Knee Pain - ACL Tears! Can you fix and prevent? David Boyer ATC, PSC, PSY

Join us on "Crackin' Backs Podcast" as we welcome back, Dave Boyer. ATC/CSCS, HMS, PSC, PSY. MS, as we delve deep into the critical world of ACL injury management.

In this episode, we explore the startling statistics of ACL injuries, impacting 1 in 3,500 people, with a staggering 72% prevalence among females.

David will unpack the decisive factors influencing surgical versus nonsurgical intervention, and rehabilitation timelines, providing invaluable insights into the latest practices for a successful return to play.

We'll examine the current trends in re-injury rates, the controversial topic of accelerated rehab protocols versus traditional ones, and their associated risks.

Furthermore, David will share his expert opinion on the intensive rehab debate, the quintessential elements for enduring ACL rehab success, and managing patient expectations across all levels of athletic performance.

Don’t miss out as we tackle the innovative approach of using the distal quad tendon for ACL repairs and the mental performance strategies for injured athletes facing the pressure to return to competition.

It's an episode packed with expert knowledge for clinicians, patients, and fitness enthusiasts alike, all seeking the path to optimal knee health and recovery.

We are two sports chiropractors, seeking knowledge from some of the best resources in the world of health. From our perspective, health is more than just “Crackin Backs” but a deep dive into physical, mental, and nutritional well-being philosophies.

Join us as we talk to some of the greatest minds and discover some of the most incredible gems you can use to maintain a higher level of health. Crackin Backs Podcast

Transcript

Dr. Spencer Baron: 0:00

Welcome to the cracking backs podcast where we zero in on the mechanics of movement and the science of pain relief. Today we're cutting into the core of anterior cruciate ligament. ACL injuries, a topic that strikes the lives of up to 200,000 individuals in the US annually and with a notable majority being female athletes. With us is David Boyer, a leading figure in rehab, strength and conditioning, who is here to unravel the complexities of ACL treatment paths from a non surgical approach to the intricacies of knee surgery, David will dissect the best practices for returning to the game post ACL injury, weighing the accelerated against traditional rehab methods. We'll dig into the specifics of return to play testing, and what the numbers say about the risk of reinjury. David will also share his insights on the debate around intense rehab routines can more actually be better without leading to overuse. We'll discuss how to tailor recovery expectations across the spectrum from pro athletes to those who play for the love the game. And we'll explore the emerging trend of using the distal quadriceps tendon in ACL repairs, as well as its potential to revolutionize recovery outcomes for anyone with their eye on knee health, whether you're a clinician, athlete, or just a plain knee conscious person. This episode is your playbook for the latest in ACL recovery science. Let's dive in. Welcome back, David. Welcome back. David Boyer, the guys

David Boyer: 1:48

having me back. And I love doing this stuff with you guys anytime to share information, get some more knowledge, both from you guys. And to put it out there is very exciting for me. Well,

Dr. Spencer Baron: 2:01

you know, it pays to be the premier, ATC CSCs and masters in psychology. So maybe you can give us a quick analysis about our co host. Terry Wyman,

Dr. Terry Weyman: 2:16

we don't have that kind of time. From California. All right. They're very,

Dr. Spencer Baron: 2:26

actually, I think is I think his Mayor needs a cross examination. I mean, Governor, Governor, sorry,

Dr. Terry Weyman: 2:33

we're not going politics. This is stick with the damn knees.

Dr. Spencer Baron: 2:38

So, Dave, you bet you dazzled us on our last program. And Dr. Terry, you know, he called and text me text me said Man, I love that kind of stuff. And, and I we heard it from a few other people that listened in so I want to start out right now talking about knees. And, and ACL injuries. And I understand a recent study in 2023 stated that the incidence of ACL injuries occurs between 100,200 1000 times in the United States. That's a wild statistic. So I'm sure you see most of those, but raising the ACL injury rates now. Yeah, right. Right. One in 3500 people in one study and 78 and 100,000. It's crazy. Um, so when it comes to gender, females account for 72%, while men are at 25%, across the board, that's a big deal, Dave, let's start off with that. And what criteria do you use for surgical versus non surgical ACLs? And how, and how long do you suggest rehab would be?

David Boyer: 3:49

Yeah, obviously, I'm not a doctor. But I'm gonna I'm gonna extrapolate a little bit on the information you have, because there's some stuff that I read. If you look at the total youth population, let's say 1321. All right. 10 million, or well, let's go 13. Let's go 13. Or let's go. What was it was I think it was eight to 18 year olds, 10 million youth athletes. Okay. All the ACLS there's probably 300,000 surgical interventions of ACLs. And a majority of those four, majority of those are the female athletes. All right. So the way that the ACL occurs is either non contact or contact 75% of ACL is or non contact, meaning that there's no external force involved with parent ACL is, you know, there's just something that happened, why do a D accelerating and running changing direction 25% of those contexts and again, the female athlete is, is more susceptible to the ACL injury than the male end? lionetti, we'll talk a little bit about why that is. But those are the statistics that I've seen recently, of ACL injuries that occur in just the youth population, just the youth. And again, like we said, most of those are females, I think there are four to six times more susceptible to an ACL injury than their male counterparts.

