The Kettlebell March Drill for Functional Core Stability

We’re big fans of farmer carries and suitcase carries at Champion.

Carries do a great job of developing functional core stability by adding an offset weight to the center of rotation of the body. But carries also offer so many other benefits – from grip strength, to upper body development, to overall athleticism.

Often times, clients with poor core strength or control will compensate during the carry.

If the core can not stabilize the trunk with the added load of the carry, it will compensate by relying on the static stabilizers of the body and rocking back into hyperextension of the back or leaning to the side.

In the below video, Kiefer Lammi, our Director of Fitness at Champion, shows how we have started to modify the carry in these individuals by adding a march. Not only does this promote better core control, it also facilitates training the trunk to remain stable while the distal extremities move functionally. This is one of the fundamental principles to enhance how well people move and perform.

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5 Reasons Why I Don’t Use the Sleeper Stretch and Why You Shouldn’t Either

Ah, the sleeper stretch.  Pretty popular right now, huh, especially in baseball players?  Seems like a ton of people are preaching the use of the sleeper stretch and why everyone needs to use it.  It’s so popular now that physicians are asking for it specifically.

I don’t like the sleeper stretch and I rarely use it, in fact I haven’t used it in years.  I don’t think you should use it either.

There, I said it, I felt like I really had the get that off my chest!

Every meeting I go to, I see more and more people talking like the sleeper stretch is the next great king of all exercises.  Then I get up there and say I don’t use it and everyone looks at me like I have two heads!  Call me crazy, but I think we probably shouldn’t be using it as much as we do.

In fact, I actually think it causes more harm than good.

 

5 Reasons Why Shouldn’t Use the Sleeper Stretch

I haven’t used the sleeper stretch in over a decade and have no issues restoring and maintaining shoulder internal rotation in my athletes with safer and more effective techniques.

If you have followed me for some time, you know that I rarely talk in definitive terms, as I always strive to continue to learn and grow.  I know my opinions will change and things aren’t black and white.  However, over the years my stance on NOT using the sleeper stretch has only strengthening.  As I learn more and grow, I actually feel more strongly that we shouldn’t be using this common stretch.

So why don’t I use the sleeper stretch?  There are actually several reasons.

 

It’s Often Performed for the Wrong Reason

The sleeper stretch is most often recommended for people with a loss of shoulder internal rotation.  When a person has a loss of internal rotation, it can be from several reasons, including:

  1. Soft tissue / muscular tightness
  2. Joint capsular tightness
  3. Joint and boney alignment of the glenohumeral joint and scapulothoracic joint
  4. Boney adaptations to repetitive tasks, such as throwing a baseball and other overhead sports

You must assess the true cause of loss of shoulder motion and treat accordingly.

Of the above reasons, you could argue that only joint capsular tightness would be an indication to perform the posterior capsule.  But see my next point below…

Performing the sleeper stretch for the other reasons could lead to more issues, especially in the case of boney adaptations.  The whole concept of glenohumeral internal rotation deficit (GIRD), is often flawed due to a lack of understanding of the normal boney adaptations in overhead athletes.

I can’t tell you how many people think they have GIRD that I evaluate and that they in fact do NOT have GIRD.  Click here to learn more about how I define GIRD.

 

It Stretches the Posterior Capsule

If you have heard me speak at any of my live or online courses, you know that I am not a believer in posterior capsule tightness in overhead athletes.  Maybe it happens, but I have to admit I rarely (if ever) see it.  In fact, I see way more issues with posterior instability.  Please keep in mind I am talking about athletes.  Not older individuals and not people postoperative.  They can absolutely have a tight posterior capsule.

But for athletes, the last thing I want to do is make an already loose athlete looser by stretching a structure that is so thin and weak, yet so important in shoulder stability.

Urayama et al in JSES have shown that stretching the shoulder into internal rotation at 90 degrees of abduction in the scapular plane does not strain the posterior capsule.  However, by performing internal rotation at 90 degrees of abduction in the sagittal plane, like the sleeper stretch position, places significantly more strain on the posterior capsule.

Based on the first two points I’ve made so far, if you have a loss of shoulder internal rotation, you should never blindly assume you have a tight posterior capsule.

Assess, don’t assume.

But be sure you know how to accurately assess the posterior capsule.  Many people perform it incorrectly.  Click here to read how to assess for a tight posterior capsule.

