The ACL Rehab Problem

At the time of writing this article, I have been treating for almost 7 years. That time has been majority orthopedic in outpatient clinics. And something I realized quick, was most outpatient clinics are not set up for return to sport rehab or performance after an ACL surgery. The beginning rehab stuff, sure. It's mostly table-based exercises focusing on swelling reduction, mobility, and getting muscles firing again. There's an argument that these patients are totally fine in an outpatient orthopedic clinic. But, it kind of ends there. When I would have an ACL patient in the clinic when I was just starting out, I was nervous to clear them from sport because no one taught me how. Since then, I have learned how to collect data and test an athlete for return to sport appropriately, but I have yet to work in a clinic that allows for it due to multiple factors. Let's go into just a couple of reasons why standard outpatient clinics are not the best place for your ACL journey:

1. Insurance restrictions, by the majority of major insurance companies, limit physical therapy visits that they will pay for. I have seen as few as 8 and as many as 65 (some have unlimited but I started seeing it less and less before I left the in-network world). Now, you would think having a surgery would change that. But no. You get what you get. After that, you pay cash for your rehab. Yep! That's right, you pay for your insurance, but they many not be paying for all of the care you need. PSA to make sure to check your benefits yearly. With this being said though, many clinics will see you 3x/week after a surgery. If you are someone that has 20 PT visits a year (a lot of people), you start running through those visits quickly. And a lot of what you are doing in the clinic, you can do at home. There's not really a big reason to go beyond 1x unless you don't do your exercises at home (BIG NO NO). But also, when you run out of visits and are paying cash to get continued care, why not pay a little bit more to get better, individualized care. 1 on 1 care from a doctor of physical therapy for an entire treatment session. Not 1 on 1 care for 10 minutes with a PT and then 45 minutes with a tech that just takes you through exercise and ends with ice for 15 minutes (which you can also do at home).

2. Most standard outpatient clinics are not equipped to help you rehab well enough to return to sport appropriately. This is 2-fold:

   1. Time: many physical therapists and physical therapy assistants are seeing 2-3+ patients an hour in order to make the clinic profitable due to low insurance reimbursement rates. Because of this, you will likely be seeing a physical therapy tech. Which sounds fancy. I thought I was fancy when I was one. We had paper charts, and I got to sign a "PTT" after my name. But really, I was a college student who knew some exercises. I was taught what different physical therapists wanted. I did not know all of the compensations I was looking for, I did not know how to change an exercise if a patient had pain, I did not know how to guide treatment based on what I saw. And if you are not seeing a physical therapist or a really good physical therapy assistant for your full treatment, your care is going to be limited.

   2. Equipment: most gyms do not have significant weight to challenge an athlete. Many do not even have a squat rack, a leg extension machine, leg press, etc. My list could go on and on. Now do you need all of the equipment in the world to rehab, no. But would you improve faster and have better outcomes if you had access to these things. Absolutely! One ACL colleague treats via telehealth only, and she requires access to a gym with specific equipment to all of her ACLers. I think this should be adopted for outpatient clinics, OR you could just see a physical therapist that has access to the equipment that will challenge you during the mid stage of care (wink wink). Many clinics do not have access to a good way to test strength or perform other objective measures that make sure you are progressing well through the stages of rehab. If your PT uses their hand to test your strength, RUN.

      On the same equipment note, many clinics do not have good access to space for return to sport challenges and activities. If your PT uses time as a guideline of when you are able to progress your rehab, RUN. And if you don't do anything but do a couple of SL hop tests to decide if you are ready to get back on the field, RUN TO US and we can test youth athletes appropriately for their return to sport in the amount of space required to do so!

Now, I bring some of this up because I've experienced it. I have worked in outpatient clinics that are patient mills. PTs do not have the time, space, or equipment to test appropriately and athletes are sent back on the field because of a hop test or because their doctor cleared them by checking range of motion and pushing on their knee. But I have also witnessed so many re-tears and tears of the other ACL because athletes were not ready. They were put back in too soon and they have another injury. Talk about devastating and really psychologically messing with an athlete. And this all comes down to the preparation and confidence an athlete has going into the game. It comes down to the PT testing the correct things and testing appropriately with actual numbers with the patient on board and understanding their progress and goals.

With Dash Physical Therapy, you are treated how you should be treated following an ACL surgery.

• We are cash pay so we don't jump through insurance hurdles (or if you want to see us after you use all of your insurance visits, that's fine, people typically don't get many - but consistency in your care is always nice)

• We work with you to set appropriate visits based on where you are, your motivation, and time.

• We perform appropriate testing to clear phases before randomly progressing based on a guide or protocol. Everyone heals differently, all ACLs are different, and we must treat them accordingly.

• We utilize weight and appropriate equipment required to get you back to where you need to be strength wise and use actual numbers to compare sides. No pushing into someone's hand to make the decision if you are strong enough to play a sport.

• We assess a players psychological readiness which is a major factor in progress and returning to sport.

• We get out on the field or court and use game-like activities and testing to get you ready to really get back out there.

Your ACL rehab journey is going to take more than 6 months. It will likely take a year or more. If you have a physical therapist who tells you it will take 6-9 months, RUN! This is hard for a lot of athletes to hear but I will say, find a physical therapist that will get you back better than before because you have their undivided attention during your sessions. A therapist that listens to your needs and regularly assesses more than your range of motion. Find someone that can get your through the frustrating times and help build your confidence through the journey (and run from all the ones who don't!)

At Dash Physical Therapy, we will be to be that provider for you. We work regularly out of a local Lexington, KY gym (Motiv8 Fitness) so we have the equipment you need and have connections and access to courts, fields, etc when that time of rehab comes. Contact us to schedule your next ACL rehab in Lexington, KY. Or send an email to kelsi@dashphysio.com and touch base.