Ep 277: Clinical pearls for thigh muscle rehabilitation (part 2), with Dermot Simpson & Simon Wallace

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[00:00:56] A lot of athletes effectively drop the weight through those last few degrees of your knee extension. So they're not really getting mechanical tension at long muscle lengths like is required for maximizing your adaptation here. So it's ensuring that we don't allow them to give up early in the rep, and that they fight that rep all the way down and all the way back up.

[00:01:23] Hello and welcome to JOSPT Insights, the podcast that aims to help you translate quality research to quality practice. I'm Claire Ardern, the Editor-in-Chief of the Journal of Orthopedic and Sports Physical Therapy. It's great to have you listening today.

[00:01:40] Last week, Dermot Simpson and Simon Wallace explained the hamstring and rectus femoris rehabilitation pathways that they and their clinical colleagues at the Aspitar Orthopedic and Sports Medicine Hospital have developed to guide their daily practice. In using the rehabilitation pathway in practice, Dermot and Simon and the team have discovered some clinical pearls that help them help the athletes they're working with. And today, Dermot and Simon are sharing those clinical tips with us.

[00:02:08] These are the things you can do in practice tomorrow to give you and the athlete the best chance of rehabilitation success. As we mentioned last week, Dermot Simpson and Simon Wallace are sports physiotherapists working at the Aspitar Hospital in Doha, Qatar. Between them, they have a couple of decades of experience in elite sport, especially in rugby and football or soccer. There are some fantastic clinical pearls in each of these published articles.

[00:02:35] If you could highlight two of them for our listeners today for hamstring, Dermot, what would you choose and why? It's really important to get a very strong assessment and that's including subjective as well. We want to know when we see a lot of hamstrings and we can see up to 200 hamstrings a year in Aspitar. We start to see patterns and we start to see what is important to ask and what is important to test. And we know and we've all made the mistake before that we missed something on our assessment and we're thinking he's doing really well.

[00:03:05] And then when we come back and something happens like, oh, yeah, I should have checked that at the very start. So one of the clinical parallels is what you don't find at the start often finds you later. Identifying key deficits early and tracking throughout allows for a targeted and progressive rehab. So let's say a guy comes in with recurrent hamstring and we do our hamstring test, we do maybe our head tests and he's okay as expected. But then we find out he's had an ankle surgery or a syndesmosis operation or a recurrent ankle sprain.

[00:03:31] And he has a lot of dorsiflexion restriction on, let's say, his left side and he's getting a lot of problems on his right side. And we need to be aware of that as well because we know when they're running at higher speeds, they might be putting an extra strain on that contralateral hamstring. Likewise, maybe at an ACL graft and that inner range hamstring strength, the medial hamstrings are just not activating as well. We're not getting the same output from that. We need to be aware of that. Or it can be other motor control deficits.

[00:03:58] So this is why it's imperative to do a follow-up assessment, as I said. And even just to come back to subjective questions, I think it goes on to the second clinical peril in the assessment is begin with the end of mind. Comprehensive assessment framework ensures rehab stays aligned with return to play goals. So probably the point there is, I mean, if we have, let's say, a player who's played five games in the last 12 months versus a player who's played 35 games,

[00:04:25] then it may be a bit different to how we approach it, especially towards the end stage, because we know his chronic load over the last year is a lot less. And it may need a bit of extra training on the pitch because we don't want the player to turn into, I think it was termed many years ago, a chronic rehabber, where he comes back, he hasn't got the load up, and then he plays a few minutes and then gets another injury. It may not even be a hamstring injury. So I think we have to take that into account. And sometimes we just need to know what the goal is of the player. So let's say he's preparing for a World Cup.

[00:04:54] He had a grade 3C hamstring in the World Cup, three or four weeks away, and he wants to make it. Then we have to prioritize towards that because in the end, the player, along with the medical team, will make this choice whether we want to get him ready for that or whether it's offseason. And we know we can take a little bit more time with the player as well. And likewise, even though our pathway is the progressions are associated with running speeds, you may have a goalkeeper versus a winger.

