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Returning to Sport from an ACL Injury with Dr. Steph Allen DPT, OCS

Brett Scott  00:01

All right, everybody. There’s another episode of the barbell therapy podcast. I’m your host, Dr. Brett Scott. And with me here today is Dr. Steph Allen. I’ve known Steph for a long time, and she has become quite the expert in ACL rehab. And there’s so much information she’s been putting out there for a long time. And she’s someone that’s just super passionate about physical therapy. She’s actually dealt with ACL and ACL repair herself. And it’s been 15 years now, I think I saw your post the other day. So there’s a lot of personal insight she has to. And to me, ACLs are one of the most common injuries we see in youth sports. And from my perspective of you know, we only typically see these after they happen. I feel like there’s a ton we could do to possibly prevent some of them, not all of them. And Steph just has a plethora of information behind her. So she has actually gone on to be a mentor for many students. So she is part of the level up initiative, which is now Cal you Community Learning, which is kind of clinical athlete and level up together. And she’s spoken internationally. She speaks at a lot of universities about ACLs and has actually just started her own business. That is Are you pretty much all ACL rehab for your new business?

01:25

Yes, there is. There are two people that have had other knee injuries. But yes, primarily ACL injuries.

Brett Scott  01:34

And where are you? Where are you guys technically based out of now?

01:39

As far as my business, or

Brett Scott  01:42

your you hail from Massachusetts

01:44

now? Okay, yeah, sorry. Sorry. I. Yes, we are still in the greater Boston area. We’re in a suburb Stoneham, just about 20 minutes north.

Brett Scott  01:57

All right. So, again, there’s a ton of information. I want to get out of stuff today, too. So if anyone has anything that has been going on, Steph is a great resource as far as ACL and just knee rehab. And she’s worked at a really cool clinic for a long time that has done a lot to, I think forward the field of physical therapy as well. So Steph, thanks for coming on. It’s a pleasure to have you here. Now, one of the big things that I’ve seen you talk about a lot in what I think most physical therapists are curious about, is the whole return to sport from an ACL tear. So you know, one thing is, are we doing a good job at this? What is the evidence saying what is happening? And go ahead and take the lead on that one?

02:50

Yeah, this can be this could probably be one podcast in and of itself. But I think that what I’ve realized is that there seems to be some confusion still about return to sport versus return to same level versus returned to like performance. So I think that a lot of times what people think is a full return to sport is that phase that they start to have some participation in their sport, but it isn’t unrestricted, it isn’t full minutes, it isn’t 100% intensity, it isn’t contact, that kind of thing. So what I think ends up happening from an expectations perspective is that people think still, that that six month timeframe is when they’re gonna go back to their sport. And unfortunately, that still happens. But as far as what evidence dictates, that’s not what you want to be doing. It is much more, like nine to 12 months, and even that, to be entirely honest, is on the early side, based on what we know is still kind of happening and improving in that knee in in your brain and body for up to two years after not saying that you have to wait two years to go back to sport. But But yeah, I think first and foremost that there’s a little bit of confusion and a mismatch in expectations. When in reality, what needs to happen is yes, around that six month mark six, seven months, if you are passing certain criteria, namely a certain level of strength that we look at, and by that for for anyone who isn’t aware of like the different types of strength testing, a lot of clinics aren’t even doing it. Or they’re just doing that thing where your PTSD doctor asks you to kick out into their hand and they subjectively tell you whether or not you’re strong enough to go play soccer or basketball or ski or volleyball or whatever. Um, so that isn’t what I’m talking about, I’m talking about a method that will allow us to actually have raw numbers that we can put relative to your bodyweight and look at percentages of your surgical or injury side to your other leg or non surgery or injury side. So that could be things like, on the lower end, as far as accuracy, like a handheld dynamometer, which is just a little kind of usually circle thing they hold in front of your knee when you kick and pull to more of an inline or a crane scale type setup, which is called isometric, or the big fancy machines where you kick and pull the isokinetic. Those give us probably the most information box, you can actually so this isn’t like, validated in research. But I’m glad you said that, because I do. We have played around with things like looking at like an isometric, mid thigh pole. There’s some research in that for the ACL as well as you can set it up. If you have a K pulley, you can set a seated knee extension up and take a look at power output because the K box will give you the app that they have gives you some input there again, those things aren’t like validated and research. However, if you’re, if you’re consistent with how you measure somebody, and you have some form of numbers, and you can put one side relative to the other, it will at least be better than nothing, essentially. So that’s what I tell people like if they don’t have a dynamometer, or they don’t have a crane scale like theirs. But if you do, or if you are an engine that has something like a K box, like there’s definitely ways you can at least get tabs on, you know how the one side is performing strength wise, compared to the other? Does that make sense?

