Episode 298 | Why “Keep Working On It” Might Not Be Enough in ACL Rehab

What is up team and welcome back to another episode on the ACL Athlete Podcast. First, I just want to say I hope that you guys are doing well. I also want to say thank you for the ongoing support, the messages, and the comments. I continue to read those every single week, and I am so thankful for them and for your support. It is the thing that keeps me going.

It brings me a lot of joy whenever someone says, “I listened to this episode, and I took action on this.” Sometimes it is not just one episode but multiple episodes that help someone take the next step. That is the goal of this podcast: for you to feel equipped to move forward, advocate for yourself, and get back to the things you want to do. I want to say thank you, and in a world where things can feel heavy, I hope this podcast helps make things feel a little lighter. I also want you to know that you are not necessarily at a loss, even when your recovery feels difficult.

I want to dive into this topic because I have been having a lot of conversations with ACLers who feel they have exhausted their options or have started taking matters into their own hands. Some feel that physical therapy has run its course, but they have not fully evaluated whether they simply need to keep working consistently or whether there is an actual roadblock. That roadblock could involve what they are doing in rehabilitation, or it could be a biological issue within the joint or something related to the surgery itself. We need to distinguish between those possibilities rather than assuming that more time and effort will solve everything.

During this process, especially when you raise a concern or ask a question within the first three months, or even the first six months, you will often hear, “Keep working on it.” Maybe your surgeon says it during a follow-up, or your physical therapist says it when you ask why your knee still will not straighten all the way. Perhaps you are still walking with a limp, or your knee swells every time you stand for a while. The response is often that it will come with time and that you should keep working on it.

The same response can apply to quadriceps strength, knee flexion, and other foundational parts of rehabilitation. These things can take time, and sometimes it is genuinely difficult to determine whether progress is simply slow. I do not want to fault the phrase itself because there are situations where it makes sense. However, I am not talking about the first time you hear it. I am talking about the third, fourth, fifth, or even tenth time, when weeks and months have passed, and you are still dealing with the same problem.

You might hear it ten times within the first three months, particularly because you see your physical therapist frequently. That frequency alone is not necessarily a problem. But as you move further along, you may continue asking when something is going to improve, only to hear the same response. “Keep working on it” or “It will get better with time” is not a particularly helpful answer when you have been working hard and nothing is changing. At some point, there needs to be more clarity about what is happening and what the next step should be.

Today, I want to talk about what “keep working on it” actually means, when it is a legitimate recommendation, and when it is time to stop simply waiting and take a closer look. If you have been listening for a while, I have already done episodes about graduating from physical therapy and the illusion that your knee will get better with time. Those episodes focused on the end of care and the belief that time fixes everything. This episode is about the middle of the process, when you raise your hand and say, “Something is off. Something does not feel right,” and you receive a response that dismisses the concern or pushes the problem down the road.

I find that this type of response can be the easiest one to give, particularly in a busy, high-volume clinic. A physical therapist may not have enough time to assess the situation thoroughly, individualize the rehabilitation plan, and consider every detail of what is happening. Similarly, a surgeon may have only five or ten minutes during an appointment, with many patients scheduled back to back. That makes it difficult to zoom out and understand the full picture of your recovery.

I am not saying this happens across the board, but it is a trend we see. A surgeon may receive only snippets of information about what has been happening between appointments, while a physical therapist may be under pressure to move through a high volume of patients. In the early stages, the default response can easily become, “Okay, just keep working on it.” Again, that is not always the wrong recommendation, but it becomes a problem when you continue to raise concerns, nothing improves, and you still do not receive a clear explanation.

I am speaking from experience, having gone through several injuries and surgeries, particularly my own ACL recovery. I encountered setbacks and received the same response that things would improve with time. For my more analytical ACLers, I think there needs to be more depth to that conversation. We should be able to assess the problem, support our decisions with appropriate testing and evidence, consider what the research tells us, and put the information together into a plan with clear action steps.