[00:05:22] And we know a goalkeeper will do accelerations, especially the modern-day goalkeepers. You've probably seen the World Cup who's on the edge of the box and needs to accelerate, but probably not reaching top speed. So we need to be maybe more bespoke in how we're looking at his running progressions as opposed to a winger who's going to do a lot of repeated sprints down the line. So that's probably the two clinical pairs from assessment and just one from milestones. So criteria-based milestones provide a structured evidence-informed pathway through rehab

[00:05:51] by progressing based on clinical benchmarks, not just time or MRI classification. This approach ensures a comprehensive recovery that reflects the multifactorial nature of pantry injuries. So we know because every injury is MRI that there's a massive overlap in time to return to play with the MRI grading, whether we're using BAMIC or the Petron scale. And probably the only ones we know what's going to be quicker is a myofascial injury. It can take a week or two. It's generally quite fast.

[00:06:18] Or a surgery, which will take a bit longer, or maybe a 4C. But everything in between, there's massive overlap. Some it takes three weeks, some it takes five weeks. And we feel that we will get more information from our objective testing and using our clinical criteria to have a better understanding of how they're progressing rather than just using an MRI. So even though it has been done and it's maybe more for confidence levels or maybe it's requested

[00:06:45] by the club, we don't normally do follow up MRIs or return to play MRIs because we feel that will not give as much strength to our decision making as our own clinical assessment. If we're meeting our clinical criteria that we've set out, including bed-based testing, including the lab-based testing, including the pitch-based, are we meeting our targets? We're a lot more confident using these metrics than going for an MRI or saying, this is a grade 3C, it takes six weeks. These are what we will depend on.

[00:07:15] I think that's a really helpful message for people listening that trust your clinical skills and make sure that your clinical skills are very strong too, is the other part of it. You can't get away with fudging it, especially not with the elite athlete population you work with, of course, Sturman. Thank you. And I think it's also partly why I didn't ask you about specific timeframes. How long do I spend or how long should I expect to spend in each of these different parts of the pathway?

[00:07:43] Because as you say, it's so different for different injuries. We talk about this a lot and I think our approach to rehab has really progressed over the last decade or more to move very much away from typical timeframes to recognising that each athlete is an individual and is going to have different requirements and progress at different rates. So now that's where your clinical skills and strong clinical skills come to the fore. Simon, let's go to you.

[00:08:11] Clinical pearls for the rectus femoris. What would you like to leave the listeners with today? The clinical pearls, Dermot touched on, are applicable to both. Training at long muscle lengths maximises adaptations in muscle size, fascicle length and tendon adaptation. This is, I suppose, we think true for all or at least most muscles when we think about this. It's been studied a lot more in our calf muscles where length and partials have become kind of

[00:08:40] a thing, especially in the bodybuilding world. Milo Wolf had a nice systematic review last year which investigated this. And it seems to be true across all muscle groups that training at long muscle lengths appears to be beneficial. So if we look at kind of the rec fem, there was a systematic review which looked at this. They kind of looked at training at a longer muscle length partial rep, a shorter muscle length partial rep, and then training through full range.

[00:09:06] And they found that the group which trained at a longer muscle length partial rep or 65 to 100 degrees of knee flexion. And in the extension machine had significant increase in muscle size on their rectus femoris. So it's obviously more beneficial to train at long muscle lengths for your rectus femoris. One of the reasons for this is probably that your rec fem works on the ascending limb of the force length relationship.

[00:09:33] As we go into more knee flexion or put that muscle more on stretch, it generally gets stronger. This has an effect on how we set up our strength training as well. So it's a biarticular muscle, much the same as the hamstrings. It crosses the hip and the knee. So if we go kind of on our traditional knee extension machine when we're looking at training our rec fem, we're usually in a fairly upright position of 90 degrees. This isn't going to bias your rectus femoris. It doesn't put it on length.