 

It is an Impingement Position

This one cracks me, check out the photos below, if you rotate a photo of the Hawkins-Kennedy impingement test 90 degrees it looks just like a sleeper stretch.  I personally try to avoid recreating provocative special tests as exercises.

sleeper stretch impingement reinold

 

This is a provocative test for a reason, by performing internal rotation in this position, you impinge the rotator cuff and biceps tendon along the coracoacromial arch.  If you actually had a tight posterior capsule, you’d get subsequent translation anteriorly during this stretch and further impingement the structures.

So based on this, even if you have a tight posterior capsule, I wouldn’t use the sleeper stretch.  I would just perform joint mobilizations in a neutral plane.

 

People Often Perform with Poor Technique

So far we’ve essentially said that people often perform the sleeper stretch for the wrong reasons and can end up torquing the wrong structure (the posterior capsule) and irritating more structures (the rotator cuff and biceps tendon).

Even if you have the right person with the right indication, the sleeper stretch is also often performed with poor technique, which can be equally as disadvantageous.

People often roll too far over onto their shoulder or start in the wrong position.  If you are going to perform the sleeper stretch, at least follow my recommendations on the correct way to perform the sleeper stretch.

 

People Get WAY too Aggressive

Despite the above reasons, this may actually be the biggest reason that I don’t use the sleeper stretch – people just get way too aggressive with the stretch.  The whole “more is better” thought process.  Being too aggressive is only going to cause more strain on the posterior capsule and more impingement.  You may actually flare up the shoulder instead of make it better.

I always say, if you have a loss of joint mobility, torquing into that loss of mobility aggressively is only going to make it worse.

 

When the Sleeper Stretch is Appropriate

There are times when the sleeper stretch is probably appropriate.  But it’s not as often as you think and it’s most often not in athletes.  The older individual with adhesive capsulitis or a postoperative stiff shoulder may be good candidates for the sleeper stretch.  But I honestly still don’t use it in these populations.  There are better things to do.

But of course, there are good ways to perform the sleeper stretch and there are bad ways, technique is important.

For more information on some alternatives to the sleeper stretch, check out my article on sleeper stretch alternatives.

 

How to Choose the Right Medicine Ball

Medicine balls are commonly used for plyometric and power development drills.

The two most common types of medicine balls can be categorized by how well they bounce, high bounce or low bounce.

There’s a time and need for both, but choosing the right medicine ball can easily make or break the effectiveness of the exercise.

A medicine ball that bounces can effectively trigger the stretch-shortening cycle of a plyometric exercise, while a medicine ball with low bounce will place the emphasis on the concentric power output.

How to Choose the Right Medicine Ball

In this video, I discuss this more and show the different emphasis that different medicine balls will produce:

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I’ve really been publishing a ton of great videos on social media lately, including this series of “Performance Therapy Tips.”  Be sure to follow me on Instagram and Facebook to get them all!

 

The Science of Plyometrics

If you want to learn more, check out my Inner Circle presentation that overviews the neurological basis, phases, and science of plyometrics:

To access this webinar:

 

The Right Way, and Wrong Way, to Do Plyometrics

Plyometric exercises have been used for decades in both the rehabilitation and sports performance settings.

I love how plyometrics can effectively be used for power development, but are also valuable in the rehabilitation setting to gradually apply load to healing tissue while working on both force production and dissipation.

To truly perform plyometric exercises and get the most out of them, you must understand the science behind the stretch-shortening cycle.  I talk about this in detail in an Inner Circle presentation on the Science of Plyometric Exercises.

To fully maximize the benefit of the stretch-shortening cycle, you have to quickly transition from the eccentric loading phase to the concentric explosion phase of the drill.

If you perform the drills to slow, you’ll reduce the effect of the stretch-shortening cycle and decrease the efficacy of the plyometric exercise.

 

The Right Way, and Wrong Way, to Do Plyometrics

Watch the quick video below to see what I mean:

The Science of Plyometrics

If you want to learn more, check out my Inner Circle presentation that overviews the neurological basis, phases, and science of plyometrics:

To access this webinar:

The Science of Plyometrics

The latest Inner Circle webinar recording on The Science of Plyometrics is now available.

