Episode 299 | More Than Exercises: Inside Our Team Meetings at The ACL Athlete

An ACLer is 11 months out, her strength is up, her symmetry is up, and her knee still hurts, still swells, and still does not feel right. That was one of the cases on the table in the recent team and coaches’ meeting. Today, I am taking you inside that meeting. 

Welcome back to the ACL Athlete Podcast. I am Ravi, the host. If you are just joining us, welcome. If you are returning, thank you so much for coming back and spending some time with me and the podcast. I hope you are able to get something out of today’s episode, and it is going to be a little different. 

Most ACLers never see what happens behind the scenes when you hire a physical therapist or a coach, especially when you are distinguishing between an in-person physical therapist and a remote physical therapist or coach. Within our team, we use those terms somewhat synonymously. A physical therapist is a coach. We are your coach. We are your PTs. We are your physical therapists. We want to take you behind the scenes because many people picture rehab as looking at some exercises, writing them down on a list, sending them to someone, and then checking in once in a while. 

Plenty of rehab looks exactly like that. You come in for your session, talk to the PT, start doing some exercises, maybe use some modalities, and then work through the session. They check in, give you some exercises to take home, and you rinse and repeat. It can look very black and white, but that is not how we run things.

Today, I want to walk you through how we approach this. I have been thinking about it, especially during our team and coaches’ meetings. For context, we meet multiple times a week to discuss our rosters, the athletes we are working with, and how we are operating as a team and a company. We look at everything together.

I have been reflecting on these meetings, the conversations we have, and what our team brings to the table. There is so much value in the humility and willingness to sit together as a group, think through different cases, and discuss what is going well, what we can improve, and what roadblocks and challenges we are facing. We continue to grow as professionals and as people serving the ACL population because this work is so important to us.

If you are working with us, I am sure that comes through in the responses and support you receive. If you are listening to the podcast, we are approaching 300 episodes. If you do not know that I care about this by now, I do not know what to tell you. I care so much because there is a significant gap in this process, and often, you do not know what you do not know.

People can be blindsided by this process, even if they are going through it for the second or third time after tearing their ACL again. Each experience can be completely different, and the process can be challenging. We want to provide everything we can and more, continue growing, and keep getting better. 

Today, I want to showcase some of that work. Think about any really good sports team. They are not just running plays or operating randomly in silos. On game day, they go home, watch film, review what happened, and sit down together. They ask, “What went well? What did not go well? Whose responsibilities are these? Who is struggling? What is working? What do we change before the next game?”

Our coaches’ meetings are like film sessions for our ACLers and for our team as a whole, including our mentorship. As I shared, we hold multiple meetings every week and go through our athletes one by one. We have a process for reviewing each athlete, discussing what they are accomplishing, identifying their next milestones, and understanding the roadblocks they are facing. Some cases are particularly challenging because we work with people who may be further along in the process. They might be six months, 12 months, two and a half years out, or anywhere across that spectrum.

These are not always people who are fresh out of surgery or preparing for surgery, although we love working with people early in the process and would do anything to help them as soon as possible. Often, however, we are brought in later to help with complex cases or people who never received the help they needed and are still struggling. Others want something on top of what they are already doing because they feel their current approach will not get them all the way there.

I want to make a promise to you: I am going to be honest about the hard parts because this process is not perfect. If someone is showcasing only the highlight reel, saying everyone is successful, crushing it, and experiencing no hiccups or problems, they are either not seeing enough ACLs, or they are hiding the difficult cases. I understand that showcasing the hard cases or the people who are not progressing as expected is not necessarily great for a company’s marketing. But I want to share these experiences because we deal with complicated cases. We have difficult conversations with athletes, and many factors can contribute to their challenges. Sometimes, we do not have the answer. Sometimes, that is exactly what we have to communicate.

This is important in healthcare because we are dealing with the human body. Biology is at play, and there are things we cannot control. Every person also has an individual context. Some people are in the thick of school and dealing with many other variables. Others have multiple jobs, travel for work, have young children or babies, or are pregnant. All these factors can influence recovery. We have to work through each person’s circumstances alongside what can already be a challenging rehabilitation process.

Everything I share today has been anonymized and blended so that no one can be identified. I want to be careful about protecting people’s identities, so I am going to discuss situations rather than individual people. 

