The Beyond Pain Podcast

Epsiode 69: Beyond 6 Months: Evidence-Based ACL Rehab Strategies for PTs and Patients with Steph Allen

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Summary

In this episode of the Beyond Pain podcast, hosts Joe Gambino and Joe LaVacca welcome physical therapist Steph Allen, founder of ACL Resolve. They discuss the intricacies of ACL rehabilitation, the importance of specialized care, and the shift towards virtual rehabilitation. 

Steph shares her journey into ACL care, the psychological aspects of recovery, and common pitfalls patients face. The conversation also touches on the significance of measuring outcomes, the role of comparison in recovery, and the importance of endurance testing. 

Listeners gain insights into the rehabilitation process and resources available for those recovering from ACL injuries.

Takeaways

  • Steph Allen has over a decade of experience in physical therapy, focusing on ACL rehabilitation.
  • The insurance model often limits the care patients receive, especially in ACL recovery.
  • Virtual rehabilitation can enhance accountability and patient engagement.
  • Psychological factors, such as fear and confidence, play a crucial role in recovery.
  • Comparison to others can negatively impact a patient's recovery journey.
  • Early stages of rehabilitation focus on reducing swelling and improving quad activation.
  • Monitoring pain and swelling is essential to adjust rehabilitation plans.
  • Return to running should be approached cautiously, with emphasis on strength and symmetry.
  • Endurance testing can provide valuable insights into a patient's readiness for sports.
  • The rehabilitation process is collaborative, requiring communication between therapist and patient.



Joe Gambino (00:43)
Welcome back to the Beyond Pain podcast. am one of your hosts, Joe Gambino, and I am here with our other host, Joe LaVacca You can find us on social media, at joegambino.dpt for myself and at strengthinmotion.com.pt for LaVacca over here. I will skip everything else because we do have a special guest with us here today. We have Steph Allen. She's a physical therapist, the founder of ACL Resolve and the co-founder of Clinical Athletes. Welcome in.

Steph (01:08)
Thank you guys, hope to be here.

Joe Gambino (01:10)
Yeah, that's well. Why don't you take a step onto the stage here and tell our listeners a little bit more about you.

Steph (01:18)
Yeah, so, and we were just talking a little bit about this, but I have been a PT for 11 years now. Pretty crazy to think. Actually had to do some math in my head there for a second. Yeah.

Joe Gambino (01:29)
When you have to think about it for a second, you know, it's been a while

Joe LaVacca (01:32)
north of 10 starts getting a little scary. You're like, wait, really? That makes me an expert, I guess.

Steph (01:34)
I'm well,

I'm allowed to say decade now? That's weird. but yeah, I've been in PC for about that time. would say like, obviously now, you know, so many people associate me with ACL related stuff, which is great. That was like, you know, originally, not really originally the plan, but ironically I didn't, didn't dive super deep into ACL specialty probably until

doing travel PT a couple of years out of school, I would say. and then kind of never looked back, but was doing travel PT and recognized didn't seem to matter where I went. Different States that this particular injury,

lack of better terms wasn't really well cared for, especially in the insurance model. And I wanted something different. So I landed at a of a forward thinking, privately owned sports clinic in Boston in 2017. And that's really where I kind of like honed, you know, anything I read, any continuing it I did, you know, most of my...

patient caseload became by the time I was done in the clinic, probably 90 to 95%, some sort of knee injury, not necessarily ACL, which was a lot for working full-time, but I learned a ton in that time and it kind of like afforded me the confidence and mental place to be to actually start something like ACL Resolve, which is what I thought would kind of allow me to give the patients and clients what

I didn't feel like I could fully give in the clinic.

Joe LaVacca (03:10)
Was there something specific about the ACL rehab frustration or anything else? Because I'm sure you saw lots of interesting things in your travel, but what stuck out to you about that ACL that you were like, hey, I need to dive into this because people need help here.

Steph (03:25)
Yeah, it seems to be that people would get to a, and by people, I should maybe clarify that more like the most glaring examples of it to me were the adolescents between, you know, early and mid twenties, maybe even late twenties, super active people who were basically like insurance was cutting them off after like three or four months, which

Again, like there's even more research now, but even at that time, you know, again, 10 ish years ago, it was still thought that like, it might be realistic between six and nine months, which again, debatable now, but they saw what we have, but either way, even knowing that it just, didn't match up to me. was like, if, research is telling us this and like, clearly this person at six months, especially depending on what they had early phase in terms of care is, is not ready, then what's the, you know, so

Again, I looked at that, what I was seeing in the clinic. And most of these in travel PT was hospital-based outpatient where pretty high volume. The clinics themselves were almost never really well equipped in terms of bringing people. And by that, mean space, weight, testing, pretty much never really was a thing there. So that was another little hurdle, but.

you know, seeing this in the clinic and then also realizing that, you know, I'm learning the different insurances and how they work. And I'm like, something like it just doesn't make sense. There's nobody ready at six months. You know what I mean? So there was that. And then I think just also seeing the some of the nonchalance maybe like, I don't know that's a word nonchalance, but like, yeah, like

Joe LaVacca (05:10)
We'll take it. We're very, we're very

lax here on the podcast stuff. You can make up words whenever you feel like it.

Steph (05:15)
Yeah, but even like other colleagues in places like that where, you know, the early phases, which again, I'm sure we'll talk about this simple, but not easy. Again, sort of like going through the motions, everybody did the same exact thing, even if they were having trouble with, you know, quad activation or things. Again, at that time, I wasn't even really well versed on, but I knew something was up. So there was just a lot of things that didn't fit. And I was like, I feel like there's got to be a better way here.

And so then I just started digging and like finding mentors and stuff.

