EP031: "My Return To Sport Progression After MCL Sprain" | Dr. Chris Garcia

if you can't put it on a whiteboard you can't put it on a piece of paper or an excel spreadsheet you can't make it happen if you're gonna go week by week it will never happen [Music] hi everyone welcome back to the podcast uh welcome all new listeners uh for those who are following along i have a good one for you today today we are reviewing a fantastic topic step-by-step progressions uh for specific injuries but before i do that i gotta give you some updates uh about life about uh things that are going on things that are coming down the pipeline um life is good for me i've got a lot of good things happening with my family and and um professionally and uh my kids are growing up uh sports performance we're in a growth mode at the moment uh fitness is good i just started a uh cut week uh like a calorie sodium carb cut this week and we've got 20 new members or sorry 20 total members in this group and all we do is we basically uh support each other through this madness so it's a significant calorie cut it's a significant sodium cut and a significant carb cut and all it is is is a great way to kind of uh we use it as a gut check as a way to just test your your uh your strength your will and uh just to reset and all you know your eating habits and everything else so i'm going through at the moment i'm currently on 1850 calories uh and i think 500 milligrams sodium and very very low carbs so it's been interesting and and the fog is starting to kick in in the brain so there you have it i'm on i'm on my cut week all right nonetheless let's move on to the podcast so how did i get to this podcast what is this topic about i think it's important to know that uh yesterday at our team meeting at sports performance one of the topics we covered was a an mcl rehab progression and i want to share with you some of these case studies because i think they're very applicable i had we had the meeting and had a conversation with a team member afterwards and um as we go through more and more scenarios i have to share that sometimes the same scenario happens within normal tissue healing guidelines and it becomes very challenging to see from a broader greater perspective what how everybody you've ever treated can be categorized into certain categories of healing and then you just insert and change out the body part so let me explain so uh we have a client uh who's an athlete and they injured their knee and they are looking to get back as soon as possible i don't want to give all the details but ultimately we're trying to get this person back asap and the question became how soon can we get this back this person back and for those of you who listen to my podcast you know i'm passionate about this if there's one thing i'm really passionate about there's s i hips and low back but then on the flip side is progressions like soft tissue healing progressions uh work backwards are we to put them in the game are we not going to put them in the game how soon can they come back what would you do at week 3 what would you do a week 17 what about week 63 i don't care like i love that because it's very predictable and i love predictable processes that are objective and sequential and you can actually put it on paper and one of the things that i want you to understand whether you're a new grad or you're a student physical therapist or you've been out for a couple years i want you to understand one thing if you can't make it happen on paper you can't make it happen at all so what i mean by that is if you're new to the rehab progression world and that doesn't mean that you you haven't been practicing you can be practicing 10 years and not see the light not see how to rehab somebody progressively over time for up to a year or more because a lot of times if you work in an orthopedic setting you're not given the opportunity or permission to do so and when you are allowed to see somebody for a year or you push somebody to be rehabbed for a year and and rehab is a is a very vague term but can you rehab or progress and return to sport somebody for 9 to 12 months out and because you haven't had that opportunity one of the best things i tell people to do is map it out if you can't put it on a whiteboard you can't put it on a piece of paper or an excel spreadsheet you can't make it happen if you're going to go week by week it will never happen it won't go the way you want you're not going to be prepared it's just like accounting and banking and and finance like if you can't see it on the sheet it's never going to happen you can't just have a plan and then hope it happens there's a difference between implementing and success so if you if you don't implement you can't be successful so when you are looking at a progression so i'm going to go through this rehab progression but what i want you to take away from this is that being able to map this out so i'm going to whether you're on audio on the podcast or you're on video on my youtube channel nonetheless you have to grasp the concept you gotta map these people's progressions out if you don't you will be just like every other physical therapist going week by week hoping that things just get better or even worse just forgetting about that client or patient and then when they come in you're like oh yeah i forgot about you and then you just try and create some creative exercises that you're not really progressing people you're not pushing them to what their limit can be now the difference between treating pro athletes or high level athletes or collegiate athletes is they usually have a deadline a timeline to achieve and you have to work backwards now what you have to do is is that a lot of time sufficient to be healed to return to sport safely that becomes a question well now when you deal with community members who not necessarily they don't have a deadline they don't have a 5k to run they don't have um a competition to run or have competition to perform that becomes very tough to work backwards so you always have to create goals so you have to know where your goals are and your objective measures in order for you to work backwards so let's go through this case all right so we have an athlete a multi-sport athlete with a grade one mcl sprain okay let's just i'm gonna give different facts about this case and and make it a little