numbers side to things that are really the things that keep us honest in this process.

And the two phrases that you’ll commonly hear are, if you’re not testing, you’re guessing. And what gets measured gets managed. Both basically saying the same thing: test. It’s very important, especially for ACL rehab. But could you imagine going to school and never getting tested? It sounds pretty sweet. But how do you know how you actually measure up to the material and anyone else’s measurement of the material, the competency in that certain area? Having those right prerequisites to enter a certain major or a certain field. I surely know that I want the surgeon I’m working with or the physical therapist or the strength coach or whoever it is that we’re working with, to have passed said number of tests and qualifications to be able to take care of me, to help guide me in this process.

The other analogy you’ll hear is the driver’s license. And that is typically here in the U.S., here in Georgia. You have to be 16 in order to drive by yourself. As a side note, I actually failed my learner’s permit, so the year before that. When you turn 15, you can get your learner’s permit. This means you can drive with a parent or an adult. And you’re able to drive around with them to gain that experience and practice. Well, guess what? I showed up for my learner’s permit test and I failed it. And that is because I didn’t study, I thought I was going to be able to wing it and pass it, and I didn’t. And that was super embarrassing, but it showed the level of incompetency that I did not have, or I was incompetent and I had to study, go back, and pass it, and it showed my level of competence. I got experience progressively in that learner’s permit year. Had to do some education training which most people have to do here, in order to get to the final test at 16. Where you have to go and drive around with a proctor and pass the test. But 16 years of age or 15 years of age automatically doesn’t mean that you’re able to drive or drive with your parents. You still have to pass a test. It shows a certain level of competency and prerequisite skills to do the task. I’d rather be in a parking lot with 116-year-old who have passed the test driving versus 116-year-old who have never passed the test. Because I don’t know if they really have the competency or prerequisites. This is just something as an example for you guys to help anchor down the importance of testing and periodically testing in this process. 

For us here at the ACL Athlete testing is related to our return-to-performance and return-to-sport criteria. And each person has their own needs analysis. Basically, what are the needs for the goals they have set that is going to be different for a basketball player versus a skier versus someone who just wants to run around with their kids or maybe be able to play pickleball? That’s all going to be different. And each individual athlete needs to make sure that they meet those demands. And what we do is we make sure we plan for that, and then we know what those demands are for that specific activity or sport. And then we’re going to reverse engineer that for each of our athletes based on where they’re at, where they need to be, and creating a phase-by-phase approach with specific criteria and with specific prerequisites to move forward. Not moving too fast, not moving too slow. And this is going to inform our next phase or our next training block and the planning for it. And when I say phase and block, think about phases, maybe a two to three-month type time span. And then blocks are a specific four to six weeks of training within that. And there are goals focused on each of those. And each of our athletes goes through a lot of these different blocks and phases individualized to them based on their goal. Building them up and making sure that the testing is helping us to give information about what to program specifically for them.

And so let’s say you’re at four months post-op, hoping to run. But your knee is at only 40% symmetry, let’s say your quad strength is 40% symmetry. Guess what? You can try running, but you just don’t have the strength to do it. This means your program is going to be geared towards getting that symmetry up to ideally 70% to 80%. But we wouldn’t know that if we didn’t test though. This is the main problem with relying on time versus criteria. Protocols are usually based on time, and that is the thing that can get people into trouble, especially if a physical therapist or coach is operating based on that. People usually don’t recover in the ” normal” timeline due to so many of those factors we mentioned earlier, as well as the ACL process in general.

Now, you’ll hear testing, and if you’re on Instagram, you’ll hear a bunch of ACL-related people say you need to test, don’t kick into a hand, and make sure that there’s an actual, reliable, and valid strength testing done. Sometimes that can feel pretty vague. Let’s break this down into some different testing buckets, if you will. There’s clinical testing, there’s patient-reported outcome measures testing like the ACL RSI, there’s functional assessments and testing. 

