525: Dr. Nicole Surdyka: Return to Performance After ACLR

In this episode, Director of Rehabilitation at OL Reign, Dr. Nicole Surdyka, talks about on-field rehab after ACL injury.

Nicole is currently the Director of Rehabilitation at OL Reign, one of the founding clubs of the National Women’s Soccer League, NWSL, which is one of the best professional women’s soccer leagues in the world.

Today, Nicole shares her 5-phase on-field rehab strategy, and the decision-making process in return-to-play and return-to-performance. What are the criteria that Nicole looks at to determine progress to the next phase of rehab? She tells us about delaying return to sport to reduce second-injury risk, the return to sport continuum and how to define it, and the use of the StARRT framework for the return-to-sport decision-making.

Nicole gives some valuable advice to her younger self, she tells us about integrating rehab with team activities, and communicating with athletes and coaches, all on today’s episode of The Healthy, Wealthy & Smart Podcast.

 

Key Takeaways

• Nicole implements on-field rehab in 5 phases.

Phase 1: Simple, pre-planned, linear movements. The focus is on quality of movement and cleaning up movement technique before moving on. Typically includes walking marches, walking lunges, side shuffles, and jogging. Nicole starts this at 70-75 quad strength limb symmetry index.

Phase 2: Pre-planned direction-changing movements. Typically includes accelerations, decelerations, sprinting, and change direction.

Phase 3: Adding reactive tasks without a soccer ball. Direction-changing with an element of reacting to an external event. Nicole starts this with at least 80% quad strength limb symmetry index.

Phase 4: Soccer-specific movements. The reactions are done in context – with a soccer ball.

Phase 5: This phase should look like a modified training session.

• Delaying return to sport: each month that you delay that, there’s a 51% reduction in second-injury risk, up until the 9-month mark.
• Return-to-participation: When athletes are participating in their sport in a modified way – participation with certain limitations on activities.

Return-to-sport: When there is no longer any medical reason to limit an athlete’s participation – “cleared to play”.

Return-to-performance: There are no restrictions and athletes are training to become better at their sport.

• “Be patient. Every experience is valuable, and you can relate any experience to what you eventually end up doing.”

 

Suggested Keywords

On-field Rehabilitation, StARRT, Injuries, ACL, Sport, Performance, Physiotherapy, PT, Therapy, Wellness, Health, Injury-Prevention, Recovery,

 

Recommended reading:

Consensus statement on return to sport: https://pubmed.ncbi.nlm.nih.gov/27226389/

On-field rehabilitation Part 1: https://pubmed.ncbi.nlm.nih.gov/31291553/

On-field rehabilitation Part 2: https://pubmed.ncbi.nlm.nih.gov/31291556/

 

More about Dr. Surdyka: 

Nicole is currently the Director of Rehabilitation at OL Reign, one of the founding clubs of the National Women’s Soccer League, NWSL, which is one of the best professional women’s soccer leagues in the world.

Nicole is a physical therapist and strength and conditioning coach. She played Division 1 college soccer at St. John’s University and then went to Emory University where she got her Doctor of Physical Therapy Degree. Throughout college and PT school, Nicole coached youth soccer and worked as a personal trainer.

After PT, school Nicole worked in various outpatient orthopaedic and sports medicine clinics before starting her own practice in 2018 where she worked with youth to professional athletes. Nicole specializes in on-field rehab for soccer players to help bridge the gap between rehab and sport performance. She is passionate about the return to sport process and how we can make better decisions for athletes returning to sport after an injury.

Nicole has a website where she writes blog posts on rehab for soccer players, has eBooks available on specific injuries, teaches continuing education courses, and has presented at CSM and other national and international sports medicine conferences.

To learn more, follow Nicole at:

Website:          Nicole Surdyka Physio

Facebook:       Nicole Surdyka Physio

Instagram:       @dr.nicolept

LinkedIn:         Nicole Surdyka PT

Twitter:            @NSurdykaPhysio

YouTube:        Nicole Surdyka

 

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Read the transcript here: 

Speaker 1 (00:00):

Hey, Nicole, welcome to the podcast. I am so excited to have you on.

Speaker 2 (00:05):

Thanks. I'm excited to be on.

