Movement Patterns Shape Knee Kinetics: Late-Stage ACL Rehab Implications

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Dr.
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Kevin McNamara, physical therapist and sports certified specialist out of
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the Washington area. You've been known for your educational story
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posts surrounding current research, and your most recent post was
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about curve decelerations and the kinetics that often occur at
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the knee that would have some impact on the capacity
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of the ACL. Before we dive into that topic, give
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us a brief synopsis on your background and your journey
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through the physical therapy field.
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Yeah, sure thing.
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I just want to say first, thank you to John
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and R2P for having me on. I'm looking forward to
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the discussion today.
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With respect to me, so my initial sort of exposure
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to the world of health and human performance primarily came
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through more of the strength and conditioning and physical preparation
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side of stuff. That's kind of where I got my start.
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Did some work in the private sector as well as
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at the university level, and then ultimately transitioned to more
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of medical or the clinical side of things through PT school.
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And then after PT school, I went and pursued a
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sports residency in the Baltimore area, actually, in Maryland, where
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I know you guys are kind of housed out of.
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And then I've transitioned since then to a private practice
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sports medicine facility outside of Seattle, Washington, where my day-to-day
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kind of involves a bit of blending of both the
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musculoskeletal medicine side of things and some of the strength
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and conditioning, where I get to work through rehabilitations from
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start to finish for the most part and get them
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to use the best of both worlds.
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Awesome. Let's get into it.
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So again, the article talked a lot about curve deceleration
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and obviously the kinetics at the knee joint itself. After
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reading this article, did this change or reassure your perspective
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of where Return to Sport following ACL reconstruction rehab is
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right now?
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Yeah, I think, I don't know that I would say
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the paper fundamentally changed my perspective, but I do think
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it It reinforced where I think.
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The profession needs to kind of continue to evolve.
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And, you know, if you asked me like five or
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10 years ago, like what makes success in ACL rehabilitation,
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it's probably going to be something along the lines of,
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you know, let's get the knee quiet.
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Let's restore their range of motion.
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Let's restore their quad strength, improve maybe their hop performance,
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and then eventually pass some degree of like a return
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to sport testing battery.
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And, you know, those things are still super important. They
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still very much matter.
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But I think the longer that I've done this, the
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more I've kind of realized that restoring the knee and
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restoring an athlete that is like ready to go back
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to the demands of sport, there's a lot of crossover,
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but they are different objectives. And I think that's kind
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of where this paper fits in for me is that
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when I first read it, my biggest takeaway wasn't really
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the increases in knee abduction moments, what they kind of
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talked about. It was the observation that changing the movement
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strategy or the movement problem changed the loading environment for
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the knee. You know, the athletes, they weren't substantially faster
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from condition to condition. The ground reaction forces were relatively
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stable across them, but the breaking.
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Strategy in that curved group did change.
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And with that change in strategy, the demands on the
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knees changed as well. So that to me is just
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as much of a biomechanics finding as it is a
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rehabilitation binding. And it kind of reinforces something that I've
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been thinking about for a while. And, you know, people
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that are well equipped in the space think about a
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lot as well is that movement is incredibly context dependent.
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And this concept or idea of ecological validity is something
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that we need to keep in mind when it comes
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to end stage rehabilitation, because athletes don't move the same
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way in every environment.
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You know, the movement is going to change depending on
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the task.
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Depending on the constraints, whether you're reacting, you're anticipating, am
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I taking space or creating?
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It's constantly changing.
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And rehabilitation, in my mind, probably has to become increasingly
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more representative of those environments as the athlete gets closer
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to return. We need to start to replicate some of those.
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And I think that's probably where our profession needs to continue.
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To evolve and get a bit better.
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Because I think that we've made a lot of progress
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over the last, 10, 15, 20 years. I think that
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we're objectively measuring strength more consistently. Forest plates are becoming
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more accessible. We are delaying return to sport now more
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than I think we may have been in the past.
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And those are good and positive developments.
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But I also think that we've probably also got pretty
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good at preparing athletes for testing. And I'm not convinced
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that we're equally as good at preparing them for competition.
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And you know, I think papers like this, we want
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to be cautious with the interpretations that we make.
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It's a small sample size.
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It's one paper, but it does maybe push us to
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ask an important question is, are we exposing athletes to
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enough of the movement problems that they're going to encounter
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in sport before we clear them? And how do we
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progressively build the athlete's capacity to tolerate the demands of
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sport before they're exposed to them in their competition? And
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And I think that ultimately that's probably an area where
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the profession can continue to evolve, and that's kind of
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what this paper reinforced to me. It's a reminder that
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the closer an athlete gets to returning to sport, the
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less rehabilitation should look like rehabilitation, and the more it
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should begin to resemble the sport that they're preparing for.
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Yeah, that's a great outlook on that. I think one
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of the biggest things is compensations with ACL rehab. Throughout
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the continuum, right, we know that they're not comfortable getting
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that positive shin angle, so they're going to compensate usually
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at the hip or ankle. And I think this is,
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like you mentioned, I think this is another bucket or
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movement pattern strategy that we need to really be kind
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of isolating, highlighting, and really bringing to the attention of
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the athlete as well as the rehab professionals that there
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are lots of compensation strategies that can occur during these
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curved and sport-specific movements. And I think this is another,
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just another, the paper just highlights the importance of just
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the same structures and principles throughout the whole ACL rehab
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is like, making sure we're exposing them to all these
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different demands and making sure that we're trying to quantify
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and visualize these compensation strategies throughout the whole perspective and
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throughout the.
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Whole continuum of care.
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So on that note, what are some buckets that can
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maybe hide early on or even in the later stages?
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Is it like rate of force development? Is it like
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overall power? Or even like energy system demands?
