Are you ready to Return to Sport After ACL Reconstruction?

As a physical therapist specializing in sports rehabilitation, one of the most rewarding aspects of my work is guiding athletes through the journey of ACL reconstruction (ACLR) recovery. This process demands dedication, a meticulous approach to addressing all the complex factors of their sport, and not least of all patience. When is an athlete truly ready to resume their athletic endeavors post-surgery? It's a question that requires a comprehensive assessment, considering not only physical readiness but also mental and emotional factors.

First and foremost, the timeline for returning to sport after ACL reconstruction varies for each individual. While there are general guidelines, such as the typical six to nine months mark, the decision should be based on objective measures of strength, stability, and range of motion, rather than solely on time elapsed. Even 9 months is aggressive depending on the persons level of function and how they show on testing. Throughout the rehabilitation process, we closely monitor the athlete's progress, gradually reintroducing sport-specific movements and assessing their ability to perform without compromising stability or risking reinjury.

A couple important markers show as a helpful predictor to success with return to sport after ACLR:

90% quad strength compared to other side

90% on the Noyes hop testing (all 4 tests)

22 single leg sit to stands

90% on side hop test

Equally important is addressing the psychological aspect of recovery. ACL injuries can be mentally taxing, and it's essential to ensure that the athlete has regained confidence in their abilities and trust in their repaired knee. Open communication and collaboration between the athlete, physical therapist, and other members of the healthcare team are crucial in this regard. Building resilience and providing support through setbacks or fears of re-injury are integral parts of the rehabilitation journey.

Ultimately, the decision to return to sport after ACL reconstruction should be a shared one, based on objective data, functional assessments, and the athlete's readiness both physically and mentally. Rushing the process can lead to setbacks or even further injury, while a thorough and systematic approach increases the likelihood of a successful return to competitive play. By focusing on comprehensive rehabilitation, we not only help athletes return to sport but also empower them to thrive and excel in their athletic pursuits once again.

How to recover from an ankle sprain

An ankle sprain can be a frustrating setback, but with the right approach, recovery is not only possible but during your rehab you may have more strength and stability than you did before. As a physical therapist, I've guided countless individuals through the rehabilitation process post-ankle sprain. Three key considerations emerge as crucial for optimal recovery: rest, rehabilitation, and gradual return to activity.

Firstly, correctly diagnosis it as ankle sprain. Following an ankle sprain, it's essential to make sure we don’t have a fracture. Luckily you may not even need to get an X-ray to find out. There is a test called the Ottawa ankle rules that allows physical therapists and health professionals to do to see if you need to get an X-ray or if it’s likely negative and you can avoid going. If the tests are all negative then we can assume for now there is no need for X-ray and can begin rehabbing.

Secondly, although we may not be ready to jump right back into our sport we actually don’t want to rest it too much. Everything depends on how much pain you’re having , how swollen the ankle is, and etc. Your physical therapist should be able to help guide you to how much rest and support you need, and how much you can push it. IF we rest too much it leads to stiffness and weakness, however if we’re too aggressive we may be going though some unnecessary pain and swelling. I do recommend doing some gentle ankle exercises to start. Even walking around if your symptoms aren’t too bad is helpful according to the research.

Thirdly, a structured rehabilitation program is essential for restoring strength, flexibility, and proprioception to the injured ankle. This typically involves exercises to improve range of motion, strengthen the surrounding muscles, and enhance balance and coordination. The balance and coordination is key. Even if you weren’t someone who struggled with it before an ankle sprain, the sprain has put some stress on the ligaments that help with balance and it’s vital we train it to go back to sport.  As a physical therapist, I tailor these exercises to each individual's specific needs, gradually progressing as tolerance increases to ensure a safe and effective recovery.

In conclusion, recovering from an ankle sprain requires patience, dedication, and proper guidance. By Listening to the body's signals and respecting the healing process, following a structured rehabilitation program, and gradually returning to activity, individuals can not only recover from their injury but also build resilience and prevent future occurrences.

What is Patellofemoral Pain Syndrome. How do we fix it?

