loris bertolacci

Sport, Health and Fitness

Is there a case for Decelerated ACL Rehabilitations?

Below is a link to an article on the recurrence of ACL injuries in the AFL.

Article on AFL Website “Recurring ACL injuries” May 6, 2014 Adam McNicol

“Eight of the injuries suffered in 2013 were cases in which players needed a second reconstruction after their initial graft failed. In three of those cases, a LARS graft had been used. Sparking concern is the fact that no more than four players experienced the failure of a knee ligament graft in one year during the previous decade”

Hamstring strains continue to be NO 1 injury in the AFL without fail, so one has to tread carefully about making too many conclusions after one years data.

But what interests me a lot is the concept of accelerated ACL rehabilitation. Because it is a fairly easy rehab program versus many others, in my view it is fraught with danger. So many athletes feel quite ok by 6 months and many young athletes simply cannot understand why they can’t twist, turn and play when they feel ok. The science behind grafts doesn’t gel with them. If it doesnt hurt and feels ok running “I should be ok!”

There are many studies appearing that look at the time to return of ACL rehab. and also recurrence rates and numbers vary. One interesting study given my interest now is often with the young athlete was a 2012 study American Journal of Sports Medicine: “Return to High School– and College-Level Football After Anterior Cruciate Ligament Reconstruction. Below is a summary of study:

” One hundred forty-seven players (including 68 high school and 26 collegiate athletes. Return to play rates for all high school and collegiate athletes were similar (63% and 69%, respectively). Based on player perception, 43% of the players were able to return to play at the same self-described performance level. Approximately 27% felt they did not perform at a level attained before their ACL tear, and 30% were unable to return to play at all. Fear of reinjury or further damage was cited by approximately 50% of the players who did not return to play. ”

But I thought an interesting excerpt from an abstract was made in the following study about return to play after ACL rehab.
International Orthopaedics February 2013,  Return to sport following anterior cruciate ligament reconstructionJulian Feller, Kate E. Webster

“Little is known about how to determine when it is safe to return to sport following ACL reconstruction or how to predict whether an athlete will be able to successfully return to sport. Finally, it needs to be recognised that return to sport following ACL reconstruction is associated with a risk of further injury and the development of osteoarthritis”

Yet time and time again on the internet or at conferences we get neat little packages of when to progress through a ACL rehab. and it reads so nicely given it is a ‘boxed in” with progressions such as ability to balance or ability to leg press or hop on the spot. Usually a neat powerpoint with each slide being a neat progression.

Given what is is appearing in studies of graft maturation and also the fact that players often take a minimum of 18 months to get some real form going one wonders if a more conservative approach is required. My subjective experience has been that athletes who  have progressed slowly and taken 12 months to rehab seem better off. I said seem! No data.

One study I read about graft revascularization said that it took 2 years to come back to normal.

Skeletal Radiology (2013) “By 2 years postoperatively, revascularization completion coincides with the homogeneously low signal intensity of the graft, closely resembling native ACL”

I know that some people can play at 6 to 9 months and are ok. And certainly avoiding high risk positions sometimes can be lucky or simply things just stick.

Another older study threw up the interesting notion of how well players perform at 18 months and this study suggests not as well which is my subjective experience.

Outcomes of Anterior Cruciate Ligament Injuries to Running Backs and Wide Receivers in the National Football League The American Journal of Sports Medicine, 2006
CONCLUSION
The present study found that approximately four fifths of NFL running backs and wide receivers who sustain ACL injuries return to an NFL game. The majority of returning players first compete in an NFL game 9 to 12 months after injury. On return to competition, running backs and wide receivers after ACL injury are approximately two thirds as productive as they were before injury. These players were selected as the focus of the study because running backs and wide receivers are the offensive skill positions with the highest frequency of injury,3 and components of their performance can be objectively measured.

And an even older study spoke about how one leg hops did not return to normal after 18 months. This is something I have often seen given lack of confidence when hoping. At one conference I went to recently a study had players hopping 3 hops the same as the good leg after 6 months. But the distances quoted were very poor so in my opinion meant little given there was doubt that the athlete has been tested maximally on the contraleteral leg. And so many footballers just hop so poorly anyway. I did a million hops myself and with athletes and have a good feeling for benchmarks for 3 hops. In my opinion these tests have to be maximal otherwise like a lot of testing is pretty useless data.

