Episode 296 | The Trust Problem in ACL Rehab and Healthcare

I had a conversation this week with an ACL athlete who told me he would almost rather someone just say it was over so he could stop fighting it. Let that sit for a second. He was not being dramatic. He was exhausted, and I could tell. He had been spending months doing everything he was told to do by everyone else, and he still could not get his knee to move in the right direction.

Here is what I have learned from talking with hundreds and thousands of athletes like him over the years. By the time many of them find us, or we are talking to them, the knee is really the second thing that is broken, if you want to use that word, or the second thing that makes their situation so challenging. The first thing we recognize is that trust has been broken.

Today’s episode is about that: how trust breaks, why nobody warns you about it, and what it does to the way athletes approach their rehab. I think this is something that might be sitting in the back of your mind, or maybe even the front of your mind, and it can bleed into a lot of your beliefs about your recovery.

Before we get into it, I want to set it up the right way. Healthcare is messy. There is no arguing about that. It is not perfect, and it looks very different from country to country. There are costs and delays. In the United States, insurance adds another layer on top of an industry that often runs on volume. Most people inside the system are working hard within a model that gives them very little time.

I want to take a second on this because I do not think people get into healthcare with bad intentions. I do not think the surgeon who might have ignored you or been rude to you necessarily got into the profession for the wrong reasons. The same thing applies to your physical therapist. They may mean well, they may be nice, and there may still be things that fall through the cracks and leave you without what you need. We do not get into physical therapy because we think we are going to make huge financial gains. That is not what you do when you get into physical therapy.

The challenge is the model and the system and how it has been designed and developed over the years. Back in the day, when people had great insurance, things were covered, and costs were relatively low; people could have deductibles of around $100. Now, it can be difficult to find anything with three digits in it. It is a very challenging system that has grown out of control, and especially in the United States, the insurance system adds another layer to an already expensive healthcare system. So this episode is not about throwing shade at healthcare. It is about recognizing that people can be working hard within a very difficult model that gives them limited time and places a significant emphasis on volume.

Plenty of athletes have great rehabs with great surgeons and great physical therapists. What I want to talk about is how these experiences shape an athlete’s trust, how that trust shapes their mindset and decisions, and especially how all of this plays out in a rehab as complicated as ACL rehab.

I have some personal experience with this. I have torn my ACL twice, had a pretty major hip surgery that is rare for someone my age, and dealt with insurance delays during my first ACL surgery. The second time, I paid $10,000 for my out-of-pocket maximum as a college student, and I did not have that kind of money because I already had student debt.

I have also watched my dad go through healthcare scares, and my parents as a whole navigate difficult situations, including my mom dealing with a potential cancer issue and my dad having a heart attack followed by a heart procedure. They are immigrant parents, so I am currently helping them navigate the healthcare system with things that are going on. Having the education and healthcare literacy that I have has helped me, but it has also been difficult. Even talking with doctors’ offices can be challenging because of miscommunication and differences in language and the way people communicate.

I am sharing all of this because I think it is a very common issue that many people face, and I do not think it is talked about enough in healthcare. People complain about healthcare, yes, but I do not know that we necessarily think about how much our previous healthcare experiences influence our current decision-making. With something like ACL rehab, that can become a slippery slope. I am not blaming anyone for having their trust broken or fractured when the process does not turn out the way they expected, because there are a lot of people who go through ACL rehab and find that it is not even close to what they expected. I want you to know that I relate to this, I have been through it, I am helping my parents through it, and I see it every day in the ACL athletes I talk to around the world.

That brings me back to the ACL athlete I talked to this week because I think his story is important to share. There are certain conversations I have where I just cannot shake them afterward, and this was one of those conversations. He opened up to me in a way that people usually do when they are really exhausted. He came into the call as someone with a lot of intensity, and you could tell he was tired and looking for some kind of escape. Before his injury, he was in the best shape of his life and had just been hired into a career he had worked hard for.

Then a training accident caused his ACL tear. It was a fluke accident that simply happened, and that was how he tore it. His surgeon wanted him to regain range of motion before operating, which I agree with, so surgery was pushed about two months. He did what he was told. He was in physical therapy almost every single day because he had a certain number of insurance visits available and was trying to use as many as possible before the end of the 2025 insurance year.

