E4: Breaking down 2024 ACL testing stats with Dr. Ravi Patel

In this episode of the proactive perspective I’m joined by special guest Dr. Ravi Patel to break down the ACL testing stats for 2024. And before we get into the discussion, everything you hear today or read on the blog is not to be taken as medical advice. If you currently have an injury, please go get evaluated by your physician or physical therapist.

Daniel Bodkin: All right, we're Welcome back to the show, everybody. And today I have a special guest with So with me today, I have Dr. Ravi Patel. Welcome back, Ravi. Yeah,…

Ravi Patel: Hey, Daniel.

Ravi Patel: Good to see you, …

Daniel Bodkin: you too, How's everything going with the new year?

Ravi Patel: it's good. had a little bit of wind down time. We got our little guy now, so it made the holidays super exciting this time around. So, his favorite,…

Ravi Patel: everyone's like, "What's his favorite toy?" And I was like, "It was the wrapping paper. but it was a good time. Yeah. Yeah.

Daniel Bodkin: That doesn't change.

Daniel Bodkin: We buy them cool expensive toys. Mine are six and seven. And they want to play with the box. They get mad when you throw the boxes out for recycling. They want to turn it into something.

Ravi Patel: I will say he loves books, but we've got all these toys that in little gadgets he can play with that are dedicated to his age. And he will crawl around and he'll find everything else. he loves a TV remote. He loves the doors stop little like springs, like Tupperware, you name it. It's like everything outside of a toy is game on for him.

Daniel Bodkin: Yeah, it's a fun exciting time.

Daniel Bodkin: I already missed those ages,…

Ravi Patel: Yeah, it's been fun for sure.

Daniel Bodkin: but by no means do I want to go back and have a third. so today we're going to talk about some of the testing stats of the patients that have come in for testing from other clinics and…

Ravi Patel: It's moving really quick, so we're trying to soak it up for right now. And then we know there's also some exciting times ahead, too.

Daniel Bodkin: I focused it on the 5 to seven month mark for ACL's only. so I haven't included anybody that was nine months or a year out and I also took out anybody that was having any significant setbacks or anything like that.

Daniel Bodkin: and it's a pretty mixed group, So, we have all the way from, I think, 14 years old all the way up to somebody that was in their early 30s. We have different groups of activity levels, whether they're playing a sport or just active adults or really active adults, right? So, it's a pretty mixed group. So, it's pretty much what most clinicians are going to see when they're treating people with s unless they're working with a specific, subset. before we get into it, can you tell everybody a little bit about yourself and the ACL athlete?

Ravi Patel: So, I am a physical therapist and I'm the founder of the ACL athlete. So, we are a hybrid online and in-person company that is focused on working with ACL's across the board. So, whether it's post injury all the way to return to performance, we get to work with people all over the world and here locally in Atlanta. so, I have an awesome team that we get to do this with.  And then we also get to teach other clinicians and coaches about this through a mentorship. So that's where we are in terms of from a company standpoint. And then yeah, I'm based here in Atlanta with my wife and my little guy Asher who's about 10 months old now. So anyways, we're just kind of doing the thing day by day.

Daniel Bodkin: testing that I typically do for most people. I like to use the force plates. I use the VA system currently and I'm doing the counter movement jump bilaterally. And when I'm I'm looking at what percentage of the involved versus uninvolved limb that they're choosing to use when they do a max effort jump. Then I do the single leg jump. That way I can put apples to apples on that.  And I break it down by the performance like jump height and RSI modified but then I also look at the metrics of the jump how do they do on the lowering the raising the landing things like that. then we go to my isocinetic machine and I do an isometric test for a max torque output and a second test for rate of torque development. I'm doing that for the quadriceps and hamstring.

Daniel Bodkin: And then we stay on the machine and we're doing the advanced isocinetic test which is concentric and eccentric isocinetic to look at the muscles. So I like looking at globally with the function on the force plate and then isolating with the machine. before I get to the numbers again, if you were to have somebody come in at or not even you, but a standard patient who's between five and seven months, roughly the time people are being discharged from their standard physical therapy, usually around 5 months or so, what are some of the things that you would

Daniel Bodkin: expect.  Is

Ravi Patel: Fantastic question because there's obviously as a lot of variance across this population. when you factor in the activity levels, what their training age is, the degree of the injury itself. and then the other component being the graph type which impacts the numbers and what we see a lot right if someone gets a tendon taken from their quad or their patella versus the hamstring or the alligraph right and so I know here we're looking a lot more at those big three in terms of the different graph types and so yeah when someone comes in around that range so usually what we kind of think of

Ravi Patel: is like when someone gets around the three to fourish month mark, we're thinking about them trying to get back to running, right? So, just kind of to build up from here. And so, some of the objective measures we're looking for this is trying to aim for at least a 70 to 80% LSI. I will say depending on this graph type and the patient, they might not get there, we like to have these targets and what we want to aim for based on the research.  But with that said, that can be a little challenging. And when we translate that over to Newton meters per kg, or torque to body weight, especially for the quad, we're aiming for at least like a 1.8, if not greater Newton meters per kg. And so that's where ideally we would like to be. there are people who if they're steady on it, they're progressing well, they can definitely hit that in that three to three to four month mark.

Ravi Patel: But I would say you're want to give yourself a little bit of a range there. And so then if we bump that up to let's just even say the five to six month range that we're looking at. That's where we're hoping this athe I'm hoping that they could be in the 80 percentile of symmetry, if you will. and when we're looking at what they're getting back to, can they run right? are they able to start running and build up some running capacity? Can they start doing some linear directional stuff like print sprinting and being at a lower intensity? And then can they deceler Can they be able to stop more in that linear fashion and then jumping, we're starting to build that up more as well, some explosive strength.

Ravi Patel: but with that said, we love to aim for that 80 percentile, but athletes still might be kind of dancing around that 70%. and I mean, we've had ranges where people are still coming in with deficits, And it just depends what type of rehab they were doing prior to if they weren't with us. and that's going to tell a lot of the story as well.  So yeah, there's a wide range, but like I would say, when we're looking at this process as a whole, we're looking at a 9 to 12 month process. So then six months, we would at least like our athletes to be somewhere in that 70 to 80 percentile of, symmetry, but we don't always get there.

