May 16, 2023 • 48 mins
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
Want to learn more from me? I have a variety of online courses on my website!
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:00):
On this episode of the sportsphysical therapy podcast, I'm
joined by Holly silvers.
Holly's a PT PhD in SantaMonica, California.
She's a member of the U S soccermedical team and chair of the
MLS soccer research committee.
We talk about her work onhamstring strains, why they're
so common and often recurrent,and some of the things we may be
missing when trying to preventin rehab these injuries.
Mike (00:35):
Hey Holly, how's everything going?
Welcome to the podcast.
Holly (00:38):
Thank you.
Pleasure to be here.
Thanks for the.
Mike (00:41):
Oh, I know, my pleasure.
Um, and I, you know, I've beensaying this a lot on the podcast
lately, but, um, it's superselfish just because I want to
talk to you, right.
And I wanna learn from you.
So, um, I, I love having guestson 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 yourbrilliance, I think are just,
(01:02):
are just so cool and you have alot of neat things to share with
people.
So I'm really excited for thisepisode.
Holly (01:07):
Well, thank you.
Very flattering.
Likewise, feelings.
Mutual.
Mike (01:11):
That, that, that's awesome.
I, I think a to a ton of peoplesee 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 coolopportunities, things that you
got, um, uh, you get to workwith.
I think a lot of people arejealous.
Right.
And, and they'd love to do that.
(01:31):
And a lot of early careerprofessionals want to, to, to
kind of hear a little bit aboutyour career arc.
So tell me about that.
You spend time, you know,obviously you, you, you must
love soccer, um, but now you'reworking football, you're working
in baseball, like all thesethings like, tell, tell us about
your journey.
Holly (01:47):
Okay, great.
Yeah, a little unorthodox too.
I mean, and some of it'sserendipitous, maybe a splash of
nepotism too, which I'll explainSo I,
Mike (01:55):
that
Holly (01:56):
I grew up I grew up in, uh, Kearney, New Jersey, which,
um, We have been dubbed SuckerTown, 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, wewere all first generation kids.
My dad's from Ireland, mymother's from London.
(02:18):
Um, we had the Portuguese andSpanish section.
We had the Italian section, youhad the Polish section, and we
all played soccer.
Um, my U seven to U 12 coachplayed for Celtic
Mike (02:30):
Oh my God,
Holly (02:31):
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 coachplayed professionally at U
seven.
Um, but, but, and then, um,interestingly, like we just, you
know, when US Soccer was gettingback on the map internationally
and like the late eighties,like, so in 1990, we had not
(02:53):
qualified for a World Cup in 52years.
So, Uh, current brother-in-lawwas my sister's boyfriend at the
time, was the goalkeeper forthat team, uh, leading up.
And he was a, like a, it wasbasically a glorified NCAA
standout team, which we the, weassembled and they qualified for
(03:13):
Italy in 1990.
And so, Um, this is kind ofspeaking to the culture of the
town.
When I told my high schoolprincipal at the time, like, I'm
going to the World Cup, I needto, to uh, take exams early.
He's like, of course you are.
And there were like several ofus doing that.
My very good friend Carolyn Mirae there were many of us doing it
cuz they, that was like revered.
So my brother-in-law is TonyMila.
(03:35):
It's full disclosure, and partof the reason I got into the a c
L world is because, um, during aUS Mexico match, we were kind
of, they were playing in Aztecaand, uh, winning and, um, he
just, he had a collision earlieron in the game, probably
sustained a concussion, nojudgment, was back in the game
(03:55):
and, uh, took a punt, a goalkick, and, um, collapsed to the
ground.
We're all quizzically lookingand I was finishing graduate
school at the time, I was in mylast year of PT school and I was
like, oh my God.
And then, you know, obviouslykind of surmising what happened.
And then he had surgery with,uh, Dr.
(04:17):
Burt Mandelbaum, who was a teamphysician at the time.
And, um, I wound up going out toone of his follow up visits with
him and meeting Bert and, uh,Bert said, you know, well, I was
literally graduating a monthlater.
He's like, what are youinterested in doing?
I said, We need to prevent ACLinjuries.
I said it sort of flippantly.
He's like, well come over onTuesday morning.
(04:38):
We meet at 6 45 every Tuesdayand let's just kind of discuss
this.
So I met with them for a coupleof months and then we got an
opportunity to apply for a grantto the LA 84 Foundation, which
was founded after the 84Olympics.
