Episode 292 | The One Skill That Separates Good ACL PTs From Great Ones

I want to start with something I do not usually lead with. I got something wrong early in my career—not a small thing. There was a pattern I missed with an athlete because I told myself the same thing a lot of well-meaning providers tell themselves: “Give it more time. It will come around.” It did not come around. And that mistake taught me more about being a good ACL physical therapist than almost anything else that has happened since. And that is what I want to talk about today. 

Last week, I did an episode walking through 20 different cases from our caseload: different ages, graft types, timelines, procedures, and levels of complexity. Some were straightforward, while others were incredibly complicated. This episode builds off of that because there was a thread running through many of those cases that I could not stop thinking about afterward. It was not necessarily about the injuries themselves; it was about how many of them looked normal on the surface right up until they did not.

It took me back to my own early misses, especially the things I should have done better and the lessons those cases taught me as I have gotten further into my career. One of the things that separates a very good ACL PT from a great ACL PT. It has nothing to do with knowing more exercises. It is not about knowing thousands and thousands of exercises. Early on, I had an athlete who was stalling, and athletes can absolutely stall during ACL rehab. There are phases where people hit a plateau and need to work through it, but this athlete was different because extension was not returning the way it should have, and swelling continued to linger longer than expected. I did what a lot of PTs do when something does not match the textbook timeline. 

I told myself it was normal variation because recovery exists within a range. I gave it more time, adjusted the program a little, and waited, thinking I could out-exercise the problem and eventually things would improve. Looking back, that was the wrong call. There were signs pointing somewhere else, but I did not yet have the experience to recognize them. I was pattern-matching against a small sample size because I simply did not have as many repetitions under my belt as I do today.

That athlete lost real time, not because I did not care or because they did not work hard. I cared deeply, and I was putting everything I had into trying to help. I simply had not developed the pattern recognition to know when normal recovery variation stops being normal. I think about that case often, not because I beat myself up over it anymore, but because it is one of the reasons I built the systems we have today. None of this exists because we think we are smarter than everyone else. It exists because we got burned by not having it.

That is one of the most important parts of this process: taking your personal expertise as a physical therapist, your education, your experiences, and the patient perspective, and then filtering all of that through what the research and totality of the data show. You need all of those lenses to come up with the right game plan and know when to pivot. When you are starting out as a young clinician, you are trying to get repetitions, understand patterns, and recognize the nuances of different recovery processes. There is no single ACL process that looks exactly the same, so you are constantly collecting more information.

It starts with N equals one, then two, three, four, five, and eventually 10, 20, 100, 200, 300, 400, and 500. Those are the repetitions that build experience. Every session, every communication touch point, and every day an athlete moves through this process gives you another opportunity to recognize patterns. But you have to be intentional about it. I know many people who have seen a lot of ACLs but continue repeating the same patterns because they never intentionally updated their thinking or reflected on what they could have done better.

You need to audit the process and ask yourself, “What could I have done better? Where were my blind spots?” That is crucial for me and for our team, and it is something we discuss every single week. We want to keep showing up as the best professionals we can be, deliver our best for our athletes and mentees, and produce the best outcomes possible. That also means making sure athletes feel heard. Pattern recognition is not a talent that someone is simply gifted with; it is built over time, repetition after repetition, including through being wrong enough times that you start noticing what “off” looks like before it becomes obvious.

I like to think about this like a Sherpa taking someone up a mountain for the first time. The Sherpa is not fearless because they are built differently. They have simply been up that mountain hundreds of times. They have seen the weather change on that exact ridge, know what normal fatigue looks like, and can distinguish changing conditions from something that is about to become a real problem. They have probably gotten it wrong once or twice, especially earlier in their career, which is part of why they trust their judgment now.

When you start getting those initial repetitions, everyone has to begin somewhere. If someone who was my first ACL ever is listening to this, I am sorry. I wish I could have done better for you, but I was trying to build my experience, and everyone has to start somewhere. As an ACLer, you understand that clinicians have to learn and accumulate experience, but you do not want your physical therapist to be learning the most important lessons on you. Repetitions have to be built over time, but there is tremendous value in building that experience before the consequences of a missed pattern fall on the athlete.