Daniel Bodkin: The people that I tested, their uninvolved leg was really strong, well above. And we have body weight norms, which I hate because it's more of like a bell-shaped curve. You have some people that are going to be way above the normal. You're going to have some that are actually their normal strength is below, right? …

Daniel Bodkin: and so we had a lot of people on here that had really big side to side differences because their other leg is well above the normal. So that makes their, side to side look worse than it is. But when you look at it relative to their body weight, it's like, you're actually looking good. And, …

Daniel Bodkin: I always tell them, my right leg doesn't care what my left leg can do when it has to make that change of direction or when it's called upon to generate that force. It doesn't care what the other leg can do.

Daniel Bodkin: It cares about how much load it's experiencing from my bo the body and stuff. all right. So, these numbers, right, we had seven females

Daniel Bodkin: and five males that I included in this data set. for the females, six of them had quad tendon graphs, one had a patellar tendon graph, so no hamstrings in that group. the males, we had two quad tendon graphs, two patellar tendon graphs, and one hamstring graft. no alligraphs are in this set of data for today. all right. So, couple takeaways on my end. I completely agree with you. I don't expect anybody to be at normal strength when they're coming in at five or six months. and it's not like the PTs or the doctors are telling them, "Hey, you're going to be back when you're discharged." Because every, PT that sent them in, they're great therapists.

Daniel Bodkin: They're not getting bad rehab.

Daniel Bodkin: And I love it when they say, they told me that this isn't a past fail."

Daniel Bodkin: And so I always try to let them know that you're right, it's not a past fail on what we're doing today. it gives you a chance to see where your strength is. And I would say this is part of the picture. the other part is,…

Daniel Bodkin: what the progressions you've had in rehab. And when you get out to the field, those progressions so it used to be thought of that this was the end all beall test and you had to hit these numbers. And that's not even the same thing too. Yes, we want to see people getting close to these numbers, close to that symmetry. But that doesn't mean that, I tell people, you don't have to completely hold off on running until you hit this number. Because, …

Daniel Bodkin: you and I both know, you don't just go from running nothing to doing a 10K or full sprints in one session. It's a continuum.

Daniel Bodkin: And the same thing with returning to play.

Daniel Bodkin: I like to think of that as a continuum that you first get back to your drills then practice you get some reps in on the court or on the field and you slowly build it up over time. All So one of the things that I expect is if they come in at 6 months that they should be halfway there to in general. if they're twothirds of the way there in my opinion they're kind of on the upper end and…

Daniel Bodkin: that's kind of what we saw in general with a lot of the averages of everybody we saw that they ended up being about 60ish% of the way there and…

Daniel Bodkin: we'll go over some of those exact numbers there.

Daniel Bodkin: So when it comes to and this is both the functional and the force plates right so when it let's look at the females first their isomemmetric bilateral deficit we had them averaging at 36.7 side to side difference meaning…

Daniel Bodkin: what 64% LSI yeah and…

Ravi Patel: Yeah. 64.

Daniel Bodkin: and that's pretty darn good right there in my opinion. and then we also can look at what was their peak torque to body weight, So, in that same group, we had a peak torque to body weight. this is pounds. Newton meters per kilogram is a little different, but that they're hitting 62 14,…

Daniel Bodkin: so 62%. And for our females, we're looking for them to be about 80 to 90% body weight there.

Daniel Bodkin: So, you can see that there's a side to side difference and there's also a body weight difference that we kind of find there. And at least for the females, for the uadriceps, their isometric findings mirrored what we found on the isocinetic, So, isometrically they were 36% deficit side to side, concentric was 39, and eccentric was 37.  So some people ask is a handheld dynamometer close enough to electromechanical right is the isometric on our machine close enough to predict what they do isocinetically and say yeah according to that absolutely

Ravi Patel: They compared the isocinetic to isometric dynamometer and there's a pretty strong relationship and I think that's been shown over some other research too. So that's good for us because where do we have the availability to not everyone has access to an isocinetic machine, right? And so…

Ravi Patel: then therefore what do we do? we can find some more affordable devices to do in clinic to continue to serial test when we don't have access to it or maybe when we have more time between those testing points with isocinetic.

Daniel Bodkin: And everybody thinks, it used to be that you needed to have these expensive machines, but now the technologies come out that you can definitely get a tin deck or…

Daniel Bodkin: you can get a handheld and that's going to get you close enough.

here let's move to the hamstrings because that's…

Daniel Bodkin: where it does deviate a little bit. Right? So for the females on their isometric hamstring side to side difference we found isometrically 14% different side to side.

Daniel Bodkin: And keep in mind there's no hamstring graphs in this group. all right but then we went to the concentric and it was just under 13%. So that's close.

Daniel Bodkin: But then we went to the eccentric hamstring and now it jumped up to a 20% difference. All right. so it didn't quite line up with we saw a bigger eccentric deficit on the side to side difference with them.

Ravi Patel: Yeah, that's interesting. What do you make of that? The differences.

Daniel Bodkin: So when I'm testing eccentrically right it's testing them.

Daniel Bodkin: I go all the way to 10° of knee extension. So, they start with their knee bent to 90. They're pulling down, but the machine is straightening that knee out for them. And the only way that you can truly get lengthening under load is doing maybe a single leg RDL with a weight to full end range.

Daniel Bodkin: And I just don't think a lot of them have experienced that at that stage because,…

Daniel Bodkin: they may have been doing Nordics, but when you do Nordic hamstrings, your hip is close to neutral. All right?

Daniel Bodkin: But you're in a seated position. So you're lengthened across the hip. And then we're lengthening across the knee as well. And your peak torque should continue getting higher and higher as your knee extends for your hamstring. And I just don't think they've experienced that yet.

Ravi Patel: H Yeah. So, it could be just more of a testing response in the sense of, they've been loading the quads a certain way or even the hamstrings concentrically, but then eccentrically being linked in two. And I mean, they might be a little more hesitant with that as well just cuz you don't want to pull a hammy or…

Ravi Patel: that thing kind of really flare up. So, who's to say that that also kind of plays into it, right? Yeah.

Daniel Bodkin: Absolutely. And this isn't in this number set, but I look at the shape of the curves, right?