Let’s say something like a Y-balance or even a quadruped rockback. They’re just different things that you’re looking at functionally, but you’re not really trying to gain too much from a strength standpoint. Can you just axe those positions? Capacity testing, strength testing, and other performance testing like reactive strength, elastic strength, change of direction, ability, speed testing. There’s so many different forms of testing within this space, and the one that you’ll hear the most is strength testing. What is that peak force or how much can that muscle put out, especially one side versus the other? These different buckets will have different levels of priority and importance depending on where the athlete is in the ACL rehab process and their goals. 

Another thing that will massively impact testing will be depending on the equipment you have and the time you have available. The most common question I get is for strength testing. Here’s my advice for strength testing. Let’s assume whatever method you use, whether it’s an isokinetic machine, a handheld dynamometer, force plates, or one to five, repetition maxes. That’s what you’ll use throughout. If you can get access to an isokinetic or handheld dynamometer, that’s 100% the way to go if possible. Isokinetics is the gold standard. The next one that’ll do is going to be a handheld dynamometer where you kick into it, but it doesn’t move. I know that not all people have access to this type of equipment or places with these testing devices. But I would highly suggest at a bare minimum, some sort of isolated knee strength measure, even if that’s a knee extension and a leg curl. That’s going to be key compared to just assuming that your strength is there based on feeling or kicking into your PT’s hand which is not a measure of strength.

Let’s say an athlete is in pre-op or prehab, we measure the uninjured side as soon as possible post-ACL injury before any strength diminishes, to get a solid uninvolved limb baseline. If not, during prehab because a lot of patients will not go into their PT until post-op, let’s see if we can get a baseline on the unoperated side or uninvolved side, week one post-op. What happens often in this process is after the injury or after surgery, your activity level decreases. This will inevitably make your uninvolved side weaker if you are not keeping up with the strength levels that you need. And so that’s why getting it before it can get to that point of getting weaker is going to be important. Getting that baseline as soon after injury or after post-op is going to be key. 

Now, let’s say you’re post-op or maybe you’re taking the non-operative approach, these principles will stay relatively the same for you. It might be a little faster if you’re on the non-operative route. But let’s just assume for this case that we’re going to talk about ACL post-op. Isometric or isokinetic baseline testing around four to eight weeks after surgery, and then can be assessed either way every four to six weeks. Sometimes we push that off to the first 8 to 12 weeks, depending on the client and how their knee is progressing in the early stages. Maybe there is an irritable knee or maybe there have been some complications, maybe non-weightbearing. So there’s no sense in necessarily pushing peak forces at that timeframe early because they didn’t have as much of an advantage compared to someone who was weight-bearing or had a smooth first four to eight weeks. 

This testing will inform rehab and the training interventions, depending of course on how the athlete is progressing in the early phases. Your program and training and how you move should give a good insight into where an athlete is at. How you’re doing? Any of our remote athletes or any of our in-person athletes, we know how they’re doing overall just based on what they’re doing in the program, the different weights they’re doing, the different movements. We have a relatively good idea. The testing itself helps anchor it for us more objectively, especially from a peak four standpoint. If we’re kicking into a handheld dynamometer or if we’re doing an isokinetic test, that’s going to give us the most precise measure versus something like a leg press. But that will still give us information and help us to assess where the athlete is. 

The other thing to note here is that you want to make sure you give it enough time between the true testing to give your body time to show physiological changes. And what we mean by that is not just this quick increase in strength, we want true structural changes. Let’s say, for example, hypertrophy, increasing the size of your muscle fibers takes some time. So that’s why maybe doing it every four to six weeks can help to be able to provide enough time for those changes. It doesn’t mean you have to stick to that. But if you test every single week, one, that’s an opportunity cost and how much changing are you going to do with that? And also give your body some time to truly change. Because we know it can take anywhere from four to eight weeks structurally and physiologically. You might be thinking this is easier for people who are in-person with their physical therapists, with their coach.

What about remote athletes you work with? This is a really solid question. A lot of these principles stay the same. The cadence, the information, the program, everything that we’re implementing. The big thing is going to be equipment and access is important. We will refer a lot of athletes to go and get isokinetic testing nearby or isometric testing at a nearby clinic as well. There are plenty of clinicians and a lot of major cities. And even smaller cities are jumping on getting some sort of device, like a 10 deck or a crane scale or something like that, in order to at least get some type of measurement that is going to help us get an objective measure. So we’ll refer people out to those types of locations in order to do that.

