Episode 291 | Twenty ACL Athletes Later, Complicated Might Be Normal In ACL Rehab

What is up, team? And welcome back to another episode on the ACL Athlete Podcast. Today’s episode is a little different than usual. Number one is because I’m really nasally congested. My little one is back into the whole school process, so he is bringing back all the germs, and he loves to pick his nose and do everything a two-year-old toddler will do, and I can only imagine the things he brings home. Here I am congested because we have started the grind of school, and I get the lovely byproduct of the germs.

But it is another week, and we have to show up, so let’s go ahead and talk through this one today. Instead of it being a deep dive on one athlete, for example, I’m going to walk you through a cross-section of just cases we’re actively working with right now and just a snippet of some of these cases. I just want to present this to you guys, and some of you listening might be on our roster right now, and you’re like, “Hey, that’s me.” Cool. Awesome. Thank you for being with us.

But with that, I’m going to just kind of share the span of cases because I think this is something that doesn’t really get highlighted that much in ACL rehab. I think that a lot of people have this kind of visual of what it looks like or a version that you picture in your head, and I want to give you the range of what ACL rehab can look like and also for some of you to be able to normalize what you might be going through: Is this normal? Am I truly behind? Is this something that I am just an outlier for?

I want to help to normalize that a little bit because I think a lot of you in this process are probably thinking that because you don’t feel this linear approach. And when you look at social media or forums, right? It’s really challenging because you see all these ACL PTs who are showing all these people getting back to these things, which is awesome, but it’s marketing, y’all.

There’s going to be rare times when they are showing the hard cases, the bad cases, the ones that are not getting there. So you have to understand that you’re looking at a highlight reel, especially on social media, and especially if the company’s goal is to sign up people and make money from that.

Now, there’s a better cause for that, of course, but the thing is, you have to kinda recognize that. And with forums, people are going to go to commiserate, so you have to also understand where that is coming from. And then most importantly, what I’m getting at is your perception of ACL rehab might be influenced by these things: what the surgeon says, what you read online, what it is that you might search on AI, and what you might be listening to on this podcast.

There’s a lot of different inputs with information, especially nowadays, so we have to kind of figure out what picture we build in our minds versus what the reality of this actually is. And so the script that normally people get going into this injury is you have the injury, you do prehab if you can, you have surgery, and then it’s on the road to a nine- to 12-month recovery, right?

You’re cleared; you get back to your sports and activities, the kind of clean-line checklist, and then you’re done. And for some people, that is genuinely how it goes. I’m not going to sit here and say it’s a rare case that you are just able to go through this that way. There are plenty of people who go through this process like that, don’t get me wrong, but there are also a lot of people who don’t, and I don’t want to categorize one as the majority and one as the minority.

Yes, there is a bell curve to this process, but I feel like most of you who are listening to this who have this nonlinear process, especially with setbacks or challenges that were just unexpected, my goal is to hopefully just also talk to you about this because this is something that we see across the board that is a bit more normal than what you would expect.

I want to help to reframe this. And if you talk to anyone who is actually seeing a high volume of ACL cases, like literally seeing hundreds of athletes a year, they will tell you that there is no clean version of this process or that everyone kind of operates in one lane. It is a much wider road that people are operating on. Most people don’t really know these other lanes exist because they just have this pictured one in their head until they’re maybe already on a different lane, right? They’re on a different journey in this. And yes, while we say that everyone has their own journey in this, and it’s very important to recognize this, it’s also important to recognize like, okay, is this lane the most efficient and best lane for you to get there? And is this more biological, or is it more systemic, meaning like, is it a healthcare-related limitation, like the access to care you have, the support you have, the surgical care you have?

There are a lot of different things that are going to influence the lanes that you are in and how fast you can go on them. And also, do you take the scenic route? Do you take the most efficient route? There’s a lot of things that factor into this. But mostly, someone just feels like something’s uniquely wrong with them, when in reality, they just didn’t know it might be a bit more normal than expected.