Dr. Spencer Baron: 5:23

It's nuts. Do you think that's because now, I mean, this is just a stab at the statistics, more more female, female, women's soccer has become so popular, even though it's non contact, but what do you think? I mean,

David Boyer: 5:41

there is some studies out there and I haven't dwelled into too much of that. But I've talked to a co worker of mine. And he seems to think that the ACL injury and the female athlete, I don't know if I necessarily agree with it. But there's, there's more involved, there's more women playing. So it seems like there's more, but the man athlete, like the football players actually suffer more ACLs also, regarding the population that's in the group of that athletic activity. So yes, I think there's more females, but then I think there's more females involved in those sports. And then this is them being so susceptible to the ACL injury has a lot to do with a like for other factors, only one that we can control. And you know, that's something that we probably like to touch on as we go through this, this process. But if you look at the ACL in its in its in its structure in the way it attaches, you know, the ACL is actually stopped tibial translation, it supports the rotational aspect of the knees, it gives IT support through that valgus Varus rotation stuff. And there's actually two bundles to the ACL, there's an anterior medial bundle that that it's tight in the flexion. And then there's a posterior lateral bundle that gets tight and knee extension. So the femoral attachments to the posterior medial surface of the lateral femoral condo, and they kind of go up there and attach to different bundles. But obviously, they come back down into one, and they a tibial attachment is actually in the front of the tibial spine and lateral to it, or anterior to the tibial spinal lateral to it. And like when you go through those motions, that lock whole mechanism, that's where that ACL is supporting all those mechanical movements of the biomechanics of that. And it's unique because the ACL also attaches to the transverse medial ligament, and it's attached to also the anterior attachment of the anterior portion attaches to the lateral meniscus. So the anterior traverse, or ligament, transverse ligament holds that meniscus doubt, you know, so So some of that attachment, I mean, unless you're pulling it off the bone, it probably is not going to disrupt that, because most of those ACL tear in the mid substance of it, so the care across the mental aspect of it, but if you get a severe enough one and goes in, it can actually lift the the meniscus off the bone by disrupting that transverse ligament, across the the whole the patella, or I'm sorry, to hold the meniscus down. So there's a lot going on. It's actually as the knee injury, you know, there's a lot that that that small little structure does for the function of the name.

Dr. Spencer Baron: 8:41

I want to ask you about your suggestions for rehab, and how you you know, like what criteria you use to determine surgical correction. But before you answer that, I have a thought about that I'd rather you answer first, we were talking about provocative factors for what, you know, stresses the ACL. We've been hearing a lot about turf versus ground. And Dr. Terry spoke with a guy, a chiropractor, who is with a colleague, excuse me, a high school team. And he reached out to me and asked if I have any research on it. Now, there is research out there and it does favor ground versus turf. But what what are you what are your thoughts on that before you answer the surgical rehab question?

David Boyer: 9:33

Well, yeah, I mean, I hear the same thing you hear, you know, I toured on turf. I toured on ground. I don't know, I haven't done enough research or investigation where most of them occur. But I think if you look at the four factors, like I talked about, what I mentioned earlier, is that the environment that you play in is very difficult. In the sense of the control, whether it's the turf or the ground, you know, if you're playing on turf, and you'd like, Well, I'm not gonna play today, because it's turf. I mean, that's, that's out of your control. I mean, it's in your control, you can say, I'm not gonna play, but then, you know, you're not going to do that more than likely, because you're, there's other things that can that you can have influence on, associated with decreasing the ACL. By understanding, you know, one, what is the ACL, two? What are the factors that can contribute to it. So the environmental factor, I don't think, is playing a big role, maybe deeper in as we go into it, the research aspect, all these turf fields might get changed to the to brass, but ACLs are still occurring on the grass. Okay. So the other thing is, is that the I mean, if you look at the ACL and things that you can't control is the anatomical structure of how you developing your skeleton system. And, you know, one study was done on the width of the notch, you know, between the femoral condyles, and attach them, maybe they see us a little bit longer, and some people as opposed to other people, but those, again, are things that you can't control. And the other thing is through the development, we talked about the female athlete, the cue angle that occurs, you know, because as these young athletes, these female athletes go in mature, their body's changing, you know, so the cue angle was another thing that you're not going to change that, alright, so there's three things, there's, you know, two categories, anatomical environment that you have no control over. But there's three things in that candidate in just those two categories. That you, you, you, you have to deal with, you know, in as the female athlete, if we just stay with the female athlete, we got to look at the hormonal aspect that changes, you know, as they're maturing, you know, and the cycle that they go through, you know, once that transition occurs, I mean, there's studies on there that the progesterone in and the estrogen actually create laxity, which we could understand that create laxity in the ligaments and structures of the female athlete. And we all know why. But these athletes can't stop playing just because they're in that cycle of their development, you know, on a monthly basis. So we have to make sure Admiral, if enough, people are looking at that, but you're not going to miss you know, seven female athletes, because they're in the system of maturing, and they're going through that process. So the one thing that we can do is really focus on the biometric biomechanical aspects of what we can control, you know, so the quad is usually dominant in female athletes. So we have to work the posterior chains to hamstrings, which the hamstring attaches on the tibia, and actually controls anterior translation of the tibia during functional movement or sports specific exercise, we have to look at the core, because as we talked previously, about that bowl of soup concept, you know, there's 29 muscles that attach to the core itself, to hold stability in the spine, or the lower lumbar, or the spine attached to the pelvis to keep that what's called neutral pelvis. And then we have to look at the, you know, how we're training, you know, the neuromuscular aspect, as far as proprioception, and going into those, those development of where you need to be as far as a stable base, like we talked about before, and how your body is going to function. I mean, if your quad dominant, and you're not doing handstands, I'm not talking a Nordic, you know, exercise that they do, or a, you know, a hamstring curl on the machine. I'm talking, you know, functional feet on the ground, close change mechanics, or activating your core through a posterior chain, you know, bridge while you're engaging some of those, you know, those hamstring exercise to create that whole unit that we've talked about as far as core stability. So I mean, there's those four things, you know, anatomical, environmental, hormonal, and biomechanical is the thing that I think you really have to focus on to really stay on what you can control to prevent ACL injuries.

Dr. Spencer Baron: 14:31

Supers super and back to the other question about you know, rehab and what you might determine surgical correction because I gotta tell you, man these days I'm starting to be very cautious about what orthopedic say they run an MRI and they go we need to clean up your knee and clean up you know, clean up and then you're off for six weeks. So what what surgical What's your determinant for surgical intervention? Do you Have one?