During every visit, the physical therapist would crank on his knee, particularly his flexion. I have talked about this before, but he told me it was the worst pain he had ever experienced. He would walk out of the clinic nauseous and seeing stars. What made the situation particularly concerning was that the numbers in the clinic looked okay from the physical therapist’s perspective. He might reach 125 degrees, for example, but then he would go home and wake up the next morning with the knee back where it started, followed by another two or three days of inflammation and irritation.

His surgeon was making decisions based on those clinic numbers, seeing 125 degrees and thinking that maybe it was good enough. But the surgeon and physical therapist were not really communicating with each other. On the day of surgery, the surgeon evaluated his knee and felt the stiffness and the rebound regression in his range of motion. He was not particularly excited to operate, but the situation was already in a gray area; the athlete had already waited two months, and he was also lacking extension. The goal going into surgery was to get the knee back to a good, restored place unless something was physically blocking it.

After surgery, he went through the same cycle. He was still stuck with his range of motion and continued pushing it with physical therapy. Around month five, he finally had an MRI to see what was going on in the knee. However, because he had hardware in the knee, the images were blurry. As he described it, he was told there was no scar tissue and that he should keep working on it. There was no clear plan or next step; the door was essentially closed with, “Just keep working on it.”

This is something we see when athletes have exhausted their rehab and the knee is still not giving them what they need. Maybe there is a strange pain sensation, range of motion is not returning, extension remains limited, functional issues continue, or strength is not progressing as expected. Through pattern recognition, we sometimes start to pick up that there may be something structural happening in the knee that is blocking the outcome. There could be a mechanical block or another issue influencing the recovery.

When we see that, we try to encourage the athlete and equip them with the information they need to talk with their surgeon and determine whether imaging is appropriate. One thing I hear from athletes repeatedly is resistance to getting an MRI. That has never sat well with me, especially because when the injury first happens, people are quick to get imaging. They want the X-ray and MRI to confirm the ACL tear. For some reason, after surgery, unless things are obviously going poorly, there can be more resistance around imaging. I understand that clinical decision-making has to be involved, but if an athlete has been consistently reporting symptoms, has followed conservative management, and continues to have problems, there needs to be a reasoned discussion about what the next step should be.

Sometimes conservative management is appropriate, and there may be additional techniques that can be considered within that approach. But if the athlete has exhausted the appropriate options, continues to have the same problems, and there is a clinical reason to investigate further, imaging or another intervention may need to be considered. Scar tissue and cyclops lesions are examples of situations where the recovery may not be following the path you would normally expect. Your gut can sometimes tell you that something is not right, and when you work with a high volume of complex ACL cases, those patterns can become easier to recognize.

The MRI finally happened, which was great, but the images were still blurry, and the surgeon did not see an obvious issue or scar tissue. The athlete left with a knee that still felt stuck and no real next step beyond being told to keep working on it. He did not accept that. He found a second surgeon, who looked at the same scan but could not read it clearly. That surgeon ordered a different MRI with contrast, and that imaging showed significant scar tissue. The surgeon operated and told him it was the most scar tissue he had ever seen, although that statement may have been an exaggeration.

He did have scar tissue, and it was cleaned up at seven months. Even then, he went back to the physical therapy clinic because he wanted guidance. There is an important part of the story here: after repeatedly being cranked on and experiencing the rebound effect, he had started going his own way. He had begun losing faith in the process because he would go to physical therapy, experience severe pain, become nauseous, get inflamed, and then see his range of motion rebound. Eventually, he decided he was done with that approach.

He briefly tried going back to the same physical therapist after the clean-out, and the same thing happened. They started cranking on his knee, and he noticed the rebound again. He had reached a point where he wanted to trust them again and see whether maybe the problem had simply been a difficult knee. But when the same approach produced the same response, he realized that something did not feel right. That is where you start looking externally and asking whether there is another explanation or another provider who may approach the situation differently.

I also want to be fair about the perspective I have. The people I hear from are usually the people who are struggling. Athletes who have a great surgeon, a physical therapist who is on top of everything, a smooth recovery, and a successful return to sport are not necessarily reaching out for help all the time. They may want an opinion, but if they feel like they have a good team and are progressing, they already have a support system they trust. So I know my perspective can be skewed toward harder cases.

