Can PCL Injuries Be Successfully Treated Without Surgery?

Champion Physical Therapy and Performance

My latest article is now up on the new Champion Physical Therapy and Performance blog!  I discuss a recent research study that looked at the outcomes of subjects with PCL deficient knees that were followed for up to 21 years.

Pretty interesting stuff that shows the efficacy of our programs!  However, as you’ll read, we can do as much harm as good when designing exercises for people with PCL injuries.

Read the article here and be sure to sign up to receive all the updates from the Champion blog, there is plenty more coming from the Champion team!

 

I have also announced my latest Inner Circle webinar will overview my manual therapy system.  I’ve been really trying to create systems for all aspects of what I do as we build out Champion Physical Therapy and Performance.

Last month, I talked about how I design functional rehabilitation programs.  This month is devoted to manual therapy.  In this webinar I’ll discuss my system to performing manual therapy, including the specific order and techniques that I perform.  This system can be used for any issue depending on the needs of the patient.

I like to take a systematic approach for several reasons:

  1. Assures consistency between sessions
  2. Assures consistency between therapists
  3. Creates reliable and predictable results
Join me Wednesday August 27th at 8:00 PM EST for the live webinar or be sure to catch the recorded when it is posted.

Expert Advice on Youth ACL Injuries

youth acl injuriesFor this week’s post, I wanted to share what I thought was a great video from the American Orthopedic Society for Sports Medicine (AOSSM) on youth ACL injuries.

In this video, noted orthopedic surgeons Chris Harner, Lyle Micheli, James Andrews, and Peter Indelicato share their advice on several topics regarding youth ACL injuries, return to play, female ACL injuries, and preventative programs.

Videos like this are important to education the parents and coaches on the realities of issues like youth ACL injuries.

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Do ACL Hamstring Grafts Fail More than Patellar Tendon Grafts?

This month’s issue of the American Journal of Sports Medicine included two studies comparing the revision rates of ACL reconstruction between hamstring grafts and patellar tendon grafts of over 25,000 people.  The overall number of people studied between the two groups was really compelling to me as a sample size this big is certainly worth discussing.

In recent years the graft choice for ACL reconstruction has been slowly shifting towards favoring hamstring grafts rather than patellar tendon grafts.  Recent reports have noted 84% of ACL reconstructions in Denmark and Sweden use hamstring grafts, 60% in Norway, and now are even becoming more popular in the US with 44% of ACL reconstructions using a hamstring graft compared to 42% using a patellar tendon graft.

Many research papers have been published showing that both grafts result in very good stability of the knee with excellent subjective outcome scores.  The major complaint of patellar tendon grafts is the increased risk of issues after surgery, such as patellofemoral pain and loss of motion.  Despite the reports of good stability and subjective outcomes, revision surgery is probably a more important factor to consider.

 

Do ACL Hamstring Grafts Fail More than Patellar Tendon Grafts?

The first study reviewed the nationwide Danish Knee Ligament Reconstruction Registry, which included 13,647 people undergoing ACL reconstruction between 2005 and 2011.

The revision rates for hamstring tendon grafts were 0.65% at 1 year after surgery, and 4.45% at 5 years after surgery.  The revision rates for patellar tendon grafts were 0.16% at 1 year after surgery, and 3.03% at 5 years after surgery.

Essentially, hamstring grafts had a 4x greater risk of revision in year one and 1.5x at 5 years following ACL reconstruction.

ACL reconstruction revision rates

The second study reviewed the nationwide Norwegian Cruciate Ligament Registry, which included 12,643 people undergoing ACL reconstruction between 2004 and 2012.

The revision rates for hamstring tendon grafts were 5.1% at 5 years after surgery, and 2.1% for patellar tendon grafts.  This study also looked at different age groups and found this increased rate to be consistent across all age group.s  However, the younger group (age 15-19) had a 9.5 revision rate at 5 years using the hamstring graft in comparison to 3.5% using a patellar tendon graft.

Together, there was a 2x greater risk of revision overall when using the hamstring graft, but closer to 3x greater risk for younger people.

