Hamstring Strains with Holly Silvers - Episode 33

Hamstring strains continue to be one of the most common injuries in sport. Despite all the attention placed on the prevent of hamstring strains, injury rates continue to rise.

In this episode I am joined by Holly Silvers, who has extensive experience working with USA soccer and the MLS, as well as the NFL and MLB. We talk about why hamstring strains are so common and often recurrent, and some things we may be missing when it comes to prevention and rehabilitation

Full show notes: https://mikereinold.com/hamstring-strains-with-holly-silvers

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Transcript

0:31

On this episode of the sports physical therapy podcast, I'm joined by Holly silvers. Holly's a PT PhD in Santa Monica, California. She's a member of the U S soccer medical team and chair of the MLS soccer research committee. We talk about her work on hamstring strains, why they're so common and often recurrent, and some of the things we may be missing when trying to prevent in rehab these injuries.

Mike: 1:07

Hey Holly, how's everything going? Welcome to the podcast.

Holly: 1:09

Thank you. Pleasure to be here. Thanks for the.

Mike: 1:12

Oh, I know, my pleasure. Um, and I, you know, I've been saying this a lot on the podcast lately, but, um, it's super selfish just because I want to talk to you, right. And I wanna learn from you. So, um, I, I love having guests on like yourself that are, you know, obviously brilliant. I mean it, you know, that, that's, that's the easy part. But the areas of your brilliance, I think are just, are just so cool and you have a lot of neat things to share with people. So I'm really excited for this episode.

Holly: 1:38

Well, thank you. Very flattering. Likewise, feelings. Mutual.

Mike: 1:42

That, that, that's awesome. I, I think a to a ton of people see where you've been, your experiences. Like your bio is just cool, right? I think that's how I would like, like phrase your bio right? You have some really cool opportunities, things that you got, um, uh, you get to work with. I think a lot of people are jealous. Right. And, and they'd love to do that. And a lot of early career professionals want to, to, to kind of hear a little bit about your career arc. So tell me about that. You spend time, you know, obviously you, you, you must love soccer, um, but now you're working football, you're working in baseball, like all these things like, tell, tell us about your journey.

Holly: 2:18

Okay, great. Yeah, a little unorthodox too. I mean, and some of it's serendipitous, maybe a splash of nepotism too, which I'll explain So I,

Mike: 2:27

that

Holly: 2:27

I grew up I grew up in, uh, Kearney, New Jersey, which, um, We have been dubbed Sucker Town, u s a. We, we just had this incredible, uh, it, it was in a really interesting place to grow up. I almost feel like I grew up in, in Europe in some ways because most of the kids I grew up, we were all first generation kids. My dad's from Ireland, my mother's from London. Um, we had the Portuguese and Spanish section. We had the Italian section, you had the Polish section, and we all played soccer. Um, my U seven to U 12 coach played for Celtic

Mike: 3:01

Oh my God,

Holly: 3:02

You know that that was my, yeah, so, and we had no idea. We just didn't know. We thought that was normal. You know, everybody's coach played professionally at U seven. Um, but, but, and then, um, interestingly, like we just, you know, when US Soccer was getting back on the map internationally and like the late eighties, like, so in 1990, we had not qualified for a World Cup in 52 years. So, Uh, current brother-in-law was my sister's boyfriend at the time, was the goalkeeper for that team, uh, leading up. And he was a, like a, it was basically a glorified NCAA standout team, which we the, we assembled and they qualified for Italy in 1990. And so, Um, this is kind of speaking to the culture of the town. When I told my high school principal at the time, like, I'm going to the World Cup, I need to, to uh, take exams early. He's like, of course you are. And there were like several of us doing that. My very good friend Carolyn Mira e there were many of us doing it cuz they, that was like revered. So my brother-in-law is Tony Mila. It's full disclosure, and part of the reason I got into the a c L world is because, um, during a US Mexico match, we were kind of, they were playing in Azteca and, uh, winning and, um, he just, he had a collision earlier on in the game, probably sustained a concussion, no judgment, was back in the game and, uh, took a punt, a goal kick, and, um, collapsed to the ground. We're all quizzically looking and I was finishing graduate school at the time, I was in my last year of PT school and I was like, oh my God. And then, you know, obviously kind of surmising what happened. And then he had surgery with, uh, Dr. Burt Mandelbaum, who was a team physician at the time. And, um, I wound up going out to one of his follow up visits with him and meeting Bert and, uh, Bert said, you know, well, I was literally graduating a month later. He's like, what are you interested in doing? I said, We need to prevent ACL injuries. I said it sort of flippantly. He's like, well come over on Tuesday morning. We meet at 6 45 every Tuesday and let's just kind of discuss this. So I met with them for a couple of months and then we got an opportunity to apply for a grant to the LA 84 Foundation, which was founded after the 84 Olympics. Cause there was a lot of money left over in a, in a good way. And we applied for this ACL prevention. and here I am 23 years later.