 

The Science Behind Plyometrics

The Science of Plyometrics

This month’s Inner Circle webinar is on The Science of Plyometrics.  In this presentation, I overview the foundation behind plyometric training so that you can perform them effectively,

This webinar will cover:

  • The goals of plyometric training
  • How the muscles spindles and golgi tendon organs interact
  • The 3 phases of plyometric exercises
  • The right way, and wrong way, to perform plyometric exercises

To access this webinar:

 

6 Hip Mobility Drills Everyone Should Perform

Recently, I have seen dozens of social media posts with “advanced” hip mobility drills that made me stop and think…

Should we actually be seeking to perform these advanced variations?

I would argue most people still need the basics, and should incorporate just a handful of more simple drills as the foundation of their mobility drills.

The internet is famous for sensationalizing the drills that look “fancy” rather than the ones that are likely the most effective.  It’s probably another case of the Pareto Principle, where 80% of the drills seen online should only be performed 20% of the time, and conversely, 20% of the drills seen online should be performed 80% of the time!  Heck it may be even less than that when it comes to hip mobility.

To make matters worse, the more advanced hip mobility drills are probably inappropriate for most people.  In my experience, limitations in hip mobility seem to be more related to the individuals unique anatomy, boney adaptations, and alignment rather than simple soft tissue limitations.  So, forcing hip mobility drills through anatomical limitations is just going to cause more impingement and issues with the hips, rather than helping.

Sometimes less is more.

 

My Favorite Hip Mobility Drills

I wanted to share my favorite hip mobility that I use with most of my clients.  I think you should really focus on these hip mobility drills before proceeding to more advanced variations.  If these don’t do the trick, it’s probably best that you seek out a qualified movement specialist to assess the reason behind you hip mobility limitations, rather than forcing more drills.

 

Quadruped Rockbacks

The first drill is a quadruped rockback.  This is one of my favorite drills for the hips, and feels great to loosen up the adductors and hip joint into flexion.  Plus, I do these barefoot to get more dorsiflexion and great toe extension.

 

Adductor Quadruped Rockbacks

The adductor quadruped rockback is a variation of the rockback that involves straightening out one hip.  This takes away a little bit of the hip flexion benefit, but enhances the effect on the adductors.  Performing this on both sides is the best of both worlds.

 

True Hip Flexor Stretch

The true hip flexor stretch is probably the most fundamental hip mobility drill we should all be performing.  I started calling it the “true” hip flexor stretch because the more common versions of this do not lock in the posterior pelvic tilt and just end up torquing the anterior capsule.

 

Posterior Hip Stretch

The posterior hip stretch feels great on the glutes and hits the posterior hip area, which is often tight.  Many people feel like the can get into a hip hinge much better after this drill.

 

Figure 4 Stretch

The posterior hip is a complicated area of muscles, I often pair the figure 4 stretch with the posterior hip stretch above to get different areas.  For me, I simple go by the feedback from my client on what feels more effective for them.

 

Spiderman

The Spiderman hip mobility drill is likely the most advanced of this list, which is why I have it last.  This is something I don’t always perform right away, but is a goal of mine to integrate with everyone eventually.  This requires more hip mobility that the others, so acts as a nice progression to put these all together.

 

How to Get Started with Hip Mobility Drills?

So wondering how to get started?  Start with the quadruped rockbacks and hip flexor stretch.  Those two are very foundational and will be the most impactful for most people.  Once you get those down, progress to the posterior hip stretch and figure 4 to hit more of the posterior aspect of the hip.  Lastly, progress to the Spiderman drill.

I honestly don’t think you need much more than that, and if you seek to get too aggressive with hip mobility drills, you often make things worse.

 

 

6 Keys to Shoulder Instability Rehabilitation

Shoulder instability is a common pathology encountered in the orthopedic and sports medicine setting.

But “shoulder instability” itself isn’t that simple to understand.

Would you treat a high school baseball player that feels like their shoulder is loose when throwing the same as a 35 year old that fell on ice onto an outstretched arm and dislocated their shoulder?  They’re both “shoulder instability,” right?

There exists a wide range of symptomatic shoulder instabilities from subtle recurrent subluxations to traumatic dislocations. Nonoperative rehabilitation is commonly utilized for shoulder instability to regain previous functional activities through specific strengthening exercises, dynamic stabilization drills, neuromuscular training, proprioception drills, scapular muscle strengthening program and a gradual return to their desired activities.

I’ve had great success rehabilitating dislocated shoulders and helping people return back to full activities without surgery.  But to truly understand shoulder instability, there are several key factors that you must consider.