easier to digest you have an mcl one a grade one sprain okay 48 hours old okay get them in the clinic can rehab them now the question becomes how soon before i get back to playing so uh let me give you an age uh i'll give you uh let's say 18 okay 18. so they're first out of high school in the college and uh there's something we call youth juice youth juice uh that's the the ability to regenerate and recover at an exponential rate and that usually starts to end around 18 years old so that we get these middle school and high school kids and maybe you have two like they have an injury and you're like oh my gosh it's going to take three and a half weeks you won't be able to play at week four and it's going to be questionable and then next week they're like running we've had that happen before we've had ankle sprains grade 2 echomosis edema and they play the next week and we're like wait a minute how did that happen youth juice it's just something that they have that we don't as adults so this person is kind of losing that aspect and so if you have a grade one let's go just normal ligamentous timelines okay so in the first 72 hours you got the swelling you got you know uh antalgic gait first three weeks three days you've got soft tissue healing immediate okay after that you got two weeks to get them non-intelligent gate get the range of motion you've got two to four weeks after that at the six week mark to get them with a grade one let's just play like normal timelines for a normal community member and then we'll work backwards with sports sorry pro sports uh or professional athletes collegiate athletes and youth juice those are different animals different ball games but if we talk about a normal community member healthy active just love staying healthy you're at the six week mark for that grade one to heal grade two grade three you're looking at ten to twelve weeks so knowing that let's work backwards so this person is a multi-sport athlete they have to be able to cut so that makes a big difference on this mcl i want to share a checklist that i've created and i've shared with the team and it's a checklist that i personally use if you ask me what's your algorithm on how you progress an athlete all the way through and on the initial evaluation or an initial visit what i'm going to use is this checklist to help me run a step-by-step progression on what deciding what that planet care and what the progression is going to be and here's what it looks like all right so step number one uh i'm gonna assess the body part now i know it's a knee um what's their sport what's your position we got multi-directional athlete and um they enjoy uh let's say soccer okay what's their training like how many days a week this person is doing six days a week so one game day five five practice one full recovery um their frequency of training um and the type of training um and then oh sorry and recovery so what do they normally do is a sunday's uh full day off or what are their lighter days that way i can put it in my plan and like if i know what they do on a day-to-day basis then i can insert what they're still allowed to do all right so let's go through the symptoms uh tenderness to palpation a little posterior swelling posterior medial swelling just from the contact so there's a contact injury contact mcl sprain and their symptoms are pain with walking full extension uh deflection beyond 90. what's their phase of healing they are definitely in the acute phase they are not feeling really good so um what's the timeline ideal world they'd like to be back within the next two weeks all right so once we know that we can kind of set the stage now what previous therapy have they had it's irrelevant here because we now need to know because we're the first responders here so now we can manage this moving forward but if you had somebody who was three four weeks out you do need to know what they've had in the past why because you don't want to over stimulate if they're seeing other providers they've seen a massage therapist they're seeing an acupuncturist you need to know because what you need to know is who's the quarterback at what time and what i mean by a quarterback is who is the person leading the rehab at what stage of healing and for some of you that's foreign because maybe you haven't worked with enough uh worked in conjunction with other providers and what i mean by that is if you have uh somebody in the acute phase of healing are they seeing a physician are they seeing you i see a massage therapist i've seen an acupuncturist i see an athletic trainer who's managing the acute phase and you can't say everyone because that person is lost imagine an athlete trying to have four different coaches tell them what to do they're like i don't know what to do somebody needs to quarterback that stage of healing and then who manages the chronic side and then who manages to return the sports side and who does the plowmetric side and who does the strength side and so if you're that one all provider good for you you better have this arsenal and you got to have this mapped out or else you can't go week to week you will set them up for failure and that's your fault that is not the right thing to do that is a waste of their time and that's because you had lack of preparation and so the best way you can prepare is going through this progression so if we want this person to be back at two weeks we have to say is that reasonable uh they're 20 years old they don't have the youth so at 19 years old they don't have 18 years old they don't have the youth juice they play soccer multi-directional and they want to be back in two weeks after an mcl grade one spring all right is this possible all right so on presentation you know they have the normal stuff you do diagnostic testing um and everything comes out negative and it's only positive for a grade one uh mcl tenderness palpation flexion beyond 90. a little soreness in full terminal knee extension um and uh and swelling and mechanism injury was a contact valgus um injury so uh besides i don't want to go through every single exercise that you can do because i think you can youtube that or instagram or whatever the the new platform is to be able to support you with like tactical exercises uh beyond that because there's going to be 50 different variations and i think that you can come up with that on your