Mike: 5:32

I know, right? It just And what, and, and it, it kept growing. I mean, you've done so much in the a c l prevention world. I mean, um, it's, it's, it's, it's really impressive. So, um, so, What I love is that you love soccer, right? And you're, you're, you're, you're passionate about it, and you got to pursue a job that gets to work in that realm. And I mean, that's the dream, right? Like you're, you're, you're passionate about it Every day, you, you combine medicine in the sport that you love, and, uh, you know, it, it's a home run. So, congrats. That's,

Holly: 6:05

Thank you. Yeah, and I, I, you know, similar to you, I feel blessed. There are a lot of people that go to work every day and sort of do it because they need to. I like fully love what I do and I, I feel like my patients appreciate that too. Cause they know I'm invested, I'm invested with them. So, um, yeah, it's, it's, it's. It's, it's the dream, right? What could be better, like loving what you do the way that, the way that we do. So I would encourage people, like of course I had a li obviously I have a brother-in-law that made a couple of introductions for me. But I always say the joke and he's like, well, I'm glad tearing my a c l is major career out of lemons. But, but I say like, it got me in the door. It doesn't keep you in the door, but you, I obviously, um, Have done some hard work and, and it's the work I enjoy doing. So my, my level of dedication is a hundred percent. Um, so I, I, but I wouldn't discourage anyone from trying to get in if you don't have a family relationship. But, um, um, like to, to your, to your earlier point, uh, How, because I get a lot of emails like this or like, Hey, how, how do I get in? Like make a way in? And now with, with whether it's soccer or baseball or, or, or football, I always say start out the community level. Cause I did that too. You know, I worked with like U 12 teams and helped them for dynamic warmups. And I, I volunteered, I, my first seven years at mls, I was a volunteer in it. So I, I, I, I, Fully giving of my time because it was something I loved. It was a passion project, so I didn't feel like work to me. But I know for some people that might be difficult. But, um, I would just say even if the grassroots community level, a high school, like volunteering, helping, because most. organizations are under-resourced. Um, I'm sure you can speak to that as well. So I think if you are willing to give your time, your energy, your expertise, um, without a lot of tentacles attached to that, I think a lot of people will be very, very receptive to that.

Mike: 7:58

Yeah, and, and I love when people combine their passions, so the sport they played and then this newfound knowledge that they got with with medicine or performance or that type of thing. Um, I, I almost feel like it's a duty of ours to give it back to the grassroots, to the kids and the parents and the coaches, and to teach them the things that we've learned. So, um, I couldn't agree more, and I'm gonna give you a little more credit. Those, um, they, they didn't help you get through that door. They opened the door for you, but you're the one that took those steps through it, you know, and, and you get to think about that. Yes, it's, it's nice to have doors open, but you have to have that, that desire to take those steps through the door too. And not everybody does.

Holly: 8:37

Yeah. Thank you. Yeah, it, yeah, I agree. Um, it's, it's been a journey of times and I've had doors closed. I'll be honest with you though, not everything has been a straight path, you know, so. but I think those obstacles always, I, I'm reflective on those and oftentimes those obstacles have, uh, built more character and, and have pushed me even harder than maybe I knew I had that sixth or seventh gear available to me. So

Mike: 9:02

That's a great way of, of thinking of it. I love that. Well, so te, tell me a little bit about a day in the life of Holly, right? Because I, I feel like you wear multiple hats

Holly: 9:10

Mm-hmm.

Mike: 9:11

obviously there's soccer, there's you're consulting with football and baseball. Tell me a little bit about the day in the life of, of, of you.

Holly: 9:17

Sure. Okay. So it varies a bit, but I have a, I have a full-time clinical practice. Like I see, like I do at least 30 hours of clinical work a week. And I absolutely love it. I love it in that, um, my husband maybe doesn't love it all the time cause I'm a little bit overtaxed, but, uh, uh, but I, I. Honest to God, even when I was finishing my PhD at University of Delaware and Lynn Snyder Mackler, who I adore was my PhD advisor and she said, um, you know, what are you doing this for? I said, to be better at, to be a better clinician. And I really didn't have any, um, grandiose. Concepts of like, going into academia, academia that didn't really appeal to me. I like to teach, but more on the, um, sort of uh, lecture circuit in terms of like, oh, let's do a course here and there. I don't think I would love to be a full-time academic. Um, but what also has been wonderful about getting a PhD has that opened a few more doors because as we know in our world, Tend to matter. And I'll give you one quick little example of that. I was probably, I was working with Dr. Mandelbaum for about 10 years and I was presenting at A O S S M, um, and this is a while back, and one of the orthopedic orthopedic surgeons said to me like, oh, you only have a master's. It's like, oh well, I'm still kind of doing the work, you know, but, um, and it appeal, it, it just was a very sort of, I, I had this catharsis of like, wow. Yeah, I'm. I, from a letter perspective, I'm not in the cache of folks that perhaps I would like to be. So, um, I had some conversations with Lynn and like, I was like, you know what, I'm gonna go back and do this. So I, I was practicing for 17 years before I went back and did a PhD.

Mike: 11:02

Oh, I didn't realize that.