Patellofemoral Pain Syndrome (PFPS) is a common condition characterized by pain around or behind the kneecap, typically aggravated by activities that involve bending the knee, such as running, squatting, or climbing stairs. It is a very common diagnosis, and the good news is this tends to be a diagnosis of exclusion, meaning that they’re aren’t any disrupted ligaments/muscles/meniscus/etc in the knee.. Understanding the underlying factors contributing to PFPS is crucial for effective treatment. One primary cause is improper tracking of the kneecap due to muscular imbalances, weak hip stability, stiff/weak ankles, or poor biomechanics during movement.

Addressing PFPS involves a multifaceted approach tailored to the individual. Firstly, as with all injury recovery, it depends on the person’s function and what their goals. No two people’s rehab should look the same. Secondly, a lot of attention has recently been given about strengthening the quadriceps however what the research shows is although that is important what is equally if not more important is strengthening your hip abductors/known as your glutes. We will target the glutes specially if the symptoms are really aggressive and quad stregthening is too much.  Additionally, strengthening is the only thing. Techniques such as foam rolling and stretching specially tight quadriceps can help reduce pains and improve flexibility. Finally, educating patients on proper body mechanics during daily activities and sports is essential for long-term management and prevention of PFPS recurrence.

In conclusion, Patellofemoral Pain Syndrome can significantly impact one's quality of life, but with the right guidance and treatment, it is manageable. As a physical therapist, my goal is to empower individuals with the knowledge and tools to address PFPS effectively, allowing them to return to their desired activities pain-free. By addressing muscular imbalances, improving biomechanics, and promoting overall joint health not only will you recover from PFPS but may even be stronger and more flexible than you were before.

The muscle hurting all of our shoulders and necks

The pec minor is a muscle that gets a lot of attention from physical therapists. It’s a muscle that connects your scapula also known as your shoulder blade to the front of your rib cage around your chest area. It’s famous for tipping your scapula forward. And often times due our modern lifestyle. This gets too stiff because we’re always in that position.  If you have a stiff pec minor this can cause a whole host of issues.  From putting pressure on your neck, to making it hard to raise your arm, to compressing your nerve. Also, it just makes your posture look worse

However, If we loosen the pec minor we can see that we get way more range of motion in the shoulder, take pressure of the neck, and free up tension in the nerves going to our hand.

The first thing I like to do is stretch this muscle, by placing my hand against the door and stepping forward while rolling my shoulder blades back. After that, I like to strengthen my muscles to keep my posture in a good position, so that muscle stays nice and supple moving forward.

Do you have flat feet?

You may have been told you have flat feet. But did you know some people’s flat feet are “fixed” and others are “flexible” meaning they can be improved with muscular strengthening. It’s a pretty easy test to determine. If you cross your arms and twist side to side and your aches lift it’s a pretty good chance your “flat feet” is flexible and can be improved.

If that is the case, then we need to determine what muscles do we need to work on to improve the foot posture. For instance, the muscle imbalance can be coming from the foot and ankle muscles or it can actually be coming from the hip. If your glutes are weak or inactive, then it will force your knees to roll inward and as a result your arch will “collapse” and your foot will appear to be flat.

The good news is once you identify the root cause you can easily work on it and improve it so you can run, dance, or do whatever sport activity you enjoy more.

How can we run better?

If you were too get a super camera and slow down the foot while running you would see that the arch of foot naturally “collapses” AKA pronates at the beginning to absorb shock. And then the arch comes back a.k.a. supinates so that the foot is locked and can propel forward to be more energy efficient. The whole time we have a series of muscles that are controlling these movements so they don’t happen erratically.

It’s a really cool mechanical process that our bodies naturally do however if we increase our running more than usual, and we are not prepared for that we might start straining those muscles that are controlling the motion.

Let’s break down each one of those phases and what we can do to keep ourselves, healthy and effective at moving.

The shock absorption phase: this is the phase where your foot arch may seem like it collapses. And although we hear all the time that it collapsed, arch is bad. This is actually good during this phase of running. This phase happens, almost immediately after your foot makes contact with the floor. The muscle that controls this phase is known as your posterior tibial muscle that muscle points your foot and roll it inward. But in this case because it’s fighting gravity, your muscle slowly losing but it’s controlling the rate at which your arch “collapses”.

If you’re having pain with running or walking, and it’s right, when your foot makes contact with the ground, it may be due to a weak muscle here and strengthening. It can help.