Cause there was a lot of moneyleft over in a, in a good way.
And we applied for this ACLprevention.
(04:58):
and here I am 23 years later.
Mike (05:01):
I know, right?
It just And what, and, and it,it kept growing.
I mean, you've done so much inthe 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 thatyou love soccer, right?
And you're, you're, you're,you're passionate about it, and
you got to pursue a job thatgets to work in that realm.
(05:23):
And I mean, that's the dream,right?
Like you're, you're, you'repassionate about it Every day,
you, you combine medicine in thesport that you love, and, uh,
you know, it, it's a home run.
So, congrats.
That's,
Holly (05:33):
Thank you.
Yeah, and I, I, you know,similar to you, I feel blessed.
There are a lot of people thatgo to work every day and sort of
do it because they need to.
I like fully love what I do andI, 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?
(05:54):
What could be better, likeloving 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 abrother-in-law that made a
couple of introductions for me.
But I always say the joke andhe's like, well, I'm glad
tearing my a c l is major careerout of lemons.
But, but I say like, it got mein the door.
It doesn't keep you in the door,but you, I obviously, um, Have
(06:15):
done some hard work and, andit's the work I enjoy doing.
So my, my level of dedication isa hundred percent.
Um, so I, I, but I wouldn'tdiscourage anyone from trying to
get in if you don't have afamily relationship.
But, um, um, like to, to your,to your earlier point, uh, How,
because I get a lot of emailslike this or like, Hey, how, how
(06:35):
do I get in?
Like make a way in?
And now with, with whether it'ssoccer or baseball or, or, or
football, I always say start outthe community level.
Cause I did that too.
You know, I worked with like U12 teams and helped them for
dynamic warmups.
And I, I volunteered, I, myfirst seven years at mls, I was
a volunteer in it.
So I, I, I, I, Fully giving ofmy time because it was something
(06:59):
I loved.
It was a passion project, so Ididn't feel like work to me.
But I know for some people thatmight be difficult.
But, um, I would just say evenif the grassroots community
level, a high school, likevolunteering, helping, because
most.
organizations areunder-resourced.
Um, I'm sure you can speak tothat as well.
So I think if you are willing togive your time, your energy,
(07:19):
your expertise, um, without alot of tentacles attached to
that, I think a lot of peoplewill be very, very receptive to
that.
Mike (07:27):
Yeah, and, and I love when people combine their passions,
so the sport they played andthen this newfound knowledge
that they got with with medicineor performance or that type of
thing.
Um, I, I almost feel like it's aduty of ours to give it back to
the grassroots, to the kids andthe parents and the coaches, and
to teach them the things thatwe've learned.
So, um, I couldn't agree more,and I'm gonna give you a little
(07:48):
more credit.
Those, um, they, they didn'thelp you get through that door.
They opened the door for you,but you're the one that took
those steps through it, youknow, and, and you get to think
about that.
Yes, it's, it's nice to havedoors open, but you have to have
that, that desire to take thosesteps through the door too.
And not everybody does.
Holly (08:06):
Yeah.
Thank you.
Yeah, it, yeah, I agree.
Um, it's, it's been a journey oftimes 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 obstaclesalways, I, I'm reflective on
those and oftentimes thoseobstacles have, uh, built more
character and, and have pushedme even harder than maybe I knew
(08:28):
I had that sixth or seventh gearavailable to me.
So
Mike (08:31):
That's a great way of, of thinking of it.
I love that.
Well, so te, tell me a littlebit about a day in the life of
Holly, right?
Because I, I feel like you wearmultiple hats
Holly (08:39):
Mm-hmm.
Mike (08:40):
obviously there's soccer, there's you're consulting with
football and baseball.
Tell me a little bit about theday in the life of, of, of you.
Holly (08:45):
Sure.
Okay.
So it varies a bit, but I havea, I have a full-time clinical
practice.
Like I see, like I do at least30 hours of clinical work a
week.
And I absolutely love it.
I love it in that, um, myhusband maybe doesn't love it
all the time cause I'm a littlebit overtaxed, but, uh, uh, but
I, I.
Honest to God, even when I wasfinishing my PhD at University
(09:06):
of Delaware and Lynn SnyderMackler, who I adore was my PhD
advisor and she said, um, youknow, what are you doing this
for?
I said, to be better at, to be abetter clinician.
And I really didn't have any,um, grandiose.
Concepts of like, going intoacademia, academia that didn't
really appeal to me.