There are excellent surgeons and clinicians out there, and plenty of athletes are getting great care. But there is also a group you never hear from: the people who struggle quietly, settle for what they think is “good enough,” and never find out that there may have been another answer. That is who I am talking about today. It is the people who feel lost, unheard, or like the people around them are not fully listening or looking deeply enough at what is happening. Those experiences influence your trust in healthcare and your trust in your providers, and that is real.

For most ACL athletes, ACL rehab is their first real medical experience. They have never done this before, so they do not have much to compare it with. If the process feels rushed or generic, they can assume that this is simply how healthcare works for everyone. Ask most people about their healthcare visits and you will hear similar experiences: they waited a long time, their questions were not all answered, or the appointment felt generic and rushed. Those experiences, combined with what people hear from friends and the media, shape their expectations before they even enter the ACL rehab process.

On the surface, the ACL rehab outline can look the same for everyone. You get injured, maybe do some rehab, have surgery, and then go through postoperative rehabilitation. But the actual process can look very different depending on the injury, the support you have, your rehab provider, your surgeon, and the overall game plan. There are a lot of layers, and most of them are invisible until you are actually in the middle of the process. I think about the factors that shape ACL rehab in three buckets: the things in your control, the things that are not in your control, and the things largely shaped by your providers.

The things within your control include your consistency, how much you communicate, and the rehabilitation programming you receive and follow. The things outside your control include how your body responds to surgery. Then there are the things largely shaped by your providers: how they test you, when they progress you, when they escalate to the next step, and how well the members of your healthcare team communicate with one another. The problem is that athletes usually cannot see that third bucket until it is already affecting them.

Throughout the process, you are asking yourself the same question over and over: “Do I trust this person, and is this the right call?” Your physical therapist and surgeon are helping steer the ship, and every visit becomes another data point for that trust. Trust starts to slip when your knee is repeatedly pushed and cranked on, when your therapist is seeing several people in an hour, or when your questions are not being answered. It also slips when you are not getting the guidance you need between visits and you feel like you are simply waiting for the next appointment.

Then you start asking yourself, “Where am I heading? What should I be doing? Am I doing enough? Am I being tested properly? Am I being tested at all?” Trust slips further when you tell someone that something is wrong with your knee and you feel like it is not being taken seriously. It keeps slipping when you are not progressing, when you feel stalled or stuck, when you keep regressing, or when every step forward is followed by five steps backward. That was the athlete’s story: the numbers looked great in the room, but the knee would rebound afterward.

Here is a practical point. If your range of motion looks great in the clinic but then regresses afterward, that is a signal worth tracking. Sometimes physical therapists can get ahead of themselves trying to create a win in the moment by pushing or cranking as hard as possible, but the question is whether that range is actually being maintained.

In my clinical opinion, forcing range of motion can trigger a negative response involving inflammation and muscle guarding. In the years I have been doing this and working with stiff knees, I have rarely seen aggressive pushing be consistently successful when the knee repeatedly responds with inflammation and rebound.

Sometimes the right answer really is to keep working on it and give it time. I am not saying that is never true. But sometimes it becomes clear that there needs to be a next step, whether that is imaging or another intervention based on what is happening. This comes back to the earlier point about the hesitation around imaging after surgery. If something is not progressing as expected, that is something you may need to discuss with your healthcare team rather than simply accepting that you have to keep pushing indefinitely.

We have weekly conversations with athletes who may need imaging while their surgeon is not necessarily on board with it. Again, that does not describe every provider, but there are situations where the athlete and their team have a concern about scar tissue, a cyclops lesion, or another issue and that concern is not being addressed.

Another challenge is that it can be difficult for someone to walk into a room for five or ten minutes, assess your knee, and make a decision without seeing the full three-month history of your rehabilitation. The surgeon may be making a clinical decision based on a very limited snapshot of what is happening. That is why it can be so important for the physical therapist to equip the athlete with accurate information that can be communicated to the surgeon.

Unfortunately, there can be red tape and communication barriers, so athletes sometimes end up having to advocate for themselves. When the physical therapist and surgeon are not on the same page, the athlete can become the messenger between the two. That is not an ideal position to be in, but being able to communicate clearly can be extremely helpful when those barriers exist.