Holly: 11:03

yeah. And then had a baby in, in the interim too, which is, um, you know, I don't recommend that, but But, uh, that, but, but, uh, but But having said that, I, I really, I loved, like I came in armed with so many ideas and like at that point I had been researching for a while and I just, I felt like, uh, in a lot of ways, um, I almost could advise myself in the sense like I had so many ideas and clinically I was the way I thought about my PhD. I am absolutely corroborating everything I've thought of for the last 17. It was like a, I was, yeah. And it was, I was so grateful to go back, cuz I think, I don't know if you had this experience, but when I was doing, when I was in PT school, I was just like looking forward to the end so I could get out there and do our thing. And this was so different cuz I was relishing, I'm like, oh. Education is wasted on the youth We, we should like, uh, here I am. I was like almost approaching Florida and I'm like, this is amazing. Like, I could not be happier doing this right now. Cause this is just the, the wonderful way of like almost going back and doing sabbaticals. I think it's like a great idea for everybody. Obviously it doesn't fit into everyone's life path, but, um, that was. That was really great for me. But anyway, so like I do the clinical steps, so each week's a little bit different based on what's going on. Like I had a research CO all earlier today I'm the research chair for Major League Soccer, which I love. And so depending on the week, like right now we're in a little bit of a low, we had our annual meeting and then we haven't started preseason physicals yet, but we're also ramping up. I took an advisory role with the NFL last year or a year and a half ago, basically trying to create ACL mitigation programs with the nfl and that's. So fun because that's obviously a sport I did not play, but I respect and enjoy. And I al always think like from a biomechanical perspective, like if, you know biomechanics, you can, you can analyze anything, right? So, um, but that's been really fun and, and really fun. Um, Getting to know a whole new group of clinicians, but also, um, understanding their obstacles, right? Because we all have our unique, uh, boundaries in place in terms of whether it's the league or legal or the players association, and how that is so different. So that's been a fascinating like learning experience for me too, um, is how you navigate, um, through different cultures and subsets of cultures within different sports within our country. And I'm sure you could speak to that with baseball as well.

Mike: 13:31

Absolutely. Yeah. I mean, it's, it's diverse in that manner. Um, it's neat, but I, I like that you're keeping with the football trend, right? Football's football. Right. If it's, uh, you know, you know, I mean, you're keeping it there, football's life. But so, um, I, I, I li I, I, I like how you're keep. Been that trend. So, um, I, I, I know we can talk a c l and I, I, I'd be excited to talk a c l but I'm being super selfish here and I wanna continue some of the past conversations that you and I have had in person at dinner about hamstrings, because I love hamstrings and that's probably after a c l that's probably your second thing, right?

Holly: 14:05

No, I love hamstrings too. I have an equal love for hamstrings.

Mike: 14:09

Oh, that's, that's, that's, that's so nice for hamstring. Um, I, I, I, I, I, I know you spend a lot of time in this and this, this is kind of funny. Holly and I were kind of laughing before we hit record on this podcast, but this might be the shortest amount of questions that have prepared for a podcast, but they're big questions, right? So I'm gonna hit you with some of these big, juicy ones. So, first one to, to me is like, I know you're spending a lot of time on hamstring trains.

Holly: 14:33

Yeah.

Mike: 14:33

Why, why are hamstring strains so common? And again, what an open-ended question. I'm just gonna say that, but like, but what, why on earth? Because they're, I think not only are they common in so many different sports, uh, they're, they seem to be getting worse. So, so why are they so common? What do you think?

Holly: 14:47

yeah. Great question. And then honestly, if. If you follow, I would recommend following young tran's work cuz he's one of the leaders from, from a, from an Amer uh, from soccer, uh, you know, European football perspective. He does all the uafa analysis of all the Champions League data. And the numbers not only are, um, still high, they're going up, which is, you know, Kind of eats at my core. Um, um, and I think part of it, part of my, uh, thought process here is that there's a category or subset of these hamstrings that are being, um, perhaps wrongly identified and undertreated, right? Not looking at this. In a macro way in treating it in a micro way. And we can kind of talk about that in a second. Cause I've certainly seen athletes like that have put in that category. I mean, and when you look at these regression analyses, you know, like, well the risk factors are like, okay, prior injury and age, well that's sort of redundant Cause if they're getting more exposure, well sure. Um, so that doesn't tell us very much. Um, you know, you can look at the mechanisms like the mechanism. I find so fascinating cuz it's, it's probably one of the cleanest in terms of the diversity and mechanisms as opposed to American football and soccer because it's a lot of it's bass riding, right? Going from home plate to first base and either on the reach or step outta the box. And I think that's been, um, really. Coolly illuminated in the last decade or so by a bunch of authors. But for from soccer, it's our number one injury in Major League soccer. It's our biggest time loss injury by far. And it continues to lead that charge since I've been, uh, involved with mls and that's over, you know, 18 years now, which is frustrating. So we've tackled it from, I can speak to Major League Soccer. The way we've tackled this is like, Building our stakeholders, so like incorporating all of our teams and saying, Hey, we recognize it's a problem. um, do you recognize it as a problem? That's question one. Um, and secondly like, what are you doing for it? So we can get a sense of like, what's being done, is that effective or not? And then lastly, how can we help you and like, what can we do? And as you know, working in professional sports, so many people, so many teams and um, institutions are very reluctant to get involved in any type of cohort or R c T study. It's just. you know, and for a lot of very good reasons. Um, so a lot of the data we've tried to pull, like is from the NCAA and try to loosely extrapolate that to the pros, which isn't often a perfect fit, particularly. Massively different. If you look at an NCAA schedule, which is basically a third, like going from August to if you're really successful into December, and then you have an incoming rookie. Cause in mls it's interesting, a lot of our rookies are immensely vulnerable to injury hamstring in particular. Um, it's because we basically tripled their load in one year. You know, they go to this full. Preseason physicals in January, and if you're successful this year being an outlier because of the, the late World Cup, but the, the season goes through December. I mean, it's wildly long. Um, not unlike baseball. So, um, I say I think a lot of it is like, We, we are like, um, Brian Hirschfeld in Wisconsin's doing some amazing work. Um, looking at, I don't know that we even know the fact, the variables that we need to be recognizing. Um, so there's a lot of work, like on the regression side that needs to be done and is being done. Um, but I think some of the athletes that I've seen that have had like recurrent, like on their fifth and sixth and seventh episodes, One of the things that I had noticed is that, wow, maybe the hamstrings not the deficit. It might be the glute like, and that was an interesting phenomenon that I found with a couple of very high level notable, um, um, US national team members and or MLS players. Um, and the same goes for gas jock too. We were kind of seeing that phenomenon like, are we, are we. And, and the other fascinating thing is when we were testing some of these players, is that the strength parameters were looking good, optimal normative, uh, some of their movement patterns and uh, performance variables were looking normative. But then when I started doing EMG analyses on these people, we were seeing some deficits and was this some sort of cortical. Element at play here and like, were we not seeing that until there was a little bit of a fatigue element or, and I don't necessarily mean physiological fatigue, but could be some upper cortical fatigue there. So, It is super complex. I think it's more complicated than acl, honestly. in a lot of ways. Yeah, because um, um, and then the other element is like, okay, there are some things in place. You look at the efficacy of the Nordics and some of these eccentric capturing type. Exercises, whether using Nord board and uh, Russian, um, the snake, whatever variants you wanna use. But then we look at this game of attrition where, what is the adherence in compliance? And that's what the extra shown, like these champions, league level teams, you're looking at a 12 to 16% adherence rate. So, yeah, very low. You know? And those were, those were, yeah, very surprising. Very surprising.

