SHOP TALK - Episode 10: ACL Rehab

On today's episode, Tyler and Trevin meet over zoom to discuss Tyler's ACL rehab approach, clinic requirements for athletes, return to sport protocols and why it matters at that level. 

Transcript

SPEAKER_02 0:03

Welcome to SHOP Talk. I'm Trevin. And I'm Tyler. We are here to break down the latest trends in rehabilitation, strength, and conditioning all through the lens of evidence-based practice. Our goal is simple cut through the noise in the fitness industry and talk about what actually matters, why it works, and how you can apply it. On today's podcast, we will be discussing ACL rehabilitation and return to sport requirements for athletes.

SPEAKER_00 0:29

Sweet. How fun. So Trevin got to run the last episode. So I'm running this one, and this is kind of my wheelhouse in terms of rehabilitation. Also, for today, um, you know, we got the Zoom going, and then anyone who's just listening in, like on Apple Podcasts or anything like that, Trevin might sound a little bit different because he's at home in Pocatello. So we are doing a distant podcast setup for today. So, you know, we're gonna see how it goes.

SPEAKER_02 0:57

Yep. Feedback. Yeah, give us feedback, honestly. Yeah. If it sounds like shit, then we'll move on, but we'll figure it out.

SPEAKER_00 1:03

Yeah. I mean, dude, if it works, it works. Like the biggest thing is like, I understand your voice isn't gonna be as clear as if you were talking into the mic here, right? But I just don't want it to sound like you're calling me from like a prison or something. Like a prison for a while. Yeah, no kidding.

SPEAKER_01 1:18

So no, heck yeah.

SPEAKER_00 1:19

But um, so today I'm gonna talk about ACL rehabilitation, return to sport requirements, stuff, some stuff like that. But before I get started, I wanted to ask Trevin. This is a really random off the topic kind of question. What's the hardest exercise for you? One that you hate doing, one that you just don't enjoy, but like sometimes you're like, yeah, I understand the benefit. I still just gotta do it.

SPEAKER_02 1:44

This is actually just recent. So I was throwing in some accessory, new accessory work into my training program, and I hadn't done Bulgarian split squats or single leg RDLs in a really long time. So I'm trying to slowly incorporate some unilateral training. And so I was like, yeah, I haven't done this in a while. And so I was doing the the Bulgarian split squats. I only did two sets of 10 on each side. Dude, I was wrecked for days. Like I'm still wrecked. This was like a week ago.

SPEAKER_03 2:16

Nice.

SPEAKER_02 2:17

So you want to talk about like DOMS? I was getting it so bad. Um, so currently it's Bulgarian split squats to where now I'm almost like dreading having to do it again because I just only honestly could ship for a week because like my legs are so sore. That's so and I only I only did a couple sets, which it's kind of funny because that just goes to show like the like the use it or lose it of certain exercises when you're not super, I guess, specific to certain exercises and they're not recurring in your training program, and then you go back to them, how ridiculously sore it can make you. So yeah, but yeah.

SPEAKER_00 2:55

And that ties in pretty well with today's topic. That's actually kind of funny, like unilateral training strength each side, because when you start doing unilateral work and you've just been doing like barbell back squats, for example, for so long, and you go into this unilateral training mode, right? Or this block maybe where you're focusing on it, it really starts to show some deficits really, really quick. You're like, man, my balance doesn't feel as good, my strength doesn't feel as good, like on the left side versus the right, like the control just isn't the same. So yeah, that dies that I guess leads into the topic pretty well. Um going on to the next part here. Second question for you. All right, let's go. What have you heard about ACL rehab and return to sport? It's a super popular topic, especially when you're in football or any sort of you know impact sport, field sports, and tons of people talk about it. Like, oh, my family member or my teammate or my friend or even yourself, like whatever it might be. I just want to know if you've heard about people tearing their ACL and like how long their rehab took or anything like that. If you don't have an example, no worries. But I was just curious what you've heard.

SPEAKER_02 4:04

So the most experience that I have with, I would say, ACL injuries are probably just teammates around me. So I've never torn an ACL. I've I've strained my MCL really bad and took me out for a couple of weeks. But in terms of return to spore and ACL injuries as a whole, from what I know from the strength and conditioning side of things, is just that females tend to have a higher tendency to tear their ACLs than than males do. I don't know how accurate that is. It's just pretty common in the literature that I read. A lot of it has to do with like the cue angle, a female's hips, or like some sometimes I've read a few things that are like it's it's more neuromuscular, that there's some neuromuscular like deficiencies that females have that are causing these ACL injuries. So that's kind of my experience with it. I've seen teammates in the past that have like really slow ACL recoveries, and then I've also seen some that are really fast. And you also hear of the horror stories of people coming back way too soon and then retearing or prolonging their rehab because they're trying to come back way too soon. Yeah, absolutely. And one thing that I had actually brought up in one of my class uh discussions was in college, currently, a lot of these top-level athletes are getting paid now with these NIL deals. I am genuinely curious to see how many athletic trainers or PTs or team doctors, not that this is appropriate, but almost pushing people through this return to play faster because there's actual real money on the line now. I think previously we had a situation where athletes could just take a medical retrick if they got hurt and they could prolong their rehab and then actually come back to play in a healthy way. And now I think what can be scary is you have almost everybody's getting paid, and it almost think in a bad way is making athletes maybe push a little bit past pain and hiding it a little bit to shorten that time of of rehab so they can get back on the field and and play and make that money. So that's something that's I guess me personally that I've always thought was interesting with just how things are changing that might negatively impact something like an ACL rehab.

SPEAKER_00 6:23

Yeah. Well, from the very beginning, you were you were right on the money. So yes, females way more likely to tear their ACL, right? So, like female soccer players, holy crap, right? Part of that is because of anatomy, right? Wider hips, more narrow, like you know, actual cue angles. So absolutely correct on that front, but then also impact sports. Do you know what I mean? Like getting hit from the side or anything like that can absolutely increase that percentage or that likelihood of tearing your ACL. Um also, I like that you brought up that it might just be a neuromuscular control issue, right? Because there are some young athletes, male or female, right, that are just not very in tune with their body or the way that they move. And that can lead to injury really, really quick. So that's something that we focus on a lot with the rehab portion as well, is like getting that control back to where it was, if not a little bit better.

SPEAKER_02 7:14

So is that more like proprioceptive is like neuromuscular coordination? Is that really where that stems from? Yes, and just like uncord, yeah.

SPEAKER_00 7:23

Proprioception is interesting because yeah, you're totally right. Like you need to know where your body is in space and how to control that. But also it's just having the strength to be able to be in those positions as well. Like you automatically get more proprioception than everything else. People think it's this magical thing that I have to put you on a BOSU ball for your proprioception to get better. And it's like, no, let's do some sport movements, let's squat a little bit, and your proprioception will get better. Like it's just it comes with the territory of strength training as well. So it's not just this magical kind of territory of, oh, it's just proprioception. I have to put you on an Air X pad and have you balance on a single leg for a minute. It's like could be helpful, but most of the time that's not demanding enough. So we can dive deeper into that for sure. Um and then you brought up like NI NIL deals and everything like that. So I was kind of in that territory a little bit in Arizona for NAU. Um, and yeah, there are definitely some athletes that are like, nope, I'm good. I'm good, I'm good to go back, whatever. And you know what I mean? We have to take that at face value, and that's really scary because and that's why it's important that we test everything, right? Because they could be telling us one thing, but then demonstrating something completely different. And we have to say, listen, you're not ready. Like you're just gonna go out there and get hurt and prolong your rehab, like you said. Um so yeah, that's a scary, scary thing. And actually, the more I got into college athletics and treating college athletes, the more I was like, this is really fun. They're really high-level athletes, and the rehab just is very, very different. But it made me realize that I like high school athletes a lot more. Do you know what I mean? It's kind of shifted now where it used to be like pros are getting the money, right? And then the college is where they're striving to get there. Do you know what I mean? But now there's so many high school athletes striving to get to college because you can make money in college athletics now. And then pro, you know what I mean? Pros very unlikely that most athletes get there, but they can make it to college and make some money there, you know? So this whole shift that has happened in athletics, it's been really interesting to watch and how now high school athletes are basically prepping as if they're going to the pros instead of now just going to the college. Do you know what I mean? So that's a that's a big factor for sure. And it does play a role in return to sport and what athletes think they they can do or how fast they can return. So yeah, that's great. I'm glad that you have some background in that.