Now let us shift to where athletes often go when that trust breaks. People who lose trust do not necessarily stop looking for answers. They start looking somewhere else. Often that means social media, podcasts, forums, and now AI. People go there to vent, share what they have experienced, see whether someone else has had a similar story, and hear other people’s opinions. A lot of the time, what they are really looking for is confirmation that they are not alone and that someone understands what they are experiencing.

I cannot tell you how many conversations I have had with ACLers who say, “Thank you for taking this time. I do not think I have ever told anyone any of this.” People have not necessarily been able to fully open up and explain their story, what is happening, or what is on their mind. There is a reason for that.

One study discussed in this context found that when a patient starts speaking during a healthcare encounter, the provider may interrupt within about eight seconds. Eight seconds is not much time to communicate everything that has happened to you. That is not even close to enough time for many patients to tell their full story. High-volume healthcare can create speed, and when the goal becomes getting to the point quickly, important details can get missed. So people want to be heard. They also want to be better equipped, and that is why they turn to forums, social media, podcasts, and other resources to ask better questions and bring up things they feel their providers have not paid enough attention to.

I understand that, and sometimes your gut feeling really is picking up on something that matters. In the story I shared, the athlete’s concern ultimately led to another evaluation that identified something his original imaging had not shown. But there is a limit to what these resources can do. A forum can tell you that you are not alone, but it cannot examine your knee. Neither can a social media post, a podcast, this podcast, or an AI tool. These resources can help you become more educated and ask better questions, but they cannot determine what is happening inside your specific knee. Even with AI, you still need someone with the appropriate expertise to interpret your situation.

When you are already frustrated, it can also become easy to collect information that supports the worst version of your story or the most confident opinion in a discussion thread. And yes, this podcast is one of those resources, so the same limitation applies to me. That is where some athletes make the next move: they start doing it themselves. When trust breaks, a few things can happen. First, there are delays. Athletes wait and hope things improve with time, do not get the imaging or help they need, and months go by.

Second, there is the sunk cost: they have already used insurance visits, invested time and money, and start thinking, “Maybe I can just finish this out.”

Third, they take matters into their own hands. They research, build their own plan, buy their own equipment, and take the DIY route.

There are usually several reasons someone ends up there: they have lost trust in the process, feel like they have exhausted what they have tried, believe they can do it better than the people they have worked with, or have run out of resources such as insurance visits or financial capacity. I do not blame anyone for any of those reactions.

When you have been treated like a number, have not gotten the results you expected, have not felt heard, and feel like you have no other choice, taking control can make sense.

But DIY should not be the goal. This is a complicated recovery, and we should treat it like one. Think about people dealing with other complex health situations. If someone has a neurological condition, a heart condition, or cancer and their first provider is not working out, they generally look for another provider rather than deciding to manage the entire situation themselves. I am not comparing ACL rehab directly to those conditions or saying they are on the same scale, but I think the comparison is useful in terms of recognizing that finding the right healthcare professional matters when the first one is not working.

ACL recovery can be a crossroads involving your health, the things you want to get back to, your mental health, and potentially your long-term physical health. That is why I think it is important to find another provider when the relationship is not working. This recovery is complex, and you need the right guide.

The other reason is objectivity. It is hard to stay objective about your own body and your own rehabilitation, and it is hard for anyone to do this entirely alone. Even if I tore my ACL again, God forbid, after working with thousands of athletes and teaching other physical therapists how to approach ACL rehab, I would not manage the entire process by myself. I would have someone else program and guide my rehabilitation. That is important to me, and it is something I want you to think about as you go through your own recovery.

I also hear this all the time: “PT did not work.” But one physical therapist not working for you does not mean the next one will not. Even if you are trying your third, fourth, fifth, or sixth physical therapist, I know that can feel exhausting. But do your research. Look at the volume of ACL patients they work with, whether their approach reflects current standards, and the outcomes they can demonstrate. Look at what people are saying. Look for people with ACL injuries who can see their own experiences reflected in the stories and reviews. Just like anything else you buy or choose today, you want to look at the reviews and see whether there is evidence behind what someone is offering.

And again, when people say, “PT does not work,” that does not mean the next PT will not work for you. Providers are not all created equal. It is like a relationship that did not work out while you were dating. You do not necessarily quit dating forever because one relationship did not work. You try again until you find the right person. The same principle applies to finding a surgeon, physical therapist, or primary care provider when you need someone who aligns with what you need.

