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Save $200 Off Our Online Knee Course
Learn how to evaluate and treat the knee with my online knee course with Lenny Macrina. Click here to learn more and save $200 off the course this week only.
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On this episode of the sports physical therapy podcast, I'm joined by Ariel Giordano. Ariel is the director of clinical services and residencies at the university of Delaware. Physical therapy clinic. And this episode, we're going to be talking about a paper that their group published in the journal of sports health that talks about their recent advances to their ACL reconstruction guidelines. I thought this was an amazing paper because a group with such extensive research and clinical experience coming together to update their guidelines is something that I found very educational. I think you're going to really enjoy this episode.
Mike:Hey Ariel. Welcome to the podcast. How's it going?
Airelle:I'm great. How are you, Mike?
Mike:I'm doing great. Um, obviously, uh, you know, thank you so much for taking time out of your day. I know you're a busy clinician, so this isn't always easy to carve out some time to share your experience and your knowledge, but we really appreciate you doing so. Awesome. So big topic for today is ACL's. And obviously you guys have so much experience with ACL's at the university of Delaware. Um, you recently were a coauthor in a paper, and I usually read the whole title, but this one's a big meaty title. So let me see. So ACL reconstruction, rehabilitation, clinical data, biological healing, and criteria, and based milestones to inform a return to sport guideline. It was a great article and what I love and what you guys should be so proud of. And you're so humbled to do it this way too, is you took a step back and you said we don't want to just sit back and do the same thing over and over again. We want to revisit our guidelines and keep them fresh. Look at the milestones and base them on current evidence and your experience. It's not just evidence, it's your experience. And I think it was such an amazing thing that you did with that paper that you did that I feel like everybody should publish a paper like that every now and then w w when you have so much experience, you have to update your stuff and you have to share that with everybody. That was really awesome. So kudos to you for doing that. I'm sure that was a big project. Uh, how many months of work did that take you
Airelle:Hm.
Mike:years?
Airelle:more exactly. It was kind of thoughts over years. And then I, you know, actually pulling that data in a system that our current system that isn't so friendly was a lot of manual labor, but, um, Um, there's residents on the paper and I had a lot of help with that. Um, but one of the, I would say one of the neat things that is a little different about this paper, we've, we've done clinical practice guidelines and milestones before, and we were really a proponent of following criteria and based milestones. What's different about this. We have this rehabilitation guideline in the early nineties, Terry Jomon, I'll put it out first. And then Doug Adams, one of our sports residents and myself were on another paper in the early two thousands. Revisiting it again with the current literature. But this time we actually, you know, over time treating patients, we're looking at the milestones and I'm like swelling. Swellings lasting longer. What's happening. We're having more meniscal repairs, of course. But even in those that aren't, um, you know, our guidelines still recent and let's actually look at what we're doing. Are we following our guidelines? Like we say, we, we, we hope we are, but are our clinicians really doing it? And so it was an interesting look.
Mike:That's awesome. And w and w what would you say, like, what was the biggest reason why you wanted to update it now? Was there a certain reason?
Airelle:Uh, it had to be, um, our previous one still had returned to sport. weeks, you know, 12, 12 to 20 weeks, you know, if they pass these milestones and they're strong, great send them back. And you know, we think back now, and how many people did you send back at 12 and 16 weeks? It makes you, it makes you shutter. So, um, as we train our students, that's, this is a big push for us in why we keep up to date on everything. We're training our students on the second floor of our building. They're coming into our clinic. Best practice. And so I go upstairs, I go to teach them and I'm like, oh, our protocol, well, this was written a few years ago. So, um, now it says this, you know, and I'm like, we have to change this. And I'd like to say why we're changing it.
Mike:Right. Right. And, and, and have a rationale as to why you're changing it and not everything can be found in evidence from research. It's also your experience. So that's why I love papers like this because you know, you're not in a lab. Right. You're on the ground floor, getting your hands dirty. So your clinical implications from your experience are super valuable to me. And I'm sure everybody listening to this. So I think that was, that was awesome. So, um, let, let's go through it, like, kind of like through the paper a little bit, let's start with some of the early stuff that you, that you mentioned. Um, I liked how you kind of broke out a section called. Call it like early clinical milestones. And you looked at things like restoring swelling, range of motion, strength, you know, kind of the basics that I think sometimes we take for granted. And then maybe sometimes that we don't have enough criteria to say like, wait a minute, like you alluded to earlier, like, is the swelling too much for them to progress to the next phase? Um, w what did you, what did you find with some of the early clinical milestones and what kind of clinical changes did you make based on these, these new five?
Airelle:Yeah. Um, great question. So I was really, I kept going back to this a fusion aspect and, you know, back in the day, when we first started practicing people were in the hospital for an ACL reconstruction. Um, they weren't cast it at that point, at least when I started practice, but you know, they were out three or four days. It was a large surgery. Now you can barely tell you have an incision same day surgery. People are working from home all the time, and they're going back to work two days later. And I think that had a big plus we're, we're re we're repairing meniscus. Right? And so that, that changes things a little bit too, but. Life is crazier.
Mike:right.
Airelle:didn't have self, we didn't have all these things to keep up on and do. And I have to go here and our kids are doing seven sports a piece. And, you know, you could sit at home for five days and get your swelling under control and have somebody take care of you. Um, so that was one reason I wanted to look at it and we really struggled to get that quad going when there's a lot of things.
Mike:Right,
Airelle:Um, and then progress weight-bearing exercises and really get to those later stages if swelling still there in the knee. So that was kind of one of the flags initially that wanted to, that made me want to look at this data. We, you know, we found we're very picky, very picky about getting that extension and range of motion back. And I think you can see that, you know, regardless of the group or what surgery they have. One to two weeks and we have, we have, um, re re sorry, extension range of motion back. Swelling is still lasting up to three months. Um,
Mike:That's crazy.