Daniel Bodkin: And if somebody can't keep loading and increasing their torque as their knee fully extends, then I'm like, hey, you're at a risk of possibly, having a hamstring strain when you get back. none of them in this group had that for males and…

Daniel Bodkin: females. So, it wasn't a length tension issue we see with injuries. one thing that I did notice with hamstrings, and this is males and females, is that we were seeing a smaller side to side difference, but when you look at their body weight deficit, it was much bigger, So, just like the hamstrings concentric for females, we saw just under 13% difference side to side, but the body weight was 28.5%.

Daniel Bodkin: And yeah, I didn't pull it in this group, but I actually looked at what the uninvolved hamstring was relative to body weight.

Daniel Bodkin: And this is for the males as well, that the hamstrings were kind of bilaterally weak. And I'm using the body weight number, but also the hamstring quad ratio of that healthy side.

Daniel Bodkin: So I'm just my take on this is that at this stage we're really the first month quiet knee healing range of motion…

Daniel Bodkin: then it's all about getting the quad and just getting function back and I think it's not that we're neglecting the hamstrings but it's not our most important thing at that stage.

Daniel Bodkin: So I, rewind 10, 15 years ago when the hamstring ruled all in the ACL world.

Daniel Bodkin: It was different. and so that's just one thing whenever I see it, …

Daniel Bodkin: I haven't had anybody that just blew away their hamstring on the other side either. and I put that in the reports that I give to the patient and the PT. It's like, hey, still we have, whatever deficit for the quad. This is the hamstring deficit, but we also got to get the other side up to its normal. so it has that protective function on the ACL and also we don't suffer an injury on the other side as well.

Ravi Patel: And those are some good points, especially with  But when you're starting off early, we are trying to target the quads. And the quads that's the focus with this whole thing. And I mean, it shows even in this data how much it kind of lags behind more than anything. And with the hamstrings, it's interesting because, there's some training related to it, but then maybe it's one of those things where we're going to start playing catch-up.  So even being able to maybe introduce a little bit heavier hamstring loading, especially if you have a quad or a patellar tendon, that posterior chain hasn't been affected and you're going to be limited a little bit by what you can load into a knee dominant movement.

Ravi Patel: So then with this said, …

Ravi Patel: maybe being able to tap into some hamstring based work, heavier loading earlier can help potentially tackle these deficits a little earlier. Right. Right.

Daniel Bodkin: And it's just most people haven't really loaded heavy on deadlifts at five or…

Daniel Bodkin: six months. or even just doing squats. once you get to a certain depth, that posterior chain really starts to kick in. And a lot of them, they might be doing full range squats,…

Daniel Bodkin: but they're not doing it under load at that point. so Mhm.

Ravi Patel: And especially with ACL's, they might still be box squatting or limiting that depth too, just because whether it's the knee flexion comfort or maybe they are sitting back a lot more because they don't want to load the knee. So the thing that I did want to point out with this was the hamstring to quad ratio because we know normative data we're looking for a 60% ratio roughly and this showed for the female group it was 76.45% and…

Ravi Patel: for the male group it was 75 so basically 77% for both groups at this time frame.

Daniel Bodkin: Is that they still just have a bigger deficit in their quad than they do of their hamstring.

Ravi Patel: What do you kind of just make of that in this particular data set? Yeah. All right.

Daniel Bodkin: Yeah, more is not better on that hamstring to quad ratio. is if you look at again just the females let's look at their isometric bilateral deficit was 14 but their quad bilateral deficit was still 36.

Daniel Bodkin: So it's just they have a high hamstring to quad ratio just because it's still the main needs to be the main focus. It's their lowest hanging fruit.

Ravi Patel: And the one thing that's also interesting is that even with this group, the graph type really does play a big role, especially with female athletes versus these male athletes here because looking at the hamstring differences, at least from a symmetry standpoint, we recognize that from body weight standpoint, there's still differences with both groups, but with the female athletes, there's a more noticeable difference compared to the male group.

Daniel Bodkin: Yeah, definitely. Yeah, I

Ravi Patel: And so with these groups, it's interesting too because with hamstrings when we're earlier in this process because they're up to five, six months posttop, that the other thing too is that at least from what I've noticed is that these athletes take on a lot more hip dominant strategies. And so that means they are leaning into their hamstrings or their glutes, whether it's on the uninvolved side or it is on the involved side. And so you almost kind of sometimes see a jump in their hamstring strength from testing in some of these windows because they're almost leaning so much on that. Especially for someone who's had,…

Ravi Patel: I would say, a quad tendon graft. I see the hamstring numbers jump up and their quads slower to rise.

Daniel Bodkin: Yeah, you've talked about the stall on your podcast before,…

Ravi Patel: Yeah. Yeah.

Daniel Bodkin: the quad stall, and yeah, that's absolutely normal at this phase, especially if they're progressing in their hip dominant movements.

Daniel Bodkin: That posterior chain starts to kind of pick up that load while the quad is taking its time adapting at this phase. All right, you ready to move on to the males?

Ravi Patel: Let's do it.

Daniel Bodkin: right, so for the males, it's kind of the same thing. all right, we had five males, two patellar tendon graphs, and one hamstring. looking at the quadriceps, isomemmetrically, they were about 30% weaker Concentrically, that jumps up to 38% and eccentrically, it's at 35.

Daniel Bodkin: So for them the isometric kind of underpredicted how they would perform under movement whereas the females it was pretty even across the board.

Daniel Bodkin: One thing that I did notice in this with them is that it's pretty homogeneous for the body weight deficit and the side to side deficit. If we're looking at the concentric and their concentric bilateral deficits 38% and the body weight deficit's 38% of, the goal that we want them to be. And it was same for eccentric. Side to side, they were 35% weaker and they were just a little bit 42% off of what I want them to be for their body weight.

Daniel Bodkin: So that was much closer on that than the females were on the body weight, but again, the isometric didn't quite pick that up there. but for the hamstrings, it was kind of the same thing. we're looking at, really low bilateral differences on all three modes,…

Daniel Bodkin: isometric, concentric, and eccentric, but looking at the body weight deficit, it was a little bit bigger. but we've already talked about that,…

Daniel Bodkin: we're just really not really engaging that posterior chain a lot. again, that's my prediction. and that person that had the hamstring graft, their hamstring, it wasn't significantly weaker. I was expecting them to perform much poor and…

Daniel Bodkin: have a much better quad, but they actually, were about the same.