Mike: 19:59

Well, no wonder why we can't figure it out. Right? They're not doing anything. I mean, is it? Is it that easy? I mean, or it's hard to say. Are we missing something if they're not compliant?

Holly: 20:09

it's complicated. But I would say from the champions lead level data like that was um, almost a little bit surprising on how low that is. And that was even partial adherence. So we have a paper coming out, um, actually in MLB cuz we did a, we did a really nice intervention study with an entire organization, which was kind of a unique opportunity cause we don't typically have those. And we were able to inter use an intervention with a lot of eccentric. It was multifactorial. And I think when we're designing project projects for pros, we're doing the same thing with the NFL right now. So instead of something like we would design typically for the youth, um, and this is some of the other programs I've been involved with, whether it was like the PEPPER L 11 plus, which was interestingly effective for hamstring mitigation as well. Um, those are kind of. Uh, dynamic warmups design cuz it's like packaged right? We only have access to some of these kids three times a week. So dynamic warmup, you kind of prepare them for movement and you know, hopefully we see injury mitigation as a result. At the pros it's very different cuz we have to kind of seed this in and um, I think oftentimes that's harder from an adherence compliance perspective. Not packaged in such a tidy way. So, and then you have to kind of really, um, work collaboratively with strength and conditioning and on, you know, the fitness performance side to make sure, well, this is something they accept as well. There's, so there's more stakeholders at play. Sometimes youth sports is easier. in some ways, you know, and to not as sort of bureaucratic if you'll, um, with full respect to strength and conditioning and performance. I don't say that

Mike: 21:42

Yeah. And, and now, now imagine the baseball season too, because, and you know, the, our, our big thing is that we play every day, right? We, we actually compete every day.

Holly: 21:53

yeah. When do you do it? Yeah.

Mike: 21:55

Yeah, I mean, you, you have 20 games in a row, like 20 days in a row with some day games and travel, like mixed in on there. Um, it, it makes it even harder in, in, in our games. So, um, I, I definitely see, I definitely see a bit of the hurdles right in not a lot of teams wanna travel with the nor board, so Yeah, of course you can, you can do Nordics in other ways, right? But it's, it's, it's just a, it's a different vibe. Um, well, I'm super excited that you talked about the EMG because you, I, you probably remember, but that's the part of our conversation we had over the summer or last year that I was super excited about. Cause that's interesting. And, and I like how you brought up the glutes. I like you brought up the calfs. So you were saying essentially that deficits in the in in the glutes, deficits in the calves might be part of what's going on with the hinging. That's why we're. So much, uh, just, just like myopically on the hamstring. Maybe we're, we're missing those other things that are, that are changing the force, but then also the emg. I, I think we gotta elaborate on that, Holly. I mean, that's, I, to me, to me that's some good stuff. Tell me a little bit about, let's start with the, the glute and the calf. What, what specifically did you find that made you start to say like, oh gosh, we missed.