[00:10:02] So you're going to produce force more using your vasocytes. So if we're looking at training our rectus femoris and we want to put it on a little bit of length, we need to recline that shear. Few studies have looked at this and what angle we should kind of recline it to. We think somewhere around 40 degrees of hip flexion is the sweet spot. If you recline it fully, it seems to have less of an effect on the rectum. So you don't need to recline that chair fully.

[00:10:30] Anecdotally, I think from playing around with some of the testing, this might be because of the trunk stability demands that are required. When we lie back fully, it's much, much harder to stabilize at your trunk because you're in a more lengthened or extended position. So training out a long muscle length means training in deep degrees of knee flexion with the seat reclined. And if any listeners don't have the ability to recline the seat under knee extension, putting the seat all the way back and getting your athlete to slouch, provided they're not a really,

[00:10:59] really tall athlete usually works almost as well. But it also has kind of an impact on how we coach this athlete, especially as we go to heavier weights. A lot of athletes kind of effectively drop the weight through those last few degrees of your knee extension. So they're not really getting mechanical tension at long muscle lengths like is required for maximizing your adaptation here. So it's ensuring that we don't allow them to give up early in the rep and that they fight

[00:11:28] that rep all the way down and all the way back up is really, really important here. This applies to your hamstring as well. If we look, the most injured muscle within your hamstring is your biceps femoris. There was a really nice study by Mayo et al, which looked at kind of your length and state eccentrics versus your nordics, which are in less hip flexion. So your nordics are kind of in hip extension. Your length and state eccentrics are in hip flexion. Both of them are eccentric knee flexion exercises.

[00:11:57] But there was a significant increase in the hamstring growth in both groups. But there was more hamstring growth in the length and state group. So again, training at a length and state is good. But almost more importantly for this was the breakdown of changes in muscle volume within the hamstring group. We saw much more biceps femoris long head hypertrophy in the length and state group and much less short head hypertrophy in that group, which we know is one of the adaptations.

[00:12:27] One of the negative adaptations, I suppose, post hamstring injury and in a lot of our athletes. So certainly for our hamstring or our rec fem, training at long muscle length seems to be key once the athlete is ready for that. We need to kind of recognize that if we do this on day one post the injury, it's probably going to be harmful for our athletes. So it's important to time that right. So that's when it comes to strength training. Really, really important to train at long muscle length.

[00:12:54] But when we're looking at our more explosive and reactive actions, I'm sorry, I'm not going to apply this to hamstring as well. But for our rec fem anyway, our rec fem isn't preferentially loaded during squat pattern exercises. Target our rec fem, we want to load it during kicking type exercises. So this is really, really important. It's more obvious, I suppose, for our footballers. But we've also got a lot of rec fem injuries in sprinters.

[00:13:21] But if we think about the mechanism of that injury, we think it's most likely during the swim phase, just after toe off when that rec fem is on maximal stretch. So if we only ever train our explosive and plyometric actions in jumping, which is a squat pattern activity, we're not really loading that rec fem effectively. And we might be setting them up for failure down the line. So things like leg swings or cable kicks and things like this, even in our non-kicking athletes,

[00:13:50] are really, really important so that we don't kind of miss this within our training. And I suppose it's more obvious for our footballers as well, but really graduating this throughout our training is really, really important as well. I love those, Simon. And especially that reminder to focus on specificity and that, yes, doing the squat pattern stuff, sure, I'm engaging the quads, but am I really engaging rec fem? And it seems like probably not.

[00:14:17] And you need to do some of that more open chain, what we think of as open chain knee extension type work to really isolate the rec fem and make sure that you're working on it. And I suppose that takes us back to the discussion we had about people compensating for the rec fem. So it's a reminder to make sure you're not inadvertently reinforcing some of those compensations. Yeah, I think like if you do want to do some closed chain stuff, like split squat type

[00:14:46] patterns are really, really good for it. It's much easier to cheat. You can easily go into an anterior tilt and it's much harder to control. So it takes a lot more coaching to get people to do these in the correct manner, which is where the kicking type stuff is almost foolproof. From that point of view, you can't really kick without using your rec fem to some degree. I think it was you, Dermot, who mentioned that this has really been developed for primarily working with elite athletes.