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Yeah, it's a good question. I think.
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One of the things that's important like mind shift shift
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mindset shift in acl rehabilitation is is kind of recognizing
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that like the the bottlenecks or like the rate limiting
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factors like they kind of change throughout the entire rehabilitation
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process right so like early on like all of our
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priorities are fairly obvious or at least like hopefully right
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it's like quiet the knee get your extension range of
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motion get the quad firing again restore gate all those
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type of things but you know, those things kind of
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dominate our decision-making because they have to, right? We're not
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going to worry about reactive change of direction capacity or
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agility-based things, multi-directional speed if someone can't fully straighten their knee.
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We can't worry about high-speed braking if they have a
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significant joint effusion, all those type of things. But, you know,
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somewhere kind of maybe in the middle to later stages,
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I do think the questions start to change or shift.
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And it's like it's no longer asking, you know, can
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they straighten their knee? Can they do a step down?
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Can they traverse stairs? It's, it's much more of like,
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can they function as an athlete again? And I think
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that's where rehabilitation gets really interesting because the late stage
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stuff is no longer really about simply restoring like isolated
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physical qualities. It's kind of restoring that athleticism and that's
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a lot more than, than strength or force production, you know? Um,
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I think it comes down to a number of different
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questions that encompasses like the totality of the athletic profile, right?
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It's like, can they produce force? Can they produce it quickly?
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Can they absorb it? Can they redirect? Can they maintain
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their movement quality? All of those type of things. And
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that's a very different conversation than what we're having early
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in the rehabilitation process.
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So I think if I had to kind of maybe.
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Center on an area that I've been thinking about more
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it's probably breaking capacity. I think we spend a lot
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of time worrying about like force production and outputs, and
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that's super important. It's hard to break those away from
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athletic movement in general, but I do think that additional
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time spent developing like eccentric strength capacities is super important.
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And it's something that maybe doesn't get as much attention
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as it should, because that's really the foundational stuff when
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it comes to breaking ability, deceleration.
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Capacity, all those types of things.
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And exposing athletes to progressively more demanding deceleration tasks is
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something that I think needs to be a very big
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component of some of your end stage work and certainly
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some of your late stage work, right? And I don't
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think that's just because that's like the only thing that matters,
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but because it's very fundamental to a majority of sporting actions, right?
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If we take acceleration or max velocity running kind of
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to the side for now, it's like every cut, every
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change of direction, like, there's a foundational capacity to decelerate
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that underpins success in those movements. And I think that's
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something that has certainly been a bigger emphasis for me
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and sort of my end stage or late stage rehabilitations.
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And it kind of goes hand in hand with.
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What you alluded to earlier, where rate of force or
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rate of torque development is increasingly important as well. Like
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those things are hard to separate when it comes to
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making a, a hard decel, like you need to be
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able to generate torque and force quickly and sport rarely
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is going to give you three to five seconds to
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to produce your force right they're all happening in like
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very short time frames fractions of sections seconds seconds so
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I think that those are two that kind of stick
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out to me and then I think the last one
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that has been sort of an emphasis for me as
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well is like we talked about kind of kicking things
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off a little bit, the, the ecological validity of like
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end stage rehabilitation to what they're getting back to. And
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then it's also just like the, the cognitive elements of it,
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the decision-making perception and action and all of those types
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of things. We need to move away from this more
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scripted sort of presentation and this less kind of sterile
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rehabilitation environment. And I think that we have to ensure
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that we're exposing them to elements of chaos, things that
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are constantly changing and, the athlete doesn't understand or know
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what's coming next. They're having to process visual information, reaction,
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all those types of things. So I think somewhere towards
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the end of rehabilitation, we need to kind of move
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away from rehearsed movement and actually start having them solve problems.
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And I think that those are kind of the big
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things for me that it seems fairly simple and straightforward
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when we're talking about it now, but I do think
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it's often maybe slept on a little bit and just
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can be sort of forgotten about towards those later stages.
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And then now we're.
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Faced with where a situation where there still is maybe
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a big gap or a big jump when we're thinking
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about ending rehabilitation, returning to practice, integrating with our team,
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training and return to competition. But I think it's sometimes
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maybe not given enough attention in our rehabilitation process.
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Yeah, I love it.
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You mentioned all these great things. Do you have any
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special tests that you like to use? Are you using
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the force plates a lot to quantify this rate of
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force development?
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Are you doing it under a fatigued state?
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Do you have any clinical pearls that you feel like
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you've really found success with successfully discharging this patient population
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towards the end stage?
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Yeah, I think big things for me ultimately always come
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back to have we fully restored the extensor function?
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I think that that's still priority number one.
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I think if you look at the research and the
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literature over the past year, you know, several decades, that's
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a recurring theme where we're just not fully.
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Restoring their quad function. But it goes deeper than that, right?
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Because it's not just simply a matter of like, am
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I restoring like their peak torque or like their.
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Max knee extensor strength?
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Like there are elements of like, can we make force fast,
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those explosive kind of strength qualities. So I think that
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it all starts for me with Did we do our
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job restoring the extensor function and quad function? I think
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that that's our primary goal as rehabilitation providers before we
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get into the weeds with anything else is like, let's
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keep the main thing, the main thing.
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Does their knee work well? Is their quad strong?
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From there, I think in terms of things that kind
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of guide my practice and end stage would be some
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00:12:52.029 --> 00:12:54.429
sort of isometric test to grab to their peak.
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But also isometric testing is.
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Likely going to be your best thing to try to
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capture some degree of rate of torque or rate of
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00:13:01.419 --> 00:13:04.519
force development. So I think like those things underpin like
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my late stages. I usually want to get some sort
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of isometric peak testing between 70 and 90 degrees.