Holly: 23:33

Well, you know, it's interesting that, because I started thinking about it like, um, when I was at University of Delaware and I was thinking about it more on the biomechanic side because we think we quantify, um, moments and like a total support moment, right? So when we're looking specifically see, like, need alga, well it's like, well what's, what's the ankle doing? What's the hip doing and what are the percentages of what they're doing? Right? And I'm like, well, why aren't we doing this for muscle? Right. That just kinda seems like kinda. Like, okay, so, so I had one national team member and I had just, I have, uh, approval to discuss his case. Um, specifically it's Jodi Al Cador and Josie Wa um, is a phenomenal still playing. I think he's in his 18th season in New England at the Revs. And, um, he, um, you know, some of you may know if you watch the Brazil World Cup within, you know, the first eight minutes against Ghana making this, he's incredibly explosive, incredibly fast. He's making. Incredible rundown the left length and kind of goes into, you know, to make a right. Um, he's being defended, of course, closely by g Ghanaian player and uh, um, and just pulls up and just grabs his left hamstring. I'm like, oh no, here we go. Right? So I hadn't seen Josie prior to that, but then after Brazil, I did a teeny bit of work with him and then, I think he was in Toronto at the time. And then, um, and then he had a second and a third and then a fourth, and then I started doing a little bit more work with him. And what was fascinating with him when we tested him pretty extensively, I'm like his hamstrings, his strength, his mg, like are all. Optimal. And what was so fascinating is that his glutes were grossly underactive and he's um, has a pretty extensive lordotic stance. He's got that anterior pelvic till. So even in standing, his hamstrings were just doing so much work. That, and some of it because of. Sort of postural positioning. So my thought was like, my God, when we ask this guy to do anything with any, you know, bit of dynamic effort for certainly at the level of what she needs to do at a World Cup, you know, performance is that one. He's either already slightly fatigued. From a hamstring perspective cuz they're working so hard just in standing. And secondly, his glutes are so underperforming that, um, from a posterior chain, if we're looking at this ratio of like hip flexion, quad anterior tib to glutes, hamstrings, gas jock, and our soleus, um, we are at a massive imbalance here, like massive. And with those forces and those. It's highly unlikely that anyone can perform at that level without having multiple strains. So we have to walk all this back. Yeah. So, so, yeah.

Mike: 26:22

I mean, it's, it's, it's a good way to think of it that not, I think sometimes we, we miss the boat because we're just our, we, we have this tunnel vision and you think, I'm just gonna, I'm just gonna work on this over and over again. But everybody's postural adaptations are different. Everybody's, you know, the way they use their bodies different. You have to think outside the box. And maybe, maybe, you know, again, with these re. Issues. Right? I mean, this is probably one of the most recurrent injuries out there, right? And, and maybe, maybe we are missing the boat. Um, tell me a little bit more about the EMG now, because that's the part that I was super excited about is that they're super strong, but EMGs off what? Tell me about that

Holly: 26:57

I, and Josie knows this, I fully credit him with my, like, complete like metamorphosis of how I think of this injury. Like I, and that, that is why I love to treat, like, cause I, cause if I'm in an academic office, I'm

Mike: 27:10

Yeah, you'd

Holly: 27:10

my hypotheses, you know,

Mike: 27:12

You'd mi you'd miss that for sure.

Holly: 27:14

have to drag me outta my clinic at 85 or something. But, um, but, um, until I get too irrelevant. But, um, uh, But, so after him, Wow. We are, I always, I joke, I'm like, half of orthopedics is neurology, isn't it? You know, we, and I think, and the other interesting thing, like what I started to do is simultaneously is testing. Okay? So we have this like magic threshold of, um, okay, what's normative? Like quad hamstring ratio, uh, quad glue. Um, what? Well, but is that normal or is that just what we. Accept because in normals we're still having high occurrences, so should we accept that as normal? So there's that question. And then the second issue is, um, what happens with, okay, once they clear or we, we, we have this sort of theoretical acceptance of return to training, uh, return to contact, return to full competition, return to play. Is there recidivism? Keep testing. Right? So what we notice is that, and this, I'm seeing this a lot on the ACL side and definitely on the hamstring side is like, okay, we'll, we'll, we'll kind of get this cortical output that we're expecting either on the strength and or EMG side. And then, um, and then there, there's this slide back, right? There's this recidivism back to a baseline that these players have gotten super comfortable with and have mastered, right? They're all. and there's this fascinating thing. Keep yourself honest by, you know, pull them back in if you have the opportunity every four to six weeks and do a retest. Now the cool thing is technology's gotten really inexpensive. Like, no, I don't have any alliance to any EMG company. I just happen to use an M trigger. They're like$400. Which is amazing for, like, your average clinical practice can probably swing that in addition to a really good dynamometer. So, you know, so we sh we, it's incumbent upon us to like, make sure we're testing both, um, because I have been. um, pleasantly surprised and sometimes un unpleasantly surprised looking at like strengthen EMG DA data that oh, they're, they're sort of corresponding and they're, they're correlated and sometimes they're not. And so we, yeah. So I think, um, I'm not making any false hypotheses here and making any false conclusions predicated on what I think is happening based on a performance or their ability to load. So I, I do think there's an incredible. um, uh, there's some incredible assets involved in continuing to test from the strength side. Obviously from the performance and biomechanics movement side, but then also from the neurological side, um, the EMG side. Um, and the cool thing is like these are all very portable units and you can do them during dynamic movements and then the treatment that the assessment becomes the treatment cuz it serves as a biofeedback.

Mike: 30:12

Right,

Holly: 30:13

And that's where I think we get real motor planning. Um, sh.

Mike: 30:17

so walk me through that, because I think a lot of people get testing right now. You think, I even think, you know, they, they understand even the positions to test a hamstring in, in, in various positions. But walk me through how, how, how do you use MG to test? What, what do you do for movements? How do you use it?