Ravi Patel: Which is interesting because in most situations like you would expect some sort of deficit,…

Ravi Patel: but there's also some people who respond really well to hamstring graphs and…

Ravi Patel: maybe this N equals one was one of those people. and they were able to. And when there's a hamstring graft done, there may be more hyperfocus on getting those hamstrings strengthened a little bit faster compared to a quad tendon or…

Ravi Patel: a patellar tendon.

Daniel Bodkin: that's what they said. they're like, "No, from the get-go, we knew that this was going to be an issue." so they were after they did a great job with that. same thing on the hamstring to quad ratio.

Daniel Bodkin: It was, 75 almost 76%. But that kind of goes along with, their biggest lowhanging fruit is the quadricep at this stage.

Ravi Patel: So it's a very interesting just data set overall when we compare the two in terms of there's definitely similarities like I would say across the board would you say we're seeing consistency of those deficits from quads to hamstring quad ratio …

Ravi Patel: but then bilateral deficits in the hamstring groups but then the one thing that was interesting was a little bit of a difference in the isometric testing with the quadriceps veus for the males versus the females for their quadriceps, right?

Daniel Bodkin: Yeah, absolutely. Are you talking about for the quadricep or for their hamstring? Yeah, isometrically they performed better than the females. The females were almost 37% side to side deficit whereas the males it was just under 30%. So they did better isometrically with that for one thing that's not in this set, but I just added it in, is that it's called an eccentric weakness. My mentor, John, he called it the neurologic weakness. And my mentor, he really kind of helped pioneer the eccentric testing for Kencom. And what this is is like the one female we tested, she had good quad curve, right?

Daniel Bodkin: It was weak side to side, but she could not generate torque evenly on the eccentric. So, she's pushing up into the dynamometer as it's forcing her knee to bend. And the listeners can't see this, but Her quad lid this. It was really wiggly lines. And it wasn't even consistent rep to rep where those wiggles occurred. Every rep just had completely different wiggles. And if visually you watch it, her whole leg was quivering and shaking, right?  And this isn't really picked up in a lot of research because eccentrics is still kind of new to isocinetics. so not a lot of people have studied this and you don't pick it up unless you test eccentrics. But we had a female who had that and I actually worked with her a little bit over the summer and it took us about six weeks for her just to be able to generate even steady torque through the range.

Daniel Bodkin: She was a quad tenigraph and she had an LT procedure. So, it really wasn't even a pain thing. even under light load, she couldn't control an eccentric load to her quad. I had a male, he was able to control the torque, right? He had a nice smooth line, but his eccentric output was the exact same as his concentric output. And we went at least, about 30% in more eccentric load.

Daniel Bodkin: So, we had what, 12 total that we tested and we picked up two of them with this. And again, it's not in the numbers there, but it just kind of, hopefully my mentor John is listening to this and he's like, that's why you test eccentric because that's the function that the knee has to go through. so it's just kind of little asterisk to what we're talking about, little caveat. It's like, you don't know your patients are going to have that unless you're testing for that as well.

Ravi Patel: and it's a good point too. And when we think about the mechanism of this injury, It's usually not a concentric based action. It's a eccentric based action. It's landing from a jump. It's changing direction. So, you're decelerating. The knee is bending.  So the quads have to work eccentrically in order to slow them down and be able to take on that impulse and be able to redirect that whatever that may be. So eccentric testing is challenging to do but with that said an isocinetic machine and being able to do that and get that information and test it under load is super helpful.

Ravi Patel: The thing that's interesting is we see this a lot, when we're working with these athletes and you might see it with a concentric piece and that kind of works its way out. but the eccentric one can kind of linger around and…

Ravi Patel: I just find this very interesting. I was going to ask you for the male, was this a quad, patellar, or hamstring graph that this athlete had?

Daniel Bodkin: He was a quad.

Ravi Patel: it's just very interesting in the people that I have noticed this present more and be more apparent is people with quad tendons. and I've had some really really tricky cases where, it just doesn't make sense why they continue to have this weird quivering or especially under the eccentric load where their quads start to shake and it might be beyond the It's normal maybe in the first four to eight weeks where their quads are getting going again, but we're talking seven months out.

Daniel Bodkin: Yeah. No, if you think about it, one is mechanical, right?

Daniel Bodkin: they just had a major injury to that graft or to that quad tendon and eccentric they're producing torque while it's being stretched and so as that knee continues to bend they're getting more and…

Daniel Bodkin: more tension through that and they're building more torque because your knee is supposed to be able to generate more torque as it bends eccentrically. So there's a mechanical aspect to it but There's a reason we test our reflexes at the patellar tendon because that's the most sensitive reflex point. It's the most, from muscle spindles, GGI tendon organs, our quad tendon and…

Daniel Bodkin: patellar tendon are loaded. They're primed for that. So, if we insult that structure that neurologically active that we use it as our test to see if somebody's neurologically, active or has that ability.

Daniel Bodkin: you're robbing that structure. third the quadricep is shuts down no matter what graft you do even if you just tear it not even the surgery right it's a protective mechanism your lizard brain thinks we still live in caves and…

Daniel Bodkin: huts. So, if you tore your ACL because you're out chasing a bear trying to, eat or you're fighting the next, warrior tribe next door, And your brain does not want to let you get out of your cave and hut to go fight again until it's healed. So, it shuts down that muscle and it takes a while for that to come back.

Daniel Bodkin: That neuroplasticity, it works both ways, unfortunately.

Ravi Patel: And the term that comes to mind here is the arthoggenic muscle inhibition,…

Ravi Patel: And so it's one that's difficult to detect especially in a clinical setting of course in research they've been able to kind of test and see who might be someone who has AMI. but it's been interesting working with more and more and more ACLs and different graph types because I think this phenomenon, if you will, or this concept is more present than we think. And there's a lot of things that go on and the analogy that's always used is essentially you have the Christmas tree, right? And you have all the lights on it, especially with Christmas just now, right?

Ravi Patel: You imagine your Christmas tree and you've got all the lights on it and you plug it in and all the lights show up, But then when AMI hits, it's a little different. It's almost like some battery gets disconnected or some of the lights are not showing up. So essentially, imagine plugging in this tree and only half of the lights show up, And so that's like your motor units in your quad firing and trying to do the same amount of work for what you're expecting of the quad.