Brett Scott  06:42

Yeah, so would those be single leg movements that would be doing versus like a bilateral, like it’s not like a squat? or deadlift, you’re doing one legged? Like, what is what is the movement you guys are using?

06:55

Yeah, it is a leg extension. And then what we do is we flip the setup so that it’s also a leg curl. So we’re looking at isolated quad or that thigh muscle that straightens out the knee, and then the hamstrings or the back of the thigh muscle that that found it.

Brett Scott  07:10

Interesting. And are there other methods? They’re looking at testing too? Because I feel like as much as these are good things to test our strength of just isometric and how much force can we produce through our quads. And I am not an ACL rehab expert. But one of my first thoughts is well, okay, that’s one contextual piece of movement. However, when we go back to a field, and we plant, there’s certain movements where it’s all on the ACL, where a leg extension isn’t just the ACL, there’s a lot more structure involved there. So what do we what do we think about that research there?

07:53

Yeah. So there’s, there’s also some research on what’s called like a, not like, on what’s called deceleration deficit. So the interesting part is I was just talking to my mentor, Laura about this last week. But I think that there is a piece of the isokinetic strength testing on the eccentric side. So that’s like the negative of the movement or the resisted, bringing the leg down, that likely has a pretty high correlation to somebody’s ability to decelerate really fast, because essentially, that is, as far as non contact injuries go. A really fast deceleration, or slow down on one leg into a change of direction is the mechanism for a non contact ACL injury. So I do think that that piece, although it isn’t, again, validated in research yet is going to be huge, but they do have field tests, that allows us to gain this, what they call deceleration deficit and compare how quickly someone is able to and how well someone is able to decelerate and change direction on one side, namely the surgery side as compared to their other side. And those kinds of things, again, I think are super helpful. So they the deceleration deficit test, they just basically use a 505 and you can do things to ramp up to that like a controlled 50 to 60% speed, like 60 degree cut, the 90 degree cut, and then 180 degree cut, or even some intermediates in between there. So just to take note, like all that kind of stuff should be happening the background before you’re doing like a max effort 505 tests or before somebody is participating in, let’s say, scrimmaging, in soccer or basketball or something because of the number of decelerations and changes of direction that need to happen. But as far as quantifying things, there are some of those field tests that we can do, in addition to the strength and addition to their conditions. laying like all the little pieces that you know also fill in those holes there but but yes there is some that are specific to deceleration

Brett Scott  10:09

and other any metrics to or ratios you want to look out for power output like we use for like sport readiness score in the gym, we have a G flight machine so it measures basically you can do a lot of just you know, looking at someone’s power in their readiness so is there ratios you guys can use of like left to right or you know, injured to non injured leg of where we should be at before we even start thinking about getting back on a field.

10:35

Yeah, so technically, I mean ng flights are good, actually to take a quick sidestep so G flight, as well as they’re like blinking per second the my jump app is also another one that can give you using slow mo video it gets a good estimate based on the person’s you know, to put their height, weight leg length, their height from a step that they’re dropping to and essentially you can put in that information in with the video marking landing times take off times it gets flight time and it’ll give you a proxy for or an estimate of somebody’s RSI or reactive Strength Index, which also is something that is looked at I feel like I want to say that the number is 2.5 or above. Don’t quote me on that I can look that up. But that would be a metric that would be something that an RSI, how explain it to people. How my mentors explained it to me is basically your springiness. Like how quickly you can you get off the ground, which basically like we were just talking about is how fast can you decelerate but just instead of forward, backward, up and down? And how quickly can you change that direction and go right back up. Because that stuff needs to in sport happened in like milliseconds. And as far as an ACL injury, that happens in milliseconds, not seconds. So if it takes you two or three seconds to do a drop jump, we have a little work to do that kind of thing, like time on the ground. Does that make sense? Absolutely. Okay, so that’s a sidestep, but also something like what my jump or chief like can do ForcePlates do stuff like that, too. But obviously, that’s more on the expensive side of equipment. So that will be a nice to have not a need to have. And then as far as just the straight strength stuff goes. Ideally, you want to be above 90 at or above 90% of the other side. So for most things, like the deceleration deficit, RSI RSI might be a little bit different, but I do kind of hold that for most things at or above 90%, ideally. And I would think that and the other thing being like, for the basics for strength, for quads, you want to be able to kick out your bodyweight. So that would be like 100% of your bodyweight. And then for hamstrings, you want to be able to curl 60% of your body weight. So because hamstrings are never going to be as strong as quads, that’s like normal anatomy.

Brett Scott  13:15

Yep. And I should have asked this sooner, but what populations Do you see that are most at risk of having an ACL tear occur?