ACL hamstring patellar tendon graft

 

Both Grafts are Great Options for ACL Reconstruction

When we really assess the numbers, it is clear that both graft options are great choices with low revision rates.  Even though we are comparing the two, realistically the revision rates after ACL reconstruction are low for both hamstring grafts and patellar tendon grafts.  There are many factors that go into deciding which graft to use.  Also realize this does not apply to skeletally immature patients.  This revision information is just a piece of the puzzle.

The patellar tendon graft has less failure rate and has been reported to heal faster in animal models due to the bone-to-tendon interface.  While this is true there are also reports of increased anterior knee pain and loss of motion.  I have discussed this in the past, but I really do believe that many of the issues with patellar tendon grafts after surgery are minimized or eliminated with proper physical therapy (in addition to excellent patient compliance).  This is especially true if these factors are the primary emphasis of the early phases of ACL rehabilitation.

SEE ALSO: 6 Keys to the Early Phases of Rehabilitation Following ACL Reconstruction Surgery

That all being said, hamstring grafts have also been shown to result in less strength of the hamstrings after surgery.  Considering the role of the hamstring to assist the ACL in control anterior tibial translation, this has to be considered when reviewing the higher ACL reconstruction revision rate when using hamstring grafts.  Perhaps it really has nothing to do with the graft itself and more to do with the hamstring strength.

Regardless, the revision rate following ACL reconstruction is higher when using a hamstring graft than when using a patellar tendon graft.

 

 

Did We Really Discover a New Ligament in the Knee?

This week’s Stuff You Should Read is about the “new” discovery of the anterolateral ligament of the knee.

 

Inner Circle and RehabWebinars.com Updates

My next live Inner Circle will be an evening live Q&A which is always fun, ask me anything!  This was a big hit last year so I expect it to be even better this year.  It will be Monday December 16th at 8:30 PM EST.  Looking forward to this one.

RehabWebinars.com has a bunch of awesome new webinars coming up over the next few months.  Michael Mullin had part 1 of a webinar on Integrating Postural Restoration Institute Concepts into Training, part is coming in January.  This was a great webinar and a great intro into the PRI concepts!  This month, David Weinstock, the developer of Neurokinetic Therapy, discusses some of the principles of NKT.

 

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The Discovery of the “New” Knee Ligament – The Anterolateral Knee Ligament

anterolateral knee ligamentFor this week’s stuff you should read, I thought I would piece together a few articles that go over the press received over the “discovery” of the “new” anterolateral ligament of the knee.  Notice all my “quotes!”  Here is a link to one of the many sensationalized articles from the media on this new ligament:

Pretty exciting title, right?!  The media cracks me up.  Sensationalizing everything.  The news report is in reference to a paper published in the Journal of Anatomy regarding the anterolateral ligament.  Here is the abstract of the paper, which ironically, starts with the phrase “In 1879, the French surgeon Segond described the existence of a ‘pearly, resistant, fibrous band’ at the anterolateral aspect of the human knee.”

The website io9 did a good job highlighting these facts in their article:

But Dr. LaPrade from the Steadman Clinic did an even better job talking about everything you want to know about this “new” ligament!

Here is a video of the ligament:

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So, nice articles and video, but no, not a new ligament.

 

 

A Simple Dynamic Stability Exercise for the Leg [Video Demo]

This week’s post is a video demonstration of a simple way to integrate reactive neuromuscular training (RNT) into your programming to enhance dynamic stabilization of the lower extremity.

Reactive Neuromuscular Training for Dynamic Stabilization of the Lower ExtremityIn this video, I show a client that has an ankle sprain.  While going through her rehabilitation, it became clear that she also needed balance training to really work her ankle, knee, and hip to stabilize during functional tasks.

To perform this exercise, you simple need a large resistance band (which are great from many stretching, strengthening, and stability exercises – here are the ones I use).  Loop the band around a rack or other object and step within the loop.  Place the band just above your knee.

I show a few exercise ideas in the video, progressing from simple balance, to unstable surfaces, to incorporating functional movements.  By using the band, you can emphasize training the bodu’s ability to stabilize in the frontal and transverse planes while performing a sagittal plane exercise.  This is essential to optimal function and a big key to my Functional Stability Training program.