Speaker 1 (00:07):

So this whole month we're talking about ACL injury and ACL rehab, and you are an expert in both. So I'm really excited to have you as one of the guests this month. And today we're going to be talking about something that is really your zone of genius, and that is the on-field rehab, a rehab techniques, I guess, that helped to bring that player back to performance. So can you talk about what is the on field rehab like?

Speaker 2 (00:45):

Yeah. So I guess it's a concept that I, you know, I was a soccer player. I was a youth soccer coach, and so I always kind of felt in the back of my mind when I was going through PT school, like, Oh, wow, I could blend. Like, if, if we're trying to get this adaptation or build up this physical attribute, we could do that through soccer. And so it just made, it was something that made sense to me trying to incorporate the sport as much as possible, but where it really all clicked and came together. For me, it was actually at the isokinetic conference that I went to a few years ago in Barcelona. And actually your previous guest on this in Arundale was the one who talked me into going. So that was great. And I saw a presentation by Matt Thorpe about on-field rehab. And of course he and Francesco via have published two different articles in WSPT on this, but kind of seeing that presentation really yeah, tied it all

Speaker 1 (01:42):

Together and made me have that aha moment

Speaker 2 (01:44):

Like, Oh, this is a thing I can make this happen. And so really what it is is it helps to bridge that gap between the gym-based rehab and then sending the athlete back for their sport. Because if you think about it, there's so much of a difference between doing a drop vertical jump in the gym and then landing from a head ball on the field. Like not even just physically that's different because the surface is different. Your shoe wear is different. The weather obviously is different, but there's also different things in your environment to make decisions based off of, and react to and respond to. So where are my teammates in space? Where is my opponent? Am I going to have a contact or an indirect contact, a perturbation while I'm in the air that I have to land on? Funny, where do I have to redirect my Ron to afterwards?

Speaker 2 (02:34):

And you can only prep for that so much in the gym. And at some point you really need to get them on the field and do in a controlled way, what they're going to have to do when they're playing with their team again. So on-field rehab. The way that I implement it is really based off of Matt, Matt backdoor, Ben for Jessica, Davey is research and there are papers on it, which is phase one, really simple pre-planned linear movements. And so that can start fairly early. They say in their paper that they want to start. When the athlete has 80% quad strength, limb symmetry index, I tend to start a little bit earlier than that. Typically, when I'm having athletes jog, then they can be doing phase one. So things like walking marches, walking lunges side shuffling is okay in this phase, jogging anything that the athlete is has pre-planned, it's a pre-planned movement and it's just linear.

Speaker 2 (03:34):

So no changes of direction yet. And in this phase, we really focus on quality of movement. And we start to address here before they move on to more complex tasks we address are they moving efficiently? And are there things we need to clean up with the technique of their movement? So something like a high skip or a walking March, are they getting a lot of trunk lean? Are they yeah. Are they kind of like looking like Gumby out there? And so we need to clean that up a little bit, and this is the phase that we can really take the time to do that. So again, I like to start this pretty early. Typically I want them to be at least 70 to 75% quad strength, limb symmetry index. But the, just as a caveat to that, the paper by Francesco and met, like they're up says 80%.

Speaker 2 (04:27):

So just be aware of that phase two, they then move on to being able to change direction. Everything is still pre-planned. So we can take those linear movements from phase one and make them a little bit more intense. So we can start working on reaching towards accelerations decelerations, maximum speed. So we start to work on sprinting here and exposing them to high-speed running on the multi-directional staff. We can have them do anything pre-planned so no reactive tasks yet, but they can start to cut decelerate, changed direction, all controlled everything throughout the unfilled rehab program is control first. Then we build volume and intensity. So after phase two, we can progress them to phase three. Now for this, I definitely want them to be at least 80% quad strength, limb symmetry index. And I would love for them even to be closer to 85% and depending on how they look functionally.

Speaker 2 (05:29):

And so this is when we start to add reactive tasks. So now change of direction tasks, but with a reactive component. So they're reacting to something external to them. So I like to mix up and I know Amy talks about internal versus external cues a little bit. And it's something that definitely is coming up a lot in ACL research with motor learning is that we want some external cues. And so that can be auditory. That can be visual. So I like to do kind of a combination of both. I'll use words that they're going to hear while they're on the field. So turn man on ball, you know, I'll use kind of those that verbiage. And then the visual is you can make it just simple. You pointing to where they have to cut to or change direction to. You can make it be, they have to follow the ball, they have to follow a runner.

