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[Physio Explained] The essentials of ACL return to play testing with Dr Tim Mcgrath

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In this episode with Dr Tim Mcgrath we explore return to play assessment of athletes post ACL reconstruction. We discuss:

  • The importance of making the rehab specific to the patient’s end goal
  • High risk manoeuvres in rehab/return to play (RTP)
  • How important is RTP testing?
  • RTP testing essentials 

This episode is closely tied to Tim’s Practical he did with us. With Practicals you can see exactly how top experts assess and treat specific conditions – so you can become a better clinician, faster.

👉🏻 Watch Tim’s Practical here with our 7-day free trial:
https://physio.network/practicals-mcgrath

Tim is a Sports Physiotherapist with over 20 years professional practice & professional sport experience. He is currently working as Senior Director of Player Health & Performance for the Washington Commanders NFL team in the USA. Tim completed his PhD from the Research Institute of Sports & Exercise (UCRISE) at the University of Canberra on the topic of ACL rehabilitation and return to sport following knee injury in 2016.

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Our host is @James_Armstrong_Physio from Physio Network

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SPEAKER_01:

Assessing capacity is a much easier thing these days. There's load cells, there's dynamometers, there's measuring tapes to measure like jump distances, there's force plates, there's even like phone apps that can rely reasonably reliably remeasure jump heights, for example, which don't cost a lot of money. So measuring capacity is a much, much simpler task than it used to be even like five kind of years ago.

SPEAKER_00:

Welcome to the Physio Explain podcast. In this episode, we're joined by leading physiotherapist Tim McGrath to unpack a crucial topic in sports rehab, and that is the return to play testing for ACL patients. Tim is a specialist sports physiotherapist with a PhD focused on return to play following ACL reconstruction, and he's worked extensively with elite athletes across many high-level sports. And is internationally recognised for his research and clinical expertise in knee rehabilitation. Building on the practicals he delivered for Physio Network, Tim shares how he assesses readiness to return to sport by measuring an athlete's true physical capacity. He explores the key markers to focus on, the clinical reasoning behind return to sport decisions, and importantly, how to adapt your testing approach no matter what equipment you have, from high-tech setups to minimal resources. If you work in ACL rehab or want to sharpen your return to play reasoning, this is a must listen. I'm James Armstrong and this is Physio Explained. Tim, welcome to the Physio Explained podcast. Great to have you on. Thanks for having me. So as many listeners probably are already aware, and if they're not, they are going to be very soon. You've already done a fabulous practicals on the Physio Network practicals suite on ACL early mid-stage rehab, which I can attest to, watching myself, really useful, very obviously practical in nature. Today we're going to be talking about return to sport testing, if it's okay. An area that we know that you've got a great interest in and a good amount of experience, believe leading on from your PhD into the work you're doing now. Do you want to give us a bit of an overview of what you're doing with that area of testing and recording?

SPEAKER_01:

I think it's like obviously the common question you get on the back end of it is like, so am I ready to go back? Either like from a coach or a parent or even like the athlete themselves. And it's obviously a complicated answer that comes from what is a pretty simple question at the end of the day. So the whole idea of any kind of benchmarking or like a return to play testing, I think is just about having some confidence that by saying yes, you're good to go back, that you've done the best that you can to sort of mitigate risk and having success when they go back to play. So it's really around doing the best job that you can to sort of try and mitigate that. Absolutely, definitely.

SPEAKER_00:

And obviously, many clinicians don't have access to super expensive, complex equipment and things like that. But that's not always necessary, is it? Well, you've obviously got with what you do access to some of that equipment. Just to kind of ease people's minds, if they're working in a in an area that doesn't have access to that, are they able still to do this well?