Joe Gambino (05:45)
So I was gonna ask, you just mentioned when you started, you were like, oh, I'm not too sure, you know, I'm seeing these things with ACLs, but you know, I knew something was up, I'm not like 100 % and you went and you did the research and you know, now that you're an expert in that area, how would you look at that as like, or what would you say is the benefit of looking for someone like yourself who's spent some time?

doing all the research and kind of specializing here versus going to your traditional pre-tip the block. When or even really when should someone decide between the two?

Steph (06:17)
And are you talking about like for care or like mentorship?

Joe Gambino (06:22)
for care.

Steph (06:23)
gotcha, yeah. It's so interesting because I know so many really good PTs who know their stuff in the insurance-based system that depending on where they are, sometimes they literally are kind of handcuffed with what they can actually do. And so I would rather them be seeing those people than nobody if someone like me is not an option because currently I'm not through insurance, which I totally understand.

We try to make things as kind of budgetable and affordable as possible. but it is one of those things that you have to ask yourself where if what you're trying to get back to is either like super high level organized sport all the way up to, know, we've worked with like semi pro or those types of situations where what you have available to you close to you is maybe not necessarily because

I've talked to a lot of people who go to whoever takes their insurance and there may be a little bit more on the active side who are getting to a higher level. And it takes them maybe two visits to figure out like, I don't know if I'm gonna be really challenged here. And they don't necessarily know how to describe it, but I know exactly what they're saying, like what they're talking about. And so if you are starting to feel those things,

you know, if you get to even that point, like some people know ahead of time, they do research and they're like, I'm not gonna go to the place near me. I know what it is. I went for my shoulder and most of the people are 30 years older than me. I'm doing similar exercises to them. Again, these are kind of like quintessential things I hear. It's not always the case, but a lot of times it is. some people know ahead of time, but other times I would say like, if you're starting to get that feeling like you're leaving PT after the very early phases of maybe surgery or injury and you're like,

feeling like you need to go work out or feeling like you need to do more or you've been doing the same things for several weeks without much change, especially in the early phase, I would like to your point, look down the street or try to do a little bit of research.

Joe LaVacca (08:21)
I know you mentioned Steph too that you're mostly or kind of all virtual right now with your ACL resolve, right? Have you noticed any differences in outcomes? Because you were doing in person PT for so long and now going all virtual. I'm sure you've gotten, you know, maybe some hesitation from folks like like me and Joe do. I don't think I could do the virtual thing. I really need you to see me. So have you noticed any differences?

And if so, what are those differences? And how do you approach that when people are kind of pushing back on you? Like, I don't know if this virtual thing can really fit what I want.

Steph (08:58)
Yeah, it's it's a conversation. Again, it's interesting to you because like, because there's so much information out there and the longer you do it, you have like, social proof of people who have done this before and things like that. I've even had former clients get in touch with a prospective client who's a little unsure.

I've had clients in the past that were unsure and then did really well. So I'm like, great, talk to this person if you would like, but I can't make that decision for you. I totally understand. And there is a subset of the population that like, honestly, I would say probably aren't the best for a virtual, like I'm not saying it's for everybody. What I have noticed though, to your point is something I didn't expect to at first. The level of accountability that I'm able to have with people virtually is so different.

than in the clinic, because what I was doing just to kind of give people context is they would maybe come see me twice a week if they were able to, if insurance, because again, with ACL stuff, we were usually trying to spread out their visits, right? So great. One option is to come once a week, once every other week, you know, as you get later on, maybe it's once a month. But then I'm writing full, full ass programs for people between their sessions, because I know that they're going to need to do more than that, what they're doing with me.

Joe LaVacca (10:07)
Ha ha ha.

Alright.

Steph (10:14)
In the clinic and in that model, it's like, okay, that's fine. But A, there's no, like, I'm doing this on top of my notes and progress notes and all those kinds of things. You're not getting paid for it. So the burnout pretty quick. If most of your caseload is that, which fine was. And the second of all, like, I don't know if they're actually doing it. Like I can, I can venture to guess when we go to test, right? Like it's really hard. The majority of who I was seeing in clinic were either high school kids, maybe some college kids that were home for summer. like,

Joe LaVacca (10:40)
Yeah.

Steph (10:43)
saw them for two or three months consistently and then I would have to kind of like hope that they would continue stuff when they left or busy working parents. And like all of the above is kind of a crap shoot in terms of like what they're doing in that time outside of in clinic time and for an ACL injury. You need to be doing so much more than that. And so what I didn't again realize is like I was already kind of doing the virtual thing without

really doing it. And then when people had the explicit, you know, we had the expectations conversation in the beginning of working with me where like, this is kind of how it works in terms of frequency. If you're early post-op, you're going to have something in there every day, like to check off and to do. and part of it is like part of my job is if you miss a day or two, or there's some issues and you don't communicate, I'm going to check in with you because, you know, and now like people are paying for it too. So it's like a

directly instead of like through their insurance. So I found compliance to be incredibly improved. And then therefore, obviously, the trickle down effects of those things are when we do testing every ideally eight to 12 weeks, depending on what they have access to virtually, which I usually help them figure that out. You know, then there is kind of steady progress every time we do that instead of, you know, sometimes it was

there would be people I would test in the clinic where I'm like, you I don't know what they've been doing outside of here. I don't really know what this is gonna go like. So yeah, I would have to look back. We track everybody's strength and psychological outcome data. And I have three, four years of that now. So I bet I could look at that and kind of, I shouldn't do that. Look at that and kind of see the trends, but it's been really...

Joe Gambino (12:24)
Hahaha.

Joe LaVacca (12:24)
Hehehehehe

Steph (12:29)
like pleasantly surprising in that way.

Joe Gambino (12:31)
I resonate with that sentiment because I feel like outcomes are just the same as when I'm in person as well. And I think having this kind of environment really allows you to spend more time with them, way more touch points, way more connection points. And Joe brought something up on another episode that we did a while back, which was interesting for me. know, when you're virtually and you're doing this through the screen, you're not in a clinic, there's no music.

there's a lot less distractions and you're kind of just really just one-on-one just you guys. And I think that was a pretty interesting point that I didn't think of before that's kind of unique to this environment.