 

Key Factors When Designing Rehabilitation Programs for Shoulder Instability

Because there are so many different variations of shoulder instability, it is extremely important to understand several factors that will impact the rehabilitation program.  This will allow us to individualize programs and enhance recovery.

There are 6 main factors that I consider when designing my rehabilitation programs for nonoperative shoulder instability rehabilitation.  I’m going to cover each in detail.

 

Factor #1 – Chronicity of Shoulder Instability

The first factor to consider in the rehabilitation of a patient with shoulder instability is the onset of the pathology.

Pathological shoulder instability may result from an acute, traumatic event or chronic, recurrent instability. The goal of the rehabilitation program may vary greatly based on the onset and mechanism of injury.

Following a traumatic subluxation or dislocation, the patient typically presents with significant tissue trauma, pain and apprehension. The patient who has sustained a dislocation often exhibits more pain due to muscle spasm than a patient who has subluxed their shoulder. Furthermore, a first time episode of dislocation is generally more painful than the repeat event.

Rehabilitation will be progressed based on the patient’s symptoms with emphasis on early controlled range of motion, reduction of muscle spasms and guarding and relief of pain.

The primary traumatic dislocation is most often treated conservatively with immobilization in a sling and early controlled passive range of motion (ROM) exercises especially with first time dislocations. The incidence of recurrent dislocation ranges from 17-96% with a mean of 67% in patient populations between the ages of 21-30 years old. Therefore, the rehabilitation program should progress cautiously in young athletic individuals. It should be noted that Hovelius et al has demonstrated that the rate of recurrent dislocations is based on the patient’s age and not affected by the length of post-injury immobilization. Individuals between the ages of 19 and 29 years are the most likely to experience multiple episodes of instability. Hovelius et al also noted patients in their 20’s exhibited a recurrence rate of 60% whereas patients in their 30’s to 40’s had less than a 20% recurrence rate. In adolescents, the recurrence rate is as high as 92% and 100% with an open physes.

Conversely, a patient presenting with atraumatic instability often presents with a history of repetitive injuries and symptomatic complaints. Often the patient does not complain of a single instability episode but rather a feeling of shoulder laxity or an inability to perform specific tasks.

Rehabilitation for this patient should focus on early proprioception training, dynamic stabilization drills, neuromuscular control, scapular muscle exercises and muscle strengthening exercises to enhance dynamic stability due to the unique characteristic of excessive capsular laxity and capsular redundancy in this type of patient.

Chronic subluxations, as seen in the atraumatic, unstable shoulder may be treated more aggressively due to the lack of acute tissue damage and less muscular guarding and inflammation. Rotator cuff and periscapular strengthening activities should be initiated while ROM exercises are progressed. Caution is placed on avoiding excessive stretching of the joint capsule through aggressive ROM activities.

The goal is to enhance strength, proprioception, dynamic stability and neuromuscular control especially in the specific points of motion or direction which results in instability complaints.

 

Factor #2 – Degree of Shoulder Instability

Bankart LesionThe second factor is the degree of instability present in the patient and its effect on their function.

Varying degrees of shoulder instability exist such as a subtle subluxation or gross instability. The term subluxation refers to the complete separation of the articular surfaces with spontaneous reduction. Conversely, a dislocation is a complete separation of the articular surfaces and requires a specific movement or manual reduction to relocate the joint. This will result in underlying capsular tissue trauma. Thus, with shoulder dislocations the degree of trauma to the glenohumeral joint’s soft tissue is much more extensive.

Speer et al have reported that in order for a shoulder dislocation to occur, a Bankart lesion must be present and also soft tissue trauma must be present on both sides of the glenohumeral joint capsule.

Thus, in the situation of an acute traumatic dislocation, the anterior capsule may be avulsed off the glenoid (this is called a Bankart lesion – see pictures to the right) and the posterior capsule may be stretched, allowing the humeral head to dislocate. This has been referred to as the “circle stability concept.”

The rate of progression will vary based upon the degree of instability and persistence of symptoms. For example, a patient with mild subluxations and muscle guarding may initially tolerate strengthening exercises and neuromuscular control drills more than a patient with a significant amount of muscular guarding.

 

Factor #3 – Concomitant Pathology

Hill Sachs LesionThe third factor involves considering other tissues that may have been affected and the premorbid status of the tissue.

