That being said, I've run into a very narrow-minded point of view from PT's and ATC's when it comes to strengthening an athlete recovering from ACL surgery. I've heard, almost verbatim, from three independent sources when the topic of ACL rehabilitation was brought up:
"Oh, ACL's are easy. I just tell them 'hamstrings, hamstrings, hamstrings'."
I almost cringe when I think about how shortsighted this outlook is, and then wonder how many of these athletes end up limping off the field, after a couple days of practice after being cleared, with a quad or hamstring pull.
Now, do hamstrings need to be strengthened? Absolutely. But this is just the beginning of the story. If we only concentrate on the hamstrings, we are completely ignoring the mechanism of an ACL injury. Let's consider some basic anatomy:
The hamstring group (Semimembranosis, Semitendonosis, and the long and short head of Biceps Femoris) originates at the ischial tuberosity, with the exception of the short head which originates at the linea aspera, at the distal end of the femur. Semimembranosis and Semitendonosis attach distally on the medial side of the tibia, and both heads of the Biceps Femoris attach on the lateral head of the fibula.
This is a very simplified picture of the attachments of the Biceps Femoris
So what does this mean? Let's go back to the mechanism of injury. Most research, and I think most top trainers, PT's and Docs would agree, that the absolute last line of defense is the hamstring. The injury starts up the chain. Most notably from the gluteals. The "funny" part is, it doesn't seem to be a lack of strength that's the problem...simply a lack of activation. The proper muscles are not turned on in the correct order, leading to medial rotation of the femur and the knee going valgus, stressing the ACL, MCL and everything else that goes along with it.
Back to the hamstrings; the only part of the hamstrings that is anywhere near the femur is the short head of the biceps. Clearly strengthening the hamstrings can't be the answer for preventing future injuries. We need to strengthen, and relearn how to activate, the external rotatores of the hip; Glute max., posterior glute medius, in addition to the lateral aspect of the hamstrings.
Now, I have a second problem with how some PT's operate. I am working with a 14 year old girl, barely 6 months post-ACL surgery, who was recently cleared by the Doctor because her knee looked really strong. Well they were right, her knee is very strong...but what about the rest of her? They didn't bother asking. Long story short, after a couple days of practice, she came to me with a strained quadriceps. Hopefully mild enough to recover in a week or so but who knows. But now I'm the bad guy who has to tell her to sit out of her first soccer scrimmage of the year, even though the Doc told her she was fine.
Sometimes we need to take away the magnifying glass and look at an athlete as a whole person, not just a joint or a couple muscle attachments.
Have a great weekend!
Jon
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