So I'll pat you on the back,

Joe LaVacca (13:06)
thanks, man. I appreciate that. Well, I think,

Steph, you know, what I found surprising when I started doing more and more virtual stuff was it wasn't actually really an age thing for me. Now, granted, you know, I wasn't as hyper focused into one area is like ACL recovery. So for me, I was always worried, the older the patient is, the less technologically gifted they are going to be. And then I didn't find that to be the case, but there was one word that you brought up.

which really resonates. And I think it's the people who want accountability. And that was a question I started asking was, what do you want out of this process? And people would be like, to get stronger. Okay, well, you don't really need me to get stronger. I mean, you could just go to the gym and keep showing up. What's deeper than that? And they're like, yeah, I'm just not gonna do it if I don't have someone watching me. So that was great. And I realized that really the more people want to be checked in on and cared for, the better they do with us.

Steph (13:44)
Yeah.

Joe LaVacca (14:00)
One other thing you brought up is that I found it interesting and I didn't realize this from the website or the stuff that I've been seeing, but like you keep track of the psychological variables throughout the recovery process. And Joe and I have talked about the identity of injury before for kids. I probably realized this is much more acute because some of them probably have aspirations of college or maybe even, you know, professional ball in some cases in different sports. So

You know, big picture stuff when it comes to ACL, I think a lot of people maybe listening or going through it, you you're pushing, hey, quad strength, quad symmetry, know, limb symmetry indexes in different, you know, hop testing, I'm sure, and range of motion and swelling. But have you found any correlate data where if you people aren't hitting those goals exactly.

this fear avoidance or kinesiophobia is maybe a bigger impact in their long-term recovery or is it really, really hit the biology stuff first?

Steph (15:00)
Yeah, I would say like, we do, we do both, obviously. But there's no way around it. Like if, if people are to your point, maybe not, maybe they're like, technically slightly behind, which is one of my like, least favorite words in this rehab. But, but there are certain indications where like, you know, maybe they are not necessarily exactly where we'd

Joe Gambino (15:17)
Mm-hmm.

Steph (15:24)
expect them to be based on their graft that was used, if they had an injury before, know, how their, if we have this information, like how their swelling range of motion and quad activation was before surgery, like a lot of things go into that. So I do my best in terms of like that initial conversation with people of what they can expect or if somebody seems very

when can I do this, when can I do that, like very timeline focused, then I may be a little bit more explicit with this, but it is like the physical stuff we can't ignore, that is really the priority and I'll tell people early on, like these are your main jobs, it's like get it as straight as possible, get your swelling down, we get the, like they're, you know, it's very hyper-focused, but I will say, and don't know if this fully answers your question, I will say there is a subset of the population where,

Joe LaVacca (16:04)
Yeah.

Steph (16:19)
I kind of can get an idea just initially getting to know them and maybe their level of anxiety or lack of confidence to your point fear avoidance. Like when you talk to that person who injured themselves two or three weeks ago and they have done nothing because they are really fearful of anything hurting means that they're going to do something worse. And I know in situations like those that it probably is going to be a little bit of a slower climb.

and so those are people that I'm probably paying even closer attention to. You know, I use the ACLRSI, that it's a 12 question, 12 question questionnaire that is validated for ACL rehab, but it asks more of those questions of how fearful are you? How confident are you in, you know, how frustrated are you by like, those questions open a lot of doors in terms of conversation.

But the TLDR is, yeah, in the beginning there does have to be kind of a little bit of that push towards, we need these physical things done. And again, I'm not giving them ultimatums, but this is really what we wanna focus on. If there's anything straying from that or we're having a lot of trouble in a certain area, in our medium virtually, you need to let me know. And they also early on are sending me, I show them how to do sweep tests and swelling things and.

Joe LaVacca (17:37)
Yeah.

Steph (17:38)
Lastly, I almost always would like them to have an in-person PT also in the beginning, even if it's just once a week for like those sorts of things, birth measurements, range of motion, manual therapy that I can't do that honestly is probably helpful in the beginning, but not necessary. So yeah, I don't know if that actually fully answers your question.

Joe LaVacca (17:56)
No, I think it does and maybe I can even do a better job at giving a different example. And I know my, again, my experience is not as extensive as yours, but typically when I was more inpatient or not sort of hyper-focused on the persistent pain community as I am now, what my bias was, and I'd love your take on this, was yes, the biology stuff is really important.

Right? Like I do want you to get as straight as possible. I want you to get as strong as possible. So there's there's minimum expectations there. You know, I'm not going to give you the go ahead if you're lacking, you know, five degrees of extension and your quad strength is 50 % of the other side. But there were so many different parameters, I think probably when we were all coming up at a school, it was like 80 % no swelling, right? Full range of motion, right? And and I feel like those things maybe have been challenged a little bit more. But my bias was

And I told this to athletes and again, maybe I was wrong, but I told them, said, I'd rather you be, you know, at 80 % confident you're going to go back to your sport and do well. Right. So no kinesophobia, no fear avoidance, then be at 90 % with the full range of motion and still be worried taking the field. And, you know, for me, it always came down to the behavior then on the field. If I was a little bit weaker.

but I was confident. Well, maybe I just fall down and get up. But if I was strong and playing stiff and apprehensive, well, maybe I'm at a bigger risk for re-injury. Do you ever weigh anything like that? Should I stop telling people that sentiment? That's basically what I really need to know.

