Welcome to the Multi-Institutional Sports Medicine Fellows Conference. Everybody, when you come on here, is going to be muted, but please keep muted until later. This is being recorded and will be transferred to the AOSSM playbook, to the Learning Management System, and be available next week. So this week's talks will be on the schedule, will be on the website for the AOSSM next week. Last week's should be on this week, if they're not on already today. For questions, again, submitted in the chat, and we'll get Dr. Cain and some of the others on, some of the other faculty on, to comment and help answer some questions and ask some questions. So we're very fortunate today to have Lyle Cain, the head team physician at Alabama. And so they, he has some very interesting perspectives on how we should really evaluate the ACL to get players back to play. It's not just about swelling, motion, and strength. So I think that there'll be some very interesting topics about how they really are helping advance the field, as this is really a hot topic for a lot of people. And so without further ado, very much a privilege to have Lyle come and talk about returning to play after ACL reconstruction. The Bama way, not the Glenn Dorch Auburn way, but the Bama way. So Lyle, take it away, man. Thanks, Mark. I appreciate you having me. Great, great progress you have here in terms of these talks. And I know it's great for these fellows to get some education since we're kind of quarantined. But what I'm going to talk about is what we've been doing in Tuscaloosa, and I'll talk about some generalities. Kevin Wilk is one of my physical therapists here. You guys may know Kevin. He's probably written most of the protocols that you guys use across the country, and he's done a lot of work on this ACL information in terms of return to play, and I'll give you some of that, and then we'll talk about specifically some of the GPS stuff we're doing in Tuscaloosa. In terms of disclosures, I'm a consultant for Arthrex and do have a royalty stream. Zero Biomet, Smith and Nephew give us research support as well as Triker, but I have no conflicts related to wearable technology specifically, which is today's talk. So the question is, you know, why is it important to have return to play criteria? You know, why do we need to test people, what tests are effective, and what does the evidence indicate, and what does return to play really mean? Does that mean back on the field or back to full go? Does that mean contact? Then we'll talk about these new technology issues and wearables. And obviously the goal we all have is to return our athletes a safe return to play and reduce re-injury rates and performance. So we don't want somebody to go back and get hurt again. We don't want them to come back and have a poor outing. We want to know the soonest they can get back. And as a good quote, you didn't come this far to only come this far. So it's important to get there, but it's also important to get there safely. So the question is, when can a player return to running, running and cutting, jumping, sports specific training, back to practice, and back to full play? Some of that depends on the level. Obviously a professional athlete has a different return to play time scale than a scholastic or recreational athlete. So the question we were asked is, how do you determine when the patient's ready to return to sports? So some of that depends on type of sport returning to. So level of sport, level one sports for the contact and high level cutting sports, football and soccer, level two and three sports, the position makes a difference. Some offensive linemen can get back quicker than a skill position player in football. And then the type of player. Some players are fairly controlled and kind of have tight movement. Other players have a lot of side-to-side cutting or much more active and may not get back as quickly. And then the age of the patient is important as well. A younger NFL player or college player may get back at a quicker rate than an older NFL player or senior athlete. And then ultimately the condition of the knee is important. So we have to know about the articular cartilage, meniscus, any associated injuries, the graft type. You know, certain grafts heal at different rates compared to others. Allograft certainly heals slower than autograft does and so that may have some bearing on decision. So what do we use? We'll use a combination of objective and subjective information. Some of these include the time frame from surgery. We know that certain grafts heal at certain rates. We have subjective factors and then we have some objective testing that we'll go over. But ultimately all of us use a lot of both tangible and intangible factors to consider when making this decision. So it's not always the same in every athlete. Be careful about reading health books. You may die of misprint. The quote from Mark Twain. And I think that gets back to this evidence-based medicine idea. And certainly I think we all believe that evidence-based medicine makes sense. You know, randomized controlled trials are the best form of evidence. But in most cases we're dealing with experience-based medicine. And the experience that you have and the experience of your mentors and fellowship determine a lot of how you get people back to play and the timing of getting them back to play. So there have been some studies out there looking at specifically football. This is an AJSM article in 2006. Looked at the effects of ACL injury of running backs and wide receivers in the NFL. 33 players total. 80% returned after ACL reconstruction in NFL play. But the performance was down. It was reduced about a third from their pre-injury status. Brophy and Dylan Lyman also looked at another cohort, NFL. They looked at difference between ACL reconstruction with or without meniscectomy on the length of career in the NFL. They had 54 athletes with meniscectomy alone and 29 athletes with ACL reconstruction and 11 with both an ACL reconstruction and a partial meniscectomy. And interestingly, the history of isolated meniscectomy, not ACL surgery, shortened their career. And the combination of both an ACL and meniscectomy was the most detrimental and affected in about two years, took about two years off their career length. A study done here in Birmingham at ASMI had 49 NFL players after ACL. We had a 63% return to NFL play, 31 out of 49. The average length of time to return was about almost 11 months. And there were several things that were factors, although age, position, number of procedures were not a factor. The most common factor that determined whether somebody made it back or not was players that had more experience, four years or more, had a higher rate of return. And players drafted earlier in the first four rounds had a higher rate of return. Now is that because the player is better, better athlete, better healing response, or is it because the team's willing to wait on them because they're high draft choices? So a lot of things in professional football that may not mean they have a bad knee, it may be something to do with the player and the team and some other variables that are hard to determine specifically in pro sports. So reasons for reduced participation for those that did not return to prior level, this was a British Sports Medicine article 2011. The most common was fear of re-injury at 19%. Problems with the structure or function of the knee in 13%. And then lifestyle changes in 11%. So it's not always the knee itself that keeps you out of play. Sometimes it's fear of re-injury or fear of something happening to the same knee. Limb confidence is important. There are a lot of ways to