SPEAKER_01:

I think like the key part to it is is like work backwards from the endpoint, which is what's the ultimate goal of the individual. Like if they just want to go back to the gym and they want to go linear running, for example, okay, well, you don't need 3D kinematics of high speed change of direction running, for example, like that's just grossly wasted resources. So I think it really comes back to like ultimately where are you trying to get them, and then putting that into a context of the whole spectrum of things that we know to be like risk factors. And I've said it too many times. So if people are listening to it and have heard me talk before, I apologize. But the only way that makes sense in my brain is to put everything into a box as to where it lives because there's so many things out there now, it has to sit in a context of those risk factors. And the analogy I use is you've got like a racing team. So you've got the racing car and you've got the racing car driver. And the context for ACL is you've got all the physical capacities that come into it, like how stable the knee is, is it is acquired. Do they have full range of motion? Do they have strength? Do they have polimetric ability, all the sort of physical elements that really at the end of the day dictate the ability of the leg to function normally and absorb and produce force? And on the other side of it is how ACLs happen. So alcohol and things like that can sometimes help lower the threshold. But you know, it's usually high-intense movement. So change of direction, reacting to an opponent at speed, landing from a jump, particularly if it's like a contested it's things where there's it's a high, stressful sort of situation. And to that end, is the rehab. If you've seen with the course that we did before, is like it's trying to take them to that sort of endpoint where you're trying to get them. And then also the benchmarking has to reflect that as well. So if it's a change of direction sport that you're trying to get them to, you have to have some level of confidence that you kind of normalize that sort of getting back to it. Assessing capacity is a much easier thing these days. There's load cells, there's dynamometers, there's measuring tapes to measure like jump distances, there's force plates, there's even like phone apps that can rely reasonably reliably remeasure jump heights, for example, which don't cost a lot of money. So measuring capacity is a much, much simpler task than it used to be even like five kind of years ago. The measurement of movement quality or normalizing relative to some of these kind of stressful movements, that's a much harder beast. And everyone who involves themselves in that ultimately has to decide where on that spectrum do you want to be. There's things that have higher accuracy, but obviously involve spending a fair amount of money and developing expertise in terms of like motion capture. And then on the other end, you've got coach's eye, you've got relatively simple phone apps and things that can sort of help quantify kind of movement, but there is inherent flaws, like the whole end of the spectrum, there is flaws, and it's really just being aware of what those are at the end of the day, just so that you know what the strengths and weaknesses are of whatever your approach is.

SPEAKER_00:

Definitely. And how important is it? I mean, if we're looking, it seems maybe from those who are knowledgeable about the area, it seems like a silly question. But how is important is it to be testing an athlete's or a patient's readiness to return to sport? Is it known to be something that reduces that risk of reinjury if we do or don't test?

SPEAKER_01:

Yeah. So for example, now, like with the pitre stuff, we've got data now on 1,500 like individuals, and about two-thirds of that is like post-ACL, like at different levels, and about 300 of those are like professional athletes, like male and female. So we got a reasonable idea now where you send them off into the wide world and then see what happens, and then which are the metrics that then correlated to people that then went on to have a subsequent kind of an injury. And within those two themes, the bit that plays out consistently is people that normalize the racing car driver element of it have a much lower risk compared to the ones that don't. Also, like the capacity side of it is helpful, but it probably gets it to like a 50-50, you know, like a 50 toss of the coin. So the measuring like normalizing capacity is important, but it's not as powerful as trying to build in resilience, especially when you start talking about do they have the ability to execute high risk, high stress movements without putting, in this context, we're talking about the ACL, like putting that at risk.

SPEAKER_00:

So that that racing driver, that that element of are we talking about allowing that athlete to be confident, reduce kinesophobia around the the activities that are related to their sport that they're doing.