SPEAKER_02 9:48

Yeah. Um so what you had just said brought up a question for me. So you had just talked about how getting paid at the next level is becoming uh it's a pretty big thing. So for high school athletes competing, trying to get to that level. Are we seeing more specialized athletes, meaning kids that are picking one sport or another, maybe too early? So they're like, oh, I'm like, holy cow, at college, like I'm a 16-year-old kid, and in three to four years, I could be making money playing division one football. Do I now just specialize in playing one sport to improve my chances of getting to that level? Probably. And also, and you might know this because I don't I I feel like I've read some research on this, but the the injury rates in athletes that are specialized in like comparison to athletes that do multiple sports.

SPEAKER_00 10:38

Yep. Absolutely. So like if you are a one sport athlete, yep, your injury rate goes up, first of all. But then, dude, I don't think there's anything more beneficial for an athlete than being multi-sport, truly. Yeah, right. And and learning to move and be powerful in so many different positions versus like take, for example, just a baseball player. Baseball players are really good at swinging a bat, really good at throwing a ball, really good at pitching, whatever, right? But when it comes to then switching to, let's say, football, you have to be strong in so many different orientations than just swinging a bat, which is like very specialized, very skilled. Do you know what I mean? So they can still interact with each other though, and they help build each other because then it's like, okay, let's say that same athlete is playing like wide receiver. So then like hand-eye coordination and reaction time gets better because they've been playing baseball. So that will only help them in football, right? And then their resiliency and their toughness and everything that's built in football will help them in baseball when they're sliding into home plate or whatever. Do you know what I mean? So they kind of build off of each other. So yeah, I I think that we have definitely seen a shift in how soon athletes are specializing in just one thing because they're like, oh, I just got to focus on football so I can get a scholarship. But it's like, dude, you might be doing yourself a disservice actually stopping your other sports rather than, you know, doing all of those things to prep you when you make that jump to college.

SPEAKER_02 12:01

Yeah. Well, and we've talked about this over and over again of just the absurd amount of like speed and agility camps and strength and conditioning camps like during the summer that are very specific, or they are just done year-round, causing, you know, some overtraining effects and things like that. And honestly, increasing the rate of injury, not necessarily ACL injuries, but overuse injuries and kids, you know, experiencing burnout with certain things. So yeah, this whole the NIL deal thing is is super scary. I mean, I didn't get paid any money to play college ball, but I can see the the pull to want to specialize in a specific sport if I could go from making no money in high school to like holy cow, I can make thousands of millions of dollars just being really good at the college level. That's that's could be life-changing for some people, right? 100%.

SPEAKER_00 12:53

100%. And I never want to discourage anyone um who wants to just focus in on one sport, but it's like, yeah, make sure you're doing the proper things for injury prevention, making sure that you're well-rounded athlete, right? My favorite quote still to this day is that anyone in the gym watching you work out, right, should not know what sport you play. They should not know what sport you play. You should be well-rounded and be doing all these different kinds of lifts and plyos and jumps and everything like that. Maybe you one day you look like a track athlete, and then the other day you look like a football athlete. Like, people should not be able to tell what sport you play based on what you're doing in the gym. So that's a I really like that. That's a big thing.

SPEAKER_02 13:31

Yeah, I one of my professors said something very similar, and we were talking about hybrid athletes specifically. So basically combining strength and aerobic conditioning, right? And he's like, you know what we used to call that back in the day before social media? He's like an athlete.

SPEAKER_00 13:48

An athlete, yeah.

SPEAKER_02 13:49

Not like he's like an athlete. He's like an athlete is able to do multiple things really well. So that just goes very much in line with what you said. And I I love that they shouldn't know what sport you play. I mean, there's some intricacies, right? Like if you're playing uh an alactic sport, you probably should be going and running miles, right? Right. But yeah, no, I I love that thought.

SPEAKER_00 14:12

Yeah. So but in terms of like sprints that are beneficial for everyone, change of direction, and then like doing some quick plyos, and then like your strength training, I think, especially. No one should be able to tell what sport you play. Like, even if you are, this is the easiest one for me that I will keep coming back to track athlete in the gym. Their strength training should look almost like a football player. I am not kidding you. Like it should look almost the same as if you're a strong football player doing trap bar deadlifts, overhead press, like that kind of stuff, right? And I'm not saying every session needs to look like that because we know that runners oftentimes hate lifting weights, but it's so beneficial to just be diverse and same thing with the sport, right? Where it's like, okay, maybe you're not being a multi-sport athlete anymore, but in the gym, you should train that way. So anyway, just be diverse. It it only helps you in reducing injury.

SPEAKER_02 15:04

So no, I love that. I think that I think sometimes we over-specify things and forget that again, the weight room is just a tool to improve performance. Like the skills of the sport can be learned on the field, on the court, whatever. It's to me, and you see it a lot on social media with a lot of different strength coaches, is almost like overkill with the specificity, like the exercise prescription, like they're trying to come up with like the perfect exercise to mimic this different thing within the sport. Yeah, and then you just get this long list of exercises that you can do in the gym, and then people are like, holy cow, I don't even know where to start because there's all these crazy exercises with bosu balls and bands and random shit, like just weird stuff. Yeah, people are doing stuff with like a landmine and different angles and different stuff, and it's honestly confusing people. And I think if you can just find the biggest bang for the buck exercises in terms of building strength, speed, you know, cardiovascular endurance, and then just focus on your skill of the sport of practice, probably go a lot further than doing these super, super, super specific things.

SPEAKER_00 16:15

Not that specificity is bad, it has a time and place, has a time and place for sure, but but not every session, not every exercise.

SPEAKER_02 16:24

But yeah, I mean, I would argue because in terms of like linear periodization, right? So if you're getting closer to a sport, you get more specific. I used to think, oh, specific is like specificity in the weight room, meaning like I need to find exercises that are as close to what they're doing on the field. But now I'm looking at it as like, how about we just spend less time in the weight room and just more time doing the skill work on the field? Like, I'm just gonna give you balance, like I'm just gonna maintain your strength levels and your cardiovascular ability, and then just go do more skill work on the field. Instead of being like, Oh, I gotta come up with these crazy drills in the gym that are super specific. It's like, I'll just let the position coaches do that. Like, I'll just let them do that on the field. I'm just here to maintain certain levels of strength. Exactly. So people are overcomplicating things, yeah, and that drives me crazy. So well now, please take the floor.

SPEAKER_00 17:14

No, no, you're gonna I dude, we can talk about that for so long and how passionate we are specifically about like, man, athletes sometimes just need to ease off the skill stuff for a second, you know what I mean, and just get stronger. But anyway, now we can dive into something that's a little bit more niche. So yeah, the first point that I want to make with this topic of ACL reconstruction rehabilitation, okay? So ACLR. Oftentimes um ACL injuries, whether it's a full rupture um or meniscus is involved or MCL is involved, whatever, okay. It is so individual to the person or the athlete. Okay. So I'll continue to make this point as we go, but that's why I'm not going to dive extremely deep into this. I don't want someone listening to this and deciding, oh, I can do my own ACL rehab and think they can use this information information to get back to sport, I guess. There's a reason education is where it's at for physical therapists, athletic trainers, doctors, all of that. Because we help with the recovery process and every patient is so individually different that it really is a case-by-case basis with expected guidelines. So these expected guidelines, it's really funny because you talked about how some people rush back to it and some people might take longer than others, right? And that's totally normal based on the recovery process and what the sport is and how bad the injury was. Like I said, if it was like a partial rupture of ACL or full rupture, was meniscus involved, that changes timeline significantly, okay? So there are this there's this timeline of nine to twelve months for ACL rehab. Nine to twelve months. Anywhere in there, that's when the athlete should be getting back to whatever they're doing. I hate that. I hate that so much, right? I get it in terms of actual tissue recovery. Nine months usually is like the minimum. But that does not mean as soon as we hit that nine month mark, oh, I'm gonna get him back to running. Oh, I'm gonna get him back to change of direction. Like, absolutely not. And I want to make that so clear for everyone listening that that is why having a PT to monitor those things and compensations and restrictions and weaknesses is so important. Just because you hit a arbitrary timeline of nine months does not mean you are ready to go. Does not mean you are ready to go even in the slightest, okay? And and every patient's different. So maybe at nine months you're looking really good, right? So then that's where you can start to progress and start doing some running and some jogging and things like that. But it totally depends on the patient and how they're recovering, okay? Also comes down to the individual's process in terms of how well they're progressing range of motion, strength, muscle coordination, confidence, pain levels, healing times. Just because someone hits that mark does not mean they're gonna get get cleared by the PT or their physician to get back to sport. So I want to make that very, very clear. Um, and I'm sure I'll mention it again as we get going.

