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June 21, 2023

ACL Grafts 101 with Dr. Yoni Rosenblatt

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Dr. Yoni Rosenblatt: Guys, thanks for listening to the True Sports Physical Therapy podcast where we always try to really deconstruct rehabilitation, sports rehabilitation and help you be a better sports physical therapist so that you can help your athlete get back sooner, quicker, stronger. Today's format a little bit different is just gonna be me, gonna be a solo podcast, and we're gonna be talking about one of my favorite topics, ACL rehabilitation or rehab following ACL reconstruction, as my surgical buddies are always correcting me. The way I went about this is I asked a dear friend and mentor of mine, coach Kelly, Ben Kelly, find him on Instagram @coach.kelly.dpt.

Dr. Yoni Rosenblatt: He's a new physical therapist. He did his last rotation up here at True Sports, but he's been a mentor of mine for a long time. Physical therapy is a second career for him. Spent some time on the West Coast fixing up motorcycles, really figuring out what the hell he wanted to do with his life, then enlisted in the Coast Guard and used that to pay for school and studied his freaking ass off as he went through some outstanding physical therapy education. And then we got lucky enough to get him up at True Sports, where he taught us all about current interventions and hopefully he learned a thing or two. And now he's finishing up his residency up in Wisconsin.

Dr. Yoni Rosenblatt: So I reached out to him and said, "I wanna do a pod on ACLs. Tell me what you wanna know. I'm sure you know everything about rehabbing ACLs." So he sent me over a couple questions that I thought were pretty interesting. I'd love to just kinda go through them, give you both what's off the top of my head and really my opinion and delve into it just a little bit of the literature to give you guys kind of an update on the way I think about ACL rehab, the way True Sports approaches rehabilitation. It's good timing for this pod 'cause we're really getting close to launching our much anticipated guide to rehabilitation following ACL, you'll be able to get your continuing Ed through True Sports Physical Therapy.

Dr. Yoni Rosenblatt: That program will probably launch within the next few weeks and we'll do really a series leading up to that to tease it a little bit, to tell you exactly why it's different, why this continuing education is different than everything that's out there, and also to highlight some of the ins and outs of what it's like to rehab an ACL at many different levels, at the prep school level, at the collegiate level, and then you'll be hearing from some NFL vets and other pro athletes that have dealt with ACL rehabilitation both with us and throughout their professional career. But before we launch that, let's launch into what's on Coach Kelly's mind. So the first question he shot over was, he wanted to dive into the different graft choices and what to expect from them in terms of rehab choice.

Dr. Yoni Rosenblatt: So what effect does the graft choice have on outcomes? So let's define outcomes a little bit 'cause there are a few outcomes that you're gonna wanna hit or they're really milestones, but you're looking for outcomes at each milestone as you move through this rehab process. And the first, very first thing is that range of motion. You've heard me preach it here before, you're gonna hear me preach it a ton. You have to get that terminal knee extension. And I'm super interested in what kind of grafts make that easier. What makes it easier to get your terminal knee range of motion, both inflection and towards extension? So dug up a little research on this, 2021 study came out from Journal Pediatric Orthopedics. They looked at 378 patients and they said, what's the rate of arthrofibrosis broken down based upon graft? Sounds like an awesome question to dive into.

Dr. Yoni Rosenblatt: Here's what came out. I wasn't shocked by this, and I'm sure everyone listening to this won't be either, but the graft choice that has the lowest incidence of arthrofibrosis, at least in this cohort, was hamstring tendon graft. 1.9% of hamstring tendons came down with arthrofibrosis, 6.3% for quad tendon and 10% were BTB or BTB led to arthrofibrosis in 10% of that population. So I'm not shocked by this. And a lot of this actually learned early on in my career in dealing with a very, very chronic arthrofibrotic patient or a patient with arthrofibrosis. Really sitting up around those fat pads, that's the number one source of where you're gonna find the tremendous amount of scar tissue adhesion and accumulation. And those are called kind of those anterior gutters of the knee as they run up along that patellar tendon. And right where the patella tendon kinda sits on those fat pads, you'll find a tremendous amount of scar tissue kinda bulked up there.

Dr. Yoni Rosenblatt: So it would make sense that if you're gonna cut open the middle of that tendon, the middle third of that tendon, that scar tissue will begin to lay down. It's much harder to break up sitting right through those intervals. So I wasn't surprised to see that. It's really confounding what leads to arthrofibrosis. We know that bleeding, the more bleeding that happens, the more scar tissue is actually laid down, tremendous amount of blood that, or trauma that's really caused to that anterior knee, right next to where that scar forms. So it would make sense that that's where you're seeing the arthrofibrosis. But as you're thinking about graft choices, and a lot of this, certainly what we see at True Sports is direct access. So the patient comes off the street, off the field or whatever and comes to us and says, "Hey, what graft should I get? What should I talk to the surgeon about?" Obviously it's a conversation between patient and surgeon.