Airelle:I, you go back, we're very particular about how we measure it too. Right. We do a suite test, you know, we're not doing, um, girth. That's not looking at the intraarticular swelling necessarily like you would have in a TKA or something, but you go back to the surgeon. He's like, oh, it looks great. There's no swelling. There's, there's still swelling.
Mike:Yeah, for sure. Yeah.
Airelle:You're seeing that. So something's not super happy in the knee and we're trying to base some of our progressions around that. So if we add exercises and the knee swelling, we're going to drop back and apply soreness, rules and swelling, and, you know, maybe take a step backwards. And so every person and how they load their knee a. Meniscal repair so on and so forth makes a difference. So we really do pay attention to that a lot. We're measuring rain, uh, effusion, maybe, you know, throughout the session while watching how immediate exercise and loading is changing that. Um, the other thing. We have our outcome measures, which isn't really sexy to anyone, but, you know, we have our, our outcomes scores and however you measure those patient reported outcome measures, we're finding those are pretty important back in the day. In our first versions of this paper, we chose. You know, we didn't, this is again, the first time that we actually looked at our data and okay. The number we chose as an expert clinicians did this match up. And so this did change a little bit. Um, we increased the, the percentage that people rate themselves out. So they feel, you know, they feel pretty good above 80% with activities of daily living by two to three months.
Mike:That's
Airelle:Um, the. Strength quad strength. That's I think that's our soapbox. Um,
Mike:That that is it's. If, of all the things that I would say, this is almost like Tommy, John injuries in baseball, I deal with all the time. We've put, we've put so much emphasis on something and yet continue to fail miserably at it. It is daunting. So everybody's talking about how quad strength is behind, behind, behind, and yet. We're still not doing it, but like you said, maybe, you know, maybe, maybe we've lost focus on some of the basics, like restoring their range of motion in their fusion before that we're just push, push, push, and maybe that's causing the inhibition, who knows. Right. But even going back to your fusion point, like I know a lot of clinicians that I talked to around the country that aren't in great settings like yourselves, they will say like, well, I don't get the opera port. I don't know. That they had a meniscus. Sometimes the surgeon doesn't even tell you some of the, you know, the, the secondary structures that were injured or maybe even surgical procedures that were done. Um, but that's the good part about your guidelines and your recommendations is it's based on pain and swelling. And that's going to tell the story probably more than anything else anyway. So, you know, that, that was, that was awesome. But yeah, let's get back to strength.
Airelle:W w we see college kids, um, you know, that are coming in from different institutions and we can't get ahold of their parents. You'd be surprised what we hear and what we don't get, um, in order to treat these guys.
Mike:I
Airelle:um, So quad strength. So, you know, we, we had bone patellar bone. We had hamstring and allograft. We didn't have any quad tendon in our studies. We've had a few in the clinic, but most of the surgeons around here are not doing that. Um, just like most of the other literature, the bone patellar bone takes longer to get strength back. And then you add the meniscal repair and we add, you know, a few more weeks to that as well. Um, and it's, it's drastically different. It's significantly different than the quad strength returning after hamstring and allograft.
Mike:Yeah, that's crazy.
Airelle:There are harder to treat you're, you're taking part of the extensor mechanism. Um, and then, you know, pretty much insulting it with attendant opposite. And so, you know, we have, we, I think we have better ways and we understand loading more. Um, but we still need to keep mindful of this. And how do you manage it when they start to have pain and know that this is going to happen in those individuals?
Mike:Right. So for your clinical milestones, the big things you found, were you in, I think the range of motion part going back to range of motion. It just goes to show that we've been harping on early knee extension for so long that I think as a profession, we can say check we've we're. We're good at that. Now we, we, we identified that we were bad at. 20 plus years ago, and we've made that evolution. Um, but now maybe we were focusing on quad and getting people moving and maybe that's too fast or maybe we're not, um, we're not, we're not giving enough credit to maybe the effusion that is present that may be inhibiting that, and maybe we should focus on that. Is that a good summary of some of the things you found with that?
Airelle:Um, yes, I agree. And I would add one more thing to that and it's gate and I, maybe that aspect doesn't stand out enough in this paper. It's a little difficult to have milestones with gate. You need to fix that day one, but they're an immobilizer and they're on crutches. What have you, but even in an immobilizer, I tell our students, like you can teach them how to put their heel on the ground and can track their quad. And if they're in that immobilizer or they're on a crutch and they're using their leg as a peg, they're not doing a superior glide of their patella. They're not stepping on it, slightly flexed, pushing it back. We see really bad compensation strategies and you can strengthen the daylights out of them and I'll get a consult or someone that comes to the clinic after going months of therapy elsewhere. And they're like, everything looks great, but I'm still struggling with the stairs. I still have patellar, you know, I still have, um, um, patellofemoral pain and then I look at them. Okay. They can't walk at all.
Mike:Right,
Airelle:think they're doing it, but they're hyperextending their knee the whole time. And if you're hyper extending your knee, at least in my experience, I don't have a, I don't have hard data on this. You're hyper extending your knee all the time, and you're not using your FOD, I guess, strengthen you all day. You're not using it. And so. Unfortunately, you know, we, we stopped seeing the increases in our maximum initial isometric contractions, which is another reason my soap box is to measure, make sure you're measuring, um, quiet strength because you don't see these subtle changes when someone's really good at compensating and then take that over life. And now we're seeing these people as total knee replacement patients, and they've been walking like this for 30 years.
Mike:Right. Yeah. That's, that's a tough strategy that they develop over time. And, you know, sometimes we take for granted, right? That if you work on patellar mobility, knee range of motion, swelling, quad control, that gate will just magically come back and oftentimes. Right for people, but some people still just resort to the path of least resistance. Right. And develop a compensation strategy. And then that over time is going to change everything from patellofemoral contact force is to your hip. I mean, yeah. There's. That's that. Yeah, that's, that's crazy. Um, well regarding quad strength, one of the more controversial recommendations, which I think is actually hilarious because there really isn't much controversy here, but like it's, it's more of a social media controversy, right? It's it's, it's when you take any concept in just 280 characters, you can argue it in either direction, either way. I think that's, what's not fair. But one, one of the more controversial things was regarding the use of open kinetic chain, knee extension. And one of the things that yourself and I've seen Lynn Snyder, Mackler talking a lot online, and I think we've all we're starting to get to this evolution that you can do full range of motion, knee extension, you know, historically for maybe some of the younger clinicians, you know, we stopped from 90 to 40 degrees because of some basic biomechanical studies that. You know, perform way back in the day that showed that strain on the ACL increases during terminal knee extension, which it does that's
Airelle:it does.