Speaker 2 (06:25):

So they have to follow where the space is that you've set up with, however, you've set up the environment. So that's where we add the reactive components and they anything pre-planned they can now be doing at speed. Next, we're going to go into phase four, which is really going to be more soccer, specific movements. So now they can react with a soccer ball. So everything we didn't base three with the reactive movements is them without a ball at their feet. Now in phase four, we can add a soccer ball. So you have to turn and either dribble, dribble, or pass, or you know, you have to collect the ball and then make a decision based on what's going on around you or what the coach or the physio calls out. And then phase five really should just look like a training session, a modified training session. So I try to replicate what the team has done in their training session or what a typical team training session would look like as much as I possibly can within a more controlled environment. So that's kind of the five phases and then, yeah, and then I started to incorporate them into the team. Okay.

Speaker 1 (07:32):

So let's, I have a couple of questions. So we're just going to back up a little bit. So for most of these phases, certainly phase one phase two phase three is the player is the player alone on the field? Do they, are they working in tandem with another player on their team?

Speaker 2 (07:50):

So typically when I was, before I had my current role, I had my own practice and I would work with the athletes. So it would be me and the athlete. If they had a friend or a teammate who was available, it's always nice to add other players. Now here at LL rain. I have two athletes right now who are going through ACL rehab together, kind of they're at a little bit different spots, but I can still work together with them, which is really nice. And then I can always pull some of the other players. So, Hey, do you want to work on crossing and finishing today? Great, like come in for this session this time and I can pull other players and you can do it alone. Eventually you need to start adding other players because there's 22 people on a soccer field. And so they need to start being able to move and react to all of those different people on the field, around them. And you can still do that in a controlled fashion. Absolutely.

Speaker 1 (08:51):

I will say to, to play or one, I want you to run down to line and cut to the right as your athlete is within the midst of whatever you're asking them to do from a rehab standpoint. Correct.

Speaker 2 (09:03):

Exactly. You can say, okay, you're going to run up and defend them. I want you to force them to their right. You know, so that way I have that person has to go to their right, so you can control for it. Whereas in a game you can't tell them, or an even in a practice session with their team, you can't say to all the other players on the field, Hey, when you go and defend, so-and-so only for, for her to her right foot, okay. That's never going to happen, but in that nice in on-field rehab, you can control for those things. And

Speaker 1 (09:31):

The other question I have was what is the criteria for entering phase two?

Speaker 2 (09:35):

Good. So, and answering into any onto three high program. I mentioned the quad strength, limb symmetry index, but also there should be no joint pain or a fusion. They can have some muscle soreness at times if they had a patella tendon graft they can have some patella tendon pain. I'm okay with that. Hamstring graft, if they have hamstring pain, I'm okay with that. But, and then also no joint laxity. So I'll typically just do a Lockman's anterior drawer test, as long as those are negative and there's no joint fusion, then we're good to go. Now it's progressed through each stage, subsequent to that, as long as they're able to do those movements with control, and there's no increase in joint pain or a fusion during any of those stages, then I can progress them. Although I still want to bear in mind, like we're not just going to do walk like phase one stuff.

Speaker 2 (10:27):

And then it's like, Oh, they felt good. Okay. Now we can do phase two. Like I still want to make sure that we get a couple sessions in and it's always going to play back into the overall big picture of where they're at in their rehab. You know, we're still doing a gym-based strength program at the same time that we're complementing with on-field rehab. So it that's where it kind of the the art of coaching takes in a little bit. And you just need to understand where your athlete is and if they still need more time in that area before moving on. Got it. And

Speaker 1 (10:59):

I know this is a question that a lot of people constantly ask when it comes to ACL, what is the timeline? Right. You know, cause you're always here. You don't want to return to play for a year for 10 months, nine months, a year, two years. So as you are going through these phases, are you also taking into account where they are in that rehab continuum or in, you know, post-surgical so how do you question

Speaker 2 (11:26):

W so it's kind of the, the short answer to that question is we can go back to some of the research that's been done by the Delaware Oslo cohort, so that, Hey, grandam over at Oslo and Lynn center Mackler at Delaware, and they've shown that delaying return to sport each month that you delay that there's a 51% reduction in second injury risk. And really the whole thing of this is when we're sending out fleets back to sport after an ACL reconstruction, our goal is to not allow that to happen again, right? The rate of a secondary injury is so high that there's obviously a flaw in how we're sending athletes back. So I think that most athletes go back too soon. And so each month that we delay up until the nine month Mark and at nine months, we, after that, we don't really see that level of reduction in, in, in second injury risk.