Dr. Yoni Rosenblatt: When you're making that choice, this is just one thing to think about. So when you talk about outcomes and you say, hey, the first thing that needs to happen is you need to get all of your range of motion, you need to hammer extension, you need to eventually get that flexion, there's actually a higher chance that you develop, at least according to this 2021 study, and we'll put the citations in the show notes, that you're gonna come down with arthrofibrosis with a patellar tendon graft. Now, here's why I point this out. Because when that patient walks in and they have a patellar tendon graft, you better pay attention to how well the patellar tendon itself is gliding, is sliding, is moving. How malleable is it? How much are you putting your hands on that patellar tendon, and then how good of a job are you doing at imploring your patient to do self mobilization at home? Or maybe you're teaching a parent to do it at home.

Dr. Yoni Rosenblatt: The more we get that patella moving, the more we get the patella tendon moving, I would say the less chance we have of it adhesing and becoming arthrofibrotic. So pay extra close attention to that patella tendon graft. But you gotta pay attention obviously to all of them, but I would definitely say that's one way in which the graft can affect the beginnings of these outcomes. The other thing I look for as we define outcomes would be quad recruitment. Now, I tried, I didn't found an awesome amount of literature that tied graft choice to quad recruitment, but anecdotally speaking, that patellar tendon graft is far harder, I believe, to really then coach the patient on recruiting the entirety of the quad or just getting what we call at True Sports the heel pop, which is that terminal quad extension or knee extension so that the heel pops up off the table. It's just more difficult with the BTB because of the anterior knee pain, maybe because of the stickiness, maybe that tourniquet is on a little bit longer, we'll get into that in a little bit.

Dr. Yoni Rosenblatt: I would ask you to shoot back or recommend that you shoot back to one of our earlier podcasts, I think it was number two or three, where we had Dr. Jamie Dreese on, who just did an awesome job of breaking down what it's like to repair an ACL. What is it like in the OR, not repair but reconstruct in the OR, and some of the considerations that go in. I think there's so much value there. By the way, you'll see Dr. Dreese in the upcoming continuing ED video on ACL rehabilitation. So he does an awesome job of breaking it down so that everyone can understand it. But thinking about really how well you can get that quad on, it's gonna be a lot easier with a hamstring graft. And I've seen anecdotally with a quad tendon graft versus your BTB. So another kind of something to think about when you start considering outcomes, all of these things affect the eventual outcome, which of course is that ultimate return to sport or return to activity.

Dr. Yoni Rosenblatt: The next thing I think about with graft choices would be if we did, getting a range of motion, if we did muscle activation, is then what's the rest of the rehab process like? So the number one limiting factor within that process would be pain during rehab. Pain in rehab with a patellar tendon graft is almost 100%. There are so few athletes that I've worked with that do not have discomfort in their anterior knee following a BTB. And we are always trying to figure out what is it that allows those patients that don't have pain, what did we do right or what did they do right or what did the surgeon do right that kept them somewhat pain free throughout? But it's almost a slam dunk that they're gonna have pain, the BTBs. Quad tendon also, I have seen a lot of pain obviously at incision or harvest site, just where that quad tendon begins to meet that superior patella or that patellar base. And with hamstring, man, there's not too much pain with a hamstring.

Dr. Yoni Rosenblatt: Those hamstring grafts, when I see that walk in the door, that's usually a pretty smooth ride. Don't get me wrong, you gotta pay attention to the heel pop and the terminal flexion and quad recruitment. Like you gotta pay attention to the details there, but it's usually far smoother of a process, far less pain as you work through that return to sport with a hami graft. So those are the things I'm thinking about. Again, by the way, these are conversations I'm having with patients all the time, with patient's parents all the time when they walk in and they're like, "Doc, what graft should we get?" All of these attributes and pieces, I love educating, talking to the patient. Obviously I leave the decision up to them, but another thing that I counsel them on, and we'll get a little bit into this in some of the ensuing questions, is figure out what your doctor is super comfortable with. So there are plenty of orthopedists that I've worked with both in Baltimore and PA and Delaware, throughout the East coast 'cause we see a lot of athletes throughout the East coast, that hey, they do 90% BTB.

Dr. Yoni Rosenblatt: It's what they learned in school, it's what they've had most success with. They will die screaming about how much more successful, let's say, the BTB is versus another graft. And if you've chosen that surgeon, you don't wanna then ask him or her to do a hamstring graft or a graft that they just don't do as much. So I would consider all of those things when thinking about your outcomes, and that's how I would say the graft choice affects the outcomes. But also when choosing a graft, make sure your surgeon is super comfortable with whatever graft, or make sure you're comfortable with what the surgeon does frequently. Just like a small pearl there. Okay. And then finally, all the way at the end, looking at this return to sport. So when we look at return to sport and we think about how the graft affects those outcomes as they return to sport, the literature is like wild, it's like it's all over the place, where I pulled a couple studies to really highlight that.

Dr. Yoni Rosenblatt: There's a study that came out in 2016. It was a Kaiser-based study, it was California-based, but they looked at 534 patients. And they were muscular, they were skeletally immature, so growth plates were still open. Median age was 14, almost 15 years old. And they were looking at return to sport rates, really seemed that there was no significant difference in return to sport based upon the graft. Now, re-tear rates they said were significantly higher, but it didn't seem to affect their return to sport regardless of what graft you take. By the way, 2021, a systematic review, meta-analysis, again, I'll put it in the show notes. They looked at 24 different studies, a total of nearly 3400 athletes. They also found no significant difference in graft failure rates between quad tendon, patellar tendon, hamstring tendon.