Mike:Right. You know, but, um, but I think what we're starting to do is say, well, quad strength. Wasn't so good. Maybe we need to evolve that. Can you tell us a little bit about your recommendation for open Canadian knee extension? Why do you recommend that and how, what parameters do you recommend that app for people to get.
Airelle:Yeah. So, you know, it's, it's like asking are anti-inflammatory safe.
Mike:Right.
Airelle:Ah, you know, it's just, you just can't answer the question like that. And so is there strain with open kinetic chain exercise? Yes, there is. But how, how does this compare to activities of daily living? How does it compare to close chain exercises of which everyone's perfectly comfortable with? Um, and you know, long story short, they result in about a third of the strain observed during walking and similar strains to close kinetic chain squatting, which we're doing very soon after these procedures. So, um, we do open chain exercises day, as soon as we see the patient post-operatively and you're, you're not.
Mike:to zero full, full on day one.
Airelle:I will say that is dependent on the graph type, right? We may actually not go all the way to 90 if your bone patellar bone. So I may not stretch it and contract it. You know, there's things like that. Are there patella, is there patellofemoral pain? Maybe we won't go all the way to zero. Um, when you're actually measuring one rep max and things like that, where we're doing more 90 to 45, we're not doing all the way to zero, but.
Mike:So, I'm glad you said that right there, because that is one of the nuances that when I look at your protocol, I read that and I know exactly what you're saying in your thinking by that. And I think that's some of the misconceptions out there is even you are saying that, yes, we do open kinetic chain, knee extension to terminal knee extension. But if we're going to do a max force this early, we're going to do it within the 90 to 40 range because yes, you can do it, but we may not want maximum force. That early. And, and I think that's the point. I, the part that scares me about this, this false controversy that's on social media is that a young clinician that is super impressionable, that doesn't have experience and wants to get on the rye ride, like lift heavy load group. I can see them being two weeks. I have an ACL on and on a knee extension machine. 200 pounds with the person and tell him to go crazy. And it's it's and that's where I just like, we have to be cautious with how we get that word out. Right. So, so I, I love that you brought that up because when I read your protocol, I know exactly what you're saying, but by putting it in there, so, so awesome. All right. So, so, uh, full knee extension right away. Tell me about your loading parameters then. Like when do you start like, like gradually increasing that load and when do you start getting more aggressive with it?
Airelle:Um, Because we measure we, and I don't do, I will say not until the later stages. Do I do a lot of one rep max testing? Um, because we have IC isokinetic dynamometers um, I would rather set them up on a knee extension machine. If you don't have a nice, a connect on anemometer and do an isometric test a little bit twofold, um, You can potentially do it at different angles. You can test them at different angles. Um, you also can then dose appropriately for NMES, which you should be doing in these patients as well. And so without a measure, I don't know if I'm getting better. We measure an MBIC a maximal isometric contraction, every single visit,
Mike:Uh, how do you do that? How do you measure that?
Airelle:we're doing it on ice kinetic dental.
Mike:Uh, right.
Airelle:But if you didn't have one, which, you know, we teach our students and then they go out and they don't have access to these devices. And we understand that you can set up a handheld dynamometer with a belt. You can put a handheld dynamometer and make the ice make the knee extension machine. Essentially isometric puts so much weight on there. You can't move it and then get a more accurate number because you're doing handheld dynamometry is not accurate in the.
Mike:right, right.
Airelle:Um, so a lot of people now that we work with have these set up on their knee extension machine. And so they're getting an easy outcome measure at that time. You know, every visit let's look at knee extension, and then we set you up isometrically, add NMES to the program, make sure that you're getting above 50%, um, dose with that.
Mike:That's great. So, so you D you'll so for most normal clinicians, that's what I'm going to call us. Like normal people that don't have amazing facilities like yours, but, so, so you're saying you, would you recommend doing an MVAC each session as just like the beginning at the beginning of them before you start applying that, which is phenomenal to track progress, right. And plateaus, like, wait, maybe the fusion, the fusion is up a little bit, but MDIC is still. Was proceeded, like those types of, of clinical interpretations. I like that. But, but again, it's that assess don't guess concept because I, that we get in trouble when, when it's obvious that the person has played plateaued, it's probably two to four weeks too late. Right.
Airelle:Absolutely. Absolutely. And we, we have a, um, it's an unwritten rule. You don't see progress in three visits. You, you need to see you. You need to talk to somebody. And so it'll be like, Hey, you know, I'm not seeing progress, but we increased knee extension. We increased squatting. We increased, they're doing all these things. They're not getting sore, but we increased all these factors and their MBIC isn't changing. And I usually say, I need to come out and look at. Like we're missing something with how they're using their leg every day. They're not having carry over and they're not using that. And, um, it's not usually the swelling goes up. We have looked at swelling and inhibition. Um, you know, when it gets wet, when you're up in those higher stages, two plus three plus, um, you'll definitely see. More difficult, poly activating that quad. But when you're down in this, you know, we're, we're really moving on close chain exercises and, you know, their trace one plus that sort of thing. Um, it doesn't usually change their MBIC, but their gait and not using it. And like, I want to show you on the camera, but you know, they're walking. They go to turn and they extend that knee to turn well, they have no confidence and no, you know, not enough strength to accept weight, flex the knee turn and push pushed off. And so it's little things like that that I don't think we have enough time to teach in the entry level program and that people are missing.