So here’s the lens I want you to hold onto today as we talk through this. Everything that complicates a case usually falls into one of two buckets, if you will. And now I’m not going to say that there aren’t other things at play, but there’s really two things that I think about. There’s the stuff that’s controllable, and there’s the stuff that’s less controllable, uncontrollable.
The controllable is who you pick on your team, right? Like your surgeon, your physical therapist, your coach, and people who are on your team who are helping you. And in some cases, that might not be as controllable, but the majority of the time, you have a choice. Like you can fire your PT, you can fire your surgeon and go find a different one. And if you’re not getting good care, you should. But those are controllable factors, right? And then you have the plan that you have and the testing and objective testing or lack thereof, or it might be your program and the individualization of that. And then you have the criteria that it is focused on and the testing versus it being just a calendar, right? There are things that you can control. Also, how frequently you’re hitting things and the intensity at which you can hit things at. There are controllable factors. And then if we zoom out, there’s obviously the nutrition aspects, the stress management. There is the recovery aspects of sleep and taking care of your body.

And then of course, the movement side of just being able to manage your load and the stress you’re putting on your knee, on your body, right? And then there’s the biological side, the biology, your own healing response. How that grass settles in there, any of the other kinds of tissues that are healing or could have gotten injured during the injury, and then maybe the surgery was also something that was done to help fix that, right?
And so it’s beyond just the ACL, but obviously that’s the main player in this. But there are things that your body is doing to be able to go through the healing process, and that is having the inflammatory phase, being able to have the proliferation phase, and then the maturation phase. Wow, pulling me back into biology and human healing. This is something that all of our tissues are going to go through. That’s something that even our skin goes through. When we have a cut, we’re going to go through these phases and these processes to be able to heal and get back to normal, with the closure of the skin and it heals. So that’s the same thing in the knee as these tissues go through this.

This is something that’s really important for us to understand: that there are controllable factors around this, and then there’s also not as many controllable factors when it comes to some of those biological processes. Now, nobody can control as much of the second one, the biological one. Yes, you can control those things around it, as I share, but in reality, like what that knee is doing through those phases, not you, not your surgeon, not me, not your physical therapist can even really do something about this, right? But even the stuff you can’t control still has a controllable response wrapped around it, and this is so important, y’all. And the longer I’ve been doing this, this is probably one of the most important things about working with someone who is really good at this process. You can’t control whether your body forms scar tissue, for example, and this might be one of the number one issues that people deal with in this process that they really can’t control fully.

Now, if you pissed this knee off for weeks and months and didn’t listen to anything and didn’t do your rehab, and it was swollen and inflamed, and you knew better, and you didn’t, then yeah, that’s something you could have controlled or had a good physical therapist to guide you around that. But at the same time, there are also people who do this perfectly and try to stay to a T, and they still have the biological processes not always working in their favor, and it could be for a number of reasons why.

One of those things that can happen is scar tissue. For example, a cyclops lesion can come up, right? The thing that I’m trying to point out here is that you still have a controllable response wrapped around this uncontrollable situation. You can control whether someone catches it in month four versus month eight, for example. No, it’s gonna depend on when it rears its head. But I think one thing that’s really important here is to be able to catch that, and I would say our team has gotten so good at this: being able to catch things that just don’t seem right. And I think in this process, what we see a lot is that it kinda kicks the can down the road. And I know so many of you listening are like, “Yeah, it does feel that way.”
It’s like, “My extension is not there yet, but I’ve been kinda bringing this up,” or, “It’s kinda concerned me. I’m limping while I’m walking, and I’m weeks and months out from this, and it should be better by now.” You’re realizing that your flexion is not really budging, or there’s a sharp pain you’re dealing with that is not improving.

Your knee is kind of shifting, and it doesn’t add up. There is a pain in the front of the knee that is just really stopping you from being able to do something. There are so many different layers to this that I know a lot of you recognize, and it’s one of those things that, kind of in your gut, you probably are like, “This doesn’t seem right.”
But then when you check with the professional, they’re like, “Oh keep working on it. Keep getting stronger. Keep working on range of motion.” And we see this a lot. A lot, y’all. And it’s one of those where I have seen cases that should’ve been resolved within a few months, and it drags out to six months, nine months, 12 months, beyond whatever their normal timing is.

I really do think in some of these cases, even for scar tissue, for example, someone’s trying to hammer extension, and the PT’s pushing on it, and you’ve got the surgeon saying, “Keep working on it,” and you’re in month three or four, and it’s not budging. There needs to be pattern recognition of testing and being able to do the right things to see, okay, should we take further steps, and not let that drag out to five or six months? And then guess what? That’s also kicking the can down the road on what you can get back to, your livelihood, and your goals, especially if it’s time-sensitive.