Dr. Yoni Rosenblatt: By the way, that little piece of failure rates, 2021 they're coming out and saying, based upon all of these studies, the 24 studies we reviewed, doesn't seem like there's a significant difference in re-tear rates. 2016, they looked at 534 patients, they found a massive difference in revision rates. So the revision rates that they found were BTB, 5.5%, you're gonna have a second surgery. For hamstring graft, autographed, 7.5% you're gonna have a second surgery, allograft 13.2%. So that's what they found in 2016. Those are the numbers ironically that... I probably came of age in my career in 2016, like that's the literature that I will frequently cite. By the way, this is the type of literature that surgeons will frequently cite when they say that BTB is the gold standard.

Dr. Yoni Rosenblatt: Bone tendon bone is the gold standard that has the lowest chance of a re-tear rate. Well, now we have a study in 2021 that says, sorry, they're all the same. So thinking about graft choices, it really depends what study you're pulling to say, "Hey, this is the chance that this given graft is going to rupture or fail." It can be supported, it can be disproven depending upon what study you pull. I have found anecdotally that there is not a difference between patellar tendon, hamstring tendon, quad tendon. We're not seeing a ton of quad tendon repairs yet, I've seen a few out of New York. There are a couple docs throughout Baltimore that do it, some in PA that we've seen, but certainly not as much as, I feel like it's BTB and hamstring tendon primarily, predominantly in Maryland. I have not noticed a difference one versus the other in re-tear rates. Thank God we at True Sports have a very low re-tear rate. I'm not saying it doesn't happen, but it is very low.

Dr. Yoni Rosenblatt: I can think of like one or two off the top of my head that we've personally treated that unfortunately have ruptured or failed, but it wasn't one versus the other. And like I said, it looks like they're getting closer. And so when this happens, when I'm able to pull different studies to support two diametrically opposed outcomes, I always go back and number one, like how do you dissect a study? No study is created equal, so you wanna really dive into that. But also I think it's of note that 2016, clear cut difference, 2021, already we're starting to see that surgeons are getting far more comfortable doing these other tendon grafts. So hamstrings, as I was coming up in the field, you would rarely see a hamstring tendon repair. I think it's 'cause docs were just simply trained with this bone patellar bone and that's just what they did more. And they got really good at it and it is a bone to bone fixation and they tell me that that's stronger, although 2021 studies would beg to differ.

Dr. Yoni Rosenblatt: And so that became the gold standard because of that, docs weren't as great at harvesting hamstrings. They have come up with far better fixation techniques with this tendon to bone techniques versus the bone to bone. Therapy, rehab has come so far. By the way, even since 2016, the knowledge base of the sports physical therapist is light years ahead of where it was five, certainly 10 years ago. It's a totally different field. I hope you're getting that from listening to some of the conversations that I'm having with athletes and hearing their stories from the past or even more seasoned PTs that talk about what it used to be. Jesus, I remember coming out of graduate school and we would have to read, I'm not that old, we would have to read the prescriptions from the doctors, and we could not do something that wasn't written on that prescription pad.

Dr. Yoni Rosenblatt: So it said ultrasound, it said e-stim. If it didn't say therapeutic exercise, we had to just do e-stim and ultrasound. And so we've come light years with the direct access act and our ability to really become discerning clinicians and deciding clinicians. That's awesome. My point is, 2021, maybe the rehab techniques are just simply better. And so that is decreasing the difference between the graphs and their re-tear rates and their failure rates. And so maybe that's the case. So let's circle all the way back to Coach Kelly's question, which is, do graph choices change your return to sport? Likelihood, doesn't seem so. Does it change the chance of a re-rupture? Does it enhance it in any way, shape or form? Depends what study you pull. I would say anecdotally, no. We definitely have therapists in True Sports which would disagree with me, but also, there's definitely literature to support that. But like I said, both ways.

Dr. Yoni Rosenblatt: Okay. And then when we talk about, overarchingly I think it's worthwhile diving into the chances of success of this ACL surgery. And by success, I mean return to sport and getting back on the field. Again, I encourage you to shoot back to previous podcasts I've done with surgeons where we talk about the rate of return to sport. It also varies from study to study. 2022 lit review leads us to believe that across many multiple studies, it ran from 71% to 83% that you are going to return to your sport, period. 2018, there's a study looking at almost 1500 athletes, they found that only 50% return to their previous level of sport within the first year. 50%, that is terrible. And by the way, far lower than I would've expected. So again, studies in 2022, they're looking 71% to 83%. 2018, they're looking all the way down at 50%. Where's the truth? Probably somewhere in the middle, but not as high as we would think.

Dr. Yoni Rosenblatt: And this is across all graft choices. So getting a little bit away from the original graft choice question, but it makes you think, it makes you think a little bit like, "Are we as good at this as we think we are? And how can we continue to get better?" And that's the name of the game. How do we continue to get better? I also thought it was really interesting, in the NFL between the years of 2009 and 2015, they ran a study, a retrospective study looking at ACL re-rupture rates after repair within that first year. They found that 18% of ACL tears re-tore in the first year of returning to sport. By the way, the likelihood that you return to your previous, previous level of sport within three years, if you're in the NFL, previous level of productivity, 50%. That's crazy. Three years post-op, only 50% returned to their previous level of sport, and they judge that with a number of metrics depending upon the position. But dude, that ain't good. That is not good.