SPEAKER_01 20:31

So yeah.

SPEAKER_02 20:32

No, no, awesome. So I did have a question. So how much does prior strength and conditioning influence an athlete's ability to recover? Does that does that speed up recovery? Is it less? Does that maybe like does it help? Does it not help? I also am kind of thinking you have these high-level, high motivated athletes that have these ACL tears. Because we have a hard time overtraining in the gym. Does that also you see that as a PT in terms of you get a really motivated athlete and they're like, no, I want more prehab. Give me more prehab, give me more, like I want to get better faster. But then you kind of have to hold it back and be like, hey, like there's a time monkey here, like you can't speed up time. Right. And almost keeping them out of the gym doing prehab exercises because they're honestly wanting to overtrain with the prehab as well. So, first question, yeah, was does prior strength and conditioning, does it influence abilities, athletes' ability to recover? And do you have a hard time keeping athletes out of the gym even when it comes to pre-voltation?

SPEAKER_00 21:36

So you mentioned like prehab, prehab for like ACLR. Um that's that's hard because oftentimes they know that surgery is coming up and they're just like, well, I'm gonna lose all this anyways. That's really hard, actually, for most athletes. Um, it is beneficial, super beneficial to make sure the quads are very, very strong, as strong as we can get them. We can work on muscle coordination, all sorts of like actual functional movement patterns. Stuff that's really beneficial. But I like your question about prior strength and conditioning stuff. Or sorry, not strength and conditioning, just like strength background in general.

SPEAKER_02 22:11

Yeah. So like I tear my ACL tomorrow, but like then another homeboy over here tears his ACL and he just never exercises. He doesn't work out. Right. So is my ability to recover a lot better than his, or is it going to be close to the same?

SPEAKER_00 22:24

Dude, it totally depends because you could come out of surgery and be feeling really good and ACL is solid, whatever. But then within a week of rehab, your quad could have what we call artrogenic inhibition. So basically, from the surgery, whether it was like a bone patellar bone or a quadricept graft or a hamstring graft, your quad will want to shut down. And that's our first fight as a physical therapist is trying to get that muscle activation back in the quad. So I've seen it both ways, where someone really, really strong and has a background in strength training, their quad comes back quick because they know how to like activate that muscle and have that kind of connection with their body and be able to squeeze it. So that was really helpful. But still, it was weak. It is super, super weak because it's an inhibition actually by your brain, if that makes sense. So it doesn't really matter how strong your muscles are beforehand if your brain's saying, Nope, we're not moving that, right? So it doesn't really matter. It totally depends on how your body responds to the surgery and the weeks after, right? So it can be, but once again, it's case by case. And I hate this because it's very common in the PT field where we say, it depends. It totally depends because I could see you a week after and you could be like, no, my quad's feeling great. Like, look at what I can do. I can do a heel pop or whatever, like within four weeks. That's awesome. Okay. But then there's other people. I've seen some really, really strong football playing athletes, right? That could not get their quad to work, right? And it took months, right? For that quad to finally be like, okay, I remember what to do now, whether that's related to swelling or the actual cortical inhibition from the brain. So anyway, it does depend. I would say when it really starts to matter is later on in the rehab process. If somebody has a strength background and like they have lifted weights before, they've ran before, like all of those things, right? That is much more helpful in the later stages of rehab. Here's the thing, though, because you said homeboy over here who has maybe never lifted weights or whatever. Maybe all he's getting back to is walking at work, right? Because like maybe he slipped on ice or something and that's how he ruptured his ATL, which would be wild. But anyway, maybe that's all he's getting back to. So his timeline might look completely different for you if you're trying to get back to, let's say, train for a high rocks or something like that. That is completely different. So that changes timelines as well, right? So even though he might not have the muscle mass, he's never trained before, things like that. And he might have a really hard time in those first couple weeks, you got to realize we're not taking him to that same level. We're gonna try to get him to as, you know, the highest level he can possibly be. But for you, your level's a lot higher, being like a highly trained sport-specific athlete. So does that make sense?

SPEAKER_02 25:11

No, it does. So would that change necessarily the rehab process for you as a as a physical therapist? So like I know, for example, plymetrics are towards like the back end of rehabilitation, right? So let's say you have somebody that doesn't place force but is recreational, and you're like, okay, we don't have to get him to the level of like this high-level athlete over here, but would you still rehab them in a way, or rehab them in a way to where, for instance, like they have a kid, they want to chase after their kid, or they want to like jump in and out of their tailgate when they're unloading stuff from Home Depot. Like just normal day-to-day things. I I think there's implications for those things, right? When it comes to physical therapy in terms of the rehab process, right? Like you wouldn't give them less PT and be like, well, I'm gonna skip this plyometric and change of direction ability or whatever, because you don't ever do that. You're still gonna probably do that in in rehab, anyways, right? Because you never know what life's gonna bring. Like you rehab them for walking, but then they have to go, you know, chase after their kid that's running into the street or whatever.

SPEAKER_00 26:22

Exactly. So that that late stage. So let me, yeah, be very clear. Absolutely. I'll never cut anyone short just because, oh, you're not an athlete. You don't need this. That's crazy. That's absurd. Here at the physio shop, we are always trying to treat everyone like an athlete because regardless if you actually do play a sport or you're just a dad, once again, chasing kids, whatever, jumping in and out of the truck, anything like that. I've had an ACL patient before who was like a 67-year-old grandma, right? She fell out of her gardening bed, twisted her leg. That's how it happened, right? Do we think that she needs to be doing plyos in the gym? No, definitely not, right? Exactly. So that's where those levels are very different of like, I'm still gonna get her as strong, as mobile, and as confident as possible, but it still looks very different on where an athlete's return to sport level is. So that's why I wanted to talk about the athletic return to sport because it's just a it's a higher level, right? Most PTs, if not every PT, even right out of school, can rehab an ACL. Get the range of motion back, get the quad functioning again, get people walking, all of that, right? But there are levels to this. There are so many PTs in so many clinics that they claim, oh, I'm sport. I'm sport, I can, I can get you back to sport. And it's like, dude, and we'll dive more into this in a second, but I promise you it matters where you go to physical therapy. I promise you, it matters, right? If you get a referral from your surgeon, your your doc or whatever, and you walk in and you are a high-level athlete and it looks like an office with treatment tables. I'm sorry, that is a red flag. You should turn out immediately, right? If it is just fully carpeted and there's just treatment tables, oh my gosh, right? You are not in the right place. I get it. They can do most of the exercises and most of the drills and everything like that. But then what about like returning to the weight room for your sport? Once again, let's take the football athlete, right? Like a collegiate strength, or sorry, not a collegiate strength athlete, a collegiate football player that has to go back to the weight room and be barbell squatting and be doing like overhead pressing and all these other exercises that are just way more demanding than what you could do in a clinic that looks like an office, right? Yeah. So anyway, that's something that I will continue to preach because it does matter. It really does. So we'll dive more into that because there's specific equipment that should be necessary for proper ACL return to sport and everything like that, but just ACL rehab in general.

SPEAKER_01 29:02

So yeah.

