CEU: Early Phase ACL Rehabilitation: From Injury to Early Post-Op - 193

Hey, this is Sandy. And Randy? And we're here on at Corner. Being an Athi trainer comes with ups and downs, and we're here to showcase it all. Join us as we share our world in sports medicine. Welcome back to another episode of At Corner. This week we have another Education episode and we're going to be staying in the knee talk about the other cruise ship ligament, the ACL. Yeah. So last week we did PCL and this week we're bringing you another CU episode, 2 CU episodes in the row.

I don't think we've ever done that before. Dude, we're just cranking them out. Just cranking them. I don't know how you're reading that fast. It's been good, it's been fun. How many? How many references do you have for this one? I think this one's only like specifically for this one is probably like maybe like 10 or 12, but like a lot of this stuff like I've read in the past. So like, I've already had them, I already had them read, so there weren't a ton that I had to add in.

That's nice, yeah. It was pretty cool. Sweet. Well, if you are interested in those Cus, make sure you check the show notes for the most updated links and instructions on how to redeem your Cus. Also, we have a tutorial on our Instagram page at AT Corner Podcast, so make sure you check that out. Thank you so much to Clinically Pressed and Athletic Training Chat for hosting these seas. So what are? We talking about Randy? Yes. So for this ACL education episode, we're really going to

be focusing on the early part. So we're talking about time of injury to the like early stages of post op. So it's such a small window because like ACL, like you could talk countless hours over the entire process and stuff like that. So. I think there are some conferences that are specifically for ACL. Yes, right. So there's there's a lot of content that can be covered.

So we're going to break this down into kind of smaller window and like and like you were saying, there's a lot of content on here. So this is like really a brief snapshot of even that. So it's kind of getting getting the ball rolling just a little bit. So as with any pathology, going to describe the anatomy, anatomy relevant to the ACL, which should be pretty quick.

We'll discuss the evaluation process of a suspected ACL entry, which by the way might surprise you, just saying, just putting out the teaser out there. And then we're going to discuss the rehabilitation concepts to treat a patient with ACL pathology pre op and early post op. Sweet. Let's get to it. Let's start with the anatomy.

So similar to the PCL, the ACL is made-up of two bundles, right? This time it's just a little bit reverse because obviously this is traveling a different direction. You have the antromedial and the antromedial bundle, which maintains its tension pretty much throughout knee flexion, right? So as the knee starts to bend, right, it's maintaining most of its tension. Whereas the posterolateral bundle has more tension in that knee extension, right?

So it's going to become less taut as you bend the knee. All right, What I did find that was interesting was the PCL is actually a stronger ligament than the ACL. I don't know why that's just ACL gets a lot of publicity. So you think like it should be pretty strong, but I mean, I guess that's why there's an issue with it, but.

Really I kind of am not too surprised by that 'cause I feel like even though the PCL doesn't get injured as much, as far as the mechanism like falling on the knee, I feel like non contact is with that being enough to tear an ACL. It must not be that. Strong of a that's true. Yeah, that's true. But yeah, so I don't know why it just anytime I hear that just it's so surprising to me.

Just like when we did the ankle 1 the ATFL is actually a pretty weak ligament, which again explains why that ligament fails so often on inversion anxious. But I don't know, it just seems surprising to me. Just 'cause it has a big name doesn't mean it's all that's wrong. Yeah, that's that's very true. That's very true. Notorious. Yes. Did you say Sartorius? No, I said. Notorious. OK, notorious. I mean sartorius. You just agreed with me when I said. Sartorius, which could work.

I mean, that's a great name, first of all. It's a great muscle. It is a great muscle and a great word, great name. So we are not talking about the sartorius in this episode, unfortunately for everybody. So that's kind of like the anatomical orientation of the ACL. Essentially everyone kind of understands the basic premise of the ACL, right? It protects from anterior translation of the tibia, right.

I feel like that's everyone kind of knows that there are some, there is the Rotary protection as well. So the ACL does protect against internal rotation of the tibia, but let's not forget the protection against posterior translation of the femur. Yes, that might be important later as we start talking about special tests and why. Tibia, posterior force of the femur. Yes, right. So don't forget that that does

play a role, right? I mean, it it, you know, has an origin and an insertion and it can have an effect on both sides. So, so, yeah, keep that in mind, as with other ligaments in the body, right? They're not the only stabilizers of a joint, right? Our muscles do have a big role in protecting our joints as well. All right. So again, I feel like it's like everyone kind of has an idea behind it. And, you know, the hamstrings all together protect against that anterior tibial

translation. But I think what we also have to remember is, you know, at certain knee angles, the hamstrings may actually have a Rotary component as well to the knee, right? So in particular, if we were trying to counteract that internal rotation of the tibia, biceps femoris, right, you know, inserts onto the fibular head, right? So that could actually help us like externally rotate that knee or externally rotate that tibia, possibly taking some pressure off the ACL.