Speaker 2 (12:22):

Now for a youth player, who's not really in a rush to get back. I will probably never let them go back before a year. I just, there was no reason it's not worth the risk. They're agreed so much more likely to have another injury. And like, why have two ACL injuries in high school before you even get to college? Right. If the goal is to, is to play in college, you're better off missing your entire junior year of high school to just rehab and then be really strong for your senior year. As opposed to feeling like, Oh, I have to show college coaches. I have to go to all these college showcase tournaments, which I know is, is pressure on the athletes, but what does it, do you any good if you go back and now you do it again and you miss all of senior year as well, right then by college, like that's not going to happen for you. Right. So more of the professional athletes, there's a little bit more pressure, it's their livelihood. Right. So I'm okay with moving or even college athletes. I'm okay with moving closer to nine months, but I will never go before that, unless I have somebody like an Adrian Peterson who is just one of those outliers, then they have to give me a really good reasons to let them go back.

Speaker 1 (13:33):

Okay. And this actually flows perfectly into the next topic I wanted to talk about. And that is that decision-making for return to performance, right? So we've got the return to play. And even if you want to talk a little bit about that distinction between return to play and return to performance and talk a little bit about what your your decision-making

Speaker 2 (13:57):

Is like. Yeah. So to talk about that continuum a little bit, and actually I just had a meeting with our coaching staff here about that to make sure you're on the same page about these definitions. And so how I define them is based off of the return to sport a consensus statement for that Claire and was lead author on where the return to participation phase is when, or end of the continuum is when athletes are participating in their sport, but in a modified way. So I have a couple athletes now who I say, I look at what the daily session plan is for, for the training session. And I'll say, okay, this athlete can do the technical warmup and they can do the [inaudible], but I don't want them doing the two V twos because it's too much deceleration cutting, et cetera. So they, that counts as returned to participation because they're participating, but I'm still putting restrictions or limitations on them.

Speaker 2 (14:53):

So anytime there's any kind of modification or restriction or limitation there in returned to participation, when the medical, when there are no longer any medical reasons to hold an athlete back, that's when they're in return to sport. So that's what I would define as saying like you're quote, unquote, clear to play, right? Is that I'm not putting any restriction on you, if you are not being selected for playing time or for your starting position. That's because the coach isn't selecting you, not because I'm holding you back, but then beyond that, because sometimes an athlete's not going to really be satisfied with that outcome, right? If you're used to being the starting center forward and scoring a goal, a game, and now you're cleared, but you're not being selected into the starting lineup, or you're not being selected to the game day roster, or you are, but you haven't scored a goal in five games.

Speaker 2 (15:44):

Now you're not performing at where you were prior to your injury. So there's no medical reason to hold you back, but maybe you're not playing as much or playing as well as you would like to be. And that's where we transition into return to performance. So return to performance is there's no restrictions on you, no medical limitations or anything holding, holding you back from a rehab perspective. And now we're training to get you to being better at your sport. And I think those are really important distinctions to make, because a lot of times athletes or coaches, and actually it will be back and cleared to play, but coaches like, well, why isn't she as fast as she used to be? Why isn't she scoring goals? Like she used to be? Is she still hurt? It's like, no, it medically fine, but we're just not at return to performance yet.

Speaker 2 (16:33):

So then to to kind of decide when to send an athlete back for each of those things, I tend to look back to the on-field rehab program and how that is structured. So I'm a big fan of integrating the team, the athlete into team activities as often, and as much as you possibly can. So if they're able to do the technical warmup with the team, I'm putting them in there because, and that would technique that would typically be if they're in stage two, right. Cause it's going to be mostly pre-planned change of direction tasks, maybe some accelerations D cells, depending on, on what the warmup looks like. Sometimes there's reactive components. And so that sometimes takes just a conversation with the performance director or the SNC coach or the sport coaches, just to say, what is involved in this? And then, you know, but if you, if that athlete is able to do those things and they've done them with you and an on-field rehab program, send them back into the team.