Mike:Right. I agree with that. So, all right. So open chain, we start early, we start loading it. Now, when you talk about load, right. And again, just even going through your protocol here, it's well, let's say we're in the four to eight week mark after, or even zero to eight week. We'll say right when you're talking about loading open kinetic chain, knee extension determined the extension. W what are we talking about for weight here? Are we talking about ankle weights? Are we talking about a machines? Like, like how aggressive of weight are you doing that early in the procedure? All the way towards terminal, knee extension.
Airelle:Yeah. Um, so dependent on the individual,
Mike:know that that was an unfair court. See, I'm getting I'm new at the podcast game. I still don't. I have a bad coup I have bad questions, but
Airelle:Oh, I think I, you know, if, and I teach the students, I'm like, if you just, if you start straight leg raises with a three pound weight and you're like, oh, that was really good. We'll do four pounds next time. Yet they could do 10, 12, 50. You didn't know he didn't measure it. Right. And then all of a sudden you have five visits of wasted. I'm going up 100 pound every day. So, um, you know, I think if they can do a straight leg raise, if they can take some cuff weights with that, Likely we're going to put them on the, any extension machine and you're going to be low 10, 15 pounds in the beginning. Um, if they can't, maybe we're going to do, you know, up by laterally down unilaterally, if they can't accept weight on there, or maybe we do go down to the cuff weight, but I find that to be rare, um, even in our total knees, like they usually can get on the, on the knee extension
Mike:I, and I great point because there's so many times we just get stuck with ankle weights. Right. And, and man, I w we probably, I don't even know why we get past ankle weights fast. Right. And, and I think that's, that's a primary goal of if it's 4, 6, 8 weeks after ACL, and you're still doing ankle weights, uh, either you have the world's largest supply of ankle weights, or you haven't progressed them fast
Airelle:Exactly. No, I don't see ankle weights other than straight leg Aires, which again, you shouldn't be doing that for weeks at a time either, but w we're not really using ankle weights, except for that. I mean, I save them for my rotator cuff people. No.
Mike:I like that. Um, and then for me, I think what, what I think you guys do well in with your procedures here too, when you start getting to, even in your protocol, again, it's reading between the lines and this is what I appreciate when I read it here. As you start talking about open kinetic chain, knee extension at percentages of rep, max is probably closer to the like. The three to four month mark give or take. And, and I think that's the message. And, and when this first came out, I saw so many young clinicians debating this and I even saw it like, even like, like, like Lynn jumping in on some of the conversations and saying, no, just go. And I agree with that concept, but I'm telling you, there's a 24 year old kid that is going to have somebody doing bodybuilding exercises for their knee extension at two weeks, you know, I was nervous.
Airelle:there, I also find, I don't think that they're going to be able to right now, I think that person will learn. They're going to piss off that person's knee and they're not going to do it again. And I hate to see that, but there is a bit of living and learning in this too. And I don't think getting back to the one rep versus when are we really loading? You know, we're more looking at a five rep, but just not the tip, not the quote-unquote, I'm going to do three sets of 10.
Mike:Right.
Airelle:what, if you did, did you ask an RPE, did you know at the 10th one that they're sweating because they couldn't barely get the 10th one up. Then okay. Maybe, maybe I'll let you slide and you can do three sets of 10 because you know, you're dosing appropriately. But if you don't do a five rep or you don't ask them at 5, 7, 9 reps, how they feel, you don't know what you're doing
Mike:right,
Airelle:and you're undertreating. And we, I think as a profession, we can, we under treat a lot, but.
Mike:And I think you, you did a really great job with your guidelines and I don't even think this was necessarily in the paper. So again, me just reading through your guidelines and trying to read between the lines is you talk about. Intent in exertion and per a percentage of perceived exertion and percentage of rep maxes. I do think that like, if we looked at university of Delaware, your ability to regain quad strength is probably a lot better than most standard outpatient clinical practices that aren't doing things like this. But I, it was amazing. Like you, like, most people don't know, like you said, that you're just doing 10 pound knee extension that maybe they could be doing 30. They're not doing it. So you guys recommending a perceived exertion and percentage of a rep, max is that is huge. And again, I think that's something you probably take for granted because you've been doing that for so long in your own clinical practice. I think most people aren't.
Airelle:Yeah, I agree. And I, I, and I think the backup is if you measure. Right. If you measure knee extension, you would know you weren't improving. And so you need to change something too. So, you know, I think they go hand in hand. Um, and I get it. I get it. We're busy in the clinic and, but we, we could pay more attention.
Mike:I love it. That's awesome. Uh, another big area of recommendation that you had that I don't know if this is necessarily different or, or current, but you know, the kind of the big topics was delaying a return to. So, and there's a ton of research out here and there's some, you know, I think you guys have done a great job trying to break down some of the research in, and that's out there with some of your editorials and stuff that have been out there, which I thought was really nice. But tell me a little bit, what's the current research saying what, you know, I think I don't want to put words in your mouth, but are you recommending it's about nine months now that we're returning to sport. Okay.
Airelle:And, and I think we listed as nine to 12
Mike:Right.
Airelle:you know, if you have. Allographs. They are recommended to be a little longer things like that. Um, but yeah,
Mike:Can it be nine can be nine to never if you have an allograft or is that now? I'm just kidding.
Airelle:yeah, I know, right.
Mike:Um, but yeah.
Airelle:Or a nine to never, if you don't have your quad strength return.
Mike:ah, I like that. That's a good one, right? Exactly. Right. You don't magically go back at 12 months, no matter what.
Airelle:Right, right,
Mike:Um, but, but T tell me a little bit about why you've evolved from four months or four months plus to nine months. What, what went into that?