So as we start thinking about kind of like rehab stuff, hey, that biceps femoris may be a pretty important hamstring muscle that we kind of want to focus on as well. Two things about this one thing is that it this is when I learned this. It was so surprising to me that hamstring graft used to be so popular. Yeah, I'm not a fan of that. Because I feel like knowing that the hamstrings and where they attach help prevent anterior translation of the tibia and they're so important in ACL

rehab. Why are we? I know, I know. It's not like there's the hamstrings are big and they're, they have a lot of fibers and we're just taking like a piece, right? And relatively small, like a relatively small piece. Right. But I still feel like it's it just never made sense to me why 'cause you do have pain on that hamstring, which then I'm thinking motor pattern. Now does this athlete patient, whoever it is, are they less

likely to fire their hamstrings? Which then if you look at actual if you look at a dance research, the dancers are actually and especially ballerinas are less likely to tear their AC LS because they activate their hamstring quicker in landing. Nice, that's cool. Like that motor pattern?

Yeah, that's cool. I wonder if they if if they'd break it down into which muscles like if biceps Morris also fired more because the because the external rotation that's I don't even know if they did look at that. That's just me. It's been a long time since I've looked at that, but I know that was something that I I did a project on. When I was a student. That's really cool. I mean, it makes sense, right? If it's quicker to fire, it's quicker to respond to any

excessive anterior translation. That makes sense. And then protecting the knee, protecting the tibia from anterior translating is a group project between the hamstrings and the ACL, not just the ACL. Yeah, for sure. But yeah, no, I, I'm, I'm the same way. I don't know. I, I, I, it's really hard for me to buy into the hamstring graph because like you said, like we want to start getting the hamstrings nice and strong.

And we all know with like the patellar tendon graph, like one of the hardest things to get back is the quad activation and quad strength. So why would we flip that and possibly put the hamstrings at risk? I don't know a big fan. Also, as we know from I believe Doctor Shepherd said this in his episode on, on our surgical series in the Great Deal, I believe he was talking about how hamstring grafts end up pretty loose most of the time.

Like when you, so if you go feel like the laxity of hamstring graft over time, you can feel like there's still an end feel, but you can feel how lax it is. It's. Getting a little loosey, right, Loosey goosey. And you know, and that's not to necessarily like scare people away from it, right? Like they still have successful rates. I mean, I think the difference between a patellar tendon and a biceps from our, again, I think Doctor Shepherd brought it up with like it's a very small

percentage, right? I mean, the edge is still given to the patellar tendon graph currently. So it's not like it's super detrimental to go hamstring. This is more just us looking at like, I don't know, it doesn't make sense physiologically to me to go to go with that one over. But yeah, along with kind of going it more into the musculature aspect, and let's not forget about those hip

muscles, right? Especially those gluteal musculature 'cause that does help stabilize the lower extremity through movement, right? So it really controls that knee valve. Just make sure we're not doing too much 'cause that's going to lead to excessive knee, possibly knee internal rotation or increases in forces going through the knee, right? So that could also be a contributor as well. So we also have to address that gluteal muscle strength as well

going forward. And that'll be kind of key as we start talking about the the pre, the prehab, and the early post op. If you do know a physician who uses hamstring grafts, please send them our way. I'd like to pick their brain. Yeah, for sure. I was going to say, I don't think I've ever. Most of the surgeons that I've worked with have all been going for the patellar tendon. Right, that seems, I mean especially in our population. Yeah, Yeah. I mean that's that's kind of the go to.

And this was in Doctor Shepherd's episode. The quad tendon is starting to get some attention, which I thought was interesting. All right, so now that we kind of have the kind of that foundation of the ACL, the

surrounding musculature that's involved with, and now we're going to talk about the evaluation of someone who may have an ACL injury. The common complaints are, you know, again, I think this is something that's more review, if anything, right, that instability sensation, right, feeling of instability. All right, And how I explain it to to my athletes, like it literally feels like the two

bones are shifting. All right, because a lot of them will say instability, but they meant like, oh, their knee gave out. Well, that's not quite the same as far as like bones shift, like you will feel it shift. That's a good way to put it, yeah. Cause a lot of people. Will have like their knee buckle for different reasons. Yeah, but that's not necessarily

instability. Exactly which early on in my career I had a lot like that was pretty common with my ACL athletes is like they felt the instability, but I feel like my last few have not felt unstable. Oh, really? Yeah. And which I thought was interesting. I mean, I know it it's not 100% that you're going to be unstable, right? Everyone's a little bit different. Muscles might be able to counteract and make you feel

pretty stable. But I feel like lately the past few have not gotten that common complaint. That's really interesting, I've I've a lot of my recent ones have been unstable. Nice. I mean, I'm. Not. Nice. Not nice. But it does make like if like your special tests were kind of walking or like, I don't know, but they say that you kind of feel better with like, yeah, I'm pretty sure that's gone, right? Yeah, they may feel a pop, right? That that seemed to be pretty consistent, right?

They felt something. That's a lot of times what my athletes like. They feel something. And especially the ones who have had it, they they tell me like I tore my ACL, like a lot of times they kind of know what's like, it's not, I don't know. It's just like a defined pop. I mean, if you if you have an idea of what is in your knee, I guess. Yeah, like, I don't know, it just every time it's kind of happening, like they know something like this doesn't feel like, oh, it's not just my knee

kind of hurts. It's just something doesn't feel right. There's a lot of times the sense that I'm getting from them. Obviously pain could be a possibility. Sometimes it's not right away. Some people it happens and they're not necessarily in pain. It's more kind of like, again, you kind of something weird is happening in my knee. This gets a lot of publicity. I think I tore my ACL, right? That could be scary, right?