own i think that's great so the question becomes besides exercises what what are you gonna do in an ideal world if you can build this out on paper what would happen at week one how many days a week would you see them at week one what are you doing uh range of motion soft tissue swelling and gait training okay what are you doing at week two and week three and week four and if they want to go back to sport at week two you better realize what percent could they possibly be going into week two now everyone's different you don't know their healing but we need to do is have a projection how much better do you expect them to be at week one all right so if you know my progressions here's what i would say week one twenty five percent week two fifty percent week three seventy five week four eighty five week five 89.6 week 6 is 90 so that's assuming they're a community member they're not they don't have a deadline whatever it may be now the question is can you expedite those percentages and it becomes not about exercise it becomes more about environmental factors so let me explain what i mean by that so normally in a rehab setting you you work on the treatment the assessment you the fancy whatever you want to do do the goni metric whatever that means absolutely nothing in the grand scheme because now you have to project can this person play because you got to have that conversation and that dictates what your treatment is going to be so instead of going treatment forward i'm going to go projection backward and then allow that to dictate what your treatment exercises are going to be so environmental factors let's talk about management what in their adls would decrease their healing or impact or impair their healing all right number one adls let's talk about sit to stands let's talk about stairs so in an ideal world on an mcl you want that thing to come together as much as possible and an mcl is going to be stretched for sure past 90 degrees of knee flexion but ultimately in an ideal world you would lock this into extension now you can go two different frameworks do you are you anticipating that they're going to go back fast and you want to heal this so you can go conservative brace them lock them to extension so they have some healing and then once you have some healing then start to bend them add some load what i'm saying here is don't bend them beyond 90. especially on a grade one they're not going to love it it's going to put that thing on stretch and they're not going to feel good it's going to impact their healing what i'm saying here is if you can't expedite the healing what you can do is minimize the impact or the negative influence on the healing so on the adls you're going to have trouble going downstairs up and down stairs so what i would do is uninvolved goes up and uninvolved and involved goes down on descending however a little trick i learned with some pro athletes you you turn around make them go backwards and that way they don't have to irritate that knee and it's less knee flexion so stairs sit to stand same thing make sure they're keeping that thing straight it's not the one raising i know it sounds simplistic to you but if you're really like in the pro world you have to limit all factors that can limit the progress on this thing and that's how you have to think it's not about what's the best exercise to activate the vmo doesn't matter minimize the reduction of stress first and then you can add in all the spices that you want you can be the main chef that you want all right occupational demands at 18 years old this person is a student and so they sit a lot what i would do is make sure the leg that involved leg is straight do not bend it leave it locked in now what do you want to add in for taping and bracing them in a brace now don't tell me like a brace is going to make them weaker you're talking about soft tissue how do you maximize this person's healing i'm not talking about what the latest research is to you know for a community member i'm talking about game time and if you've never managed a pro athlete or putting somebody into play you got to imagine i told my team yesterday stop being a physical therapist and start being a human now when you think like yourself right you're a different person you're like if you had an mcl sprain would you brace yourself so you can heal and give yourself a better timeline and expectation to be able to play in two weeks yes you would why because you're going to throw everything the kitchen sink at this knee to give you the best possible outcome so take all the outside factors let's talk about like being a human this athlete wants to play and if it's a scholarship opportunity for a d1 soccer player you better believe we're going to throw all of it all of this stuff at that athlete if we have only have two weeks guess what the sideline ex you know leg raises and the bike and the quad activation and glue like that's not going to do it you want to minimize all the stress so i would brace this person i would tape them every day if their skin can handle it give them support i would have a um a neoprene sleeve on this thing swelling reduction brace them lock them in extension uh if they need to have a little bit of flexion i'd block the 90 degrees tape them every day uh neoprene plus brace all waking hours don't allow them to flex their knee at night have it elevated knee extended all these little tricks are massive to keep this thing healing and away from all the irritants that would delay healing okay so we talked about adls we talked about occupational demands uh we talked about the taping embracing now the psychological aspect of this all right this is this is a big one and um you need to put yourself in this position if if if going to pt school was on the line for you and you had something come up you would make every effort to do to try and make it to pt school or take the gre or whatever it is and if it took all this time to prepare and something happened right beforehand you're better believe you're going to take every effort to make anything happen to ensure that you achieve your goal now if that happens you better believe that your mental strength you're going to be challenged mentally on what that means and you as a provider if you've heard me in the past you understand that i think that we as providers are like nine or ten different providers