I asked Evan to share about his clinical experience as a student with us earlier this year. He has since finished school and passed his boards! I hope this is informative for any students and new grads that are interested in ACL rehab. Everything below is written by Evan.
1. Don’t expect someone to be high level just because they are far out from their surgery
a. This was something that surprised me even after my first week of clinical. Upon talking to Wesley about his patient caseload, it seemed like the majority of patients, especially ACL patients were multiple months out. This could even be 5-6 months out of surgery and they already did rehab. Part of me wondered why they would now choose to switch to a cash-based setting that is more expensive. I figured that the rehab time would be spent doing really high level return to sport type of activity; reacting and cutting, live drills, single leg plyometrics and everything else that falls into this category. I was instantly surprised to find out that many of these patients were coming it at 6 months and did not even have some of the fundamental rehab goals met. Some were lacking extension, some lacking flexion, quadricep assymmetries, and even quad. inhibition. I couldn’t believe that someone who had been going to rehab for 6 months would be lacking any of these criteria. That was one of the moments when I realized just how important the cash-based setting was and that ACL rehab can drastically vary between clinicians.
2. The small details matter
a. Sometimes the small stuff is just something that clinicians like to argue about, little gimmicks here and there that they hold dearly. However, when it comes to ACL rehab the small details really do matter. Maybe they are able to squat and have progressed to a barbell back squat but you never bothered to notice that they won’t translate the affected knee anteriorly, potentially causing some pelvis rotation and improper mechanics. Left alone, sure, their quads might get stronger, but if ignored for long enough, it may become a movement pattern that affects everything else. I even saw situations like this impact every day activities such as going down stairs. The patient had issues simply because these small details were never evaluated. Even small things like proper quad contraction can be looked over. Sure, the patient can squat, but when they try to isolate the quadricep, is it a strong contraction to the other side? Is it equal? Did you feel it to see if its recruiting fully? These things could really change the plan of care when looked at thoroughly.
3. Fear is real, hard to overcome, and is a conversation we should all be having with our patients and athletes
a. How do you measure fear in a clinic? Does an ACL-RSI cover all of your bases or are you having these hard conversations with your patient? I learned that there are some deep seeded beliefs and fears that athletes have about returning to sport and exercise that may not ever come up unless you ask. No one necessarily wants to engage and start this topic but it is something that is so crucial to returning to play. I learned that navigating this with your athletes is absolutely critical, almost as much so as the physical aspect of recovery. It also helps to build trust between you and your patients. If you are able to know more about them, know what they are scared about, and help them overcome it, you can build lasting relationships with athletes.
4. Rehab HAS to be challenging
a. This topic kind of explains itself but was still something that I experienced on a first hand basis during my time at Healthy Baller. I will never forget one of the first evals I got to work with and them subjectively reporting at 7 months post op that they, “Had not used weights in rehab yet.” I think I went into a bout of a-fib upon hearing that sentence. I couldn’t believe it. These were athletes that were close to the return to sport timeline and they hadn’t been even remotely challenged in their rehab protocol. How would we ever expect them to return to the extreme challenge in a true sport scenario.
5. Expose your athletes to gameplay environments
a. When athletes are getting ready to get back to the playing field, it isn’t enough to just have them pass the objective criteria and send them out to their first game. We need to set up an environment where they can not only strengthen, but practice their sport in a controlled fashion. PT is one of the few places where you can have them do any sporting activity in an extremely controlled manner. Constraints can be put on the task at hand to make it easier, levels of difficulty can be increased beyond what they might see on the field. Exposing them to what they are going to have to do, and pushing beyond is critical to feel safe about them returning. Once they are out of your hands and at practice or games, as much as we want to try to “limit,” or “take it easy,” nothing is controllable.
6. Know your goals, communicate about the whole process and expectations
a. This one was one of my favorite things that I got to see in person. When someone came in for an eval, instead of just measuring objective orthopedic measures, we sat down and talked to our patients for sometimes a whole hour. Discussing back and forth what our goals and the patients goals were for therapy, how long it might take, how we would handle setbacks, and even setting expectations. ACL rehab is a long process. Setting guidelines and defining expectations on Day 1 can go a long way for starting to build a relationship with your patients. They need to know that this process could be up to a year, and it is going to be hard. However, helping them to understand the ins and outs of it all, and getting to the bottom of their concerns on the first day is the best starting point possible.
7. Stand your ground on return to sport and have a reason and an objective measure of why or why not your athlete can go back to playing
a. This is something that is hard as a student, and will continue to be hard to begin with as a new grad. Soon, I’ll be the one calling the shots and allowing or disallowing an athlete from practicing, playing, and everything in between. This is a scary thought at times. However, if there is one big takeaway that I learned from Wesley, it is that you have to have a reason behind your choices. Not only does this make your choice objectively verified, it makes it easier to explain and understand for the patient or family. Pick what you think is the most comprehensive and accurate testing for return to sport, and do not budge on it. If an athlete is at 86% and you want them to be at 90% or higher on your testing, is it close enough? That is something that you as a clinician has to wrestle with. No matter the decision there are always consequences, maybe you have to break it to your athlete that they will miss games, or a season if you don’t let them return. Or, if you return them anyway they could have a second injury occur. At which point not only did you potentially lose the trust of your patient, but you also have to deal with the mental stress knowing that they did not meet criteria and you let them go back anyway. Wesley taught me to test, retest, test again, and make sure that you are 100% confident. These measures also give you something to show coaches or parents if they question your judgement.
8. Make the most of your time and become friends with your athletes, they are there for a long time and it will fly by
a. ACL rehab is unique in that you may be spending 12 months of PT visits with a patient. This is a lot of time and something we should take advantage of. Not only does it make it more fun to build strong relationships with your patients, but it also helps them to trust you. Sadly, the 12 months will also go by very quickly. Taking time to get to know them as a person, form a connection, and get updates from them after they leave is something invaluable. There were many days at the clinic that a patient would come visit who had rehab with Wesley years ago. They just wanted to stop in, say hi, and show him how well they were doing. These are the moments that make our job as a PT worth every second.
9. Lastly, and most importantly is something I learned that I also want to put out as a challenge for anyone reading this:
There are a lot of people and clinicians who do ACL rehab wrong, strive to be one that does it right.