So sometimes it's fear as opposed to pain, but sometimes pain comes on a little bit earlier and sometimes it's right away. I've had athletes, it's been intense pain. So pain's kind of hit or miss. Some people haven't, some people don't. What I thought was interesting on the observation part was like, I feel like it makes sense, but there is a pretty good time limit to the where effusion comes pretty quickly right? And one article kind of stated

it comes within about two hours. That's a good time frame. Yeah, right. So like if it's been like a day and there hasn't been a fusion, right, maybe we're not looking quite like ACL. Like I mean, that's not the only thing we're looking at. But like going into your special test, you can maybe feel a little bit better, like maybe it's not ACL. Whereas if a fusion popped up pretty quick, something definitely internal is

happening. Am I correct if I'm remembering correctly that meniscus effusion happens later than ACL effusion? Was that in your reading? I didn't see that in my reading 'cause everything I read was strictly ACL. OK? As opposed to like combined or also meniscus? That's a good question. I'm not sure, but this did bring up like literally my last patient right now that just recently, like within a couple weeks toward their ACL didn't have like swelling or effusion

when it happened, right? Cause a lot of times, not a lot of times, but I feel like most times that I've seen it, it's come on pretty quickly, like on the field for me. What do you mean on the field? Like within this, definitely within an hour, not even 2 hours, like maybe even within maybe within like 30 minutes that there was a lot of effusion. But this one didn't. Like the knee looked fairly normal. Like I couldn't tell tell a difference like it between a

fusion or edema. But then over the weekend sent it. So like I'm sure that night it got really swollen. But the next day he sent me a picture of it and it was like like hella swollen. I was like, oh Yep, definitely something's going on in there. Right. I don't know that I've noticed a time frame because I mean, I feel like once I kind of, well, I, I pretty, unless I put ice on them, I'm pretty quick to put them in an A strap and then a straight leg brace.

And then I just, OK, see me tomorrow. Yeah, or usually happens on Saturday. So see me on Monday. Yeah, that's fair. Oh yeah, it does. Yeah, I didn't think of that. It does technically happen on Saturdays for you. Unfortunately. So those are kind of like, again, I feel like that's duh, the effusions going to happen with an internal joint injury there. But I, I think it's good to get that kind of basis and the time frame what I thought was very interesting.

But now as we go into again, it's not an eval without special tests, right? And I think for special tests, most people are pretty familiar with, I named this myself. I don't think people called this the big three. That sounds like a Randy name. Yeah, if anyone wants to use that, please, you're more than welcome to. The first one is the pivot shift. Why did you not put a lockman first? Genuine question. I wanted to build up into the lockman. OK, sorry I still.

I wanted to bring the pivot shift first, OK, OK. All right, So you have the pivot shift, OK, which apparently you know, shouldn't be first on this list, which actually tends to have the lowest sensitivity, which kind of makes sense to me. So again, sensitivity is remember the snout. And so if it's negative, you can feel pretty good that it's not that condition. Well, with if being low sensitivity, just because it's negative doesn't mean you might still be looking at ACL tear, right?

So the sensitivity is actually rated about 55%, right? So you're looking at basically like almost a coin flip if it's negative, if it's truly negative or not. And some of it makes sense because it is like it's a pretty dynamic motion. So someone with an ACL could probably guard and you don't really feel the subluxation right away. So I could see that made sense to me. But this is probably one of the more specific tests about. It sits around about 94%.

That's a really good. Yeah. So if it is positive you feel the subluxation, Yeah, you're you could feel pretty confident that's probably a torn ACL. Yeah, unless it's unless you have an MCL. Yeah, that's, that's something that I know you guys were you and your colleagues were talking about not that long ago, I feel like. Well, I don't think you can use pivot shift if you have an associated MCL injury because of the bogus that you have to put on it. So you could get a false positive.

Yeah. Also, sometimes you could do a Mcmurray's in it pivot shifts on its own. Have you done that? Yep. I have not done. That Yep, I was doing a Mcmurray's on someone and there was some there was, it was a significant sublux. I had to stop like it was. Like you know that? And hindsight I was like, oh, that makes sense why that happened. But initially I did not. I was like, oh, that was really

weird. And I just because it wasn't pivot shift, I didn't think that I basically pivot shifted, you know what I mean? But yes, apparently I could pivot shift on a Mcmurray's. Good to good to think about. Yeah. So if you ever do a Mcmurray's and the Tibius sublux, just associate that as a pivot shift. And the thing with the pivot shift is like, it's a really good test, especially under anesthesia.

And I feel like a lot of surgeons are the one or, or who who do the pivot shift, you know, while the patient's under anesthesia, I know there are, you could still do pivot shift clinically. And then there are clinicians who love it and who do it. Shout out one yeah. Which did a football episode where we probably talked about pivot shift, maybe, maybe. That's his favorite test, so.

I mean it, it's very specific. So I feel like if you, if you don't feel super confident with like the pivot shift, it's not the end of the world. There's still some other ones that are really good, right? So again, the pivot shift is limited just cause of sensitivity, but it is very specific. The next one, which apparently some people argue could be #1. I will argue. Is the Lockmans yes, this is going to be everyone's bread and

butter, right? This is this is the big dog right and from a clinical standpoint, like like actual like in the clinic, right, this commonly viewed as like this is kind of the go to right? This is kind of the best one, right? The idea is be, you know, because of the the slight knee flexion right, it really minimizes guarding so you can get a good feel of it right? So this is viewed as hey this is the. This is like the do this first before they guard.