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Can Tight Hip Flexors Cause Tight Hamstrings?

I like the title of this article – Can Tight Hip Flexors Cause Tight Hamstrings?  It is sort of like a riddle, isn’t it?

I was working with a client recently that is knowledgable and understands anatomy fairly well.  He came to see me for several reasons, but high on the list was “my hamstrings are tight” followed by a poor attempt at touching their toes.  His hands were about 3 inches from the floor with his knees bent!  He added, “I don’t know why I can’t touch my toes, I have been stretching and working on my hamstrings for months!”

After spending time assessing him from head-to-toe, I shared with him that I thought his hamstrings were “tight” because his hip flexors were tight.  He thought about it for a second and then tried to call BS, stating “If my hamstrings are tight, shouldn’t my hip flexors be loose?”

My answer was “I don’t think your hamstrings are tight.”  At this point, he was about ready to leave the session, thinking I was the craziest person in the world, stating “but I can’t touch my toes?!?”

 

How Tight Hip Flexors Can Cause Tight Hamstrings

I bet you’ve had clients like this in the past.  They know just enough to be dangerous.  The answer to my riddle is more semantics than anything else.  Yes, hamstring tightness can limit your ability to touch your toes, but that isn’t the only cause.

We have actually done a great job understanding this concept over the last several years.  People like Gray Cook, Lee Burton, Brett Jones, and others have done wonders teaching many people that sometimes there are other reasons why you can have a limited toe-touch, specifically because of poor motor control and core stabilization.

However, hip flexor tightness can be a contributor as well, as backwards as that seems.  Again, it comes down to semantics.  I am actually talking about anterior pelvic tilt limiting your ability to touch your toes.

Here is an interesting an example.  Which hamstring is shorter in the below image?

hip flexor hamstring tightness

If you answered the left leg, you are guessing!  Without a comprehensive exam, you are just guessing.  What if his left pelvis was anterior tilted?  This would cause the proximal attachment of the hamstring to move superiorly and look just like a tight hamstring, such as in this example:

tight hamstring anterior pelvic tilt

Whenever someone appears to have tight hamstrings or can not touch their toes, I look first at pelvic alignment to see if they are in excessive anterior tilt.  Everything revolves around assessing your starting point.

As you can see in the example below, if you are starting in a large anterior pelvic tilt, then you are theoretically starting with the hamstrings long.  I used the simple math numbers of 45 degrees and 90 degrees, which is pretty excessive, but you see what I mean.  In a large anterior pelvic tilt, your normal starting position in this example would already be close to 45 degrees!

Anterior Pelvic Tilt

So, can having tight hip flexors cause tight hamstrings?  I’m not sure about that.  But I know that being in anterior pelvic tilt can limit your ability to touch your toes.  Again, it always comes down to:

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Assess, Don’t Assume

This is one of my major concepts from the Functional Stability Training for the Lower Body program.  Assess alignment before you just start treating.  Resist the urge to just foam rolling, massaging, and stretching your hamstrings without truly assessing if this is the reason why you can’t touch your toes.  Sometime having tight hip flexors and an anterior pelvic tilt can limit your ability to touch your toes just as much.

Functional Stability Training for the Lower Body

I am super excited to announce that Eric Cressey and I’s latest product, Functional Stability Training for the Lower Body, is now available!  Last year, we released the first module in our Functional Stability Training system, FST for the Core, which was hugely popular.  Since then, Eric and I get weekly, almost daily, emails asking when more FST products were going to become available.  Well, FST for the Lower Body is finally here!

 

Functional Stability Training for the Lower Body

Functional-Stability-Training-Lower-BodyFST for the Lower Body is a comprehensive program that combines the way I approach my rehabilitation programs with how Eric approaches his strength and performance programs.  We talk about a ton of topics that merge our philosophies.

Functional Stability Training for the Lower Body takes a hard look at the lower extremity and how to most effectively optimize function.  By addressing alignment, strength, mobility, and dynamic motor control, you can maximize your rehabilitation and training programs to reach optimal performance.