Steph (19:33)
No, I don't, mean, again, there's truth in that in terms of, I do tell people if you are hesitant, if you're nervous, if you're not confident in any certain way, you're gonna move differently. You're gonna move cautiously, even if it's subconscious. And that's not something we want in the column of.

injury risk mitigation. Like we don't want that. I want you to move like fluidly. want to essentially in somebody's ramp up to sport phase, if they're lucky enough to have it be with someone like me or have that be overseen. Because a lot of times it is just like, okay, you've passed these tests, you can gradually ramp up. So what does that mean? The coach doesn't know that, the kid doesn't know that, or individual, whatever. Even if it's like rec sports when you're older, nobody...

Joe LaVacca (19:58)
Yeah.

Steph (20:24)
Nobody ramps up to that. They work all during the week and then they go once one weeknight a week and they go ham. yeah, that piece is huge. But what I would say too is that if you are being challenged the way that you're supposed to be, there's very few people that are still.

lacking in confidence significantly because they have been exposed to You know on field on court, whatever it is. They've been exposed to You know minute restrictions and then you know, no contact and then contact and like it's very It's very calculative if that makes sense where again as it should be like that's what a ramp up should be in that case

you should be stepping on the field to your point, like having already been exposed to stuff that you're sure that you can withstand. You should have already fallen and realized, I can fall and I'm not gonna retire my ACL. ⁓ So it is tough. Like I would say it's that annoying answer of it depends slash it's both. Because yeah, technically there's also pretty robust.

Joe LaVacca (21:19)
Right, right.

Yeah.

Steph (21:32)
literature that if your quad is not strong enough, you're at pretty high risk. Even if it isn't for a re-injury of the same injury, you're at risk for something else because you'll compensate and some other tissues are going to take the brunt of it and then you have a groin or hamstring strain. So yeah, my answer is both.

Joe LaVacca (21:49)
Well, no,

I yeah, no, I appreciate that. And that's a perfectly fine answer ⁓ from from an education standpoint, for sure. And I think just listening to your input on that, it made me self reflect on the questions I would follow up with typically was what haven't we done that would restore your confidence? Right? Like what is still that hesitation? What can we do to prove it to you that you are ready? So I think that that's a good sort of like self reflection point for people who are out there. Yeah.

Joe Gambino (21:53)
Ha

Steph (22:06)
Mm. Mm-hmm.

I ask people that still all the time, even when

I'm the one putting together the calculated ramp up, because there are still people that are like, you know, there's one or two things on the ACLR site, or they literally tell me like, you know, yeah, this one still just feels a little like, I don't feel like I can kind of really go into that decel and change of direction at the same speed. okay, then, you know, let's dig into that a little bit more. Or it's like, they'll rate.

couple of things that are saying the same on the ACLRSI. And I'm like, can you tell me more about that? Like what would make you closer to that 100? Because the higher the score on ACLRSI is better. So I'm still asking that all the time. Because sometimes people won't, they get into the motions of it. They're invested in rehab, which is great. But then even with something like the questionnaires, they won't really address it. They won't ask themselves, to your point, like the deeper question of like, well,

Okay, I understand I'm not confident here, but like why? Because we've been doing this shit for the last two or three months. What is it about it that you feel like? And sometimes it's that they haven't had contact yet. Like, okay, let's figure out a way to ⁓ do that in a controlled way first.

Joe LaVacca (23:14)
Yeah.

Yeah, I get you.

Joe Gambino (23:26)
I like that because I think people also have a really good sense of their bodies and when you ask those questions sometimes your mind, right? Like this is the natural progression. You're gonna get some stuff that popped up that you may not have known otherwise. Why do you want to switch? It's not really completely a switch but you know when you're getting into any surgery, you know, I think mindset is a big deal. So are there any pitfalls that you think know ACLers kind of fall into that can negatively impact?

their care or their journey.

Steph (23:59)
and you're talking still like mentally? I would say the biggest one I see the most is comparison.

It's a pretty, ironically this injury is studied so much and yet there's still so much that we don't really know, especially with new procedures, repairs versus reconstruction, different graft types, long-term follow-up on the graft types. And it is common enough that a lot of times they either know somebody or have even had a different injury themselves and it's really hard to not.

compare, even if all they're comparing themselves to is what the surgeon protocol says. Which is tough because I'm like, glad that they have them for guidelines and especially for maybe somebody who hasn't worked a lot with the injury. But it is very, I mean, you guys have looked at protocols, ACL isn't the only situation where you look at it you're like, okay, they're not allowed to do.

knee extensions for six weeks, but they can squat and then they can run at 12 weeks. ⁓ It doesn't add up. So yeah, that's a different conversation. But yeah, I would say that like both comparison to others, comparison to expectations that they had going into surgery, which hopefully I try to intercept and change a little bit if we can, or comparison to past self. The three of those really.

Joe Gambino (25:03)
You

Joe LaVacca (25:04)
Yeah.

Steph (25:23)
swirl and can cause some not great things mentally.

Joe Gambino (25:28)
Yeah, I like that. And I have two examples in my mind that I've seen, especially as I was a younger physical therapist that really kind of hit home. it's they're both patients that had the same surgery on both sides of their body at different times of their life. And the first one went really, really well. So they had the exact same expectation going into the second surgery. One was a meniscus and one was a bunion surgery. And both of them were drastically harder recoveries the second time around. And they were just so distraught by that.

Joe LaVacca (25:46)
Yeah.

Joe Gambino (25:57)
concept because their expectations were completely different. And so I use those stories to try to educate people when they're going through any type of surgeries because it's really important for someone to know if they're trying to compare themselves to a friend or somebody else, every surgery is going to be different and your outcomes are going to be different and it's okay if you're a little behind or a little ahead or you're right on track with some of these benchmarks and I use the protocols to kind of educate and say, this is somewhat what you can expect along the journey. So I think that's a really

Important concept to get across so listeners take that home with you. It is very hard

Steph (26:29)
It's hard. I'm not saying it's

easy thing, but it is.