These are things that are really important. You have a controllable response to the uncontrollable stuff. And I do want to spend a minute on this kinda second part, if you will, because it’s actually the whole point of today’s episode. The people who end up finding us have often already hit a wall somewhere else, right? They have been working with a physical therapist in person. A lot of times, people are kind of struggling with guidance. They don’t feel like they have structure. They feel lost. They just don’t have what they feel like they need whenever they’re in PT with the attention or even outside of it with what they should be getting, and that is influencing their progress or lack thereof. People might go through one PT, two PT, three PTs. Y’all, we’ve seen it all, all across where people have changed different PTs, but it almost feels like you’re just kind of putting yourself in the same kind of situation, and it ends up being not much of a change. Now, some people do, and it’s amazing.

At the end of the day, all we care about is that you have good help to get you there.
But it is really challenging in this space with the way that the system is designed, and that’s one of the biggest things that’s hard and I always tell you guys, that it’s not going to be a matter of if; it’s a matter of when. You’re going to have to decide when is the time that you’re going to have to figure out to find an expert to help you with the rest of this process.
And it’s ideal to start with this, but then there’s some of you who will go to use your in-person PT, and then it’s a matter of if insurance runs out or if the skill set is just not valuable anymore. There’s a certain threshold where your physical therapist might not necessarily know how to get you all the way back to full functioning, or they are in a clinic in a system that is designed to just not help.
I’ve talked to so many ACLers who are like, “I have a great PT. I like them, and they’re nice.” And some will even say, “They’re smart and helpful.” But then they say, “I only get 10 minutes with them. I only get 20 minutes with them, and it’s once a week, twice a week.” Whatever the frequency that they’re going, and it’s like it’s still really hard.
You can give the best construction worker or carpenter or builder to build this house, and if you only give them a hammer and they need so much more, it’s going to be really hard. It doesn’t matter how smart they are. It’s if they don’t have the tools, the time, and the skill set available, it’s going to be really hard to do that. But even with the skill set, if you don’t have the proper tools or the resources, it’s going to be really hard to do that.

And so that’s one of the challenges with this. And so my point in bringing this up is that while there are challenges in the system, people hit these walls with physical therapists, or they just feel like they’re just not gonna get good enough care with where they are or who they’re seeing. And so I want to also make sure that it’s clear that, by trying the local insurance-covered route, I’m not saying that it’s a bad route.

I understand that we pay into these things, and so you want to get out of it what you have paid into. So that is justified. I just think you need to know what you could be expecting based on that and based on just what the average is. And I have amazing friends and colleagues who are in out-of-network, no-insurance connections and clinics, and then I have people who are also in insurance-based who absolutely crush it.

Again, state-specific, country-specific, and all these things can kind of influence things. But we know as a whole that it is not necessarily the best system designed to get ACLers from point A to point B with as much support and guidance as possible. And it’s not lost on me on that, and the cost is real, I understand, and that’s not a knock on anyone’s judgment in terms of going to do the insurance-based route.
But it does mean, like what I’m sharing here, is that what we see can kind of skew towards cases that didn’t resolve cleanly the first time. And yeah, we get the proactive people who are like, “I just want y’all’s help. I want to be able to go through this from start to finish,” which is amazing. We’re able to make it a fairly smooth process overall.
But then there are a lot of people who are like, “I’m on, number three PT,” or, “I just feel like my PT isn’t getting there.” So then we understand we will naturally see the more complex cases. Here’s what that actually gives you, though, and it’s not about being the smartest person in the room. It’s about pattern recognition.

When you’ve worked with such a wide range of cases across different surgeons, different graft types, and different sports and activities, you start to recognize things faster. A knee that isn’t responding the way it should, a symptom that doesn’t fit the usual timeline, a small red flag that’s easy to miss the first time you see it, but it’s pretty obvious on your 50th or your 100th or your 200th, and that pattern recognition is the entire difference between catching something in month two, month four versus month eight or month nine, 10, 11, 12, wherever you are.

It’s not this magic thing, and it’s not about having all the answers. We still have tons of answers that we are still trying to find and learn together as a team. But it is about having seen enough of the pattern to know when something needs a closer look and knowing what question to ask next.