13:26

Technically, the highest risks are those who have had an injury before. That’s just by numbers. And I, I want to say that what I’ve seen thus far are more so adolescent females, but I don’t And again, that population is more common. But that also may be selection bias, as well, like I am a female provider, I get a lot of female athletes. But in general, numbers would probably also agree with the fact that is a little higher in that age group around like, fairly young, I think one of the last things I read was like between 13 and 17.

Brett Scott  14:16

Yep. And what are some of the big reasons these, these injuries are happening? And, you know, for those that don’t know, there’s basically two types, there’s contact and non contact that can happen. So I think, you know, for a lot of times, if you’re a football player and your leg gets locked to the ground, and then someone comes from the side and takes out your knee. That’s one thing that’s, you know, might be somewhat unpreventable. You know, the more strength training and things you do, maybe the more likelihood you would have of not tearing it. However your your knees probably going to still hurt if you get taken out like that. So but in those that, you know, especially now Contact injuries what what’s happening there?

15:04

Yeah, so I’m, I’m going to admit that I’m biased in my looking at things. And I, for my own sake, I usually try to simplify things. So oftentimes, I think what happens is that there is a demand to capacity mismatch. So a lot of times it’s quad strength, but it could be other, you know, global strength in general, because of the other piece that I’ll get to in a second. Because I think if more young athletes, particularly females were strength training, I wonder how much of this injury we would see. But before we get to that, yes, I do think that if you think about running really, really fast, straight on a soccer field, it’s where a lot of my analogies will come from, because I see a lot of soccer players, even though I played basketball my whole life, but you know, running straight and then you need to, either you know, one of two things, you need to plant really quickly and follow a offender, like you’re on defense, you need to change really quickly. And they’re, they’re changing and you’re attending to the person you’re attending to where your leg is, or you are someone that needs to plant really hard and backpedal. Sometimes I see that as well. But that really fast, slow down into your change of direction, when done properly is almost entirely your quad muscle. And if that quad muscle can do what it needs to with the deceleration. And you don’t get low enough, essentially, there’s some specifics in there, but you potentially put the joint and the ACL at risk as far as the forces that have to go through the knee in order for you to complete your task. So all of that, really to say that a lot of what the muscles, particularly the quads have to do for your knee to stabilize it in certain game like situations like that, that have a tiny bit of flexion or bend, a little bit of rotation, but a lot of force that tends to be kind of like the trifecta. And it doesn’t mean that I think the thing that’s hard for people to understand is that these are high level athletes, a lot of times, not always, sometimes it’s a misstep or a fall. I’m just, you know, somebody who doesn’t play a sport, but for the most time, especially noncontact. They are in these, you know, sort of elite situations. And there’s such high performers, people are like, they’re they’re so strong that person is to try and like they probably are, you know, and that doesn’t, it doesn’t preclude you essentially from from having this injury. So that’s, that’s mostly I think, situationally, what happens? And like I said, the the other piece that I am curious about would be you know, if generally, our youth athletes were actually lifting things more than bodyweight. Not that everybody has to get under a barbell at age 10. But doing something more than bodyweight on at least a once to twice a week basis. I just knowing what a big piece strength is in this injury, I just wonder, and not just this one, I feel like hamstring strains, growing strains and field sports, I think that we would see less.

Brett Scott  18:21

And that being said, I’m talking about strength training. You mentioned a lot about the hamstrings in the quads. What about the glutes? That’s what everyone wants to kind of focus on in there are a lot of icy trainers and stuff talk about so what are the glutes involvement in ACLs? And just kind of a lateral chain of things.

18:45

You’re just trying to like trigger me today, aren’t you, Brett? Yeah. No, actually, I’ve I’ve come full circle. And I, I am more open to an empathetic to that question. Now. For anyone who doesn’t understand why I’m being weird about this. There. There has been a big trend, especially in noncontact female ACL injuries that one of the biggest issues was that we have wider hips and weaker hips. Therefore, the angle at which our hip makes relative to our knee, called our cue angle is like, anatomically why we’re more predisposed to this injury. And that has been somewhat disproven, thank goodness, because that narrative basically just makes can function and making females feel as though they have no control and they’re just kind of already at high risk based on how they’re built. But I will say because of what happens after this injury, as far as to the quads, because the quads you know, it’s a it’s the best way to explain it almost like your body’s defense mechanism to shut down the quads because it doesn’t want to load the knee and you need the quads for pretty much any activity in your day. So, because that happens, other areas pick up the slack, essentially, your body’s super smart, it’s still going to get you from point A to point B, it’s going to try to get you to complete whatever task you need to do. It’s just not gonna use the quads. So I actually find a lot of people that I have after an ACL injury when we’re testing hips, that surgery side hip is way stronger. Because it is, has been dependent on the word. Yeah, exactly, exactly. And, depending on people’s movement patterns, and you know, not a big, right or wrong or good or bad movement patterns, but depending on how they moved prior to, they may have just been used to using more hips and glutes than their quads and hamstrings anyway. That being said, it is important to have strong hips as far as stabilizing, you know, again, another word I’m wary of using, but basically, keeping tension and strength in your core, your midsection of your pelvis while you’re on one leg can also be helpful for not having your knee be in a position where it might be predisposed to an ACL injury. So I will never knock, making sure that hips and glutes are strong, but I will knock them being a causative factor in an ACL injury. Yeah,