Speaker 2 (17:33):

Cause that is just to me is another level of like the cognitive awareness and their ability to see what's going on on the field, around them and adding more athletes into the mix that they have to interact with. So I'm a big fan of that. So I'll typically have them in that return to participation phase for a fairly long time, like a few months before I say, okay, you're good. So, and the example right now, I have an athlete, who's doing portions of training sessions, but I probably won't like clear her quote unquote, clear her to play in a game until somewhere in the middle of April. Right. So she'll be,

Speaker 1 (18:16):

Is she about like six months then? Post ACL? Yeah. Yeah. Yeah. Okay. Yeah. And I think it's important to mention all of this because oftentimes a lot of physical therapists and I, this is not to throw our profession under the bus or anything, but a lot of physical therapists tend to be a little bit more restrained. They won't want them to go onto field. They won't want them to do this on-field rehab until they're at 90%. Right. And or until the doctor clears them to return to play well, you can't just be cleared to return to play. And you've only done a weight training program, proprioception, maybe some motor control stuff and then throw somebody on a field.

Speaker 2 (18:56):

Yeah. And I've seen that way too often.

Speaker 1 (18:59):

Yeah. Yeah. And so it's, I think that I'm really happy that you're saying like, Hey, you know, at six months they can be with the team, they can do some things. It just, it sounds to me like it's a lot of communication and collaboration from the, all of the stakeholders, right?

Speaker 2 (19:14):

It is, it does take a lot of communication. And we have twice a day meetings, constant emails, constant communication about where each athlete is. And then, you know, there is things that come up that we have to adapt to, like this was the training session plan. And this athlete was going to be able to do this amount of load that day. And then based on what was happening in the session, the plan changed. And so we have to adapt to that. And then we just supplement that with it with more on field work, you know, if they weren't able to do as much in the session with the team, then I just will take them to the side and do more work with them on the field. Now I will say that this is a lot easier to do in a team setting. And now I didn't work in a team setting for most, all of my career up until very recently.

Speaker 2 (20:01):

And so what I did in that situation, working in an outpatient clinic, that doesn't mean that this doesn't apply to you because you can still use this. And so what I used to do is whatever I would see my athlete do in the clinic with me or on the field with me, I would say, okay, I want you to go do this in practice with your team. So I want you to do the dynamic warmup with your team and then that's it. And then report back to me if that felt okay for them, then I'll say, okay, you can do any technical drill. You can do rondos, you can do, you know, possession style games but no contact. You can be neutral player. And I'll tell the athlete that depending on their age, I'll also tell their parents I do or did before I was in my current, always try to reach out to their club coach or their high school or college coach and let them know what the restrictions were. I understand sometimes we don't get responses when we reach out. I didn't always get responses when I reached out. But as long as you talk to the athlete and or their parent about that, and just make it very clear to them, like you can do this, you can not do that and then have them report back. But I, my rule of thumb was I wanted to see them do that type of activity with me before I had them do it with their team.

Speaker 1 (21:18):

Makes sense. And, and I think it's also important to note that just because you work in an outpatient clinic, doesn't mean you can't take these athletes onto a field. I live in New York city. I see patients in their home. I have a 14 year old who had a ACL rupture and subsequent surgery. And when she was 12 she's 14 now. Wow. Yeah. And we still got her out onto a field, got her. We went to the park, we did as much as we could on field. And sometimes that was just me having to be the defender or setting up cones and having her do stuff. But I think it's really important that if you work in an outpatient clinic, don't kind of wall yourself in with the walls literally. Yeah, exactly. You can take them out onto a field somewhere. I mean, if I feel like if I can do it in the middle of Manhattan, then people could probably have a much easier time doing it in places with more space.

Speaker 2 (22:15):

Yeah. And I would even get like, I've worked in clinics where the only space we had was the parking lot. And maybe that's where we did that. Or again, you can always say like, okay, I've, we've done the 11 plus warmup in our, in our gym based sessions. So you can go do that with your team now. Or we've done some volleying and passing and moving, you just need 10 yards of space. Right. We've done that in the clinic. So now I want you to try that with your team, or can you go in the backyard with your mom, dad, sister, brother, whomever, teammate, friend. And I want you to do these types of exercises in your backyard, you know, like have that be their AGP instead of having them do straight leg raises for six months. I mean, I have that either ETP.