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For us here.
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00:13:13.000 --> 00:13:15.639
I'd like to do some sort of rate of torque
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development test as well, which again, I'm lucky because I
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do have a dynamometer. I think you guys just purchased
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a humac as well. So you're also in the lucky
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group there. But an isometric test, an isometric like RFD
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or RTD test as well, where I'll have them just
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do like a one second push. And then I'm just
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00:13:33.379 --> 00:13:36.960
trying to kind of capture, you know, torque at 200 milliseconds.
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You know, relative to what they weigh, limb to limb.
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What are the kind of the, how do those limbs
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stack up there? Obviously an isokinetic test as well. 60
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degrees per second is kind of the workhorse for me.
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I think that gives us a very good capture of
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their ability to make force fast and Because in many ways,
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when you think about isokinetic testing, there is a bigger
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rate demand. More or less, you have to hit your
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peak torque in one second if we're testing at 60
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degrees per second. So that can be quite sensitive for
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the rate side of things as well. And then it
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also just gives you a picture of strength through range.
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So I think that in terms of hanging my hat on,
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did I do a good job of restoring the extensor function?
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Those are kind of the big three for me with
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respect to quad output. I'm still a big fan of
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00:14:23.279 --> 00:14:27.379
drop jumps. The reason why I like them is the
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00:14:27.399 --> 00:14:31.720
drop height is fairly standardized, so their collision that they're
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having to deal with when they hit the plates is
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going to be consistent. Both single leg and double leg,
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00:14:37.570 --> 00:14:39.049
those are big ones for me just to get an
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00:14:39.090 --> 00:14:42.970
understanding of some of their elastic qualities, their reactive strength measures.
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00:14:43.909 --> 00:14:47.190
Particularly single leg is more of a lagging test, I
292
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would say. can take quite some time for that to
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approach some degree of normalcy both with respect to symmetry
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limb to limb and also some of their more performance
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00:14:57.350 --> 00:15:00.870
measures if we're anchoring to either normative data or something
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00:15:00.889 --> 00:15:02.830
like that so I think that's an important one for
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00:15:02.850 --> 00:15:06.309
the reactive strength side of stuff and then from maybe.
298
00:15:06.090 --> 00:15:09.309
More of like the longer ground.
299
00:15:09.129 --> 00:15:12.830
Contact times or more explosive strength elements I still have
300
00:15:12.850 --> 00:15:15.769
a good counter movement jump double leg and single leg
301
00:15:16.250 --> 00:15:20.840
and then I'll often try to introduce some degree of
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00:15:21.120 --> 00:15:23.539
external load on a counter movement jump as well. So
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00:15:24.080 --> 00:15:26.870
Matt Jordan talks a lot about using a loaded counter
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00:15:26.889 --> 00:15:29.509
movement jump. That's part of our end stage battery there
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00:15:29.549 --> 00:15:32.470
as well, 30% and 60% of body mass.
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And the reason why.
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00:15:34.230 --> 00:15:37.960
I think that's a valuable test is it's very difficult
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00:15:38.080 --> 00:15:42.059
to hide any eccentric strength deficits limb to limb once
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00:15:42.100 --> 00:15:44.960
you start to get into a loaded environment. So you
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can oftentimes find people will normalize maybe their eccentric decel
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impulse or their breaking impulse through a body weight environment
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00:15:53.289 --> 00:15:55.529
in their counter movement jump. And then once you start
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to add on a little bit extra load, those kinds
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of deficits start to peak their head out again.
315
00:16:00.850 --> 00:16:02.309
It's very similar to.
316
00:16:03.950 --> 00:16:10.360
This period in rehabilitation when initially their eccentric peak velocity
317
00:16:10.460 --> 00:16:12.509
may be on the lower side where they're not really
318
00:16:12.549 --> 00:16:15.840
attacking the plates very aggressively or with a ton of intent.
319
00:16:16.559 --> 00:16:20.059
And they can almost have this false negative.
320
00:16:19.720 --> 00:16:22.740
Where their eccentric decel impulse really doesn't have much of
321
00:16:22.799 --> 00:16:23.399
an asymmetry.
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But as they start to attack the plates with more
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intent and they're.
324
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Dropping faster, their EPV is rising. Now all of a sudden,
325
00:16:31.559 --> 00:16:34.120
like that deficit starts to rear its head again. So
326
00:16:34.639 --> 00:16:36.639
I look at loaded counter movement jumps kind of in
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00:16:36.679 --> 00:16:38.840
a similar way to where like the forces that they're
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00:16:38.860 --> 00:16:42.639
having to manage, particularly eccentrically climb, that can start to
329
00:16:43.330 --> 00:16:46.279
appear again in end stage as a deficit with respect
330
00:16:46.299 --> 00:16:48.220
to their deceleration impulse.
331
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Or their vertical braking.
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00:16:49.830 --> 00:16:52.529
And then I think for more field-based stuff, I'm still
333
00:16:52.549 --> 00:16:55.690
a big fan of a 505 test. I don't use
334
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time to completion as a marker with respect to things
335
00:17:00.509 --> 00:17:03.529
that I'm monitoring. But I do think that if you
336
00:17:03.570 --> 00:17:07.019
can get some element of a qualitative assessment of their
337
00:17:07.059 --> 00:17:09.799
ability to brake at high speed, even if it's just
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a 30-meter entry to a stop, and then 180 degree
339
00:17:14.549 --> 00:17:18.690
change on like a 505, looking at breaking steps, looking
340
00:17:18.710 --> 00:17:21.670
at some of the kinematics as they're hitting those final
341
00:17:21.730 --> 00:17:25.329
three foot contacts. I like to use those as a
342
00:17:25.369 --> 00:17:27.309
bit more of like a field screen for like their
343
00:17:27.349 --> 00:17:28.569
deceleration capacity.