To explain how this works, we meet multiple times a week and review our ACLers. We update one another on where each person is in the process and ask the same questions every time. What is going well? What are we working on? Who has hit a roadblock? What next steps do we need to tackle? We also ask who has gone quiet or pulled back a little. Not everyone maintains 100% compliance all the time. People go through different phases. It could be their headspace or something happening in life. They might get sick and be out for a week or two, or they might be traveling. Even youth athletes who have the summer off from school can be incredibly busy. There are many things we have to account for.

We also ask who needs another set of eyes or another opinion. A coach might bring up an athlete who flared up after a big weekend or ask for input on what to tell an athlete about skiing. Each situation is different, and the answer is not always obvious, especially when multiple factors are involved and reinjury is a concern.

As a team, we have collectively seen thousands of knees and thousands of ACLs. That experience allows us to consider an athlete’s context, assessment results, numbers, and subjective reports. We can look at the case through different lenses and discuss how to approach it as effectively as possible, especially when someone has a challenging recovery. And it is not just talk. Every case ends with a next step, which is really important. That might be sending a message, following up with a call, scheduling a test, or arranging a follow-up with a surgeon or another professional. We help make sure the athlete knows what needs to happen next. We also follow up with athletes who may have gone quiet. The point is to maintain accountability and make sure everyone understands where they are and what comes next.

As I shared earlier, we do not always receive the straightforward cases or work with someone from day one after surgery. When we do, we love it. But we build the plan around where each person is when they come to us. People find us at different points, from pre-surgery and nonoperative management to a few months after surgery or years into recovery.

Often, they have already been given a timeline that did not work out. They might have been told nine to 12 months, which can serve as a rough reference point, but people vary considerably. Their progress should continue to be reassessed throughout the process. They may have a more complicated surgery, a challenging rehabilitation history, lingering symptoms, or findings that have not been investigated or addressed.

If I asked our coaches to rate the complexity of our roster from zero to 10, I think we would put it around eight or nine out of 10 on average. That is my estimate, of course, and the rest of the team might rate it differently. But I would say we work with a highly complex group of athletes.

We love getting the straightforward cases, but we also embrace the challenge of helping people who have been through multiple providers, been written off, or felt dismissed. We want to make sure they have a next step, especially when they feel lost. We believe there is something we can do in every case within the limits of what we can control. If something falls outside our scope, we want to get the athlete into the right hands and help them take the next step toward recovery. 

I am not sharing this so you will feel sorry for us. I genuinely enjoy this work, and complicated cases are often where we spend much of our time. We also work with people who do not necessarily have complex cases. Some are three months out from an ACL injury or surgery and have run out of insurance coverage or simply feel lost. The beautiful thing about this process is the range of people we can help, and we are excited to work with anyone who wants our support.

I believe it is important for your PT or coach to continue growing and to have a team or sounding board. They should keep improving clinically and professionally rather than simply piling on more training volume without taking time to reflect, discuss cases, and learn. That growth matters because it influences outcomes for our athletes. If you are a clinician or coach listening to this, I hope you can take some of these lessons and apply them to the people you work with. Find people you can talk to, whether through mentorship, colleagues at your clinic, or a professional group. We need to keep learning and improving if we want to change this process for the better.

Let me walk you through one case that stuck with me. Picture an ACLer about a year and a half out from surgery. Skiing is not just a hobby for her; it is part of her work and identity. She has a demanding winter course coming up that involves skiing. It is an intensive program lasting a week, and she needs to commit within the next week or two. It is October, and she has not skied yet. She wants to know one thing: Is she ready to ski?

This has been a difficult case with ups and downs. There are personal factors involved, and this is not the first ACL injury or knee issue she has dealt with. It has not been straightforward.

Let me give you some numbers. When we tested her isometric quadriceps strength at 60 degrees, she had 95% symmetry. That is excellent. At 90 degrees, her symmetry was 65%. We also tested her five-repetition maximum on knee extension, which was around 80% symmetry. We were gathering different measures to understand her capacity, and that test was limited more by discomfort than by strength.

Her single-leg drop jump showed 97% symmetry. This is a vertical jump test that involves contributions from the knee, hip, and ankle, unlike horizontal hop tests. Her symmetry looked good, and qualitatively, her jumping looked great.