Ravi Patel: So there's just this whole cascade of this process that's just really interesting that I find and also just makes it a big hill to climb with this process because as soon as this injury happens we kind of think this can unfold but coming back to these athletes I sometimes think that there are certain people who are just predisposed to it and when it happens and they have this ACL injury they have this thing where it just takes a long time for their quads to get going and it's more than usual a typical muscle response with a good functioning muscle with a nerve coming into it it should take six to eight weeks for some sort of change from a physiological and strength standpoint.

Ravi Patel: But as we know, working with this population, it's like, man, we'll work on this for 6, 8, 10, 12 weeks, and there's almost no movement. And so, it's just very, and the athletes also kind of like, I just don't feel like I can turn my quad on.

Ravi Patel: So, it's just interesting hearing you talk about these athletes and just some of the experiences we've had as a team dealing with people having difficulty with the quad. I can't take credit for that.

Daniel Bodkin: Your Christmas light analogy was the best thing I think I've ever heard to describe that.

Ravi Patel: There's someone super smart that came up with that.

Daniel Bodkin: Not only that, they're not included in this data set, but I tested two people. one she was a year and a half out after ACL and the other one she was I think just a little bit over a year. they both one she actually had a femoral nerve pulsey from just the nerve block.

Daniel Bodkin: I had to it's called zero gravity isocinetic where it basically manipulates gravity of the machine while they're testing just to be able for her to produce torque. Right.

Daniel Bodkin: The other one, just extreme AMI, she could produce 25 p pounds of force, isometrically at 60°. And I was like, okay, that'd be great if you weighed 25 lbs. and unfortunately, because of her insurance and what she was working with, she had to stop rehab. She wasn't able to keep going beyond. so her PT sent if anybody hasn't sent me a patient here in Atlanta, I do one free test she was the test for one of the clinics and they were like,…

Daniel Bodkin: "Hey, she's been discharged six months ago. She's been working on her own, but we want to see how she is." And her PTS even came in and watched her do the test and they were just like, I didn't know it was that low. And it wasn' that she wasn't working on it, she was going to the gym multiple times a week just kind of doing her own thing.

Daniel Bodkin: But that really kind of, lit the fire under her to really start pushing it. I even said, "Hey, this is good justification if you guys want to use this objective data to try to get more visits from insurance." I know she continued to work with her PTS. I don't know if it was actually in office visits or if they were programming it for her, but we're actually going to be testing her again later this week. She's going to come back in just to see what kind of progress she made. Yeah.

Ravi Patel: is at yeah and this is just a very good example of the research I do think that there is one thought of research shows one thing and it's good for us to operate from that sense of knowing what the data shows from aggregating everything right and we have these timelines or all right we have these certain points where we test people three  nine months. And if you look at the research there, there's some studies where they get a good group of people and they test them and at 20 weeks, they're at 90% symmetry, right? is there torque to body weight numbers related to that? Usually, not always.

Ravi Patel: But with that said, I think that there's a lane that research goes in and then especially because the human variability just so much factors that play into this process that we just have to know that it is quite a range and…

Ravi Patel: it's good to anchor to this stuff, but I think we have to be very intentional about the way that we communicate where people need to be because if we tell someone they need to be at 90% symmetry at six months and they're still If this is a 14yeold female athlete that's want to play soccer that sucks, right? But we so…

Ravi Patel: therefore and we've all faced these battles. So all this coming back around to essentially we wouldn't know that if we didn't have the data to support it. So that's where testing and knowing this stuff is so key. And this athlete sees it, the athlete that you said they see this stuff and they're "Okay, cool.

Ravi Patel: we can target and be a little bit more put our scope on something and be like this is what we need to work on versus trying to kind of shotgun this whole thing.

Daniel Bodkin: Absolutely. It's not a one-sizefits-all. It's not the patient's fault. It's not the PT's fault. It's not the doctor's fault. that's the way it goes sometimes. Not everybody's going to follow along on that trajectory.

Ravi Patel: Yeah. Yeah. Yeah. And so I think that's a big player in a lot of this and I think that the numbers really do help to guide the process and being able to get this information. So this is really cool stuff to be able to see and compare. Absolutely. Yeah.

Daniel Bodkin: Do you have time to look at the force plate data real fast? All right. So, on the forest plate, same group of people. we did the counter movement jump bilaterally, and we'll do males and females and before we go to the single leg.

Daniel Bodkin: what I'm really looking at is how much are they using the involved versus the uninvolved at different points in the jump. So, I broke it down by the eccentric peak force asymmetry. that's the lowering phase, the concentric peak force asymmetry, that's the raising phase, and then the landing asymmetry. for females, they were 26 I'm just going to get rid of the decimals.  2 on the 24% more on the healthy side of the raising phase and landing 14% more on the healthy side. And that kind of matches up closely with the isocinet I picked up on. Yes.

Ravi Patel: about compared to the deficits that they're dealing with.

Ravi Patel: But yeah, it does line up pretty well, I would say.

Daniel Bodkin: One thing,…

Daniel Bodkin: unless you've done it before, it is really hard to, be consistent with jumps at max effort.

Daniel Bodkin: If you're just doing 50% effort, you can pretty much force bilateral. But when you're having this person jump as hard as they possibly can. so we may see it's usually the eccentric and concentric are the three reps together average out pretty the close the same. But the landing I might have rep one they land 40% more on their healthy side. Rep two they land 20% more on their healthy side, but rep three they landed 30% on their surgical side. average So the landing is we call it the coefficient of variance.

Daniel Bodkin: how closely do the three reps match? It's really hard to get a good coefficient of variance on your landing.

Daniel Bodkin: So, there's just that little caveat on that, so we're a little bit more lenient with our side to side difference…

Daniel Bodkin: because it's really hard. Even when I do mine, never having been injured, I'm usually around 12% difference on these. So, I'm very happy with 24 and 26% for the females. Mhm.

Ravi Patel: Yeah. Yeah. And it's interesting too cuz a lot of this does come back to how much jump training have they been doing? what is their training age again like that plays into it also familiarity of doing this because as you had mentioned it's just you're getting tested like getting going through a standard process and you have so many degrees of freedom moving and…

Ravi Patel: the other thing too is that most of these athletes at this point have been constantly communicated hey shift come back to center and a lot of times what'll happen is that they'll start off without thinking about it and then they'll start to notice it and then they'll actually overcompensate to the other side.