I like to teach, but more onthe, um, sort of uh, lecture
(09:30):
circuit in terms of like, oh,let's do a course here and
there.
I don't think I would love to bea full-time academic.
Um, but what also has beenwonderful about getting a PhD
has that opened a few more doorsbecause as we know in our world,
Tend to matter.
And I'll give you one quicklittle example of that.
I was probably, I was workingwith Dr.
Mandelbaum for about 10 yearsand I was presenting at A O S S
(09:54):
M, um, and this is a while back,and one of the orthopedic
orthopedic surgeons said to melike, oh, you only have a
master's.
It's like, oh well, I'm stillkind 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.
(10:15):
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 conversationswith Lynn and like, I was like,
you know what, I'm gonna go backand do this.
So I, I was practicing for 17years before I went back and did
a PhD.
Mike (10:30):
Oh, I didn't realize that.
Holly (10:32):
yeah.
And then had a baby in, in theinterim too, which is, um, you
know, I don't recommend that,but But, uh, that, but, but, uh,
but But having said that, I, Ireally, I loved, like I came in
armed with so many ideas andlike at that point I had been
researching for a while and Ijust, I felt like, uh, in a lot
(10:52):
of ways, um, I almost couldadvise myself in the sense like
I had so many ideas andclinically I was the way I
thought about my PhD.
I am absolutely corroboratingeverything I've thought of for
the last 17.
It was like a, I was, yeah.
And it was, I was so grateful togo back, cuz I think, I don't
know if you had this experience,but when I was doing, when I was
(11:12):
in PT school, I was just likelooking forward to the end so I
could get out there and do ourthing.
And this was so different cuz Iwas relishing, I'm like, oh.
Education is wasted on the youthWe, we should like, uh, here I
am.
I was like almost approachingFlorida and I'm like, this is
amazing.
Like, I could not be happierdoing this right now.
Cause this is just the, thewonderful way of like almost
(11:35):
going back and doingsabbaticals.
I think it's like a great ideafor everybody.
Obviously it doesn't fit intoeveryone's life path, but, um,
that was.
That was really great for me.
But anyway, so like I do theclinical steps, so each week's a
little bit different based onwhat's going on.
Like I had a research CO allearlier today I'm the research
chair for Major League Soccer,which I love.
(11:55):
And so depending on the week,like right now we're in a little
bit of a low, we had our annualmeeting and then we haven't
started preseason physicals yet,but we're also ramping up.
I took an advisory role with theNFL last year or a year and a
half ago, basically trying tocreate ACL mitigation programs
with the nfl and that's.
So fun because that's obviouslya sport I did not play, but I
(12:16):
respect and enjoy.
And I al always think like froma biomechanical perspective,
like if, you know biomechanics,you can, you can analyze
anything, right?
So, um, but that's been reallyfun and, and really fun.
Um, Getting to know a whole newgroup of clinicians, but also,
um, understanding theirobstacles, right?
Because we all have our unique,uh, boundaries in place in terms
(12:40):
of whether it's the league orlegal or the players
association, and how that is sodifferent.
So that's been a fascinatinglike learning experience for me
too, um, is how you navigate,um, through different cultures
and subsets of cultures withindifferent sports within our
country.
And I'm sure you could speak tothat with baseball as well.
Mike (12:59):
Absolutely.
Yeah.
I mean, it's, it's diverse inthat manner.
Um, it's neat, but I, I likethat 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, Ilike how you're keep.
Been that trend.
So, um, I, I, I know we can talka c l and I, I, I'd be excited
to talk a c l but I'm beingsuper selfish here and I wanna
(13:23):
continue some of the pastconversations that you and I
have had in person at dinnerabout hamstrings, because I love
hamstrings and that's probablyafter a c l that's probably your
second thing, right?
Holly (13:34):
No, I love hamstrings too.
I have an equal love forhamstrings.
Mike (13:38):
Oh, that's, that's, that's, that's so nice for
hamstring.
Um, I, I, I, I, I, I know youspend a lot of time in this and
this, this is kind of funny.
Holly and I were kind oflaughing before we hit record on
this podcast, but this might bethe shortest amount of questions
that have prepared for apodcast, but they're big
questions, right?
So I'm gonna hit you with someof these big, juicy ones.
So, first one to, to me is like,I know you're spending a lot of
(14:00):
time on hamstring trains.
Holly (14:01):
Yeah.
Mike (14:02):
Why, why are hamstring strains so common?
And again, what an open-endedquestion.