As we previously discussed, disruption of the anterior capsulolabral complex from the glenoid commonly occurs during a traumatic injury resulting in an anterior Bankart lesion. But other tissues may also be involved.

Often osseous lesions may be present such as a concomitant Hill Sach’s lesion caused by an impaction of the posterolateral aspect of the humeral head as it compresses against the anterior glenoid rim during relocation. This has been reported in up to 80% of dislocations. Conversely, a reverse Hill Sach’s lesion may be present on the anterior aspect of the humeral head due to a posterior dislocation.

Occasionally, a bone bruise may be present in individuals who have sustained a shoulder dislocation as well as pathology to the rotator cuff. In rare cases of extreme trauma, the brachial plexus may become involved as well. Other common injuries in the unstable shoulder may involve the superior labrum (SLAP lesion) such as a type V SLAP lesion characterized by a Bankart lesion of the anterior capsule extending into the anterior superior labrum. These concomitant lesions will affect the rehabilitation significantly in order to protect the healing tissue.

 

 

Factor # 4 – Direction of Shoulder Instability

Shoulder Multidirectional InstabilityThe next factor to consider is the direction of shoulder instability present. The three most common forms include anterior, posterior and multidirectional.

Anterior shoulder instability is the most common traumatic type of instability seen in the general orthopedic population. It has been reported that this type of instability represents approximately 95% of all traumatic shoulder instabilities. However, the incidence of posterior instabilities appears to be dependent on the patient population. For example, in professional or collegiate football, the incidence of posterior shoulder instability appears higher than the general population. This is especially true in linemen. Often, these posterior instability patients require surgery as Mair et al reported 75% required surgical stabilization.

Following a traumatic event in which the humeral head is forced into extremes of abduction and external rotation, or horizontal abduction, the glenolabral complex and capsule may become detached from the glenoid rim resulting in anterior instability, or a Bankart lesion as discussed above.

Conversely, rarely will a patient with atraumatic instability due to capsular redundancy dislocate their shoulder. These individuals are more likely to repeatedly sublux the joint without complete separation of the humerus from the glenoid rim.

Posterior shoulder instability occurs less frequently, only accounting for less than 5% of traumatic shoulder dislocations.

This type of instability is often seen following a traumatic event such as falling onto an outstretched hand or from a pushing mechanism. However, patients with significant atraumatic laxity may complain of posterior instability especially with shoulder elevation, horizontal adduction and excessive internal rotation due to the strain placed on the posterior capsule in these positions.

Multidirectional instability (MDI) can be identified as shoulder instability in more than one plane of motion. Patients with MDI have a congenital predisposition and exhibit ligamentous laxity due to excessive collagen elasticity of the capsule.

Shoulder Sulcus SignOne of the most simple tests you can perform to assess MDI is the sulcus sign.

I would consider an inferior displacement of greater than 8-10mm during the sulcus maneuver with the arm adducted to the side as significant hypermobility, thus suggesting significant congenital laxity.  You can see this pretty good in this photo to the right, the sulcus is clearly larger than my finger width.

Due to the atraumatic mechanism and lack of acute tissue damage with MDI, ROM is often normal to excessive.

Patients with recurrent shoulder instability due to MDI generally have weakness in the rotator cuff, deltoid and scapular stabilizers with poor dynamic stabilization and inadequate static stabilizers. Initially, the focus is on maximizing dynamic stability, scapula positioning, proprioception and improving neuromuscular control in mid ROM.

Also, rehabilitation should focus on improving the efficiency and effectiveness of glenohumeral joint force couples through co-contraction exercises, rhythmic stabilization and neuromuscular control drills. Isotonic strengthening exercises for the rotator cuff, deltoid and scapular muscles are also emphasized to enhance dynamic stability.

 

Factor #5 – Neuromuscular Control

neuromuscular controlThe fifth factor to consider is the patient’s level of neuromuscular control, particularly at end range.

Injury with resultant insufficient neuromuscular control could result in deleterious effects to the patient. As a result, the humeral head may not center itself within the glenoid, thereby compromising the surrounding static stabilizers. The patient with poor neuromuscular control may exhibit excessive humeral head migration with the potential for injury, an inflammatory response, and reflexive inhibition of the dynamic stabilizers.

Several authors have reported that neuromuscular control of the glenohumeral joint may be negatively affected by joint instability.