SPEAKER_01:

There's so many elements to that, right? Like it's you've got the actual mechanics of like people dislocate their shoulder when their arm is generally like in an abducted, externally rotated position. For an ACL, it's not an absolute, but it tends to be lower knee flexion, as in the straighter your leg is, which matches up to when you're doing a Lockman test on someone. If you have to have their leg at a certain amount of extension to be able to get tension on it, otherwise you can't get an end feel, like anyway. So it's generally sort of lower knee flexion. For a change of direction, you're talking about how wide their foot is relative to their center of mass. The knee becomes the fulcrum then between uh where the ground is, where their foot is, and where the proximal segment kind of ends up being. And then the other part, which is like again, replicates a pivot shift, is I call it like pepper grind, which is where you have the proximal segments going in a different direction to the lower sort of segment. So there you're sort of your high risk maneuvers, and and it's basically the ability to not do that under high stressful situations is like the part of it. And then the other element of it is protective behaviors. So, like we talk about fear, for example, as being like uh something that is highly relevant. And rather than focusing on, say, questionnaires for someone to say yes, I'm confident I'm ready to go back, because that can be misplaced as well. Like, you know, you can have people who are in a good place but frightened. You can have people that are not frightened, but for all good intensive reasons, they probably should be frightened. So I tend to not focus on that part. Obviously, have conversations around like where the headspace is at with it. For me, it's around especially like change direction sports, is if they can gas in, they can execute a high speed change of direction maneuver, like the correlation tends to be pretty strong with someone who isn't necessarily frightened. And then also like the cognitive rigidity. So, like, for example, if I've got like a if I've injured my right knee, then my instinct is to do everything I can to protect that right knee. So I'm gonna try and step off my left leg, or if I'm running into change direction, I'm pre-planning, I'm going like right leg. And then in the end, if it's not the right leg, oh, like it's this jumbled mess because they don't have the ability to adapt to the environment at the same time. So, like under that whole kind of like movement banner is people's cognitive rigidity, like their ability to execute a task in a safe way, and then also confidence, which is usually a byproduct of all the things that go into like a good rehab.

SPEAKER_00:

Want an easy way to improve your assessment and treatment skills? Introducing practicals, where you can watch video recordings showing exactly how top experts assess and treat a range of conditions. It's the fastest way to develop your practical skills and enhance your clinical reasoning. Treat your patients like the experts do with practicals by Physio Network. Click the link in the show notes to try it for free today. So in terms of testing, are there any elements of both capacity and, as we talked about, the racing driver element to it? Are there any of those that you feel are non-negotiables, things that you'd recommend to clinicians that they really aim to not miss and not test?

SPEAKER_01:

I mean, you have to have a happy knee, you have to have a knee that can get full extension, you have to have a stable knee, lack of joint effusion, lack of irritability around the knee, that has to be a non-negotiable. I feel, and especially it's pretty easy to get these days, is you have to have some kind of a quad index, something that measures quad strength because that's ultimately the suspension system of the knee. So if they don't, if they can't do that, then knee is either going to get angry as soon as it starts getting low thrown at it because it's the joint's gonna cop it instead of the soft tissue is kind of around it. And also quad is helpful in D cell hamstring calf strength, again, like just for general sort of lower limb kind of strength. And then some form of like, you know, hop testing is a cheap thing to do. Like I would say that's a non-negotiable because there's no real barrier there other than maybe a bit of time that's kind of part of that. Again, like jump testing, like vertical testing, I think is good. And again, you can get web apps that don't require a lot of or not a big expense, you know, be able to access that. But again, those are all very much centered on the racing car sort of element of it. So, really, like on the other side of it, you're either relying on like to objectively measure it, you need some form of technology to help you, or you're relying on coach's eye, which obviously, depending on the experience of the person, takes a fair amount of time to develop. And it's massively prone to bias. People changing direction now, and you'd be surprised, like in real time, like a usually teams send send staff members with the athlete when they test and they say, like, what do you think? And I'll go, Oh, like this and this and then that. I surprise myself like how wrong I can be sometimes, just because your biases tend to play out, like you tend to see what you want to see a lot of the time.

SPEAKER_00:

I'm particularly interested in this moving away from the capacity because I think we're beginning to now get to the point where a lot more people are comfortable with measuring capacity, whether it be for routine rehab or return to play. But when you separate it out into that more applicable, specific return to play elements that you you talk about, the racing driver, what sort of spectrum is available, I suppose? Everything from I have nothing of a single one-man, one-woman band physio in a clinic to a large corporate with lots of money. What's the spectrum available?