Ravi Patel: So then that could also influence these measures a little bit in terms of they're on their uninvolved side more and then involved side more. So that kind of can influence that too,…

Daniel Bodkin: And I never test somebody on something they haven't done before. So if they haven't done jumping,…

Ravi Patel: right? Yeah.

Daniel Bodkin: we're not testing it. so most of them have done testing, but they haven't done max effort. That's, …

Daniel Bodkin: we're jump over the line, land off of this box, maybe jump onto the box or jump down from a step. most of the time at five or even six months out, nobody's done a max effort jump. And your hands are on your hips,…

Ravi Patel: Right. Right.

Daniel Bodkin: so you can't use your arms to generate that force.

Daniel Bodkin: So it's a good test…

Daniel Bodkin: because it gets them out of something that they've practiced. males was pretty close as well. Their eccentric or…

Daniel Bodkin: the lowering, they were 15% better on their healthy side. On the raising phase, concentric, it was 21% more on the healthy. Now, their landing was at 33%. So, the males are definitely landing more on their healthier side relative to the females. Mhm.

Ravi Patel: And one thing with this that I was kind of taking note of is that I think with this obviously the strength deficits we just talked about…

Ravi Patel: but now we're tying in some rate of force that plays into this a lot too. So, how quickly they develop this force and counter movement jump isn't necessarily a true plyometric because there's no stretch in it.

Ravi Patel: But with that said, we're still being able to measure this and being able to see this and I think the graph type is influencing this probably a good bit when we think about most of the females were quads and the quad tendons and these males were stretched across quad patellar and hamstring.

Daniel Bodkin: Yeah. Absolutely. one thing that isn't being pulled up in the bilateral jump is their RSI modified kind of like their jump efficiency.

Daniel Bodkin: when I test them day one the first time they come and then I test them later on I do to look at how much they improved but that's not in this data set right all right so when we go to the single leg that is there right so single leg jump hands on your hips I have this broken down by the jump height the bil the RSI bilateral asymmetry and the best way I heard this explained is if I have two athletes  and we're both jumping to get the ball after a rebound. If we can jump the exact same height, but athlete A can get there faster than athlete B, they're going to get that So the RSI takes your jump height divided by the amount of time it takes to perform the jump. Right? So it's kind of like not just your height, but how quickly can you do it, right?

Daniel Bodkin: So, on this we're looking at jump height, the RSI, then their eccentric braking impulse, and impulse is the force over the amount of time. and when you're lowering in a jump, there comes a point where you have to hit the brakes, stop moving, and then pop back up. So, we're looking to see how quickly can they hit the brakes, how stiff are they at that bottom of the jump. And then, the last metric is the concentric impulse asymmetry. All right. So then we are bringing a little bit of that rate of torque development sort of.

Daniel Bodkin: So for the females first just looking at jump height asymmetry. Females were 37% better on their healthy side. Males were 31% better. And that kind of lines up with what we saw on the isocinetic test. 60ish% of the way there.

Daniel Bodkin: And any thoughts on that?

Ravi Patel: I think really here is the deficit being a little less mainly because of I think the graph type has a very very strong relationship here of these athletes had a little bit better quad output in terms of for the male group compared to at least from an isometric standoint.

Ravi Patel: point especially.

Ravi Patel: So I think that that plays into this and I think maybe some experience with this could potentially also play into it depending on the athletes and their sport depending on this data set and their experience.

Daniel Bodkin: AB absolutely does. graphite is huge on this.

Daniel Bodkin: And the other thing, if you've only ever done drop jumps or you've only ever jumped over the line or…

Daniel Bodkin: a piece of tape on the floor versus the person that's actually, more athletic, so they have, a few more weeks of experiencing more intense single leg work, they're going to naturally perform better because they've experienced that. They've been exposed to it. the other one there is RSI that modified for the females they were 40% better and males they were 31% better on their healthy side.

Daniel Bodkin: So again pretty close there. and…

Ravi Patel: Yeah, and…

Ravi Patel: I think that just lines up similar to what you were just sharing before and the factors that we had talked about.

Daniel Bodkin: yeah and I forgot to even mention this.

Daniel Bodkin: When we do a vertical jump like we're doing on the force plates, when you get rid of the arm swing, right, 30 about 30% of your output comes from the hip, then 30 then another 30 from the ankle, When you do like a horizontal hop, like a triple hop or a hop for distance, the knee contribution goes down to 12 to 13%. So, by doing a vertical hop, you're exposing more of the knee.  But we have had people they're just really good with their Achilles, calf, ankle, or hip that kind of not just covers up the deficit at the knee, but still you're going to expose, about 30% of the knee with this. So, it's pretty neat to see how much it's lining up closely with what it looks like with the isolated test.

Ravi Patel: And I think this is where getting a quantitative and…

Ravi Patel: qualitative measure really does help paint a really good picture. because we can't operate with just the data and we can't just operate with just the way someone looks. we can make, assumptions about everything, but when we have both, it's obviously going to be the best combination. And there's some athletes who they can even look good to the naked eye and be able to really cover up those deficits. because they have strategies to figure out the around that, like you said, their ankle calf complex can really allow them to use strategies that are a little bit more beneficial towards this.

Ravi Patel: but then still are able to kind of see what the body does in terms of weight distribution. Right. Right.

Daniel Bodkin: it during the warm-up. So, I always kind of warm them up first. If I notice that they're just collapsing in the frontal plane, I'll cue them because I don't want them to injure themselves doing the testing.

Daniel Bodkin: But, …

Daniel Bodkin: I'm not giving My cue is I want you to jump as high as fast as high as you can and as fast and explosive as you can. I'm not telling them, feel the floor and do you know, I'm not giving them all those internal cues with that. something that's interesting on the eccentric breaking and the concentric impulse for males and females right so for the females they're 26% better on the eccentric breaking impulse and 24% on the concentric of their healthy side and the males it's 28 and 18 right so from this it's showing about both phases evenly but when

Daniel Bodkin: I look at the individual data points. Most people had one that was more dominant the other. Meaning, on the lowering, they might have a 50 or 60% worse on their surgical side, but their concentric is really close. Or it's the other way. they look good on the lowering phase. it's closer to symmetry, but on the raising phase, we had, 40% different. but when you average them all together, it ends up being, what 20 to 25% roughly. but it's cool for them to see. This is like, hey, if we want to get our jump improved, this is your lowest hanging fruit. So, before you get too aggressive in your progressive plyometrics and single leg work, let's really nail down this one phase. Work on those drop landings.