Speaker 1 (23:06):

Yeah. I had my patient probably much, much to her. Neighbors' dismay, but we would be in the hallway of the building. Yeah. Or go into the basement of a building. I see a girl now for she's a softball pitcher. We go into an empty storefront. That's kind of attached to the building. I mean, you make it work, you know, you just have to

Speaker 2 (23:29):

Exactly. And like, if you can't find a way to make it work, you have to ask yourself, should I really be working with this type of athlete? Right. If you can't find a way to give the athlete what they need to get back safely and appropriately, then maybe that's not the setting, the athlete to be seeing you.

Speaker 1 (23:47):

Right. So it's you do the, I call it the blessing release. Oh yes. More, you need more space, you need XYZ. So I'm going to release you to someone that can, can finish the job if you will.

Speaker 2 (24:01):

Exactly. And that takes, like, I feel like in all walks of life, like just not having an ego is such an important skill set to have. And just saying, I know that there's so much more that can be done for you. And I know that there are too many limitations on me to be able to do this. So here's someone who can help you and you should move on to this person.

Speaker 1 (24:22):

Yeah. Yeah. And I think that's fair. And again, patient centered. And when you think about that return to sport, decision-making a lot of Claire, our Dern's work is that patient centered decision returned to sport decision-making. And so what you just said is exactly that. And so I think it's important for people listening that it may not always be you. Yes. That is such an important point. Yeah. Now, is there anything that we missed or that I glossed over that you're like, Oh man, I really wanted to make this point. Did we hit everything? Yeah. We hit everything.

Speaker 2 (24:57):

The only thing I would add is just as something for people to maybe go look up and learn more about is in that consensus statement, they talk about the start framework and that's what I use to guide my return to sport. Decision-Making right. So it's really just a simple needs analysis. What are the demands that this athlete is going to have to face and are they prepared for those? And yeah. So the start framework is a really great method. It's what it's literally what I use to help guide decision-making because it doesn't just look at, like, it looks at the tissue health, it looks at the demands. It also looks at what are some modifiers of those. So is it preseason? And so we can err on the side of being a little conservative or are we in the playoffs and this is one of our star athletes and we need them on the field. And so we're willing to take a little bit more risk. So yeah, I think that that's a really important framework to utilize because it provides you with that context that surrounds the kind of the risk reward ratio.

Speaker 1 (25:59):

Exactly. Yeah. And that's what I said to my, this 12 year old, who's now 14, but you know, she, we waited a year, at least a year for return to sport and then COVID hit and that night Oh yeah. Which I have to say, I wasn't mad about two years, you know, that's awesome. But you know, like what I told her was exactly what you she's like, Oh, do you think I can like play in this, you know, showcase she's an eighth grade. Yeah. No Roland showcase. And I was like, listen, here's the deal. Can you do this? Yes. Will you be at your best? No. Are you going to college? Is if this, what? And I said, it was like, if this was your senior year and it was the last game

Speaker 2 (26:45):

Sure. Have at it, you know,

Speaker 1 (26:47):

But it's not, so you're not going to do it. Are we in agreement there? And, and that's the hard part, right. Is trying to say to like a 12 or 13 was 13 or 14, 13 maybe was, do you want to play in high school? Yes. Would you like to play in college? Yes. Well then you don't need to do this exam because we're not taking any unnecessary risks and that's kind of, how did that start framework is looking at that context and I'm sure you have those difficult conversations all the time.

Speaker 2 (27:15):

All the time. Yeah. It, and especially after something like Nazi has already been cleared by a physician or previous physical therapist or athletic trainer or whomever, and then it's like, Oh no, I know that you were cleared, but we'll, you are certainly not ready. And just having that conversation can be difficult, but as super important, because all they're going to do is go right back. And the likelihood of them getting another ACL injury within the first year or two is pretty substantial. So sometimes scare tactics, work a little in that regard.

Speaker 1 (27:46):

And it's not, it's just, you're just being honest. Yeah. Like you can't like, you're the professional, you're the expert. They're the patient they're going to you because you're the expert. Yeah. Right. And so you have to be honest and you have to be upfront and you have to give them all of the options that they have and looking at things realistically, because just, you know, people say, Oh, runners, they just want to run. Well, it's the same with any sport soccer players. They just want to play soccer, football, I just want to play. And so there there's a lot of mental gymnastics that can happen in one's brains in order to justify doing that.