THIS STUDY BELOW TALKS ABOUT 2 YEARS TO GET BACK TO NORMAL WITH HOPS

J Athl Train. 2002 Strength, Functional Outcome, and Postural Stability After Anterior Cruciate Ligament Reconstruction

“After ACLR (mean = 18 ± 10 months), subjects did not have significant loss in bilateral or single-limb postural stability when assessed with a Biodex Stability System.Functional hop performance were not within normal limits when compared with the contralateral limb and a control group.  (as assessed with a single-leg hop-for-distance test) may not return to normal (±5%) for up to 2 years”

Exercise Physiologists and rehabilitation specialists often get very excited about getting a player back to play. But with the statistics seemingly showing that there are many issues associated after an ACL rehabilitation, I wanted to throw up a curve ball.

What would these statistics be if worldwide everyone for 10 years  slowed down and progressed slowly and played high level sport ( twisting/pivoting/accelerating etc) after a 14 or even 18  months ACL rehab?

I remember once at a conference an eminent doctor in the AFL saying that 3 weeks was enough for an AFL hamstring rehab because whilst there would be the odd clanger 4/5 weeks was just too long and hurt clubs on the field missing good players. Well years later clubs were forced to take longer with hammie rehabs and recurrence rates were lowered.

Tough one the ACL reco. But what worries me so often is the cavalier attitude of young athletes who have been reconstructed, the lack of understanding of what is happening and the excitement that many rehab professionals have in getting an athlete back on the pitch early. Plus the Internet!

 

 

 

 

 

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May 6, 2014 Posted by | Rehabilitation | Leave a comment

HAMSTRING REHABILITATION E BOOK

ham-book-cover.JPG

Available on my website now

Loris Bertolacci Site

http://www.bertolacci.com.au/LorisBertolacci/Welcome.html

This E Book is a complete resource for anyone that needs to devise practical programs for hamstring rehabilitation. It delves into the current research on this area to back up the programs.

This 120 page manual includes over 150 Exercises and 8 different programs including specifically designed Running, Agility, Stretching and Weight Programs to help any athlete get on the road to a safer and more sound recovery.

Section 1: Hamstring Theory

  1. Introduction

  2. Anatomy

  3. Overstriding and Hamstring Injury

  4. New Studies Implicates the Core in Hamstring Injury

  5. Other Muscles that Impact on the Hamstring

  6. Hamstring Exercises

  7. Why Injuries

  8. Trunk Stability and Hamstrings

  9. Different sports and Hamstring Rehabilitation

  10. So what do you do if you hurt your Hamstring?

  11. Healing Times and Rehabilitation

    Section 2: Practical Section

    Program Advice

  12. Sample Sessions

  13. Mobilization Sessions

  14. Running Sessions

  15. Mobility Drills

  16. Running Drills

  17. Running Sessions 2

  18. Strides

  19. Agility Sessions

  20. Weights Sessions

  21. Stretching after Training

  22. Plan your own rehabilitation

October 14, 2007 Posted by | AFL, General, Rehabilitation, Soccer, Strength and Conditioning, Tennis, Track and Field, Volleyball Strength and Conditioning | Leave a comment

Hamstring Injury Statistics in the AFL and E Book

What qualifies me to write an E Book on Hamstring Rehabilitation?

I was a track coach in the 80’s before starting in the AFL in 1987 and trained some good sprinters and jumpers and so experienced first hand the needs of high speed running.

I was very lucky to work in the AFL for 20 years and to experience the day to day needs of rehabilitation, and in this case hamstrings.

Given this “hands on” practice I learn’t by trial and error. But also I was privy to many experts in this area. I researched every journal, went to conferences and spoke to anyone who seemed to know what they were doing, here and overseas.

From 1997 to 2005 in particular I was able to develop some specific strategies to try and prevent hamstring injuries and also rehabilitate them efficiently and not make mistakes in when to return to competition. Recurrences cause so many long term problems.

I have already gone through this in another article. ( Hamstring Injuries in the AFL. Perception becomes Reality). It involves a multifactorial approach. From core stability to running fast to recovery and load management.

The statistics I achieved validated my plans. I had an average of under 10 games lost per year to hamstrings. AFL has averaged approximately 20 games lost per club per year. My worst year in this block, was one year at average AFL statistics.

Apart from the AFL, I have worked with many elite sportspeople and athletes over this time and continue to do so. I have worked in soccer, tennis and track and field recently and saw the different demands on hamstrings compared to the AFL. This year I also did some work in Volleyball and the equation changes again.

The best way to learn how to do something is hands on. I have done that. But I also have taken an evidence based approach to ths area.

The E Book will have a comprehensive theory section and then some practical programs that can be used for 2/3/4/5 and 6 week programs.

I am sure it will be useful and interesting.