344
00:17:28.589 --> 00:17:29.970
And then ultimately I.
345
00:17:29.950 --> 00:17:34.109
Think that if you've restored their knee extensor function, both
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00:17:34.190 --> 00:17:38.369
peak and rate concentrically and eccentrically, they've shown to you
347
00:17:38.390 --> 00:17:42.660
that they can decelerate at progressive entry velocities and most
348
00:17:42.680 --> 00:17:46.119
of the change of direction stuff should be fairly good
349
00:17:46.359 --> 00:17:48.460
at that point in time because they kind of have
350
00:17:48.500 --> 00:17:52.279
the underpinning foundations to where it's probably quicker fixes around
351
00:17:52.319 --> 00:17:55.299
like some cueing or maybe some constraints, constraint based things.
352
00:17:55.420 --> 00:17:57.160
But I think those are the big ones for me
353
00:17:57.220 --> 00:18:01.380
when it comes to end stages, get the knee extensor
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00:18:01.420 --> 00:18:04.460
function back, make sure that they can break vertically and
355
00:18:04.640 --> 00:18:08.559
horizontally at speed and with intent. Most people are in
356
00:18:08.579 --> 00:18:10.619
a pretty good place by the time they've checked those off.
357
00:18:11.509 --> 00:18:13.329
And you've kind of already hit on this at this
358
00:18:13.369 --> 00:18:16.710
last point, but again, obviously re-injury rates of ACL reconstructions
359
00:18:17.170 --> 00:18:20.490
remains pretty high up there. Is there anything that we
360
00:18:20.549 --> 00:18:22.609
haven't talked about that you still feel like is a
361
00:18:22.670 --> 00:18:24.950
gap in the field that's kind of leaving these athletes
362
00:18:25.009 --> 00:18:26.109
vulnerable for re-tears?
363
00:18:26.950 --> 00:18:28.009
Yeah, it's a good question.
364
00:18:28.029 --> 00:18:31.579
And I've been thinking about this a fair amount lately,
365
00:18:31.650 --> 00:18:35.299
so I appreciated the question that we had that came through.
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00:18:35.319 --> 00:18:40.250
I don't know that I would say that like our
367
00:18:40.309 --> 00:18:43.339
protocols are failing. If anything, I think that we've made
368
00:18:43.359 --> 00:18:45.160
a lot of progress if we look back on like
369
00:18:45.200 --> 00:18:51.099
maybe the state of ACL rehabilitation several years ago. So
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00:18:51.160 --> 00:18:54.140
I think that we're making better clinical decisions and more
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informed clinical decisions. So I don't know that we're failing.
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00:18:56.700 --> 00:18:59.829
I think that we've evolved. But I do think that
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there is a bit of a paradox in ACL rehabilitation
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00:19:04.109 --> 00:19:06.089
that I don't think we talk about enough or I
375
00:19:06.109 --> 00:19:08.589
don't hear discussed enough. And it's kind of honestly the
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00:19:08.630 --> 00:19:11.680
way that I view or the lens that I view.
377
00:19:12.180 --> 00:19:13.079
Return to sport through.
378
00:19:14.099 --> 00:19:19.690
And ultimately, if we've done our job really well, and
379
00:19:19.710 --> 00:19:23.789
the athlete returns to high level sport, high level sport
380
00:19:23.869 --> 00:19:26.349
is inherently one of like the biggest risk environments that
381
00:19:26.369 --> 00:19:28.130
they're ever gonna experience, right?
382
00:19:28.170 --> 00:19:29.720
And if I've done a good job on the rehab
383
00:19:29.740 --> 00:19:30.359
side of things.
384
00:19:31.140 --> 00:19:33.559
They're gonna be sprinting faster, they're gonna be breaking harder,
385
00:19:33.579 --> 00:19:36.839
they're gonna be cutting more aggressively, they're gonna be reacting
386
00:19:36.900 --> 00:19:40.140
as opposed to like anticipating You know, they're competing against
387
00:19:40.180 --> 00:19:47.309
other individuals. And I think that success in rehabilitation doesn't
388
00:19:47.990 --> 00:19:50.460
eliminate exposure to risk. If anything, I would say that
389
00:19:50.500 --> 00:19:53.799
success in rehab actually restores the exposure to it because
390
00:19:53.819 --> 00:19:55.359
we're getting them back to doing the thing.
391
00:19:56.319 --> 00:19:59.410
And I don't say that to be like pessimistic, but it's.
392
00:19:59.769 --> 00:20:01.549
The reality that we live in is that we live
393
00:20:01.569 --> 00:20:07.170
in like a risk compression environment with the even if
394
00:20:07.210 --> 00:20:09.589
we do everything right, like the outcome isn't always going
395
00:20:09.609 --> 00:20:11.190
to be what we want. So we can have an
396
00:20:11.309 --> 00:20:14.500
athlete that has gone through a great process. They're incredibly
397
00:20:14.519 --> 00:20:17.599
well prepared and they can still suffer another injury. Meanwhile,
398
00:20:17.660 --> 00:20:20.339
you have the individuals that are maybe less of a
399
00:20:20.380 --> 00:20:24.140
rigorous process or less well prepared that don't re-injure. And
400
00:20:24.180 --> 00:20:25.819
I think that that's just kind of the nature of things.
401
00:20:25.859 --> 00:20:30.099
And it's an unfortunate reality. But the goal of rehab
402
00:20:30.119 --> 00:20:32.829
isn't to eliminate high risk exposures.