determine that. There are different tests we'll talk about. But some of these functional tests such as the Y-balance and step-down test are tests to try to determine how confident the person is in their post-surgical knee compared to their non-operative knee. So how do you know when your patient's ready to return to sports? You know, this guy, Adrian Peterson, has a certain level of demand. Obviously, basketball players have a certain level of demand. Soccer. And then you got the pizza skier on the right that's going to be pretty probably low demand, but she's going to put a lot of stress on her knees because she's going to ski all the way down the mountain with her knees like this in a pizza position. So sometimes the coach determines when they come back. I guarantee if you leave any freedom, the earliest you say, if you say, coach, it takes between five and seven months for an ACL, this guy expects it at four and a half. So you have to be careful about how you lay the groundwork after an ACL injury. So in terms of functional screening tests, there are a lot of tests that are out there. Some of them aren't very good, really, at the end of the day. And I think we have, this is what we're looking for, ultimately, is we're looking for good function. So whether you're doing a y-balance test or a hop test or a landing jump, we're looking for people that have these risk factors, that have this valgus landing motion. It probably puts the knee at risk, not only the operative knee, but also the non-operative knee as they land from a jump. And most people that see these pictures think, well, this is just, you know, these are young female athletes or a small male athlete that aren't in very good shape. But we see this in NFL guys, too. This is an NFL quarterback at the combine a few years ago, and look at his landing position. His jumping and landing position is terrible. Big valgus angles, and this guy, you can almost predict, is going to have a knee injury at some point in his future. So there are a lot of components that are necessary when we're looking at criteria for return to play. Subjective knee ratings, so what the patient thinks. Ligamentous assessment, which is essentially how we feel the knee is from a tightness standpoint. Strength testing, hop testing, and then functional testing. So subjectively, there are a lot of things to look at. This is one of the scales, the Cincinnati Knee Rating Scale. There's also IKDC scales. The problem with most of these scales is they're not really specific for high-level sports. They deal with a lot of stair climbing, squatting, bending, getting up out of a chair. They're not asking if you can run a 40 and do a 5-10-5 type cutting maneuver. They're asking basic simple things. The kinesiophobia scale is an interesting thing that Kevin Wilk talks a lot about. I think if you look at the 19 percent of patients that didn't get back in the British Journal based on fear of re-injury, it has to do with this kinesiophobia. So this Tampa scale of kinesiophobia is a good way to look into that. If you have a patient that you think looks great, but they just don't seem psychologically ready, this is a good way to assess that, the kinesiophobia scale. Ligamentous assessment, a lot of ways to feel the ligament. You know, when I was a fellow, we did a lot of these KT tests. This is a KT-1000 test. It's a manual test using an instrument that measures displacement posterior-anterior, and it gives you a force displacement curve, and it's an objective measure. And what it does, it gives you this curve right here. So this is three consecutive pulls where you push posterior, which is the lower part of the scale, you pull anterior, which is the upper higher part of the scale, and you get a total displacement number at different forces. So you can do 15 pounds, and you can do manual maximum manual pounds poundage to see how much displacement you have. And this kind of is similar to an instrumented ligament exam, and it's pretty good for research purposes, but I think most of us have abandoned this as a routine follow-up maneuver. So this is what it would give you. It'd give you these score cards where you can look at the pre-op laxity, and this particular person had 6.5 millimeters pre-op laxity. And then post-op, they were actually one millimeter tighter than their non-involved leg on a KT test. But I think most of us now just use our hands. We do a lot from the exam, pivot shift. We get the ligamentous assessment manually rather than using instrumented testing. Strength testing is important. You know, the Biodex isometric testing, I think, is a key part of our return to play criteria, just to learn when players have enough function to be able to get back into some kind of strengthening and return to play scenario. The Biodex system, or the isokinetic testing system, if you haven't seen it, we do it at 180 and 300 degrees per second. You do 10 and 15 repetitions with a standardized warm-up, and it gives you charts like this. And you can see several things from this. The pie chart shows side-to-side difference ratios. It gives you several numbers above. The ones that we look at the most are the quad peak torque to body weight ratio, which is a number that tells you how strong their quad is compared to the body weight. Normal for males is 60 to 65 percent, females 50 to 55 percent. We also look at the hamstring to quad ratio, some people call the agonist to antagonist ratio, because the hamstring technically holds the tibia posterior, and the quad technically pulls the tibia anterior, which puts stress on the ACL graft. So we want the hamstring to quad ratio to be good. Normally, males about 70 percent and females 75 percent. And then we look at the hamstring peak torque to body weight ratio as well, which is just another measure of hamstring strength. The first thing people notice is the bilateral comparison, which is the pie chart right in the center of the page. And we look for about 80 percent to get back into running and doing basic things, and around 90 percent to get back into cutting sports. We can also look at endurance, which is the faster 300 degrees per second biodex test, which shows you how their muscle endurance is, not just the raw power. And you can see acceleration rates, it gives you an idea of how quickly the muscle contracts and fires. If you don't have an isokinetic test, you know, for my small town Alabama people, I use a single leg press. I think it's pretty good, it's close. I tell the players, you know, somebody that's a 40-year-old tennis player, you don't have to come back for testing, but whatever you can do about the same amount of weight on both legs for the single leg press, you're probably okay to go back. And that's usually around six to eight months, is what I tell them. So biodex and isokinetic testing is not mandatory for every athlete, but certainly for the high-level athletes, I think it makes sense. Hamstring strength is really important. If you look at the European soccer leagues and the medical side, the European and international soccer teams have figured out that hamstring strength can help protect the ACL. This is known as a Russian negative or Russian curl. It's a good way to strengthen the hamstring, and we've been using this for several years to try to strengthen the hamstring after an ACL or preventatively to prevent ACLs. But now there's a test, there's this NORBOR, which is a hamstring testing system that we have at the University of Alabama, we have in a lot of our physical therapy centers, where you can actually measure the hamstring torque and you compare side to side. It's great for preventative measures for hamstring injuries as well