Yes. Because if you do pivot shift, they're going to guard and then you're not going to be able to do any other test. Yes, especially in an acute setting, I don't know too many of my ACL patients that would love for me to do that big of a knee motion, right. So yes, the guarding aspects. Lachman first, then everything else. So surprisingly with how much it is kind of viewed as like, hey, this is like your go to the numbers are were. I mean they're good.

Compared to other evaluation stuff, they're good numbers, but compared to all the other like ACL tests, they're not that much better. If anything, they stay around the same as all the other ones. I guess it also depends on if how good you are at Lochman. 'S, yeah, which I'm going to get into that. I'll get into that. Side note for students, the way that I got my Lochman down because I could always do it on Randy's knee, but it was like.

I also have I also have the build of a cross country runner. So I mean, how many Lochman's on those kids are we doing?

Yeah. So like Randy's knee was like, oh, I could get this and I'd go to my site and then like, I couldn't do it. But then in my first year, I think certified, I did a lot of physicals with, well, like my last year as a student and then in my first year certified, I did a ton of physicals where I was part of the ortho screen and I did a lockman on everyone on the same day. Like literally like 100 athletes in a row just doing a lockman, doing a lockman, doing a lockman.

And that helped so much. So if you can get an ortho screen or like just get your hands on a bunch of different knees and practice, practice, practice. For sure. And that's what I tell students like when they're evaluating knees, like I know we're like they're trying to learn how to like streamline and become efficient, right? But my students, I feel like, especially when it comes to those kind of special tests like Lockman, I tell them, just do it. It doesn't take that long, right?

Like. And also it's something you don't want to miss. Exactly. And like granted, like like I'll tell them like even if the mechanism like I know it's not ACL, right, even if it's an overuse injury, like if they're if it's a knee, I want them to at least do it so they. Also want to know, sorry I didn't mean. To no, no, you're right, you

should rule it out. No, what what I was going to say is you also want to know if it's LAX, because if it's LAX, that could contribute to your overuse injuries. That's true. All right. So like I want them to be able to do all that because they can get practice that way. That's what I did as a student, right? And then as they get certified, like, OK, right, I'm not if it's an overuse injury, right? Times like we're trying to be efficient here.

Like I get you don't, I'm, I'm not doing that for everybody, right? But but for my students, man, I want them to, I want them to practice, right? I'm not, I'm not mad at you if you, if you take the time to bust out a Lochman. So numbers wise, sensitivity is only around 81%. Again, that's pretty good for special tests in general. But again, how we talk about the Lochman, you'd almost think this was 100 Batten 100. Nope. No, it's not.

It's not, but the specificity is really good, right, 85 to 93%. So if that bad boy is positive, you can feel pretty good. That ACL is pretty gone. But there are some conditions that could kind of mask or give you a false positive, right? Like AMCL right? MCL tear could give that. Well, if you if you do a proper lockman, an MCL will not affect your lockman. However, if you are pulling the tibia. With rotation.

With rotation or a little bit laterally with you when you have an MCL, then you will get false positive because of the laxity of the MCL, Yeah. Yeah, so which? Has happened to me before. I had an MCL grade 2 and I did a lock min and I felt an end point but it felt really LAX and so I thought it was a partial lacel yeah nice. And it was not. I never considered that about like that rotation or where force is being pulled and how other knee ligament injuries might affect that.

So now because of that, I literally take the the tibial tuberosity and I almost like internally rotate their tibia just a little bit. So then I really get. Oh, interesting. A Lachman that's like I almost over exaggerate away from yeah, stressing that MCL. Interesting. OK, nice. But yeah, so so the numbers again, pretty good, but not not this like out of the park that we thought that I that it feels like it would be for the lockman.

All right, then next we have the classic, the classic of the big threes, the anterior drawer. All right. So this has a, you know, sensitivities around the same as kind of lockman 75% to 83%, right? So again, not bad, right? All in all, compared to like our other special tests, like shoot special tests in the shoulder, those are those are a disaster, right? And so this is not too bad, right?

One thing that I do like about the anterior drawer, like of course I love Lochman, but with the anterior drawer, like if you're kind of iffy on your Lochman, like you just didn't feel like it didn't feel great and you're like, I don't know what I just felt right. Doing an anterior drawer is pretty great because I do like to feel if they're going to guard now 'cause if they're going to guard that tells me something, right? Maybe not for sure.

ACL is torn but obviously something traumatics in the knee that they their body does not like you pull in on their knee. Well, you can. You're also in the perfect position to like, feel the hamstring tendons. Exactly, exactly. And same thing with the anterior drawer. The specificity is about the same, 85 to 92%, right? So if that bad boy is positive, you feel pretty good that that's positive, right?