David Boyer: 15:01

Well, I mean, I think a lot of that goes to the subjective information you get from the patient, or let's say it's athlete, and the athlete and what, what they're going but I mean, a competitive athlete. And as we talked, you know, the function of the ACL is, is this all stability and control to create functional movement. But as a competitive athlete, if you have a ACL injury, whether it's a partial tear, or full thickness tear, I think the likelihood depending on what age you're at, and how we you know where you want to go, as far as your career, the likelihood of having a surgical intervention is 100%. Because I don't think you can, I do not think you can function at the level that you think you want to function by not having an ACL intervention to a surgical surgical intervention to stabilize anything. I mean, you're, you're I've seen some of the things like, Oh, I heal this ACL and, you know, just by without surgery, but we never know how much of a tear it was where it was, was, it just was it was it just one of the bundles that tore, you know, I mean, when I, when I first got back into the private sector, they were doing double bundle repair ACLs. And I was like, what is that, you know, and they never worked, you know, they, the failure rate was astronomical, from what I what my own perception of what these individuals had to go through, you know. So I think you have to really dig deep and go back to what's been working for such a long period of time. You know, like you were mentioning some about the quad. I've seen probably two quad ACLs in the last 10 years, 12 years, you know, where they they do that auto graph of the quad itself. You know, seven years ago, when I again, when I first got out pro sports, they were doing the hamstring, but in my, in my understanding if the hamstring is the thing that helps support the, you know, control the anterior translation of the tibia, why would you want to take the hamstring? So that's just me thinking out loud, you know, so I always go back to to the patellar tendon. I mean, 30 years ago, that's what they did. That was the gold standard, let's do the patellar tendon. And now they say they don't want to. They don't want to involve the extensor mechanism of the knee itself. But yeah, I mean that the quad is going to pull into a transit or you know, tibial translation forward, but the hamstrings what's going to control it? So what's the lesser of two evils in my mind? So I mean, if I can extrapolate on this, you know, the autograph is a hamstring, patella, tendon, quad tendon. Alright, the aloe graph is all that irradiated non irradiated cadavers stuff. So in studies, the autograph had a failure of 6%. And the failure rate of the aloe graph was for non aerated I think I've seen there irradiated was 9% in the irradiated was 34% Oh, god that was a study done

Dr. Terry Weyman: 18:41

was I

David Boyer: 18:43

can't remember the year but it was 2011 or something like that. You know, then in a in a different study. You know, they always say that there's significant failure in youth athletes in using a cadaver ligament. Now, what's significant is I don't remember what that is. But then there is a systematic review of seven different studies with 788, autographs and 288 Telegraph's with the age of 21 in 9.6, failure rate in the autographs, which is their hamstring, and excuse me, patella, and a 25% failure rate in the Telegraph cadaveric ligament. So and I think in that same study, there was there was a longer study related to it, which indicated that the patellar tendon so the autograph of the patellar tendon was better than the hamstring tendon. So with that information, I mean, if it's my kid, yeah, listen, you're gonna get it fixed because you're a good athlete. You're whatever 14 years old, and you're gonna use your patellar tendon. You know. So, which you can control that a little bit more now as you go through the physical therapy aspect of things, right? So I don't know if that answers your question, oh, it

Dr. Spencer Baron: 20:15

does much. No. There's this new thing that some of our peers are doing. And it's prehab prehab. So if you're destined to get ACL surgery, some of them are entertaining this preparation for the event of surgery. So do you do you guys do any of that or do

David Boyer: 20:41

well? Is it acute injury? I mean, what are we talking about pregame? I want you to go to therapy for four weeks before we do the surgery. Yeah, sure. Because if you have a Dima, after a significant and isolate, I'm just talking isolated ACL on all this information, because the meniscus and all that stuff changes everything. But if you have a significant enough ACL injury, you're going to have a Deema, you're going to have limited range of motion due to the game, you're gonna have muscle fatigue. So yes, the prehab aspect of things is to keep the muscle active control the swelling, you know, keep your range of motion going, again, isolated ACL, not a meniscus that's touching and pinching and limiting your extension or whatever it is not that you can not have limited range of motion with an isolated ACL. But yeah, I think the prehab aspect is you want to get them to be as good functionally as they can possibly be, before you go in and surgically repair that thing. Because you're gonna have more activation in your muscle, you're gonna have control Bheema, that, you know, it's gonna be less, you're gonna have good range of motion. So prehab Yes, I think you should do it. Now. You know, it's, again, it's, it's up to the athlete, but the doctor is going to really control that, you know, I think a lot of doctors, I think, like you said, they're doing a little bit more prehab to get everything prep. Maybe there's a psychological aspect to it, too. But you still have to present that to the athlete in the sense of like, this is we're going to do prehab, you're going to get an idea what you're going to go through, you got to start laying that that path. You know, proper healing recovery, so you can get back into sports. Now. I know one thing we're probably touch base on is the is the acceleration rehab aspect of things. Is that part of the acceleration rehab aspect of it? Yes, possibly. Because now I know where I'm at, I know what I'm doing. I don't have to come to therapy and go like, what am I doing here? Like, I'm never gonna play a game, you know? So I think the prehab aspect of things is, yeah, it's sort of true purpose physically, in the mental aspect of it to get prepared for what's going to come.

Dr. Spencer Baron: 22:58

What do you say into these unfortunate athletes that get these ACL tears? Or need the surgery? Are you? What is your return to play criteria? When they say, you know, when you tell them or give them an objective? Because they're going to ask you, when can I go back?