as ACL stability, but it also tells you after an injury when the athlete's back to the normal baseline, both with ACL or with a hamstring injury. This is one of our NFL players a couple of years ago doing this. This is really hard to do. I've done it myself. I had my suit on and I thought my leg was about to rip off and I got to this point, so it's very difficult, but it gives you a graph that shows you how much hamstring torque is in each leg. Hop testing I think has become popular. Frank Noyes and the Cincinnati group popularized this several years ago going back to the early 90s, and it is a good test. It gives you an idea of the explosiveness of the operative leg versus non-operative leg, and you can look a lot of different things. You look at hop distance, you look at hop timing, you look at crossover hop, a lot of ways to evaluate this, essentially trying to see what the explosiveness and landing is off of the operative leg as opposed to the non-operative leg, and it gives you this kind of data where you get a functional hop test log, essentially. Functional testing is something that, you know, they do at the NFL Combine, obviously. We just had the Combine a few weeks ago. They do all the 5-10-5 shuttles, 40-yard dash, vertical jump, raw jump, and one thing that's done commonly in most college programs and they do in the NFL now as well is this functional movement screen, which we'll talk about. The functional movement screen was developed or first reported in 2014 in the Journal of Sports Rehab, and it's essentially seven different movements and tests, and you have a score from zero to three for each movement, and a score of less than 14 predicts serious injury, and a combination of a low score and side-to-side asymmetry can give you a relative risk of injury, so we actually do this in all of our college football players when they get to campus and most of our other athletes as well, not just football, and it's amazing to see that you have these elite athletes, some of these guys that are number one overall draft choices in the NBA, and they can't do simple things like a wide balance. This guy couldn't squat down and keep his heels on the ground. He couldn't step over this plate without raising his back heel, and he couldn't do the wide balance test, and this is a guy after an ACL tear, but my suspicion is his mechanics were probably pretty poor before the ACL tear as well, so I think this is one of those tests that's good for pre-injury evaluation, but certainly helps you post-injury determine when the player is back to function. Then there's some sport-specific tests such as front step downs, jump downs, reaction drills, shuttle tests, and specific tests like this. This is a ladder drill we do with a lot of our football players. This guy's pretty good at it. He's got a defensive back, and then he can be on Dancing with the Stars. He was Alabama DB that played in the NFL for several years. If you compare him and his movement, this young lady is a college basketball player. So what's new with Return to Play? Well, these wearable technology devices I think have really made a big difference in my plan for our college players especially. This is the setup we have. If you look at wearables in general, they're common every day. All of us have an iPhone, and we all look at our steps each day. We have Fitbits, we have other things. Those are all GPS methods to collect data on your movements, and surprisingly, most professional and many college teams have these in their training room, and there have been rapid advances. It's hard to believe the Apple iPhone was just introduced June 29, 2007. It's only been 13 years essentially since it was introduced, and it's made a tremendous number of changes, and technology is crazy. If you look at just Amazon search wearable technology, there are amazing things out there right now. There's actually wearables that can look at diabetics' sugar content by tasting the skin. They can feel, they can check the blood sugar in the skin through a wearable. They can check your sweat through a wearable and sense your electrolyte loss. This is great for COVID-19 protection. This is a drone that's available in some countries where it essentially, when it senses pollution, it goes up and filters the air in front of your nose and follows you along through the air. It's a drone, so perfect for COVID-19, but the wearables are pretty amazing. There's also computerized cloth where a fabric now can have electrodes essentially in it that measure your motion, not only your range of motion, but your distance and velocity and angulation, and I think it's really going to change how we follow patients in a rehab standpoint. But how do we apply it right now in sports medicine? So these are the systems that are currently used in NFL, NBA, Major League Baseball, Major League Soccer, NCAA. What we're going to talk about specifically is the catapult system because it's one we have in Tuscaloosa, University of Alabama. It's generally used in most programs, including most NFL teams, by the strength and conditioning coaches, not the medical staff. So when I first gave this talk at our Herodakis meeting a couple years ago, I think most of the doctors in the room were college and NFL doctors, and they didn't know their team had this device because it was bought essentially for training and tracking velocity and speed and cutting. It was not bought for medical purposes, but it's actually really good at evaluating injuries, recovery, and function after an injury. So most of these physicians now know they have it, and it's been amazing over the last three or four years how many people have come online with using this medically. So the nice thing about this system is you can measure a lot of variables. You can measure total distance. I'm going to go back and show you the picture of what it is. Anyway, we look at total distance, max velocity, player load. We can chart them out. The total distance and max velocity are shown here. We can look at player load and explosiveness. We can look at cutting direction and acceleration. So up would be acceleration. Going downward is deceleration. left is high change of direction to the left and right is high change of direction to the right. And that's inertial movement analysis. You can also look at symmetry. You can look at whether they explode more off the right or left leg consistently over time. And you can look at it several days in a row. You can assess workload and overuse, return to play. And you can also potentially prevent injuries. We'll talk about that as well. So we started using this in 2013. We have 80 players in the University of Alabama football team that wear these devices both in practice and games. Every practice and every game, including spring, including summer workouts, they're wearing it all the time. And it's one of the many methods we utilize to evaluate performance and also injury risk. So this is the setup. It fits in the shoulder pads. It has a little data collection device, a GPS device that fits in the shoulder pads. It also has a small one that they can wear in their shirt if they're not wearing shoulder pads for summer workouts or for on-field non-pad activities. Each player has their own little device. We have a master's level ATC that his job is to collect data, keep up with these information points, and to let the coaches and athletic trainers and medical staff know when someone is off course and out of their normal routine. This is some of the data we collect. It's about 300 to 400 data points per player per day. So it's a lot of data, 80 players per day. We also get heart rate, metabolic rate, and other things that can help you