SPEAKER_00 29:03

Anyway, um the next point I want to make is that there are hundreds, if not thousands, of guidelines for ACL rehab, and surgeons will often recommend specific guidelines based on their area of education or the most recent research, along with the PT. The PT should be helping decide that as well, right? Surgeons always have their preference. I get that. But guess what? Surgeons aren't the rehab specialists, they are the surgeon specialists, right? They have done their job inside the joint, making sure the patient is actually getting that hardware or that graft, and they do a really good job. But now it's my turn. I'm the rehab specialist, right? So another reason why I didn't want to dive into crazy depth is because PT should be in control, in control of monitoring these guidelines based on the protocol and progressing based on what the PT and the surgeon discussed, hopefully together as a team. That's ideal, right? I don't want to recommend a specific clinical practice guideline and have someone try to rehab everything based on those timelines. I already said that, but you know, just to reiterate, I think that's important. I want to provide education, but at the same time, it's a scary line to draw because people will often do anything to save time and money and be like, oh, I can do this myself. And that's that's scary because once again, there are things your PT is watching that you are not paying attention to if you're trying to just get strength back on your own, right? There are so many other things that we're watching for, like red flag signs and symptoms, um, any sort of swelling, any sort of restriction of the capsule, any sort of red flag of like, oh, you actually might have like a cyclops lesion inside that graph. Like that's really scary, right? Because then it's just gonna stiffen up and it's basically scar tissue and your knee won't bend, right? That's really scary. So that's why it's important to have a PT on your side and helping guide the ACL rehab. So Okay. Also, like biomechanical faults. I put that in here as well. Biomechanical faults, compensations. That usually comes, you know, after about a month or so when you're actually getting back into some strength movements, single leg movements, stuff like that, when you're out of the brace, um, you're away from any assistive device, anything like that. That's when we're watching for compensations, weaknesses, all of that. So Okay. Nice. The main reason I wanted to talk about this topic today and ACL specifically is because, first of all, very, very common injury for athletes and even just day-to-day people, right? But there are too many PTs that just follow timelines and then push the patient out the door. And this can be said with many injuries, but ACL is kind of scary, right? Because we need our knees for a lot of things. I've seen it time and time again where an athlete will come back to the physio shop. This was in Arizona specifically, because their first round of PT was not good enough or did not prep them for their sport. And they're like, hey, I'm just not confident in my leg. It still feels weak. I don't feel strong. I don't feel powerful, whatever it might be. But they hit the range of motion guidelines, they hit the strength metrics, but time-wise, they were still not prepared and even mentally probably not prepared. On top of this, this kind of dives into what we already talked about, but there are many clinics that just aren't suited for return to sport testing for ACL reconstruction. Whether it's a space issue that restricts the athlete athlete from running, bounding, jumping, change of direction drills, or plyometric testing. I've seen some wild settings for athletes in clinics that have no reason to be doing that kind of rehab, right? And I'm not just trying to talk shit, but it's like, let's let's help each other out, right? If if somebody wants to come to me for ACL rehab, right, I have the space, I have the equipment for it. That's amazing, right? But then if I have, let's say, I'll never turn anyone away, but like an elderly gentleman that just doesn't like the vibe of my gym because it's loud, I have music, uh, there's barbells dropping, all of that. Then it's like, okay, I'll refer you to a different clinic that's a little bit more slow paced, it's a little bit more chill, whatever, right? So it's like, let's help each other out so that everyone gets the best rehab they can possibly get, right? So um I will say this part. Sorry, last last part here. No, you're good, dude. It matters where you go to physical therapy for any injury because it requires specific equipment, space, and PTs that understand the demands of sport. That's a big one. That last one right there. Listen, I'm not saying that I was a high-level performer athlete. Like I played football in high school. There you go, right? And then I moved into powerlifting. So it's not like I understand what you're doing on the field as like a collegiate football player or on the track as a track athlete, sprinter, or anything like that. But I'm in that realm. I'm in that realm. I'm watching it. I am I don't know how else to say it. There's like scopes, you know what I mean? Where it's like there's neuro and there's some PTs that really like neuro, right? And that's their specific scope, right? Even though PT is all-encompassing of all sorts of different geriatric, pediatric, neuro, ortho, sport, whatever, it's like people can kind of fall into these categories of where they really like to be. And when you surround yourself with athletes and you understand the demand of sport, it's different than just walking into an orthopedic rehab place and they treat you the same because it's not the same. So it's really hard for me, but you just have to realize that some people understand where the next level goes to, if that makes sense. I don't know how else to explain it. And it's not like I'm just trying to toot my own horn, like, oh, I'm that guy. I understand sports, blah, blah, blah. But it's like, no, I understand how that weight feels when you're going back to your strength and conditioning program in the fall or whatever, right? Like I understand what you need to do because I've been around it. Part of that is my education at NAU, right? And then the physio shop was part of the NAU athletics program. So it was helping rehab, prehab, and maintenance with all these different athletes. So it's like I've trained and I've been around that area. I understand it, right? So there's just some PTs and other professionals, clinical professionals, that just don't understand the demands, which is hard because then they're like, oh, you're good to go, you're good to go. And they don't really understand what you're going back to.

SPEAKER_02 35:39

No, I love that you basically are making the point of specificity in terms of like the practitioner. And I can relate in a different way as it relates to like strength and conditioning, right? So you have personal trainers, you have strength and conditioning coaches, and then under each of those, everybody has like specific sports or individuals under those umbrellas that they specialize in, and they're really good at that one thing. And I imagine PTs are just like that, but to a whole nother extreme, right? Or you have, like you said, PTs that are great with the neural stuff. Um, you have maybe some PTs that are really good with training kids because they're just like they just have that personality that they're really good at getting along with like younger kids and and prehabbing or rehabbing them that way, or you have like the geriatric community where you might either love or hate, you know, rehabbing those kind of people, right? And there's there's so many different intricacies that I think of when it comes to like your profession, especially when it comes to like your specifics, like you're a power lifter, right? So there's gonna be some benefit to you being an electic anaerobic athlete in terms of getting those type of athletes back to sport because you've been there, you know what the sport requires. Right. Because if you were to like get on a certain kind of athlete that you knew nothing about, you'd probably still train them, but you'd probably go ask a different PT that maybe has more experience in that field, right?

SPEAKER_00 37:14

Exactly.

SPEAKER_02 37:15

Like you get like an endurance, like a major endurance athlete that's having certain issues that like maybe you've never seen before, you might refer to somebody else, or maybe try to get information from another DPT that knows a lot about endurance sports in terms of the rehabilitation process. So I just think I love that you brought that up because there's just you're really good at what you do, and it takes a great deal of specificity to train the kind of people or rehab the kind of people that you're trying to target, right?

SPEAKER_00 37:44

Absolutely. And here's the part that's really hard about this. I love all PTs, PT school is hard, I get it. But guess what? They are trying to make you a general practitioner, okay? And be able to be well-rounded and well-versed in all sorts of areas of physical therapy, okay? But I'll tell you what, if somebody came for me or to me in my clinic for pediatric therapy, absolutely not. I'm not going to take that on thinking that, oh, I'm the best PT, I can treat anything, right? That is not my area of expertise, right? So that's when I would refer to another therapist. And they should do the same thing. If somebody walks into a pediatric office, let's just say this is a crazy example, but and they're like, oh, I need ACL rehab. That pediatric PT should refer to me, right? Because that's how we have kind of, I guess, followed our own little trail after PT school. Cause then you can start to specialize in things, right? So my specialty is sport and ortho. So I love anything related to that. And don't get me wrong, I have a good background in, of course, soft tissue stuff, joint mobilization and manipulation, and then also neuro. Neuro, I got really good background because of Valerie Carter at NAU. Shout out Val. Crazy, but she's amazing. She's super smart and just incredible. Anyway, so a lot of like neurointensive clinics and stuff like that. But guess what? My specialty is still sport and ortho because that's all the research that I do. Those are the patients that I see, and that's the realm that I'm in personally, right? So, yeah, absolutely. I think you nailed it. It's like I'm not gonna try to take on somebody, I don't know. Let's say vestibular rehab. Vestibular rehab is very, very intricate. I can treat the basic stuff, right? Um, BPPV, I can do that, no problem, right? Positional testing, no problem. I got a really good background in that. But if it is like ongoing stuff that is like cerebral or cerebrum kind of involvement, and it's like, oh, it's not just positional, you know, issues and nystagmus that's ongoing. It's like, okay, I'm not the pro at this. I'm going to refer to an ENT. I'm gonna refer to a PT that is just well-versed and has the right equipment to monitor eye movement and all that stuff, right? So it gets deeper and deeper. It's just hard because PTs are told that they're well-rounded and they can treat so many different people and so many different things. But it's like when you get down to it, the nitty-gritty stuff, it's like it really does matter what your background is in. It does. So, um, yeah.