Airelle:Yeah. Um, I don't think we can take credit for that. Although we have done a study on it. I wouldn't say we're the ones who have pioneered, Hey, we need to wait in sport and it's, you know, it wasn't met easily with physicians, then you look great at four months. Well looking great. What does that actually mean? Back back to measuring, um, and. I've measured, plenty of people in there ready to go. These high end athletes, they're ready to go at 12, 12, 16 weeks, you know, and right before the chat we talked and I was like, I think back now, and I'm like, oh, like it, it makes me sweat. how many, how many people, you know, went on to a second injury because of that potentially, but looking at large datasets, which is. What we haven't had since the beginning of time where people are actually sharing information, we're putting data into large registries, looking at those types of things. You can see. If you return. Um, and, and one of our studies showed it to, with, um, we had it, we had a group that we also looked at Norway and we had over a hundred patients. And those that returned to that high level cutting pivoting level one sports had almost four and a half times higher reinjury rate than those who didn't. And it was significantly reduced by. every month, they delayed their return to sport up to nine months. So there's, it's pretty big. It's pretty big. Uh, we don't, we still don't have the answer. It's not just time. I would love to say that, but, um, and then also those who didn't pass return to sport criteria, right? There's some people out there and I hate to say it. You go back, you look great. You know, if I hear your one more time. Oh, your, your quad still a little small. So you can't go back. I mean, what, what are we measuring?
Mike:Right.
Airelle:But those who didn't pass that return to sport criteria, um, you know, almost 6% higher, um, failure rates and second injury. So it's, it's a big deal.
Mike:Yeah, that's that's too much and that's just, that's preventable, but I hate to say, but because when you get to six months, it's almost too late. Right. I mean, if you're behind, that's it, you know, you got behind the whole process,
Airelle:is super hard to get those people stronger if they've gone that long and they have so many compensations and, you know, and really good athletes, like they get around whatever they need to, to get back to doing what they're doing. Um,
Mike:right.
Airelle:but it puts them at risk.
Mike:I appreciate that statistically, when you look at means, and you look at stuff like that, that nine months was a statistical number. Am I going to die? If I come back at eight?
Airelle:No, you're not going to die.
Mike:Is my ACL gonna rip in half? Or am I going to tear my other, see if I come back, is there, what if w what if there's a statistical probability is what if somebody does look amazing? What if we're talking about like an NFL running back that. You know what I mean? An NFL running back there in the prime of their career there they're preconditioned was amazing, right? The head extensive rehab, three times a day with their athletic training staffs and they look absolutely amazing and pass every single one of your tests at six months. What do you do?
Airelle:I I stutter
Mike:I'm going to leave.
Airelle:of water.
Mike:I'm going to, I'm not, I'm going to make sure that pause isn't edited because I actually think that that that was a dramatic pause, but that was good. Yeah. What do you do?
Airelle:Um, there's a lot of factors that I think would still possibly allow for someone to go back. I would not do three months. Again, I don't care how much you paid me, but, you know, and, and I do see even some college athletes, the surgeons are like, you know, we'll start at six. I don't think of that age. Granted you're in essence, you're still getting paid. And I understand there's a lot of stress to that. There's a, there's a real, there's a really big risk. And especially if you're female and going back at that level, that.
Mike:right,
Airelle:If you're a senior and it's your last game personally, I would do it,
Mike:right. Yeah.
Airelle:Um, but I think those are things you need to discuss with the person who is in a million-dollar athlete. Absolutely. Those are, those are factors that are much larger than just healing timeframes and assuming they measure. And they, they are at that level. Um, but they still are a higher risk. And, and I think everyone has to understand that, understand the risk and agree to it or not agree to it, to move forward.
Mike:Yeah. You know, the part that scares me with this evolution is we're seeing this with Tommy John's a little bit too, as we're doing the new internal brace procedure so it's a different, uh, surgical approach. And we're all excited that we could potentially go faster with it. But what we're finding is that these are still 16 year old kids that probably toured their Tommy John, because of. Physical status was terrible or their biomechanics were terrible. Right. And that's why they did it. And us rushing to get them back faster. Doesn't give us enough time to get them ready. We don't get their range of motion that we don't get their strength back before all of a sudden the physician's like, did you start pliers yet? Did you start throwing? I, I'm kind of worried about that with ACL's in the future. As, as we get there, I feel like that might become.
Airelle:Yeah. Yeah. Well, and, and, you know, moving this surgery too, it doesn't seem like a big deal. You know, we were almost at a scope point of ACL reconstructions and that, but they still are still doing the same procedure in there. So there's a lot done and there's a lot of healing that needs to take place. And our imaging is better. We're able to now see, you know, The homeostasis of the knee doesn't really happen for one to two years, two years of chondral services. And, you know, we, we are seeing such young people with osteoarthritis and, you know, you have that ACL tear. W when do you tell them in the family that they're gonna have a total knee at a younger age than somebody else? You know, it's it's, um, but again, these are choices and, uh, you know, we're, this is athletics too. Hopefully medicine keeps changing, but, uh, yeah, there, there are large points that we need to take into account.
Mike:Yeah. Okay. So let's talk about, a little bit about your approach to return to sport testing. Um, why don't we go through that a little bit here, because I think when we're talking about somebody being ready and if they're ready early, um, what are the things that go into university of Delaware's, uh, returned to sport protocol? What do you test in, when do you start testing? Walk me through the sequence.
Airelle:Yup. Um, they effusion, so they have to have a quiet what we call a quiet knee, pretty much tracer, less a fusion, very little, um, full range of motion equal to the other side. Uh, we could debate extension and all that all day long, but you know, essentially let's call it full range of motion. Um, you know, gauge to be normalized. Their quad strength needs to be over 80% for us to test them. To actually qualify to go back to sport. We want them even higher over 90. And I would even argue, I, I would like them darn near equal because I do think more has come out in the last couple of years, especially with Liz Wellsand stuff that. And we have a luxury at times to test people preoperatively. So they tear their ACL. They come in here, they get some pre rehab before surgery because we know outcomes are better too, if you go in with a quiet knee. Um, and so we look at strength testing prior to surgery, and what we found is after surgery, they're, un-involved goes down. And so now we're comparing down and even more down and then.
Mike:20% deficit for some reason.