Speaker 2 (28:21):

Definitely. I think athletes actually appreciate that when you say like, like maybe in the moment they're frustrated, but it's not with you. It's just with the situation. And I think that makes it easier to swallow is that like, Hey, like they appreciate knowing that you're taking that context into consideration. Like, say like, Hey, if you're going to get re-injured, it's going to be in the championship game, not in a preseason friendly, like what sense does that make? And I think they do for the most part, appreciate that and understand it. Even if, again, in the moment it frustrates them a little bit. Yeah.

Speaker 1 (28:51):

I mean, there's a little bit of disappointment, but you know, something it's upsetting

Speaker 2 (28:56):

Templating moment. Get over it. You'll be fine. I feel the same. Exactly. I've never said that, but in my head I'm like, you'll be fine. You'll be to sign. Yeah. Like 10 years. That's fine. If you do it again and have to go through another year of this

Speaker 1 (29:09):

Exactly. Like 10 years from now, you're not going to be like, man, I didn't get to play in this showcase when I was in eighth grade.

Speaker 2 (29:17):

Yeah. Definitely not. It doesn't make sense.

Speaker 1 (29:20):

So I think thank you for bringing up that start framework and we'll try and get links to all of this and put them into the show notes so that everyone if you're looking for those papers on on-field rehab, the start framework and the consensus, we'll get all those and put them into the show notes. So you one click and everybody can read all of them. So Nicole, before we end our talk is the question I ask everyone. And that's knowing where you are now in life and career. What advice would you give to your younger self?

Speaker 2 (29:51):

I would definitely tell myself to be patient. I came out of school thinking like, okay, I just want to work with athletes. You know, I have to find a place where I can just do that. And anything else I do is a waste of time. And what I will say, what I would tell myself is that every experience is valuable and you can relate any experience to what you eventually ended up doing. Even working with a, you know, if it working with the elderly population that has nothing to do with working with athletes, but teaching them a new skill. If you can teach it an older person, who's never worked out a new skill, you can teach an athlete, a new skill, right. It's somebody who's like coordinated and strong and athletic as opposed to an older individual who's never worked out before. So I think that I would tell myself again, just be patient there's value in every experience and yeah, you'll, you'll eventually get to what you're looking for. Just take it, take things in stride and learn from each experience.

Speaker 1 (30:56):

Excellent advice. Now, where can people find you on social media? I think you've also got an ebook available. So give us all the goods.

Speaker 2 (31:03):

Yes. So you could to reach out to me. I'm I'm on social media. Instagram is at Dr. Nicole PT. My Twitter is at Encirca physio and my website is Nicole Serta, physio.com. I have a blog there that I grew up on this. I'm going to try to write more. I took a little hiatus. You had,

Speaker 1 (31:28):

I had a major change of life yourself from California to Portland and a new job. And so I think we, we understand we'll give you

Speaker 2 (31:40):

We're in the middle of a pandemic. So yeah, I think somewhere in the middle of the Vietnam, I just kind of lost a little motivation there

Speaker 1 (31:48):

With you all.

Speaker 2 (31:51):

Okay. It's okay. There's no need to like, feel guilty if you're in the same boat, cause I'm right there with you. But yeah, I will be writing more on that blog. I have actually a couple of different topics on the blog. One is just kind of rehab of soccer related injuries. And then I talk about some of the social issues related to soccer, things like racism and soccer and inclusion and diversity and things like that. And then also I have this little fun part. That's kind of just for me as a little self-indulgent, but life lessons that I've learned through soccer. And so that's on there as well. I also have some eBooks on my website. You can get to just by going and Nicole Serta, physio.com and it's under the eBooks tab. So on an ACL injuries, ankle injuries maybe hamstring injuries too. There's a couple on there now. Awesome. yeah, that's it. Excellent. Well, Nicole,

Speaker 1 (32:42):

Thank you so much. This was great. I great addition to our month on ACL injury and rehab. So I thank you very, very much. Thank you

Speaker 2 (32:52):

For having me on carrying this. When I graduated PT school, this is the first PT podcast I started listening to. So it's awesome to be on it. It's come full circle. It truly has. Yes.

Speaker 1 (33:04):

Well thank you and everyone. Thank you so much for listening. Have a great week and stay healthy, wealthy and smart.