Returning to sport after an injury is always a challenge. In the profession, a lot of attention has been given to objective testing to determine when and how to progress athletes. This has been a significant evolution that will definitely improve outcomes.
But what do you do when an athlete passes objective testing but not psychological readiness testing?
We talk about what we do in this week’s podcast episode.
To view more episodes, subscribe, and ask your questions, go to mikereinold.com/askmikereinold.
#AskMikeReinold Episode 374: What to Do When an Athlete Passes Objective Testing But Not Psychological Readiness
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Show Notes
• Evaluation and Treatment of the Knee
Transcript
Francesco Casale:
All right, we got Nora from Maryland. Long-time podcast listener. “I feel like I have slowly improved with my return to sport decision-making, now that I have started to focus on objective strength testing based on some of your past recommendations. Sometimes I feel like my athletes might pass testing, but they aren’t really confident they are ready to go back to sports. How do you balance objective strength testing with psychological readiness in return to sport decisions?”
Mike Reinold:
Awesome, Nora. Good question. I feel like we get this opposite question all the time. Somebody that doesn’t pass objective testing. That’s all we love to talk about on social media and the internet right now is somebody that doesn’t. But what do you do if somebody does pass objective testing, but not some of the psychological readiness stuff? What a question, Nora. I love that. And if you haven’t seen that yet, hopefully as we continue to evolve our rehab principles, which I think we’re getting better and better because we have really, really exposed this on the internet… There’s a lot of attention to getting better at our rehab principles following ACL and other stuff. I think we’re going to get better and better. And you’re going to start seeing this more.
Before you’re eight months out, your objective testing was behind, your psychological readiness was behind, and you’re like, “Yeah, of course. Why wouldn’t they be synced up?” But what do you do? And I’d love to hear some thoughts, but I kind of want to hear a couple of thoughts from you guys. One is why do you think that might be? And then two, what do you do about it? And I guess three, do you let them return to sport or not? That’s the interesting question, but I don’t know. Len, you want to go first?
Lenny Macrina:
Yeah, I’ll go first. I mean, I come across this. It’s not a fun one because you don’t want to push them into an uncomfortable zone, but you need to begin to push them to be uncomfortable because in a test tube, essentially like a trial in your gym or whatever you can do for drills to give them the comfort and give them the confidence to get back to their sport. The strength testing is one small piece of it, and we see that all the time. Where, like you said, the other side is, “No, I’m ready to go.” And then you test them, they’re like 80% LSI. So you need… If the strength is there, including the deceleration strength and breaking strength, that you’ve been able to measure that and observe that and get objective numbers, then you need to, as the PT, you got to start playing your mind games with them and put them in positions to show them that they are ready to do things on a field or for their team.
But don’t force it. Take your time, but give them drills, whether it’s a deceleration drill, whether it’s, “No, no, you did great. Look at that. Look at what you just did.” You should take a video, let them see the video, let them see themselves performing the act of whatever they’re going to do. Do some contact drills if you feel comfortable doing that in your gym, and let them see that they were able to handle it well, and you’re building up their confidence. You’re building up their ego. So a lot of what we do are mind games with our patients from the beginning, at least I do, is trying to get in their head and see how they handle a challenge early on. Whether it’s just like, “No, let’s get off the crutch. Let’s just use one crutch right now. I think you can do it.” And they look at you like you’re crazy.
And you just see… Look in their eyes and see how they respond to that challenge. And you slowly are playing little games with them. At least I do throughout the process. I’m like, “Let’s take the crutches away,” or “Let’s take the brace away. Let’s just walk out to the gym and not need anything,” right? And they’re like, “Wait, are you serious? Does the doctor say that’s okay?” I’m like, “No, you’re fine.” And you’re slowly playing those games with them along the whole rehab portion, and you just see how they do. It’s no different right now, that you can prove to them through video, through them watching themselves and performing, that they’re ready to go. So it’s not easy. Sometimes people need a brace, sometimes they’ll want an ACL brace. If doctors don’t want them to have one, that might be a little thing you put them in to give them a little confidence. You don’t want to rely on the brace. But some kind of functional ACL brace also can build some confidence in people, too. So I don’t know. Yeah, I’m curious what others have to say as well.