That’s what good guidance actually does. It doesn’t control your biology. It makes sure the controllable side of your case never becomes the reason an uncomfortable or uncontrollable complication turns into a lost year, and that is so key.
There’s such an opportunity cost to this, and I’m not saying we’re perfect in this, but I will say that our team has gotten incredibly good at being able to recognize these things in these cases. And I’m able to suss this out from even initial consultations to when people start working with us, and we start collecting data and being able to assess and see where they’re at.

We’re able to say pretty quickly, “Okay, this is what we’re seeing. This is your history that you’ve told us about, and these are the data points we see, and these are the next steps,” right? In case we need to kinda go further beyond just a rehab process.
And I would love to say that we can work out any issue, but we just can’t. It’s why medicine exists. It’s why surgical processes and other non-invasive processes exist. The thing that is so key in this is being able to recognize this quickly and make decisions quickly.

And it’s the thing that when I’m seeing what these athletes are saying about working with us and being able to just tackle these issues quickly is so important. And the one thing that is really important is that I understand that we might have a selection bias towards people needing more complex help. But I will say that I want to also normalize that this might be more normal than what most of you think.

And again, it’s because of the exposure that you might have to this process that I think is really important to share. And so what I would like to do is just dive into some of these cases, and I’m just going to go rapid-fire into these. So I have 10 that I have that I’m going to kind of expand on in more detail, and then I have 10 that I’m going to really rapid-fire for you guys to get an idea of this.

And my goal of this is to help normalize some things, but also for you to maybe feel seen in this. Sometimes people are like, “I feel like I might be the only person who’s in this situation. I feel like X, Y, and Z.” So I want to be able to showcase to you guys this is just a drop in the bucket of being able to share some athletes and some cases that we work with to be able to see the wide range of what exists in this world and to normalize this a little bit, so you don’t also feel crazy about this either.

Number one, a sophomore in college, pre-op surgery is about a week and a half out, worried about her post-op physical therapist near the school isn’t going to be the right fit for a varsity athlete, and wants to come back and play varsity. 

Number two, a finance professional based in another country, 13 weeks post-op. Nothing biologically unusual happened there, but there’s been zero objective testing anywhere in her care, and she’s stuck in a one-step-forward, two-steps-back kind of pattern with no way to explain why. There was no kind of digging into it. Beach volleyball is her top priority. 

Number three, a 14-year-old managing a partial tear conservatively about two months post-injury. Dad’s biggest fear is the re-injury, of course, in the fall without proper preparation over the summer. Wants to be strong and confident heading back into the season.

Number four, a physical therapist, she is further out on one ACL and she has had quite a long process of tearing her ACL to being someone who had the procedure, and then she was told that what she was feeling in her knee was not necessarily real, if you will, or maybe in her head a little bit. And turns out she had a screw-related issue that ended up getting that hardware taken out, which improved that, but then had some complications after, and then also had some tunnel widening and some other kinda scar tissue-related issues. And so it’s been a long, hard process. And so all that needed to be cleaned out and fixed. And so she wants to get back to being able to do the stuff that she wants to do. She’s very active, and she’s a physical therapist. This is someone who has some of this knowledge but is choosing to also work with us to be able to try and get through this process without also doing it herself.

Number five, an executive in his 40s who is in the early weeks post-op, on his second ACL on the same knee, having managed the first one without surgery earlier. Heavy travel, work schedule. Top goal is to be skiing, which tells you exactly how much he needs to trust his knee to rebuild it in that knee, and skiing being heli-skiing specifically.

Number six, a working professional whose complexity has nothing to do with surgery date at all, has a metabolic-related condition that has influenced a lot of her process and progress until it finally got captured and then started to realize, oh, we need to address this, and then started to see some progress. Wants to get back to being able to run, be able to lift again, being active as a professional. And this is something, for a lot of these cases, these are not ones we start with from the beginning. These are all ones that we are starting later in this process.
And so this is something that’s really important because they’re coming in at certain points with certain issues that they’re dealing with.

Number seven, a professional acrobat, six weeks post-op on the second knee, bilateral kneecap fractures six months apart. This one’s actually not an ACL, but she’s rebuilding two with hardware put in, trying to trust those knees. Imagine two patella fractures. That’s not great at all, and it’s challenging to deal with. So that is something that we’re also trying to manage to get her back to doing these things and performing well.