Practically, this is what building those repetitions looks like for our team. We meet every week, multiple times a week, and talk through our athletes’ cases. We do not only discuss the easy cases or the complicated ones; we talk through all of them. We know where each athlete is, where they are going, and what we are seeing along the way. Sometimes we will spend 30 minutes on one case because it is complicated enough to deserve that attention.

If you are one of our athletes, I promise you have been part of those conversations. Especially if you are dealing with a complicated case, you have probably received significant face time in our team meetings because we talk through the cases that make us scratch our heads and ask, “This does not really add up.” We are talking about hundreds and thousands of ACLers at this point, going back and forth, pressure-testing what each person is seeing, and learning from one another. Sometimes we decide something needs to move faster, while other times we decide we need to slow things down and allow the process to develop.

We do not walk into those conversations with all the answers. Nobody does. We see a huge range of cases, including simple ones that are genuinely enjoyable to watch because an athlete can move through the process smoothly, as well as complicated cases that require more time and more eyes than a typical visit may allow. That is not a criticism of any individual provider. It is often a consequence of a healthcare system and care model built around volume rather than the one-on-one detail and depth that some athletes need.

Accumulating repetitions, discussing cases as a team, troubleshooting problems, getting things wrong, and correcting them is what pattern recognition actually looks like. It is not about being naturally gifted at spotting every problem. It is about accumulating exposure, paying close attention, and having a system that forces you to track trends instead of treating every athlete as an isolated case. That means tracking data, connecting the dots, and identifying what is trending in the right direction and what is not. You cannot know what is happening unless you are consistently assessing and keeping up with those changes.

That is why the data matters so much to us. If we are applying the knowledge, frameworks, and processes we have developed and something still is not moving in the expected direction, we start asking questions. We start thinking like detectives: “This is what typically happens in this situation, so why is this not happening here?” That is when we need to investigate rather than simply continue doing more of the same. 

I want to give you two examples because they show how much timing matters. The first is scar tissue and a cyclops lesion. These can form in the front of the knee and interfere with full extension, sometimes producing symptoms such as anterior knee pain. If you identify the problem around month four, it can become a relatively straightforward conversation and course correction. I recently had this happen with one of my athletes, and we caught it early enough to intervene, have the tissue removed, and continue down the road to recovery. She had been doing everything right, but scar tissue and a cyclops lesion still developed, which is an important reminder that not every complication is caused by something the athlete or PT did wrong.

The important part was recognizing what was happening and acting on it. If the same problem is not identified until month 10 because it was repeatedly explained away as tightness, normal stiffness, or “close enough” extension, the situation becomes very different. At that point, someone may still be walking abnormally, struggling to get the quad to engage, experiencing anterior knee pain, and wondering why they are not back to the activities they want to do. Instead of being on the field, court, or slopes at month 10, they are still trying to figure out why the knee is not progressing. The difference is not necessarily the existence of the scar tissue; it is the amount of time it was allowed to interfere with the recovery.

I am not saying that scar tissue or a cyclops lesion will always show up early. Sometimes these problems develop or become apparent later. The important question is whether a problem was already present and simply kept getting pushed down the road. We have had athletes go back to their surgeon and hear, “Keep working on the extension. It will be fine,” while we are looking at the presentation and thinking, “This does not fit.” In those situations, further evaluation or imaging may be appropriate, especially when the athlete has persistent symptoms that are not resolving as expected.

Sometimes the athlete has to advocate for that next step. We try to equip them with the right questions and information so they can communicate clearly with their healthcare team. If the surgeon does not listen or the concern remains unresolved, seeking another opinion is reasonable. We have had cases where further evaluation confirmed scar tissue or a cyclops lesion, the issue was addressed, and the athlete could finally move forward rather than spending additional months working around something that rehab alone was never going to resolve.

The second example is chronic extension loss, which can show up as a limp. This gets normalized far too often, with people being told that it will eventually work itself out, that they simply need to stretch more, or that they need to give it more time. When a problem persists beyond the point where normal recovery variation can explain it, that persistence becomes a signal. It is not necessarily a personality trait of the knee or something the athlete simply has to accept. The challenge is knowing where the line is between “normal recovery noise” and a meaningful “signal,” and that line becomes easier to recognize as you gain more experience.