403
00:20:32.849 --> 00:20:33.890
I think that's impossible.
404
00:20:34.009 --> 00:20:37.400
It's going to be inherently demanding in our job as
405
00:20:37.440 --> 00:20:42.369
clinicians is to progressively expose athletes and prepare them for
406
00:20:42.430 --> 00:20:45.609
those demands and you know I think in terms of
407
00:20:45.630 --> 00:20:50.970
things that were maybe missing I think it probably comes
408
00:20:51.029 --> 00:20:54.490
back to the idea that I think why persistent re-injury
409
00:20:54.539 --> 00:20:57.359
rates don't necessarily tell me that our protocols are falling
410
00:20:57.440 --> 00:21:00.920
is failing is because it just kind of showcases like
411
00:21:01.019 --> 00:21:04.019
how difficult the task really is when we're returning someone
412
00:21:04.039 --> 00:21:08.029
back to sport it's an incredibly high bar And the
413
00:21:08.069 --> 00:21:10.230
only thing that I would say is maybe an area
414
00:21:10.289 --> 00:21:13.730
where we could continue to improve is going to be
415
00:21:13.789 --> 00:21:16.509
like that final transitionary period. I do think that there's
416
00:21:16.529 --> 00:21:18.690
a lot of gaps there, depending on the settings that
417
00:21:18.710 --> 00:21:23.000
you're working in, where it's just hard to consistently replicate
418
00:21:23.039 --> 00:21:27.279
the demands in a very controlled and dosed fashion when
419
00:21:27.299 --> 00:21:28.539
we get to those late stages.
420
00:21:28.799 --> 00:21:32.309
And I think that that's not really a a knock
421
00:21:32.380 --> 00:21:33.150
on the profession.
422
00:21:33.190 --> 00:21:35.250
I think it's just like an objective reality of like
423
00:21:35.329 --> 00:21:37.430
the nature and the constraints of some of the environments
424
00:21:37.450 --> 00:21:40.289
that we're working in where it's hard to have a
425
00:21:40.369 --> 00:21:45.369
very dialed, progressive and detailed, like on field progression in
426
00:21:45.390 --> 00:21:48.329
those final few months, particularly if you're working in settings
427
00:21:48.349 --> 00:21:49.470
where that's just not viable.
428
00:21:49.589 --> 00:21:51.349
So I would say that that's.
429
00:21:51.210 --> 00:21:53.559
More of just like an organizational problem, I would say.
430
00:21:54.099 --> 00:21:55.859
But I do think that that's an area where I
431
00:21:55.960 --> 00:21:58.819
still feel like, even in my own practice at times, like,
432
00:21:59.609 --> 00:22:02.730
We need to be able to create environments and opportunities
433
00:22:02.809 --> 00:22:08.630
to really smooth that transition from clinic to field and
434
00:22:08.650 --> 00:22:10.880
then field to competition. And I think that that's an
435
00:22:10.910 --> 00:22:13.700
area where I think there's the biggest room for improvement
436
00:22:14.339 --> 00:22:16.220
with respect to our rehabilitation process.
437
00:22:17.019 --> 00:22:19.240
Sticking on the same kind of theme here, we know
438
00:22:19.259 --> 00:22:23.140
that LSI is a very dominant objective measure. We're chasing
439
00:22:23.240 --> 00:22:25.839
LSI in a lot of different areas of objective testing,
440
00:22:25.859 --> 00:22:28.980
but we know that even healthy individuals aren't meeting these
441
00:22:29.019 --> 00:22:31.529
criterias that we set up and they're healthy, right?
442
00:22:31.549 --> 00:22:33.609
They're pain-free, they're injury-free.
443
00:22:33.630 --> 00:22:35.950
So how much, like, um, how many eggs are you
444
00:22:35.970 --> 00:22:38.769
putting in that basket of it's really, really necessary to
445
00:22:38.789 --> 00:22:41.490
get above those 90% thresholds of symmetry and a lot
446
00:22:41.529 --> 00:22:43.210
of these objective testing for your athletes?
447
00:22:44.069 --> 00:22:44.970
Yeah, it's a good question.
448
00:22:45.019 --> 00:22:48.000
I mean, I think LSI is valuable in my mind
449
00:22:48.059 --> 00:22:49.980
because I think that what it's done just as a
450
00:22:50.019 --> 00:22:52.819
profession is it's kind of moved us away from just
451
00:22:53.000 --> 00:22:56.539
clearing athletes based on time, right? It's, it's, for all
452
00:22:56.559 --> 00:22:58.819
of its flaws and all of its problem, like it
453
00:22:58.880 --> 00:23:02.430
has forced us to start to objectively measure some type
454
00:23:02.470 --> 00:23:04.990
of a physical capacity. So I think that that's a
455
00:23:05.009 --> 00:23:08.369
step forward. I don't think the answer is like abandoning
456
00:23:08.430 --> 00:23:09.069
limb symmetry.
457
00:23:09.130 --> 00:23:12.869
Like I still use it. Um, obviously hopefully we're anchoring to.
458
00:23:13.289 --> 00:23:16.509
Either like normative data or relative outputs, you know, torque
459
00:23:16.549 --> 00:23:19.839
to body weight, things of that nature. So I think
460
00:23:19.859 --> 00:23:22.859
that the answer isn't just like throwing LSI to the
461
00:23:22.900 --> 00:23:28.309
side despite its problems. It's more on understanding what information
462
00:23:28.369 --> 00:23:31.289
it's actually giving us, right? So at the end of
463
00:23:31.309 --> 00:23:34.009
the day, limb symmetry index is exactly.
464
00:23:33.569 --> 00:23:35.289
What it says it is. It's a comparison.