David Boyer: 23:19

You Yeah, but they get so much information. You know, it's sometimes it's a shame, you know, like, they want to come back in seven months, they want to come back in eight months. So let's look at the healing process. You know, let's look at the healing process. So you go in and you have an ACL surgery. The fact is, is that you're going in, now you're going to take your patellar tendon, you're going to disrupt your patellar tendon, you're going to attach it to two bones. Well, the first week, you get into that a avascular necrosis aspect of things, and we all know that in a hip, if you're a basketball, you're having a total hip replacement, right? I mean, that's just things got to get disrupted before they get aligned to be in place to have the proper healing. You know, and then you're gonna get the real the revascularisation aspect of it between I think it's three to 20 weeks, which is fine. That's a process that occurs. So 20 weeks is what four months? Yeah, four and a half months. And that's okay. That's the healing process. But in those 23 to 20 weeks, that six to 12 week, is when all this graph disorganized is all the collagen in it doesn't know what it's supposed to be doing. So that's the weakest point. So but a lot of these kids don't understand that in the parents, if they're young enough, need to be informed of it. So the basic, you know, six to 12 weeks, is when everything's starting to fall in place, but it's still at its weakest point at that point. All right, that cycle or that stage. You know, and then then what you get is you get past that three months, which is four 812. You know, then you get into the 20 aspect of it, you start doing more college sports, specific movements, but it's not playing sports, right? You know, so that progression, the skill team training starts at 24 weeks. I always tell everybody, listen, you got to year, okay? You got to year because that in 12 months, that graph is only 80% healed. So at six months, and there's a chart, I wish I had it, I would have brought, you know, I would have showed you whatever, but it's six months, it's only 50% here. So these kids, and they watch like these pro athletes coming back at six months, you know, one in whatever, 790 pro football players or whatever it is. That's just, that's an outlier. Okay, well, this guy did it in six months, and he's playing in the NFL or whatever, I think was it Adrian Peterson or something like that? Oh, yeah. It's like, Yeah, but you're like 15 years old. Okay. So slow down. So I was telling him, Listen, you got 12 months, okay, how you doing the beginning, you can take a little bit off, but at 12 months, you're still only percent. And there's a study out there, that after a year, the after you you progress to an ACL after a year, anytime after a year, this the this the the sub net severity, but the likelihood of having a real injury increased. So if my daughter or son is playing soccer, I'm telling them right out, you got 12 months, and if I can hold them back for 12 months, then I'll open the gate at 12 months and let him go. But most of these kids want to come back, they want to, and you're going to have a significant increase of a likelihood of a re tear or a tear on the uninvolved side. And that's all related to just not giving the love to that uninvolved side. So So those, those are the things that I lay the foundation on, and then we can go through, you know, other return to play stuff once the, once they come out of therapy, and we see where they're at. But even the therapeutic aspect and going through that process needs to be expressed in informed to them, and let them know what they need to get through as far as the physical therapy aspect, and where they should be at a certain time to get back into, you know, what I say I'd like to take them all at three months and put them you know, in the, in the post PT program, you know, because I think some of the therapy, and again, it's based on how the how the information is, is transferred back and forth between the athlete and the therapist and how their healing process goes. But I think a lot of them want to keep them, I shouldn't say did not want to keep them but think they have to keep them a little bit longer, you know, so I'd like to see more. Three, three and a half months get pushed to a post be a good post PT, you know, ACL recovery program.

Dr. Spencer Baron: 28:20

Do you base your opinion on return to play on any particular test, though? I mean, or, you know, range of motion or strength or a maybe running? Or what do you think? Well, the

David Boyer: 28:35

return to play let's let's look at the psychological aspect first. I mean, there's a there's a I think it's art in and colleagues did a study that 44 to 55% are the only group that returned to competitive sports after an ACL injury. So you think about that, you know, if we think about it, you know, when I don't know what the the the guideline is already came back, but he played a lesser level or they didn't. My understanding is they didn't get back to where they were, of the competitive nature of what they're doing. All right. So so return the play in the physical therapy setting. I think you do you do. You look at the subjective stuff as far as how they're feeling. You look at the side the side deficit, muscle activation, you look at well, we functional aspect to hop test. And there's a few hop tests. There's there's one for distance, there's one for crossover, you correlate single leg balance you know, between the involved and uninvolved and I think they used to do that with the remember the isokinetic machines. Yeah, for peak torque. Yeah, but there's there's a there's a comparison between I can't remember his name right now. But a comparison between those extension of peak torque at 120 180 degrees has a correlation between a single hop test for distance. So I mean, that's out there that's already there. And then there's, you know, you can do, you know, obviously look at where they're at, you know, join a fusion at six months. And there's an issue, which I think I've mentioned, I had a young lady who was having issues 18 months old, but she was, excuse me wanted to get back into competitive sports. Yeah, look at the range of motion, and you got to look at different legs cemetry, like side to side, like I mentioned, but one thing I think people miss out on is what's happening below the joint. And you got to remember, you have ankle mobility. And you know, if you have limited extension, and you go into a running program, or progression to a running program, you are more susceptible to gaining or getting arthritis or arthritic conditions at a earlier stage. Okay, so the key for the physical therapy aspect, and when we get into physical therapy is to control their swelling, control the edema, you know, use the range of motion to get that extension, because you've got to get full quad activation to get full extension, to decrease the likelihood likelihood of earlier onset of arthritic condition, you have to get, you know, knee flexion, I mean, the goal is to get knee flexion, by the fourth week at 90 degrees, or, you know, full I'm sorry for knee flexion in four to six weeks and 90 degrees in the first week. And you know, the patellar mobilization, because if you've taken the patellar tendon, things are scarring down with the kneecap doesn't glide superiorly, you're not going to get full quad activation, therefore, you're not going to get full extension. All right, so you're going to miss out on that screw home mechanism, which gives that nice stability, where everything comes together at the same time to lock full extension to possibly avoid a hyperextension or an increased rotational injury, therefore creating an ACL. So there's a lot of things that you have to look at in the physical therapy aspect, and then promote that to that recovery, or post PT recover ACL. But even on the progression, they say you can progress this running gait or running patterns or running progression at four months. But if you don't have full extension, what do you do? You know, like, like, if somebody comes to me without full extension, and the PT says, hey, they can do this ready, I'm going to say, in my head, because we all have to, you know, have respect for other people. But it's like, no, let's do this first, you know, and, and how is your running progression going, it's gonna go straight aways, it's gonna go curves, you're gonna build up to it. If you have swelling in there, then you got to go backwards, you know. So that's a good way to progress through the running that everybody wants to get into, because obviously, your legs are meant to run. I don't know if there's one sport, other than swimming, or horseback riding something like that, that you're not on your feet. Yeah, you know, I mean, the big sports, let's say. So, you know, and then you keep progressing. But your progression into your running is really functional. You guys evaluation as you go through it, to determine whether you're limited your range of motion, your hip, you know, Trendelenburg kind of thing because it Glatter looks weak, or you know, you get swelling or pain. So, the progression back in which I think you still have to have the foundation understanding what all this ACL stuff is,