Holly: 30:32

Oh, sure thing. Yeah. And you can be, you're only limited by your own creativity, quite frankly. So I kind of make it sports specific. So we'll do like the basic standard test because oftentimes I'll check a strength and an EMG at the same time. So, um, m trigger, again, I have no financial relationship with, but they have a really crafty test built into their, their app. And it's a five second repeated. NBC basically, and you're, and I do that in, um, I have just this like, setup onto one of my highlight tables and they, you can do it either in prone or in seated at 45 and or I might test the player, like if it was an insertional tendonopathy versus a mid bely or like depending, I might test them at different angles. So I'll customize it. Um, and there you could, it's, it's very easy cuz you can just do that setup using Gate beltz or, you know, It doesn't need to be expensive. Um, and then, um, what I will also do is strength test in those same positions. So if we come up with anything or we see a deficit or imbalance, Between sides, um, uh, then we can train in those specific areas. We can get highly specific, but I would say don't get too highly specific. Cause you wanna make sure, you know, you're, like I say in one hand you wanna do things like, I think a really good example is like this whole toss up of like what's the most effective is centric. And if you look at some of the EMG data on looking at a Nordic versus a Russian versus. any other type of, um, what's interesting when you have that sort of concentric eccentric component of a, of a, of a Russian, um, uh, you get a little bit more semi involvement, right? You'll see some semi semit involvement and gracilis. Um, And then where unlike the Nordic, they're getting a little bit more bicep fems. Um, do them both. You know? Why not? And I, you know, and I love the utility of working varying ranges. The concentric, eccentric, eccentric alone. Um, so then, and then, so from the MG perspective, it's like, okay. So then let's do some more sports specific stuff. Let's look at them on a treadmill. Let's put them at speed. And, and I just watched the feed live. And then we can capture certain segments at certain speeds and then do a right and left comparison, whether we're looking at biceps, fem, uh, you wanna compare the biceps to the semis. Um, you could do that contra, um, again, It's um, I think you clinically think through it and you think of, okay, where is this um, uh, player or this athlete's major deficit? And then you kind of work from there. But again, kind of, I think the common thread to this whole discussion is like, think macro, not micro. Like don't overly get specific because that can come back to haunt you. It really, really can, you know, so kind of cre create. You wanna have. Ready for everything. That's the way I think about in terms of preparation for a player to going back to, and like I talked about it earlier, but I have a very, um, like methodical return to train, uh, and then return to training with some like friendly contact. And that's usually a coach or another athlete who has been injured recently, and then return to full contact in a training and then return to full play in competition with some minute, um, allotments obviously and some requirements.

Mike: 33:46

That's great. So, so, so I think we, I think you talked a lot there about why recurrent hamstrings happen, and I think we can extrapolate a lot of that to saying, okay, we need to improve our rehab programs, you know, based on some of these macro things that we just talked about. Um, what, what, what about preventing though, I, I mean, let's, let's go back to preventing just for a hot second here and say, yeah, what, what, what are we, what do you think we're missing preventing? Is it, is it still using that same thing? Do. Trained all of our players this way, right? To assure that we're having all this stuff happen, or what do you think is our lowest hanging fruit for preventing these injuries in the first place?

Holly: 34:21

Yeah, that's a great question. And I think if we got super, so if we're talking like a thousand feet up, I'd say, okay, let's just talk the basics of having people adhere or comply Like let's just do something

Mike: 34:33

I guess so, right?

Holly: 34:34

and be relatively consistent. Okay.

Mike: 34:37

a good point.

Holly: 34:38

I think we would get at least maybe 10 to 20% there. And that's easy. Right? That's easy. But I will say, you know, having these conversations with coaches like this happened in the NFL study. Cause we have, and we are including a variable of the eccentric hamstring into this program that we're designing. And one of the strength and conditioning coaches who is absolutely amazing. It's like, Holly, I'm gonna have a really hard time getting that in. Where do we insert it such that they're not going to be sore. It won't impact any, like midweek, like a Thursday night game, a Sunday. And um, is, is it best placed into preseason? But then the coaches will be disappointed because then they can't get onto their twoo days because there's some soreness quotient. And I said, I know it is an absolute conundrum, and my answer is that hopefully you and I can inspire some young clinicians out there to. Almost combat the notion of getting to that level and not having enough eccentric, capturing strength cuz it's been introduced at the youth. You know, these are, these are principles that we need to be, um, these kids need to be engaged and knowing that this is actually part of proper training and should be hopefully introduced like, you know, the youth in high school levels. So there, there, there's that.

Mike: 35:54

That's awesome. And, and I, I, you're right, maybe that is the future. Right? Um, we, we, we've seen so many people try their hardest and players that aren't compliant in the off-season with these programs. And then, you know, we expect'em to be there. We have to unravel. A little bit at the beginning in our pre-season and, and you know, on-ramp, their sprinting on-ramp, their strength and, you know, it just never goes well once you're behind the gun with these things. Cuz we, we have so many competing stresses. Um, uh, wait, what, what about sprints? You know, we talked a lot about strength. What about, what about, um, just dosage of like max velocity in, in, in, in 10 full sprints. Um, how much do you put that into your programs for prevent.