SPEAKER_01:

Yeah, I mean, the spectrum, the most cost-effective one is your eyes, a coach's eye. Then probably moving up along that spectrum is you have GoPros, iPhones, like things that sort of record people doing, and then you can reflect on what that you're like, you can use that as a way of reviewing. And athletes tend to like that as well. So you forget like the return to play thing is like that can be a good thing because they can, especially if there's sound recording, then they can like hear your cues, the things that you're trying to teach them. So it's like a good learning tool. Moving up from that, there's a few apps on iPhone, iPad that will do skeletal annotations so that they can be able to put body part attached joint centers onto where your hip joint center, your knee joint center, like that sort of stuff, which is not bad for pure sagittal plane viewing. So if you're looking at someone doing a single egg squat, for example, and you're viewing it from side on, it actually lines up pretty well with even like 3D kinematics. But as long as you're perfectly perpendicular to the view, as soon as you start to drift slightly forward or slightly back, it completely alters the view, so it can affect the results. Then the next level up from that is you've got what they call markerless motion capture, which is 3D. So they'll build a camera volume like in a lab or so forth. And then they'll do the same thing. So they'll have an avatar and they'll sort of put body attached body segments to that and it'll calculate joint angles. They've done research on that, and it's again pretty good sagittal plane. It gets worse frontal plane and more so like axial plane compared to markerless, sorry, marker motion capture, which is like the gold standard. So then, like you've got companies that have marker-based motion capture. Again, you build a 3D volume, you attach markers to people, and it's like an infrared sort of system where you know it emits out light and it bounces back. So you get like you know, millimeter accuracy uh around that compared to what is happening in real life, it's been shown to be relatively valid and reliable. The disadvantage of that is you have to then stick markers on people. If you want to assess a rugby player tackling someone, then they're gonna knock the marker off every time they sort of go and tackle, you know, like that sort of stuff. So coming up with an ecologically valid sort of situation, like from a movement competency, there's time challenges, there's cost challenges, there's logistic challenges. And like I've done a lot of it now, and I had to go and do like a computer science qualification at the end of it after I did my PhD because it pumps out so much data that you have to be able to extract it and put it in meaningful context. So you can have all this information, but it doesn't mean that it's gonna be necessarily clinically useful at the end of the day. So there is a spectrum, and that's the hard bit is everyone goes, okay, so what should I do? And it's like, well, honestly, there's a thousand answers to, you know, it's gonna be like different courses for different horses.

SPEAKER_00:

But I think that's really useful because knowing that spectrum means that the listeners can now start to think about where they fit on that spectrum. Are they doing anything as the number one? Can they do something? Where in that spectrum is it gonna be? And then as you rightly said, I'm sure it's knowing what are the limitations of where you sit, and as long as you're aware of that.

SPEAKER_01:

And I think that's the important part is like you still see thankfully it's getting less, but you'll still people talking about oh, like as long as I have quad symmetry within 90% of the opposite side, like then they're ready to return to play. And the part of me that's been doing this for a while is like, yes, it does demonstrate some capacity around the leg, but it is missing a whole swathe of things that we know are important, like from like a return to play sort of element. So it's nothing else people are aware of the context and aren't fooling themselves that they are addressing things to a high level when they're missing potentially large chunks of the large chunks of the rehab or l large chunks of the evaluation, I should say.

SPEAKER_00:

Evaluation as you get to that point. As you get to that point. Tim, brilliant. We've already got to that point. As always, in this podcast, it runs out way too quickly. Thank you so much for your time. Do all listeners watching this get yourself onto practicals and watch Tim's practical. He he does a really good job of breaking down how to take patients through a variety of different rehab options for early and mid-stage ACL rehab, which is fantastic. So, Tim, thank you very much. I'm sure we will definitely get you back on again.