This blog post refers directly to ACL injuries but is also applicable to Meniscal tears, MCL tears, micro fracture surgeries, and other significant injuries of both the upper and lower extremity.
ACL Injuries
ACL injuries are extremely common in athletics. There are between 100,000 to 200,000 ACL ruptures per year in the United States Alone (Friedberg,2017)! If you're one of the individuals who tears their ACL, thats extremely unfortunate, and I wouldn't wish an injury on anyone. The good news is you can bounce back from an ACL injury and you can perform at a high level in your sport when you return from injury. It is a lengthy process but with time and proper rehabilitation, you have the possibility to be better than you were before!
Choose the Right Physical Therapist (Rehab Coach)
You injure your ACL, you get surgery, you are told which physical therapist to go to, and you rehab your injury. This is the normal process. But not the way it should be. The physical therapist you work with will have a direct impact on how well you recover from your injury and the chances that you will re-injure your knee. The chances of re-injuring your knee was measured as high as 30% in one study (Paterno, AJSM 2014).
When beginning therapy, your physical therapist is now rehab coach. He/she is the one that is going to train you to be ready for the sport/activity you wish to return to! In sports you can pick your strength and conditioning coach. You have the ability to seek out and interact with the coach that's going to help you achieve your goals. Do you have the ability to pick your physical therapist? Yes, you do have the ability to pick the professional you want to rehab with. It's your right as a patient.
Make sure the therapist you choose is the therapist you want to work with. Make sure that your therapist cares as deeply about your recovery as you do as an athlete. You want a therapist who understands your needs along with the rehab process. He/she should understand the sport in which you're striving to get back to and has a strong understanding in strength and conditioning. You're an athlete, you live in the world of athletics, you need more than just being able to function in regular, daily life. Recovering your knee to take the daily stress of life is one thing but recovering your knee to withstand the demands of your sport is another. Your athletic future is worth it! You get one shot at rehabbing your injury and one shot at making a strong return to your sport, make sure you do it right!
Understand the Financial Responsibility (insurance co-pays, your deductible, and out of network physical therapy)
When deciding the physical therapy clinic in which you chose to rehab, its important to understand who's treating you, how much attention you'll get, and what kind of treatments will they be doing. Make sure you're getting the treatment that's going to help you the most...you're paying for it! The rehab process is expensive, make sure you're getting the best treatment for your money.
In most outpatient insurance based clinics you'll be working with a Physical Therapy Assistant and the Physical Therapist will be balancing you with 2-3 other patients at the same timOn top of that, you are paying top dollar for it!The problem is not them. It's the model they work in where their practice is strongly influenced by 3rd party payers and reimbursement rates.e. As an athlete, you are dedicated and determined to return better than you were when you suffered your injury. You show up on time, you do all your exercises, and you're rewarded by entering the PT's patient juggling act while receiving sub par generic treatments from a PTA, They are forced to perform a patient juggling act just to stay in business. They work in a model of Quantity over Quality. They can't provide you optimal care, you don't receive optimal treatment, and the quality of your rehab is greatly decreased. You only have one shot to rehab from your injury, make it count, your money shouldn't be wasted. It's important that you understand your deductible! If your deductible hasn't been reached, you will end up getting a bill a few weeks after you start treatment. That bill could be as high as $200+ per hour, for the subpar treatment that you are receiving! Not all insurance based practices are this way either, but many are. It's how they stay in business. Make sure you understand how you will be treated before committing to your rehab at that location.
It's ok if your physical therapist does not deal directly with insurance companies. The majority of the time, you can be reimbursed by your insurance company for out-of-network physical therapy. Your physical therapist will provide you with whats called a "superbill". This is a form in which you as the patient can send in to your insurance company to gain reimbursement from them. The form will have all the information on it that the insurance company will need. Reimbursement differs depending on your insurance plan and your deductible. It's best to call your insurance company to learn how you can be reimbursed by them directly for your therapy.
Quality of Care
Make sure you are receiving the highest quality of care that you can possibly get. The highest quality of care you can possibly receive is 1-on-1 treatment sessions with a Doctor of Physical Therapy; who understands your sport, understands rehab, and understands strength and conditioning.
You have the option to choose your physical therapist. The Physical Therapist you need is probably not going to be found in the clinic that your doctor sent you to (Once again, there are great PT's in those practices, but many times the model sets them up to provide sub-par treatments.) You need 1-on-1 therapy with a professional who is every bit as invested in your recovery as you are. They are your coach. They will coach you and train you along your rehabilitation journey. This includes the immediate rehab process AND the return to sport phase of your journey. In order for your therapist to do so, they need to understand strength and conditioning. Sure, you can hire an independent strength coach... they however know nothing about rehab, your injury, and have not been tuned in to your rehab process along the way. You need a professional who can serve as your rehab coach AND your strength and conditioning coach.