Brett Scott  21:25

that’s, that’s one thing I’ve always kind of gone back and forth with and part of why I wanted to have you on is like, what I’ve seen a lot with post op ACLs, is a lot of these people do have a significant amount of valgus. And especially when we start we go back to any type of plyometric jumping Landing stuff, you see that knees start to cave in, it’s like, okay, is this was this something happening before your injury occurred? Or, or no, but something. And I think, too many people put the emphasis on strength, or strengthen in weakness, right. And it’s not that it’s necessarily weak. It I think, sometimes it might just be more of an awareness thing where people don’t know how to plants. And something I’ve always, and there was some research that came out a while ago, I saw that said like, this doesn’t matter, right? valgus doesn’t matter. And for in certain contexts, maybe it doesn’t. But I’ve always kind of been on the essence of like, I’m not gonna just cue them to let their need do whatever it wants. And maybe to some level, you should, because sports don’t happen in a vacuum, I can’t always land and put my leg exactly like I want in the training environment. But what what are your thoughts on that?

22:47

Yeah, I actually am. I’m in line mostly with what you’re saying. I think that the so there was research a while ago, where that that used the, the less like outcome measure lower extremity. Something scale

Brett Scott  23:08

I functional scale. Yeah.

23:10

But it was the less was specific for jumping. So the research that came out of that originally was like, they had a large cohort and everything. But the, the data showed that essentially, it didn’t matter. But the very small end of the spectrum where people were like, where their junk was like horrendous looking like a, an egregious amount of the knees touching and like their knees looked like these, that small subset did go on to have a higher rate of because this was a really long term study. I can look it up afterwards, too. And the length scale is super long. So actually from, from a clinical perspective, it’s not super applicable. From a research research perspective, I think it is because it looks at a lot of different variables at the jump in the land. So I do think that you know that the camp that I’ve sort of been in is that if it’s a little bit of it, could very well likely be how their body is basically almost winding up in creating a little bit of torque around the hips and the knees in order to jump back up. Like if we’re talking about a depth jump. Or that’s what it needs to generate enough force to decelerate and land. That can happen especially with adolescents, when they’re really at that lanky phase and their femurs are so long, and their strength hasn’t kind of caught up yet. They’re going to use other mechanisms in order to generate force and it might be position to position to their hips and knees. So if it’s, you know, a little bit or if it’s enough that maybe I can do things like oh, don’t let your knees instead of saying Don’t let your knees come in all use things sometimes, like from an external cue standpoint, like either putting something outside of them and try to like To shoot your knees towards here, or sometimes I’ll use the laser pointer analogy with young kids, like you have a laser pointer on each of your knees pointing straight forward, I want you to point them out towards the corners of the room the whole time, like things that aren’t internal cues. Again, that could also be another conversation. But I will help sort of teach the jump in land a little bit like you were saying, less so of like, oh, we need to correct how you’re moving like, Oh, here’s a really more efficient way to jump and land for you to go back to your sport. Just because again, if they are, if they are after this injury in general, they already feel not a lot of confidence in in how they’re moving, they’re probably a little scared about going back to their sport. If they’re not, again, I don’t want them to feel like they are moving terribly. Because sometimes some of those really elite kids, when you get them to do single leg stuff, or you get them to do some other just general stuff, you’re like, how do you move that way on the field? You know, you can’t Can you can’t stand on one leg, how are you such such a high level. So I’m sorry, that was a little bit of a rant. But I do think that there, there are some things where I’ll I’ll intervene a little bit without making it seem like this is bad or wrong. And then the the rest of the people that kind of do a little bit of it. Or even like a max effort squat, sometimes these will cave in a little bit to come up like it’s a lot of force you need to generate. So you might need to move your knees in and out a little bit to create instability to come up. So the rest of the that spectrum is I kind of leave it alone and let strength sort of even out.