Dr. Yoni Rosenblatt: So how do we get better at this? If the re-tear rates are as high as we're talking about, certainly at this level in the NFL, are there things that we could be doing better on the rehab process and maybe there's something that we could be doing better in the surgical process. And so I also think this is a worthwhile conversation because I think this opens our eyes to this idea of the ALL reconstruction. And so what the ALL does is, just so we can kind of explain it to everyone, is it's a ligament that lives in the anterolateral portion of the knee. And it's kind of, I've heard it described as like a seatbelt to the ligament. And it's interesting because this did not exist arguably in orthopedics when I came out of graduate school, call it 13 years ago, 14 years ago. It's almost like this ligament was newly discovered and now docs have understood either how to reconstruct it or how to reinforce it.

Dr. Yoni Rosenblatt: And so what it does is it decreases the rotational aspect of tibia on femur. And so that's gonna decrease the torque going through the entire knee, and it is pretty astounding. I urge everyone listening to do a quick lit review at re-tear rates following the use of an ALL reconstruction in an ACL primary, even primary tear. They're really seeing almost a near absence of re-tears. Obviously it's not full, but a significant reduction in re-tear without an increase in what we were previously worried about with this procedure, which is lateral compartment osteoarthritis, without further complications or risks of infection certainly with Arthrofibrosis. I think we found early on, I know throughout True Sports, it's so interesting like the difference in doctor or MD intervention. I always say like I can spot a givens surgeon work as soon as that patient walks in following ACL. I just know what a Dr. X knee looks like, I know what a Dr. Y knee looks like.

Dr. Yoni Rosenblatt: We had a doc that the patients would come in and their knee was invariably stiff and angry following this ALL procedure. And turns out like his placement of that ALL was not ideal and so the knee was simply angry and had a lot of problems. And this is what you'll see with a poorly placed ALL, a lot of problems getting into flexion because the ALL is put in too far anteriorly. And so that starts to block flexion. When it's done properly, obviously, it's really convincing. I don't know how much some of that newer surgical technique, it's probably been around for the last five or so years, is seeping all the way down to the physical therapy education, to the new PT students. You'll definitely hear about it in the True Sports continuing education or guide towards ACL rehab, but a massive player. And so I'm always thinking, how are we gonna do this better? And when we look at return to sport rates and how at times paltry they are, especially at these elite levels of sport, I know we mentioned NFL, it gives some of our Australian brothers a little bit of love, it's the same in the AFL.

Dr. Yoni Rosenblatt: They're looking at an 18% rupture rate or failure rate when returning back to the AFL, which is an unbelievable sport, I encourage you to check that out. Just some of the best athletes in the world. However, maybe we start thinking about putting in those ALLs a little bit more often. It's certainly a conversation to have with the patient and with your surgeons around the area, and will certainly kind of lead to just more back and forth and the people that gain from that are certainly the patients. So in summary, those are the things that I think about when I say you gotta consider these outcomes based upon the graft choice. These are some of the conversations that I have both with patients and with surgeons to try to determine what is the ideal graft choice for the given athlete in front of you. Dr. Ben Kelly, I hope that answers some of your questions. Okay, next. The other thing that I'm thinking about or the next question that I got to consider is what are some of the biggest mistakes physical therapists make when rehabbing ACLs?

Dr. Yoni Rosenblatt: This is a question right out of my playbook. So, Ben, thanks for shooting this one over. I got a million of these. It's almost like a million pet peeves. Number one is the number, the way we prescribe sessions. I am sick of living in this, "Yep, two visits a week. So go ahead and schedule up front." Or, "Three visits a week... " I don't know where we came up with this. I always give the patient two answers. One answer is, here's what I would say if you were a pro athlete or if you have insurance, if money was zero object, I'm just gonna tell you the absolute best thing for you, how many sessions you should have this week and maybe over the first month of rehab. Between four and five a week. And the only reason I wouldn't say five a week is because maybe I wanna give you a Friday off to go to the beach or something, to the ocean, because the more I see you, I think the better you're gonna do.

Dr. Yoni Rosenblatt: Early on, here's what I'm definitely gonna say. The more I see you, the better chance it is that we get all of your motion. And that is a number one. That is your number one goal when that patient walks in post-op is, can I help them get that range of motion? The chances I can help them are far greater if I'm seeing them every damn day early on or as much as possible, as much as mom can bring 'em or whatever, than it is if I say, "Yep, twice a week." Because why? Because that's what my CI said? It just doesn't make sense. So I urge the audience, reconsider that notion of how we prescribe sessions. Just make it freaking make sense. You wanna spend time with your hands on the patient, you wanna check in with the patient, you wanna progress the patient. You can't do that if they're coming in twice a week. If you're dead set on avoiding scopes, arthrofibrosis, the laying down of scar tissue, by the way, pain, increasing the chances that we can recruit that quad immediately 'cause that's the secret to terminal extension, see 'em as much as possible.