The propulsion phase: this phase is right after the absorption phase and your foot arch goes back so that it is locked in more energy efficient for moving forward.  The muscle that controls this phase is a set of muscles called your fibulari muscles. These muscles also point your foot, but unlike the posterior tibial muscle, they roll your foot outward. If you’re having pain during this phase of running, which may be hard to tell, without having an expert set of eyes look at it, it may be due to a weak muscle here. Often times when people have a history of an ankle sprain this muscle gets a little bit weaker and then when they go back to running, they have pain until they strengthen this muscle.

Here is a recent Instagram post. I did that highlights this interesting biomechanical process and the exercises that can help with it.

https://www.instagram.com/reel/C2iNQFhPet5/?igsh=MzRlODBiNWFlZA==

The shoulder muscle you are neglecting

The shoulder is a very complex joint that can do some pretty remarkable things. From lifting hundreds of pounds overhead, to do balancing on handstands, or helping us swim across seas, it is incredibly versatile and impressive.

However, shoulder pain is a very common complain that I see many times. Often time there is one muscle that gets neglected and as such causes a host of issues down the chain.

The lower trapezius (AKA Trap 3) is a muscle that I believe is heavily under developed in most people and is causing issues.

Maybe that’s because this super important muscles doesn’t even attach to the shoulder bone. It starts at the spine at attaches to the shoulder blade. But what often times people don’t understand is that the shoulder blade is the root of a lot of shoulder dysfunctions.

Our modern lifestyle has put everything in front of us. Our computers, phone, and cars keep our arms in front of us all the time. We are not often lifting things overhead and rowing back. Because of this our back muscles get underdeveloped.

However many people know the importance of good back musculature but they still often miss the lower trapezius. That’s because since it’s so weak on so many people, they overcompensate with so many other muscles. Instead if you can teach that muscles to get stronger with very specific exercises we see that people’s shoulder pain gets much better and they can go back to doing all the things they enjoy.

What are the benefits of manual therapy?

Manual therapy is a term physical therapists use when we talk about doing a hands-on service to our patients. This can look like soft tissue massage, joint mobilizations, “adjustments”, nerve mobilizations, stretching and so much more. Manual therapy is a skilled and trained procedure your physical therapist may perform.

Recently many physical therapists have moved away from manual therapy because they feel it gets over-perscirbed and their patients feel reliant on them. While that may be true it is still a very useful and power asset to the rehabilitation process.

Manual therapy has a lot of benefits but should be done when your healthcare provider deems it appropriate. Not everyone should receive the same kind of manual therapy because everyone has a different context, status, and goals with their health. For instance, two people can both have limited hip mobility, but one person may need stretching, and the other person may need joint mobilizations. The physical therapist should be able to run tests to differentiate which ones will help.

Now let’s address some of the benefits of manual therapy.

Reduced pain

Improved flexibility

Decreased swelling

Improved nerve mobility

Improved joint play

Muscle inhibition/excitation

Decreased muscle tension

Improved bloodflow

There are so many benefits to manual therapy, specially if it’s target at specific needs and matches your current presentation. Physical therapists can be excellent providers for manual therapy as they have a great understanding of anatomy and biomechanics.Talk with your physical therapist if it’s appropriate for you.

How to pick you physical therapist?

Having a good physical therapist in your corner can change your life, but the field is really new and not all physical therapists are the same. Even the requirements to become a physical therapist in the United States has changed a lot in my lifetime.

For instance, not a lot of people know that some physical therapists have a bachelor degree and some have a doctorate degree. Some do additional training after graduate school (if they went), and some work immediately.

Here are a few different things to consider when selecting your physical therapist.

1. Level of training- Did they just finish school and go straight into the field or decided to residency? Unlike MDs, residency is optional for physical therapists and very few choose to do it. For instance, I chose to do one and less than 10% of my classmates in graduate school did it with me. It makes a big difference if you do one because if you complete one you can be a specialist.

2. Insurance- Sometimes a PT not accepting your insurance, or even taking insurance to begin with may not be a bad thing. Cash based clinics (no insurance) often means you get more time with the therapist and may get better results in less time.