And then let’s say someone is limited in resources. That might be a clinic nearby that really does that type of testing, maybe it’s a different country where they don’t do any type of testing like that or are familiar with the machines, then we got to make sure we can measure strength in some capacity. This might be where we implement the gym-based equipment and do a one to five-repetition max to see how we’re doing. We might be doing the isolated work of a single-leg leg press, one side to the other, a double-leg leg press, and squatting-based movements. And then we definitely are trying to hit single-leg knee extensions and single-leg leg curls to isolate the hamstrings and isolate the quadriceps. Those are going to be key in order to try and gain some sort of measure of strength within those different muscle groups. 

And one side note here, many of our athletes sometimes have no idea we’re testing, when in fact their programming for that day or for that week might be intentionally built to test on our end. We’re doing this behind the scenes to see their output, but it might just look like a normal programming and training week for them. And that might be building up to heavier repetition maxes, like a three-repetition max on a single-leg knee extension, and going to failure to help anchor the weight and the reps at the end of the block. Some of you who are listening to our remote ACL athlete or maybe in-person, and you’re like, oh, this makes a lot of sense. Yep, that’s what we do. So when you see that stuff, not always, but we have a rhyme and a reason to why we’re doing this. This would give us insight into how each side is doing, as well as inform our programming for the next training block.

It does not always have to be a structured strength test or a strength testing day or a week. Although, if it’s available to do some strength testing with the isokinetic dynamometer, or you could do it with a handheld dynamometer, that’s money. Because we can’t get more accurate than those measures. From a simplicity point of view, you can look at this as a test, and analyze the testing. We’re going to let that inform our programming for the next four to six weeks as well as some of the long-term. And then guess what? We’re going to test again, we’re going to analyze, we’re going to program, and we’re going to repeat that process. And this is all while we’re communicating with each and every one of our athletes to know how they’re doing, how’s the program going, how they’re feeling, and their confidence levels. All of this plays into the testing, the analyzing, and the programming, to make sure that we can get them to that end goal. 

Some recommendations I have for you. Going off the same thought, each individual session is technically a test, even if you don’t intentionally plan it to be. There’s always a qualitative and quantitative assessment to be made from any session, remote or in-person, from the weight chosen to how the movements were executed. This is feedback to help adjust future sessions. This is not an excuse to not test consistently. But any good coach uses their sessions as insight for future progressions and planning. Some other thoughts here as well. If you’re testing or being tested, but that isn’t changing the program you’re doing or how you are programming it, then honestly there’s not really much point with the testing. It’s good to have that information, but if it is not informing the program or the trajectory of what you’re working towards, then the testing is just data and it’s just information, but it’s not being put to use. So that is something to just consider. 

Sometimes we gather testing and information and don’t implement after. As I mentioned before, your testing is going to inform your programming and especially let you know what is the low-hanging fruit, the biggest gaps, the biggest deficits, impairments, and we’re going to make sure to plug those in that are inhibiting you or preventing you from getting to those goals. If you are testing, but the setup and directions are not consistent, then that can be dangerous. Because that’s going to give you some pretty big fluctuations in the data, then that could potentially inform poor programming. You might be chasing certain things that you don’t need to chase. 

And this ties into my last point, which is if you’re testing with certain equipment or methods that are not valid and not reliable, or have not been proven in the research, then this honestly might be the most dangerous place to be in. And let me break this down more specifically. To have numbers that might be an over or an underestimated number for a specific metric. Let’s say for quad strength, you think that you are strong and that you’re at 90% symmetry, but you’re actually realistically only at 40. That’s not a good place to be in because you have a false security or a false sense of being stronger than you actually are. And the example that we use commonly in this space is the MMT (the manual muscle test). So that is where you are sitting on a table, knee bent at 90 degrees, a PT, or a coach, or your surgeon is going to put their hand at your ankle, put the hand on the top of your thigh, and you’re going to kick into it. They’re going to ask you to kick into it. And a lot of times the response, and this depends on what their belief is, but they think that’s measuring your strength. And they’ll say, oh, your knee is strong, your quad is strong. When in reality, you’re just kicking out against your own hand. So that is no comparison to strength. It’s just can that muscle turn on or not? That’s basically it. And that was the whole point of MMTs is to basically say, is the muscle active? And that’s all that it really provides. Outside of that, not very much. 