Mike Reinold:
Yeah, good start, Len. Kev, what do you think?
Kevin Coughlin:
Yeah, I think I definitely agree with everything Lenny had just said there. I think what I was wondering when they say that they’re passing tests is just maybe what tests they’re passing, because I think as Lenny alluded to, if they’re passing the strength testing, that’s just one small piece of the whole return to sport picture. So I know at Champion we use… We’re lucky to have force plates, so we’ll look at vertical jumping on that, a bunch of different ways. Usually like a counter-movement jump, a single leg counter-movement jump, a single leg drop jump, and then we might even look at stuff on the 10/80 for horizontal jumping, like single leg bounding, and then even a 5, 10, 5 agility. So they’ve kind of done a lot of these different tests that are challenging the knee and a bunch of different things related to sport.
And then if they’re passing all of those things and they still don’t feel quite ready, I think exactly what Lenny said, towards the end of rehab, we’re trying to put them in situations that are similar to what they’re going to see on the field or on the court. So we’re trying to replicate that as much as we can. And then also there’s a phase where they’re getting back to practice with a team, and maybe they’re staying away from contact drills initially, but even that’s like a gradual reintroduction into their sport. So it’s not like we go through rehab, we pass the test, and we say, “Go play in the game this weekend.”
They should have built a lot of confidence through the end of rehab and also through some practicing with the team. So by the time they’re fully passed and fully cleared, they should feel like they’ve had a lot of experience doing those things, and this is just the last 1 or 2% to get them there. So I think if you think big picture like that and you’re checking all of those boxes, most people should feel fairly ready. And if not, it’s obviously just a discussion with the patient about, “What are you still worried about?” and how can we best help them get through that, whether maybe sometimes it’s a referral to a sports psychologist or something like that. But I think in most cases, if we’re checking those rehab boxes, the person hopefully will feel ready at that point.
Mike Reinold:
I think that’s a good way of saying it too, Kev. You explained a lot of our late phases of rehab, especially at Champion, with our athletes. I used to always tell the people that, “Look, when you go back to sport, it’s going to be anticlimactic.” I think I said that yesterday to somebody that’s about to start a throwing program. It’s going to be anticlimactic to what we did. So I think a lot of times it comes back to just your graded exposure to the loads that they’re going to have. And just to be honest with you, Nora, the first time somebody does almost any activity, there’s probably going to be some apprehension. And then the brain, they figure that out. They reconcile a little bit like, “Oh, okay, my knee didn’t pop, I didn’t give out. Great.” And then the next time, they have a little bit more confidence they do it. So it’s kind of about that graded exposure to it. So I like that, Kev. I think that’s a good way of saying it. Dan, I saw you raise your hand for Kevin. What do you got?
Dan Pope:
Yeah, I think all of that’s really important. And I always wonder when athletes feel like they’re not prepared, what was that protocol like? Did they have a lot of agility, jumping, changing direction? I think that overall, that’s probably one of the bigger problems for most PT facilities. They don’t have the insurance reimbursement or the facility set up to do that. But I think the other one is that you can ask them and just try to figure out why they don’t feel prepared, and then you could basically cater your program towards whatever inefficiency they may have.
And I think the other thing is that some athletes are just kind of scared to bridge that gap between… Maybe they are performing at a very high level in the physical therapy facility, and then going back to practice is a little scary. I think one of the things that can help, and it’s very important, is to try to get the coach involved and come up with a really reasonable plan for that athlete to go back so they’re not getting thrown immediately into the fire, that you have specific drills that they start with, maybe not going every single day. They’re not doing anything live when they start, no contact, whatever it is. And then making a plan that’s patient-centered. So it’s, “Okay, are you a little freaked out by these things? I can understand why. Let’s make a plan that makes you feel comfortable, and when you go back, we can always pull back or speed ahead depending on how it goes.” I think that helps to increase comfort because their specific needs are being met a little bit better.