We also assessed her ACL Return to Sport after Injury scale, or ACL-RSI, which measures psychological readiness and confidence. We give this questionnaire to our athletes at certain intervals because confidence and readiness are important considerations when returning to sport. Earlier in the year, her score was in the 50s. In her last two assessments, it had dropped into the 30s. Her strength was improving while her confidence was decreasing. Those measures are typically positively correlated, but that was not happening in this case.

One of the first things our team discussed was testing her in positions that reflect the demands of skiing. Skiing at speed requires getting into deeper knee-flexion positions, around 90 degrees, and recovering when landing in the back seat or sitting back, especially on steep terrain where you have to counteract those forces. Looking good at 60 degrees does not necessarily tell us how she will perform in those deeper ranges. 

In our experience, people with a quadriceps tendon graft can take longer to regain strength in deeper knee-flexion positions. That pattern is common in our practice, and athletes may report discomfort around the donor site or continued weakness. We explained that this is common. We would hope to see things in a better place more than a year after surgery, but that is not always what happens. There are things we can work on, and there are also biological factors that may be outside our control. It is a matter of navigating the individual situation.

There is no graft choice without potential downsides. Even an allograft, which uses donor tissue, can have disadvantages. Every graft has pros and cons, and there is no perfect option. Some people experience more residual issues because surgery changes the body’s structures and takes tissue from one area to reconstruct another. That tissue and the donor site may take longer to recover, and some people continue to experience residual symptoms.

The second consideration was not handing her a final decision without involving her in the conversation. If a coach simply tells a frustrated athlete, “You are not ready,” she may stop listening. Instead, we ask questions: How do you feel about skiing? What would you need to feel ready? Where would you rate yourself from zero to 100%?

It is important to ask questions that help athletes understand where they are, both psychologically and physically. We connect their test results with their questionnaire responses and what they tell us about how they feel. We want to understand how those different pieces fit together.

We have to be careful because the ACL recovery journey can be an emotional roller coaster. There are high points and low points, and it can be difficult to stay somewhere in the middle. Whether someone is three months, six months, or more than 12 months out, the process can be challenging.

It is not enough to say, “Just keep working at it. Celebrate the small wins.” Those things matter, but the activity that is important to this athlete also comes with a time cost. She has to make a decision without knowing every detail, and we need to account for that emotional context and the uncertainty involved. These decisions are not always black and white.

The third consideration was letting her articulate the risks herself. We discussed whether we could help her work through the potential risks rather than immediately telling her that she had a higher risk of reinjury or that skiing was a bad idea because of the positions involved.

If she arrives at a conclusion herself, she has ownership of that decision. If we immediately tell her she is going to reinjure her knee or that an activity is a bad idea, it could shut down the conversation. That does not mean we never discuss risk directly. It means we have to consider the context of the individual athlete and communicate carefully.

The fourth consideration was giving her input into her programming. She wanted to have a meaningful role in what she was doing, so we incorporated her ideas while continuing to guide the overall plan. We provide the GPS, but we can still allow athletes to make choices and influence their programming when those choices support the goals we are working toward.

The fifth consideration was using stories. Storytelling can be powerful. We shared experiences of skiers we have worked with who did not fully trust their knees until they gradually returned to the snow, got their feet wet, and started finding their rhythm again.

I also want to share where this case landed. We do not want to give someone a green light when meaningful deficits remain. At the same time, we recognize that she may still choose to ski. The plan is to give her a clear roadmap: two months of focused work on tolerating deeper positions, alongside an honest conversation about the risks she would be accepting if she decided to ski.

It is important that she has the opportunity to talk through those risks rather than simply hearing us list every possible negative consequence. We are not there to overwhelm her with negativity. We are there to highlight the relevant considerations so she can make an informed decision. At the end of the day, people make their own choices. We might advise that returning to sport at six months is not appropriate for a youth athlete, but the athlete and their parents may still decide to proceed. We are not the ones who can make that decision for them. Our role is to provide advice and guidance.

We use what we know about the research, data, testing, science, and reinjury risk, while also considering performance, the athlete’s short-term goals, their long-term goals, and their health. We can make a recommendation, but each athlete ultimately has to decide what to do with that information. The risk might be high, but the activity may be important enough to them that they are willing to accept it after weighing the options.