Number eight, a woman in her 60s, pre-op, her ACL went untreated for quite a while after being told for years that she wasn’t athletic enough to need the surgery. A recent fall had created a fracture and also had a second ligament sprain on top of the original injury. I call that collateral damage. And this is something that, had she maybe seen a different surgeon back in the day, could have been a little different. But she wants to walk without a limp and be able to get on the floor with her grandkids. 

Number nine, an adult athlete, six months post a full ACL revision. Newer graft alternative used the first time around, re-injured it, and is now managing a revision with a meniscus-related repair, chasing a competitive season that’s ahead, trying to get his strength numbers in a good place. Definitely complex process, especially going from one procedure to another. 

And then number 10, an adult athlete currently in the middle of two-stage revision. The most layered case, I would say, is probably on our entire roster, with the history that unfolds with this. But two prior repairs on the same knee with both did not do well. Then also had an infection scare and some antibiotics-related issues, and then had an unrelated reaction, metabolically. And so this is—and I’m saying this ’cause I’m like, man, this has definitely been a wild journey—and I also came up with some anemia with blood work. A lot of metabolic-related things and some autoimmune, and then also dealing with doing a two-stage revision, which is, you go in and you put the tunnels, fill them back in, let them heal for three to six months typically, and then have a new ACL procedure. So a lot of things are stacking on top of them.

And then that’s 10. Are you guys with me so far? You’re like, “Come on, Ravi.” But I want to share these. Some of you might be relating to these. You’re like, “Wow, this is quite a spread.” So now I’m going to give you 10 and just kind of give you a slice of it to just give you another kind of wide example of this.
A PE teacher, mother of two, choosing a non-operative route, and wanting to get back to being active, especially being a PE teacher and being able to do all these things. A teenage national-level team player for soccer overseas has been getting back to things, but then has had some things during the process that weren’t super straightforward.

But it’s something that they needed: that structure; they needed more of the education, with the dad helping and the mom helping in this process. An engineer was undertreated twice by the same kind of generalist provider for two separate knee issues that she’s dealing with. A dance-related professional, in the earlier parts of this process, was tracking her own extension numbers because the PT just wasn’t really prioritizing it, and she was walking with a limp.
An operating room nurse who was discharged from PT early has dealt with, yes, a quad that has been challenging to recover from but has recovered over time and then had a hip labral issue that had to be repaired, and then also got that repaired and now is having to rehab from both and trying to get back to things.

A college athlete who managed a torn ACL without surgery for two years before re-injuring it, now seen by three different surgeons. Orthopedic surgeon himself who tore his own ACL skiing and then had surgery, going through this process, needing to get back to work, being able to do his total knee replacements, and be able to support that leg. Super key in this process for him.

A working overseas tore her ACL hiking near a cliff, then tore her ankle mid-rehab, requiring its own separate surgery on the same leg. A hypermobile athlete managing some hormonal transitions alongside additional ligament repair and early cartilage wear. A mom who self-diagnosed her own scar tissue lesion after a PT dismissed it confirmed it herself roughly two and a half years into this journey.

This is something that is just a range, y’all. It’s a range. Every single one of those is still just biology or circumstance, right? Not a failure on anyone’s part. But with 20 cases across this episode, every one of them fits into that same lens I gave you at the start.

Biology, which nobody necessarily controls, or the controllables, which is the guidance and the structure around it, which can absolutely be managed well or managed poorly and influence this process a lot. And here’s what I want you to actually take from today: this range isn’t just rare. It’s normal. And if your recovery hasn’t looked like that kind of cleaned version that you pictured walking in with or what’s on the highlight reels or social media, whatever it might be, or what you had asked AI about, that doesn’t mean something’s wrong with you. It means you’re closer to the middle of the pack than the outlier, even if nobody around you has really told you that, and I think that’s really important to share with you.

The other piece I want you to leave with is this: nobody can promise you control over your own healing. What good guidance actually does is catch the pattern early. Recognize the thing that doesn’t fit before it becomes a bigger problem. I always tell people we are able to catch things and get ahead of things, of problems that could have happened because we are able to track these things ahead of time and just know what that could look like. And that’s the thing that you are looking to invest in and to be able to work with somebody: to be able to know what that path looks like.