Daniel Bodkin: And then, it's like, you might have been doing it from a 12-in step, but maybe we need to do it from a higher step or do it and then explode up into a second jump to really, get that stretch shortening cycle nailed down. Or on the other end, they're eccentric breaking is good, but the concentric that's like they have a bigger deficit there. So then they can really, focus on working on that explosive concentric strength.  Mhm. No.

Ravi Patel: deficits, Because these are adaptive strategies that their bodies are learning because they're operating with a certain amount of quad hamstring strength. Who knows if these athletes are dealing with swelling or pain potentially that can kind of come into play here.

Ravi Patel: And so then therefore this allows us to be more targeted and them because sometimes we almost want to restore that muscle capacity first. Maybe we need to take that step back and restore that a little bit more and then we'll see these numbers clean up and come together a little bit better. Or maybe that muscle capacity is there and they've just learned that adaptive strategy and then therefore we need to coach them out of it.

Daniel Bodkin: like I said at the start, nobody's come in and was completely ready for it, And I always tell the athlete, I tell the PT, it's not to show you what you're doing bad on. It's just to identify…

Daniel Bodkin: what that last phase so you can be more targeted like you said. and I never say, " you need to do these 10 exercises to implement." No, it's like here's the data. the PT knows…

Daniel Bodkin: what they're doing.

Daniel Bodkin: the athletic trainer knows what they're doing, And so they're able to kind of take this and then say, "Okay, so how can I, use that to help design this final phase for them. yeah, it's just I always try to find what is the most important thing? What's the lowest hanging fruit?" Because, if you clear that up or…

Daniel Bodkin: you start, working toward that, a lot of the other things will kind of work their way out as well. but yeah, I've never had nobody in this group has come in and…

Daniel Bodkin: they just did terrible.

Daniel Bodkin: right, everybody's pretty much expect where I would expect them to be at this point. and I always tell the patient, hey, we always focus on what is the deficit, but give yourself credit for what you've already made up. when we look at the torque lines,…

Daniel Bodkin: they always look, what's the difference between that red line and the blue line, left and right?

Daniel Bodkin: I say, " look at where the zero line is and how far you've gotten that blue line up already.

Ravi Patel: And testing is one of those things where it can be daunting. especially because it can be built up depending on who is sharing information about all right at six months you need to be here or three months here. and so then therefore letting athletes know that you had mentioned right we're not aiming for a past fail here and this is also to see what progress you made and also what we need to work on right and so it's almost like setting the expectation of knowing hey you're going to have deficits sometimes they almost want to hit this perfect all right I'm at 90% symmetry and if you're close to the end and you've been working really hard that's okay to have that expectation to some degree

Ravi Patel: But if you're in this first nine month process and…

Ravi Patel: especially if you're in the first one month to, seven, eight months, we're expecting to see some differences. And that's good in a sense because that allows us to be as targeted as possible with what we're going to prescribe for you. Yeah.

Daniel Bodkin: 100%. And I would say, people make their own choice based on the risk. This just kind of identifies risk. We had one guy come in. He was just right over five months high school football running back. It was about two weeks before summer camp started and he's 20 to 25% off of what we were wanting, He still played. He went back, but he knows, hey, you don't just go back and start playing right away. you got to keep working on your strength because at this point when the team is playing, they're not going to be in the gym two to three times a week.

Daniel Bodkin: And you don't go out there and…

Daniel Bodkin: hit every drill 100%. right now I want you walking through, slow everything down, build it up. take the next two or three months just getting back into football shape.

Ravi Patel: Yeah. Right.

Ravi Patel: Right. Right.

Daniel Bodkin: So, it's not like you need to hit this exact number and it's an all or none. You go from zero play on Monday to full play on Tuesday because you hit a magic number, right? It just kind of identifies where they are on that continuum.

Ravi Patel: Yeah. And that's so huge. And luckily these numbers do anchor us and give us an idea of all right if we're at a 50% deficit or a certain torque to body weight like we still got a minute but if we're at 70 80 and…

Ravi Patel: depending on how far the athletes out and also what are the things they're trying to get back to is it a time sensitive like this football athlete.  So then maybe we create a plan that is going to help work alongside getting them stronger and clearing up these deficits and being able to allow them to join in a very safe progression and then building up from there from participation to sport and to performance and being able to have that go in line with also continuing to work on these certain qualities that we're trying to improve.

Ravi Patel: prove, right? And some people that it is challenging because some people, these numbers they see them, they know about them and our job is like to educate them as best as we can of riskreward of this stuff. And sometimes it is having the hard conversations and some people who operate in that gray. There's a big thing that I will only do once in my lifetime that's a month away and I'm still at 70% deficit. What do I do? And all we do is educate them and just help them make the best decision in that situation.

Ravi Patel: And ultimately, this is a game of there's no perfect you hit 90%, you're invincible now. you're at risk.

Ravi Patel: It's just like how much risk do you want to take on?

Daniel Bodkin: It's all about, finding that risk and, do, you know, making the best choice on that. All right. So, patient comes in, we do their test, right? It doesn't mean they're not going to be discharged from a traditional plan of care insurance model.

Daniel Bodkin: So Hopefully we have some PTs who are listening to this as Patient skill going to be released from physical therapy. Right? Where do they go from there? Is there somebody that can help them out on that final phase?

Daniel Bodkin: whether they live here in Atlanta or they live in, I don't know, Juno, Alaska, All right, Robbie, is there anybody out there that can be that last step for the patient? Mhm.

Ravi Patel: Yeah, this is honestly a really really good question and…

Ravi Patel: I think I always tell people, don't prepare for when because it's going to happen and  Look, we worked with people all over the world. you name the health care system. we've had a fortunate opportunity to work with them. And so, with that said, and it's not like socialized medicine is any better than what we have here in the States with insurance. There's pros and cons to everything.  And so with that said, essentially if you're going through this process, whether you are a clinician, coach, provider, or you're on the ACL side going through this, unless you have the most perfect, health care situation, insurance, unless you're the professional athlete that has all the affordances or the college athlete, right?