So I thought it was actually pretty interesting that Lockman is actually pretty comparable to some of those other tests like anterior drawer. But we got a new kid on the block and this one's gotten a little. I feel like this one's starting to get a little popular. At least the students talk about it, which means in the future more people are going to talk about it. This is a lever sign or what? Some people commonly know it as Lelli's test because Doctor Lelli is the one who came up

with it essentially. I feel like if you haven't heard of this test, this test really goes off the idea of that posterior translation of the femur. So basically what you do is your fist is under like the proximal third of their calf and then you apply a posterior force to the femur. Now you don't have to push super. It's like a moderate force. So you're not going in like lightly and you're not just

crushing them. Even though the video from Lily on YouTube. OK, but the video from Lily on YouTube is of. Under anesthesia, Under anesthesia. But I'm just saying he's cranking on that thing. He's like blowing their femur up. I'm like dude. Well, he's about to do surgery on them, so I'm. Just saying it's just funny to watch and blowing up his femur, right? So it, it's not a lot of force,

right? It's about a moderate force to do it. And basically normal or negative would be when you apply that posterior force, the heel comes off the table. And if there's someone, if it's positive or a torn ACL, when you apply that posterior force, the heel stays on the table. Because the tibia is translating. Exactly right. So there's there's no connection between the femur and the tibia from the ACL so that you don't get that that that tautness doesn't create the knee extension part.

All right, so this test numbers are actually pretty similar to Lockman. I have I have to pause you though. The test numbers are under anesthesia. I I thought that they were. No, these, these numbers are a clinical like a clinical population interesting. These are not anesthesia. None of these numbers were anesthesia. So all these are good to know all these numbers. Are pretty good then. That's what I'm saying it. I don't know, it just catches me by surprise.

OK, this was fun to read. OK, right. So the sensitivity is actually 77 up to 98%. 98 That's huge. That's wild. So it's negative. You can be like. You feel pretty good. Right. If their heel comes up, it's not a seal. And then the specificity again, 90 to 93%, that's pretty good. That's an A. That's a big time A all right, there is some caveat. That's some of the because you know, sensitivity and

specificity is only a snapshot. All right, you the more stats that go into this like positive likelihood ratios and like stuff like that really kind of help determine the strength. And as it gets more advanced into statistics, like there are some limitations to this test. So even though these numbers are really good and I feel like we do this anyways with ACL, this isn't like I'm just doing this test and then I'm done, right? You should probably still pair in a lockman or an anterior

drawer in there, right? But like, this test shouldn't be discredited I feel like. It has. It kind of has been discredited I feel like. Right. It it feels like people kind of write it off, but this actually clinically is showing really good numbers. So try it for yourself. It's actually. Actually I am trying to implement this. Really I kind of want to try it. I want to see how this works because the advantage to this, this test is like for patients that have larger limbs right?

Like. Any football player. Any football player, right, like some people like it's really hard to just do a normal lockman and of course you can kind of adjust it like having something underneath to stabilize the femur, right, But this could be a nice quick way to kind of account for that as opposed to maybe throwing your leg under or

something like that right. So I thought that was very interesting and also I was just, it's like from a not super acute, but maybe like the next day or two right when they're really guarding really swollen, right, trying to move them around a little bit might be a little difficult. Your lock them in kind of like, I can't really feel it anymore.

This might be a good thing for those situations, like to help kind of count for guarding because there's not a lot guarding the femur from translating posterior. Except for the quad, kind of maybe. Right, because the quads would do knee extension, so they but then that pull would pull anterior. I wouldn't I wouldn't think the quads would want to, right. They would try to avoid that, I feel like right. So I feel like this could be a pretty good option for guarding.

Yeah, that'd be. Interesting, right? So that's why I'm trying needs more research. That's why I'm trying to sit there. Think like I kind of. Want to start doing this a little bit? More and see what happens. So I am trying to play with it a little bit. I think at the end of the day though, like all these tests, they they all have great numbers. I mean, the only one that's really limited is pivot shift. But I think pick a couple tests as a clinician that you feel

comfortable and rock with those. Don't worry, I did right rock with those because that was cool, right? So find something that like you feel good with, right? And I think the nice thing too, with all these options that show very similar numbers, is if you're not strong at Lockman, like you don't have to feel like a failure. Like, Oh my gosh, I can't do Lockman right. There are others. There are.

Others and if you get the same. Result through anterior drawer or Lelli's pivot shift, then that doesn't matter as long as you're comfortable and you're getting good results from what you're using, right? I mean, obviously we all want to try and Lockman is a great test, but I feel like you don't have to beat yourself up or even anterior drawer. If I mean, if anterior drawer is just like, I don't get it. It's not working for me. I never get a good reading.

Well, then hey, Lachman, Lily's might be your go to, right? So I think find a couple tests that you feel really comfortable with and then just go with those. And again, each situation might make make the test that you choose different, right? Like again, there's a difference between on the field, right? Like if it literally just happened, right, Lockman's going to be a pretty good one to do right away, right? Lily's might be a little bit

hard on the field, right? Whereas like maybe it's a couple days since you last saw them, or maybe they're just coming in from like a weekend where they might have torn their ACL and you're seeing them on like day 2, but and you can't really get a good Lockman into your drawer. Might be tough. Maybe Lily's is better, right. So I think pick a couple things that you like and then bring that bring that to your clinic. Sweet. So that was. Evaluation. What about once we know we have

an ACL? Yeah. So once we kind of. Know that ACL is a little damaged, just a little, just a little bit for. The most part right if. We're working with an active, you know, population, someone who's an athlete, someone who's going to go back to sport, right? Surgery is going to be that next step, all right? So everything's going to be really game planning towards that surgery. And that's kind of where this

episode's going, right? So obviously you could do non operative and people do great with that and there's not that much of a difference. But right now we're talking surgery. So initially after an ACL is damaged, there are a lot of issues that we're going to need to address, right? There's the instability component and you can't be walking around with bone shifting. That's a problem. Obviously they're going to have some discomfort, right? Effusion, right? That happens in two hours.