Joe LaVacca (26:33)
Yeah. I'd actually

like to know your thoughts on that, Steph, especially if you've seen like right and left sort of injuries, which I'm sure a lot of your athletes have had. And to Joe's point that I think that's a common thing. Like the second surgery typically is not as good as the first. Is that a pattern you found? Cause I always think that kind of falls into like Louie Giffords, like vulnerable organism model, you know, like something changes in the state of the organism.

Steph (26:41)
Mm-hmm.

Joe LaVacca (26:58)
even though you build up resilience, you know, maybe the capacity to handle something like that again from an ecosystem level. Is that something that you've found? Like the second one doesn't go as smoothly or lags behind a bit?

Steph (27:11)
Yes, I would say the times that it is less so or there's less of a chance of that happening is when they happen, unfortunately, like close together. ⁓ Because some of the reasons why I think it does happen are a little bit more to what you were talking about when you mentioned Louis. It's like enough time has passed from the first one that they forget how effing hard it is. And so they're like flabbergasted. If enough time has gone by, they may be slightly older. I'm not.

Joe LaVacca (27:21)
Yeah.

Steph (27:38)
trying to be a doctor here, but like it's different. It's different. I have very little recollection of my initial rehab when I was 17. I just remember going to the place and letting them, letting them, letting me choose the channel when I was doing ice and stim. Like that's really, I don't really remember. So there's those, there's those factors as well. And I think the bigger, in my opinion, again, I haven't, this is not from a study, but

Joe LaVacca (27:38)
Right. No, it's biology. Yeah.

Steph (28:08)
the, I have to do this again, is like, so it's gonna make things like finding joy in the process, getting excited and motivated, you know, continuing to show up. It's just gonna make those things so much harder. And then if you do those even slightly less, then obviously some of the physical changes are gonna take a little bit longer because you don't have the same drive during it. And I can't blame anybody for that because I don't know that I would be any different if it happened to me twice.

Joe Gambino (28:35)
Hmm.

Joe LaVacca (28:35)
Yeah,

I completely agree with you.

Joe Gambino (28:36)
So let's, I'm really curious about just kind of talking a little bit more about what ACL rehab kind of looks like. So I want to start early stage and you what could somebody, you know, what should they be looking for? How, know, you mentioned before it should be challenging. You shouldn't feel like you can go do like another workout afterwards. So how hard should it be? What can they expect? are the goals? And I'm really curious to know how you're measuring things virtually versus what they would see in clinic and how those things kind of align.

Steph (29:04)
Yeah. Yeah. So if we're going from like the, I'll give the base example of, you know, isolated ACL, meaning you didn't have a meniscus surgery as well. You can touch a little bit on that, but they didn't do anything to anything else besides your, besides your ACL, no MCL, no meniscus. And they used one of the usual, I will say, graphs like hamstring quad or patellar.

The, and you don't have weight bearing restrictions. That would be the other thing. Your main job in the first really 30 days, but you can start to do more after like the first week in terms of like working out as long as you're feeling okay. That knee needs to be straight. And what I tell people is we need to define what straight means because so many times I've

worked with people three, six plus months out who are coming to me after like an initial phase with someone and they'll say, yeah, I have full range of motion. And then we look at it and they can barely get to neutral on the surgery side and the other side has like 10 to 15 degrees of hyperextension. But again, their expectation and they're told is they just need to get it straight. So we talk specifically about that and what it's gonna take to get there. And usually it's, don't be in your brace all the time.

Joe LaVacca (29:59)
Right.

Steph (30:19)
take it off when you're laying down, heel prop yourself so that there's like space underneath the knee. It needs to be able to sink into extension. Obviously you can't do that all day. It won't feel good. We'll talk about those on off times. The other one is getting swelling down as quickly as possible. We talk about why as well. Swelling will inhibit your quads. The longer your quads are inhibited, the more muddy water we get into. that is...

And so the other thing that I'll oftentimes having, I'm having people do early as well, cause the third big one is quad activation or maybe essentially waking them up. And I explain your brain essentially is turning the dial down on all the juice two quads on purpose. It's protective because it knows that there was just a trauma to your joint. So we're working against that a little bit. And so right now there's a, there's

There's one left that's not crazy expensive, but like a portable stim machine that isn't like the Chattanooga or some of the bigger name ones that are probably like three or $400. Cause I understand they're investing in working with me and I can't say, oh, you have to get all this equipment for yourself at home. So there's one that's like 60 bucks that has enough technically milliamps or, you power, you will, to, especially in the early phases actually be getting a pretty strong, to use NME-S and get a really strong.

Joe LaVacca (31:19)
See

you

Steph (31:38)
e-stim or quad contraction. So that's on their, you know, that's the third quad contraction. They've got homework for that. And then if they are, weight bearing is tolerated. This has definitely shifted a little bit for me in the last probably two to three or maybe five years. I want swelling down so much more than I want them walking a bunch. So.

We don't have anything specific in terms of gait training in the first few days, but after that it will likely be with at least one crutch for monitoring swelling. And it's not usually like taking laps. It's like, I'll call them like up and overs, like you step up and over with being able to actually bend your knee, come back. and basically like some of the components of walking without putting a ton of weight on it. because that will kind of prolong.

the swelling a little bit too. So I really like to see that come down before we turn the dial up on more walking stuff. Cause that is another thing that's hard when it's so stiff, you can't walk normally and then you learn to walk. There's like pretty clear research that people are distributing weight differently and using different muscles at different times differently in the gait cycle after this injury. And some of that might even persist even if we do everything right. So,

I'm not effing around too, too much with that. And like the first few days to first week, it's probably a little after that. How I look at things virtually. So like I said, I mentioned before, I teach them early sweep test for swelling. So sweeping up on the inside, pushing down on the outside. If anything pushes back over, that's a positive test. Or if the swelling just stays there, like in the beginning it's going to. So if they are also, it's rare that they're not. So usually,

Joe LaVacca (33:07)
Right.