[00:15:13] But I suppose there's no reason why if you don't work with elite athletes, you couldn't take this as a starting point. You might have to adapt some stuff. But it's still the basic principles are still a good, at least a good foundation for your rehab. Would you agree with that? So when we created it, it was for the highest level because it's always easier to make it suitable for recreational if we had the highest level. And of course, at Aspitar, we have all the resources. And I suppose one of the discussion points at the beginning was how many tests we do.

[00:15:43] Of course, we tried to pick the best tests and most appropriate tests because if we do 20 tests, one is too many. And probably a lot of them are not going to be reliable as they're not going to show week by week improvements. They're going to be very up and down. So we were trying to pick tests that were best associated in previous research or from our own experience. And that is going to be more of a linear pattern in terms of improving. Of course, no test is strictly an error because we know tiredness DOMs and different things can affect the scores.

[00:16:12] But we try to keep it simple in our daily testing. So we only have three tests that can be done within one minute. And then we do our other tests twice a week. So mainly our handheld dynamometer strength tests and any other capacity test twice a week. And that will give us a flavor of how they're progressing. And I think these can be used for all levels of players because all what we use is, I mean, palpation. We can do by ourselves. We use our phones for measuring the range of motion.

[00:16:41] And then we use a handheld dynamometer for strength. And these are our regular clinical tests are done quite easily. So I think this can definitely be adapted across all clinics, across all populations. And we have a guide on how we do these tests in the pathway and just the positions we set up. And hopefully the graphics can explain it a little bit better than I'm explaining it right now. And then for the lab-based testing, it's probably, as I said, focused to more the professional player.

[00:17:09] So we have our isokinetic testing. We have some biomechanical testing. We might use high-density EMG, especially for these recurrent hamstrings. We see very nice information in the recurrent ones and also the post-op. Likewise, in the biomechanics, we see some interesting patterns with these players also. So these ones, maybe not everyone will have access to, but anyone that does have access

[00:17:35] to, I think there's information in the pathway on what way we would utilize them. So I think it's just really to give everyone a flavor of what we feel or what we have found useful and then to pick what might be suitable for them, whether it's from assessment, whether it's from the strength progressions, the explosiveness, the running progressions, the motor control exercises. I think there's hopefully a bit of information that might be useful for people who maybe

[00:18:03] are not accustomed to some components of this program. Yeah, definitely. The other thing is, even though the pathway looks very, very extensive, even for our elite athletes, we don't do every bit of it for every athlete. We're targeted in what we do. So that's why the assessment is so important, because as you can see, I think it would take a year to run through every exercise within the pathway. So it's kind of picking the right one for the athlete that's in front of you. And that's really the goal.

[00:18:33] You might not have all the tools. You might not have all the facilities that we have access to. But I mean, are you including some form of strength test in your program? Are you including some form of jump test within your program app? Like there's apps on your phones that can measure these kinds of stuff these days. It doesn't take a full biomechanics lab to get some of the results back. You just get a bit more detailed information if you have more equipment, but it's not impossible to do without it.

[00:19:02] You've both mentioned this is a pathway that was developed from long clinical experience. Many people at Aspitar, and I would say the Aspitar rehabilitation team has a long and one, dare I say it, storied history of documenting what you're doing and sharing it with the public. That's not to say that this is the only way or these are the only tests or everyone has to follow the Aspitar way, so to speak. I think it gives us all a very helpful starting point.

[00:19:31] People can adapt it as you've talked about. And I'm really grateful to both of you for sharing it with us in its written form and also today on the podcast. So Dermot Simpson, Simon Wallace, thanks for joining me on JOSPT Insights. Thanks very much, Dermot. Thanks for listening to the podcast. This episode of JOSPT Insights. For more discussion of the issues in musculoskeletal rehabilitation that are relevant to your practice,

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