Dr. Spencer Baron: 33:57

are you seeing a lot of reinjury by any chance?

David Boyer: 34:01

Yeah, there's there's a lottery but I think there's, there's a lot because we want to come back to early. Yeah. I mean, I see, you know, there's especially against the female athletes out there, uninvolved side gets involved. Yeah, I think we have to think as professionals like, Hey, you're gonna do single leg bridges on your golf side, I want you to do them on your uninvolved side. You're gonna you know, when you get into proprioception, balance, posterior chain activity for neutral pelvis. And I'm not sure that we are really, as professionals, we are really on these young athletes to really properly put the mechanics in place. And that may be because we have to hurry him through we got a nice see another patient there just the time. I think we could spend a little bit more time making sure that these kids are set in their foundation that come back the way that should

Dr. Spencer Baron: 35:03

do? Well, do you find it there? If you don't perform some of these tests that that you would typically do? Do they get a reinjure if they're obviously they can reinjure if they go back too fast, but you know, there are certain activities that they are prohibited from doing, once they start back to a little more, you know, like their practice or anything you find, you have to limit them. Let's say like a soccer player, or we're, you know, are you just having them run linear, and then waiting to do side to side or anything like that,

David Boyer: 35:47

you got to go through the full gamut of that functional testing, to see how they respond. Like, just because I'm 12 months, and if I never ran, or jogged a straight line, or did a, you know, curls, or SS, or even a little bit of a crossover, like, your stage has to be like you said, linear to horizontal, just like your stage, your plyometric aspect of things has to be, this is the way I do it, you take a jump, I know everybody can jump, not everybody, but you know what I'm saying the mechanics of it have to be there. But you're not just gonna go and do a jump, which is two feet, like a jump, you're gonna jump, you're gonna slow it down, you're going to feel the tension on the muscle, you're gonna feel the shin come over the top. So your jumps is going to be a jump, feel the mechanics of it, jump again, you know, that would be like a phase one for me. And that could be a month, it could be, you know, it could be three weeks, it could be two weeks, depending on what the observation is, I see. And then we can do a jump. And then what we can do is we can get into a about, you know, but the bounce still has to start linear, and then we can go horizontal, and then we can get into a hot, which is same late. But again, the same leg still has to go linear. Before you can do a horizontal before you can change any type of height, you know, as a plyometric. So the running progression is going to be the same way, you know, linear, you know, linear s, you know, that kind of thing until you can get into crossovers. So when the athletes 12 months, they should already have done all that stuff. Like I shouldn't send an athlete back to their team to get functionally tested on whether they can play. You know, as a trainer, you know, unless I'm the trainer of that team. I'm already doing this stuff. So the trainer should be Hey, thanks a lot. Is she ready to go? Yes, this is what it is. Okay? Because he's busy taking care of all the other stuff. It's, you have to progress these kids by neutral pelvis by stiff spines, shallowing motions, forward, backwards, right fill up, and then get them into their skill aspect of things where they can like, I have a girl doing soccer, not skills, but dribbling, which is fine. She's for whatever, five months. But she's she's stationary doing. So that's okay. There's no rotational stuff going on. There's no, you know, impacting going up, it's just touching the ball again, you only get and that's okay, that's that. What that does, psychologically, it gets your closer to our goal, right? What that does physically allows her to accept where she's at. So in my mind, that's the way I look at it. You know, so it's, it's a progression that we all miss out on, because we all want to live in the future. And then when we get to the future, we don't like what we did. Right? So now we're gonna live in the past, and I should have done this kind of thing. And so, I mean, that's the same way I do. That's the same way I try to express everything, whether it's physical, whether it's mental, you know, you have to you have to know where you're at. Yeah, before you can know where you're gonna go. Are you gonna?

Dr. Terry Weyman: 39:06

I got a question. You know, and across the board, not just youth athletes, but college, you know, middle age pros, all the way up into the older athlete. What's your opinion on speeding up some of the recovery based on if time is not a factor on multiple workouts per day? For example, three to five hours of rehab, stretching, training, that spread out throughout the day, compared to that one hour PT appointment? Absolutely, assuming overuse injuries, avoid that we're not doing overuse or anything like that.