465
00:23:35.569 --> 00:23:37.670
It tells us how one limb compares to the other,
466
00:23:37.789 --> 00:23:41.309
performs to the other. That's still valuable information, but I
467
00:23:41.349 --> 00:23:46.230
don't know that it's ever been intended to answer the
468
00:23:46.279 --> 00:23:48.759
question that we're asking of it. It's like, it's not like,
469
00:23:48.819 --> 00:23:51.289
are these limbs symmetrical or the question that we're really
470
00:23:51.390 --> 00:23:54.269
asking is like, is the athlete prepared, ready for the
471
00:23:54.309 --> 00:23:55.470
demands of their competition?
472
00:23:55.509 --> 00:23:57.950
I think that those are two very different questions.
473
00:23:58.349 --> 00:24:01.819
Because to your point, you know, you can have great symmetry,
474
00:24:02.119 --> 00:24:06.460
but you could have two symmetrically, uh, weak limbs, right?
475
00:24:06.500 --> 00:24:07.279
Like that's a problem.
476
00:24:07.299 --> 00:24:11.819
We understand that, um, they may have great symmetrical quadriceps strength,
477
00:24:11.880 --> 00:24:14.660
but they have impairments in other qualities like RFD, like
478
00:24:14.680 --> 00:24:17.339
we chatted about a little bit earlier. So I think
479
00:24:17.400 --> 00:24:22.089
that because symmetry is, is not the same thing as preparedness.
480
00:24:22.589 --> 00:24:24.029
That's something that we need to kind of sit with
481
00:24:24.069 --> 00:24:27.539
and understand. Like preparedness isn't a number that's much more
482
00:24:27.559 --> 00:24:30.519
of like a profile. And I think that's probably how
483
00:24:30.559 --> 00:24:32.900
we should think about return to sport as opposed to
484
00:24:32.960 --> 00:24:35.380
like holding on to LSI as like, this is the
485
00:24:35.460 --> 00:24:37.299
ultimate thing that we're going to.
486
00:24:37.339 --> 00:24:38.460
Anchor our decisions to.
487
00:24:39.420 --> 00:24:40.839
It should be much more broad than that when it
488
00:24:40.880 --> 00:24:43.450
comes to our assessments and then our return to play decisions.
489
00:24:43.470 --> 00:24:45.829
Like it should not be anchored off of performance in
490
00:24:45.910 --> 00:24:48.430
one single test, regardless of if their LSI is like,
491
00:24:48.930 --> 00:24:51.970
good or middle of the road. I think that starting
492
00:24:51.990 --> 00:24:57.390
to shift away towards a more encompassing battery of stuff
493
00:24:57.630 --> 00:24:59.950
that actually allows you to build the entirety of the
494
00:24:59.990 --> 00:25:03.529
physical profile for that athlete and then weighing some of
495
00:25:03.549 --> 00:25:06.299
those things potentially more heavily than others based off of
496
00:25:06.410 --> 00:25:09.539
kind of your clinical reasoning and your decision making is
497
00:25:09.619 --> 00:25:12.599
much more of kind of my approach to things. LSI
498
00:25:12.640 --> 00:25:16.059
is still valuable, but just understand the question that you're
499
00:25:16.140 --> 00:25:18.769
asking of it. And I think you use that as
500
00:25:18.809 --> 00:25:21.190
kind of your marker for how much weight you're going
501
00:25:21.210 --> 00:25:24.400
to put into something like a limb symmetry index. Still valuable,
502
00:25:24.440 --> 00:25:27.900
but certainly is going to be incomplete relative to what
503
00:25:27.940 --> 00:25:30.220
we're probably hoping for, what we should be shooting for,
504
00:25:30.240 --> 00:25:32.019
for some of those return decisions.
505
00:25:32.920 --> 00:25:34.559
Yeah, I love it. I completely agree.
506
00:25:34.599 --> 00:25:37.809
I think LSI in one test tells us a lot,
507
00:25:37.829 --> 00:25:40.549
but again, it doesn't tell us nearly enough to get
508
00:25:40.589 --> 00:25:42.690
an athlete back on the field. So I appreciate you
509
00:25:42.710 --> 00:25:45.650
kind of making that delineation of the testing battery and
510
00:25:45.650 --> 00:25:48.839
90% across all your whole battery probably holds a lot.
511
00:25:48.740 --> 00:25:50.400
More weight than an isolated test.
512
00:25:50.480 --> 00:25:53.180
So one of the hardest things to quantify is that
513
00:25:53.420 --> 00:25:58.349
psychology of the injury. How do you feel like you're
514
00:25:58.410 --> 00:26:02.250
assessing this fear of re-injury, fear of movement, fear of
515
00:26:02.569 --> 00:26:04.170
returning to sport? Can you just talk a little bit
516
00:26:04.190 --> 00:26:06.910
about just how you approach either this conversation or how
517
00:26:06.930 --> 00:26:09.049
you're training this throughout your rehab?
518
00:26:09.869 --> 00:26:15.720
Yeah, I think psychological readiness is an interesting thing for me.