That is particularly important when someone is facing a specific event, a final season, or another opportunity that matters to them. They might not meet every metric. Perhaps they have 82% symmetry rather than 90%, or their movement still looks a little different from side to side. We consider the whole picture rather than treating a single number as the final answer.

We have these conversations because we need to understand each athlete’s context. The athlete makes the final decision, but our job is not to decide for them or leave them guessing. They need objective information, a clear understanding of their situation, and support in making the best decision for themselves.

Here is the second case, and it is a tough one. This is the athlete I mentioned at the beginning of the episode. She is 11 months out from ACL reconstruction after a partial ACL tear. Her strength testing is in the 80s, and her symmetry has improved. However, her pain, swelling, and heel pop have not changed. She feels stronger and is happy about that, but the improvements are not addressing what bothers her most.

Her MRI shows a partial tear and a few other findings, including a possible cyclops-type lesion. She has not experienced giving way or instability, and it is understandable that she is frustrated. When strength improves, but symptoms do not, we have to acknowledge that rehabilitation alone may not always be the answer. That is difficult to say, but part of our job is knowing what we cannot fix, just as much as knowing what we can.

We cannot resolve a cyclops lesion through exercise alone. A cartilage issue is not necessarily going to improve by simply doing more repetitions or adding more exercises. Recognizing patterns and identifying when an athlete may need further assessment is valuable. Getting an ACLer to the appropriate care early can make a difference in how they navigate the next steps.

One of our coaches had a strong suspicion about what might be happening, but we chose not to share that suspicion with the athlete as if it were a diagnosis. If you introduce a diagnosis before there is evidence, it can influence how someone hears the surgeon’s assessment. Instead, we helped prepare her for the appointment with a good question and a series of questions so she would be equipped to have that conversation. We also prepared for the possibility that the answer might be that there was nothing to operate on. That can be difficult to hear, so it is important to talk through the possibility ahead of time.

Another pattern we see is that many ACLers carry a nine-to-12-month timeline in their heads because that is what they were told. When they reach the one-year mark and are not where they expected to be, it can feel like rock bottom. But that does not necessarily mean they have failed. They may have been given the wrong map or guidance that did not account for their individual situation. Some factors may also be biological and outside their control.

Our role is to help them take things week by week. There is no need to rush into major decisions without understanding the situation. Instead, we look for a winnable moment in the next few weeks and build from there. As a team, we see a wide variety of cases. Our roster includes different graft types, procedures, surgeons, protocols, and points of entry into rehabilitation. We also work with people managing their ACL injuries nonoperatively and people who come to us with other knee conditions or surgeries.

Some of our pattern recognition has come from early cases that did not add up. I have learned a great deal from cases I unfortunately did not recognize as well as I could have earlier in my career. Through repetition, team discussions, and seeing how test results align with what athletes report, we have become better at identifying patterns.

Sometimes, we can recognize a possible issue from a single conversation about an athlete’s history and symptoms. I recently spoke with an athlete who described her experience, and my initial instinct was that I understood what might be happening. But I did not share that conclusion immediately. I wanted to reinforce it with testing and objective information before discussing it.

We have become better at recognizing patterns, particularly when things do not add up. Now, we discuss those patterns as a team every week, which helps us identify concerns sooner and develop a process for finding the most appropriate next step for each athlete.

Let me shift gears to something lighter, but just as important. One of our coaches shared a conversation with a high-level athlete who had a demanding sports schedule outside of her knee rehabilitation. She was drained. Her coach reduced her ACL rehab and training from three days a week to two, prioritized the quadriceps, and removed work that was not especially important at that point.

Those exercises were secondary rather than high priorities. The athlete felt relieved, and she made that clear to us. A perfect program on paper can fail if the athlete is overloaded or potentially under-fueled. It is not normal to feel run down every day and consistently miss your numbers, and we do not want to normalize that. We start with less. It is much easier to add a session than to backtrack after giving someone too much. We also use the 80/20 rule: if you cut 80% of the plan, what is the 20% you would keep? Sometimes, three or four carefully selected exercises and movements will allow an athlete to work with greater intent and focus.

Imagine looking at a workout with three or four exercises instead of a list of 10 that could take more than an hour. You also need to explain why the plan has changed. When athletes understand the reason for two shorter sessions, they are more likely to buy into the approach.