We should also be able to explain what improvement ought to look like over a defined period. A good physical therapist should have a reasonable understanding of how much a particular quality or symptom might change over the next two to four weeks or six to eight weeks. We have reference points for the physiological processes and the qualities we are trying to develop, including symptoms, range of motion, strength, power, and reactivity. Those expectations should help guide the rehabilitation process rather than leaving you to guess whether you are making progress. There should be checkpoints to help determine whether things are moving in the right direction. We need to look at trends across multiple data points instead of making decisions based on one appointment or one isolated measurement. 

I also want to be fair to surgeons here because they generally see you at specific time points rather than following your recovery week to week. We need to understand that context instead of assuming that every provider has the same information available. Physical therapists are also working within a healthcare system that is often driven by patient volume, making it difficult to account for every nuance. Sometimes, continuing to work on a problem really is the right call, particularly early in recovery. You may need consistent repetitions, appropriate exercise frequency and dosage, better swelling management, or more time for your range of motion to respond to consistent rehabilitation. The important distinction is that there should be a reason for continuing, and you should have a way to determine whether that approach is working.

“Keep working on it” only counts as a plan when three things are attached to it: a number, a plan, and a date.  First, what are we measuring, and where are you today? Second, what exactly are you doing, how often are you doing it, and how hard are you working? Third, when are we going to reassess the problem? For us, we look at progress every week, with a more defined set of assessments every four to six weeks, whether those assessments are built into the programming and reported results or involve direct testing.

There are different ways to assess progress, but we should be looking at it consistently. Every week tells us something, and every session and data point contributes to the bigger picture. We are tracking different qualities and criteria alongside what you report about your symptoms and experience. If we have a number, a plan, and a date, and the number is improving, that is great. Continuing with the current approach may be entirely appropriate.

If none of those three things exist, however, you do not really have a plan. You have a recommendation to keep going without a clear way to determine whether it is working. This is especially important when you are being given exercises or a protocol without a closer assessment, even though you can tell that things are not improving as expected. You need more detail about what is being addressed, why it is being addressed that way, and how you will know whether the intervention is successful.

The problem could involve knee extension or flexion, persistent pain and swelling, limping, quadriceps strength, or difficulty walking down stairs. Later in the process, it might involve a lack of power in the leg, difficulty getting the knee over the toes, or an inability to jump on one leg. There are different things to assess at different stages of recovery, but persistent foundational problems deserve particular attention. As you get further along, you need to look more deeply at deficits that are not resolving.

If you have been working on a problem for three months, or perhaps six months, without meaningful improvement, it is less likely that time alone will resolve it. That does not mean every problem requires surgery or another intervention. It means that the situation needs to be reassessed, with appropriate testing and a more specific rehabilitation plan. Once again, you need numbers, a plan, and a date.

This connects to what I discussed in the episode about time: time plus testing, a plan, and guidance. Time by itself is not the recipe. If you have been told to keep working on something without a measurement, a plan, or a date for reassessment, you may simply be moving forward without knowing whether the approach is appropriate. The distinction becomes particularly important when you have already put in months of work and still have persistent extension deficits, swelling, or pain.

Maybe you have been doing everything you were told to do. You show up to physical therapy, complete your exercises, and put in the work, but the problem persists. You might find yourself searching Reddit or Facebook groups for people with similar experiences, sharing your story, or looking for exercises that might help you make progress. Yet the answer from your healthcare team remains the same: “Keep working on it.” That is the point when the situation needs an audit.

The first question is whether you are dealing with a rehabilitation programming or dosage problem, or whether there is a biological or surgical problem. On the rehabilitation side, the issue could be the wrong frequency, the wrong intensity, poorly managed loading, or exercises that do not provide the stimulus needed to develop the quality you are targeting. More exercise does not automatically mean better rehabilitation. The structure, dosage, and purpose of the work matter just as much as the amount of effort you put in.

We have seen athletes who spend hours every day working on range of motion but are not doing the right things to make meaningful progress. They may be combining exercises they found on YouTube with recommendations from their physical therapist, creating a do-it-yourself collection of techniques without a coherent plan. Sometimes, the answer is to back off, reduce the volume substantially, and reorganize the frequency and dosage. Athletes can be surprised that doing less, but structuring it more appropriately and using feedback to guide the process, can help them move forward.