519
00:26:16.039 --> 00:26:18.180
And I think it's It's kind of one of the
520
00:26:18.500 --> 00:26:22.900
more misunderstood or maybe misapplied aspects of ACL rehabilitation in
521
00:26:22.940 --> 00:26:25.880
my mind because I think a lot of times when
522
00:26:25.920 --> 00:26:33.230
we talk about physical rehabilitation and psychological rehabilitation, it seems
523
00:26:33.269 --> 00:26:35.509
as though we can sometimes treat them as though they're
524
00:26:35.569 --> 00:26:40.099
two completely separate processes. And I just don't think about
525
00:26:40.119 --> 00:26:41.839
it that way. I think that those things are kind
526
00:26:41.859 --> 00:26:47.430
of happening... simultaneously, like throughout the entire rehabilitation journey. So
527
00:26:47.990 --> 00:26:51.289
to me, confidence isn't something that I'm like just assessing,
528
00:26:51.329 --> 00:26:53.930
like once an athlete hits the nine month mark or
529
00:26:53.970 --> 00:26:56.380
the six month mark, you know, there's still value in
530
00:26:56.440 --> 00:26:59.799
using questionnaires. The ACL RSI is something that I use frequently,
531
00:27:00.099 --> 00:27:03.519
but I think it's, it's a bit reductionist to look
532
00:27:03.539 --> 00:27:06.400
at it that way. So like, I think confidence is
533
00:27:06.460 --> 00:27:09.650
something that you're kind of actively building with the athlete
534
00:27:10.349 --> 00:27:12.730
every single session or every single day that you're with them, right?
535
00:27:12.750 --> 00:27:15.289
Like every single time we prescribe a drill or an
536
00:27:15.309 --> 00:27:19.630
intervention that goes well like their their confidence should grow
537
00:27:19.650 --> 00:27:22.369
you know every successful progression that we make i think
538
00:27:22.410 --> 00:27:25.170
is gaining their confidence and i think it's it's something
539
00:27:25.190 --> 00:27:27.930
that we don't really like give athletes or they can't
540
00:27:27.970 --> 00:27:32.730
give themselves like it's earned throughout right so correct me
541
00:27:32.769 --> 00:27:34.799
if i'm wrong john but i've never had an athlete
542
00:27:34.819 --> 00:27:37.799
that you know wakes up one morning and like suddenly
543
00:27:37.839 --> 00:27:40.799
decides that uh I'm going to like trust my knee.
544
00:27:40.960 --> 00:27:42.559
It just like doesn't happen like that. It's kind of
545
00:27:42.599 --> 00:27:45.980
like this evolving thing, almost like a snowball kind of
546
00:27:46.000 --> 00:27:49.960
rolling downhill. And I think my analogy that I use
547
00:27:50.549 --> 00:27:54.230
when talking about this is it's kind of like a
548
00:27:55.609 --> 00:27:57.410
checking account or like a bank account to where it's
549
00:27:57.430 --> 00:28:00.710
like every time we have a successful exposure to whatever
550
00:28:00.750 --> 00:28:04.569
it is or we see improvements in our capacities throughout
551
00:28:04.609 --> 00:28:08.259
the rehab process, like they're constantly like putting deposits into
552
00:28:08.410 --> 00:28:12.000
the confidence bank account. And then ideally, like if we've
553
00:28:12.119 --> 00:28:16.829
stacked those up across six, nine, 12, whatever months, like
554
00:28:17.410 --> 00:28:19.710
competition comes in and like, that's when like the deposit
555
00:28:19.769 --> 00:28:22.529
is made or excuse me, the withdrawal is made. But
556
00:28:22.549 --> 00:28:26.119
I think that if we've spent the last nine, 12
557
00:28:26.119 --> 00:28:30.480
months consistently making deposits, showing them that they can progress
558
00:28:30.980 --> 00:28:33.039
all of these types of things, setting up an environment
559
00:28:33.059 --> 00:28:36.000
for them to be successful, they're usually in a really
560
00:28:36.019 --> 00:28:40.289
good place. And I think that That's kind of more
561
00:28:40.309 --> 00:28:43.450
of my view with respect to the psychology part of
562
00:28:43.490 --> 00:28:47.380
things is if we're doing a good job restoring a
563
00:28:47.619 --> 00:28:50.819
lot of like the physical preparedness side of stuff and
564
00:28:50.839 --> 00:28:54.299
we're being appropriate in our progressions with the individual, I
565
00:28:54.940 --> 00:28:57.920
think that their confidence kind of grows alongside that. Not
566
00:28:57.960 --> 00:29:01.019
as though it's like some separate entity that's distinct.
567
00:29:00.609 --> 00:29:01.509
From the process.
568
00:29:01.589 --> 00:29:05.009
I think that they kind of go together like psychological
569
00:29:05.069 --> 00:29:08.390
confidence and trust in the knee. comes as their physical
570
00:29:08.430 --> 00:29:12.079
preparedness continues to grow and expand and reach kind of
571
00:29:12.119 --> 00:29:14.240
that level that we're hoping it gets to by the
572
00:29:14.279 --> 00:29:15.480
time they're at the end of the process.
573
00:29:16.579 --> 00:29:21.230
Yeah, I think people think of psychological readiness starting towards
574
00:29:21.250 --> 00:29:23.329
the end of the six, nine month mark.
575
00:29:23.450 --> 00:29:24.430
I think it starts day one.
576
00:29:24.450 --> 00:29:27.799
I think, like you said, it's If you progress properly,
577
00:29:28.130 --> 00:29:32.079
this psychological readiness is being worked on every single session
578
00:29:32.099 --> 00:29:33.920
you have, every single home exercise program.
579
00:29:34.140 --> 00:29:36.890
It's a long, long process to build this.
580
00:29:36.990 --> 00:29:39.690
And like you said, you can't wake up one morning
581
00:29:39.730 --> 00:29:41.599
and be like, hey, I'm going to go run, I'm
582
00:29:41.619 --> 00:29:42.779
going to go compete, I'm going to go do all
583
00:29:42.799 --> 00:29:44.940
this stuff. So that's a great point you make, and
584
00:29:45.000 --> 00:29:48.539
I definitely agree with regards to psychological readiness. I think, again,
585
00:29:48.660 --> 00:29:52.000
it's very underrated, very important, but it starts at day one.