SPEAKER_02 40:23

It makes me kind of think of no, just like the ethics of being a PT, and I we've talked about gatekeeping a lot. And instead of competing with other PTs, it's more of like working together to give out the best product to everybody, right? So I mean, in a perfect world, you would say, like, okay, well, I have a bunch of PT friends that are really good at specific things, and I can refer people to them when they're dealing with the patient that came to me that I don't really want to touch that. But then on the on the flip side, like you said, you have another PT that's like, oh nope, that's Tyler. He's really good at that. I'm gonna like refer you to them. Like, that's a perfect world. But I imagine, unfortunately, just because PT is a business, then a lot of people might be taking on too many clients or patients, or almost too much, they're biting off more than they can handle because they they want the business, right? Like, can you like elaborate on that? Because I don't know, but I just imagine when it comes to the you have the real world like perfect scenario, everyone's just putting out the best service for the individual, but we kind of know how things are, and there's a competition side of it, there's a business side of it, there's like an ethical component to this that kind of makes me curious. I love it. And it probably frustrates you or maybe other PTs when they see them rehabbing an athlete that is just they're doing it in the wrong way or too fast or too slow, or you know, you know, you tell me about that.

SPEAKER_00 41:55

Absolutely. In an ideal world, right, everyone would just have their own little specialty and be able to refer to all these different places and these other PTs, right? Yeah. But that's a serious issue. And once again, PTs and and PT clinics have to make a living, right? And don't get me wrong, they are still helping people regardless, right? But when you are talking about athletes and that type of rehab and that, and you're trying to get them back to such an intense sport, it's like there's levels to this, man. There really are. And that's why it matters where you go to physical therapy. I'm not just trying to put down other clinics and say, oh, you you can't do that or you're doing that wrong. It's like, no, let's do what's best for the patient, right? And oftentimes it doesn't work like that. It really doesn't, right? A patient will get the referral from their surgeon and they're gonna go to the closest PT clinic to their house because that's what's easiest, right? But here's the thing, that's why I'm trying to make it a very extreme and well-known point that it does matter where you go to physical therapy. It really does, okay? Whether it's equipment, whether it's the PT's background, whatever it might be, right? It does matter. Go somewhere that fits you and fits where what your goals are. Okay. That's huge. But you're right. PTs will just be like, oh, no, no, no, I can do that. I can do that. I'm a PT, right? Like I have my I have my certification. I have I passed my boards, like I know how to treat this patient. Yes and no. You're probably gonna get their range of motion back, you'll get their strength back, right? But do you know what it's like? Like, oh, do you know what it's like? I don't know, running routes on the field and then getting tackled. No, you don't. So then it's like it's really hard for me to be like, are you giving them the best rehab and the best chance at returning to their sport at full capacity as possible? It's really hard for me. But yeah, we have to do what we can in this broken medical model of the US, if that makes sense.

SPEAKER_02 43:50

Well, yeah, I no, I I totally get that. So to kind of double down on that question, so just to bring it back to ACLs, so what And you can go into as much depth as you'd like to, but what does like the basic basic ACL rehab process look like for you in terms of the methods that you are using? And then what is separating you as a PT in regards to the methods that you're choosing to use and the environment that you create as a practitioner?

SPEAKER_00 44:19

Yeah, that's huge. That's a very deep question. So let me start first by doing this clinic-wise. That's different. The setup is different, right? Sure. Early on, soft tissue work and lymphatic drainage and getting swelling out of the joint, that's important. And that can be done anywhere. Okay. Here's the thing though. When you're trying to treat an athlete that is getting back to sport, you need a few things. And this is seen time and time again in some of the best rehab for the best athletes, right? And it's not like I'm just trying to copy and paste whatever because it's based on the individual. But every clinic that thinks that they can take on athletes for ACLR or like rehab, they need a BFR unit, right? For early strength training, but it's basically just body weight and fatigue and everything like that. So BFR unit, dry needling certifications for trying to get that quad to activate. So dry needling the quad, hooking it up to STEM. So then that way we can do some like not only just trying to get that muscle to chill a little bit, but also help with the contraction of that muscle when you hook it up to STEM. So handheld dynamometer that can also be set up for isomess isometric strength testing or a biodex machine. Those are like $35,000 pieces of equipment. So I don't have that here, right, for biodex testing. However, I do have a handheld dynamometer, and there's great ways to test it. Either way, okay. Weights and gym equipment that suits the athlete and their sport requirements. Space to run, jump, change direction, plyo bar, plyo boxes, barbells, and turf. Okay. So that's already like environmental, what's what's different than just like an office setting type of PT. Okay. Those things should be almost a necessity for ACL rehab, honestly, especially early on. But then you brought up like what is my process, right? My process totally depends on the patient and how they're responding to that treatment. Okay. We talked about how there are clinical practice guidelines, like zero to four weeks, this is where you should be. Four to eight weeks, this is where you should be, blah, blah, blah. But it's like, dude, we have to do what we see on the table and with that person. Okay. Biggest thing for me is making the patient comfortable and making the patient know that, hey, this is a low spot, but we are going to build back up slowly. And it's going to be really, it's going to be painful for them. Not painful physically, but mentally, because they just want to go and they're like, man, my knee feels good. Can I just walk on it? Can I just run on it? Whatever. And I have to be the person that's like, not yet. Trust the process. If you're trying to get back to sport and you want to be confident in this leg, you need to make sure that we are, we need to make sure, I guess is the easier way to say that. We need to make sure that we're doing all the steps properly so that you can actually trust that leg when you get back to sport. Okay. So it's a big deal for me when I'm going to do it. It's a big deal when athletes trust me with their rehab. Right? Because it's a big deal. That's a huge injury. ACL, maybe meniscus is involved. Medial meniscus is torn too. So that had to be, you know, minisectomy or repaired or anything like that. And then maybe MCL too. Like that's a huge injury. They're going to be out of sport for probably a full year, right? So, first of all, having an environment that's welcoming, friendly, I'm friendly, I'm happy, regardless of what's going on in their life. And I try to push them in a way that they feel comfortable and once again build that confidence. Okay. And every PT should be doing that. Like, I'm not saying, like, oh, I'm the best, blah, blah, blah. But it's like, that's how I set the athlete up for success into these next phases. Okay. Don't get me wrong. Any PT can look up these clinical practice guidelines and follow these steps, right? But it's it's a mental game too. It's a mental game on how you approach those athletes because it's huge. That is such an important factor in their recovery and how well they recover too. And if they hate PT, they're not going to want to be as consistent, right? So that's another thing. And then I forgot the back half of your question. You said, like, what do I do PT wise? How is it different? Everything like that. What was the back half?

SPEAKER_02 48:34

So I think really I would just like to know and just give you an opportunity to explain how you're getting buy-in from these athletes because of the environment that you created. Because that is a skill. Learning how to coach these athletes is a skill, how to be empathetic to their injury, that is a skill. So you're almost creating an environment that they're excited to be in, especially in a situation that isn't ideal. You're bringing in these athletes that are dealing with an injury, whether it's high school, college, or professional level, these have huge impacts on their life, right? And I'm assuming those are things that you have to consider when you're training them. So when you're bringing these athletes in that are probably already down in the dumps, they have to sit and practice all day, watch their friends practice, watch their friends play games, watch their friends win games. They're not a part of it. Like there's definitely a mental health component to that as well. So how do you, as a PT, create a more uplifting environment or an environment that makes them feel like they are progressing and that they aren't just following this, you know, I don't know, like, oh, I gotta do this stupid PT because you know, somebody told me to, in opposed to where you're creating an environment where athletes are almost excited to come in, or it's just giving them a little bit of a spark to get back to sport, and opposed to just being in this kind of like nursing home atmosphere where it's just kind of like blah. You know what I mean?