with heat exhaustion potentially. But the question when we first started this was what's important to look at? We've got so many data points. We suspect that for ACL return, deceleration seems to be the last thing to return. And so it may be the last thing to normalize before they get back to full activities. High ankle sprains obviously is changing direction, but also acceleration is off. Hamstring strains, acceleration, max velocity, but also player load. And then for hip and FAI issues, change of direction, deceleration again is one of the common problems. So we've looked at several players over the years. When we did this report a couple of years ago, we had eight players that we had both pre and post-injury data on. There were different positions and different injuries. There were three ACLs, one hip, one Achilles, a couple of foot and ankle injuries. And we followed them along. And what we found was that based on return to play, our ACL, the three ACLs got back an average to play, which means on the field practice at 4.2 months. But they didn't get back to normal on their actual GPS data until 8.7 months, which was really amazing because if you watched them on the field, you would think they were normal. And a lot of them played in games, but were not normal at the time. This is one example. This is a softball running back. He had a left ACL in September of 2015. That early preseason was a reference point. And he was coming back in the spring of 16. So this was his initial date with the explosive change of direction. As you can see, this pre-injury September of 2015 data, the green mark on the left was his pre-injury. And it's interesting that he was very apprehensive about cutting off of his left ACL. So if you look at high direction, change of direction left, cutting off his right leg, it's way far on the left side of the curve here. Whereas cutting off his left leg going right, he didn't go nearly as hard. That was pre-injury. So the question is, was that a precursor to his ACL? Was he having some kind of problem? Was he having something going on in the knee that caused him to not want to cut off his left leg pre-injury? Then he has the ACL, we reconstruct his ACL. You can see his yardage, his velocity, everything goes way down in the early spring of 2016. At this point, he's about six months out from surgery. He's in spring practice. He's doing non-contact drills, but he's going through them. We can see him gradually increase his yardage and increase his velocity until eventually he gets back to where he's pretty normal and pretty symmetric. So if you look at his last curve, this blue one, he's still a little bit apprehensive cutting to the left. He's been cutting to the left this way, but it's certainly a little bit better than it was pre-injury. And he's back to his same general curve. So the question is, should we have noticed and modified his training before his injury, September 2015, because we knew that he didn't like to cut off his left leg? Did he need some evaluation? Would he have a weak quad, weak hamstrings? Was he apprehensive? And we don't know, we can't go back and look at it, but certainly in the future, when we notice these asymmetries, it's probably important to look at this before the player gets injured and possibly prevent their ACL injury. So this is what happened to him. He came back in that following season. You can see his left leg looks like it's working pretty well. Of course, he's playing a Pac-10 team, but still running pretty well. Ouch. It takes three or four to get him down, typically. He's playing for the Detroit Lions now, had a really good season this year, and came back and did well. The limitations in terms of GPS is that the GPS part is only available outdoors because of the GPS satellites. Some teams use radio frequency in the NFL, and they have radio frequency wave monitors, essentially, in the stadiums, and they can do indoor measuring. You cannot do anything to look at their mechanics. So if someone cuts and has a valgus knee posture, you won't know that by GPS data. There's a ton of data points. We get over 200,000 data points per week, and trying to manage that is really cumbersome. And we have one full-time master's ATC that does it, and he's learned how to really load the system quickly and look for important outliers. But we need to know what data is important and how do we catalog the data and keep up with it so that we can use it and make it usable to not just the strength and conditioning guys, but the medical guys. Couple of case examples. This is a sophomore, a defensive back. If you look right here, he cuts and tears his ACL. On a part return, that was in 2014. This is his baseline data. So his baseline load to explosive ratio. He has surgery, goes down as expected. We can kind of watch him increase his activity level as he goes through the following fall. And eventually, he gets back close to where he was before in terms of explosiveness, but we're still not putting him at the load where he was pre-injury. He's still not quite back to full load. This is his maximum velocity. The three red lines represent, the center line is his average velocity and the other red line above and line below. So here and here are one standard deviation above and below his mean velocity. These blue lines are his actual maximum velocity at each one of these points in practice or games. And you can see that his pre-injury velocity, he actually surpassed that prior to coming back to play. He was able to have a higher velocity post-injury than he had pre-injury. And this was an example of that. This was that return season. He's pretty good at that still. He plays for the Bears, I believe. His specialty is taking passes back for touchdowns because he was a heck of a front returner. Any Georgia people on the line, check out the score here. Ouch, ouch. The 31 to three and three. Glenn wants to show some Auburn highlights. Thanks. Yeah, I'll bet. So the second kicker, this is a junior running back. This is not an ACL. This is an ankle fracture dislocation. But he's injured in this game. You can see he gets tackled. You'll see his left ankle is fractured, dislocated. He was reduced on the field and had surgery that evening. We were playing at Ole Miss and I brought him back to Tuscaloosa. The worst part about it, watch number seven or 11, he's a junior running back. He's a junior running back. Worst part about it, watch number seven at Ole Miss, kicking in the head when he's done. That was a good move. Kicked the ball out of his head. So he has ankle fracture dislocation. Foot gets stuck, valgus injury. He has a fracture dislocation. He's pulling back that night. Ends up having fixation with plate and two tight rope devices. He was able to come back in spring practice, about five months out from surgery. Limited reps and contact. And we closely monitored his catapult numbers. This baseline season was 2014. When he came back, his player load was pretty high, amazingly. But his explosive ratio kept going down. At this point, he came to the coaches and said, hey, I'm worn out. I don't feel good. I don't think my ankle is doing very well. And so we had to back off of his load and he eventually got his explosiveness back. If you look at his velocity acceleration, his pre-injury velocity averaged around 19 miles per hour. His highest velocity was around 21 miles per hour, which is pretty fast, obviously. This is a kickoff in that championship game the following season after his ankle fracture dislocation. He ran the fastest time that we've had in University of Alabama history at 23.1 miles per hour. Okay. This is an example of some kids playing football. It'll make you