Brett Scott  26:38

Yeah, that’s one of the things I’ve just always seen, then. I think some providers out there aren’t up to date with the research and our communication, everything. And it’s like, especially on the training side, like some coaches like you don’t let your knees come in, because you’ll hurt your knee. And it’s like, well, no, yeah, that’s not the case. My thing is, in the rehab process, like I always want you as a, as an athlete or patient to have options and variability, right? We can’t just go one place all the time. And so a lot of times what I’ve done is like when we’re doing squatting and more controlled movements, yeah, I’ll put a band around the knee and have them just like cue, like you said, I’ve even taken we have a motion guidance, laser pointer, I’ll put that on their knees, and have them like point it towards the room. And even when they land, like land and stick it and see where they go, and just gives them some, some learning. Yep, just some feedback of different options. And then, you know, sometimes we go back to the plyometric phase. And that’s where I’m kind of like, okay, their knees caving a little bit. But I also, I don’t want to be so much on the side of knees out, knees out, knees out. And I think this is where a lot of re injury might happen is if we’re not exposing the ACL to any load at all. It’s not going to get stronger. And then we as providers might actually be putting people at more of a injury risk of not loading that ACL.

28:02

Yeah, there’s a try, I think the most tactful way to say this, I do feel as though I mean, the reinjury rate is one in four. It’s not good, that’s not good. And I am, for the most part, like it’s not common for surgeons to do the surgery wrong. Or like for the alignment to be slightly off. To me, it’s, it’s rehab, there is we haven’t, we are not doing what we need to do to prepare people for the demands of their sport, or their life, or whatever it is. Some of that’s not on us. Some of that is compliance. Some of that is you know, because it’s, it’s a commitment, it’s hard work to be able to, you know, you aren’t just trying to get your surgical leg to just about knee, your non surgery, like you’re trying to get both of them stronger than you were before. And that takes consistency. And it takes about at least a year to I feel like feel like somebody should be close to feeling fairly normal. And that’s it, there’s no hiccups. So I understand the, I guess a bit of a mountain. That is we’re trying to kind of climb up and the commitment and consistency that it takes and it’s going to test you mentally and physically but knowing all of that. They don’t think how things are set up in our country, an insurance based outpatient clinic, particularly the resources that the PTS themselves have and the time that they have. It’s not set up for this injury, not for full recovery. No,

Brett Scott  29:45

I completely agree. And one thing you mentioned to that I really want to touch on for people is finding the provider that’s right for you is especially important when you know especially I think this if parents are Listen to this, too, is a lot of these kids that have these injuries like sports or their life at the time they so between 13 and 17 kids identify as athletes. And when they can’t do that, and there’s question about it and everything, and then we go into a rehab space where someone is telling us we’re doing things wrong, were weak, like we’re incapable. That’s not helping the mental space of getting this person back to a healthy outcome, a healthy mental space, or like a positive outcome with back to playing ball, because there might always be this fear and connotation in their mind that something’s gonna go wrong, or they’re doing something wrong, and they’re gonna get hurt. And so that’s a whole nother piece. I think we can segue into now, of the whole psychological readiness, of returning to sport with ACL tear, which I’ve seen you post a fair amount about before.