I also want to acknowledge that this is part of the business we run. We provide remote ACL coaching, and it is something we are passionate about, so weigh what I am saying with that in mind. I am not saying that it has to be us. I am saying that you should find someone who cares and has the knowledge to help get you from A to B. That is what matters to me: that you have the right guidance and good care because it can genuinely change your life.

Here is the practical part as we land this episode. You do not need to be a clinician to check whether your care is earning your trust, and you do not need your physical therapist and surgeon on the same call to start asking these questions.

First, ask: “What are my priorities, and how are we objectively measuring them?” Ask what the numbers are and whether they hold up outside the clinic. If your range of motion looks great in the room but is gone by the morning, that is important information to communicate consistently.

Second, ask what criteria and milestones you are working toward. That could include returning to the gym, jumping, running, sprinting, changing direction, and eventually performance relative to your goals and sport or activity. Ask whether you are progressing based on criteria or simply based on time. It should not simply be, “Six weeks have passed, so we progress.” There should be specific criteria and milestones that support that progression.

Third, ask: “If I am not progressing by a certain point, what is the next step, and what triggers it?” That could involve imaging, a second opinion, or a referral. Your surgeon may be difficult to reach, so it is fair to ask your physical therapist how they would handle that referral or escalation.

Fourth, ask: “Will my questions get answered, and how?” That includes what happens between visits, not just during them.

There is so much that happens between physical therapy sessions. If you have a session on Thursday and the next one is not until Tuesday, that is a long time if something happens, you have a question, or you need an adjustment. Something that could create anxiety on Thursday or Friday might be resolved quickly with appropriate communication, rather than leaving you to sit with it throughout the weekend. Having support between sessions can be an important part of the process.

If you cannot get clear answers to these questions, that does not necessarily mean there is something wrong with you or that this is simply how healthcare has to be. It is information you can use to decide whether the current setup is sustainable and whether it is actually moving you toward your end goal.

Communication is the foundation of this process. Whether we are talking about our remote athletes or our in-person athletes, communication has to work both ways between the healthcare team and the athlete.

Trust does not usually break because of one bad day. It breaks in small, specific moments, almost like a compounding factor. A rushed visit, an unanswered question, a scan that nobody follows up on, or repeated experiences of not feeling heard can gradually change the relationship. Once that trust breaks, athletes may stop following the process and start looking elsewhere or trying to do more on their own. I am not saying that looking elsewhere is automatically bad, but it is important to recognize what is happening when that relationship with healthcare begins to fracture.

If you are in the middle of this right now and it feels like you are being pushed down a conveyor belt, like you are not being heard, I want you to know that just because something is common in healthcare does not mean it should be the standard. Just because you are not getting heard does not mean that is simply how things are supposed to be. You deserve a plan. You deserve real answers. You deserve structure around your recovery and someone in your corner who knows what they are doing.

And if this episode hit home, send it to someone who is going through it. If you have a story about your own rehab, good or bad, I want to hear it. You can send it to me through email, messenger, or whatever method works for you. Sharing these experiences is important because it allows us to continue improving the process, advocate for ourselves, and take more control of our own health.

Do not let time compound on itself while months get away from you. If something has been this way for weeks or months, do not simply keep waiting to see if it gets better. One conversation might change things, but if the same pattern has continued for a long time, it is worth making a decision about what needs to change. Ask yourself how much you trust your surgeon, how much you trust your physical therapist, and how you feel about the overall support and plan you are receiving.

You do not have to accept “This is just the way it is.” Other options exist, and your knee and your health are important enough to seek the support and care you need. This is not something that should be reserved for professional athletes or people competing at the highest levels. Every person going through ACL rehab deserves appropriate care and support.

I appreciate you for listening to this very long episode. This is something that has been sitting on my heart for a little while, and I felt like this story and this case connected all of these ideas. I wanted to put some words around why someone’s trust might be influenced by their healthcare experience, and I do not want to blame people when they eventually try to do things themselves. I just want to caution you that when you reach that point, it is worth remembering that ACL rehab is complex and that finding the next person may be a better path than trying to carry the entire process alone.

It is like dating. You are not necessarily going to stop dating because one relationship did not work. You keep going until you find the person who is right for you. The same thing applies here: keep going until you find the right person to guide your recovery. When you find that person, you will know, and you will be able to say, “This is it.” This is your host, Ravi Patel, signing off.