But let’s run with this for a second. Let’s say that you are at a nine-month check-in with your PT or your surgeon. You kick into their hand and they say, your knee is good. You’re cleared. You could go play pickleball, or you could go play soccer, ski, whatever it is. And they based it just based on that testing of kicking into their hand. And you think that you are strong, you’re capable, you’re confident. But this may be only relative to the rehab that you’re doing, as well as just your day-to-day function. You’re not feeling pain. You could do all your daily tasks. But what about that specific activity? How does that go? How does that feel? 

Well, let’s say you go give it a whirl. Let’s say skiing, you go and do it. You’ve had this sense of like, all right, I’ve been cleared, but there’s been no objective testing related to that. And you get on your skis and you go and something happens. You had this sense of feeling like your knee was good, that your quad was good. And honestly, this comes back to the professionals you’re working with at the end of the day. And they should have had a better sense of giving you objective testing. But if that was not given and it was based on a false test of an MMT, then that’s that false sense of confidence, you’re strong. And therefore you go to do an activity that is going to stress your knee where you need that strength. That’s where I want to hit this point home here is that, if the tests are not made to actually test strength, so we’re looking at isokinetic strength testing, a handheld dynamometer, a force plate, something that is going to be able to test a one to five repetition max and isolate that specific muscle, then you’re not really going to get a strength or a force measure. So that is why we have to be very careful with that false sense of thinking a test, is providing the information when in reality it is not. 

In review, how often should ACLers get tested? It’s going to depend, but overall, try to hit it at your pre-op or prehab or week post-op. And then if possible, you can get that done every four to six weeks. Not always the case, but that is the sequence that we go through. And if you’re working with a good ACL physical therapist, a good strength coach, then they will be able to help you out and be able to know, okay, here is our main focus for this specific block, and here are the things that are going to help us measure that. And we’re going to make sure that we test periodically, in order to make sure we’re meeting the specific goals of that phase.

Let’s say, for example, is to get you to run. Well, you should have certain KPIs there and benchmarks like 70% to 80% of quad strength and symmetry, maybe it’s to get the quiet knee, maybe it’s to get a certain capacity level for your calf muscles and your quads and your hamstrings and glutes. There are a lot of different measures that people will use, but it’s important to have those to work backwards from. And if you are someone who is kind of stuck in this, looking for someone for testing, or maybe your physical therapist or coach is like, no, we don’t need that, or maybe they are doing the MMT, then this is something that you want to question and if it is not working out, then it is time to pivot. Go back and listen to my previous episode, episode 88: Should you fire your pt? Maybe that is the case or maybe you have to pivot or have a conversation. But it’s going to be important to make sure testing is a part of the arsenal and that is happening periodically. And that it is informing your program in order to get you to the short and long-term goals you have set for your ACL rehab. 

And lastly, and most importantly, you hit these specific benchmarks via testing and hitting these criteria to make sure that you pass the return-to-sport testing, can do your set activity, said sport and are meeting the demands of that. And that is going to be what’s most crucial. And if we circle back all the way to the beginning of why the testing is important, it’s to make sure that you don’t face a re-injury, that you can get back to the things you love to do, pickleball, soccer, sport, whatever it is. And also the long-term health outcomes, whether that’s osteoarthritis, daily functional tasks, or just for the long-term health of the knee, of that joint, and of your body.

Also, if you are an ACLer going through this process, if you’re feeling lost or if you’re like, I don’t know anything about this testing stuff and my PT or my surgeon’s doing the MMT, basically doing all the things I had mentioned that you don’t want to do, then just reach out. We’ll be happy to point you in the right direction, making sure you have good care. We don’t even care if it’s with us. It could be with anybody, local, remote, whatever it is. Just get into good hands to make sure you can make the most of this process, and become a better athlete. At the end of the day, get back to what you want to be doing. That’s going to be it for today, gang.

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