I'm just gonna say that, butlike, but what, why on earth?
Because they're, I think notonly 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 (14:16):
yeah.
Great question.
And then honestly, if.
If you follow, I would recommendfollowing young tran's work cuz
he's one of the leaders from,from a, from an Amer uh, from
soccer, uh, you know, Europeanfootball perspective.
He does all the uafa analysis ofall the Champions League data.
And the numbers not only are,um, still high, they're going
(14:37):
up, which is, you know, Kind ofeats at my core.
Um, um, and I think part of it,part of my, uh, thought process
here is that there's a categoryor subset of these hamstrings
that are being, um, perhapswrongly identified and
undertreated, right?
Not looking at this.
(14:57):
In a macro way in treating it ina micro way.
And we can kind of talk aboutthat in a second.
Cause I've certainly seenathletes like that have put in
that category.
I mean, and when you look atthese regression analyses, you
know, like, well the riskfactors are like, okay, prior
injury and age, well that's sortof redundant Cause if they're
getting more exposure, wellsure.
Um, so that doesn't tell us verymuch.
(15:18):
Um, you know, you can look atthe mechanisms like the
mechanism.
I find so fascinating cuz it's,it's probably one of the
cleanest in terms of thediversity and mechanisms as
opposed to American football andsoccer because it's a lot of
it's bass riding, right?
Going from home plate to firstbase and either on the reach or
step outta the box.
And I think that's been, um,really.
(15:38):
Coolly illuminated in the lastdecade or so by a bunch of
authors.
But for from soccer, it's ournumber one injury in Major
League soccer.
It's our biggest time lossinjury by far.
And it continues to lead thatcharge since I've been, uh,
involved with mls and that'sover, you know, 18 years now,
which is frustrating.
So we've tackled it from, I canspeak to Major League Soccer.
(16:01):
The way we've tackled this islike, Building our stakeholders,
so like incorporating all of ourteams and saying, Hey, we
recognize it's a problem.
um, do you recognize it as aproblem?
That's question one.
Um, and secondly like, what areyou 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 helpyou and like, what can we do?
(16:22):
And as you know, working inprofessional sports, so many
people, so many teams and um,institutions are very reluctant
to get involved in any type ofcohort or R c T study.
It's just.
you know, and for a lot of verygood reasons.
Um, so a lot of the data we'vetried to pull, like is from the
NCAA and try to looselyextrapolate that to the pros,
(16:43):
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'rereally successful into December,
and then you have an incomingrookie.
Cause in mls it's interesting, alot of our rookies are immensely
(17:03):
vulnerable to injury hamstringin particular.
Um, it's because we basicallytripled 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 ofthe, the late World Cup, but
the, the season goes throughDecember.
I mean, it's wildly long.
Um, not unlike baseball.
So, um, I say I think a lot ofit is like, We, we are like, um,
(17:28):
Brian Hirschfeld in Wisconsin'sdoing some amazing work.
Um, looking at, I don't knowthat we even know the fact, the
variables that we need to berecognizing.
Um, so there's a lot of work,like on the regression side that
needs to be done and is beingdone.
Um, but I think some of theathletes that I've seen that
have had like recurrent, like ontheir fifth and sixth and
seventh episodes, One of thethings that I had noticed is
(17:52):
that, wow, maybe the hamstringsnot the deficit.
It might be the glute like, andthat was an interesting
phenomenon that I found with acouple of very high level
notable, um, um, US nationalteam members and or MLS players.
Um, and the same goes for gasjock too.
We were kind of seeing thatphenomenon like, are we, are we.
And, and the other fascinatingthing is when we were testing
(18:15):
some of these players, is thatthe strength parameters were
looking good, optimal normative,uh, some of their movement
patterns and uh, performancevariables were looking
normative.
But then when I started doingEMG analyses on these people, we
were seeing some deficits andwas this some sort of cortical.
Element at play here and like,were we not seeing that until
(18:36):
there was a little bit of afatigue element or, and I don't
necessarily mean physiologicalfatigue, but could be some upper
cortical fatigue there.
So, It is super complex.
I think it's more complicatedthan acl, honestly.
in a lot of ways.
Yeah, because um, um, and thenthe other element is like, okay,
(18:56):
there are some things in place.
You look at the efficacy of theNordics and some of these
eccentric capturing type.
Exercises, whether using Nordboard and uh, Russian, um, the
snake, whatever variants youwanna use.
But then we look at this game ofattrition where, what is the
adherence in compliance?