That is the controllable side of rehabilitation: the exercise plan, the dosage, and the management of the stress being placed on the knee. Then there is the biological side, which we cannot control to the same degree. You can influence movement, nutrition, stress, sleep, recovery, and the loading you apply to your knee, but the body still has its own healing process. Your history, age, genetics, surgical procedure, hardware, and graft choice can all contribute to how recovery unfolds.

Biological problems involve what is happening inside the joint, how the body is healing, and whether the surgery has resulted in an issue that is affecting progress. Scar tissue or a mechanical restriction, for example, may prevent the knee from moving as expected. In those situations, no amount of effort will necessarily solve the problem. Trying to exercise your way through a restriction can sometimes irritate the knee further instead of resolving it.

These situations require more investigation and another set of eyes. That might mean another surgical consultation, additional imaging, or a more detailed assessment to understand what is happening. You cannot determine which category the problem falls into simply by telling someone to keep working on it. You need to play detective by testing, measuring, collecting objective data, and asking better questions about the athlete’s experience.

Ask the athlete what they feel when they perform a particular movement. Have them walk you through their day and their week, including when symptoms flare up, what makes them feel better, and what makes them feel worse. Track those patterns over time rather than relying on a vague impression of how the knee feels during one appointment. If extension is the issue, for example, we should be tracking it consistently and assessing what the athlete’s heel pop looks like and feels like.

We should also look at how the knee responds to the exercises being prescribed. Working harder on the wrong problem can be incredibly frustrating, which is why we need to assess the situation before simply introducing another exercise and hoping it helps. Knee extension deficits are a good example because they do not necessarily resolve on their own. I have seen people carry extension deficits for months or years because they assumed the knee would eventually straighten without further intervention.

If your extension has remained limited and you have repeatedly been told to keep working on it, that is a reason to reassess the situation, particularly beyond the three-to-six-month window. The same is true if you initially regained extension but then lost it again, your knee no longer matches the other side, you cannot achieve a heel pop, or your knee still looks slightly bent when you stand in front of a mirror. Those signs deserve a closer look rather than another assumption that time will solve the problem.

That assessment should include passive and active extension, appropriate testing to help identify what is happening, and a review of your rehabilitation history. We need to understand what you have been doing, how your knee has responded, and whether the current plan is producing the expected changes. It is not enough to look at a single measurement and move on. The pattern over time is often what helps determine the next step.

One concerning shift can happen around the six-to-twelve-month mark, particularly as athletes approach a year after surgery. People stop asking whether their recovery is progressing appropriately unless something is obviously wrong. If your knee is stuck 15 degrees short of extension, you would expect that to get attention. But what happens when the deficit is smaller and the problem is less obvious?

Maybe your knee does not match the other side, you cannot get a heel pop, but you can feel your quadriceps working and complete some exercises. You may still have discomfort or feel a restriction in the joint without being completely blocked from doing rehabilitation. The same can happen with flexion, persistent mild swelling, sharp discomfort during certain extension movements, or quadriceps strength that does not respond to loading as expected. You might also experience ongoing discomfort around the graft harvest site, whether that is the quadriceps tendon, patellar tendon, or another area of the knee.

These problems may not create a complete brick wall in your recovery. You can still perform many rehabilitation exercises, even if you cannot do them to the extent you want, so you modify around the symptoms and carry on. You may feel that you are 70% or 80% of the way there, but something is still missing. As time passes, people often stop asking, “Is this right?” and start asking, “Is this just me?”

I want you to pause and think about that question. Is this right, or is it just me? After months of hearing that you should keep working on it, it is understandable that you might begin to believe your current knee is simply your new normal. People may tell you that you have had an injury and a reconstruction, so you should not expect the knee to feel the same as the other side. There is an important distinction here: you should expect your knee to feel different, but that does not mean it has to function at a lower level.