Dr. Yoni Rosenblatt: So go heavy on scheduling early and often. Little tip, maybe both business, I'd say practice management wise, the patient calls, they tell the front desk, "Hey, I just had ACL surgery with doctor whatever. I wanna make an appointment." Have the receptionist schedule them for five times that first week. Just, "Here's the way we do it at True Sports, we're gonna see you four to five times that first week. I'll check your insurance. The PT will go back and check your insurance, make sure you have enough visits 'cause we wanna be judicious with that. But we wanna see you as much as possible. If you come in and you look amazing and you don't need that many sessions or whatever, we'll pare 'em down but better you get 'em on the books," that's the way you train your front desk. That's the way you help your patient understand what is expected of me. And that's the way you make sure they have the visits.

Dr. Yoni Rosenblatt: The worst thing is patient comes in for their eval and then you can't see 'em for another two weeks because your schedule's slamming 'cause you've been listening to the True Sports podcast and you're the best PT in the world. So just make sure you schedule them in advance or as soon as they call in, just schedule them at least all the way out for that first week. So that's number one. Mike, I hope you edit out that drink of water. Okay. Back at it. Number two. My number two biggest mistake I think therapists make when they're rehabbing ACLs is their lack of planning out sessions and varying inputs. Here's what I mean. You need to think like a strength coach throughout rehab, throughout certainly this rehab process. So think about periodization. When do I want these athletes to peak? When are they actually thinking about returning to sport, if you're getting close to that or maybe they have a return to doctor that you want 'em to look a certain way or they're coming up on a healing stage or phase and you're getting ready to get them to weight bearing, let's say, or squat work or running.

Dr. Yoni Rosenblatt: You gotta periodize your sessions so you're hitting your goals appropriately and you're managing overall load. I think it's super important that you need to hit your multiple planes of motion, right? So maybe you're doing a little bit of that in each session, or maybe today, day one of the week, we are simply working in the frontal plane. We're gonna load the crap out of you in the frontal plane. We're gonna hit endurance in the frontal plane. Whatever your mode or theme of that day is, they come in day two. Okay, let's work sagittal. We're working sagittal plane, we're working on lunges, we're working on skips, we're working on stuff like that. But think about your planes of motion. The bottom line is think about planning it out. And then as you're planning these sessions, you have to properly supplement things at home.

Dr. Yoni Rosenblatt: Day one, I clearly explain to my patients, "You are gonna do more for yourself at home than I'm gonna do for you when you walk in here. So you gotta get tight around that homework. Here's exactly the homework I want you to do. Here's exactly how long I want you to do it. Here's how many reps, here's how many sets, etcetera." But make them responsible for that. And then when they come back in, you're checking on that. And then you have to be progressing that. That's another thing you're gonna see in the True Sports ACL program, is what is a good idea? What is three, four exercises that they can be manning at home so that you know you're making progress. And then as you move from functional phase to functional phase, that homework also should be moving and being progressed. We use an in-house app to make sure that we're able to monitor that appropriately and keep track of it.

Dr. Yoni Rosenblatt: You've gotta come up with solutions in order to do that. But I would say that's one of the biggest mistakes is that therapists don't necessarily plan out their sessions. They show up at the same time the patient shows up, they don't have stuff written out, they don't have, at least in their mental notebook what they're gonna do. I think that has to change. Another mistake that therapists often use is they stop using... Or another mistake that therapists often make is they stop using stim far too soon or they never bring it back. So I'm really talking about quad recruitment here. That is of utmost importance, maybe tied with range of motion. Range of motion, I'd say is more important. So it is second to getting your full range of motion is being able to turn that quad on, not just turn it on, turn it all the way on, supplementing that with stim.

Dr. Yoni Rosenblatt: We know adding neuromuscular electric stim to exercise is gonna enhance how many muscle fibers are actually recruited. The more muscle fibers recruited, the more hypertrophy you're gonna see under load, the less knee pain you're gonna see, certainly less patellar tendon pain you're gonna see. That's why isometrics work beautifully for patellar tendon pain, which like I said, is inevitable when you get a BTB. And so if that crops up, if that starts rearing its head, pop that stim back on, get 'em a home stim unit. Use stim again. It's one of the big mistakes that I see therapists making is not using it enough and not using it often enough. So make sure you don't fall out of love with your electric stim. Another mistake that I think therapists make at times when rehabbing ACLs is the way they use the time in a given session.

Dr. Yoni Rosenblatt: Not every session has to be half on the table, half on the gym. Let your patient's presentation dictate how you utilize that time in your given session. At True Sports, we treat one-on-one for 45 minutes. Sometimes I spend 45 minutes to an hour on the floor lifting, loading, hopping, changing direction, getting ready to get back on the field, sometimes I spend 45 minutes with the patient on the table. It depends what the patient needs that day. You gotta be able to make that assessment rapidly. Sometimes I'll text the patient before they come in, "Hey, how you doing?" So I can begin to plan. "Okay, I'm gonna spend 10 minutes working on motion. Okay, they got their motion, let's hit the gym and reinforce it." Or, "My knee's killing me, it's swollen. We need to calm it down. What can we do?" Most of that session is gonna be on the table. So thinking all the way through that, but using it properly and not just falling into a rut. Not every ACL is the same, even two weeks out, three weeks out, you could have two patients at those same timeframes and they're doing totally different things. So meet your patient where they are.