And that's what the extra shown,like these champions, league
level teams, you're looking at a12 to 16% adherence rate.
(19:20):
So, yeah, very low.
You know?
And those were, those were,yeah, very surprising.
Very surprising.
Mike (19:28):
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 ifthey're not compliant?
Holly (19:38):
it's complicated.
But I would say from thechampions lead level data like
that was um, almost a little bitsurprising on how low that is.
And that was even partialadherence.
So we have a paper coming out,um, actually in MLB cuz we did
a, we did a really niceintervention study with an
entire organization, which waskind of a unique opportunity
cause we don't typically havethose.
(19:58):
And we were able to inter use anintervention with a lot of
eccentric.
It was multifactorial.
And I think when we're designingproject projects for pros, we're
doing the same thing with theNFL right now.
So instead of something like wewould design typically for the
youth, um, and this is some ofthe other programs I've been
involved with, whether it waslike the PEPPER L 11 plus, which
was interestingly effective forhamstring mitigation as well.
(20:20):
Um, those are kind of.
Uh, dynamic warmups design cuzit's like packaged right?
We only have access to some ofthese kids three times a week.
So dynamic warmup, you kind ofprepare them for movement and
you know, hopefully we seeinjury mitigation as a result.
At the pros it's very differentcuz we have to kind of seed this
in and um, I think oftentimesthat's harder from an adherence
(20:43):
compliance perspective.
Not packaged in such a tidy way.
So, and then you have to kind ofreally, um, work collaboratively
with strength and conditioningand on, you know, the fitness
performance side to make sure,well, this is something they
accept as well.
There's, so there's morestakeholders at play.
Sometimes youth sports iseasier.
in some ways, you know, and tonot as sort of bureaucratic if
(21:06):
you'll, um, with full respect tostrength and conditioning and
performance.
I don't say that
Mike (21:11):
Yeah.
And, and now, now imagine thebaseball season too, because,
and you know, the, our, our bigthing is that we play every day,
right?
We, we actually compete everyday.
Holly (21:22):
yeah.
When do you do it?
Yeah.
Mike (21:23):
Yeah, I mean, you, you have 20 games in a row, like 20
days in a row with some daygames and travel, like mixed in
on there.
Um, it, it makes it even harderin, in, in our games.
So, um, I, I definitely see, Idefinitely see a bit of the
hurdles right in not a lot ofteams wanna travel with the nor
board, so Yeah, of course youcan, you can do Nordics in other
(21:44):
ways, right?
But it's, it's, it's just a,it's a different vibe.
Um, well, I'm super excited thatyou talked about the EMG because
you, I, you probably remember,but that's the part of our
conversation we had over thesummer or last year that I was
super excited about.
Cause that's interesting.
And, and I like how you broughtup the glutes.
I like you brought up the calfs.
So you were saying essentiallythat deficits in the in in the
(22:05):
glutes, deficits in the calvesmight be part of what's going on
with the hinging.
That's why we're.
So much, uh, just, just likemyopically on the hamstring.
Maybe we're, we're missing thoseother things that are, that are
changing the force, but thenalso the emg.
I, I think we gotta elaborate onthat, Holly.
I mean, that's, I, to me, to methat's some good stuff.
(22:25):
Tell me a little bit about,let's start with the, the glute
and the calf.
What, what specifically did youfind that made you start to say
like, oh gosh, we missed.
Holly (22:35):
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 thinkingabout it more on the biomechanic
side because we think wequantify, um, moments and like a
total support moment, right?
So when we're lookingspecifically see, like, need
alga, well it's like, wellwhat's, what's the ankle doing?
What's the hip doing and whatare the percentages of what
(22:56):
they're doing?
Right?
And I'm like, well, why aren'twe doing this for muscle?
Right.
That just kinda seems likekinda.
Like, okay, so, so I had onenational team member and I had
just, I have, uh, approval todiscuss his case.
Um, specifically it's Jodi AlCador and Josie Wa um, is a
phenomenal still playing.
I think he's in his 18th seasonin New England at the Revs.
(23:19):
And, um, he, um, you know, someof you may know if you watch the
Brazil World Cup within, youknow, the first eight minutes
against Ghana making this, he'sincredibly explosive, incredibly
fast.
He's making.
Incredible rundown the leftlength and kind of goes into,
you know, to make a right.
Um, he's being defended, ofcourse, closely by g Ghanaian
(23:41):
player and uh, um, and justpulls up and just grabs his left
hamstring.