With good rehabilitation, an appropriate surgical process, and the right plan, your knee can feel different because it has been reconstructed and has experienced a major injury. However, the goal should still be to restore function and performance as much as possible, including getting the knee back to the level you had before the injury and making it comparable to the other side. That is a critical distinction. Do not lower the standard simply because you have had surgery or because your recovery has been difficult.

As I said last time, “Good enough only works in horseshoes and hand grenades.” I may have to start saying that more often because good enough should not be the standard for ACL rehabilitation. When people accept a lower level of function without appropriate testing, they may return to activity without knowing whether they have met the necessary criteria. We need to be careful about normalizing that outcome or treating it as the best a person can achieve.

Sometimes, the clinic itself reaches its limit. Your insurance visits may run out, the clinic may lack the space or equipment to progress you into more dynamic work, or your physical therapist may have provided everything their current skill set allows. I have talked about this before, but we spent very little time on ACL rehabilitation in physical therapy school. We covered the knee within a broader curriculum, but we did not spend much time on detailed rehabilitation progressions, return-to-sport decision-making, or testing.

A dynamometer was never mentioned in our rehabilitation class. It was not a requirement of our board examination or licensure process, either. That is important to understand when you are evaluating the expertise available to you. It is similar to asking a medical doctor for detailed nutrition advice when nutrition may have received limited attention during their training. They may be able to provide basic guidance, but that does not necessarily mean they have the specialized expertise required for every situation.

Physical therapists generally graduate as generalists. We are trained to work with many different diagnoses and conditions, but we do not automatically become specialists in every area. Developing ACL-specific expertise requires additional education, training, and experience. Some clinicians gain that experience over time, while others deliberately pursue more specialized work, but you should not assume that every physical therapist has the same depth of knowledge about ACL rehabilitation.

People sometimes assume that because a physical therapist has a doctorate and a license, they automatically know how to get them all the way back to their desired level of activity. But professionals are not all created equal. There is a basic level of competence that you should expect, yet the depth of expertise can vary considerably across any profession, whether you are talking about teachers, doctors, engineers, or contractors. A person can sound knowledgeable, particularly when speaking to someone who has limited experience with orthopedic care, without necessarily having the specialized skill set your case requires.

ACL rehabilitation is a specific area, and not every physical therapist sees a high volume of ACL cases. That is why it is important to look at both experience and outcomes when choosing a provider. Review the testimonials and feedback from people who have worked with them, and look for evidence that they regularly manage cases similar to yours. Just as you would research a major purchase and compare multiple reviews rather than relying on one person’s opinion, you should consider the totality of the evidence when evaluating a healthcare provider.

This brings me to the point where a clinic has done what it can, or you are told that you have graduated from physical therapy. We have already discussed how the word “graduated” can make people feel as though their rehabilitation is complete when they may only be a third of the way through the process. I want to be careful because this is not about blaming physical therapists or surgeons. Most are working hard within a system that was not designed to take every patient all the way back to high-level sport or activity.

But I need you to understand this distinction: the clinic reaching its ceiling does not mean your knee has reached its ceiling. It means you have reached the limits of that particular system, clinic, or provider’s available resources and expertise. Your insurance visits may be over, or the clinic may no longer have the tools or answers you need, but that tells you nothing definitive about what your knee is still capable of achieving.

This is why I do not want you trying to manage the entire process alone. You cannot simply compensate for a weak quadriceps muscle at month four, five, or nine by testing yourself, running, jumping, and hoping things work out. That is guessing, and guessing can create problems during ACL rehabilitation. We need to measure and assess properly because those findings should help determine the path forward.

So, what do you do with all of this? First, get your numbers. That means measuring your range of motion and comparing it with the other side, as well as assessing quadriceps and hamstring strength using objective methods rather than guessing. Depending on the situation and available equipment, that could include isokinetic dynamometry, isometric dynamometry, or, at a minimum, an isolated five-repetition-maximum test. You should also be assessing how you run, jump, and change direction, using both objective measures and qualitative observations where appropriate. If nobody has ever given you a number, that is the first thing to address. You need to know where you are today before you can determine whether you are improving. 