3. Niche- Different clinicians have different niches. For instance, a lot of my clients are stunt performers and martial artists because I happen to be one too. I understand their needs and it makes it easier to treat them. Finding a PT that understands your needs is very helpful to getting great care.

There are few more reasons I outline in this video. Check it out and let me know if there are any other questions I can help you with regards to picking a physical therapist so you can improve your health and performance.

5 things to consider when selecting a physical therapist

Master this exercise to live longer

Squat! This exercise although super simple is very popular because quite frankly it’s very important and targets a lot of key muscles. Why is it important, well because if you try to lift something heavy off the ground (which we all need to do) without bending your knees, there is a good chance your going to hurt yourself. If you want to sit down into a chair, get off the toilet, or travel guess what? You’re going to need to do a squat. In fact, A 2014 study found that being able to get up and off the floor with as little support as possible was a predictor of mortality. Those who need less assistance from different parts of their body on average lived longer. In Eastern countries like China and Japan, they on average show much less prevalence of Hip osteoarthritis. Now we don’t know exactly why but one prevailing theory is that it’s because in those countries they squat very low as part of their day to day life. 

So how do we build a good squat. First we need to make sure we have enough mobility, specifically in our knees, hips and ankles. If you don’t have the mobility you may still be able to squat low but you might compensating with rounding your low back and that overtime can lead to some pain.

Secondly we need to make sure we are turning on the right muscles. Are we activating our quads, glutes, and abs. A lot of people have a hard time with last two and there are a lot great exercises that can help you get there if you are struggling with that.

Third, we need to make sure we are strong enough. And in my opinion, just being able to get up and down isn’t enough because over time we will get weaker and we want to set ourselves up for success in the future, so let’s get a higher baseline now.

Lastly, if we have all those building blocks we just want to do it with good form. We should always lead with our hips because they are the strongest part of the body. If you are unsure, hire a physical therapies or coach to look at it for you! 

Let’s squat to feel better, look better, do more, and for our loved ones so they don’t need to help us get up as we get older. 

Dudda M, Kim YJ, Zhang Y, Nevitt MC, Xu L, Niu J, Goggins J, Doherty M, Felson DT. Morphologic differences between the hips of Chinese women and white women: could they account for the ethnic difference in the prevalence of hip osteoarthritis? Arthritis Rheum. 2011 Oct;63(10):2992-9. doi: 10.1002/art.30472. PMID: 21647861; PMCID: PMC3178680.

How to treat low back pain?

In order to treat low back pain, we first need to see if there are any red flags or dangerous signs. Usually by asking some questions and running some tests, we can determine if we need to follow up with a medical doctor for more tests or are we safe for physical therapy.

After that we want to categorize our patients based on how they present. The American physical therapy association has four classification categories. A manipulation category, a stabilization category, a directional preference category, progressive exercises and fitness activities for chronic back pain 

Classifying our patients in the correct category allows us to treat them properly so they get better results faster. 

Should you get your neck adjusted?

There definitely is a risk with getting neck adjustments. Sadly some people have been paralyzed after or even passed away. However, they can also be very effective. In order to minimize the risk of a neck adjustment it should really be done if there’s no red flags in the medical exam and if the patient presents with the following signs and symptoms.

1. positive expectation manip will help

2. duration of symptoms <38 days

3. cervical range of motion difference >/= 10 deg (strongest predictive value)

4. Pain with PA spring test of mid cervical spine 

greater than 3/4 items on this brought the success from 38%-90%

If present with the signs and symptoms they’re usually a good candidate for manipulation and will benefit from the treatment. In my opinion, only when there’s no red flags and they fit that category then is a neck manipulation warranted. 

What is patellofemoral pain syndrome?

Patellofemoral pain syndrome is a fancy word for pain around the kneecap. Although we’re not 100% sure about the mechanisms of pain we do have a few classification categories to help us get effective treatment.

Patellofemoral pain syndrome with mobility deficits: You can be either really stiff around the knee or too mobile in the foot.

Patellofemoral pain syndrome with muscle power deficits: You can have some quad and glute weakness .

Patellofemoral pain syndrome with overuse and overload disorder: You could just be training too hard causing knee pain.

Patellofemoral pain syndrome with movement coordination deficits: You could be doing some movements wrong causing the pain.

Once we can come up with the appropriate classification then we can figure out how to treat it best. 