I'm like, oh no, here we go.
Right?
So I hadn't seen Josie prior tothat, but then after Brazil, I
did a teeny bit of work with himand then, I think he was in
Toronto at the time.
And then, um, and then he had asecond and a third and then a
(24:01):
fourth, and then I started doinga little bit more work with him.
And what was fascinating withhim when we tested him pretty
extensively, I'm like hishamstrings, his strength, his
mg, like are all.
Optimal.
And what was so fascinating isthat his glutes were grossly
underactive and he's um, has apretty extensive lordotic
(24:22):
stance.
He's got that anterior pelvictill.
So even in standing, hishamstrings 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, bitof dynamic effort for certainly
at the level of what she needsto do at a World Cup, you know,
(24:45):
performance is that one.
He's either already slightlyfatigued.
From a hamstring perspective cuzthey're working so hard just in
standing.
And secondly, his glutes are sounderperforming that, um, from a
posterior chain, if we'relooking at this ratio of like
hip flexion, quad anterior tibto glutes, hamstrings, gas jock,
(25:06):
and our soleus, um, we are at amassive imbalance here, like
massive.
And with those forces and those.
It's highly unlikely that anyonecan perform at that level
without having multiple strains.
So we have to walk all thisback.
Yeah.
So, so, yeah.
Mike (25:24):
I mean, it's, it's, it's a good way to think of it that
not, I think sometimes we, wemiss the boat because we're just
our, we, we have this tunnelvision and you think, I'm just
gonna, I'm just gonna work onthis over and over again.
But everybody's posturaladaptations are different.
Everybody's, you know, the waythey use their bodies different.
You have to think outside thebox.
And maybe, maybe, you know,again, with these re.
(25:45):
Issues.
Right?
I mean, this is probably one ofthe most recurrent injuries out
there, right?
And, and maybe, maybe we aremissing the boat.
Um, tell me a little bit moreabout the EMG now, because
that's the part that I was superexcited about is that they're
super strong, but EMGs off what?
Tell me about that
Holly (25:59):
I, and Josie knows this, I fully credit him with my,
like, complete likemetamorphosis of how I think of
this injury.
Like I, and that, that is why Ilove to treat, like, cause I,
cause if I'm in an academicoffice, I'm
Mike (26:12):
Yeah, you'd
Holly (26:13):
my hypotheses, you know,
Mike (26:14):
You'd mi you'd miss that for sure.
Holly (26:16):
have to drag me outta my clinic at 85 or something.
But, um, but, um, until I gettoo irrelevant.
But, um, uh, But, so after him,Wow.
We are, I always, I joke, I'mlike, half of orthopedics is
neurology, isn't it?
You know, we, and I think, andthe other interesting thing,
(26:38):
like what I started to do issimultaneously is testing.
Okay?
So we have this like magicthreshold of, um, okay, what's
normative?
Like quad hamstring ratio, uh,quad glue.
Um, what?
Well, but is that normal or isthat just what we.
Accept because in normals we'restill having high occurrences,
so should we accept that asnormal?
(26:59):
So there's that question.
And then the second issue is,um, what happens with, okay,
once they clear or we, we, wehave this sort of theoretical
acceptance of return totraining, uh, return to contact,
return to full competition,return to play.
Is there recidivism?
Keep testing.
(27:20):
Right?
So what we notice is that, andthis, I'm seeing this a lot on
the ACL side and definitely onthe hamstring side is like,
okay, we'll, we'll, we'll kindof get this cortical output that
we're expecting either on thestrength and or EMG side.
And then, um, and then there,there's this slide back, right?
There's this recidivism back toa baseline that these players
(27:42):
have gotten super comfortablewith and have mastered, right?
They're all.
and there's this fascinatingthing.
Keep yourself honest by, youknow, pull them back in if you
have the opportunity every fourto six weeks and do a retest.
Now the cool thing istechnology's gotten really
inexpensive.
Like, no, I don't have anyalliance to any EMG company.
(28:03):
I just happen to use an Mtrigger.
They're like$400.
Which is amazing for, like, youraverage clinical practice can
probably swing that in additionto a really good dynamometer.
So, you know, so we sh we, it'sincumbent upon us to like, make
sure we're testing both, um,because I have been.
um, pleasantly surprised andsometimes un unpleasantly
(28:24):
surprised looking at likestrengthen EMG DA data that oh,
they're, they're sort ofcorresponding and they're,
they're correlated and sometimesthey're not.