Lephart et al compared the ability to detect passive motion and the ability to reproduce joint positions in normal, unstable and surgically repaired shoulders. The authors reported a significant decrease in proprioception and kinesthesia in the shoulders with instability when compared to both normal shoulders and shoulders undergoing surgical stabilization procedures.

Smith and Brunoli reported a significant decrease in proprioception following a shoulder dislocation.

Blasier et al reported that individuals with significant capsular laxity exhibited a decrease in proprioception compared to patients with normal laxity.

Zuckerman et al noted that proprioception is affected by the patient’s age with older subjects exhibiting diminished proprioception than a comparably younger population.

Thus, the patient presenting with traumatic or acquired instability may present with poor neuromuscular control that must be addressed.

 

Factor # 6 – Pre-Injury Activity Level

The final factor to consider in the nonoperative rehabilitation of the unstable shoulder is the arm dominance and the desired activity level of the patient.

If the patient frequently performs an overhead motion or sporting activities such as a tennis, volleyball or a throwing sport, then the rehabilitation program should include sport specific dynamic stabilization exercises, neuromuscular control drills and plyometric exercises in the overhead position once full, pain free ROM and adequate strength has been achieved.

Patients whose functional demands involve below shoulder level activities will follow a progressive exercise program to return full ROM and strength. The success rates of patients returning to overhead sports after a traumatic dislocation of their dominant arm are often low, but possible.

Arm dominance can also significantly influence the successful outcome. The recurrence rates of instabilities vary based on age, activity level and arm dominance. In athletes involved in collision sports, the recurrence rates have been reported between 86-94%.

 

Keys to Shoulder Instability Rehabilitation

To summarize, nonoperative rehabilitation of shoulder instability has many subtle variations.  To simplify my thought process, I always think of these 6 key factors before I decide what I want to do.  I hope these factors help you too.  What other factors do you consider when designing rehabilitation programs for shoulder instability?

 

Learn How I Evaluate and Treat the Shoulder

shoulder seminarWant to learn exactly how I rehabilitate shoulder instability?

I have a whole lesson on this as part of my comprehensive online program on the Evidence Based Evaluation and Treatment of the Shoulder at ShoulderSeminar.com.  If you want to learn exactly how I evaluate and treat the shoulder, including shoulder instability, this course is for you.  You’ll be an expert on shoulders!

 

 

 

 

What is the Best Graft Choice for ACL Reconstruction?

Today’s article is from my co-owner of Champion PT and Performance and co-author of OnlineKneeSeminar.com, Lenny Macrina.  Lenny does a great job discussing and comparing the different options when it comes to graft choice for ACL reconstruction.

Tearing an ACL can be a devastating experience.  Fortunately you are not alone as more than 250,000 people will tear their ACL in the United States and over 80% of people will have that tear reconstructed.

When the injury does occur, the person has some serious decisions to make including which graft to choose for the reconstruction. Often times, the person will leave that decision up to the orthopedic surgeon and blindly go with that decision.

All too often, the graft choice for that person may not be the best option for their age, goals and for their lifestyle, amongst many other things.  Consideration for the current research should play a big role in this decision-making process on which graft to use for ACL reconstruction.

So, what graft choices are out there and why may one be better than another one?

Well, as I normally say ‘it often depends,’ but I usually coach my clients and start with the gold standard, consider the pros and cons, then move onto the next best option.

ACL Reconstruction Graft Choices

What are the options and why choose one over the other?  First, I want to clarify the difference between “autograft” and “allograft.”  Autograft means using your own tissue.  Allograft means using tissue from a cadaver.

The most common choices available are:

  • Patellar tendon autograft
  • Hamstring autograft
  • Quadriceps tendon autograft
  • Patella tendon allograft

Let’s look at some of the research behind each ACL graft choice.

 

Patella Tendon Autograft

To me, the gold standard of ACL reconstruction is the patella tendon autograft and should be considered for most people in their teens, 20’s and for many in their 30’s or 40’s.

It is believed that the bone-patella tendon-bone graft has a stronger fixation because of the bone plugs that can incorporate into the femoral and tibial tunnels by 6-8 weeks after surgery.

Better graft fixation may prevent stretching or excessive laxity that is often seen with hamstring autografts and allografts. A strong and stable graft is key when considering the long term stability of the knee joint, as seen in this video showing the harvesting of the graft and the reconstruction.