Holly: 36:34

Yeah. Massively important. Particularly your sport. One, one little thing, if I wanted to mention the one paper we looked at, cause we did a study with the Cape Cod League in the North Woods League, and just the establishing prevalence of hamstring. 26% of those kids already had a hamstring. And like this is ostensibly the feeder, right? For the minors. And like, I'm like, oh boy. And see that's where I think really the heavy lifting has to be done, no pun intended,

Mike: 37:00

Yeah. Yeah.

Holly: 37:00

we need to get them early, right? We can't have these young kids coming in. Um, they're all ostensibly playing high level D one, you know, really competitive baseball programs and it's. Like, my God, if they're a quarter of them are already afflicted and we're looking at age and recurrence as the primary, um, risk factors we're in a little bit of trouble. But yeah, to your point on the sprint side, so like that would be a little bit specific in terms of like, for, for, for soccer would be like, okay, what are the demands of their particular position? Right? Is that, is that their strength? Um, like if it's a goalkeeper, obviously not a. You know, a big component of it, but absolutely we build it in. Cuz I love all, like, if any of you are reading any of like the arch, like looking at, um, hamstring architecture and the classical morphology, I think we can all agree that obviously having, um, real, uh, the, the granularity to which we're understanding how morphology is really important in hamstring injury is, is. Fascinating to me and how we train that. Right. So that's where the eccentrics can come in really, um, helpful looking at ation angles and looking at these dynamic assessments with ultrasounds and how that is important from a performance side. So we have to perform at length in order to not get injured at length.

Mike: 38:16

Right, right. And, and I, I think when you, when you start to think of it from this fashion, you can see that we have a lot of work to do.

Holly: 38:25

Yeah.

Mike: 38:26

Um, and I think we're at the point now where you, people like yourself have done so much research to find a lot of these things. If we don't do the two components, get the youth to do'em before it's a problem, and then to get people more compliant in it. We really are gonna have a hard time assessing if all this hard work you've put into it. It worked, right? It's, it's, it's unfair. If nobody's, you know, if compliance is 16%, then you know what, you know, it's, it's hard to say if we're doing, um, you know, the right job. So, um, you know, we appreciate people like yourself in all that you do. Um, this might have been the most educational, uh, podcast episode I think I've had so far. Um, which, which would just your, your brilliance raining down. Holly, I feel like we solved some pro problems today. I think we did. I think we did. So

Holly: 39:14

Oh, good.

Mike: 39:17

spread, spread this, this message from Holly to, uh, to all your local youth, uh, coaches, strength and conditioning, uh, facilities. And, you know, not to say that like strength and conditioning facilities are guilty of this too. Not to go off on a tangent here at the end, but like, man, we, we got like super, super into power. Right. Like it's, we, you know, the last decade or so and Glu glu glute and not hamstring, hamstring, hamstring a lot. So you, you, you said the flip where, you know, we're focusing too much on the hamstring and not on the others. I, I think if you look at a lot of the youth, they're squatting and deadlifting a ton and they're not doing a lot of isolated hamstring.

Holly: 39:52

Absolutely, I could not agree more. And I see that a lot, particularly like in my kind of high level, like 14 to 18 year old group. And I could not agree more. And this is where I plead, like with the coaches, it's like, let us help you like just take a little dose of this. We're only asking for a lot of this dynamic stuff. We're lucky. We're asking for about a 28 minute commitment a week. And if you kind of stratify that through the calendar and if that's gonna. Some of your best players available to you in the post-season. It is such a win-win, you know? So, um, yeah. And, uh, and on the strength and conditioning side, it's like, yeah, sometimes we, we try to get a little too clever and sometimes we don't need to be that, that crafty or that that creative or that unique, we can kind of stick with some of the basics because they work and like dedicated hamstring work absolutely has to be a, a. Primary component of everything because a lot of the sports will, um, you know, just by virtue of competition and playing and participating, your quads are gonna stay pretty darn strong. And it's, it's the posterior chain that we really have to make sure we're, we're involving as well.

Mike: 40:55

Right. And who knows what we can influence with the youth as they're growing and they're adopting their, their, their, you know, their, their, their growth spurts and all these things, uh, with the muscle architecture. I, I, I think you're completely right. I think, I think that is probably gonna be our next area that we have, have to e emphasize the most. So, um, uh, amazing stuff. Holly, this was awesome. Uh, before I let you go, I gotta end with our high five, five quick questions that I'm, I'm eager to hear your answers. I think you're gonna have great. Five quick questions, five quick answers. Learn a little bit about you and your brain, how you think, but first question, what are you currently working on for your own professional development, not teaching us, but what are you learning yourself?

Holly: 41:36

You know, I have to say I love reading, like I, I, my, my Twitter feed is like, I, I use Twitter to. Follow things that I wouldn't normally feed, like read things outside the box. Like I follow, um, oncology, I follow I read anything, I'm, I'm a bit of a geek obviously. I think you probably picked that up in the last 45 minutes. But, um, I'll, I read anything and everything, reading about long covid reading about um, uh, you know, novel treatments. Cuz I think anything you learn to extrapolate, um, one might help you help a patient like inadvertently, but also I think it allows your brain to. create tentacles for yourself, particularly as I get a little bit longer into my career. Um, I love switching things up and making things, um, you know, sometimes difficult on myself because I think that makes me better at what I do overall.

Mike: 42:27

Yeah. I love it. That's a great one. What's one thing that you've recently changed your mind about?