30:57

Yeah, I think my biggest interest with that is because I’ve seen actually, I’ll back up there’s a story related to this. So aside from my own, I had been out for, you know, maybe six years five or six years practicing and had been at Boston PT for a little bit. And I worked with an athlete who physically was passing everything like we didn’t even have the force gauge yet. I was sending her somewhere for that. But with everything we were testing, strength wise in the clinic and field stuff, like I had her film and do stuff on a field and saw her do some, some things in clinic on the turf. Everything that I was giving her physically, she was passing with flying colors. And this girl could not have been more terrified to go back to her sport like that, what was that what was crippling her that was making her that’s what was making her movements hesitant. And even that in and of itself, if you’re moving differently because of fear, you’re not moving how you normally would, who’s to say that that doesn’t also have an impact on reentering or injuring something else. So after seeing that particular athlete, I remember it was a moment in my career where I was like, Whoa, like, I didn’t catch this, I didn’t ask her I didn’t. And now we’re doing return to sport stuff, because she wants to play in her season and a couple of months, and she is not ready. So it was a an ownership part on my part. But it was also let even a little bit more of a fire to sort of investigate that. And so I went down and research rabbit hole after that. And of course, there was a plethora that I hadn’t read yet. Particularly Julie Berlin’s work was really informative for me. And then it made me rethink about my story. And like, I never went back to basketball because I was scared if I, if I actually stepped back and think about it, you know, I had like maybe three months of rehab, and then I went to college, and I didn’t, you know, it wasn’t mature enough or have the wherewithal enough to know that actually, completing this rehab would be super important. And I justified not trying out for the basketball team, I’d have to go which I probably could have played two girls that I played with in high school played on the team. And I justified it as Yo, you know, PT school is really demanding. And I’d rather focus on academics and yeah, sure stuff, okay. Like, you would have frickin loved to play basketball. So that was a, that’s still something that I deal with. Because I’m like, God, I, I wonder what I could have done not that I was gonna go to the WNBA. But like, you know, so I don’t part of it is that I don’t want that for anybody else. Because there was no reason that I couldn’t have rehabbed better and gotten back to at least playing like, you know, club or something like that. So those, those two pieces were big for me as far as diving more into that. But I think that it doesn’t have to be, you know, for maybe potentially any providers that are listening and even like parents or athletes themselves. It is important for those types of things to be brought up in therapy, like in the very early stages, like they should be able to do upper body stuff or other things that kind of make them sweat a little bit and have fun if they’re an athlete, but also, they should be asked like how they’re feeling with things. How sometimes it’s as simple as like, Hey, how you been sleeping. I know sometimes it’s hard to sleep when you have surgery early on, but something like that to just start to dig can reveal like, yeah, since the surgery because this could be like, a couple months out. People are saying yeah, and that really don’t really sit down. I really find that I’m like, hungry and I’m like, Okay, well, you’re healing. So we need to talk about, you know, in my head, I’m thinking that You just continue to ask more questions, but it affects more than people think. And I think that when you’re actually looking for someone that should be sort of part of how they interact with you. It shouldn’t just be like, Hey, how’s your knee feel? I think that’s like a big. That would be a green light. In my opinion. If you are with someone during a concert, you’re talking to someone, and they they’re asking you questions that aren’t specifically just about physical stuff. Yeah.

Brett Scott  35:31

And so other certain, like readiness questionnaires, or anything we as providers should be giving to our patients, or ones that people can find and do at home to see if they’re, you know, where they are on the scale of readiness.

35:45

Yeah, yeah. So the one that I use is the ACL, RSI, it’s the ACL return to sport index. I love it, because it’s only 12 questions. And they are framed in such a way that they begin with like, how feel fearful, are you? How nervous Are you? How confident are you? How much does it bother you that? So it’s on a one to 10 scale. But those types of things can actually help initiate the conversations that I was just mentioning before, because if somebody is, you know, they believe fully 100%, they can get back to their sport, no problem, like those ones are scoring high. But then they score really low on the ones of like, how much does it bother you that you’re limited? Or how nervous Are you have accidentally reinjuring or things like that where they might be a little bit more, seemingly down on themselves are down on the fact that they’re physically not where they want to be? Then I’m going to interact with them slightly differently in a way of like, I am going to make sure for one that I’m giving them exercises that I know will challenge them, but I know for sure that they can complete well, because if they’re in this area, or they’re struggling a little bit, and then I just give them really hard stuff that’s like borderline they can’t fully do, then that’s going to send them down the deep end. Sometimes it’s the opposite. Sometimes somebody is like 100% confident with everything at three months. And I’m like, okay, that’s rare. That’s way more rare. But in that case, then I might in their program, give them things that are just above where they’re at, so that it’s a little bit of a reminder of where they need to go still.

Brett Scott  37:40

Yeah, that’s one of our principles has always been find the hardest thing you do well, and and start low build up to that, and then crush that for a while, and then we can talk about progressing it like that. Yeah, that’s something from I learned from Craig Robinson at one of his courses, it was really good. And he’s got a lot of good stuff. He does. And so as far as the rehab sides in that psychological readiness, what what is, are we as a country, or as providers in this country doing well, and what things do we need to do better? To make sure, you know, we’re sending people back that are actually ready in trying to not let people go back that aren’t ready.

38:28

Yeah, gosh, if I feel like if, if I could answer that, like, concisely, then I, you know, somebody should pay me a lot of money. But

Brett Scott  38:38

I mean, one thing I’ve seen is like, there’s people in clinics. And granted, not every clinic has the resources to do this, like you said, we’re just not given it. But you know, I have 75 feet of turf in my clinic. So it’s nice that I can do reactive movements, things that people can’t predict, they have to react to them versus like, a lot of times I’ve seen, especially when I was an aide like 10 years ago was like, Okay, you’re going to do some little box jumps on this five inch box. And you’re going to do these little like, single leg hops back and forth. But it’s all predicted movements that from, for people that don’t know, there’s different types of motor programming, and one is that we’re predicting it, and we can forecast the outcome of where we’re going to go. It’s a closed environment, where there’s nothing getting in the way, but when you’re on a field or court or, you know, hockey rink, things happen much faster and you are reacting versus being proactive about your movement strategies. And so I think that’s the big thing a lot of people miss but correct me if I’m wrong stuff.