We can explain the science behind reducing the number of sessions without necessarily losing the training stimulus we need. We still consider appropriate volume, sets taken close to failure, and fatigue so the athlete can continue making progress. The goal is not to remove work arbitrarily. It is to identify what matters most and preserve the stimulus needed to move forward. Explaining the reasoning and bringing the science into the conversation is crucial because there are many ways to adapt rehabilitation. This is how physical therapy and rehab should work. The plan should meet people where they are, accounting for the season of life they are in, travel, sickness, time constraints, work, school, and other activities.

We have to figure out how to condense the plan, so it continues moving the needle while allowing people to manage everything else they have going on. When we explain the why, athletes tend to engage more with the process.

One of our coaches put it best: “People don’t always want more. Sometimes they’re waiting for us to tell them they need less.” I want to repeat that because it is such a good quote. People don’t always want more. Sometimes they’re waiting for us to tell them they need less. Athletes may think they need to keep grinding and pushing, when the better approach may be to reduce the workload. This is where the principle of less is more, or addition by subtraction, can make a real difference.

Here is another quick example. We had an ACLer who had been working with us for a while and was doing very well in the resilience phase. She had a flare-up after a particularly stacked day and week. She ran with her kids, played tennis, and completed a workout that evening, after which her knee flared up. We needed to make some adjustments. It was not simply a matter of waiting it out and seeing what happened. We made more immediate adjustments to her activities and provided strategies to work around the flare-up. Rather than waiting a week or two and hoping the symptoms would settle, we adapted the plan and kept things moving.

Small flare-ups happen during rehabilitation because athletes are challenging their knees and trying to build capacity. We want to keep them moving forward without making the problem more pronounced. The goal is to calm things down enough for them to continue building. We navigate flare-ups regularly. Sometimes, people do more work than we prescribed. Sometimes, their overall workload is too high for several reasons, and sometimes a flare-up happens without an obvious cause. The important thing is to have a plan, adapt quickly, and make adjustments so that a short detour does not turn into a long, unnecessary one.

I want to end the case discussion with the honest part about our meetings. Some ACLers do not get a clean ending. Some finish their time with us while symptoms remain unresolved, some drift away, and a few remain mysteries even after our team has spent considerable time working through their cases. We control the controllables. That is important to us, and I want to be transparent about it because I do not think enough of this gets shared in the ACL space. People mostly see the highlight reels. There are many reasons why outcomes differ, but we focus on what we can influence. Athletes do the same to the extent that they can, and we give them a clear picture of where they are and what needs to happen next.

Scar tissue, cartilage issues, biology, and potentially hardware-related or systemic issues can fall outside the scope of what rehabilitation can address. There may be other health conditions involved, including autoimmune issues. ACL rehabilitation does not happen in isolation. It happens within a person’s body and alongside their school, occupation, family, and other responsibilities. Recovery does not take place in a vacuum.

We measure progress against reality, not perfection. Return-to-sport outcomes reported in research are far from 100% for everyone. If you chase a perfect record, you may struggle to appreciate the good work you do. You have to stay grounded in the reality of the process.

When we zoom out and look at the whole caseload, most athletes are progressing well. The one or two difficult cases can stand out because they are genuinely difficult. Consider an ACLer who has torn their ACL for the third time, has a stiff knee, has undergone multiple procedures, and has a complex surgical history. They might have a quadriceps tendon graft, a lateral extra-articular tenodesis, and a meniscus repair, followed by six weeks of being locked in a brace and remaining non-weight-bearing. That is a hard recovery.

These cases stand out even more when we did not start working with the athlete from day one. We might begin at month six, month 12, or even month 18. We have to take that into account and ask a different question. Instead of asking, “Did I fix them?” We should ask, “Did I leave this person better off and better equipped to handle what comes next?”

That may mean helping someone graduate from our care, or it may mean recognizing that they need additional support for other reasons. One athlete who ultimately needed more care elsewhere told us it was a relief to know he had done everything right in rehabilitation. He no longer had to wonder whether poor rehab was the reason he was still struggling. He needed more surgical insight for a particularly nuanced case, and we wanted to make sure he sought the appropriate opinions while also considering the other things happening in his life.

For the physical therapists, clinicians, and coaches listening, I want to share something about my own experience. Early in my career, I felt personally responsible for saving people. If someone did not get back to their sport, I felt that it was my fault. I took it personally. But there are so many variables in an ACLer’s life that we cannot control, no matter how good the plan, exercise prescription, accountability, communication, or testing may be.