Numerous studies have shown that re-tear rates are also significantly lower in patients undergoing a reconstruction with a patella tendon versus a hamstring tendon autograft.

A Scandinavian study looking at nearly 46,000 reconstructions showed this as well as a Norwegian study looking at greater than 12,000 reconstructions.  Furthermore a Danish study of nearly 14,000 reconstructions showed similar results.

Here in the US, a similar trend has been identified when looking at revision rates amongst the different graft choices. In this study out of over 21,000 reconstructions in California, patients under 21 years old with hamstring autografts had a 1.61 times higher risk of revision than did patients with patella tendon autografts. In patients less than 40 years old, those with allografts had a higher risk of revision than those with patellar tendon autografts.

A couple of disadvantages that are often reported after the surgery are an increase in general knee pain because of the soft tissue and bony dissection and anterior knee pain. This anterior knee pain may be more of a long term issue for some, especially while trying to kneel, because of the graft harvesting and scar that remains. To me, this is a small inconvenience but I always let my clients know of the potential long term kneeling limits. Usually not a big deal for most but you never know.

Some often say that it is more difficult to get a patient’s range of motion back, especially their hyperextension, if a patella tendon graft was used. I, personally have not seen this and have addressed this in a past article on 3 Ways to Avoid Loss of Motion After ACL Reconstruction.

I’ve actually had more difficult times getting hyperextension back in my hamstring autografts for some reason. They often feel that residual medial knee pain where the tendon was harvested and are reluctant to allow me to stretch them out into hyperextension.

Regardless, while anterior knee pain and range of motion restrictions are often cited as concerns, in my experience I feel these can be overcome with good postoperative rehabilitation.

 

Hamstring Tendon Autograft

The hamstring tendon autograft is another graft option for someone about to undergo an ACL reconstruction, as you can see in this video by Dr. Khalfayan:

I think it is too widely used currently and we need to further assess the outcomes and high risk of re-tear rate studies that I just presented.

Yeah, it may hurt less, and I stress MAY, but in my experience it is a graft that often presents a pretty big pain challenge. I’ve seen people in very comparable pain to a patella tendon graft because of the soft tissue dissection involved in the harvesting.

Think about a tendon shaver being poked under your skin high enough to clip the tendon from the muscle belly. No wonder hamstring grafts have a pretty significant bruising effect on the posterior aspect of their knees.

Ok, what about the famous: “But you can come back faster and progress rehab faster?”

I often hear this from patients who have done some research or have spoken to other health care practitioners but I completely disagree and actually progress people SLOWER with a hamstring autograft.

And here’s why…

The healing capacity for a hamstring autograft is believe to be inferior to the patella tendon graft.  Remember the Ekdahl study from 2008 but there are others too.

I know many are in sheep, goats and dogs but that’s all we have to guide us right now. Until humans will volunteer their knees periodically through a study to get histological samples, then we have to rely on animal studies to guide our thoughts and progressions.

And don’t forget there is an increased risk of infection with a hamstring graft compared to a patella tendon autograft or allograft.

But good news, many say the hamstring will regenerate after being taken out although the strength deficits into knee flexion persist.

Because of this, I often progress my patients that have ACL reconstruction using a hamstring autograft much slower than those with patellar tendon autografts.

A slower healing potential that may lead to graft stretching and eventual failure, never mind the potential strength deficits that may persist and affect jumping/landing biomechanics due to the use of the hamstring.

Remember, the hamstrings line of pull will help limit anterior translation of the tibia and dynamically stabilize during running, jumping and cutting tasks. If we take 1-2 of those tendons out, how will that affect the athlete short term and long term as they return to their function/sport.

Maybe that’ another reason why re-tear rates are statistically higher in ACL’s reconstructed with a hamstring graft?

I definitely go slower with my female clients, as well, who are much more likely to tear their ACL’s, in general.

Remember, numerous studies like this, this, this, and this have shown females to land in a quadriceps dominant and valgus position, which may predispose them ACL rupture, amongst many other reasons.

So, why would we even consider a hamstring graft in an active female population and take away one for their main stabilizers. It’s almost like we’re promoting the quadriceps dominant position by “robbing Peter to pay Paul.”

For this reason, I almost always tell my female clients to highly consider a patella tendon autograft. Furthermore, I very rarely recommend a hamstring graft for most of my patients that ask.