Steph (33:12)
They also have an in-person PT, even if it's just once a week, to kind of help with some of these measurements. So I can't say that I'm doing like all of it, but I do have filmed videos and we can do an extra Zoom call if we need to in terms of explaining what exactly we're doing to monitor things like swelling. So they also have instructions on how to do girth measurements for knee joint line, calf, and mid-thigh. But usually the PT, in-person PT's are doing that and I'm just getting that information from them.

Oftentimes teaching them self patellar mobs, especially if they had a patellar or a quad graft. It's definitely something that I feel like early in my career, I slept on a little bit and definitely can make a difference, especially for reflection with people. So we're doing those things. And then the strength really is the first real test, if you will, because other than that, we're basically monitoring symptoms. And I'm taking a look at

Joe LaVacca (33:51)
Hmm.

Steph (34:04)
what their quad contraction looks like, both with the stim on, like POV with your phone, show me what it looks like, and without, because there are some indications by looking at it if there is still maybe some inhibition going on. So those are kind of like the early KPIs, if you will, not super fancy, but very just we frequently look at those. And then,

I would love to, again, if they didn't have meniscus or any other issues, no hiccups, I would love to get testing somewhere between, usually by weeks 10 to 12. I say that because technically you could do it sometime between six and eight weeks safely, especially if it's 60 to 90 degrees of flexion, but they're often just not tolerating a max effort.

the extension at that point, I to have been doing some knee extensions and ISOs for like a good number of weeks first. And in that phase, I'm having them test at week six to eight and it flares them up. Like, that's not really how I want to start. And it doesn't happen to everybody. Like there's those, people who just like, they're like, yeah, nothing really hurts, you know, it's, but that's, that's rare. so that's when we'll kind of start the more, the more formal testing.

Joe LaVacca (34:54)
Right.

Sure, sure.

Is there any, you mentioned how you monitor pain and you want to control the swelling. And obviously the kind of swelling idea is such an objective thing that we all can look at, your clients can look at, right? And whereas pain, like especially for your athletes, I'm sure they're like, no, no, you know, I'm okay, I'm okay. It doesn't hurt that bad. You know, I can tolerate a lot, right? Yeah, yeah, some of them I should, yeah, some of them, correct. When you're progressing through this rehab, as you're kind of talking about things that kind of keep moving.

Steph (35:35)
Come around.

Joe LaVacca (35:44)
forward, are there ever signs maybe like this swelling where you're like, Hey, this is a sign we're doing too much. That's a little bit more objective than say, you know, just a pain scale. And do you like really kind of get a little bit of leeway with swelling or you're really strict if swelling comes back? Because I know the sweep test, like you mentioned, there's different grades of it. So how do you approach that if you know your athlete or maybe is doing too much in their sessions?

Steph (36:10)
Yeah, that's actually why I started, that's why I filmed and like, am equipping everyone with the sweep test skill because I am pretty strict with it, but I don't, I would say I am strict with spelling, but I don't freak out if it comes up. So like, let's say we get it down within the first eight weeks.

which is great, but there's still a lot of people that have a little bit of lingering around that time. And again, I don't freak out as long as their quad contraction is good and they're getting like active heel pop on a, you exactly. if, but yes, if that, if it does come back, ha and that's part of the expectation setting too of like, once we get it down, if it

If it comes back, even if it's just like a little bit, you just see a little pocket, it doesn't mean that the joint is reacting in some way. It doesn't mean that I'm going to shut everything down for a week, but we are going to monitor it. I may have you do a little bit more of like elevation, like legs up on the wall midday or an end of day or, you know, compression sleeve for whatever. Occasionally, if it's cranky enough and seems to be a little persistent, we'll try like.

Ibuprofen for a week or something like that. But it, I'm strict in that sense, but it also is something that again, like there's a major surgery to the joint. Some people, this isn't their first surgery. So if when we start to get into some plyos and running, it gives us a little kickback. like, you know, yeah, I might scale back a little bit and we're definitely not gonna progress until this is resolved, but it might also.

the way I explain it to people too, is it may also need an adjustment period to these loads. So we're not gonna increase the frequency if anything, we may pull back a little bit, but I don't wanna bring it to zero unless it's really kind of like continuing to get cranky or be persistent past like a couple of weeks because I wanna allow it to like, when we're progressing to these different phases, it's not just necessarily gonna do nothing, especially after a surgery, so.

Joe LaVacca (38:10)
Thank you for that. And I really appreciate you mentioned the ibuprofen too, because that's the other thing I wanted to ask you about. Like working with a lot of people with these recurrent swelling things, they're just so adamant. I don't want to take anything. You know, I don't want to put this in and I'm like, well, we have signs of inflammation or joint reaction. This can, right, this can help for like you said, seven or 10 days and then we'll come off it. I promise. But as long as you don't have any like liver or kidney or stomach issues like

Joe Gambino (38:21)
Mm-hmm.

Mm-hmm.

Joe LaVacca (38:37)
This is 2025, we can use medicine with your rehab to help us with outcomes. I do think I really appreciate that you said that.

Steph (38:46)
Yep. Have somebody doing it right now.

Joe LaVacca (38:49)
Okay.

Joe Gambino (38:49)
So what about, let's shift here to maybe later stage. Same thing, I'm curious about like return to testing, know, what do you look for specifically, especially in a virtual environment? And then I'm also curious while we're talking about that running, I've seen a lot of different things very early, much later. So when are you looking at, you know, getting back into running that initial process and what kind of things are you looking for to clear them?

Steph (39:06)
.