Yeah, within two hours. Right. This leads to quad activation decreases, this leads to lower quad strength. And then just overall just they're going to have just poor function, right? Obviously if you're limping, you're not going to be living the life you quite normally would live. Right. So what does that mean for? Us, I can tell you it means plenty. That means we have a lot to work with, right? So at this point, our prehab is very important, right?

Obviously we want to correct these issues, but also what makes it so important is we're setting the table for the Thanksgiving dinner. That is the entire rehab process. So this is this is. This is where you bring out the nice China, right? The stuff that mom told you we never use except once a year. This is what we're bringing out. OK, yes. And so our goal going into prehab is basically to address those deficits and give them a strong foundation for when they

do get deficits post surgery. It's not as much of A deficit compared to like doing nothing. Well, it's the same. Deficit. It's just they were at a higher previous level. Exactly. Yes. Right. So like if you're arbitrary. Numbers if you're at level 4 and you got brought down to level 2, that's a lot different than if you were at level 2 and you got brought down to level 0. You're still bringing down to levels yes right, but you're.

You're where your start from is a little bit higher, which means when you come into post op you're starting a little bit higher. I always tell my athletes. We're taking four steps forward and one step back. Got it. Rather than. Just staying where we are and then taking a step back. Yeah, OK. Gotcha. And there's actually good evidence into the effects of

prehab, right? So right, having increased quad activation going into the surgery does lead to higher quad activation post op compared to not doing anything or not having a focused prehab. Increasing strength again going into surgery led to higher quad strength post op, right? And a lot of these studies looked at mostly the quad stuff because that's the biggest kind of like one of the things that lags behind and most ACL surgeries is that quad. But the idea is the same too, right?

We want to make sure the hamstrings are strong because surgery will also affect them. And same thing with like the calf. So it's still you're trying to hit all these areas, but in general, right? It's not just about strength, right? Our prehab does need to be well-rounded, right? So again, you want to focus on hamstrings, the glutes, the calves, but also include some more functional tasks like incorporating proprioception, right?

Having those better foundations going in, you know, like coming from the surgery is going to make it a lot better throughout each rehab phase, right? You're going to be a lot more functional than if you didn't do those things or if you just didn't really have a focused like rehab approach. Can you give an example of? Proprioception like just balance

stuff. Single leg stuff doing, I mean shoot like some prehabs take it as far as like doing plyometrics like they're able to kind of do that, yes. It depends on how. Long before your surgery, exactly. Right. But like balance of single egg stuff, right? Proprioception like that leads to better outcomes going forward. So that. Brings up the timing. So how long are we looking for

this prehab? And what I thought was really interesting is because I feel like we always talk about how important pre AB is, You don't want to rush into surgery. But there's actually literature that shows that there is no difference between doing a delay or immediate surgery, right? The outcomes are actually pretty similar. So then what? What's the difference Then? Why do all these studies show that it is probably better to do

a pre AB? And I think it does boil down to before you do surgery you should be meeting a criteria, right? So it doesn't matter necessarily time wise as long as you hit the criteria before you before you hit the surgery. That makes sense. So. I would say like making sure we have normal range of motion, right? You're pretty close to normal, right? Effusion should be pretty minimal, right? Making sure our function is pretty close to normal and then making sure our quads are

strong. Some studies have shown about going in with about 80% of normal should be OK. All right. So I think that's where the where the study that kind of looked at delayed surgery or not because they did have like. It wasn't just. Oh they didn't do anything right. Everyone in that study did get like some kind of pre AB I think. That's what made. It the difference right? As long as you hit that criteria like you should be OK now if you did immediate surgery and your

knee is still huge. You can barely bend it right? That's where we might see a deficit in outcomes, but I still think hitting that criteria is what really matters as opposed to necessarily time. So on average studies were showing about a 14 week prehab. Holy crap. Yeah. And this and of course there there's a range, right. So some studies this was as short as three weeks, some studies went to 24 weeks. Who does prehab? For 24 weeks. I'm genuinely curious. I don't know.

I don't know ours. On average is about a month before our doc before range motion is back to full. And our doc is like OK, we can schedule surgery. But you see usually it's about a month, 4 weeks. And that's nice, because there was. Criteria, right? We're looking for things to start to normalize before we go in, right? And, you know, start cutting and drilling. All right. So yeah, the 24 weeks, that is interesting also. Because of the for the fusion to

go down, yeah. So really what we're. Working on is range of motion and bringing down our swelling, yeah. For sure, which that again, that

same idea that we're taking into pre route prehab is going into what we do for early post op, right? It's the same idea is now we're going to start looking at trying. To get that range of motion.

Normalized and effusion, right? But a lot of what you're doing in your rehab protocol really depends on kind of does a surgeon have one or does your team doc have a particular one that, you know, they kind of like to follow what kind of procedure they did, right, 'cause you're a lot, you're going to do certain things depending if it's a patellar tendon graft or a hamstring graft, right?