And so we, yeah.
So I think, um, I'm not makingany false hypotheses here and
making any false conclusionspredicated on what I think is
happening based on a performanceor their ability to load.
(28:46):
So I, I do think there's anincredible.
um, uh, there's some incredibleassets involved in continuing to
test from the strength side.
Obviously from the performanceand biomechanics movement side,
but then also from theneurological side, um, the EMG
side.
Um, and the cool thing is likethese are all very portable
(29:06):
units and you can do them duringdynamic movements and then the
treatment that the assessmentbecomes the treatment cuz it
serves as a biofeedback.
Mike (29:14):
Right,
Holly (29:15):
And that's where I think we get real motor planning.
Um, sh.
Mike (29:19):
so walk me through that, because I think a lot of people
get testing right now.
You think, I even think, youknow, they, they understand even
the positions to test ahamstring in, in, in various
positions.
But walk me through how, how,how do you use MG to test?
What, what do you do formovements?
How do you use it?
Holly (29:34):
Oh, sure thing.
Yeah.
And you can be, you're onlylimited by your own creativity,
quite frankly.
So I kind of make it sportsspecific.
So we'll do like the basicstandard test because oftentimes
I'll check a strength and an EMGat the same time.
So, um, m trigger, again, I haveno financial relationship with,
but they have a really craftytest built into their, their
app.
And it's a five second repeated.
(29:55):
NBC basically, and you're, and Ido that in, um, I have just this
like, setup onto one of myhighlight tables and they, you
can do it either in prone or inseated at 45 and or I might test
the player, like if it was aninsertional tendonopathy versus
a mid bely or like depending, Imight test them at different
angles.
(30:15):
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 beltzor, you know, It doesn't need to
be expensive.
Um, and then, um, what I willalso do is strength test in
those same positions.
So if we come up with anythingor we see a deficit or
imbalance, Between sides, um,uh, then we can train in those
(30:37):
specific areas.
We can get highly specific, butI would say don't get too highly
specific.
Cause you wanna make sure, youknow, you're, like I say in one
hand you wanna do things like, Ithink a really good example is
like this whole toss up of likewhat's the most effective is
centric.
And if you look at some of theEMG data on looking at a Nordic
versus a Russian versus.
(30:58):
any other type of, um, what'sinteresting when you have that
sort of concentric eccentriccomponent of a, of a, of a
Russian, um, uh, you get alittle bit more semi
involvement, right?
You'll see some semi semitinvolvement and gracilis.
Um, And then where unlike theNordic, they're getting a little
bit more bicep fems.
Um, do them both.
(31:19):
You know?
Why not?
And I, you know, and I love theutility of working varying
ranges.
The concentric, eccentric,eccentric alone.
Um, so then, and then, so fromthe MG perspective, it's like,
okay.
So then let's do some moresports specific stuff.
Let's look at them on atreadmill.
Let's put them at speed.
And, and I just watched the feedlive.
And then we can capture certainsegments at certain speeds and
(31:41):
then do a right and leftcomparison, whether we're
looking at biceps, fem, uh, youwanna compare the biceps to the
semis.
Um, you could do that contra,um, again, It's um, I think you
clinically think through it andyou think of, okay, where is
this um, uh, player or thisathlete's major deficit?
And then you kind of work fromthere.
(32:01):
But again, kind of, I think thecommon thread to this whole
discussion is like, think macro,not micro.
Like don't overly get specificbecause 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 interms of preparation for a
(32:22):
player to going back to, andlike I talked about it earlier,
but I have a very, um, likemethodical return to train, uh,
and then return to training withsome like friendly contact.
And that's usually a coach oranother athlete who has been
injured recently, and thenreturn to full contact in a
training and then return to fullplay in competition with some
(32:43):
minute, um, allotments obviouslyand some requirements.
Mike (32:48):
That's great.
So, so, so I think we, I thinkyou talked a lot there about why
recurrent hamstrings happen, andI think we can extrapolate a lot
of that to saying, okay, we needto improve our rehab programs,
you know, based on some of thesemacro things that we just talked
about.
Um, what, what, what aboutpreventing though, I, I mean,
let's, let's go back topreventing just for a hot second
here and say, yeah, what, what,what are we, what do you think
(33:09):
we're missing preventing?
Is it, is it still using thatsame thing?
Do.
Trained all of our players thisway, right?
To assure that we're having allthis stuff happen, or what do
you think is our lowest hangingfruit for preventing these
injuries in the first place?