Yeah, with running again, something that's probably shifted a little bit for me over the years is, because I still agree it's a huge milestone, whether or not you are a runner. But if you are not a runner and it's not like the highest priority thing for you, I would rather wait. And by that, mean, you know, a lot of protocols will say week 12 for, you know, uncomplicated, no concomitant.

procedures or surgeries done. I found, again, unless it's, we're talking about somebody who had like a super high level of strength and force producing capabilities prior to surgery, elite level people, very few people are like just super ready to go at like week 10 to 12. More so from a symmetry perspective. So there's some people that actually from a, like a torque to body weight.

ratio perspective, which we can talk about in the return to sport testing too, but in terms of how we're measuring, are they strong enough for their body weight? They might be close at around that time if they're doing really, really well. But a lot of times the other leg is just far enough ahead that something like running just looks and feels a little wonky because they're so different. And so I would rather, even if it isn't painful,

So unless it's something like super high priority for them, I really like between like 16 to 18 or even 20 weeks for some people, because they're gonna be doing conditioning if you're doing the rehab well anyway, they're going to have been doing some form of conditioning regularly anyway. But from that, I feel like the joint, the transition for the joint tends to be a little bit better. And just the.

the pattern itself is a little bit more natural if we can wait. But technically, if it's super important for them and or their sport and their numbers are decent, they've been doing plyos for two to four weeks, like level one or lower level, whatever you want to call it, they've been exposed to some sort of repetitive impact prior to running. That's one other non-negotiable I have. If those things are feeling good at week 12, then like,

Sure, we can try it because the worst case scenario is like, you're not gonna tear your ACL doing that. So the worst case scenario is that like, they do it and they're like, they do a few rounds, like, this does not, this does not feel right. Or it's painful and the pain doesn't go away as they do a couple of intervals, like 30 second intervals, then okay, pull back for another two to four weeks and try again. In terms of the strength.

Joe LaVacca (41:29)
Yeah.

Steph (41:41)
numbers that we want to see in this for running, I have seen so many different things. So I do think this particular one is probably, like I can give you what I would like to see, but I can also tell you that I've seen people with those numbers that it looks and feels crappy and people who don't hit those numbers, who they really want to try it. And I let them and it's important to them for their sport and they do it and it looks and it feels great. And I'm like, well, you know, as long as we're monitoring swelling and it's not.

pissing it off, like I'm not gonna tell you not to do it. We just monitor volume. So in terms of those strength numbers, ideally from a symmetry perspective, I do feel like I have wiggle room with the symmetry. So if it's above 70%, meaning surgery side quad, as a percentage of non-surgery side or uninjured. But I will say that I do think, again, the people that more often do well with that initiation of running are probably between 75 and 80.

Joe LaVacca (42:35)
Mm-hmm.

Steph (42:35)
There's papers, research out there that will like, you know, very hardly has to be above 80%.

I don't know, maybe it's because I've been doing it for a while and I always want to read those things, but there's also like, if we're going back to the mental piece too, like this is all this person wants to do and this is going to be a huge win for them and I think it might actually go okay, like there's not anything indicating to me that it's going to be a complete disaster, then I'm going to them try it because if it's super low volume, they're only doing it once a week, it's not pissing off the knee and they know now that they're running, I don't know, it's, I don't know.

Joe LaVacca (42:42)
Yeah.

Steph (43:07)
That's maybe to your point before Joe, that's one area I have some wiggle room on. And then in terms of torque to body weight, if it's being done isometrically, and I'm looking at Newton meters per kilogram, I know that might sound weird to some people, but I would love them to be for quads as close to two Newton meters per kilogram, but honestly, people are...

Because there's also norm studies that they've done where people are just uninjured people are walking around at like 1.5, 1.7. again, not that we don't create a bar for somebody, but if somebody is doing well and they're checking all the other boxes and they're at like 1.8 and their symmetry is good, we can probably try it if they want to. Does that part make sense?

Joe LaVacca (43:54)
Yeah, for sure. And I think the thing that you're pointing out with all the testing is that the return to sports stuff that I've read is across all sports. you're recruiting people for your ACL study. But like you said, someone might just want to get back to running. Someone might need to get back to football. Someone might need get back to hockey.

Steph (44:04)
Yeah.

Joe LaVacca (44:14)
And it's like, well, all of those things probably have more or less different demands. So then when you put all these people into, you know, this umbrella, well then yeah, then this like cutoff comes up for like 80%. And, know, I have a meniscal, actually meniscal transplant, transplant patient right now. And he's about 16 weeks out. He's cruising. And, you know, we do this little torque to body weight ratio and limb symmetry thing. And he's at like 77%. And I was like,

I was like, hey man, you're doing awesome. was like, if you want to start running, I'm cool with it. And your swelling is minimal, your back across fit. And he's like, yeah, the doc just told me to wait till this time. And I was like, all right, that's cool. But I think what I loved hearing from your story there and your perspective was the collaborative approach. Like, hey, yeah, I'm probably going to caution you against running if you're at 40 % or if you're at 0.3. But ultimately,

the rehab process is a two way street. Like we give information, we give guidance, and then it's up to our clients to enact that. So I really enjoyed hearing that. With all the testing and stuff, and this maybe could be from like your own data, and if you have like a big research study going and you don't want to talk about it, I'm totally cool with that, or you design something, but has there been anything that you found surprising that you just started?

Steph (45:30)
Yeah.

Joe LaVacca (45:38)
throwing in, whether it's like a deep neck flexor endurance test, you're like, well, you know, I haven't found any literature on this. But what I've seen is people can't control their heads or more at risk or is it a grip strength test or is it something like that that surprised you in these few years of like your focus in this field?

Steph (45:48)
Yes.

That's a good question. Maybe I should throw a wrench in there just to see. ⁓ I will say that the endurance-based tests, meaning, so one of the...