October 4, 2007 Posted by | Rehabilitation, Uncategorized | Leave a comment

HAMSTRING REHABILITATION and RUNNING PROGAMS

The biggest mistake with hamstring running programs is to have more than a 10% increase in speed from running session to session. Whatever the method you use, it is critical that you progress evenly from session to session. The other biggest problem is that because often, at Day 10 for example, the leg feels ok, the athlete gambles. He or she runs at 80% instead of 70% to see how the leg feels and recurs. Thus you have set yourself back longer. So much is written about gym and rehab programs but little advice is provided about running programs. In fact this is the critical area. Thus in a “garden variety” 21 day hamstring rehab one would jog at day 5 to 6 then do that for a few days. Then the next sessions at day 8 or 9 might be strides at 50% speed and no faster.Then this is progressed evenly with 10% increases every second day. Given the short time frame, often it is difficult to go 100% at day 18 as a test, so the program has to be structured to allow the player or athlete to perform fresh and ready on day 21. Again running programs are the number one concern in a hamstring rehabilitation program, and you may use repeat 100m strides or flying 20m or flying 30m. It doesn’t matter. What matters is that you progress to a plan carefully and done gamble. Remember when you go to the casino you can win, but in the end the casino always wins.

October 2, 2007 Posted by | Rehabilitation | Leave a comment

HAMSTRING REHABILITATION AND HEALING

Soon I will publish an E Book on strength and conditioning programs after a hamstring injury. Specifically soft tissue and not back related etc. One area that seems to cause problems is athletes working too intensely too soon after a muscle injury is diagnosed and taking gambles. Jarvinen’s review emphasizes the need for 3 days immobilization to allow healing as a critical phase. Respecting the stages and phases of healing in soft tissue injury is vital. Some researchers categorize these stages differently. From acute ( inflammatory) up to 7 days to proliferation ( 7 to 21 days) and maturation and remodelling ( >21 days).

Not respecting healing dogma is fraught with danger given that means trying to beat nature. Programs in my e book are based on this dogma. And Jarvinen is very clear about the processes involved.

I was lucky to work in the AFL for 20 years and since 1999 till April 2006 I was operating at approximately half the average games lost for hamstrings in the AFL. I coached sprinters in the 80’s and simply spent a lot of time researching and working this area.

HEALING MUSCLE INJURIES
Muscle Injuries: Biology and Treatment: Järvinen
The American Journal of Sports Medicine, Vol. 33, No. 5

This study emphasizes the need to immobilize in the acute phase which as minimum from healing studies should be 3 days.

REST IS CRITICAL IN THE ACUTE PHASE!

Even slight use of the injured muscle in this Acute Phase needs to be avoided according to Jarvinen. He also talks about reruptures at the same site if mobilization is too soon. By resting in this phase less scar is put down.

WHAT HAPPENS AFTER THIS IMMOBILIZATION PHASE ?

PARADOX: Use it or lose it!

The rest in the immobilization phase allows the scar to get some strength. In fact after 10 days the scar is quite strong

After the immobilization phase is over then active mobilization enhances the penetration of muscle fibres into the scar tissue, limits the size of the scar and aligns the regenerating muscle tissue.

“If immobilization is continued past the acute phase (first few days) of muscle regeneration, the deleterious effects become particularly evident during the remodeling phase of muscle healing”

September 4, 2007 Posted by | AFL, General, Rehabilitation, Soccer, Strength and Conditioning, Tennis, Track and Field, Volleyball Strength and Conditioning | 1 Comment

Hamstring Injuries in the AFL. Perception becomes Reality

If you check my CV, you can see I was co-ordinating strength and conditioning programs at Essendon from 1994 and Geelong from 1998.

Hamstrings are the biggest cause of injury in the AFL. The game goes for 120 mins and has 4 breaks. They will start warming up at 1.20 for a 2.10 game and then rest before running out. Then 1/4 time/1/2 time and 3/4 time. Game finishes at almost 5pm! They kick on the run and also bend over at speed. Just a recipe for injury. Also they have to carry some bulk for contact needs, but still run and run. Thus more hamstrings than soccer and rugby for instance.

In 1997 a group of Essendon coaches, fitness, medical and management people went to the AIS to examine training methods.

With respect to injury management it was an important trip for me. I changed my training methods a lot then.

Proprioception circuit before weights. Screening of biomechanics of players. Core stability screening. Core stability and core strength circuits. Specific unilateral training for the lower extremity. Specific attention to gluteal and hamstring strength work. Lots of running drills and faster running. More individualized training. Full time massage therapists. Full time physiotherapists, Full time training. Databases of loads and education of coaches to manage training loads and kicking loads inseason a bit better. Pre- training meetings to plan training with medical staff.