Dr. Yoni Rosenblatt: Another pet peeve watching other PTs rehab their ACL patients or their patients that went through ACL reconstruction is running before jumping. I beg you to send me a DM and justify when you would run before you could jump. Because to me, running is a series of small level single leg hops. And you need to build up to that. You need to be able to show that you can own a certain amount of foot contacts before you get all the way back to run. You need to break it down, be systematic about it. Hey, I'm gonna start low level up to a box, that makes the most sense to me, far less force going through anterior knee when moving concentrically and landing on an elevated surface. I start there, then I move from up to down. Then I move to over two legs to one leg playing with your different planes. But why would a patient run before they have proven that they can jump? Why would a patient go through running, which involves producing force, receiving force before they have proven that they can do that in a very controlled environment, one rep at a time?

Dr. Yoni Rosenblatt: Send me an email. Tell me why you would do that., I'd love to hear it. For now, until I hear a convincing argument, I love getting my athletes jumping, owning that plyometric activity, perfecting it before we progress towards run, and then get really tight around how am I gonna prescribe run? I hate when patients are just told, "Yeah, go run. Let's try half a mile, come back and let me know how it goes." No, get really tight around it so we know how to progress it. I use the Delaware return to run protocol. Delaware always tells me that they are the number one orthopedic school in the country, so in this instance I believe it, but the reason I like it is it gives you soreness rules, it tells you how to progress, it tells you how to scale, there's a lot of greed in there but bottom line is, it just gives you a number of stuff so the athlete knows the plan they're on. Stop running before you jump.

Dr. Yoni Rosenblatt: Okay. Last but not least, we touch on this a little bit, one of the biggest mistakes therapists make when rehabbing their ACLs is they forget how important homework is. Be unbelievably specific with your bag hangs early on, try like hell to either become that therapist strength coach, find them a strength coach, coordinate with their existing strength coach so that they can get the most out of the days that they're not with you, make sure they are recovering appropriately, and then nutrition. I love when I have therapists on staff that are nutritional experts. I am not one, but I rely... I have a network of nutritionists, of sports-based nutritionists. Use them because, man, we got... Before I really started using them consistently, nutritionists, I saw a lot of athletes, specifically female athletes, have a lot of trouble putting muscle mass on post-op, keeping muscle mass, preventing atrophy.

Dr. Yoni Rosenblatt: Please God, think about using blood flow restriction. At this point, with the current price points, it's hard to justify not having one. You cannot justify not having one. You have to have a blood flow restriction in your clinic because it's, at the very least, gonna prevent atrophy, early on it's gonna possibly enhance hypertrophy. Go back to our previous pod with one of the founders from Owen Science on strength and conditioning, Dr. Kiesel. It's totally standard at this point. So I think those things are so important, both with homework as well as using just the latest and greatest, you gotta be doing those things when rehabbing these ACLs. Our third question, when should athletes start rehab? Easy, immediately. I want you to see them pre-op. We know outcomes from patients that have done prehab are better than those who don't.

Dr. Yoni Rosenblatt: And we are talking one, two, three sessions, teach 'em what a heel pop is before they go into surgery, teach 'em what they are gonna do when they open their eyes, "You are gonna squeeze your quad. I know your quad is not gonna turn on, but try to turn it on 'cause that's gonna equate to success down the road the quicker that quadriceps turn on." They come in for prehab, see if you can get them a stim unit for home. That way when they get home, tell them, "Hey, unwrap it. For the most part, at least get to your quad, pop some stim on it. Even if you can't turn it on, push this button a million times till it turns your quad on." They are gonna look better for coming in early, they are gonna look better for coming to see your pre-op and getting some of these nitty-gritty. They should already have their homework on their app or however you relay that information in your given clinic before they go to sleep for the surgery.

Dr. Yoni Rosenblatt: Now, post-op, I love seeing them within 24-48 hours. They will hate you on that day. They will be quizzy. They probably won't remember the session, but they will benefit from you getting that knee moving as soon as possible. It kills me, another question previously was, what are the biggest problems I see with therapists doing rehab? The biggest problem I see with surgeons post-op instruction is telling them to wait or putting 'em in a brace that doesn't actually hold their knee inflection. I've seen surgeons in Maryland put them in cast, in straight leg cast, but still their knee is slightly flex in those cast, and they don't let me get to them for 8-10 days. It's nuts. Like, there is no stress being put through that graft with passive range of motion. I just don't understand, before they wake up, surgeon puts in the ACL and rips them through their given range of motion, wakes 'em up and then for some reason, they can't come to PT.