586
00:29:52.880 --> 00:29:53.619
Any other thoughts on that?
587
00:29:54.440 --> 00:29:56.109
No, I mean, I think I feel similarly.
588
00:29:56.170 --> 00:29:58.170
I think the other thing of it too, right, is
589
00:29:59.059 --> 00:30:02.980
I think fear and hesitancy through this process is normal.
590
00:30:03.180 --> 00:30:06.180
If you're returning to sport after a major knee injury,
591
00:30:06.809 --> 00:30:09.809
there's going to be some level of apprehension that is
592
00:30:10.390 --> 00:30:14.089
probably justified and expected. So I think it comes back
593
00:30:14.130 --> 00:30:18.289
to more of like, if we have secured the physical
594
00:30:18.349 --> 00:30:21.089
profile or the physical readiness markers that I think we
595
00:30:21.190 --> 00:30:25.049
need to kind of make that progression and make that
596
00:30:25.089 --> 00:30:27.650
return to sport. And they're still lacking some of maybe
597
00:30:27.690 --> 00:30:31.289
like the, the psychological preparedness side of it. Um, I
598
00:30:31.329 --> 00:30:33.329
think that's, it becomes a little bit of a different question.
599
00:30:33.390 --> 00:30:35.069
Like that becomes something that we need to try to
600
00:30:35.109 --> 00:30:37.190
maybe dig a little bit deeper and understand why.
601
00:30:37.210 --> 00:30:39.910
But I, I think that more often.
602
00:30:39.690 --> 00:30:46.359
Than not, the individual that is physically prepared, confident, we've
603
00:30:46.400 --> 00:30:50.900
exposed them very well throughout their rehabilitation process. Their RSI
604
00:30:50.940 --> 00:30:53.740
value is going to track along, just as they progress
605
00:30:53.759 --> 00:30:56.839
their way through rehab. So I think that in many ways,
606
00:30:56.900 --> 00:30:59.539
it's probably not as though they need distinct interventions. I
607
00:30:59.579 --> 00:31:01.619
think that there's a lot of crossover and carryover that
608
00:31:02.660 --> 00:31:05.900
has them progressing throughout rehabilitation.
609
00:31:06.660 --> 00:31:06.960
Awesome.
610
00:31:07.039 --> 00:31:08.519
I think that wraps it up. Do you have any
611
00:31:08.680 --> 00:31:13.009
other comments, concerns, questions about this topic that you really
612
00:31:13.069 --> 00:31:17.589
want clinicians, coaches, athletes to know before we end here?
613
00:31:18.430 --> 00:31:20.319
No, I mean, I don't think so. I mean, Once again,
614
00:31:20.359 --> 00:31:22.319
thanks for having me on, John. I appreciate the discussion.
615
00:31:22.339 --> 00:31:26.160
It's definitely a good one. Hopefully I didn't run away
616
00:31:26.400 --> 00:31:28.420
with the train of thought too much. But I think
617
00:31:28.460 --> 00:31:31.839
the biggest thing that I would say is ACL rehabilitation
618
00:31:31.880 --> 00:31:35.259
is hard. I think that it's often presented as something
619
00:31:35.279 --> 00:31:38.240
that is much more glamorous than it actually is. And
620
00:31:38.279 --> 00:31:42.099
the reality is that we're all going to have outcomes
621
00:31:42.480 --> 00:31:45.839
that are maybe not what we envisioned or what we wanted.
622
00:31:46.059 --> 00:31:49.519
And I think that that's just a consequence of the
623
00:31:49.920 --> 00:31:52.440
very difficult task that it is of restoring someone to
624
00:31:52.619 --> 00:31:56.200
returning someone to sport restoring their level of performance nobody's
625
00:31:56.240 --> 00:31:59.420
batting a thousand out here it's a very difficult task
626
00:31:59.579 --> 00:32:02.680
but I think that if you can have confidence in
627
00:32:02.700 --> 00:32:07.170
your process the outcomes hopefully are going to take care
628
00:32:07.190 --> 00:32:10.349
of themselves but that doesn't necessarily mean that because we
629
00:32:10.390 --> 00:32:12.710
had a bad outcome that our process was bad I
630
00:32:12.730 --> 00:32:14.910
think that that's an important thing to kind of sit
631
00:32:14.950 --> 00:32:17.440
with is the only thing that we can control through
632
00:32:17.480 --> 00:32:21.559
this process is is how we're handling our day-to-day, what
633
00:32:21.579 --> 00:32:24.579
our rehabilitation process looks like. If we've done a good
634
00:32:24.619 --> 00:32:27.680
job with that, I think that we can be confident
635
00:32:27.839 --> 00:32:30.480
with the approach that we took, even though we may
636
00:32:30.500 --> 00:32:33.900
have outcomes that don't always go our way. Process is important.
637
00:32:34.480 --> 00:32:37.200
It's never going to be perfect. Keep doing the thing,
638
00:32:37.809 --> 00:32:41.750
get your quads strong. And I think that ultimately let's
639
00:32:41.769 --> 00:32:43.930
continue to try to kind of drive the ship towards
640
00:32:45.009 --> 00:32:48.230
having better outcomes more repeatedly, but it's just a difficult
641
00:32:48.269 --> 00:32:51.680
task And something that I'm continuing to try to refine.
642
00:32:52.019 --> 00:32:55.019
And I think that we're all probably somewhere along that
643
00:32:55.059 --> 00:32:56.420
journey in the same boat as well.
644
00:32:57.240 --> 00:32:59.079
Awesome, Kevin. Thank you very much for your time. And
645
00:32:59.099 --> 00:33:01.220
I know the audience will definitely benefit from it. So
646
00:33:01.349 --> 00:33:01.789
thank you again.