all in one we're not we're not phenomenal at massage we're not phenomenal at mobilizations or grade fives or manipulation whatever you want to call it we're not phenomenal at medications we're not phenomenal at reading mris we're not phenomenal at being a sports like we're not phenomenal at being a nutritionist however we have the capability the basic knowledge to help sort support somebody in each of these aspects and rehab them or while they rehab and what that does is it puts you in a unique position if they're here to rehab you can add little elements and so you definitely have to be a sports psychologist at this point at this point but you don't have to like delineate it and be like well you're injured so now i'm going to be your sports cycle no you're injured how are things at home how is school keep their focus keep their attention keep their motivation high and when you do this it allows them to heal because like not only are they injured on that knee but they're also injured in that head and what you need to do is help keep them positive keep them mental focused we know that if people believe they're going to get better it actually is going to help them fulfill that mission and if they don't believe they're going to get better guess what they won't so you need to help them in that aspect of all so keep in mind keep in mind the psychological factors if you see them down lift them up keep them put you know pushing and motivated always moving forward if you if you end up on my table as a client and you have an injured knee i don't care if you're a physical therapist you're a physician you're a chiropractor you're a dentist i'm going to teach you the exact same way i'm going to treat you like an athlete and you better believe i'm going to push you and keep you motivated because i know what that feels like and i'm going to treat you like a pro athlete and if you need to consider that this is an mcl on a 18 year old multi-directional soccer player guess what the same principles can be applied to a 27 year old weekend warrior basketball player or a 42 year old professional football quarterback you better believe the same things happen so i'm just breaking down the fundamentals notice how we haven't even talked about exercises exercises are just the that's the icing on the cake the layers the foundation is this okay so we went through adl management we went through occupational demands uh occupational events just if they're a soccer player great like but if they're a factory worker a community member you kind of have to put those in like if they stand for a living you might have to see if you can get a doctor's note to you know put them in sitting and maximize recovery but these people usually this is a full-time job uh they are a student so i think a lot of people are virtual at the moment so if they're sitting for a long ter long time they just need to keep that foot elevated and straight type of embracing and just keep their motivation high right so now now that we know all of this now we can establish the greatest best plan of care knowing that we have all the information we have a timeline of two weeks so if this were gonna go backwards you gotta understand if you have 14 days and three days already have been wasted on soft tissue healing now you have 11 days how are you going to get 11 days to return to sport so if you're gonna return to sport you gotta have contact or what about this let's go non-contact practice multi-directional let's assume on friday uh let's go saturday is a game friday is a light practice walkthrough drills and thursday is a little bit of a mini scrimmage with a little bit of contact so let's assume they go non-contact on thursday they have to be able to go multi-directional so you do multi-directional testing on wednesday let's zoom they had lateral on tuesday linear on monday that means they had to start jogging on sunday that means they had to have been able to accept load and plow metric on saturday that means on friday they had normalized gait and ability to step up and down sorry let's go step up and down pain free that means on thursday or friday they had normalized gate that means on you know wednesday thursday they had normalized range of motion do you see how like working backwards this person's healing needs to be like pristine in order for this to happen and if it doesn't then all you're doing is pushing everything back so on a community member if we said six weeks was the time to heal fully that we know at this point then we would say six weeks is you know return to sport that week they're doing con contact the week before that doing non-contact so at week four they're doing linear lateral multi-directional work at week three they're doing strength work at week two the normalizing gait and week one you're doing soft tissue healing very possible at the six week mark if you can't work backwards it's not possible your exercises are irrelevant if you don't know what your target is so week one range of motion get everything swelling reduction week two get some you know uh normalized walking uh work through some normal progressions week three start strengthening week four work on linear and impact week five lateral multi-directional non-contact uh week six uh multi sorry contact to be ready to play at six weeks if they cannot achieve that they're just gonna be like just shift the whole progression over a week or two or three but you know what's gonna make it worse where you would put your most bang for your buck don't mess them up in the first two weeks let that first phase of healing happen don't be superman and this is where i have the biggest challenge with students new grads established people who work in an orthopedic setting and haven't managed people who have a deadline and they've not seen acute injuries as much and what this does is it messes them up and it pushes their it shifts their whole progression weeks down the line so in the first two weeks don't touch it leave it alone don't be superman don't be doing like plowmetrics and high level stuff treat them conservatively but if you map out the next four weeks they understand like we're doing this for a purpose first two weeks just buy you some time let the healing happen stay mentally strong allow yourself to get fully healed focus on what's coming up next you got four weeks after that to like crush