run faster. So he dives across the course. Just to give you some idea of what that means, this is the highest velocity in the 2019 NFL season. So nobody ran over 22.1 miles, 22.3 miles per hour. And can you imagine 23.1 on this particular flight? Right here, he's doing 23.1 miles an hour outrun the last guy on the kickoff team. Are you trying to make a pitch before the draft that Tua's bilateral ankles is gonna make him faster? Is that what you're trying to say? I should have shown his catapult data so we don't have the hip data back yet. So if you notice on this picture, this was the Sports Illustrator after that game. If any of you know my foot and ankle partner that fixed his ankle, he's the guy on the white on the far side, Norman Waldrop. So Norman is not only is he a foot and ankle surgeon that fixed his ankle, but he was also on the cover of Sports Illustrated celebrating his touchdown in the next championship game. So it makes it a lot of fun. So in conclusion, my return to play criteria in 2020, I still do a subjective knee rating scale. I still examine the knee, make sure they have a tight ACL, no pivot shift. I still like an isokinetic biodex type test with greater than 90% side to side symmetry. I still do the hop test and Kevin Wilk and the guys in PT will do that for me. We'll still do some functional testing. But ultimately, the wearable technology for the high level athletes confirms that he's truly returned to play and gives me the confidence to allow him to get back to the elite athletes. It makes me feel better about him not hurting their knee. Thank you. Just one quick notes on this. This is my game and the guy in the center right here is my 16 year old son who was the Gatorade guy for the last couple of years. When I was copying these pictures, I noticed that he's got a credential on and he doesn't get credentials from games. So I had to zoom in. He's Dr. James Andrews. I'm on muting a couple of people here, Lyle. That was great. I appreciate it. And, you know, people that have some questions, you know, because the catapult data, how accurate is the catapult data? There's a lot of other systems that are out there that might be more accurate. What's your thought on that? Yeah, I mean, I think it's a good question. I mean, I think it's a good question. Accurate. What's your thought on that? Yeah, I think there's a lot of data that's given out and when you plot the data out, there are definitely some outliers. If you take 200 data points on a person, you'll find two or three outliers, but the overall trend is generally pretty consistent. And I think the key is to have pre and post-injury data because the pre and post-injury data gives you not a single snapshot, but it gives you over time a consistent following of what that player does. Even if there are a few outliers in the data, I think it gives you a pretty smooth data collection because there's so many different points together. Cool. So we'll start off if there's any questions. There was a comment about the 2019 Bama-Auburn game about some interceptions returned for TDs, but the interceptions were thrown by the team in the red and the white, but that's another, that was just a comment. If you don't let them win every four or five years, it's not a robbery. All right. So are you still using, so is the catapult still your go-to, what you're doing? Yeah, so essentially, I do all the basic stuff. So I do the exam and all the basic stuff. And once I see that their strength numbers and isoconnect testing are close, then I get them on the field. And once I get them on the field, I start watching the catapult there. And so the trainers in Alabama, Jeff Allen and Jeremy Gazelle, well, each time I see the player and we talk about him, they'll say, hey, he's up to 80% of his baseline catapult information, or 85%. And as they get closer to 100%, that's when I let them go back in to own the field, true activities, not just individual drills, get them back into full play. So it's kind of the last straw that allows me to get back. Okay, so Tim McAdams from here asks, can you comment on thigh girth, proximal versus distal, and correlation with isoconnect studies? No. Yeah, you know, the isoconnect test, I teach the fellows at the beginning of the year, because most fellows have not been isoconnected since they get here. Yeah, we go over all the different charts and numbers. And I guess my kind of simplistic look at it is I want them to be close to symmetric if they have a normal opposite leg. I want them to have a strong enough hamstring to quad ratio that they don't over pull the tibia anteriorly with a strong quad to integrate. And I want them to have essentially a quad to body weight and quad to hamstring to body weight ratio that seems to be close enough to normal that I think they can run in. So I'm pretty simple. I don't get into a lot of very deep details with the biodeck test. I think it's just something to get them ready to start doing some tomorrow night activities. All right. I have a question, Mark. Yeah, go ahead, Dave. Hey, it's Dave Dedock. Lyle, great talk, really enjoyed it. Learned a lot from this as well as I did at the Herodicus presentation a while back. So I think the challenge for many of us is what about the rank and file high school athlete where we're not gonna have catapult data and we gotta make this decision to return to play? Like many people, we're doing the same type of testing you're talking about, isokinetic testing, hop testing, et cetera, and trying to make a decision. And we've now generated a fairly large database and we thought, well, maybe this would be predictive. And we looked at actual re-entry rates and unfortunately the isometry was not protective. The quad thresholds were not protected. The only thing that was protected was time. So it was kind of disconcerting. We thought maybe with our sophisticated testing and meeting criteria for return to play, we'd be doing a better job of preventing re-injury, but it still seemed to me that time was the most helpful thing, certainly to your approach nine months. So I don't know if you have anything to share there, if you've been looking at re-entry rates for the larger population you serve. Yeah, so we did a look at re-injury rates about five or six years ago in JBJS and the lead author was Brent Ponce. And what we found was that the re-injury rates in our follow-up, we had about 5,000 patients, but the only re-injuries we had were the ones that returned to us. We didn't get follow-up on every patient. So we didn't find all 5,000. Anybody that came back to us for re-injury was logged. And that included myself, Jeff Douglas, Jim Andrews, and Bill Clancy back then. And our overall re-injury rate, we couldn't tell any variable specifically that made a difference. The contralateral knee was about twice as likely as the ipsilateral knee to be injured. There's been data of both directions on that. Some say it's equal, some say it's a little higher. We couldn't tell that time made a difference in our numbers. It wasn't specifically a certain month interval that made a difference. Really, the main factor that we found in that particular study was that there was one particular surgeon in the six surgeons that was doing a very low medial portal, kind of low femoral ACL, and their failure rate was about three times the average. And that was the only really we could find in that study was what they called surgeon choice. And that meant a low kind of horizontal ACL graph that tend to have a higher failure rate. Hey, Lyle, I'm gonna ask, I don't mean to put you on the spot, Floyd, but if you're on, one of our trainers, I'm sorry, a physical therapist, at Stanford, we