Second, get another set of eyes on your situation. Ask directly, “What is this recommendation based on?” and “What is the plan if this has not changed in four to six weeks?” If you cannot get a clear answer, consider an outside opinion, whether that means another rehabilitation provider or another surgical consultation. Seeking a second, third, or even fourth opinion is not disloyal. Some people feel as though they are betraying their physical therapist or surgeon by asking someone else to assess their case. But this is your health and your knee, and you should not feel obligated to stay with a provider if you are not receiving the guidance you need. Eventually, your formal physical therapy relationship will end, regardless of how good the relationship was, and you do not need to sacrifice your own care to avoid hurting someone’s feelings.

A good medical professional should understand that another opinion can be helpful, particularly in a challenging case that is not progressing as expected. If one of my athletes told me they wanted another set of eyes on their situation, I would respect that decision. It is part of doing your due diligence. Seek another opinion when you can, and remember that the goal is not to prove your current provider wrong but to make sure you have the information and support you need.

Third, and I am going to be direct here, do not try to do the entire process yourself. I understand the instinct. You are tired, you have spent time and money, you may have lost trust in the people you have worked with, and perhaps you have already seen several surgeons or physical therapists. You might think that you should simply figure it out on your own, stop doing the activities that feel risky, and work around the problem. But the middle and later stages of ACL rehabilitation can be especially difficult to navigate alone, and doing more of what has already failed is not a new plan.

Look for someone who works with ACL injuries regularly, not someone who sees them only occasionally. Look for a provider who objectively tests your knee and shows you your numbers, has credible reviews and testimonials, and is comfortable working with complicated cases. If your recovery has been straightforward, you may not need someone who specializes in complex cases. But if you have not been improving and need someone to investigate the nuances of your situation, that experience becomes much more important.

I recently spoke with someone who had been dealing with her recovery for well over a year and had started questioning whether she was simply overthinking things. As soon as we talked, I recognized several areas that did not appear to have been fully assessed. There were specific things we could measure and changes we could make to see whether her recovery would respond. I had a strong clinical impression that there were still areas worth investigating, although the important thing was to assess them rather than assume that we already knew the answer.

What was difficult was realizing that these questions could have been addressed much earlier. Sometimes people remain with the same provider because they have already seen their surgeon, have been told to keep working on it, and have made some changes without achieving the progress they expected. We work with athletes who have gone through double-digit numbers of healthcare professionals before finally finding someone who takes the time to listen, develop a plan, assess their progress, and support them through each step. That is a reminder of how important it is to find the right guidance, particularly when the case is not straightforward.

Is more always possible? No, and I want to be transparent about that. Finances, insurance, time, access, and other life circumstances are real limitations. You may be caring for a newborn, supporting an ill family member, or going through a period when additional appointments and expenses are simply not feasible. I understand those realities, and I am not suggesting that every person has unlimited resources or flexibility.

However, in my clinical experience—and I want to be clear that this is my experience, not a statistic from a research paper—the large majority of people who tell me they have reached their ceiling have not necessarily exhausted every possibility. They have reached the end of what was available to them or what they knew to try. Those are two very different things. If you have done the work but nobody has provided a clear plan or assessed your progress consistently, that does not mean you failed; it means the process may not have given you what you needed.

What you do next is your responsibility, and that is also the good news because it means there may be steps you can take. You may still be working with your current surgeon or physical therapist, or you may already have started looking for someone else. You do not necessarily need to end those relationships, but you can reassess your options and make a change when it is appropriate. If this episode resonates with you, you do not have to wait until you are completely stuck before asking for a more thorough assessment.

I have never finished a call with someone and thought that every possible option had been exhausted, and there was absolutely nothing left to investigate. I remember a particularly vulnerable conversation I shared with you guys recently that affected me deeply. This person was essentially asking whether this was as good as it was ever going to get. My response was that he had not been listened to properly, and when we laid out the first set of exercises and a more structured plan, things started to shift.