What I saw in the 1998 was a big drop in soft tissue injury after those initiatives, especially hamstrings.

I had done comprehensive isokinetic testing a few times in the 90;s but this multifactorial approach seemed to work better.

I went to Geelong in 1998 with a brief to reduce injury. I implemented the same initiatives. I used Mark Sayers the biomechanist to screen every player. Employed more masseurs. They did lots of core stability and core strength work. They trained faster. And so on. It really seemed to work. We had a huge drop in soft tissue and hamstring injury rates. There seemed to be some consistent line to all this.

I remember one year getting to round 18 and not having lost a player to hamstring injury, Then fatigue hit with a player and we lost a few games to hamstrings but not many. So all these initiatives as a whole seemed to work. Which one helped most? Now that is a tough question. Massage or core stability or running faster? Difficult! I always lean to fast running in the preparation block as a key.

I was operating at about half the incidence of games lost for hamstring injury relative to the AFL.

But perceptions can become reality in elite sport.

Unsubstantiated media reports of huge soft tissue injury rates and hamstring injury in particular often abound.

Now every club gets hamstrings. One must look at trends and overall rates over years with the same staff in a club.

One well informed scribe said I had been sacked from Essendon for too many hamstrings! Just weird . I left. Simple. This type of ‘waffle” often becomes the norm in the media. On TV and radio. Raw hard data was never accessed. Then “JO BLOGGS” starts saying the same thing. Oh well!

The crazy part of all this was that a representative from a Monash University Hamstring Injury Research group had spoken to me about how they had noticed I had a consistent low rate in Hamstring Injuries and how interesting that was. Oh well. All history now!

More importantly the take home message is to use a multifactorial approach to hamstring injury prevention and rehabilitation. Make sure you have ticked most boxes. I will soon be putting some information out on a strength and conditioning program for hamstring injury.

SOME THINGS ( JUST A FEW!) THAT NEED TO BE COVERED FOR PREVENTION OF HAMSTRING INJURY.

1. Core Stability. Is the inner core functioning properly?

2. Core Strength: Has the athlete got sufficient strength to cope with the forces required in fast sports.

4. Pelvic Stability: Is the athlete unbalanced or does the athlete have a weakness in gluteus medius for example.

5. Overstriding: Is the athletes running technique a disaster? Combined with lack of pelvic stability do they over-stride and tire the hammies out.

6. Hamstring and Gluteal Strength: Does the athlete lack the abilty to switch the glutes on or have little strength both concentrically or eccentrically or the whole lot?

7. Lower back problems; Do they exist? Gluteal referred problems?

8. Previous history of injury.

9. Has the athlete prepared themselves for fast running and adapted to high eccentric loads in pre-season.

10. Is the athlete fit enough? Can they last?

11. Is the athlete too tired from training?

12. Has the athlete trained hard the day before and is doing fast running today and thus will be more prone to injury?

13. Are you too old?

AND SO ON AND SO ON.

That is why there is no cookbook recipe to preventing hamstrings.

Just need to keep ticking those boxes

August 10, 2007 Posted by | AFL, Rehabilitation, Strength and Conditioning | Leave a comment

Sandilands, Osteitis Pubis and Rotations in the AFL

It was reported in the media that Aaron Sandilands from Fremantle has Osteitis Pubis. In 2005 especially I noticed early in the season that clubs like Sydney, West Coast and Adelaide were playing 2 Ruckmen. There had been the intervention with the centre circle to stop PCL injuries. But clubs had realized that playing 100 minutes plus for ruckmen was just too much. Almost a midfielders role and yet these guys are huge men. Some have amazing endurance capacities but still big blokes who are not going to excel in distance running. They are more like big rowers.

One exception was Jim Stynes who played so much football. He was quite light and an exceptional runner and also played in another era.

The problem that clubs had and have is that their ruckmen has to get some possessions and be a normal player unlike the lumbering giants of the past. This was the only way of justifying 2 ruck players.

Coaches in general were scared to go 2 ruckmen in the early 2000’s ( although EFC had Alessio and Barnes) given they wanted run. So rotations and ruckman that can get their hands on the ball have become the key. And so many ruckmen were worked into the ground in this period when the game became super quick, making them look even worse given they often played 100% of game time .

I was very keen for this to happen in 2005 . IE Rotating ruck men and rotations in general. Sydney had Ball and Jolly,West Coast ( Cox and Seaby) and Adelaide ( Biglands and Hudson). All these players rotated almost predictively when interchanges were studied and also had an impact on the game both as ruckman and as general players picking up kicks and stats around the ground. Also given the increase in the speed of the game the theory was to decrease their risk of overuse injury and injury in general. But performance was the main aim.