developed a test called the FLEE, the functional lower extremity evaluation, which is a little bit different than the one you had. Floyd, can you comment to that for, and we'll get Lyle and other people's input. Obviously, this is the hot topic of late of really trying to figure out other criteria other than emotion, strength, and a few. So comment on the FLEE? Yeah, absolutely. So it is very similar to a noise hop test. It does incorporate a couple of additional things, such as a timed step-down assessment to really look at muscular endurance. And just as with all of the noise hop assessments, we try to standardize it. So we use a metronome at a rate where you're allowed to do about 40 step-downs per minute. And what we're looking at is that limb symmetry index of how the operative limb is compared to the operative limb. In addition to that, we have the hop assessments, the single leg hop for distance, triple hop for distance and crossover. Then we also incorporate something developed by Dr. George Davies, a physical therapist. I forgot exactly what state he's from, but a lower extremity functional test, which is just a series of run assessments that includes linear movements, lateral shuffles, karaoke movements, backpedaling. And basically what we try to do is compile these eight assessments to be a little bit of a comprehensive breakdown. Again, like what you said, we're looking at the limb symmetry, but at least this gives us some data that we could work off of if we don't have the access to a biodex or anything of that sort. We're still in the midst of collecting data, trying to hopefully break it down in terms of not only with the football players, not only they're given biometrics and how big they are and their sizes, but also their positions. Yeah, that's great. I asked Kevin Wilk the other day, if he had one test that he could do to determine if somebody's ready, he said that it was hopping off of a block. So essentially a hop test where he would watch them land off of a block and look at their knee position, hip position, body control. And he felt like that was the one test that he used to determine when somebody had the mechanics to be safe and get back into sports. Absolutely. Hey, Tim McDowell, what are you guys doing for the 49ers? Tim, are you still on? Or I unmuted him. Yeah, sorry, having mute issues. Yeah, very similar using catapult system. And like I said, just trying to make sense of all the data. But what's really been fun is really more working a lot more with strength and conditioning and athletic trainers and now these performance specialists. So it's really takes a group of people from different backgrounds. Mark, can I make an addition, Seth? Yeah, Seth, please. Great talk, Lyle. So I went through the flea with Floyd when I got to Stanford eight months ago. And the one thing that we were doing in Mizzou was using the connect for drop vertical jump. So I think similar to what Kevin said, that one test, jumping off of a block and seeing how they land, I think can add value. So I completely agree with that. Another thing, ACL RSI is another thing that we can allow our athletes to do to test that confidence and see if they're able to do it. And then I guess my question for you would be, what happens when these athletes fail? So what's your retest protocol? Because often they're passing even, you know, biodex hops and they fail, maybe they're drop vertical and, you know, they have another couple of months to go or they're not confident enough. So what are your thresholds and how do you handle that? Yeah, I think it depends on the sport and the athlete. But I think that certainly in sports medicine, I think we're probably 90% of the time Yeah, in sports medicine, I think we're probably 95% psychologists and 5% doctors. And that's part of the psychology is, you know, you have to spend enough time and know the athlete and know their situation. You know, I try to explain to them, you know, why we're being so demanding or so particular about their return. And most, I think most athletes when they're not ready, they know they're not ready. So, you know, my experience is even the ones that look really good, these NFL guys that have these monster quads and they look like they're 100% at three months. They know they're not ready. They can tell, their body feels it. They may act ready, but they know it. And so in most cases, I think the athlete is kind of relieved when you tell them that they've got another month or two of rehab before their time to go. Latul, you had a question? Yeah, so, Lyle, this is a great talk. You know, I think we get out into practice after fellowship and I don't think many of us worry about where we're going to put the ACL. We figure that out. These are the things that we really have questions about that we don't always get during our training. So this is, thanks for giving a great talk. So what's your parting line? So the athlete comes in, whether it's a pro college or high school and they ask about bracing. Because, you know, when I first began, no one got braces and I was kind of anti-brace. As I've been further and further into practice, I don't demand all patients get bracing, but the ones who do, I don't have a problem with it. What are you telling your athletes? So I think, yeah, so I typically have, you know, most contact sports, so football particularly, I'll have them wear it when they first come back. I'll have them wear some kind of a functional brace. And I think most of it is, for me, is peace of mind for the athlete because they have to get the confidence back. They have to fall a few times, get hit on the knee, have some awkward landings before they're confident. But typically, whenever the athlete's tired of it, I'll take it off. Or if they get to where they're completely symmetric, I'll take it off. My college soccer players, you know, I tell the female soccer players they're going to wear it the first season back. But as soon as they start complaining to the trainer that they don't want it, I'll take it off. I think it's one of those little extra psychological advantages sometimes that helps the player. But as soon as they don't want it, I'm generally okay taking it off. So I don't demand that they wear it for a certain amount of time. All right, Lyle, I'm going to give you a question out of left field. Yep. BFR and ACL, are you guys using it? If so, do you think it's changing your ability to rehab, the timing of rehab, the timing of return to play? What's your thoughts? Yeah, I'm a big fan of BFR. I think it's, you know, both in the college training room and our local PT unit with Kevin Wilk, it's made a big difference on quad return. I think the problem really is that the biology doesn't change. You know, the healing of the graft doesn't change. The other factors are still the same. So you get muscle return quicker. I'm convinced that I've had a few players that had probably some continued effusions and, you know, had some stuff going on in the knee because they got their quad back so fast that they thought they were normal at three months. So I think that it's great for muscle return. But I think, in my mind, it hasn't really changed the ultimate return to play time. Anybody else? I guess that's biology more than purely muscle mass. Yeah. Does anybody else have any comments on the BFR, what you're doing or not doing? You know, Mark, I presented on some BFR stuff about eight months ago, mainly for my patella femoral patients. And as big a place as the Cleveland Clinic is, we don't do blood flow restriction. We didn't have the machines to do it. And they kind of considered it experimental, even though there's quite a bit of literature out there