3 Mistakes people make when rehabbing an ankle sprain:

1. Not getting on their feet as quickly as possible: Believe it or not after you sprain your ankle it’s a good idea to put some weight on it and walk. Wearing a brace to help support is a good idea too.

2. Not working on balance training: After you irritate a ligament and muscles, they need to be challenged in order to return to the previous function. After an ankle sprain, you really want to work on balance training to get the proprioceptors in the ankle functioning as much as possible.  

3. Not using a brace when going back to training: The research really supports the use of wearing a lace up ankle brace, specially if you’re doing an activity where you’re on your feet and need a lot of agility.

If you suffer an ankle sprain, go get evaluated by a physical therapist so they can help you recover sooner. 

How to be more coordinated?

As a professional stuntman, breakdancer, and martial artists, I’ve spent my life trying to learn how to do weird things with my body. Wether it’s a backflip, spinning on my head, or fighting someone who is 100lbs heavier than me, it’s definitely been years of practice. So how do we get better at skills?

The answer which you can guess is practice. You hear it all the time. “Practice makes perfect”. It’s true except there is a subtle difference that I want to explore more. The challenge is not just practicing, it’s practicing well. What does that mean? I have two important criteria for good practice: First, is the task perfectly hard enough? Second, are you getting feedback?

Let’s break down the first one. I think this is the most challenging aspect of practicing, finding the perfect difficulty. We hear all these motivational speeches about getting outside your comfort zone, failing, get back up and get after it again. Yes that does hold merit but the problem is, if you’re picking up a challenge you’re not ready for, you may be making bad habits, you may get frustrated and give up, or you may even get hurt attempting. Instead we want to find the right level of difficulty. When I was learning how to flip, my coach use to say we want to train in the zone of  “Difficult but possible”. That’s because it requires our attention to focus and sync everything up but it’s not so unreasonable we’re not going to make progress. In my opinion, if you’re attempting something and your success rate is less than 50% per trial, you should make it slightly easier so you can work on building good habits and eventually move onto something harder. Once your success rate is higher, on that task close to 90%, that’s where I would make it a little harder to add more challenge. I think this is a very important nuance that allows us to get more out of each session. If you want to get better at something that seems impossible, try to break the task down to something easier to start, master that fundamental than add a little bit more. I wish someone show’d me this while I was breakdancing and I probably could have avoided a few surgeries and have had a better career.

Once we get the right difficulty, we want to address the second problem. Are we getting feedback? If we want to get better at some skill, we need feedback to tell us if we’re doing it right. At the beginning specially we need lots of external feedback to tell us, but as we get better we can switch to internal feedback (Does this feel good or bad?). If you don’t have a coach to give you that feedback that’s where watching footage of yourself and analyzing it is very helpful. Often times you don’t realize your making mistakes till you see it in third person. However I highly recommend getting a coach or physical therapist to watch you instead. 

I hope this helps you accomplish some skill you’ve been wanting to learn, or maybe something that even hurts and you’re trying to adjust. As always go see a physical therapist to help breakdown any barriers so you can better results, faster.

How to get stronger?

There is a study that shows when you compare people with high strength to low strength there is a decrease in call cause mortality by 3-fold. It might be because being strong means you can hold onto things easier, get up and off the ground easier, and just do more. Well you might be saying, I can already do those things so why do I need to get even stronger? The issue is that no matter what, we will all lose strength as we get older. It is the nature of life. However if we can get our baselines really high, then even though as time takes it toll on us, we can end at higher percentage and enjoy our life more. I certainly want to try to be independent and able to do as much as I can as long as I can so I can enjoy life and my family does not have to help me. 

So how do we get stronger? The first answer is simple: Exercise? However the nuance is in how we do that. If our goal is to simply get stronger then what we want to do is challenge our body just under our 1-rep max (1RM). 1-rep max means, how much can you perform a certain lift and not be able to do a second time without resting. There are ways of calculating that without having to fully test it but many people will get a coach or a physical therapist to help them test that. Once you figure out your 1 rep max number you want to be doing 3-5 reps of that exercise but only 70-85% of that 1 rep max. Essentially you are going below the level of your maximum but doing more reps of that.