David Boyer: 39:43

Do you have PT as part of that? Three to five hour block? Yes. Okay, so, so that's, you can break that down into like if I if I put it on a piece of paper You come in, okay, we're gonna work on your mobility, flexibility. But that takes 40 minutes. Now I want you go to PT and work on your injury, you know, get some hands on, get some manual, get some range of motion, get some scar tissue stuff taken care of, you know, you've already done, call it the foam roller before, so you didn't there, start your core activation in your PT, come out of PT and go to your strength and conditioning aspect of things where your work in general strength. But even my general strength would be like, I'm going to take some of your PT start you in the general strength, but focus on the PT like core activation, continue with your balance, before I get you into the general strength aspect of things, once the general strength aspect, depending where your time is, and how you're handling all that you can get into a skill aspect. You know, now, obviously, this is a high level athlete who has nothing to worry about. But playing the next game, which might be six months away. Yeah, this is not a high school kid. This is not a I mean, even even a college kids probably not going to have that setup, if he does, it's going to be a three hour block. So if you, if you strategically place it, I think you run a lot less risk, there's any kind of overuse is if you don't, you have a high likelihood to have an overuse injury, if you don't, if you don't place it in the right spot, there's a great amount of likelihood that you're going to have an overuse injury in my mind. You know, if you're not doing core activation for the multifidus. And those local muscles, the erector spinal, you're going to have an increase, this was a study done, I have to look it up and tell you, but you're gonna have an increased likelihood of hamstring strains and hip flexor soreness or strain by not stabilizing what's called those local muscles. Because what happens if you don't stabilize the shearing and the stability aspect of the spine on the pelvis, then those other global muscles which are your rectus, abdominal muscle, your obliques, which control torque, we're going to have to give into the proximal muscles, which control neutral pelvis. Now you can't control neutral pelvis, if your hamstrings and hip flexors store because you didn't control the global muscles, which didn't allow you you didn't control the local muscles, which you know how it worked down the line like that. So like we said before, you always got to look at the inside out, you know, and so you can strategically placed to answer your question, yes, you can get a five hour block without overtraining, based on how you chronologically involve it into their, their daily schedule. Again, that's a highly competitive athlete, it's not high school, that's gonna be tough. And

Dr. Terry Weyman: 43:01

I said, you know, with that with time wasn't an issue. You know, we could probably speed up. But is it realistic? I don't think so, you know, with time depending on who you are, right? That you're saying, speed,

David Boyer: 43:14

speed up the healing process? Can

Dr. Terry Weyman: 43:17

we can we speed up the recovery process if time is not an element, and we were able to do that block versus that the the average person spends what, one to three, one hour in PT or therapy two to three times a week, sometimes three to four times a week? If time was not an s a problem? Could the recovery time be sped up with a three to five hour block of of doing multiple things? Like you said?

David Boyer: 43:45

Yes, I think you could, because what you what you engage in is neurological response. And proprioception is a big component of decreasing the likelihood of ACLs and decreasing a secondary ACL. So yes, I think you can, but if you go deeper into the knee, remember what I said earlier, your ACL is only healed at 80% and 12 months up? So do I think you can speed it up from an external aspect as far as muscles stability, central nervous system, you know, proprioception, mechanical receptors of the joint to prevent excess stress on the ACL? I think you could. But you're still gonna run a risk of you know, it six months, eight months, it's only 50% and 80%.

Dr. Terry Weyman: 44:33

So I think that I think you're answering my second question, which what would you say is the top limiting factor for ACL rehab being successful and staying successful? You're it's probably what you just mentioned. That'd be correct.

David Boyer: 44:46

Well, yes, I think I think you can put an ACL recovery in an ACL prevention program as the same thing. So there, there's you have to look at so the American A Journal of Sports Medicine, medicine 2007 showed an individual with decreased trunk control during functional exercise had a in which, what it was decreased trunk control during functional exercise show decreased proprioception for those mechanical receptors inside the knee, which increases the risk of ACL injuries. So you could, you could treat the prevention program if it's done the right way, in a recovery program the same way, by utilizing those local muscles of the core to get to your global muscles, to get to what you need to get to, to make yourself better and expedite the recovery aspect. Proprioception is the key of exercise in a functional position to decrease the likelihood of ACLs or injuries in general, the American Academy of orthopedics, showed that neuromuscular training, reduced noncontact ACLs, ACL injuries, so neuro muscular proprioception, so to go through it, you have to work your balance in the balance is visual, sensory, and proprioception. And it's not just single leg balance, okay, so you got to, you know, like the balance board aspect of things, you have to be in the right position to turn everything on to stabilize the joint through core training, which was those 29 muscles, and in the posterior chain of the proximal hip, to create neutral pelvis position, so that spine can sit on there and use those local muscles. So you don't have that forward lean of that truck. So that in itself, yes, you have to do your general strength train squats and all that stuff, to control external resistance that's coming at you. But if you talk in just non contact ACLs, you have to definitely go from the inside out, work the local muscles, the multifidus, all those small spinal stabilizers, to the global muscles, which controlled torque to the proximal muscles, which control neutral pelvis. All that can be done and should be done in a balanced position for proprioception, stimulation color. And I think you can you can expedite your recovery. But you still I think you still especially on the jump, because you still have to look at the graph of how that ACL recovers in itself. And it's out there. It's called months. Like I say, I can't stress it enough. It's only 80% healed.

Dr. Terry Weyman: 47:59

All right, you touched on that earlier of the the mental aspect of the injury. So I'm kind of curious, how do you manage the expectations between the professional, the high performing amateur, both high school and college and then non athlete with the knee rehabilitation?