talking about the benefits. And I think slowly we began to adopt it. And so I think at some of the higher-level places, you know, I think you may have some of that stuff available. But I think for a lot of the people going out into practice, they may not have someone at their institution or in town that may even be doing that. I mean, you don't need any special equipment, right? You can always just use a blood pressure cuff, right? So that's what I brought up. And our head of PT seemed to think that, you know, there needed to be a special machine. And I think there is a special machine that is used. But, you know, and that was one of those things that, again, I didn't know enough about it to really challenge him on it. I am happy to say they are starting to do some here, which is good. Does anybody else using it or comments on it? Steve, Dave, you want to comment on it? Yeah, we're using it. We're using it in Philly. And we definitely used it with the Phillies and our professional guys. I agree with Lyle. And this is a great topic. We could probably talk for hours about return to play. But, you know, I agree with Lyle. I think it affects muscle activity, but it's really not going to change biology. So guys are feeling a little bit better more quickly. It allows them to get their quad back sooner. So I think it's great. We also use a return to play program that we developed here. We have seven different components to it. And we make sure that the athlete has to pass six out of seven. So if they pass five out of seven, then we go back and retest them. And Dave Deduck and the group out of UVA, they recently published the study looking at, you know, if you fail a return to play test, that going back six weeks later is really the ideal time to do that. And I think Lyle's point of, well, it could be, you have to look at your athlete. It could be four weeks. It could be, you know, there are certain factors. And sometimes, you know, it's learning the test and redoing it again, just like anything else. So, you know, somebody may not do as well the first time through because we use hop testing. We use functional movement screen. We use, you know, a pro agility and a movement assessment. So, you know, sometimes and some of it, honestly, is the IKDC when we use that just as one component of it. But, you know, they get through this questionnaires and some things they've done and some things they haven't done. And so they're not quite sure how to answer. So I think it's great. I think we all should be using something objective and not, you know, oh, it's six months and go ahead because it's six months. Dave, did you want to comment since Steve opened the door for you? BFR has been useful. Early stages doesn't change the return to sport date. And yes, Steve alluded to what we found was if you're doing this functional testing, the athlete's always eager, the coach is even more eager and the parent's even more eager still. If they don't pass it the first time, they want to come back in two weeks or three weeks. So we looked at our database and actually found there was a two month increment for you to move the needle enough to matter. And if you test them more frequently than that, they just get frustrated. So you want to use this motivationally. And we found a two month period of time between testing reached some statistical measure of improvement or change to be a value to retest. So that's pretty useful. Now we've actually changed the way we do it. We used to wait until the six month point in test, but we realized that if they fail at that point, they can get very discouraged. So we've now gone to a four month test and it's actually flipped this. It's become very motivational. We say, okay, your four month results will help guide the remaining rehab. We'll test you again at six months and this produced positive results for us, at least for the testing. Dave, we're actually the opposite of that. We actually test them at seven months because we know we don't really want them to go back or think that they're ready to go back. If they pass the test at five months or six months, then they think they're ready to go back. So we actually wait to test them at seven months. And if they pass, then we say, okay, now we feel comfortable, ready to go. I mean, we don't have Nick Saban barking at us, telling them that they need to be ready at four months, but we actually wait till seven. Maybe I misspoke. The four month test doesn't include all the hopping and functional tests. It just is the ischemic and strength measures. And it's not meant to be a clearance for sport test. It's more to guide the remaining rehab, but it did serve to be motivational. The six month test would incorporate the rest of the testing, but nobody's passing. I mean, almost nobody gets there at six months, even with all the resources available. So almost everybody's coming back at eight months and testing, and that's where we found when we tracked people in re-injury, it's really the longer they waited, the safer it got. We've become more conservative as a result of instituting these tests in our practice. Kind of an interesting- I wonder if you push it back a little bit, it might even be better. Yeah, exactly. We found out to nine months it was protective. And that's, you know, so we thought with all these tests, we maybe push the envelope, get people back sooner, a select group that were more ready, just the opposite. We're more conservative than ever. All right, so I'm going to throw out to what I'm calling this panel of team physicians here. So I've got two different sets of questions, but the first question, if in an ideal world, when are you letting an athlete back after an ACL? I mean, what is going to be kind of your minimum, if you're saying that these are not necessarily returned to play criteria, you know, doing these different tests. And being pressed on time, what is the absolute minimum amount of time that you'll let somebody back? So ideal, and let's say, you know, your football practices or football season starts at a given date, or basketball season starts at a given date. What is your earliest that you're going to be comfortable with letting a player back? I know Nick Saban's answer is, after the wounds are healed, I got that. So, we'll start with that. Go ahead, whoever wants to start. Yeah, I would throw out six months earliest, nine months ideal. Seth? Minimum six, eight to 12 is ideal. Steve? Yeah, I'll go with David. David didn't say anything yet. I did. That was a six to nine. He started that. Oh, David was six to nine. I thought that was Lyle. All right, Lyle. I've been at the Nick Saban School of Medicine for too long. My ideal is around six or seven months. Realistically, I've had plenty of players come back at the Division I level at about four, four and a half months, and haven't had any re-tear, knock on wood, but I'm apprehensive a little bit, but I think biologically, the ACL's pretty well revascularized by about three to four months. And so, Nick Saban told me they all heal by four months. We just started doing that, and it's worked out. All right, the tail wagging the dog. The tool. Yeah, I'm also a little bit aggressive with this, and I quote to athletes six to eight months, but I've gotten a lot of athletes back at five months, but they have to look like an athlete, and I think that's some of the value of doing some of these hop tests in the office because I think it can pick up some kinesiophobia as quick to do, and it can convince patients that they may not be ready. On the flip side, it lets me know that patients may be ready and embraced, and I've gotten back some athletes because you're short on time. Yeah, you do