 Then the follow up questions are: How many times? How often? Rest? How many days a week? Dr. Andy Galpin is a famous exercise science research and on an episode of the Huberman lab explained the 3-5 principle. It goes: 3-5 reps (70-85% your 1RM), 3-5 sets, 3-5 minutes of rest between sets, 3-5 days a week. So when in doubt…3-5 is the answer. 

How long till we see results? In general, strength changes take 6-8 weeks. That’s because our body wants to prove that we’re going to be doing this a lot in order to make changes. Consistency is key.

Let’s get strong so we can enjoy our lives and be independent. Remember, always consult with a physical therapist or healthcare professional to get better results and be safer.

García-Hermoso A, Cavero-Redondo I, Ramírez-Vélez R, Ruiz JR, Ortega FB, Lee DC, Martínez-Vizcaíno V. Muscular Strength as a Predictor of All-Cause Mortality in an Apparently Healthy Population: A Systematic Review and Meta-Analysis of Data From Approximately 2 Million Men and Women. Arch Phys Med Rehabil. 2018 Oct;99(10):2100-2113.e5. doi: 10.1016/j.apmr.2018.01.008. Epub 2018 Feb 7. PMID: 29425700.

How to activate muscles?

Certain muscles are notorious for being quiet. It may sound silly but that is actually one of the biggest challenges in rehab. What happens is that being sedentary, injured, or doing the same thing over and over again changes the activation pattern of your muscles. This can cause pain, bad movement leading to injury, or just not letting you progress forward. So how do we fix that? 

Well the first question is: Are we seeing a problem because a muscle is in fact “quiet” or is it because another muscle is being too “loud”? If a muscle is being too loud, that is where hands on techniques such as massage, stretching, deep trigger point pressure and more can quiet it down. I like to utilize this before my own training. If I’m trying to squat but my back muscles are taking over instead of my glutes, I will get on the foam roller and stretch those back muscles out to calm them down. Now I’m ready to fire those glutes up.

If instead the muscle is too quiet this is where activation exercises are great. The best one generally in my opinion are isometrics. That’s a really good place to start but some people respond better to different things which is why having a physical therapist analyze that for you is key. For instance, often times people have this called “glute amnesia” which means forgetting how to use their glutes. It sounds silly but it can lead to so many injuries and dysfunctions that cause pain. Getting people to turn on their glutes take a little bit of finesse because you’re asking someone to change a habit. We know that is not that easy. So I will make sure I position someone where there other muscles are quiet and have them do some basic glute exercises. All the while I’m monitoring that they’re not compensating with their bad habits. Once we dial it down, I want the person to turn on those glutes for so long that it starts to burn. This is so the brain can remember what that feels like. If it’s their first session and they don’t have any competitions coming up, I want those muscles sore so that when they’re walking around, going up stairs, sitting down and standing up, their brain remembers that feeling and they learn how to fire those glutes on command. There are definitely a few more nuances hard to explain on a blog post but if you feel like you need help getting certain muscles fired up so you can train harder or get out of pain, definitely consulting with a physical therapist is a great idea. 

Why your rehab should be organized?

In order to get the best results we always need to ask ourselves what barriers are in the way of our success? As a physical therapist when someone comes to me with pain or difficulty doing something the question I ask myself is: What barriers are getting in the way of this person doing that activity or experiencing pain while doing it? Then we need to go into testing to figure it out. I always want to see four main things. Flexibility, activation, strength, and timing. And as a matter of fact I go in that order. Because if you don’t have enough flexibility to do the motion that you want to be better at or experience less pain, then all the things after that don’t matter until we address that. It’s really important we go step by step because if we skip steps than we’re just going to running into road blocks that get us nowhere. Unfortunately, I know this isn’t common practice probably because it takes long. But that’s why I believe longer appointment sessions are necessary. For instance, my initial treatments are 1 hour just with me because I need 30 minutes just to get all the data we need to answer why we’re having pain and what are all the building blocks we need to work on. That may sound like a lot of time in today’s fast paced world but it’s necessary to create results. I personally believe that if we do a good assessment, organize our treatment to address the needs first we can improve more people and get them in less pain. If you want to see more of how I organize my rehab or performance sessions, I have created a YouTube video that breaks it down. 

https://youtu.be/vegnJlSDYgw