The more cases you see, the better you become at distinguishing signal from noise. That is why volume matters, but I would argue that volume plus outcomes matter even more. Someone saying they have treated or operated on 100 ACLs in a year does not automatically tell you how good they are. I want to know what happened to those athletes and whether there is actual evidence of the outcomes they achieved. Volume provides exposure, but outcomes provide evidence that the experience is translating into meaningful results.

That is important when evaluating both PTs and surgeons. Look for evidence of volume, outcomes, education, background, and expertise rather than simply accepting someone’s claim that they are a guru. In today’s healthcare environment, where there is a lot of information, marketing, and people selling solutions, actual proof matters. Patient experiences, reviews, outcomes, and transparent evidence can help you determine whether someone truly has the experience they claim to have. You want to know that you are working with someone who not only has seen a lot of ACLs but has also demonstrated the ability to help those athletes achieve good outcomes.

What should you actually do when something feels off? This is where I think the real value is, because noticing a problem is only part of the process; you also need to know what to do next. We need a decision-making process that asks what happens if step one does not work, what happens if step two does not work, and when we need to move to a different level of intervention. Sometimes the answer is conservative, and sometimes you need to move more quickly depending on what the evidence is showing.

That might mean adapting the rehab program with small adjustments based on how the athlete is responding. Sometimes it means pivoting the entire approach because what worked previously is no longer working for that particular case. It may mean referring out for imaging, such as an X-ray, MRI, or CT scan, depending on the question we are trying to answer. For example, we may need to understand the tunnels, their size, positioning, or other structural factors instead of continuing to guess. At the same time, we are collecting assessments and objective data so we can connect the dots and make a more informed decision.

Sometimes there is a conservative medical route, such as medication to help manage swelling or inflammation. Sometimes an injection may be considered, either to calm something locally or to help diagnostically determine where a problem is coming from. For example, if there is a suspected screw-related issue, a local anesthetic can sometimes help determine whether that specific area is contributing to the symptoms. The point is that interventions can serve different purposes, and the right choice depends on what we are trying to learn or accomplish. These decisions should be made alongside the orthopedic or surgical team rather than in isolation.

Sometimes the appropriate route is more invasive. We do not love that option, and as a physical therapist, my bias is always to avoid surgery when it is not necessary. But over the years, I have learned that there are situations where surgery is the quickest or only realistic way to achieve the outcome we need. Scar tissue removal, revision surgery, or repair are examples of problems that rehabilitation alone may never resolve. Recognizing that does not mean we failed at rehab; it means we recognized the limits of what rehab can accomplish in a particular situation.

When we feel strongly that something needs further investigation and the surgeon dismisses it, we help the athlete seek another opinion. That does not mean we think we know more than the surgeon. It means we have learned that sitting on a concern for months and simply hoping it resolves rarely turns out to be the better option when the pattern continues to suggest otherwise. We have had many athletes told to keep strengthening the quad, keep working on extension, keep doing PT, or simply take more time. Sometimes that is appropriate, but sometimes it is not, and pattern recognition helps us know when we need to ask a different question.

We had one athlete recently who had been dealing with extension issues and whom we believed might have scar tissue formation. She flew internationally to see her surgeon, only to spend about five minutes in the office before being told, “The knee looks great.” She had made that trip specifically to get answers, yet her concerns were not meaningfully investigated. She is a younger athlete and did not necessarily feel equipped to advocate for herself, so we are now helping her seek another opinion.

Unfortunately, she has already lost time, and the healthcare system she is navigating makes it difficult to simply move to another surgeon. This is a situation where the problem may have been addressed sooner if more time and attention had been given to what she was reporting. Expertise can sometimes create its own blind spot when a provider assumes they already know what is happening. We need to listen to athletes more carefully because it is their body, and it is extremely difficult to determine whether someone is overreacting or identifying a legitimate concern after only a few minutes.