their ACL in March, and they have to be ready for two days in August. Yeah, you can't tell that athlete, that senior athlete, well, you can tell them, but I'm not sure you can tell them that they can't play their senior year. They're gonna get on board in September, October of the senior year. So we've pushed the envelope. I don't like doing it, but we've done it. All right, Will Workman with the Oakland A's. You there? Yeah, I'm here. I'm a little more conservative, I think. You know, I do, I agree with the functional testing, and I agree with not sticking to a strict timeline, but, you know, even at the pre-op appointment, you kind of have to lay out the timeline for the patients, and, you know, I generally say six months back to sort of sports-specific cutting, pivoting activity, and then eight to 12 months return to play, and I think, I can't quote anybody, but I think a lot of guys are getting even more conservative than that as far as return to play, maybe even beyond a year, kind of like the direction we headed with UCL's in the elbow, but I agree that if they're looking really good with their kinesiology and their ability to pass a test, they probably could be early, but I would be very careful about getting them back early. Certainly somebody with a year, maybe their senior year, you have to kind of go for broke anyway, but I would say no sooner than six months. Tim McAdams? Yeah, for NFL, it's generally going to be a situation where you're waiting until training camp anyway, so you got that nine-month luxury if the injury happened during that prior season. If it's up against it, certainly six months minimum. I think we've all had people at four months or so that have gone back maybe against their wishes and have done well, but that's just a little bit early to my mind. Okay, so I'm going to ask a question here. Actually, Sandeep Manaba asked, so this is a little bit difficult question, but it's, can the panel comment on return to work after ACL, especially workman's comp? I think it kind of depends a bit on what the job they're doing. So, Sandeep, actually, I'm going to try to unmute you so you can ask what are you asking here more specifically? Go ahead, Sandeep. Yeah, so I think the big question for me is, you know, you have a manual laborer, a construction worker, something like that. You know, they come in, you know, not as high demand as some of our athletes or college athletes, and they're wondering, okay, when can I get back? Are you saying six weeks, eight weeks with the brace on, or is that pushing it too much? Wow. Yeah, so I know NFL, and I know Alabama football is workman's comp, but, you know. That's good. You know, I think it depends on the job, obviously. I think for most manual labor jobs, I lay the groundwork at three months for them to get back, because I think that's when I normally let people do impact loading, running, you know, jogging kind of stuff, because I feel like the graft is mature enough where it can handle that kind of sheer stress. If it's going to be a heavy laborer, somebody that's a coal miner or something like that, where they're underground, uneven ground, a lot of twisting, turning, it's probably six months. So it depends on the job itself and the person, but I generally, for work comp, make my maximum medical improvement date at the beginning at the six-month mark. So I tell the adjuster that I'll set their impairment rating and see how they're doing at six months, but if they do a medium job, I'll let them get back at three months. Anybody else have any other comments on that one? Yeah, you know, if you're treating police, fire, those type people, that's a high-level job. So I agree, six months on those people, and, you know, you want us to tread lightly for sure. All right, I'm going to ask the last question here that's going to be interesting, I think, I hope. At least it is to me. So kinesiophobia, right? Some people don't want to get back because of kinesiophobia. How do you address that? How do you try to get them to overcome that? Can you overcome that? So Lyle, since you're our guru today. Yeah, so I think that's the one place where you really can't speed the process up. I mean, you can do sports psychology training and all that, but I think there's some people that just are not confident in their knee mechanics, and those are the ones that may take a year, 18 months to get back, or they may never quite get back to normal. I'm not sure you can change that psychologically. Now, if it's a pro athlete, you may go more aggressive and try to get them in with a sports psychologist, but for the general public that is kinesiophobic, I think you just wait them out and try to encourage them to keep working and keep getting their strength back, and I think their confidence comes over time. Dave, do you have any tricks? I don't. Steve, Latul? I think Lyle's point about sports psychology is really important. I think if you have, like, the parent will usually kind of tell you. They'll look at you and go and say, you know, something, they just, they don't seem right, and they'll ask you, they may pull you aside and say, do you have a sports psychologist or anybody you recommend, so when in doubt, talk to them about, you know, the fear, you know, the fear factor involved with it because, you know, ultimately, they have to get over that hump before they can get back. Yeah. Go ahead. Yeah, Latul? Yeah, brace them, validate their concerns, tell them that they're not the only people who experience that, and I think that goes a long way, and, you know, we got a sports psychologist at our institute that we can send a patient to also. I mean, I think that sometimes, you know, the mechanoreceptors within the ACL don't come back till a year and a half anyways, right? So, I mean, do you guys try, like, knee sleeves to help the cutaneous proprioception or actually we have some therapists on this call. Do you guys have any other tips or tricks that we can do? But do you guys, are any of you guys using, like, knee sleeves to try to help with the proprioception as a way to manage some of the kinesiophobia or do you think it's all super above the shoulders, not below the waist? This is Floyd from Stanford again. I do think that, yeah, obviously, there is the mental and the sports psychology factor, but we are using some bracing, even something as simple as taping. That could be of benefit. And what we try to address is just try to simulate the motion, now breaking it down so that the student athlete will have a sense as to what the ultimate end goal movement is, but breaking it up into pieces that are a little bit more, a little easier to digest, so to speak. So, breaking down the cutting movement into its very fundamental prerequisite movements. Anybody else have any other tricks? Does anybody else use knee sleeves for their proprioception or not really? Dave's taking a said no. I'm going to try this. No? No. All right. Great. Lyle, I'm a smarter man now than I was an hour ago. Thanks, Mark. Appreciate you setting this up. I appreciate you giving the talk. Of course, we are, by the way, just so you know, it is the PAC-12. It's not the PAC-10. So, that was an old video of old times. But I appreciate everybody being on this session and everybody's contribution. Hope you all have a good evening and stay safe and hopefully we'll see you all tomorrow. Thanks, Lyle. Thanks, guys. Appreciate it. See you, guys. Thanks, Mark. Thanks, Lyle. Take care. Thanks, everybody. Bye-bye.

ACL reconstruction

return to play

evaluation factors

wearable technology

Catapult system

athlete performance

isokinetic testing

functional movement screens

timing for return to play

kinesiophobia