SPEAKER_00 50:02

And that's a big, big reason I started the clinic as I did and like the gym setting, because that's huge. When you, even though you're not part of it, but you can see people who are in every other area of their life, maybe older folks, maybe, maybe somebody who's in their 30s, whatever, right? And you're a young high school kid, you get to watch all these other people lift weights out here in the gym, and that's really encouraging. That's awesome. That's a really uplifting and good environment to be in, rather than a bunch of people on 10 different treatment tables in a clinic, and you walk in, you're like, wow, I'm I'm getting the same treatment as these 10 other people right now on a treatment table, right? That sucks. Next thing, for me personally, this is huge. Celebrate the small wins. Okay. Nothing is bigger for an athlete than even though it's not like, oh, you just won the state championship, right? Because those are huge wins, right? But the small stuff with PT, that is so important. Okay. If we can get that leg straight, huge win. Absolutely huge win, right? If we can get their strength back, huge win, right? Within 95%, and that's late stage. If we can get their strength back in their quads, huge win. And then, like, let's think early on, let's say their their range of motion is now at 110 compared to the other side that's 135. It's like celebrating, oh my gosh, you're past 90 degrees. That's amazing. Like you're doing so good. Encouraging the athlete that they are winning and they are progressing. It's slow and it's mentally exhausting because the athlete's like, oh my gosh, PT is so freaking boring, right? But once again, environment matters, community matters, and the way the PT approaches that patient with empathy and sympathy as well. But also just having an uplifting spirit for those athletes. That's that's huge. And I think that's what I bring to the table more than anything, because man, I don't even know how to say it because I haven't torn an ACL, right? But I've seen how these athletes can get down in the dumps mentally. And it is, it's really hard for them. It's very hard. So I don't know. I don't know. I hope that answers your question because it's not like, oh, my place is magical. Come see me. I'm magical, right? Like blah, blah, blah. No, no, I'm gonna get your leg better and we're gonna celebrate the small wins so that you know that you're actually making progress where it matters.

SPEAKER_02 52:21

No, I like that. I just the way I think of it is there is just a lot more environmental factors that come into play than just the rehabilitation procedures that you talked about. Like, okay, this is these are the steps, we're gonna follow them, then we're gonna kick you out the door and kind of good luck. I just think coming from like a former athlete perspective, or even now if I'm a tear in ACL, the type of environment that I would want to be in in terms of rehabilitation would be more uplifting, celebrating the small wins and getting almost like a group of people behind me that that are supportive, because you're probably not gonna get that support anywhere else. Because I I think back to some of the more minor injuries that I had when I played college ball. Um I got third-degree strain ankle that put me out for three or four weeks as a freshman. And then I told you I trained my MCL, my senior year. So I missed the first like four games of the season, which I spent all summer training going into my senior year, team captain. Like I just had run my fastest 40-year dash. Like, you have all this hype going into the season, and now it's just basically cut out from under you, and it's literally the next mana mentality. I'm standing on the sideline, like I'm on crutches, nobody's asking me how I'm doing. I'm going to the athletic trainers, and they're doing this pre, like, you know, at the time was, in my opinion, lazy pre-hab work. And they didn't care because they were just collecting a paycheck. And so, from my experience, I I didn't have a good environment around me that was really pushing me to get excited about the process that I was in. And it almost just enhanced the really shitty situation that I was in. Right. Because no one's no one's kind of you know gathered around the injured person. It really is the next man up.

unknown 54:17

Yeah.

SPEAKER_02 54:17

And so one thing that I've noticed with you as a PT in the environment that you create is it is it is somewhere where athletes can come in and they actually feel like they have a team behind them supporting them, getting them back to where they need to be, and opposed to just they're just another, you know, patient to the door. It's like, yeah, yeah, let's just collect the insurance money, send them on their way, whatever. Good luck, dude. I don't really care. Where what real like athletes really need is a huge support system, even more so when they're injured than they do when they're successful on the field. Yeah.

SPEAKER_00 54:49

So I and I appreciate that. And I will say right now, I will fight tooth and nail for any patient that walks through my door and trusts me with their rehab, right? Yeah. Regardless of what that means. Whether it's, oh, we need to push for an MRI. We need to push for that, push for that, push for that, and fight against insurance. We need more visits. We need to push for that, push for that. Or patients have approached me and they're like, listen, I can't afford this right now. Guess what? I'm gonna work with you, right? I'm going to work with you because you came to me to trust me and get better, right? I understand money's tight. And for a lot of people, that's a huge restricting factor for physical therapy. And it's like, no, that's not how it should be. So, yes, I understand I have a business to run. I got to keep the lights on. I have so much that I need to worry about business-wise. But man, it's so much more important to me that people are successful in my clinic and that they get wins in my clinic because it builds everyone else up around them. If that makes sense. It's it's not just like this individual type of thing. It it's community, truly. And I try to build that here. And I think that's super important. So I appreciate that. Um, because like I said, I'll fight for for any athlete, any patient, any person that comes to me for rehab. That's that's my job. So Yeah.

SPEAKER_02 56:08

No, that's great.

SPEAKER_00 56:09

Um, a couple other things. Oh, I said this already, but if you're an athlete and you walk into your referred physical therapy practice and it's a fucking office with 10 treatment tables, guess what? You're in the wrong place. You're in the wrong place, okay? It's so true. It's so true. So, some things to consider when going to the best clinic or clinician for your ACL rehab. Um, regardless of how good somebody is, right? And how good or um I guess fancy their place is, PT is still a controlled environment. It is not a chaotic kind of situation like game time, right? No matter how hard we try, it's not the same intensity as sport. This is why specific guidelines and progressions are important because we cannot simulate game time situations in a clinic no matter how good we are. We talked last episode about how quick game time movements are and how fast athletes have to react. And oftentimes we can't do that in rehab, right? We we can try our absolute hardest to make it chaotic and especially late stage, we want to make it reactive and quick and fast and explosive and all of those things. But it's like, guess what? Once it's game time, that's a different level, right? So that's why us as PTs need to be doing everything possible to prep that athlete and prep that leg, that knee, that shoulder, whatever, in order to get back to their sport so that they feel ready, they feel confident, they're not babying their leg. Because guess what? If you get back to your sport and you start babying that, it's just gonna lead to other issues either on the other side or that same side. That's a huge, huge issue. And that's why I never want to rush somebody back to sport. So this is a whole kind of wraparound conversation here, but I never want to rush anyone back to sport, even if they are hitting those specific strength goals, range of motion goals, whatever, because it's like I want to make sure you as a person are ready for it, right? Because if you start babying that thing out there, guess what? You're gonna be held back, you're gonna be trying to run a little bit different, you're gonna be trying to cut a little bit different, and then maybe it could lead to an awkward tackle, something like that. I've seen it happen before. So it's like we just got to make sure that you are physically and mentally prepared to get back on the field.

SPEAKER_02 58:24

I love that. So, in terms of what you just said, you talked about there, there's definitely some freak accidents that happen on the field that you really can't prevent in terms of causing an ACL tear. What are things that athletes can do, especially girls, right? Women, because we discussed how they're more prone to ACL tears. What can we do within the weight room to better prepare these athletes for situations where there's a difference between tearing the ACL and not? Like, so what are some methods or training, you know, ideas, I guess, that these people could use that are listening to almost prevent these injuries? Not that you can prevent every scenario, but what are some preventative measures that we can take, right? Like specifically for females, right?