And if there's any other structures that they needed to kind of repair or take care of while they were in there, right? Like meniscus, right? Meniscus repair compared to partial menisectomy, it's going to be treated slightly different along with that ACL, right? So a lot of that is going to be

kind of patient specific. But in general, we're going to try and protect the healing graft, whatever one it is, whether it's the patellar tendon or the hamstring graft, we're going to try and decrease pain and swelling. And this is really where you're going to work on that range of motion. All right, so one of the biggest. Things to really think about is getting that knee extension back.

I feel like that's especially if you had a patellar tendon graft, that's always like the hardest thing it seems like to get back is that knee extension and really it is. Are you talking about prehab? Or you? No, we're early post op, so this. Is like the first like 6-8 weeks after? Getting that knee extension back.

Quickly is very important. There's studies that show if you can't get full extension by three weeks post op that that that person's at a higher risk of Cyclops lesion or even like arthro fibrosis. So actual excessive scarring in the joint. And so it is very important that we, hey, we got to start getting that range of motion going all right. And overall delays in getting knee extension can lead to a lot worse outcomes going into the later stages of rehab. Well, they shouldn't really be

walking. On a knee that can't fully extend or doesn't have good quad activation either. Exactly, and that's why. Criteria. Progression criteria is important and I feel like I don't know if. This is the same across everywhere, but I know with our docs they're really pushing away from timelines and really going more based off criteria. So it's like, OK, well, when can we get them out of a straight

leg brace? Well, you have to have quad activation enough to be have a normal gait in order to get out of the straight leg brace. So like things like that instead of like 01 week post op you get out of the brace or you know, whatever for sure. Yeah, absolutely. I feel like that, yeah. And that's what's been advocated for in the literature, is we need to stop just going off of just time and start. What about all the athletes? Who went away for the summer or went home for the summer and

stopped PT? Yeah. And then all of a sudden come back and. They're like, oh, I didn't do PT for two months, what have we learned? In anything in sports medicine, slash rehab is. Just rest doesn't. Solve the problem. So it's same idea here. That's not where I thought you were going. To I was going to say being an AT is about being adaptable, which is true too. Right. But again, right, like we're not the rest or the the time, just the time doesn't address the deficits, right.

Just the tissue that has been torn and drilled into healed. That's about the difference. All right. So yeah, for sure. Right. And that's what has been advocated for in the literature, is progression should be based on criteria, not necessarily by time. The time's nice because. It does kind of I like it 'cause it like it gives me an idea of where we're kind of at right. But again, it's all criteria

based knee flexion. I from my experience seems to be a little bit easier to get back and they should be able to get to at least 110 to 120 by weeks four to six like right in that range they should be able to get there unless they. Have a an MCL or meniscus involvement and then you're talking to your doc about when they want range of motion to be done. I was going to say when you can even. Start that process.

So yeah, again, that's why it is so specific to whatever structure is is being repaired as well.

And along with the pain. Aspect and the swelling right icing right making sure we're doing our cryotherapy and this can actually help with inhibition as well right so this can actually kind of limit that arthrogenic inhibition that happens when your joint is swollen so the the quads turn off because of this the hamstrings can turn off because of this right this icing actually helps kind of decrease that right so it is very beneficial so those people who

are. Looking for time and a place for ice? Here is the time and here is the place. Yes, it actually can be. Very beneficial post surgical and then again our modalities, right? Like our 10s, you know, E stem stuff like that. That's really good for decreasing pain. Russian stem. Yep. Which that. Will actually ties in nicely into our next aspect of increasing activation and strength. Right. So at this point. In the rehab, right, this early on, we're just trying to

strengthen everything, right? And a lot of the stuff because they're still going to be, you know, in a brace at least early on, right, is trying to get like, hey, start getting the hips worked on. All right, let's get the quad starting to activate, right? And that's one area that gets a lot of attention is that knee extensor strength, because again, that tends to be the problem because most of the surgeries are patellar tendon graft. So we're seeing some issues with the quad, right?

And really it is very important to start this early because strength at six weeks post op has been able to predict hot performance at six months. So if you're not seeing good strength gains early on, it could have a big impact on that mid to late ACL time frame, right? So that's why each stage of ACL rehab is just as important as the next, right? Right.

And again I think this. Also does show the importance of prehab, because again, if you're starting at a higher base, you have more strength to play with than if you did absolutely nothing. Funny how that works, yeah? Weird. So when we start talking about that kind of activation and strengthening, right, some actually really cool tips kind of think about most people do think about the Russian stem, right? But we can we can do more also and get creative, right?

Again, cryotherapy could be huge. And some studies talk about doing ice on the knee like for like 20-30 minutes ice on like pathogen, yeah, like the actual knee joint. And then going into your quad activation or your your early stage quad exercises because that ice is limiting the pain signal which is causing that arthrogenic or contributing to that arthrogenic inhibition.

So now with the ice kind of turning that basically turning things back on the quads can have a better chance of firing more. It's like cryo kinetics. Exactly same idea, yeah. Another thing that I thought was interesting that I didn't think about is doing like doing fatiguing hamstring exercise first. So the hamstrings are fatigued and then going into quad because post op because of the pain signal from the knee, everything's like Co activated, right?