Airelle:Right. So our 19 B is now probably 75, if we're lucky. And so it's not great. And mate, is that why we're increasing contralateral risk as well as, so, um, okay. So we have the quad index, uh, over 80 just to test and then
Mike:when do you, when do you start like, like a running progression and a jumping and agility progression? Do you have to be above 80 for that?
Airelle:you do.
Mike:Okay. And, but, but if you're, if you're above 80, but not 90, you're not even in the category of returning the sport yet. So we're
Airelle:No, sir.
Mike:through the test. I like that. Okay, great.
Airelle:Now I will say some people will start looking at some things like what, what does hopping look like? You're back in the day we would, we would do the hop test at 12, 16 weeks. It also gave you information. And so it's not that I wouldn't do it. I don't want them to pass. Right. That's scary. And most of them at this point are not passing at that timeframe, but, um, Well, we need quad strength. We need to have gone through running progression. Um, we, we limit running progression and starting that to around 12 to 16 weeks, depending on Monicka and, and stuff like that. Quiet knee. Um, but when you start loading, if you don't have the quad strength to load, you're going to swell and get irritated. So, um, when we get through the running progression, you know, I've, I've had some arguments with people like football players. Don't run two miles. You know, let, let's get up to a mile of running. We're, we're loading that knee for 10 minutes at a time. However you want to skin that cat. And then, you
Mike:haven't run a mile cumulative in my life. So I mean, it's so I, I may not be a good patient of yours, but yeah. Sorry.
Airelle:um, and you know, then we get into, what if I don't want to run? What if I, you know, whatever, um, there that's all clinical decision-making, um, that's why this is not called a protocol. It's called a guideline.
Mike:I like
Airelle:And so we run well, once we can run and the knee feels fine. And you know, now we might have an alter G to add to that, which we didn't have back in the day when we were getting people back running. Um, so you can all flow them a little longer and increase that over time, which is, which is a nice progression. If you have insurance visits left, right. That's our other problem. But then, um, we do a sprinting. And we have a stage sprinting progression that is newer in this protocol as well. And Dan Lorenz, we, um, that's part of his, um, sprinting progression that we have in our
Mike:had a
Airelle:guideline. And then. Greater home. Once we get through one stage that we'll start some agility training, right? Making sure that they can land on one leg, they can accept the weight on that side. There's, you know, not fear. Um, and that they're doing it correctly before we move into the agility side. So you're looking at four to six months for that timeframe. You're really good. You know, we might start for 16 weeks, 20 weeks. Um, but most people are kind of out that six month mark. Starting agilities, which is working nice to get back at nine. Right. We stretch it out a little bit. The problem is insurance visits. You know, now that things are stretched out. And I'll say though, even before some of some people weren't ready, they left us and they never were ready. So they were likely at even worse risk going back to sport.
Mike:And you know, and we're fortunate up at champion is that we have a gym. Like we have a whole sports performance facility as part of our complex. So we just, we evolve them. If you don't have access to that, like we do right. Then you have to find somebody near you like a sports performance specialist, or, you know, a gym near you that you can collaborate with. So that way you can build programs together and you can talk about, Hey, what's our six month after. Program going to look like for training in there, and you can have a collaborative relationship with that. I think that's going to be beneficial for everybody, but most importantly, the person in front of you, if you don't have that. So, um, that's awesome. You know, and again, reading between the lines which I like to do with, with your stuff here is, is what I think. With how many sequential steps you have is that their return to sport criteria to step four, is that you, you perform step three. Well, right. And I, and I think that's an important concept right here is when you lay out such systemized progressions very well that your sport return to sport testing is just simply that you, you went through the progression. Well, because this is based on an almost infinite amount of data points now at this point. And, and I think that's really awesome.
Airelle:Yeah. And you know, I don't know that ever really thought about it that way. That's I think that's a really good point because our return to sport testing, it's not perfect and it doesn't necessarily, it's not quality. Qualitative essentially. And other people would argue, you need a vertical jump, you needed this. You knew that I'm not arguing that none of it comes out perfectly to, we know that we're reducing how much reinjury. So, you know, this is what we have now, but you're right. Like all these other data. Whereas before, when we didn't have those, we only had returned to sport testing on that day that a lot of people can just get through minus minus the strength component, but like some people are, they can hop in their agile. Um, so
Mike:Can we be honest for a second? Let's just, it's just me and you on this recording. Although thousands of people will listen to this. What do you got on hop test?
Airelle:when.
Mike:No. What have you got on hop test? Do you like hop test still?
Airelle:Uh, I know everyone, everyone gets tired of it. I think because it's been around since the beginning of time, it's like, it's the old thing that we should throw out. I do feel it's a bit of a gold standard. It's actually one of the few tests we have in ACL, um, or in lower extremity returned to sport really that's valid and reliable in this patch in this population, but it's not the end all be all. And I, I fully recognize that, um, But how are they landing? So it's, again, there is between the lines on this, especially, you know, we have a single hop, how are they? Landing were very particular. They have to land on one leg. They have to accept weight. They can't bunny hop. You know, we used to have closed hallways. They can't touch the walls. They can't, you know, they can't jitter step. They have to land on one leg. And when you ask anyone to do. They have to be confident and ready to go on that side. And then you take that and you do lateral hops, you know, side to side, um, that adds an extra component, um, that a lot of them are fearful to do. So, and then time, top is more, is quick, you know, more fast paced again, is it perfect? No, but I still get a lot out of the test and if they, if they are right around 90%, I will stay, they do not want. They don't look normal. They don't look normal. So, you know, that's why I'm also pushing that. We probably need it even higher, if anything.
Mike:I like that. And I think, I think the big take home right there is that are, are there some issues with hop test? Probably only if you're using hop test as the only return to sport metric and that's the end all be all. And I don't even know if they were ever designed. That you know, but they're, they're probably still an important component of our return to sport testing. I liked that. Um, I will say we're, we're like evolving a little bit away from it a little bit because we're doing more force plate and vertical jumps stuff. But I think, I think you're right. It's almost like, uh, you know, how well they perform it versus like their score is, you know, X like the quantitative versus qualitative again becomes a big factor. And if you're never watching your people hop and jump, then you're probably, you're probably missing.