It was not rocket science. The difference was that someone had finally taken the time to listen, understand the challenges, develop an appropriate plan, and assess the response. That is what a good provider should be doing, and that is what ACL rehabilitation should strive to offer. I am not saying that your situation is your fault, but the decisions you make next can be important. You can advocate for yourself, even when resources are limited, insurance has run out, or money is tight.

I understand the financial side of this because I experienced it myself as a college student with significant student debt and a $10,000 out-of-pocket maximum when I needed surgery. I felt that I could not continue living with my knee shifting, so I had to find a way to make it happen. My brother helped me with a credit card payment, and I made monthly payments to keep the debt from going to collections. I know how difficult these decisions can be, and I am not suggesting that everyone can afford additional care without making sacrifices.

The point is to recognize how important this decision may be for your future. In complex cases, it is rare for someone to be able to guide themselves through every aspect of rehabilitation without help. You need a knowledgeable guide, and I am not saying that person has to be us. We are here if you want help, but the priority is finding someone who can assess your situation and guide you toward the best possible outcome.

This can be a fork in the road. You could spend the next ten years wondering whether you would have recovered differently if you had taken action sooner, or you could decide to draw a line in the sand and investigate what options remain. That might mean dealing with financial pressure, travel, time, or the inconvenience of finding another provider. I have had people drive three to five hours or even fly in for an assessment because they wanted another perspective on a difficult case.

You have to work within your own circumstances and resources, of course. But it is important not to assume that your current healthcare system will automatically provide every stage of ACL rehabilitation from surgery through a full return to sport. In my experience working with people around the world, I have not seen a system that consistently delivers a complete, high-quality process from beginning to end for every person. That means you may need to plan for what happens when your available care or resources come to an end.

I get fired up about this because I have so many conversations with people who say they are not sure what to do, think they can figure it out themselves, or need more time to consider their options. Sometimes they are nervous, and sometimes the financial, time, and emotional barriers are very real. But the message I want you to take from this is not that you need to work with us. It is that I want you to make a positive change for yourself rather than settling for 70% or 80% of what you are capable of achieving without investigating whether more can be done.

Your knee is connected to your sport, your activity, your job, and your overall health. I have seen people who did not receive the attention they needed and later struggled with chronic pain, weight gain, metabolic disease, depression, and anxiety. I am not suggesting that every one of these outcomes is caused by an ACL injury, but an injury can affect many aspects of life beyond the knee itself. That is why your recovery deserves attention, and why it is important to take your concerns seriously when you feel that something remains unresolved.

If your gut is telling you that something is still off and you are not getting the support you need, please look for that support. I would rather you hear this now than be one of the people who reaches out five or ten years later and says, “I wish I had done something sooner.” You do not have to accept that outcome simply because you have been told repeatedly to keep working on it. There may be other options worth exploring.

If you have been told to keep working on it, ask three questions: What is the number? What is the plan? When do we retest? I would also ask what you should reasonably expect to change and over what period. If nobody can answer those questions or lay out a clear plan, find someone who can. When you first speak with a provider and throughout the process, you should feel that someone is listening, assessing your situation, and guiding you rather than leaving you to guess.

Think about the feeling of driving somewhere unfamiliar and finally having a GPS that guides you in the right direction. You should feel that you have a team supporting you and helping you understand the next step. If you have questions, reach out. We have been taking on more cases, including complicated recoveries, and it has been rewarding to work with athletes whose situations require a more individualized approach.

We are here to help you find the right direction, and you may notice a meaningful difference in how you understand and navigate the process. I am not promising that everything will change in two, three, or six months, because every case is different. But having a clear plan, objective assessments, and appropriate guidance can change how you approach your recovery and what you are able to work toward.

The focus of this episode is simple: if you feel that the can keeps getting kicked down the road, that you are not being heard or supported, or that there is no clear plan for measuring your progress, consider making a change. Find someone who can be your guide. The time, investment, and effort may feel inconvenient, but you may be in a completely different place six to twelve months from now. Many people would love the opportunity to look back a year from today and know they took meaningful steps toward improving their recovery.

If you need anything, we are here. Otherwise, I will catch you in the next episode. This is your host, Ravi Patel, signing off.