The lower extremities work in conjunction with the core to provide mobility, strength, and power to the entire body.  Any deficits throughout the lower body’s kinetic chain can lead to injury, dysfunction, and a decrease in performance.  FST for the Lower Body aims to help formulate rehabilitation and training programs designed to optimize how the lower body functions.

 

The FST for the Lower Body program can be applied to rehabilitation, injury prevention, and performance enhancement programs.

For the rehabilitation specialist, the information will help you restore functional activities faster.  For the fitness and performance specialists, the information will help you achieve new progress with your clients to maximize functional and athletic potential.  For the fitness enthusiast, the information will help you gain control of your lower body, maximize functional movement, and reduce wear and tear due to faulty movement patterns.

Here is the outline of presentations and lab demonstrations in the program:

  1. Training the Hip for FST for the Lower Body
  2. Assessing Lower Body Alignment and Movement
  3. Preparing the Adductors for Health and Performance
  4. Hip Internal Rotation Deficits: Why You Have Them and What to Do About Them
  5. Training the Foot and Ankle for FST for the Lower Body
  6. Understanding and Implementing Neuromuscular Control Progressions into your Programs
  7. How to Integrate Neuromuscular Control Progressions
  8. 15 Things I’ve Learned About the Deadlift
  9. Developing Lower Extremity Strength and Power Outside the Sagittal Plane

 

We’ve had some great reviews so far, here is one example:

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I honestly feel the FST for the Lower Body may be our best product yet, so if you have seen FST for the Core or Optimal Shoulder Performance, you are definitely going to want to go through the FST for the Lower Body program as well.

 

Special Discount Price This Week Only!

FST for the Lower Body is available now as a fully online educational product with the option of purchasing the DVDs.  There is a special discount price of $79.95  this week only so head over to FunctionalStability.com and learn more.  This is a great deal and more than the half of the price of what you’d normally pay for seminar of this quality.  The special price is only available until the end of the weekend.

Functional Stability Training for the Lower Body

[button link=”http://www.1shoppingcart.com/app/?Clk=4683845″ size=”large” color=”orange”]Get FST for the Lower Body Now![/button]

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A Quick and Easy Way to Assess Pelvic Alignment

It’s been over a year in the making, but Eric Cressey and I are about to release our next module in the Functional Stability Training System on the Lower Body.  Last year we released the extremely popular FST for the Core program and began discussing how we both integrate rehabilitation with performance training.  We are really excited to be releasing the program for the lower body now as well.

One of the aspects of the program that I discuss is alignment.  We have really progressed our understanding of functional movement in recent years, however, you may be missing the boat if you assume that we are symmetrical and neutral.  I am a believer that we need to assess and address our alignment before we can properly look at our movement patterns and restrictions.

Some of the more basic tests for alignment, like posture assessment and pelvic palpation, have many flaws and ultimately low reliability and validity.  However, I feel that this is the case when assess in isolation.  I prefer to take clients through a detailed assessment that looks at many different aspects of alignment and mobility.  What you start to see is that patterns emerge.  When several alignment tests are all pointing in the same direction, I start to feel more comfortable about the reliability and validity of my assessment.

I talk about this a lot in FST for the Lower Body and even go through an assessment process where we put the pieces of a puzzle together for one individual.  Below is a quick clip showing a really quick and easy way to assess pelvic alignment.  Next time you assess hamstring length, look down and see what position the leg is in.  Is it rotated?  abducted or adducted?

Because we force the motion and raise the leg in the sagittal plane, if there is any pelvic obliquity, there is going to be a subsequent re-alignment of the lower extremity.

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This is just a quick clip of one little aspect of the process, and really not very useful in isolation, but a nice little clip to get you thinking when you are stretching or assessing hamstring length on your next client!  Take this into consideration with a full assessment and it’s results may be more useful to you.

Eric and I’s Functional Stability Training for the Lower Body comes out on Monday is now available for a special discount this week.  You are not going to want to miss this!   Click the image below to learn more!

Functional Stability Training Lower Body

Learn more at FunctionalStability.com

 

 

 

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