David Boyer: 48:19

Well, the the non athlete still suffered an injury. So you have to look at the injury as like you take everything away, and injuries and injuries and ACL injury, you have to look at the individual and see what they've lost because of that injury. Now, the athlete lost the support group of their team. If they're in college, they lost the they've lost the support group of their family, because they're awake. So they've lost two things. The non athlete has lost their ability to function, whether it's taking care of their family, Kid wise, or you know, that kind of thing, or going to work. So maybe that's their support structure go into work, their family, their work, you know, so you have to look at the what they've lost, to build the foundation of what how they can work towards getting back to what they want to do. So yeah, that's the first thing and to get back to what you do, well, let's take the athlete in general, their biggest concern is the loss of their support, but their fear of re injury. So that builds your foundation of, okay, how do we establish this to move forward? You know, the return to play fear of athletes is, is the biggest thing. And it's they've, like we went and we talked about the 4544 to 55% are the only ones that came back. What happened to the other percent most of them dropped off because of that fear of re injury. So the stay at home mom or whatever, the dad, you know, shoveling snow slips on the steps. He's still lost his ability to function. So we You have to start setting goals for them. You know, I mean, in my mind, it's, it's, I don't want to say it's easier for the athlete because I know what they got to get back to. And I don't see too many of the column non athletes, because they don't they don't transfer into me. You know, once they get out of PT, they're feel good. I'll be careful, blah, blah. But if it's a weekend warrior, that's an athlete. So you have to, you have to begin by understanding like, okay, let's set a goal. And it's not a goal. I want to get back to sport, because that's very long term. Where do you want to be in a month? How do you want to get there, you got to, I think we've talked about this before it's shrink the time down, change the mindset to achieve smaller goals, because for small goals is a big goal, you know, so they can see that progression. And their success will build upon that in order to get them to where they want to go. So you change the mindset, you established a direct path based on their goal. And you but then you internally, you have to start controlling the thoughts. Am I ever going to get better? My knees sore today, but you have to give them that information. And then you can go back to like, okay, let's, let's talk about where you want to go. This is a little setback. So let's visualize what it felt when you were performing at your best. You know, so you control that thought, let's let's get a stimulating imagery of a predator that you can, you can, you know, you can become when you have a setback. So now you can move through that. Let's look at what you were doing when you were good. Like, what was your What was your strength? I was a good kicker, I was a good, you know, slap shot, I was a good skater. Okay, so there's your objective, because you have a little setback, you know, because it's short, it's going to get so it's a process, you have to do steps. But if you use visualization, if you use goal setting, if you use the controlling the emotional aspect of it, like if you get angry, because your pain, you have pain now, or it's swelling up all the time, you're out of your comfort zone of when you need to perform at your best to heal. If you get depressed, you're out of your comfort zone. So how do you how are you going to maintain it's like a five to six on a scale of one to 10? Because that's where you perform your best. So how do you maintain, you get too high, slow down, take a breath, get that neurological system set in place, so you're not so tense. If you're too low. Remember your goal. Remember your predator? Where do you want to be tomorrow? Where do you want this pain to stop? Okay, now you have an objective. So don't forget about the don't think about you know that aspect and it's never going to get better. Now you can now you can start focusing on what do I have to make? What do I have to do to make it better tomorrow? So I mean, it's unique, because if you set the mindset in the right direction, those things will take care of themselves. We are creatures that always want to, like I said earlier, you know, we want to change the past and we want to predict the future something we have no control over, you know, can we work towards a better future? Of course, you know, but things are gonna happen. So how resilient Are you going to be to get over that to get to where you want to be or what you want to be or how you want to be, you know,

Dr. Terry Weyman: 53:29

how often you get the perfect,

Dr. Spencer Baron: 53:32

how often how often are you seeing knee replacement surgery after a quad tendon repair?

David Boyer: 53:39

Knee replacement?

Unknown: 53:41

Yeah.

David Boyer: 53:43

Well, you know, the quad tendon is a very hard muscle to tear. I mean, you need a very ballistic thing I I think I've only seen like maybe four or five quad ruptures. One was a bodybuilder who's just squatting too much weight. One actually was a slip and fall after an ACL injury. He was older, not older, but a middle aged gentleman. Yeah, as she. I said, Where are you been? What happened to you? I had to have another you know, this is his first day back because we missed him for whatever a month. So what happened? And he told me he was out getting ready to shovel the sidewalk and he slipped on the water in the garage I'm in and he actually sat there because he couldn't get up for like an hour before his son came home and said what are you doing? He said, I think I tore my quad I can't get up. So I will see too many quad ruptures. The same as I don't see too many quad tendons used as the ACL. Because I just it's I don't know why I don't maybe there's not enough depth, you know where they're coming from or whatever. But you know me as quad ruptures, those are very, those are tough injuries.

Dr. Spencer Baron: 55:01

There's, uh, you know, controversy, or, you know, depending on the surgeon they'll want to do. They'll either take hamstring or they'll take, you know, quad tendon or patellar tendon or cadaver or a combination of synthetic. Do you see any difference? Do you have a preference?

David Boyer: 55:27

You're asking me if I have a preference? Yeah. Anybody I know, is getting a patellar tendon graft. What about, like I said, when I first came out, they want to do something called this double bundle or single bundle? You know, and I never really understood it, because I would always be like, yeah, what are you doing? Like, just keep up until it 10? People have their reasons,

Dr. Terry Weyman: 55:48

you know? Well, a second, does your opinion change with the age of the athlete?

David Boyer: 55:54

Ah, is it an athlete?

Dr. Terry Weyman: 55:59

Well, active person? No, the reason that the reason I asked that is, you know, when they get to be 40 and 50. And they're still very athletic. You know, I have a, we had an orthopedist and the test and he likes using cadavers after the age of 40. Mainly because it's younger tissue than their older patella tendon graph. And he found that the younger one of the reasons they failed, the younger athlete, they feel so good with that could ever attend that they do stupid things in the outlet, they're really great in and lock in, where the the older out there has the more patience with the work, but he he likes using the younger tissue with the older athlete. What's your thoughts on that?

David Boyer: 56:46

I mean, I don't know enough about how they harvest and how they, as far as I know, the they radiate that tissue, you know, to kill all the whatever it is to kill. Yeah, you know, now, can they non radiate? Sure. But based on the study regarding athletes, there's a 9.6% failure of the autograph compared to a 25% failure of the Alibre, which is Cadabra. Is is he's got a reasoning for which is, that's fine. But for me, personally, you take in the patellar tendon. I mean, it just based on the information that I know, and I'm not saying I know everything, there might be something out there, I've never looked into too much of the cadaver tendon. I always shook my hands. Like, why are you doing that? You know, some, some people don't want to disrupt the extensor mechanism, you know, of the knee itself. But I don't know, I just see so much. So much more. Such better results for the patellar tendon graft. Now, if it's a non, you know, athletic individual, or, you know, someone can control themselves, like you were saying, they're not as aggressive because he feels so good. It might be good for them. You know, but as far as I'm concerned, personal messages personally, everybody that I asked me, I'm going for the patellar tendon. Hey, and even like you said, I mean, they want to use younger tissue, but how much do they beat it up? Is the healing process the same with the Allah grab that in the autograph? I mean, that's something that might be looked at, you know, as far as the graph about how it's a I would, I would think that it is, because your body's going to heal, just because you have, you know, that different tendon in there, does one heal faster than the other? I don't think so. I think the graph itself is goes through this, you know, this 12 month process, you know, they might feel better, because they're not as active, which is fine. And they don't have to deal with, you know, the patellar tendon and scar tissue and stuff like that. So they might get better quicker. But again, they're not going to go and play soccer, right. know whether you're 40 years old, or even a weekend warrior? Yeah, I mean, so I mean, those are my, my impressions only those are my thoughts. I guess.