Airelle:Yeah. Um, and to tell you the truth, it can be a long test because we make them land single legged where some people, they just have them do it and you know, they land and they almost land bilaterally. That's not allowed. And so they have to do a lot of trials. Um, you know, you're looking at a 15, 20 minute test if they're not great at hopping. And so you also get, I went on, I'm not sure I'd call it a Durance, but you know, Oh, how do you test the person? Should they go to practice then? Should they come in? You know, is the injury in the beginning of the game? Is it in the end of the game? Like there's so many factors that were, I don't know if we'll ever have it perfectly right. There's hormones. There's not modifiable factors. So, um, we have a long ways to go.
Mike:W we, we try to control the uncontrollable sometimes, right. Especially in our prevent, prevent, uh, profession where we're always trying to, you know, be in control, but you're right. There's so many factors outside our influence that it's just not fair. Um, uh, another area that I see. As a profession we missed the boat on for a little bit was, is kind of the psychological readiness kind of factors that go into this. And, um, it's actually pretty, pretty, uh, interesting to see the research coming out on this, but why don't you tell us a little bit more about that? What's the research showing on psychological readiness and how, and when do you start measuring the.
Airelle:Yeah. Pretty. So th the, the patient reported outcome measures on this are not perfect. Um, and nothing's perfect, but they are at least from perfect of the ones that we're using. Um, we we've added the ACL RSI to, um, we've looked at the tsk 11 as well for the knee, but the anterior cruciate ligament returned to sport after injury form is one that we've recommended in this guideline that we hadn't before. Um, Clara Clara, Arden is one of the. The founders of that test. Uh, we don't have a great number as to. Over this, you should, you shouldn't worry. Or if you're under this, you should worry and you shouldn't send them back. Um, we, we don't have that perfect number. We have chosen 80% with some discussion with her. Um, but we don't have that information well laid out yet. So I will say that, but we early on, if you're really confident, those people are at higher risk for terrorists, we have found that. And then. Right. And then later on, if you're not confident you're at risk. So, um, it's it's and again, that's not the only factor, so, uh, but it's a little tricky and how we're incorporating that. Isn't that definitely hasn't been perfected yet, but there is a lot, I, I feel like there's a lot more hesitancy of athletes now and just, just the way society is moving. Um, They questioned things more in the more hesitant to the return, uh, females, more than males and, um, a lot more psycho-education has to go in to our treatment. Um, almost in the same vein as chronic low back pain. Uh, which is, I don't think is something we're used to working with our athletes on as much. And so I think we need to progress in that area.
Mike:Yeah, well said. And hopefully if people have followed your guidelines, right. And they're going through and going through each step of that sequential, they should be succeeding if they've progressed to the next step, that's paramount. Right. So that's important. But then I think what they're probably doing is they're building confidence in that. And their
Airelle:Yeah. Yeah.
Mike:and their ability to do it. So again, if I think the goal is, if you're struggling in a lot of your athletes don't have good results on that RSI, for example, then I think, you know, one thing you have to do is reflect on your rehab progression a little bit, or did they disappear for two months because they ran out of visits and what have they been doing? So, you know, to me is I, we say that all the time, when you get back to sport, sometimes it's, anti-climatic from all the great stuff we've been doing in rehab,
Airelle:Yeah. Yeah. And their injury, their injuries, a huge factor too, you know, was, this was where they hit by someone and, you know, or was it, was it that fluke where most ACL's happen and you're out there for no reason at all. And you cut, this happens like, you know, and how it, how it affects the psyche of each individual is completely different. So I don't know that we'll ever have a great answer because each person handles it so differently.
Mike:For sure. Yeah. All right. Well, one of the best recommendations I think you had, because I think when you put it in a guideline than this and you, you put it in front of everybody, I think it, I don't want to say it as sure as it gets done a little bit more, but what you did is you put right in front and center that, um, a secondary prevention program and which essentially is ongoing care and ongoing maintenance. Keeping it, keeping your progression going is super important. Tell me a little bit about what you would recommend. Somebody they finished rehab there they've returned to sport it's not over. Right. And, and what would you recommend people continue to do as the secondary prevention
Airelle:Yeah. I like how you like it the most. It's my least favorite. Um, just
Mike:I do own a gym, so like maybe that's part of it.
Airelle:yeah, maybe, um, I get really excited when they're injured and. Yeah, I, you know, I've I find this as the hardest I find prep. Primary prevention is very difficult in getting in it's the same issue with secondary prevention, other than. The athlete's like, Ooh, I still remember this injury and maybe I don't want to go through that again, but, um, they're also tired of going through rehab and they're there. They might have no funds left and their insurance isn't paying and are they really gonna stay with something almost for them lifelong in their lower extremity sport, um, is really what we're looking for. So, Um, we do have any prevention CPG, and that talks a lot about primary prevention. Um, we're coming out with an update, hopefully this fall, we know primary prevention works and for the most part we've taken some of that primary prevention. We're doing it after first, second, third injury. And, um, you know, the neuromuscular control, especially after injury and the, the lack of some information within the knee, uh, and proprioception, these guys really need to do this. It's really important. And with it, you don't want to scare them to death that they're going to be re-injured, but the probability is pretty darn high. If they're going to go back to this level one sport, um, so. We did look at a study, um, adding secondary prevention after their first injury, um, in, in discussing it with the physicians like neuromuscular rehab and stuff like that, they wouldn't let us start till about the six to eight week mark. So we did regular rehab, progressive rehab up to that six to eight week mark. And then we did. Like 10 plus sessions of strengthening if they weren't at that 80% and higher, but also neuromuscular balance boards, perturbation training, things like that. Um, landing, uh, box jumps, you know, more in, in. We had two arms of the study, the males, um, it worked great in the cohort that we had in our male arm. They had a 2.7, 5% return rate, uh, which is much lower than the normal population. And, but our females were still around 22%. What we found, they, uh, hair, the, but what we did see more. Had gone back to the higher level sport. So after their primary injury, we did have more return. Was that because of the rehab, but, um, the retail rate. Wasn't great. Uh, so you know, the females there, I think there are many more non-model potentially non-modifiable factors with them too, but it is. need more of it. Um, how long does it last, you know, our coaches really implementing this? There's a lot of barriers when it, when it goes outside your clinic walls. So, um,
Mike:the point of getting that this needs to be a part of the equation. I think the surgeons need to know this. I think we need to be talking about this with the parents and the athletes, like on day one, like, oh, you just hurt your ACL. Great. Okay. You know, I have to, you have to do this for the rest of your athletic career,
Airelle:Yeah. You know, there's so much feedback that they need to, I think as a profession, we need to do better at a ground roots grassroots level of helping people implement these things. You know, we, we came out with a new prevention, CBG. We have exercises in there. We're trying to make more manuals and kind of the knowledge translation piece. The coaches don't want to take the time to do a 20 to 30 minute session two to three days a week. It is a lot of time, but then you may never see that athlete again because they only have, you know, it's like flipping a coin, whether they're going to get back to sport or not after an ACL tear. So, um, we need buy-in and, and better ways of doing that.