So the hamstrings are going to activate also with the quads because again, your knee went through some trauma and your body's like. All hands. On deck, yeah, I don't want. To move. I don't want to move. Nothing's moving. So it's going to act. It's going to get a lot of Co contraction between both. Well, another inhibition concept, reciprocal inhibition says if the hamstrings fire, that means the quads have to turn off. Well, if hamstrings are Co activating with quads, we're

losing activation. So if we fatigue the hamstrings, there's less activation, more should be able to go to the quad and fatiguing. The hamstring also most likely means strengthening the hamstring. It does, especially early. On it'll you'll get strength gains from that and then of course BFR is becoming very popular. We did do an episode on that, I feel like a while ago. I feel like that's an oldie. It is, but we. I feel like we focus more on like floss band BFR. Yeah, we did.

We did more kind of, yeah, yeah, you're right. We didn't do one truly on just BFR yet. TBD. We'll get there. Yeah, BFR can be an be an option because you can, you're basically tricking the body into, you're doing a low load exercise. So the load's still safe for a healing, you know, post op situation. But your body is being stressed a lot because the lack of blood flow to the area and it it thinks it's a high load.

All right. So that means it's going to increase activation to try and accommodate the perceived high load. And then and then of. Course, in this kind of early stage, we want to really kind of start to normalize just movement in general and walking, all right? This is where we relearn to walk, especially once we start getting that full knee extension. Now we need to remember how to use it within the gate and this is always the hardest part for

people it seems like. It's like you don't realize how much you extend your knee and walking until you can't do it also. Taking weight is difficult because you have to go through a straight leg to a bent knee, and that bent knee is an eccentric motion of the quad. Which is. A lot of load and a lot of demand and again this. Kind of normalized part like obviously this isn't necessarily day one, right. There is a criteria for this, right?

We have to make sure we are still able like they're activating their quad appropriately, right? They're able to actually have sufficient strength within the quad to actually be able to start the walk in process, right. So it's not just like, OK, you just had surgery let's get walking right. But this is also a good time to to start retraining movement,

right. One of the worst things that you know, or not worse, but one of the things you see with people post OP is like their squats or like someone who's had ACL, I should say. Their squats aren't that great, right? They tend to kind of ride away from the the surgical leg, right. This is your chance to start retraining that motion and having them learn to squat symmetrically. Yeah. And actually, you know, be able to start loading that other leg more.

All right, So. So that's what that's what I've been trying to do is like, this is really where I can start to retrain their squat form and like, let's start now. Yeah. And. That's what it is. Right, You're starting with those mini squats, right, 'cause you shouldn't, you're not going to be able to go into deeper ranges of motion until more of the middle stage rehab. Yeah. So this is a great start to start or great place to start to

retrain that movement again. For me I do weight shifts like just from one leg to another for sure and then I and then I have them bend their knee and weight shift from 1:00 to another before I have them start with gait retraining. Oh, that's a good idea. Because I. Want them to get a little bit of that eccentric load for sure for the quad before they have to just fully commit, yeah. Oh that's cool I like that. Nice.

Also just watch videos. On gate retraining, like just watch gate and learn the different phrases. We did a long time ago. I think we did one on gate. We did one on. Pathological gate. Yes, this was, this was a that's a throwback when we were little babies. That was a. Throwback. That was a fun one. I liked that episode. I like Gate. I used to work with runners. So sweet. Oh, there you go. That's early stage ACL. And then it's only up from there. Yep, and. Then you build into the next

phases. What's your action item? Randy. I would say. My action items twofold. One, have just two really good, at least two really good ACL tests that you feel comfortable with. And then for the rehab component, just let's start strengthening, right? Dive in, get going, right? Communicate with your doc what they're what, what the protocol is, what they're comfortable

with. And you know, and I think emphasize this, the importance of that to your student athletes or your patients, 'cause I feel like I don't know, at least my population, I've noticed like. I don't know how like. I don't think they really perceive like how intensive this rehab process is like for post ACL. And I feel like I've had to let them know like, like this is like you got to be all in on this.

Like if you if you want a good outcome and you really want to like hit the goals that they say they want as especially as a student athlete, you got to dive in. And it's it's hard because this is you're looking at nine months to a year and some some may take a little bit longer than a year. And I think that especially for like a college aged person, that's really hard to fathom just to just conceptualize.

But that's the biggest thing is just really educate them on like, hey, this is there are reasons why it's intensive like this. And This is why. Because like all these early. Stages are just as important as the middle and the late, and maybe even slightly more important because it sets the table for them. It's true. That's what I got. So if you are. Interested in? Another ACL type episode. We did an interview with Doctor Shepherd that was a really great one.

I don't remember what number it is off the top of my head, but make sure you check that out. Also, if you're interested in these Cus, again, go down to the show notes, All of the links for the show notes, all of the links for our Cus and updated everything is down in the show notes below. So check that out. And again, thank you to athletic training chat and clinically pressed for those. Absolutely. If you. Guys are new. We do every episode as story episodes, education or interviews.

So interviews we bring people on. Education episodes are just like this where we Randy reads a bunch of research articles and we kind of synthesize and converse about it. And then we also have story episodes where we have a highlight topic that we bring stories on from athletic trainers all over the world and just talk experiences. So we kind of bridge that gap between experience and evidence. Absolutely. I think that's all I have. Thank you for helping us

showcase. Athlete training behind the tape. Bye.