Ravi Patel: to be able to do this as a full-time job essentially, you need to plan for what's going to happen because this data clearly shows that these athletes have pretty big deficits and they're at five, six months out, right? And the narrative that used to be that still is present is that, hey, we're going to get you cleared at six months, but at this point, they're only operating at anywhere from 50 to 60% of their capacity.  And then we wonder why reinjury rates are so high and why the other side gets injured, And it's because we rely on that thing so much because that the ACL involved side hasn't got up to speed where it needs to be. And so people are kind of left to their own affordances of I've exhausted insurance or my healthcare or my PT or the thing that you'll typically hear as you're kind of mentioning is I've graduated PT or I've been discharged.

Ravi Patel: So, I think what ends up happening is that there's this perception of, " I'm good now or I'm good to start doing my stuff again." And I think that's…

Ravi Patel: where it comes back on us as providers to make sure we educate to let them know you're not done yet. To let them know that this is at least a 9 to 12 month process and these numbers are going to really dictate where we define done, And how much exposure you've had to the thing.  But with that said, if you have getting back to the answer and the question if you are in this place then therefore you almost kind of want to see okay locally to me you can always look at can I continue to go to if you like your PT and they're great can I continue going and paying out of pocket and I Yes.

Ravi Patel: there's incredible PTs all over the place, but if all they have is 10 pound weights, I promise you they're not going to be able to get you loaded to where you need to be ready for your sport. It doesn't matter how smart they are. And so with that said, your environment will impact a lot of how you can progress as well as who you're working with.  And so with that said, if you can go back there and they have a good clinic, then you could pay out of pocket. You could potentially find a different clinic that may serve as that. there's also places that may do bridge programs or groups that you can inquire about.

Ravi Patel: and then the other thing that I think is very important, especially if there's clinicians working and listening to this, is that the cheat code is partnering with a very good personal trainer, strength and conditioning coach who is on the same page as that you can pass off this athlete because of course it's probably going to be a little bit more affordable for them and maybe more frequency.  And so then therefore that allows them the opportunity to work towards the strength and conditioning route especially if they're at this phase of six months out, wherever that may be. And then that's the in-person components. And then there's the remote components that exist. And we do this stuff like we work with people remotely. and then there's also lots of other providers in our network remotely who are doing incredible work.

Ravi Patel: so those are a lot of the different mediums, if you will. But I think the biggest take-home here is knowing these deficits exist. I promise you are not the exception. And so therefore, we need to make sure we ride this thing out I know, and this is coming from someone who's had two ACL injuries myself, right? I've rode this thing out.  And the thing is that while it feels like it's another six months to do this, I promise you the cost of another ACL injury will be way worse than doing this thing right the first time. So I always tell people, let's make sure this is your last ACL injury and do it right. I appreciate it.

Daniel Bodkin: I'm a big believer in the model that you guys have created. I love it. it's a great final phase for that patient because you're a PT. and the strength conditioning side, you see it all the way through, right? You can have that handoff from their PT. You can find out the minutia of what issues have they been running into? what are we working on? So you're not just going into it blind. And I've had patients,…

Daniel Bodkin: we discharge all of our ACLs eventually,…

Daniel Bodkin: and I've worked in those clinics where the heaviest weight we had was a 10 pound ankle weight, right? We weren't the answer for them at that point.

Daniel Bodkin: It was all right, go find a personal trainer or hopefully you had an athletic trainer that had the time at your school to kind of get you through those next few steps.

Daniel Bodkin: But I love this remote model that you have and especially with you having the experience of doing this yourself twice over. how can PTS or how can the find the ACL athlete?

Ravi Patel: I appreciate that. And the big goal is for us to be able to try and fill a gap that I feel like I fell into. And then also we see a lot of people and a lot of athletes fall into with just and I'm not here to throw shade at the system. I know the system isn't great and…

Ravi Patel: it does great to keep us alive but in terms are proactively taking care of us there's a lot of things we still need to work on. but with that said there are other options out there. So, I think that's the biggest thing that I want to make sure anyone listening takes home here. and just finish this thing all the way through. But, to find us, you can go to the website, the ASL athlete.com. you can find all of our information there. I have a podcast where I talk all things ACL and somehow have done this for 200 plus episodes every single week so far. and I haven't had things to run out of talking about. So, anyways, those are the main mediums.

Ravi Patel: And then you can find me on Instagram, Robbie Patel.TE. BT. …

Daniel Bodkin: Robbie, I appreciate you taking the time to come in and…

Daniel Bodkin: This is much more interesting than me just sitting here. I actually recorded about 20 minutes of this myself and I was like, this is just boring. I'm just reading numbers. So, I'm very thankful that you were able to take the time to come in and chat this with me. Plus, I love nerding out about this stuff.

Ravi Patel: me too, As soon as you texted me and you're like, "Hey, you want to do this?" I was like, "Heck yeah, I do." So, I appreciate the opportunity and you keep doing your thing, too. you're really having what I call a force multiplier effect of you helping all these clinics and different places install these machines and put it on the map helps us to be able to help as many not only ACLs but all these other demographics. but obviously AC close to you and I both of who we work with.

Ravi Patel: So anyways, appreciate you for doing that and for helping all these athletes around Atlanta as well.  Yeah. Yeah. Yeah.

Daniel Bodkin: Absolutely. My goal is to,…

Daniel Bodkin: because testing isn't available for most, right? And nine times out of 10, or I guess what, six to seven times out of 10, they're going to be fine without ever getting tested and just going through and being discharged and then kind of figuring out how they've been. But it's that, 40% that are going to retire.

Daniel Bodkin: So that's my goal is to, identify those ones and…

Daniel Bodkin: help them to not fall through the cracks and get reinjured and bring that overall, that local Atlanta reterate kind of bring that down by allowing or by making testing available.

Ravi Patel: Yeah. and…

Ravi Patel: it's going to help us as a profession. And I think it's going to help us with like you said that retire rate 30 to 40%. that's pretty high. if you flip a coin, one out of three people are going to go on to tear their ACL again.  And so therefore that's too high of a number for us to be comfortable with in this space. And so I think being able to provide that testing and doing it across different places is super helpful. So that's great Of course. Thanks Daniel.