Mike:Yeah. And we're all competing for time to write. And, you know, we deal with that a lot with our skill coaches and even, you know, sports science in, in the professional collegiate sports, or is growing a little bit in everybody's everybody's trying to get the time for the athlete to do different things. We're running out of time right now. I, I think, I think that's where it happens all the time. So, um, awesome. Ariel. That was amazing. We could talk for two more
Airelle:Yeah. I know this long.
Mike:We would have, we would have a masterclass on ACL, which is good. But again, w when you have, uh, oodles of, uh, clinical experience, there's a lot to talk about. And I think, you know, w when, as people, maybe when, if you just treat 1, 2, 3, 4, ACL's a year, it's good to hear these things from people like yourself that treats so many, because I, I think, you know, probably more than anything, people just feel like, okay, I'm comfortable, I'm on the right track. And it's good to hear. So thank you for coming on and sharing that. I do like to end with a little segment called the high five, five quick questions, five quick answers. Right. We won't go crazy. But you know, again, the point though is I want to show all, all the people listening here that even people like yourself that are so busy doing all this, that you have a growth mindset and you're doing all these neat things. So first question is what are you currently working on yourself or your own professional development?
Airelle:Oh my own professional development. Um, we are updating the knee prevention CBG as well as starting the concussion or concussion, CPG revision. So I would say we're, I'm deep into those two areas of literature.
Mike:I love it. And again, I mean, there's recurring themes, everyone here, but the people that are producing the most are the ones that are also staying the most current. So we've got to stay current. I love that. That's awesome. Um, what's one thing you've recently evolved your thoughts on, I feel like this episode, this, this is an evolution of thought episode, but in addition to what we talked about, what's the one.
Airelle:Yeah, yeah. I would say within the knee in general. Um, and, and probably because I'm aging, um, is, and it comes with experience, right. I feel like we grow as clinicians with more years, but we really pushed to get that extension. Right. I think we're rather good at. But we don't always take it back to the person's life. And so are they able to sit with their leg out and their toe up in the air and nothing under there? Or were you just saying, oh, do bag hangs at home, like do this two times a day for 10 minutes and you'll get your extension back. Like they're still not really incorporating it into lives. So I'm more about trying to make habits stick at home. Especially as we move on to these TK, to the TK population, they have compensations that we can't change and their pain is better, but their function isn't,
Mike:Right. I like that. That's a, that's a, that's a good one. And taking something from outside, like, you know, changing habits and stuff. I think that's, that's an important one. Awesome. All right. You have a ton of students. What's the best piece of advice that you give your students, you think pay
Airelle:Um,
Mike:Fast
Airelle:yeah, I know, right. Um, I want you to ask why, uh, I don't, don't be afraid to ask a question of why, uh, I don't want you to memorize this. Isn't a protocol. Understand why we have this written, um, if you're doing something and you don't know why that, I don't know why.
Mike:Love it. Great books, Simon Sinek, start with why? Good stuff. I always recommend it. I love it. Um, all right. In addition to some great CPGs that are coming out, what's coming up next for Ariel.
Airelle:Um, I recently, um, became the director of, uh, of the university of Delaware, physical therapy clinic. Uh, there's been a lot of trans thanks, a lot of transition this year, but, um, I foresee some more community outreach, especially. You know, and we're insurance doesn't exist anymore. And how can we change, practice beyond our walls? Um, and we are in the midst of going live with a new EHR. So I hope that that system, yeah, it's pretty painful. Um, I hope that improves our knowledge and translation reach though.
Mike:Right. I like that. That's good. And I foresee some more involvement in the American academy of sports, physical therapy button up,
Airelle:Sure.
Mike:but, um, all right. So how, how can, how can listeners learn more about aerial? So I, and I don't want to say you're one of the behind the scenes people, because that's not quite fair for you, but you know what I mean? Like, like, like, uh, th the people in the clinical trenches, aren't always the people that are up front, but where can people find more.
Airelle:Um, I'm not gonna lie. I don't share much. Um, I am on Twitter. Um, I may have posted this article, but I don't even remember. Um, So, uh, I am on Twitter, but, uh, you know, email and, and our website, our website will be read on, we have all of these clinical practice guidelines in many different areas on our website. Um, I love speaking to clinicians about how they can grow. So, um, more one-on-one is my way.
Mike:And, and again, so this is Ariel just gave you an open invitation if you see, or if you bumped into her at CSM or the, you know, the academy meeting, like come, come say hi and, uh, ask her about, um, her return to sport testing protocol in person. It would be fun conversation. So, um, awesome. Thank you so much, Ariel. We really appreciate taking the time teaching everybody, all these great things. Hope to have you on in a future episode too, but thanks again.
Airelle:Thank you.