Dr. Spencer Baron: 59:15

That's why we asked you. But let's go mental. Let's go the mental component right now and ask about how if, if a player needs to compete in a couple days, and, you know, what, do you win your approach to what you're saying to them? You know, that, you know, that's not an area that we have a specialty in, but is there a higher level approach that you would consider how you wouldn't have a conversation with them? Well,

David Boyer: 59:42

I think you have to leave it on the player. Now in the past late 90s. When I started it, he never left anything with the player. Yeah, yeah. But now you have to, you have to, you have to listen. You have to go through your physical testing, right? You have The you have to understand their preparedness. And then you can get into the mental aspect of it. Like, I feel like I'm ready. Okay, you pass the test your, your preparedness is ready. So have you practiced? Well, no, I don't need to practice. Do you know? So you got, I think, objectively, you have to look at what they've done like, say 1112 13 months or even, you know, let's say it's early, let's say it's 910 11 months to really determine because once you have a setback, mentally, you're going to be destroyed. None. Yeah, now you're working even harder to get them back to where they want to go. So what's one what's waiting another week, like we talked about before, compared to being ready for long term. So mentally, I think you have to find out where they're at. You know, and you have to make sure you you siphon through any external noise. That's been beating them down. coaches, parents, teammates, college scouts, all those other things that make them understand and realize like, this is yours. Okay. You're not expected to know what you're supposed to do. Mentally, physically, unless you given the information. So where do you think you are? Just between you and I about playing? Then you'll I think you'll get a real answers like, oh, you know, I really haven't. But you gotta give me information. I really haven't practice. I really was a little sore after it swelled up a little bit, are like, Listen, I've been here for a week. I've been hitting guys, I've been shooting the puck, I've been kicking the ball. I scored five goals in practice yesterday. You know. So I think you have to look at all the information to really give it to them. And then make a decision mentally, because the mental aspect is the thing that can can be the worst for you. Yeah, make a decision, mentally, all the physical stuff aside, we'll make a decision mentally. Where do you where do you think you're really at?

Dr. Terry Weyman: 1:02:10

All right, this has been great. And I'm so glad that you chimed in to ask us to talk about the ACL because you know, the stats are just crazy. And now we're in football season so and you know, we have soccer season at the college level, we have female and all that. But I've already seen two or three ACL injuries just at the high school football level. So what enclosing? What some we didn't do the rapid fire. I know Spencer's really upset about that. But what's your best tip? So I'll give you one rapid fire, what's your best tip for the younger and older athlete to keep from injuring their ACL?

David Boyer: 1:02:52

core activation with a neutral pelvis and a stiff, stiff spine through functional movement patterns. For both for that's where it all starts. For both. I mean, look at it look at a young athlete, like an adolescent is not as a youth. He doesn't even know his body, you know, he's flopping all over, he's, he can't control a neutral pelvis. He doesn't know how to do a first simple exercise of Glute Bridge, you can barely get his knee over his toe to get into a good strong athletic position. And then you are even balance you know, as a youth, you know, eight to 13 year old. Yeah. And then you take the next group who's kind of evolved a little bit and they've done a lot of weight training, you know, let's say 14 to 18. They still are not doing proper core activation with a stiff spine to create a neutral pelvis in a functional position. They want to see how much weight they can live. They want to you know, they want to do their What is it PR their personal record or you know, and so, I am seeing this so it It upsets me so much. Because these kids, youth and adolescent still don't understand the neutral pelvis to control all the movements that occur in the hip, knee, ankle, spine, like thoracic spine is where your rotation comes from. It's not your lumbar, that you get a little bit but if you want to throw the ball harder, you have to have a locked in base to wrap around that thoracic spine to get there, that coil effect to get that object to go. It's the same with shooting a hockey puck. It's I mean, it's the same almost with shooting a soccer ball. You still have a neutral, it's a check stick. It's the same with change of direction. You know, am I going to flex over the top and shut my glute off the motion or push laterally. So that's that's my whole thing. is neutral pelvis, stiff spine in a you know, balance in a functional position, you know, the control all that midsection was 29 muscles in need to work the right wave. So those those strength and plow metric aspects explosion stuff can function efficiently. Remember, a weak motif is this gives you a weak hamstring gives you a weak hip flexor gives you an unstable pelvis, which create whatever strains, tendinitis, whatever it is inflammation. And that's how you Dave

Dr. Spencer Baron: 1:05:39

I don't know, man, you know so much stuff about this ACL. Great, man. I really appreciate everything. We're going to wrap up on this one and feed the masses with their with your understanding of ACL injuries, because I

David Boyer: 1:05:56

appreciate you guys letting me come back because I mean this. Yeah, anytime I can get a chance to share it. I want to share it. Perfect, beautiful

Dr. Spencer Baron: 1:06:05

stuff. Thanks, Dave. All right. Thanks, guys. Thank you for listening to today's episode of The cracking backs podcast. We hope you enjoyed it. Make sure you follow us on Instagram at cracking backs podcast. catch new episodes every Monday. See you next time.