it but if you mess them up in the first two weeks it's significantly exponentially going to delay their healing so in the first weeks be conservative the next four work them out but in a timeline like this where i have a 18 year old professional soccer player this is going to be a tough timeline and we had a good question is it our job to get them back to 100 percent our job is to get them back safely and if they're an adult they're going to make that decision but you got to give them the repercussions or the possibilities of what they can do to this knee and what that means for them and your job as a rehab you know specialist or health care provider is really to do that is to to give them the outline make sure that they know where where you're going to take them and if they don't understand that what they're going to do is assume that you're going week to week and mentally that doesn't allow them to prep and all you're doing is increasing their anxiety they don't know where you're going to go it's like not knowing what's going to happen next week and as an athlete this is their identity this is their income and that gives them a lot of fear and what you need to do is control and manage those variables the best thing you can do is tell them what the timeline looks like given the expectations once you do that they now have a realistic expectation of what's to come and something to focus on it is the job of an athlete they have that that's their whole life this is our who they are as a human and if you are a pro athlete whether you're a physical therapist or a student this is who you are let me let me just explain this to you if you're listening to this podcast i promise you you are super passionate you're going to be doing big things in your life you're you want to be successful you want to be the best in whatever you do and if it was sports you better believe you wanted to be that pro athlete or you had that potential or you you had the work ethic you had the skill and these people think like you and if you were injured you want to know day by day progressions and if you don't do these progressions let me give you a little reality check it's because you don't know how or you're lazy there's there's two things you have the skill or the will and if you have both you're going to be a fantastic clinician if you have the skill to do it great if you don't then build it the will i can't change like if you're if you're if you're lazy that's a different story like so you just need somebody to like shake you and like come on like pick you up for the same reason this athlete needs that motivation like let's go so but if it's skill problem it there's not a lot of it's pretty basic guys you've learned this in pt school i think that the problem is you're trying to consume too much like zone out see the rehab progression on an mcl 18 year old professional soccer player uh scholarship on the line can we do this in two weeks it's gonna be tight can we do this in four to six yeah but don't mess it up in the first two weeks and the biggest thing i want you to understand is with my checklist you need to manage the external variables it's not about the exercise exercise is just one variable to get them there but if you have the outline you can't mess up in those blocks and that'll set them up for success and they will absolutely love you i promise it is it just works it soft tissue healing it's science it's art it's a progression it is what i love it's what i love and i will share more and more of these case studies i'm getting good great feedback from you guys as listeners and i uh one of the things i'll do is i will i'll get emails from you guys like hey can you cover this or you know based on responses from my instagram at chris garcia dpt you guys give me feedback like hey i like these topics can you give more of this yeah perfect i'll do that but just know at some point like it's all the same stuff it's just the progressions and if you don't want to learn the progressions you're always going to be seeking out like well do you do internal rotation of that and the lateral rotation of this and then you do hip mobilization it doesn't matter because the block is what matters just don't mess it up get them to week two so they can buy some time to get week four and then get them in practice at week five it didn't matter was it it was a poster cloud or medial glide it just mad it mattered that you didn't mess them up don't mess them up like the general principle here do me a favor i i i you'll hear my outro on this thing what i want you to do is if you love this podcast if you're like man i love hearing about the real side of physical therapy sports physical therapy and you know sometimes i i don't i get consumed by the data and all the little things and all the research and sometimes it's hard to take a bigger picture here's what i want you to do if you love it i need your i need your support here i need you to leave me a five-star review on um itunes and what this does is it helps me reach more people just like you uh you know i i have some exciting news coming down the pipeline of of conferences and things i want to do with students new grads and and establish pts but the the i need your support i need you to share this like let other people know like what is it that you love about this give it a five star and tell people what it is that you love like it's real it's practical it's not just research that it's like easy to implement and it's like foundational large big picture things and allows people to see what they really do for people instead of what they do to people i am trying to get you to understand what you do for people not to people understand that okay all right um i appreciate that in advance uh give me a shout out on a five-star review i'll uh shout you out on my instagram i'll i don't know i'll put you on the newsletter i'll do whatever whatever it is but i just need the support i appreciate you guys tremendously and and thank you guys for the support uh we are going to conquer the world and get people to think large scale uh as they grow and uh that's that's my mission so i hope you enjoyed the podcast i hope you guys are staying uh safe and healthy and uh you're enjoying uh life and living it um i know because i am all right i will see you guys on the next episode thanks for tuning in see you guys