Dr. Yoni Rosenblatt: You gotta get to the patients, educate them appropriately, tell 'em to get their asses in very early on. Also talk to the doc, explain, "Hey, I'm not gonna re-tear your graft, I'm not starting patellar tendinitis issues. If I see 'em day one or day two, I'll tell you what I'm doing, I'm decreasing the chance you have to scope 'em and rip out scar tissue. So let's see if we can get 'em in a little bit earlier." I would probably put it nicer if I was talking to an orthopedist, but those are the points that you gotta convey. A good question, Ben Kelly. Okay, last but not least, how do you know what surgeon to recommend when a patient walks in? I love this question, because it speaks to both the business side of my brain and the clinical side of my brain. I wanna make a recommendation of a surgeon who is an outstanding communicator. That might be number one.

Dr. Yoni Rosenblatt: I love that when a surgeon will care enough and take the time to sit down and talk to their patient and say, "Here's the surgery I'm gonna do, here are the potential outcomes, here are the risks, here's how we know you're gonna do it great, you have to go to True Sports within the first 24 hours." Things like that, but they have to be able to communicate. I think that is of utmost import. And so as you go out to market, it's unbelievable how these tables have turned. When I came out of school, I would walk into surgeon's office and beg them to send me patients. Now I have surgeons coming to True Sports and saying, "How do we get to see some of the athletes that walk in here?" And that's because of the direct access nature of Maryland, it's one of the few awesome things about the state of Maryland, is that patients can just walk in and see us, and we make tons of recommendations to orthopedists.

Dr. Yoni Rosenblatt: Here's how you know it's a good one, is if they're able to communicate. But when you go out to market, is what I was saying previously, and you say, "Hey, I'm the new therapist in town," or, "I just joined this company," or whatever, as you start to meet those doctors, you can start to develop the rapport and be super comfortable in saying, "Hey, go see this doctor around the corner. He's outstanding for X, Y, Z. Let me send them an email because I have their email, or shoot 'em a text," or whatever, because you know that that surgeon is a great communicator. Another thing I think PTs should begin to get used to, and I learned this from the last pod that we did with Dr. Dreese was tourniquet time. So PTs should know and kind of ask and glean somehow how long is that tourniquet on the patient's leg pumped all the way up during surgery? It's interesting to hear. Now I have a couple of buddies who are orthopedic surgeons.

Dr. Yoni Rosenblatt: Some are total joint and some are sports. And just talking to them casually, they love talking about how rapidly they're able to do surgeries. I always thought that was like crazy, and I had a lot of bravado behind it. I'm like, "How is it possible you're racing?" But one good side is the quicker that surgery is done, the less compression was taking place around that limb. That means blood flow can come back quicker, so healing can start. That means, probably most importantly, the nerves, the peripheral nerves, are not being crushed for as long under that searing pressure. That is totally going to affect... Although there are no studies, 'cause I tried to find them, but that will totally affect, when that patient walks on into your office and on your table within 24-48 hours, how well they turn their quad on.

Dr. Yoni Rosenblatt: Invariably shorter tourniquet times translates to enhanced, increased quad recruitment. Talk to your doc about it. Learn about it. Great way to develop rapport with your doc, but it'll also help you make those referrals out to the doctors. Another thing you wanna know when looking for a surgeon that you're gonna send to, does this doctor work with athletes? Their expectation levels, their... By the way, some of their techniques are even gonna differ based upon what they wanna see on the field. This is totally true. Maybe more so with shoulders and baseball players. And you know how passionate I am about this because you heard how high my voice just got when describing that. And by the way, this is similar to another podcast we did with the Mets surgeon in which we were talking about how do you look at labral tears in a baseball player versus in gen pop.

Dr. Yoni Rosenblatt: They're totally different outlooks, totally different surgical techniques. There's something here with the knee. I don't think it's as apparent or obvious as it is with shoulder. But you want a doctor that works with athletes, potentially high-level athletes, just because as they coach them through their return to sport, that's gonna play a big part. So I'm really big on taking videos of my patients, especially when they're doing really well, or if we're really struggling, shooting them to the doctor, I love if the doctor knows, "Hey, this is where the athlete should be if we're looking to get him back on the field in however long." That reference point can only be understood if your doctor works on athletes. I also want to send to a doctor that is always learning and evolving. I don't want someone who's still putting in ACLs straight North South.

Dr. Yoni Rosenblatt: There was a godfather of sports medicine in Baltimore and in Maryland, and man, you could see his knees a mile away on radiographs. You knew what knee he did because that graph went in straight up and down, which is totally old school, which is how you learned in med school. But why would that surgery be done the exact same way as it was 35 years ago when he was in med school? It should have evolved, everyone else's has evolved. So I want a doc that's on the cutting edge. And yeah, I had an awesome opportunity recently, we didn't even talk about this in this ACL pod, but we talked about graph choices, but now we're talking about and learning about ACL repairs, not reconstructions. And so the ability to wrap a torn ACL in what's called a bridge or a bear technique, where they wrap it in what looks like a marshmallow with growth factor and blood surrounding it, and they kind of shove that marshmallow in and join the ends of the ACL, I think I'm describing this properly, so that it can then knit itself back together and grow back together.