We are here to help, not to rescue. We are here to be the GPS, not to drive the car. Athletes are the ones who ultimately have to navigate the process. A team-based approach is important because it provides guidance, individualized assessment, objective testing, and support. Athletes also have to meet us halfway and engage with the process.

Some cases remain challenging even when both sides are doing everything they can. Progress may be slow, or recovery may feel like a roller coaster with repeated ups and downs. That is an important reality to understand about ACL rehabilitation. For some people, it is a longer process.

Even so, I do not believe we have reached a point where we have had to tell someone, “You’re at the end of the road. This is it.” There is usually another step to consider. But that step has to be evaluated in the context of the person’s life, timing, and circumstances. Someone might need another surgery but may not be in a position to pursue it because they have a newborn, are caring for an unwell family member, have lost a job, or are supporting someone else.

There are so many variables that shape these decisions. It is not a failure when factors outside our control win, as long as we have done our due diligence. As a team, we reflect on what we can improve every week because there is always something we can do better. We will never reach a point where we have made it and no longer need to grow. We are working with a complex system: the human body, a human being, and a rehabilitation process with a substantial reinjury concern. We are also working within a healthcare system and model that often leave people without the support they need.

That is the gap we are trying to fill. Some cases are difficult to take on because of all the factors I have shared. But when we zoom out and look at the whole caseload, we also see athletes who came to us struggling and have made remarkable progress.

It is amazing to see where people end up after our team has continued to learn, improve, and stay diligent throughout the process. It also takes athletes who are willing to engage. They decide to draw a line in the sand and see what happens when they fully commit to getting the most out of rehabilitation.

I would say that 98% of these people do. I say that with the caveat that the circumstances of some athletes make their journeys particularly difficult. This process is not always sunshine and rainbows, but when people engage with it, progress is possible.

It might not happen as quickly as they want, and unexpected turns will probably come up. Having a guide to help navigate those turns is key.

Let me pull everything together. Coaching is a team sport. Your coach has a backup, and we discuss every ACLer every week. Readiness is a conversation, not just a number. The data tells us where to look, and the conversation tells us what we are going to do about it.

Sometimes rehabilitation cannot fix the problem. Part of our job is recognizing that and helping you find the right person to guide the next step. Less is often more, and as an ACLer, you are allowed to ask for less when the workload is not serving you.

We will not get every outcome perfect, but we will show up for you. You should know what to do next, what the path looks like, and that you have support along the way. This is what your physical therapist, coach, and team should provide. You should not be left wandering through the process alone. You should have people in your corner who are ready to work through the challenges with you.

Today, I have pulled back the curtain on our coaches’ meetings, shared some of the cases we discuss, and explained some of the nuances we consider as we continue to grow as a team and as individuals. We review our athletes, identify what comes next, and look for ways to improve.

The goal is to help ACLers return to what they want to do faster, better, and stronger, with fewer roadblocks along the way. We want people to feel seen and heard, receive guidance and a roadmap, undergo objective testing, and know that we are listening to how they feel and comparing that with what the assessments show.

That is what this process should look like. We want athletes to return to the activities they care about. When we do not have the answer, we help them find the next step to get it. That is crucial, and it is the standard we believe ACL rehabilitation should meet.

If you are listening to this, I hope this behind-the-scenes look gives you some insight into the cases we discuss, the complexities we consider, and the ways we continue to improve. There is much more we could share, and I will aim to bring you more of these lessons so you can apply them to your own recovery.

If you want a team that thinks about your knee this way, takes the time to individualize your care, looks at your progress objectively, listens to your story, and guides you through the process, we are here to help. You can find the information in the show notes.

We have had amazing ACLers join us who are in challenging situations, and we are excited to be part of their journeys, whether they are seeing someone in person or working with us remotely. This is the work we do, and it is not something we shy away from. I believe it will continue to help more and more ACLers.

I appreciate you for getting through this long episode. I know it is a little different from usual, but I wanted to share why having a team behind you matters and how that team can support you throughout the process. That is going to be it for today. Take care of yourself, your knee, and your rehab, and I will catch you in the next episode.

This is your host, Ravi Patel, signing off.