Does your doctor know your sport? Do they understand what it takes to compete as an athlete? Do they understand that you want to be better than you were before? Do they understand that you refuse to just "stop playing" your sport? Do they know what the demands are of your sport? These are all things to consider.
Does the Therapy Clinic Resemble a Training Facility?
What does the physical therapy clinic look like? You can learn a lot from what the clinic looks like. Does the physical therapy clinic look like a sterile room, with multiple tables, a few pulleys, a cable column, a few bands, a total gym machine, and a few bikes? Or does it look like a training facility with the space and equipment needed to fully return you to your sport. The clinic should have open space, barbells, kettle bells, plyo-boxes, agility ladders, and squat racks. Your "rehab" is more than rehab. It's training for your future and training for your sport.
Does it look like this...
...Or does it look like this...
Does Your Therapist Have Access to Cutting Edge Therapies Which Will Help You Recover Faster and Better?
When choosing your therapist, make sure they have access to advanced and more effective treatment strategies. Specifically, make sure they have access to blood flow restriction therapy. This is known as BFR. With BFR you will recover faster and you will recover better!
What is BFR?
BFR stands for Blood Flow Restriction therapy. It's a process in which blood circulation is occluded through a limb, and then it's asked to work. It may sound scary, but the process is completely safe! With BFR you see improved strength and endurance gains at a lower load, larger muscle growth at lower load, faster tissue healing, and aid in reversing anabolic resistance after injury. Anabolic resistance is when the body limits the amount of muscle growth in the injured limb. This process normally happens following a major knee surgery/injury. Look at the quadricep of someone who injured their leg, it atrophies rapidly and it always seems to stay smaller than the other leg, no matter how hard they train. This is an example of anabolic resistance.
After knee surgery, you are not going to be able to effectively challenge your leg for true muscle hypertrophy (growth). This is due to the surgical site needing to heal. With BFR therapy, however, you are able to create muscle growth which helps you gain your strength back and helps the tissues heal without causing damage to the surgical site. On top of this, the hormonal release when performing BFR actually helps your tissues heal quicker and build strength more quickly.
Video provided by Dr. Michael Belkowski of ProActive Health in Montana. He can be found here (http://www.proactivehealthmt.com)
Your Rehab is More Than Just Rehab, It's Training For Your Sport!
Your rehab process should be considered training for your sport. Rehab should blend physical therapy and strength and conditioning. Your goals should be individualized and targeted at the sport you are wishing to return to. These goals should be known from the start and as your rehab program progresses the rehab should incorporate your athletic goals.
Your strength and stability in your leg do not function alone. First, they need to be addressed in an isolated manner. Your leg is weak, your muscles have atrophied, and your brain cannot control them as sufficiently. You need to train them in isolation, then progress into dynamic whole body sport specific training. In order for this to be effectively done, your therapist needs to understand strength and conditioning principles and your sport. Your goal shouldn't be to "just be as good" as when you were injured, you need to be better than you were before!
At the end of your treatment; your movement dysfunctions should be resolved. You need to show greater strength than you had before and you need to show greater control than you had before. When you step back on that field, there should be no question if you're ready. You need to prove it in therapy and in training, over and over and over before stepping back out into play. When you step on the field again, the only thing you should be thinking about is performing your best, there should be no question about if your knee is ready.
For more information on where you could find the therapist in which you wish to work with, check these sites below
Mobility WOD List: https://www.mobilitywod.com/mwod-list-info/
Clinical Athlete List: www.clinicalathlete.com (Full screen map of clinicians)
OR
Contact me by sending me an email HERE. I will be happy to help you find a therapist who suits your needs.
I would also love to work with you! My office is located in Chapel Hill, NC. I would love to help you along your recovery process and return you stronger than you were when you left!
Dr. Michael Tancini, DPT
Ground to Overhead Physical Therapy
Phone: (919) 960-1351
Address: 201 S Estes Dr, Chapel Hill, NC 27514
Instagram @groundtooverheadpt
Chapel Hill, North Carolina , Physical Therapy, Crossfit, Sports Therapy, Recovery, Rehabilitation , Movement Specialist, Knee pain, Back Pain, Hip pain, Shoulder pain, ACL Recovery Specialist
References:
Friedberg, R. P., MD. (2017, August 4). Anterior cruciate ligament injury. Retrieved September 28, 2017, from http://www.uptodate.com/contents/anterior-cruciate-ligament-injury
Paterno MV, Rauh MJ, Schmitt LC, et al. Incidence of second ACL injuries 2 years after primary ACL reconstruction and return to sport. Am J Sports Med 2014;42(7):1567-1573