Dr. Yoni Rosenblatt: So I went to a local sports hospital where they were learning the procedure in a lab. I haven't been in a cadaver lab in a while, but they have all these knees hanging from all these hooks. And I watched these surgeons learn a new technique. By the way, these are surgeons that we work with, we refer to all the time and refer to us all the time. It was fascinating to watch them try to learn something new. It was eye-opening to see who was really good at it, who was humble about it, who was cutting corners with a scalpel in their hand. It was really awesome to be a fly on the wall of watching something like that. But, man, did that help make up my idea of who do I wanna send to? Who do I wanna say, "This is the surgeon that would repair my knee," That's who you wanna send your patients to. I just thought that was an awesome experience and something I would recommend to anyone listening here to try to wrap your head around that.

Dr. Yoni Rosenblatt: Another great example, a dear friend of mine and an outstanding surgeon, a guy named Dr. Bashir Zikria, yeah, a Hopkins doctor, who when I was working for someone else, I was just cold calling and trying to develop some type of network that I could refer to and certainly that could refer back to me. I called Dr. Zikria and he said something really interesting to me, he's like, "Listen, I'd love to sit down and talk but don't bring me food because we're not allowed to have PTs bring us lunch anymore." I'm like, "Okay, I'm not a caterer, so I wasn't planning on bringing you food. I won't bring you food but would love to sit down." And so I went in and talked to him, and it was... We were talking about a patient that I had that was struggling with IT pain after an ACL reconstruction and it was really because of the scar that was forming proximal to his lateral joint line, like right on the femur, like right along IT band, and will look almost like a giant bullet hole that's somewhat keloided. It's probably the size of a quarter.

Dr. Yoni Rosenblatt: And that's where Dr. Zikria pulled his femoral attachment out so that he could construct that ACL, and it left this massive scar. So I was saying like, "Doc, he's got all this IT friction. I don't really know what it is." And Dr. Zikria was like, "Yeah, I stopped doing the surgery like that. That pain will go away but I don't do the surgery like that anymore." I thought that was crazy. But he had seen it enough. Now you'll see there is a very small pinhole right in that point I described. It was... It did use to look like a bullet hole and now it looks like a little pinhole, but Dr. Zikria was all over that where he changed his technique to make it a far smaller incision. I think they now call it like an inside out where as they come out of femur pulling that graft, they actually kind of reverse the drill, I guess, or the hook that's around it. I know the surgeon would know that perfect technique. As it comes out, it kind of collapses.

Dr. Yoni Rosenblatt: So the hole actually gets more narrow as you get to the lateral portion of the bone, and so it leaves a very small pinhole. You might not even notice it when you're rehabbing it, but that decreases the friction right along that side, so the IT band syndrome never goes away. Anyway, my point is... Or goes away. My point is Dr. Zikria was always learning, which is probably why he's been on sabbatical for three years in Qatar being their head orthopedist of the World Cup, but you want docs that are always learning, always bettering themselves, just like you should be, that's why you're listening to the pod. But that's my answer to how things I think about when I recommend surgeons. And then last but not least, just to kind of wrap this episode up, I'm always asking guests what they're reading.

Dr. Yoni Rosenblatt: So thank you for asking me what I'm reading. I just finished up Mind of a Leader. It's about mindfulness in leadership. I highly recommend it, I actually love it. And then I just got a recommendation today by a legend, Dr. Kelly Starrett, who may be on pod episode number three of the True Sports Physical Therapy Podcast. Go back and listen to that. He recommended a book named Maror, which is Hebrew for bitter. And it shocked me because when I had him on the pod, Kelly actually mispronounced some therapist name, a Hebrew, the guy's name was Moshe and he said Moshi or something. I told him it was Moshe. And then he made... He said that, "Oh, I have to brush up on my Israeli." I'm like, "Oh, I think you mean Hebrew." Meanwhile fast forward like three months, the guy's reading a book on... With a Hebrew title Maror, which I said, "Oh, actually that means bitter." He's like, "Yeah, I know."

Dr. Yoni Rosenblatt: I mean, the guy is just constantly trying to learn. He's an inspiration to me. He's probably an inspiration to a lot of people listening to this. I'll let you know what I think of Maror. It will be my first foray into fiction in about 30 years. But Ben, that's what I'm reading. Dr. Ben Kelly, I wanna thank you for almost interviewing me with your questions, so I appreciate that, made it a lot easier for me. I hope everyone listening to this learned all about graft options, learned about some of the current literature surrounding them, and at times, how conflicting that literature is, and also about return to sport abilities, as well as pain levels throughout, and then how you start talking to your patient, how you start educating your patient, important things to remember through the rehab process, like planning out your sessions, being intelligent and thoughtful with how many sessions a week you're prescribing to the patient, as well as educating them on their homework.

Dr. Yoni Rosenblatt: And then how are you going to surround yourself with doctors that'll set you up for success, set your patience up for success, all of that, hopefully, you gain from this. Remember, shameless plug, when that True Sports ACL course comes out, I urge you to take it. I urge you to buy it and just learn the way we do these things. We are so passionate about providing the best to our patients, as well as to our physical therapists. And I think you're gonna get both of those things through the course. Stay tuned, the next few episodes will be surrounding this awesome ACL topic. If you have questions, comments, concerns about ACL rehab or anything else, DM us, truesportspt on Instagram. My email is I really hope you learned something. I hope you share it. Thanks so much. Bye-bye.


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