Unfortunately, I see far too many patients following ACL reconstruction in my sports medicine practice. In any given month, I am rehabbing between 10 and 15 patients who have lost their season to this injury. Most of the time it is a non-contact mechanism of injury, often involving additional trauma to the collateral ligaments, menisci and/or cartilage within the joint.
Throughout my career, I have rehabbed several hundred athletes with ACL tears. It has always been an area of interest and passion for me as well as prevention. Blending my background in performance training with rehab, I have fostered through much trial and adjustment what seems to be a very effective approach to rehab and return to sport. Rehabbing higher level athletes is much like working on a high performance sports cars.
If you own a high performance vehicle, you would prefer to have it serviced at a dealership where the mechanics are experienced working on similar cars, yes? I feel the same care and application is relevant with ACL rehab. PT that is too aggressive or too conservative can impede progress and negatively impact peak performance.
I rehab far too many athletes under the age of 18 with ACL tears. In many cases, I am rehabbing some who have suffered multiple ACL ruptures before they graduate from high school. The burning question is why do so many clients suffer a graft failure or contralateral injury so so often?
Is it related to genetics? Is sports specialization to blame? Perhaps fatigue and limited recovery is a problem. I think the answer is multifactorial, but to be perfectly honest we as a profession have yet to truly arrive at a consensus as to when the “right time” to return to play is. Opinions vary widely based on the athlete, sport, native movement patterns, graft choice, additional injuries (ligament, cartilage or soft tissue) and the provider.
As a clinician dedicated to both prevention and the best rehab, I am always re-evlauating my own algorithm and rehab techniques, while looking for scientific rationale to direct my exercise selection and decision making processes. A recent paper by Webster and Feller in the November 2016 edition of AJSM looked at subsequent ACL injuries in subjects who underwent their primary ACLR under the age of 20 utilizing a hamstring autograft reconstruction procedure.
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Many people suffer from chronic hamstring pain. The question is what is the root source the pain? As a seasoned clinician, I see many patients who present with pain in the upper hamstring/ischial region. Referral sources can include the low back, hip, SI joint, proximal hamstrings, gluteals, piriformis, and ischial bursitis to name a few. In some cases, the pain can be multi-factorial as I see some runners with low level discogenic (nerve) pain and proximal hamstring tendinopathy. The sciatic nerve and its proximity with the hamstrings necessitates thoroughly vetting the symptoms and its pattern in each client. Assessing SLR, slump test, reflexes, myotomes and dermatomes is a must.
Determining what the exact source of can be difficult and requires a good subjective exam and objective testing. For the purposes of this particular post, I am focusing on the proximal hamstrings themselves as the primary source of the pain, as I see so many who struggle with proximal tendinopathy who have seen many providers with little relief.
I treat many runners and middle aged adults who experience this high hamstring or buttock pain that is often worse with:
As with traditional hamstring strains, eccentric strengthening is a must for this population. However, we must consider the myofascial component and contributions to this pain as well. In many cases, these patients have ischial tuberosity tenderness. Consider the referral pattern of the medial HS illustrated below:
I typically like to consider using hip and core strengthening, dry needling, IASTM, stretching and eccentric strengthening to address the pain. If I feel the problem may include a sciatic nerve component and there is an extension bias, I will utilize some PA glides and extension exercises too. In addressing this pain pattern, we must be thorough.
A 2014 case study published in JOSPT looked at a case study with two runners (71 and 69 y/o men) who were treated with eccentric exercises, trigger point dry needling and lumbopelvic stability exercises. The rehab was phase based and the results are as follows:
Patient 1 was treated in physical therapy for 9 visits over 8 weeks. At discharge, he had achieved his goal of running 8 to 10 km 5 times each week pain free. An e-mail received 6 months following discharge noted that he had remained symptom free with all activity and that he completed a triathlon symptom free.
Patient 2 was seen in physical therapy for 8 visits over the course of 10 weeks and discharge were performed by the same therapist who performed the initial evaluations and oversaw each treatment. He was discharged after running 30 km without symptoms and reporting significant decrease in hamstring pain. The patient was seen 6 months later in physical therapy for unrelated right shoulder subacromial impingement but reported no hamstring symptoms and that he had participated pain free in a marathon.
In my practice, I have found dry needling, heat and soft tissue work to be very helpful along with stretching and strengthening. I like to use eccentric PREs and hip stability work to resolve proximal hamstring pain. Specifically, I have used the following two exercises with very good results:
Single leg RDL
Supine reverse hamstring curls using gliding discs
Both of these exercises are effective in promoting eccentric hamstring strength, hip stability, and improved hamstring mobility. Furthermore, they can be effectively used in rehab, rehab and training situations. I routinely use them in all of the above. For a more detailed explanation of the reverse curls, be sure to check out my upcoming Functionally Fit column at www.fit-pro.com.
Keep in mind that hamstring pain can be caused by one or multiple sources. It is best to seek a medical evaluation to determine the exact source of pain and address it safely and effectively. Exercises such as the ones demonstrated in this post represent a few options for addressing hamstring strains/tendinopathy. Others may include Nordic hamstring curls, prone eccentric hamstring curls and hamstring walkouts. Using manual interventions along with exercise is often effective in accelerating and optimizing full recovery.
Jayaseelan DJ, Moats N, Ricardo C. Rehabilitation of Proximal Hamstring Tendinopathy Utilizing Eccentric Training, Lumbopelvic Stabilization, and Trigger Point Dry Needling: 2 Case Reports. J Orhtop Sports Phys Ther 2014 (44)3:198-205.
As a sports medicine professional and physical therapist working with lots of athletes after ACL surgery, I am always looking for ways to improve post-op rehab and prevent a subsequent ACL injury. While we have lots of research looking at neuromuscular, genetic, sex and morphologic risk factors, we have not been able to make significant progress in injury reduction. So many athletes suffer the dreaded “pop” making a simple athletic maneuver they have done a thousand times before.
Based on nearly 19 years of experience training and rehabbing athletes from youth to professionals, I see strong links to a genetic predisposition (family history and prior injury) as well as concerns over neural fatigue. We already know the age of injury is a significant as research indicates those tearing at a younger age (around 20-21 y/o) are more likely to suffer a second injury. But what we know less about is the impact of ankle biomechanics (namely limited dorsiflexion) and how proximal weakness in the hip affects injury risk.
The latter topic was the focus of a study just published in the current edition of the American Journal of Sports Medicine. In this prospective study, researchers sought to determine if baseline hip strength can predict future non-contact ACL tears in athletes.