That is why athletes need to be equipped to advocate for themselves. You should know what to ask, what information to bring forward, and when it is appropriate to push for more evaluation rather than simply accepting, “It will get better with time.” Sometimes the opportunity to address something is right in front of you, and you need to take it because another appointment or another opinion may be months away. Healthcare systems have constraints, and those constraints can make timing even more important.

I had another athlete recently who was eight months out and still occasionally limping. You might think that is unusual, but it happens far more often than people realize. In her case, the limp had been normalized throughout the entire process. Her surgeon had not watched her walk, despite her reporting that she might be limping, and her PT had told her that it would improve with time.

From everything we have discussed about her case, I believe there is something underlying that has not yet been addressed. Time alone is not going to fix it if the underlying problem remains unidentified. It will simply cost her more time. And that is what I want athletes to understand most: if something in your gut is telling you that it does not feel normal, that feeling is data.

You are not being dramatic or impatient simply because you have questions about your recovery. Asking questions, seeking a second opinion, or even getting a third or fourth opinion is not a betrayal of your provider. It is you advocating for your recovery. It is your body, your livelihood, and your outcome. You have to take an active role in the process. There is no perfect healthcare system, and it is easy to fall through the cracks when everyone assumes someone else is watching the bigger picture.

We are incredibly good at keeping people alive, but healthcare is not always as good at proactively identifying problems before they become bigger ones. That is something worth recognizing in any healthcare system. If you are an ACL athlete or supporting professional, the takeaway is simple: trust what you are feeling in your body and ask questions. A second or third opinion can be completely normal, and any provider worth working with should welcome that process. We welcome it, too, because if someone feels they need another opinion, I am not going to take offense.

If you are a clinician or coach, the takeaway is different but equally important. Pattern recognition does not simply happen, and you are not born with it. It is built through repetition, reflection, and intentionally tracking what happens across your caseload. Build time into your schedule to talk through complex cases, even if it is only with one colleague. Most importantly, be honest about the cases you have gotten wrong, especially the ones that did not improve or did not return to the outcome you expected.

Those are the cases you need to audit, not just the success stories. The difficult cases are where you learn the most, and those are the cases we spend the most time discussing on our team calls. They are the ones that do not add up, the ones that challenge our assumptions, and the ones that ultimately make us better professionals. ACL rehab is already complicated and difficult enough, so we owe it to our ACLers to keep learning from the cases that challenge us.

I am not sharing any of this because we have everything figured out. Far from it. We are still building and refining our systems every week, continuing to learn, improve, and occasionally get humbled by a case that does not fit the pattern we expected. That is the entire point: we keep learning from those cases. If you feel like you are handling every case perfectly, I would almost argue that you are probably not seeing enough complicated cases, because there will always be athletes who make you stop and think.

We continue to improve by making sure our athletes know what the next step is, whether that is step one, two, three, or four, and by staying alongside them throughout the process. If there is one quality that I think separates good from great in ACL rehab, among many other characteristics, it is the ability to learn from mistakes, accumulate meaningful repetitions, demonstrate outcomes, and develop pattern recognition. That ability can be the difference between an ACL recovery that takes nine months and one that takes 18 months, or one that takes 12 months and one that stretches into three years. We have seen it happen repeatedly.

Sometimes the problem is not that someone did something terribly wrong. It is that something was not recognized early enough, so everyone accepted it as normal and continued moving forward without addressing it. The problem then continues to interfere with recovery for weeks or months. Often, the athlete already knows something does not add up. That gut feeling matters, especially when it continues to persist despite the care they are receiving.

Evaluate the opportunity cost of doing nothing. If you feel stuck, lost, or uncertain, take action and make sure you are moving in the right direction with a team that understands what you are dealing with. Maybe you are a complex case, or maybe you are a straightforward case and simply need a clear weekly structure and someone who can provide guidance. Having the right GPS and the right team can give you the clarity to finally exhale and feel like you have a plan. We are here to help. 

Please reach out to us. We can point you in the right direction. You can find all of our information in the show notes. We want the ACL community as a whole, including ACL PTs, coaches, and everyone involved in this process, to become better at what we do and to keep improving the experience and outcomes for ACLers.

Reach out if you need anything. Otherwise, I will find you guys in the next episode. This is your host, Ravi Patel, signing off.