SPEAKER_00 59:15

I love it. I love it. And biggest thing, if somebody comes to me for that kind of stuff and like injury prevention kind of stuff, first of all, depends on the athlete. Okay. Depends on what I see, where their weaknesses are, where their compensations are. Totally depends. However, I can say this you need to get strong as shit. There you go, right? Hamstrings need to be super, super strong. Proximal hip musculature needs to be really, really strong. That helps with knee control in terms of cutting, stopping, everything like that, right? And then doing drills that help simulate sport as best as possible, right? You're never gonna get to that level of intensity and and reaction time, but do stuff that's close so you can work on that control. That's why I still like skill work. Skill work's important. I get it. But guess what? In terms of injury prevention, you want to know what's way more important, being resilient and strong. So get your ass in the weight room. If you want to actually be not injury prone, what's the best way to say that? Resilient is the best way to say that, right? Resilience, yeah. And and build that up as much as you can in the weight room. Be strong. Build every single muscle that you possibly can think of. Glutes are important, hamstrings are important, especially for ACL stuff. But single leg work, we talked about unilateral work, right? Making sure you're strong on both sides. Here's a really, really quick tidbit. Oftentimes in the NFL, one of the most common injuries is a hamstring strain, right? And then athletes come back and guess what? They strain it again, and then they go back and they strain it again, and it's ongoing, ongoing for basically their whole career. Um, I forget what school did this, but it's because they were basically sending them back to sport or back to game time, and their hamstring strength was like 66% of the other side. It was absolutely unbelievable. It was a whole study. I'll try to find it because it was actually really interesting. So now there's actual protocols in place to make sure we are getting at least 90 to 100% equal strength on each side. Because guess what? If that muscle is weaker on that side, you're gonna hurt it again. There you go, right? Because you're gonna demand as much as you can out of your body. And it it happens. It happens. Like you said, sometimes you can't prevent it. You're out there, you're sprinting, you're tackling, you're jumping, whatever. We need to make sure your body is as resilient as possible.

SPEAKER_02 1:01:27

So, for females, like let's say you get girls in the gym that have a really wide cue angle. Does that change how you would prepare them for sport? Not like would you do more glutamade stuff, or are you doing more like deceleration stuff for females, um, teaching them how to absorb force better? Because you hear it all the time. Oh, they're glutamides weak, they're glut mead's weak. So we do a bunch of like, you know, abductor exercises. Like, is that actually true, or is there more to that?

SPEAKER_00 1:01:59

It can be helpful for sure. It can be helpful. But guess what? If your athlete is like D cell D cell and they have a slight knee valgus, right? But they are still in control of that movement and they are quick and they're explosive and everything, that's not something I'm gonna try to change. That is not something I'm gonna try to change. You should see some of the most well-known athletes in the world, I think, immediately to some of these basketball players. And when you see them jump, their knee goes into Valgus, right? Your adductors are really, really strong. So it's not like it's a bad thing, but if we can control that position and be strong in that position, that's more important than me trying to correct it and be like, nope, your knee needs to be on the outside. You have to keep pressure out here. Because what happens when I've been correcting it, let's say for months and months and months, but then they go to game time and now all of a sudden they're actually playing at their 100% capacity and they go to stop and turn or whatever, and their leg goes into Vis, their knee's not used to being there anymore. Their knee's not strong in that position anymore, right? Because I've been trying to train it out of that valgus position for so long. So then that could lead to an injury too. So yeah, I want to make sure that they are strong in any position that they are comfortable in, if that makes sense. Right. No, so that's why, like with my volleyball player that I've been treating, dude, amazing athlete. She can jump so high. But I'm not trying to change what her legs are doing during this jump. I'm just trying to make her stronger and more explosive, more powerful through the ground, right? Of course, I give little cues of like, nope, you need to reach your arms up. We need to be quicker through the feet, things like that. But I'm not like, oh, hey, keep in mind where your knees are, like everything like that. There's no way. There's no way. Because when it comes game time, they're not going to be able to control that. Yeah. So yeah, it's a good question. Cause oftentimes if you see knee valgus, that's a it's a scary position. If you see it with a female athlete, it's scary, right? That's how ACL, meniscus injuries, MCLs, that's how that happens. I get that. But if you're strong in that position and it's not excessive, I think is the most important part. And that's how their body naturally moves, keep it that way and get strong in that position.

SPEAKER_02 1:04:06

Gotcha. So and like if you were evaluating a female on like a like a depth jump, like jump off a box and land, if their ability to decelerate from a high box is really well, but there's a little bit of knee valgus, you wouldn't be super concerned about it. But if they dropped off and their D cell was shitty and they had knee valgus, then you could maybe say, like, maybe there's some like glue mead there or just lack of eccentric strength. Like they just need to get stronger. Exactly. They'd be better at decelerating their body weight. Exactly.

SPEAKER_00 1:04:37

And if it's not excessive, like I said, if it's so freaking excessive and that knee is just like all the way in there, then I would be like, okay, we need we can work on that, right? But if it's minor, even moderate sometimes and it's well controlled, it's not something that I'm worried about.

SPEAKER_02 1:04:52

So, in terms of testing and eval, in terms of like you as a strength and conditioning coach, how would you evaluate somebody's potential for injury before it happens? And how would you address it personally? Specifically, specifically for the ACL, right? Because that's what the our topic is today.

SPEAKER_00 1:05:14

Yeah. Um, looking at things that you've already mentioned actually is huge, right? E-centric control and what their body is doing on a single leg and jumping, plyos, change of direction, all of those things are things that I look at at an eval. If somebody comes to me and they're like, hey, I'm an athlete, I'm in the offseason, I just want to do some injury prevention and strength and conditioning stuff. So anyway, it's hard. Um, because I thought you were going to talk about like, oh, ACL evaluation. And that's pretty easy because it's like, okay, you had ACL reconstruction. I know what's going on, right? We assess range of motion, and that's about it. So anyway. Um, but yeah, in terms of injury prevention, there's a lot that goes into it, and every athlete's gonna be a little bit different, but like. Like I said, basically seeing what their fundamental movement patterns look like. So when I say that, like squat, hinge, all of those things, right? Basic movement patterns, what do those look like? And then what does their single leg control look like? What does their jumping look like? And my favorite one is like a tall box jump and just landing, right? Death jump. So that's that's an awesome one to screen for basically all athletes. And then doing an even smaller jump off of a box and landing single leg and seeing what that looks like comparatively, side to side. Because everyone has a dominant side, right? So it's like if we can match those as much as possible, that's huge. Um, and then what was the second part of the question? Because that's like eval-wise, depends on the athlete, but anyway.

SPEAKER_02 1:06:43

Yeah, so depending on a sport, for let's say you're evaluating somebody and they might have some discrepancies and something that you want to address, how much time would you spend in a strength and conditioning program addressing those things with, for instance, accessory work, or how many of those things can just be addressed by foundational movement patterns and just building general strike?

SPEAKER_00 1:07:07

A lot of those things can be targeted with just foundational movement patterns. Absolutely. Okay. But if an athlete really does, let's take your example again with extreme knee valgus, and that's something that I am worried about if it is to an excessive point. And I'm like, well, listen, she's a soccer player, she needs to control that a little bit better, right? That's when I would be hitting accessory work every time I see them three times a week, right? And doing a few drills, a few exercises every single time. It wouldn't just be something that I just tack on at the end. I would make sure that it's actually part of the program and something that we are progressing so that when we do like a progress note or kind of like a checkup, we can see, okay, is that actually improving?

SPEAKER_02 1:07:47

Yeah. And that makes me think of just the importance of having a good strength and condition coach or PT to catch those things during a training session. So let's say you are training somebody that you know has some extreme knee vogus or some discrepancies. Well, that's gonna affect basically a lot of the primary movement patterns, right? They're squatting and hinging with knee valgus. You got to be able to catch that and then cue them to, hey, drive your knees out. Hey, your knees are caving in. Whatever cue you want to use with whatever exercise they're doing, you need to be there to catch them doing it. Um, if you're sending this kid off and saying, hey, just go do this program and these are the accessories that I want you to do, well, they might be hitting the accessory work, but their technique is still shit when they're doing, you know, primary exercises or they're sprinting or they're doing plymetrics, or they're maybe doing advanced plymetrics that they're not even ready for because they do have such ridiculous knee vogus or whatever. Yeah.

SPEAKER_00 1:08:49

So yeah, no, it's huge. And it's it's part of the process with strength and conditioning for like younger athletes that are just trying to be more resilient and less injury prone. It's it's a big thing. And I wish that I could spend the whole session sometimes just doing like prehab stuff, you know what I mean, or preventative work. But guess what? What's even more beneficial sometimes than doing specific, very, you know, isolated hip uh glute mead exercises would be doing something like a barbell back squat and being like, okay, where are these weaknesses? And then after that, taking them to a single leg and doing very basic hip hinge single leg exercises and seeing what that looks like. Like so as much as I want to be like, oh, yep, these are the specific exercises that I would do for this person or whatever, it's like I kind of have to see what's happening first and go off of that and build from there. And it's a mix between foundational movement patterns, right? Squat, hinge, all of that, and then also that individual isometric, not isometric isolation work to those muscles. So I don't know. It gets deep, dude. It really does. It gets deep really, really quick, and it can get messy. That's what's really hard with me right now, and trying to find this line between, okay, the PT side of things, rehab, prehab, all of that, and like paying attention to pain levels and all that, and then personal training and strength and conditioning stuff. Because sometimes with strength and conditioning stuff, hey, I don't care. We just need to get the work done, right? Your squat is in the allowable range. It's not absolutely perfect 100%, but it's in that allowable range where we can start pushing weight. So it's like, let's just get it done. So for me, it's like I'm torn back and forth because I can't spend every session with my personal training clients trying to perfect these movements and stuff like I would for physical therapy.