Holly: 42:33

Um, and this isn't super recent, but, uh, one of the things, oh, uh, uh, well we talked a little bit about like looking at gluten and not totally isolating hamstring or vice versa, right? There's that. And then secondly, um, uh, uh, one of the, oh, hip flexor is a fascinating one to me. Early on in my career,

Mike: 42:56

I love the excitement. I love this. I love hip flexors too.

Holly: 43:00

So, you know, probably early on we, you probably started similar time as me, where we kind of thought, oh, we can stretch some of these issues away. And now I have like completely abandoned that thought and now I am like, we are going to strengthen these issues away. So that has been a real slip and I love explaining that to patients because that's been a bit of dogma. Like, I have tight hip flexors and I was like, yeah, the reason you do that because you sit in a corporate job for like, you know, nine hours a day and we're gonna kind of work your way out of it and this is what we're gonna.

Mike: 43:27

Yeah, that's a great one. I think that's great and you've seen success with that.

Holly: 43:31

Yes, yes. Well, and the stretching matters. I'm not, I, maybe I overstated that a bit, but I think like oftentimes they're weak. Use your dynamometers and figure it out. Like, are they weak? You

Mike: 43:40

that's a good, that's a, yeah. Very well said. I like that. Uh, what's your favorite piece of advice that you give students?

Holly: 43:46

Oh, you know, just stay hungry. I mean, you know, I've been doing this for 23 years and it's, if I've been doing it for one, I am. I just like you. I love what I do. And if you're not happy in your current job situation, then find a way. Maybe it's just that particular situation, like volunteer. I, I can't tell you how many philanthropic hours I have done throughout my career, and it has led me to some of the most rewarding. Career and life experiences that I have, like genuinely had the honor to have. Um, so I would say, um, don't, don't expect things to come your way. You have to work hard to find relationships and network and conversations, but also volunteer cause some of the most fruitful things you might experience, not only professionally, but personally, uh, maybe of a genuine surprise to you,

Mike: 44:33

I love it. That was gold. I like that. That was a good one. Uh, what's coming up next for you? I'm sure you get a bunch what's coming

Holly: 44:38

Oh yeah. Well, loving the N F L stuff. Continuing. Some work with M L D, which I also love. This is a funny question or funny quick story if you have a second. Um, when I first started getting involved in MLB and we were on a call with multiple teams and we were in the height, this is many years ago when there was like this big rise in, uh, um, Hamstring incidents and, um, one, I won't name any names, but there was a team member or affiliate member from, uh, one of the clinical staff and an MLB team. And he's like, and all due respect, like, you're a soccer person. Like, what do you know about baseball? And I'm like, I'll have, you know, I was a mean. Third base, little league player,

Mike: 45:15

There you go.

Holly: 45:16

I said, so I would say one of my things I say obviously being a woman and not being able to play, you know, high level baseball. I played softball, but, um, or, uh, uh, football. But I, I would say, um, be open-minded in terms of people's experiences. Like, um, some of the best coaches in the world weren't the greatest players, and I think that goes for like our profession as well. You don't necessarily have to play the sport, but, but be well versed. I immerse myself and try, I know every position and I know, you know, watching my nephews play throughout the year. Like I, I, I definitely am a student of the game. I'm a student of life, but I am a student of the game and I turn, I,

Mike: 45:54

I'm picking up

Holly: 45:55

it's very important.

Mike: 45:56

I'm, I'm picking up on that. I feel, I feel like you're one of those people that got very little work done during the World Cup, right? Are you in, are you in you in that boat?

Holly: 46:05

It's fascinating. That was a fascinating World Cup for a variety of reasons. That might be our next podcast. Mike

Mike: 46:10

Yeah, exactly right. Awesome. All right. Well, how, how can people learn more about you? I know, I know you just mentioned Twitter. Um, do you have, do you have, but like what's the best places for people to learn more about you and your research and all the stuff

Holly: 46:21

I'm, I'm more active on Twitter than Instagram. Maybe that's sort of uncool of me. But, um, that's the facts, And then, um, I have a website. Um, it's just my small clinical practice, but I post things about like our, our newest. Uh, sort of research anything that's getting published. And then, um, and I, and I retweet things that I think are really important to our profession. Um, whether it's on like the A P T A or sports section, political side, or, you know, ways to stay involved. Um, opportunities that I think might be of interest to my former self, you know, 20 years ago. Um, but I just think. If I can just give a little bit of advice to young clinicians. It's just read, read, read, and read from a variety of sources in terms of, um, and I think Twitter and, and social media has made that so much easier now and palatable because it's just like, it's, you can design your own news, source your newsfeed, which is phenomenal.

Mike: 47:13

Yeah, it's a great opportunity and it's a great opportunity to get to interact with people like yourself, right? I mean, like, think about that. That's crazy. I can't, I'm sure you, you respond to people. I mean, that, that's amazing that you can do that nowadays. So, um, you know, re really appreciate everything you do for the profession, um, and taking some time out to come here and, um, probably give the most information per second on, on the podcast history if we. If we look at a ratio of brilliance per second. But thank you so much, Holly. We love it. Um, I, I feel like we, we gotta do an ACL one in the future, but, but thanks so much and uh, and I hope to see you soon. Thank you again.

Holly: 47:49

my pleasure. Thank you for the invitation. Really a blast. Thank you.