Mike Reinold:
What a great way to say it. That was awesome. Just ask them. You’re probably right. They’re probably going to tell you exactly what they’re most hesitant and apprehensive about, and then you can build your program around it. That’s awesome. Anthony, do you want to jump in?
Anthony Videtto:
Yeah, I was going to say, I feel like when athletes are ready to get back to sport, their coaches have this unreal expectation or put unreal expectations on them that they’re just going to be fully 100% ready to go the second they get cleared to sport from their PT or surgeon. So I feel like having that open line of communication, like Dan said, and having a plan set in place where they feel comfortable enough to go to their coach and say, “Hey, I need to build back slowly into this sport that I’m getting back into,” whatever it may be. And I feel like sometimes coaches just have this expectation that they’re cleared, they can play 60 minutes of a soccer game, whatever it may be, and kind of just go zero to a hundred really quick. And sometimes I feel like athletes just aren’t prepared to do that. And then so having open lines of communication with PT, doctor, and then with the coach, and just having that open line of communication, I think that’s an important piece of this too.
Mike Reinold:
I love it. I would say in my experience in that model… I’ve worked in a couple of different variations that I’ve worked in. One, where the coaching staff works with you, which is great. The coaching staff wants to hear, “Oh, there’s some limitations, but he can do some stuff.” Great, let’s start integrating them. And I’ve worked with others that are like, “I don’t want them until they’re a hundred percent, don’t even bring them anywhere near the field or whatever until they’re a hundred percent. I don’t even want to see them, they’re yours.” So that’s actually a good point, Anthony, is just making sure what model is the coaching staff that you’re working with probably part of, so that way there’s realistic expectations for you and the athlete going into it. So good stuff. Gates, what do you think?
Brendan Gates:
Yeah, so I feel like we’re all pretty much on the same page here, and I love that everything you guys have been saying is just in line with what I was thinking, but I think, in short, confidence is built through preparation, and I think talking about the graded return to sport is really important. One thing that I think is kind of a fun perk of our job is that while we test for strength through the handheld dynamometry, throughout rehab, we can monitor psychological readiness through some of the outcome measures, like for the ACL-RSI or the Tampa Scale 11, things like that. But I think, and we’ve talked about this on this show before, sometimes people are really eager to get back. They know if they score high on those, it might boost them up a little bit in their rehab return time.
So I think what’s cool about our job is that yes, we can use those measures and yes, I think they’re important, but you also get the chance to talk with these people once, twice a week and get into their heads and see if they actually are confident, or if they’re just using that test as a way to get back. So I think that’s important to do. Just check in, see how they’re feeling throughout the whole course of rehab instead of waiting to the end and just giving them the ACL-RSI and being like, “Good luck. Hope that you score high on this.” So I think we can use our time to our advantage there.
Mike Reinold:
Yeah, that’s a great way of saying it too. And I guess you see athletes of all sorts. So that’s a good point. Some people that are eager to get back, some people that aren’t, and everywhere in between. Sometimes you can fudge kind of those scales a little bit. That’s a really good point, Brendan. Awesome.
Well, Nora, I hope that helps. If you’re interested in this stuff… I mean, I don’t want to put too much pressure on everybody here, but Dan, Kevin, and I are working on a return to sport course that is hopefully coming out in the future here. So keep your eyes peeled. We’ll see when we can get that going. I think that’ll be a good baseline to help people progress to make sure that we’re conquering both of these, both the physical and the psychological aspect, to get people ready. But anyway, if you have a question like that, head to mikereinold.com, click on that podcast link, and ask away. And please subscribe on whatever thing you use to listen to your podcast nowadays. We’ll see you on the next episode.