SPEAKER_02 1:10:42

Yeah. No, I I think the biggest point, and I say it all the time, is it's just keep it simple, stupid. It's it's so funny when you look at injury prevention or building performance. It really doesn't take a whole lot of complexity, you know, to get better.

unknown 1:11:00

Yeah.

SPEAKER_02 1:11:00

But like you said, I'm not going to do these, all these crazy individual glute meat exercises or accessory work. Like we don't have all the time in the day to train. And athletes are even worse because they're super busy. And even just normal adults don't have the time to do a ton of accessory work. So finding the biggest bang for your buck exercises, squat, deadlifts, bench press, things like that that help prevent injury just by improving overall general strength. Like it just can't be said enough of just keeping it simple. And it just drives me nuts how much extreme, again, specificity you see out there.

SPEAKER_00 1:11:37

Yeah. Because sometimes it's not necessary. Like sometimes it's just like, listen, I'm not worried about your knee valgus. It's like you're in a good range, I'm comfortable with it, you have good control. So we're gonna focus on your strength. We're gonna build strength because that's gonna be more bet beneficial than me trying to make these very, very small changes with these very specific muscles in these specific orientations that when it comes game time, that shit doesn't matter, right? What matters is you being strong and resilient in every sort of position. That's what's more important.

SPEAKER_01 1:12:05

So yeah, nice. Yeah.

SPEAKER_00 1:12:08

Oh, yeah. It's crazy, dude. I don't know. I don't know. And then I think the last thing that I was gonna say is in if anyone's interested in a good clinical practice guideline, um the Ohio State University um from Wexner Medical Center.

SPEAKER_03 1:12:24

Ohio, dude, let's go.

SPEAKER_00 1:12:25

Yeah, they they have a really good post-ACLR um kind of protocol. By all means, you guys can take a look at this. You cannot, it doesn't matter because your PT might have something a little bit more updated. It might be a little bit more um specific to your injury because once again, it matters if there's other tissues involved. But this one is really good and it's really good for return to sport. So down at the very bottom, criteria to return to sport. I'll go through these really quick. Full range of motion, pain-free, uh, symmetrical with uninvolved limb, isokinetic testing, 90% or greater for hamstring and quad at 60 degrees per second and 300 degrees per second. Effusion, no reactive effusion with sport-specific activity, greater or equal to plus one. Weight bearing, normalized gait and jogging mechanics, neuromuscular control needs to be appropriate mechanics and force attenuation strategies with high level agility, plyometrics, and high impact movements. Functional hop testing, this gets a little crazy and out of control. I think I'll make this my last point here in a second. Um, 90% or greater for all tests. And then, of course, PT and physician clearance. So um functional hop testing, man. I might punch a hole through a wall because there are so many PTs that make their patients do this, these random jumping drills that are not beneficial at all. It's it's it's really weird. There are specific ones like the triple single leg hop, the 360 jump, the um 180 jump turns, and what's uh what else? Oh, there's like the I can't remember the specific name. It's the one where you're hopping from side to side over a line, but you go for a time basically. Anyway, there are ones that I would do absolutely because it's important to make sure that they can jump and turn and twist and land and control, right? And make sure each side is equal, at least in terms of height and speed, reaction time, whatever. But the some of the stuff I see on Instagram, I'm like, what are they doing? That's not like a actual, I don't know, not approved. What am I what am I trying to think of here? Like a uh research-backed jumping progression. Like that is not necessary in any way. So I get really frustrated when PTs start just making their clients do all sorts of weird jumping shit that doesn't make sense because it's like, no, there's actual protocols that have these jumping proto or these jumping progressions. So anyway, that's that's what I like is the Ohio State University one. You guys can go take a look at that. If you have any questions, let me know. Um, but yeah, it has all sorts of agility and plyometric progressions and suggested interventions and whatnot. Once again, consult your PT or your physician before doing any of this.

SPEAKER_01 1:15:14

So yeah.

SPEAKER_02 1:15:16

That's great, dude.

SPEAKER_00 1:15:17

Yeah, but that is it. That's it on my end.

SPEAKER_02 1:15:19

So it's a lot of info, man. That's good. I did have one last question. How much like cross-education do you see towards like the later end of rehab? Right? So like training one, like let's say this person just tore their ACL and they can't obviously train that leg super hard. Well, if I'm doing single leg strength work on the opposing limb, how much cross education are you seeing on the other limb that is not being trained because of the ACL injury? So, like, let's talk about like your just your quad muscle mass, right? So guys say I'm just doing leg extensions on my left leg, my uninjured leg. How much cross education are you seeing into the right leg? Or is that even a thing with ACL injuries?

SPEAKER_00 1:16:04

Absolutely. That's something that I focus a lot on too, especially early on, is like let's say I have them long sitting on a table or something or on the ground and their leg is over a foam roller. I'm not just gonna make them try to extend the involved side. I'm gonna make them do it at the same time because our brain really does function that way, right? Cross-training is so important. Same thing with like shoulders too, right? If they can't do overhead stuff on this side and it's like, let's say post op and they're still in a sling or whatever, dude, I am training that other side as much as I can because that is so, so helpful in the rehab process. It's not something that I can visually see and put a note and say, oh, his cross-training has helped 60% in whatever. You know what I mean? Yeah, it's more so something that has just been shown throughout time that is helpful, this cross-training, because your brain responds really well to that, right? Because if you can work the quad on one side, it wants to work it on the other side too. Even though it might not be able to at the moment, it's helpful for sure. Yeah, I love that. That's actually a really good topic. So I didn't even mention that today, but very helpful.

SPEAKER_02 1:17:08

Yeah, I was just kind of curious. So we see a lot of that just in the strength and conditioning literature, like the cross-education of one limb to the other, and even just for like minor injuries, maybe not like surgically involved injuries, but just like strains and sprains and things like that. That, you know, uh, I can't train on this, you know, ankle, knee, shoulder, whatever for a couple weeks. Well, I can still do single arm stuff with limited atrophy of the other limb just because of the cross-education effect.

SPEAKER_00 1:17:35

So I love it, dude. No, that's cool. It's so, so helpful. And it's so interesting the way our brains work like that. So I love that. I love that stuff. I do it, I do that all the time. So I'm really glad you brought that up, actually. It's yeah, it's very helpful. Um, and also doing it with like BFR early on, too, is really helpful. So putting BFR on both sides and making them do because, like, sure, anyone could put a cuff on the involved side and then just try to do quad extension, quad extension, hit straight leg lift, whatever, right? But as soon as you involve that other side, yeah, dude, it's so, so helpful because it's still challenging for that other side, and your brain takes that into consideration. Now it's hard on both sides, not oh, this one's really, really strong and you know, able, and then this one's not, right? If it's challenging on both sides, that's even more beneficial.

SPEAKER_01 1:18:22

Yeah, that's sweet, dude. Yeah, yeah. Well, yeah, that's that's all I got, question wise, dude. That was sweet.

SPEAKER_00 1:18:28

Cool. Well, if anyone has questions on any guidelines or rehab processes with ACLRs, let me know. Reach out over Instagram or send me a DM. Come into the physio shop, ask questions, whatever. But otherwise, that's it. So yeah. Hell yeah. Thanks for uh hopping on Zoom today.

SPEAKER_01 1:18:49

Hell yeah, dude. It's great. That's good stuff.

SPEAKER_00 1:18:51

Okay, well, we will see everyone else on Monday. Thanks, everyone.

SPEAKER_01 1:18:57

Sweet.