Joe Gambino (45:58)
You

Steph (46:03)
So obviously hop tests have come under a lot of fire in the last several years, which I don't disagree with. I'll still take a look at them more qualitatively. And by hop test, I'm talking about horizontal hop tests, like, you know, triple hop, six meter hop, those types of things. But the repeated single leg hop test, so it's 30 centimeters side to side, it's single leg.

and they're going for 30 seconds and they're counting how many they actually crossed the two 30 centimeter mark with. That's very easy to set up virtually. Whereas like ideally if I had force plates, access to force plates or somebody near them does then especially for people like skiers, like single leg repeated, single leg counter movement jump type of things, you can get better, more granular information there. But even just doing

those more recently, like more consistently with people over the last couple of years versus the entire time I've been doing it virtually is that endurance piece is definitely something I feel like earlier in my career I missed a little bit with some people because they'll look good when we do two or three sets of six to eight or something like that, like single leg, like they'll nail it, which is good. They need to be able to do that.

But when we incite some fatigue, there's definitely another subset that all of that qualitative stuff just goes. And or they start to feel like symptoms or something. So that is definitely if I were to pick one that since doing it more often, I'll actually try to do it with people earlier on and like, again, measure that a little bit longer because, and even in there, the flip side of that is like, okay,

For me, I only like to test things that I know are going to make me program or treat differently. Or, you know, are they giving us information that's actually gonna be like, okay, you know, this is an area where this endurance piece I'm talking about, like I could be better at preparing them for that in the actual programming. So some of the playos, maybe we're doing them for time instead of just doing sets and reps, especially for somebody like ski or volleyball player, things like that.

I get a lot of scares. So that was definitely something that I think was maybe not necessarily surprising, but in a way that was like, OK, yeah, this is something I need to have a little better tabs on and track.

Joe LaVacca (48:23)
Thank you.

Joe Gambino (48:23)
I do want to be mindful of your time steps. So Joe, do you have any other questions or thoughts? And I want to give you some time to talk about where our listeners can learn more from you and find you and all that fun stuff too.

Joe LaVacca (48:36)
Yeah, no, think Steph, this is great. Thank you so much for your knowledge and sharing your perception. There was one thing that we just forgot to ask, though, that we have to ask everybody. And as Steph was intro-ing herself, it just seemed like a really nice segue to just kind of get into the conversation. But I do want to backtrack one thing, if it's OK with you. And Steph, need to know, everyone needs to know, how do you take your coffee?

Joe Gambino (48:39)
Yes.

Steph (49:01)
Oh yes, we did forget about that. saw that on the question. I'm such a like, it depends. Wow. Okay. So it just like infiltrates my whole life apparently. In the morning, like right now in the morning, I'm drinking it black or like sometimes with just a little bit of milk. I do like if I'm getting coffee out, I do like myself an oat milk latte every once in a while.

Joe Gambino (49:09)
You

Joe LaVacca (49:27)
Very nice,

very nice.

Steph (49:28)
⁓ not

a big sweetener thing, although sometimes I get, I get suckered into like the pumpkin spice time of year. However, I always have to do like, if I'm going to do that, because sometimes it does kind of mess with my stomach, the sweeteners, but sometimes I'm like, whatever, it's worth it. but I do, I do need to ask for like half sweet, whatever they, whatever they give. Cause then I feel like sometimes it just starts to taste chemically to me. Maybe it's just a taste bud thing. I don't know. but I am usually, we either do like.

Joe LaVacca (49:36)
Nice.

You

Yeah, okay.

Steph (49:55)
drip or french press here and it's usually like black or with a little bit of milk. I'm pretty simple.

Joe LaVacca (50:01)
Yeah, all right, perfect. Well, you touched on pumpkin spice, which was actually, it was a trap question. I wanted you to go that way. You went that way. So Steph, very happy. Absolutely.

Joe Gambino (50:06)
Hahaha.

Steph (50:08)
Yeah, I have to because I'm from New Jersey too. So like it's a big, but yes, thank you guys.

Joe Gambino (50:12)
You

I do remember a short period of time where Joe was an oatmeal cloth that kind of guy though. It was brief, but it was strong.

Joe LaVacca (50:21)
I that was very brief, very brief. You know, I tried to go I tried to go to

the I tried to go the hipster route because oat milk was the craze. But now every time I go and order coffee, I'm like, can I get a coffee with whole milk? Because now I there's, there's half and half there's whole milk. And then they're like oat milk. I'm like, no whole milk. Yeah, yeah. Yeah. And I feel like I'm it's like Peyton Manning and Peyton Manning. You know, if you ever seen that commercial, I'm always like reminded of that. I was I want to like hold up a sign like you know,

Steph (50:40)
hole and yes that's happened to me too.

Joe Gambino (50:40)
Hahaha

Steph (50:45)
Yeah, yes, yes.

Joe Gambino (50:46)
You

Joe LaVacca (50:50)
whole milk, like with it written out.

Steph (50:51)
Yeah,

oat milk definitely doesn't froth as well. I'll give you that. It doesn't have the same smooth froth.

Joe LaVacca (50:55)
Yes, agreed.

Uh-huh. Uh-huh.

Steph (51:00)
Thank

Joe Gambino (51:01)
All right, Steph, why don't you let our listeners know a little bit more where they can find you and then Jerry Boy can take us home.

Steph (51:07)
Yes, yes. So most kind of often on Instagram, just StephAllen.dpt or ACLresolve. I just, to be honest, don't do as much on that one. And then clinical athlete is also, in terms of social media, that's mostly Zach and Quinn, but know, clinicalathlete.com and aclresolve.com have all those details we're doing.

Some really cool stuff with clinical athlete coming up. So we're pumped to hopefully be able to share a little bit more about that in the next few months. And yeah, pretty, you know, open book. Anything people want to reach out about, I'm here.

Joe LaVacca (51:46)
All right, well.

Joe Gambino (51:46)
and they should definitely

do it if they need it.

Joe LaVacca (51:48)
Absolutely, absolutely. Well, Steph, thank you so much. We love all of our guests. We love you. Joe, we love you. Listeners, we love you. Thank you so much for listening in and don't forget to tune in next week for another episode of the Beyond Pain podcast.