39:40

Yes, you are not wrong. So another like even step before that, so even before what’s going on in the PT clinics, a lot of times what happens is these athletes are cleared by the surgeon. They’re not cleared by us and what is the surgeon going to do in a nine by nine office? that’s going to demonstrate to him that this person is ready to go back to elite level anything, especially when

Brett Scott  40:08

they take 10 to 15 minutes with a patient, and they’re not looking at all the other aspects. Yeah,

40:14

so that’s one issue. Because then what it creates as the person comes back to the PTE, and they say that they were cleared. And even if the PT knows that, that’s not right, you now have to be able to have an arsenal of things behind you that explain this is why you’re not ready. You know, it is ultimately up to you. But I can’t give you my blessing here. Because these criteria need to be met, because those are the criteria, we’re gonna need to at least we can be 90% sure that you’re okay. Like, that’s the thing, we’re not even 100% sure of everything is passed with flying colors, you’re still at higher risk if you had an injury before. So I think that’s one piece, I think that as far as you’re talking about, most places don’t have the, I don’t even care about out about equipment as much they don’t have the space to be able to kind of test and challenge athletes on a on a regular basis for you know, months leading up to even doing like noncontact scrimmaging or something like that. And I’ll be honest, our clinic didn’t have that. But what then it required was, sometimes I would go to a field with a kid, when it’s not on my off office hours, you know, you’re not getting paid for that. Or they have to come up with a plan for the person to carry out on the field by themselves and film it and hope that they film it. Okay. And like, then have the end of all of that is, you know, we were talking about this before the call that all of that was going into when I could because that’s the thing. It’s mostly high school kids, there was a handful of them that were diligent and mature enough to actually carry that on their own. So we were strength testing, but that was probably the the most solid thing we had. Because there I’ve had a handful of kids two or three, that I’ve been able to have that committed to going to a field doing stuff either with me or on their own. And having that in addition to my jump, a sprint progression, some shorter change of direction stuff in clinic and the strength stuff that went into us deciding and as the provider, if you have more than one kid on your caseload that is that like, you don’t have the bandwidth.

Brett Scott  42:37

Yeah, that’s really tough. All right. And one of the last things I had here too, that I know, just being a weightlifter. And looking at the research, there is, I think something some people are scared of doing. And some providers for some reason are scared of doing this half people do deep squats, like astagraf squats. And so what I’ve seen from the research is that Olympic weightlifters, so for those that don’t know what that is, it’s like some movement you see in CrossFit or whatever. It’s the SNATCH and clean and jerk, but you’re getting the goal is basically you’re trying to move the weight actually as as little as possible, and get under it as quick as you can. So most of the time, you’ll end up in a really deep squat where your butt is basically sitting on your heels. And we’ve seen that weight lifters have the thickest ACLs of any population of athletes. And so that’s one thing that definitely I play hockey still. And it gives me confidence that I’m not, you know, I’m going to less likely percentage to tear an ACL. But what are your thoughts on that? And is that something people should potentially be doing that they’re just not getting from a PT or a coach or anything after? Because there’s just this, there’s always been this connotation that squatting deep is gonna hurt your knees anyways.

43:57

Yeah, yeah, we’re still still climbing that one as well. Um, so interestingly enough, if we’re talking about general joint mechanics and anatomy, the more flexion or the more bend that your knee is in basically, the lower you are in squat. There is less tension on the ACL. More of that is open chain, meaning like when your foot is in there. It’s interesting, the thicken thickening of the ACL in weightlifters, I think that also because that their joint goes through much more range of motion and load through that whole range of motion. I wonder how much of that has to do with it there but I agree with you in the sense that regardless of what is happening anatomically or the response of the thickening ACL to load being placed through it, which is the positive response, just like bone health is good. You would like to add, add weight more than In bodyweight for bone health, similar thing happens with soft tissues as well. So they’re going to adapt to what you put through it as long as it’s not more than what they have the capacity to do. So there are definitely times early on where I will limit the range of motion of things like a knee extension, for instance, but as far as squatting later on, and this might, you know, this could be a topic for another day, I don’t squat super early, and that’s more so because the quads themselves, like I said, like we talked about before your body is going to do set tasks that you ask it to do, but it’s just not going to use your quads, I don’t want people to learn how to squat without using our quad, even if they look fairly symmetrical. But the the argument or the fear around squatting, in general or around knee extensions, I think is actually part of what has been detrimental for people, because there’s a point at which when I feel they’re ready, and sometimes, you know, there’s a spectrum of this, like, a compound movement, like a squat for an athlete, or a deadlift, or an athlete like, or single leg of either of them, but mostly the compound ones like that is whole body strength. And that is also mental competence. So I’m not going to hold off for super long, because of those things. And because we know that after a certain period of time, except for those first few weeks, really, that it’s it’s safe to do from an ACL loading perspective.