It’s like the Sherpa trying to climb Everest, right? And I know that seems extreme, but you’re trusting someone who has done this already, who has walked this with many people, doing this miles after miles, in different conditions, in different cases. That’s essentially what you’re trying to sign up for: finding the best Sherpa, the best GPS to take you through this. And that’s the real value of working with someone who’s seen a wide range of these cases. And this is something that I confidently can say about our team and what we do, and this is something that I used to just try to be a little bit more; kind of don’t talk about this. But after the years of us working and what we’re doing and us meeting weekly, multiple times, to talk through athletes’ cases, every single case gets discussed that we talk through.

We are not missing anyone who is going through this process with us. And the thing is that you get a whole team behind you, and more importantly, we talk through things and we’re learning about things, and we’re always trying to figure out what we can do better to help these athletes. And it might be referral sources, it might be exercise prescription, and it might be the ability to structure things a little differently. But we are also trying to catch things ahead of time before they turn into kicking the can down the road. And it’s the thing that bothers me the most about this is that, as ACLers, I think there’s a lot of guilt in this, and I think sometimes it can be warranted and sometimes not.

And you’re trying to do right by what resources you have, but then you have to look otherwise. And it’s really hard in this. And so I think that this is something that, with what a good ACL professional, if they’ve seen a wide variety of cases, then they’re able to pick up on these things.

And the thing that is also hard is that there are also professionals who see ACLs locally, and they see it from one, two, maybe three surgeons. And so their sample size is a little bit more selected than that, right? They see those same procedures and types of processes, and usually from start to finish, maybe they come in later. But that’s a little different even for the high-volume cases. The thing that we have a unique snapshot of is that we get to pull across the entire world: different surgeons, different graft types, different techniques, different types of physical therapy that we hear about and different goals, different types of populations, and different types of resources.

This is something that has pulled over hundreds and hundreds of ACLers and thousands of ACLers to this point in this company. And so this allows us to have so many repetitions to be able to focus on one thing, and that is ACL rehab. And that is why this podcast is almost hitting 300 episodes: this is the thing that I obsess about; this is what I care about. I think that is the thing that I want to get across to you guys today, is that, one, I wanna try and normalize maybe some of the craziness you feel, to know that there is a wide range of cases. And I think anyone who’s seeing a high volume of cases, that they will say, “Yeah, this is actually not abnormal.”

This is literally just a week for us, and we will continue to get the crazy cases all the way down to the simplest case, right? And we welcome them all, and it’s awesome to be able to work with them. And if that is something that you’re interested in, we would love to help you.

And I do think that if you are someone who is struggling, does not have structure, do feel like you need better guidance and better overall support, then we are here to help. After doing this for such a long period of time, I want to just kind of welcome and keep the door open for you guys if that’s something that you need more support with. But that’s where the real value comes, is from, being able to work with someone who can see these cases, not because they have all the answers. I’m not sitting here saying we have every single answer possible, but we have a lot of them. We have a lot of them. And I promise you, if we don’t have the answer, we will find it, and we will figure it out together.

But the thing is that they have seen enough of these cases to be able to recognize and ask the right questions sooner. And this could be literally the difference between you getting back in within that year and it being a two-year process.

I see this so much, and I look across our roster, and I’m like, “Man, if we could have just gotten you from the start, this would’ve been so different.” And that’s the thing that I want to just save you guys from, is like just make sure that if you feel like something does not feel right, make sure that you find the help sooner.

And worst case, yeah, it’s some, if you had to spend some funds on it, okay. We have to invest in our health, and that’s important. Number two is that if there’s nothing that comes up, great. Just keep moving forward. Just make sure you find better support and help for it.

But this is something that I wanted to share today. I think it was really important to open it up to you guys to be able to see this and to also just transparently talk about what it is that we do, and also to be able to help anyone who is feeling the need that they need some more support. And so this episode touches on that real clinical side.

It touches on the emotional side of things. So if any of that, of what you heard today, is hitting close to home, then please reach out, whether it is to your own care team or a mental health professional if you feel like you need support in that or reaching out to us if you need advice on next steps, because we are here to help in any way that we can.

Thank you guys so much for being here. If you need anything, we’ve got you. I’ll see you in the next episode. This is your host, Ravi Patel, signing off.