I just feel like the risk of re-tear outweighs the POTENTIAL for increased anterior knee pain after surgery. They tend to agree, quite often.

 

Quadriceps Tendon Autograft

Another autologous graft option, which I feel is underutilized, is harvesting a quadriceps tendon autograft to reconstruct the ACL. Honestly, the more I researched this graft option, the more I consider this a truly viable choice.

This video give a great overview of graft harvesting for the quadriceps tendon:

Numerous studies have shown very good outcome compared to hamstring and patellar tendon autografts. I could make a pretty good sized list but have picked just a few to make my point. Like this one, this one,  or this one.

Because of the size comparison and increased collagen present within the graft, the quadriceps tendon graft is definitely a graft with comparable strength qualities compared to the previous grafts mentioned.

This table, taken from the lectures at from my online course with Mike Reinold at OnlineKneeSeminar.com, summarized strength and strength to failure of the various graft choices.

What is the Best Graft Choice for ACL Reconstruction

Biomechanically, the cross-sectional area of the quadriceps tendon was nearly twice that of the patellar tendon. Ultimate load to failure and stiffness were also significantly higher for the quadriceps tendon graft.

Well, maybe we consider a hamstring graft if the primary revision failed and we need a new graft option?

I still say maybe consider an ipsilateral quadriceps tendon before thinking about a hamstring tendon. This study showed revision ACL reconstruction using the quadriceps tendon graft showed clinical outcomes similar to those of the contralateral hamstrings graft in terms of knee stability and function.

But we said pain was less in hamstring grafts, right?

We’d rather have less pain so I can progress ROM and function quicker, no?

Well, maybe not, as this study showed comparing quadriceps to hamstring autografts. Supplementary analgesic drug was 38% higher in the hamstring group compared with the quadriceps tendon group.

Guess the hamstring option isn’t so painless!

 

Allograft Tissue

What about the ‘other’ graft choice that seems to be utilized a decent amount in the sports medicine and orthopedic world, the allograft.

Allograft tissue, or cadaver grafts, have recently become very popular in the United States for some reason, despite the numerous studies like this or this that show higher revision rates and graft stretching never mind the often under-reported cases of allografts being degraded by the body’s immune response.

I will say there is some research out there that is showing similar outcomes in allografts not chemically processed or irradiated when compared to autografts.  But we are still learning.

This study looked at outcomes and revision rate after bone-patellar tendon-bone allograft versus autograft ACL reconstruction in patients aged 18 years or younger with closed physes. They determined there was no significant differences in function, activity, or satisfaction were found between allograft and autograft reconstructions BUT the allograft group had a failure rate 15 times greater than that in the autograft group, with all failures occurring within the first year after reconstruction.

I’ve spoken to surgeons who have  reported almost no remnants of the previous allograft at the time of the revision surgery. It’s like the patient’s body completely rejected the graft.

That’s just a risk I almost never want to take.

I’d maybe consider an allograft for an older but active patient, say in their 50’s or 60’s but very rarely for an active person. I’d definitely not recommend an allograft to an athlete in their teens and 20’s although I have personally seen many kids present to me post- primary or revision surgery with an allograft reconstruction.

When I asked them why they chose it, they most often say: “it was recommended by the physician because I may be able to return to sports sooner and less pain.”

I could not disagree anymore and usually have to give them my dissertation on graft healing and the potential for graft rejection (as I mentioned previously).

Again, we think it takes several months longer for allograft tissue to incorporate itself compared to autograft tissue. There are very few reasons why someone should return their sport any quicker when the tissue is not fully incorporated, so why even consider it?

I very RARELY recommend an allograft for an ACL reconstruction. I frequently have to talk clients out of this option because the 1st thing they see or hear is there’s less pain. When they hear the whole story, they quickly realize an autograft seems to be the right choice.

 

Choosing the Right ACL Graft

Which autograft will depend on many factors but it seems like a patella tendon or quadriceps tendon may be the grafts of choice.

If you tore your ACL and are considering ACL reconstruction surgery, consider these factors when deciding which graft may be the most appropriate for you.

 

Learn How I Evaluate and Treat the Knee

If you want to learn even more about ACL rehabilitation, we discuss all of this this and much more in our online knee course at OnlineKneeSeminar.com where we teach you exactly how we evaluate and treat the knee.