Brett Scott  46:33

I think too. So yeah, one of the things I saw with like the weightlifting was they correlated to some of the deep squats, but what you’re saying it maybe it’s not that but I think it might be

46:47

chain, it might I have to double check that though, because when you’re not left open or closed chain, but when both feet are on the ground, there, there may be a little bit more. But I think because of the constraints of the movement, you really can’t tear an ACL. Like it’s very, very rare in weightlifting or powerlifting.

Brett Scott  47:05

Yeah, so the other piece there, I’m thinking that might be a training consideration that maybe we should look into more is a the frequency of training with with weightlifters is very high. Your every day is leg day, right? So you have cleans, you have jerks, you have snatches, you have accessories, it’s all your legs work everyday. weight lifters have big, strong legs. The other part too, that might be different from powerlifting is we do a fair amount of work on what we call a power position, which is more of your your like athletic ready position, where you know, when you’re doing a power jerk or split jerk or anything like that, you’re only dipping about probably 15 to 25 degrees, which typically is where NaCl is on the most tension. And there is a lot of force. So like, you know, yesterday for a cattle workout, I work up to 300 pounds on my jerks, and you’re only dipping to that 15 to 35 degree piece. And then, you know, tomorrow I have power snatch, hang power snatch it just in that basically like that just do a box jump position and catching weight over my head there. So that could also maybe be something that’s I don’t know, maybe we should do more of these, like partial movements with heavy load. We’re not squatting to depth has always been a bad thing to most people. But maybe it’s not. So

48:34

yeah, it’s interesting you say that too, because I I know the very basics of most of the hang movements and a couple of the phones as far as even being able to coach them, it’s actually something that’s my my, I don’t want to put it a to do list because something I do really want to do. But from a even aside from being comfortable in a in a, you know, moderately bent knee position, which is hard after the surgery. Those types of movements when we get into sort of are cleared and ready for more working on power and rate of force development. Ollie lifts in their variations that are pretty safe to do. And most athletes that move pretty well pick it up pretty fast like those are great for that. Like you can use things like med balls, kettlebell swing, like certain things like that, but just the mechanics of it as well as like moving things fast but then also needing to decelerate that weight fastly, or sorry, quickly. Like that is that’s something that I’m excited to learn a little more about and try you know, whatever my knee can tolerate. Some try on my own as far as adding into my programming as well. We do some hang stuff toward like when people are ready or even you’d be surprised like a barbell PUSH PRESS even to dip really quick and come up like you don’t need to be super well versed in, in weightlifting to be able to at least initiate that process with people.

Brett Scott  50:11

I will let you know stuff I don’t know if you saw but I did a course with modern manual therapy. That’s all about weightlifting and powerlifting. Yeah, so we’re gonna do some live ones, I’ll send you, I’ll send you a discount code, but it’s all about basically coaching and rehabbing strength athletes for the Olympic lifts and the power lifts. So there’s a fair amount of like, the bridge between the rehab and in coaching and knowing what you’re looking at and assessing to so we can talk more after about that if you want. Yeah. And you’re always more than welcome to come by, like Saturdays are our day at the gym to have a good time and lifts? Okay, come hang out, get a lift in with us. And

50:53

yeah, see my face?

Brett Scott  50:56

Be more than happy to. So Steph, I know you have to go. So we’ve already gone a few minutes over time here. So Steph, where can people find you? Is there anything else you wanted to add?

51:09

Yes, sorry. My dog just came in anyone to say hi. Yeah, so mostly on and most comfortable with Instagram. It’s Steph L and DPT. I am working on a website for my business ACL resolve this coming year. That’s a 2023 goals. So we’ll put information on my profile about that. And honestly, I do get emails sometimes from students, clinicians, happy to have kind of an open book. So that’s just Steph at the level up initiative.com. And yeah, happy to chat anytime.

Brett Scott  51:48

Yes, that’s been an awesome resource for me. I’ve reached out to her plenty of times. So she does know her stuff, obviously after listening to this. So thank you so much for coming on. It’s been a while that I’ve been trying to get you on but I was busy starting my business. And now you’re starting to know the struggles too. So

52:04

all good things. Yes. Yeah. It was a pleasure. Had fun. Yeah.

Brett Scott  52:08

All right. Thanks for coming on. And for those that have any questions, feel free to feel free to reach out to her and if you forget how to reach out to her, just shoot us a message as well. And we can always put you in touch. So thanks for listening and hope to see you next time.

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