So back to Sandilands. I don’t have his game time statistics but it seemed to me that in 2006 he played a lot of football on the ball and did some very hard running. He played 18 games and bore the brunt of the load in the ruck as far as I could see.

Just a tough gig to do it without adequate help. Ottens and Blake are working effectively in tandem now since Mark has matured. In the Sydney final of 2005 King was playing his 3rd game in 18 days ( Sun RD 22 Rich/Sat Final Melb/Fri Semi Sydney) and came up against Ball and Jolly by himself and was off with a hamstring by the 3rd quarter. Ball was the class act and Jolly is a good hard runner.

So Osteitis is often a reflection of load and the inability of the core to stand up to fatigue. I think we will see Sandilands rotated a lot more next year.

But eh I might be wrong. Trends and players often go against theories. What will be the new trend in this area? 2 * Jimmy Stynes?

July 30, 2007 Posted by | AFL, Rehabilitation, Uncategorized | Leave a comment

AFL and Hamstring Rehabilitation

Hamstring Rehabilitation in the AFL

Given my association in the AFL and also track and field I have learnt a lot about hamstring injury prevention and rehabilitation. I was also lucky enough to coach sprinters who put huge stress on their hamstrings. Now I am involved with soccer where the rate of hamstring injury is lower.

At Geelong Football Club in particular I had a very low rate of injury from 1998 to 2006 and kept games lost at less than half the rate of the average in the AFL which is approximately 20/22 games lost per year.

In the early 90’s I often consulted the AIS and Craig Purdam and Peter Stanton on this topic. Especially because at Essendon we had Dean Wallis who had chronic injuries. The only solution in the end with Dean was lots of fast running and eccentric weight training. This was 1990 and looking back we should have also done more specific core stability work. An athlete like Dean who is explosive needed fast technically efficient running, eccentric weight training and core stability work.

Luck or management with low soft tissue rates? Definitely management with a process in place. I was employed in 1998 ( Gary Ayres) to assist the club in injury management more than anything. And what was the mainstay of that process? Simply the most important variable is running fast in pre-season as soon as possible whether in skills or running to achieve specific adaptations without breaking people down. Alan McConnell ( now AIS) had already organised indoor and outdoor small games in the PXMAS block and these games played at 100% intensity coupled with specific running and conditioning meant that there were very few soft tissue injuries in 98/99.

But after addressing sports specific running needs I made sure many variables were covered. Core stability and core strength. Running mechanics and overstriding. Drill education. Massage. Specific muscular imbalances. Specific hamstring muscle weaknesses. From concentric to eccentric to functional training. Totally individualized approach to preparation in strength work. Lack of gluteal firing. Poor range of motion. Hip imbalances. Plyometrics. Monitoring fatigue and periodization of training. Having sufficient aerobic and anaerobic fitness to not allow fatigue. The list goes on.

Hugh Seward at the 2006 AFL conference on hamstrings said that the AFL was undertaking research to pinpoint solutions to hamstring injuries. A great initiative but he made it sound as if there was little known about the area. Unfortunately there will never be a cookbook for all this. But the research is out there and this is a multifactorial issue that needs to be addressed for each individual.

The cure is hard intelligent work. Again in the animal kingdom and humans simply running fast and adapting to that stress is the best solution. And even in rehabilitation progressively running faster and respecting the laws of nature and healing is a very effective tool.

But in many rehabilitations individuals must be assessed from tip to toe to achieve the the required result. The biggest problem I see time and time again is trying to beat nature. Simply takes tissue “X” days to heal and strengthen ( IE approx 3 weeks plus for basic healing and up to 8 for full strength). Simply takes “X” time to adapt to high intensity exercise ( over a week for a session and 6/8 weeks for a programme). So one has to always respect these laws and suffer the consequences if one doesn’t.

One thing that is confusing for many is the simplistic nature of how researchers and strength and conditioning experts sometimes polarize injury prevention and rehabilitation methods with almost religious fervour. Often there is a marketing spin to all this.

Some athletes have to spend time on totally non – functional unilateral concentric exercises to reverse imbalances and then transfer this to eccentric and then running specific needs. A long process. Some need to do some inner core work and slow drill work for weeks and then move to fast running. Others as I have explained simply have to run fast. And some lucky , lazy people seem to rest for 8 weeks, run fast once, get sore as hell then adapt in 2 weeks and play. The knowledge is out there now. It is all over the place. Soft tissue injuries will occur.

Do some hard smart investigative work and find out what your athlete needs and then be specific and evidence based and create an individualized solution.

July 21, 2007 Posted by | AFL, Rehabilitation | Leave a comment