Holly (33:23):
Yeah, that's a great question.
And I think if we got super, soif we're talking like a thousand
feet up, I'd say, okay, let'sjust talk the basics of having
people adhere or comply Likelet's just do something
Mike (33:35):
I guess so, right?
Holly (33:37):
and be relatively consistent.
Okay.
Mike (33:39):
a good point.
Holly (33:40):
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, havingthese conversations with coaches
like this happened in the NFLstudy.
Cause we have, and we areincluding a variable of the
eccentric hamstring into thisprogram that we're designing.
And one of the strength andconditioning coaches who is
absolutely amazing.
(34:00):
It's like, Holly, I'm gonna havea really hard time getting that
in.
Where do we insert it such thatthey're not going to be sore.
It won't impact any, likemidweek, like a Thursday night
game, a Sunday.
And um, is, is it best placedinto preseason?
But then the coaches will bedisappointed because then they
can't get onto their twoo daysbecause there's some soreness
(34:23):
quotient.
And I said, I know it is anabsolute conundrum, and my
answer is that hopefully you andI can inspire some young
clinicians out there to.
Almost combat the notion ofgetting to that level and not
having enough eccentric,capturing strength cuz it's been
introduced at the youth.
You know, these are, these areprinciples that we need to be,
(34:44):
um, these kids need to beengaged and knowing that this is
actually part of proper trainingand should be hopefully
introduced like, you know, theyouth in high school levels.
So there, there, there's that.
Mike (34:56):
That's awesome.
And, and I, I, you're right,maybe that is the future.
Right?
Um, we, we, we've seen so manypeople try their hardest and
players that aren't compliant inthe off-season with these
programs.
And then, you know, we expect'emto be there.
We have to unravel.
A little bit at the beginning inour pre-season and, and you
know, on-ramp, their sprintingon-ramp, their strength and, you
(35:17):
know, it just never goes wellonce you're behind the gun with
these things.
Cuz we, we have so manycompeting stresses.
Um, uh, wait, what, what aboutsprints?
You know, we talked a lot aboutstrength.
What about, what about, um, justdosage of like max velocity in,
in, in, in 10 full sprints.
Um, how much do you put thatinto your programs for prevent.
Holly (35:36):
Yeah.
Massively important.
Particularly your sport.
One, one little thing, if Iwanted to mention the one paper
we looked at, cause we did astudy with the Cape Cod League
in the North Woods League, andjust the establishing prevalence
of hamstring.
26% of those kids already had ahamstring.
And like this is ostensibly thefeeder, right?
For the minors.
And like, I'm like, oh boy.
(35:57):
And see that's where I thinkreally the heavy lifting has to
be done, no pun intended,
Mike (36:02):
Yeah.
Yeah.
Holly (36:03):
we need to get them early, right?
We can't have these young kidscoming in.
Um, they're all ostensiblyplaying high level D one, you
know, really competitivebaseball programs and it's.
Like, my God, if they're aquarter of them are already
afflicted and we're looking atage and recurrence as the
primary, um, risk factors we'rein a little bit of trouble.
But yeah, to your point on thesprint side, so like that would
(36:25):
be a little bit specific interms of like, for, for, for
soccer would be like, okay, whatare 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 ofyou are reading any of like the
(36:46):
arch, like looking at, um,hamstring architecture and the
classical morphology, I think wecan all agree that obviously
having, um, real, uh, the, thegranularity to which we're
understanding how morphology isreally important in hamstring
injury is, is.
Fascinating to me and how wetrain that.
Right.
So that's where the eccentricscan come in really, um, helpful
(37:08):
looking at ation angles andlooking at these dynamic
assessments with ultrasounds andhow that is important from a
performance side.
So we have to perform at lengthin order to not get injured at
length.
Mike (37:18):
Right, right.
And, and I, I think when you,when you start to think of it
from this fashion, you can seethat we have a lot of work to
do.
Holly (37:27):
Yeah.
Mike (37:28):
Um, and I think we're at the point now where you, people
like yourself have done so muchresearch to find a lot of these
things.
If we don't do the twocomponents, get the youth to do
'em before it's a problem, andthen to get people more
compliant in it.
We really are gonna have a hardtime assessing if all this hard
work you've put into it.
It worked, right?
(37:49):
It's, it's, it's unfair.
If nobody's, you know, ifcompliance is 16%, then you know
what, you know, it's, it's hardto say if we're doing, um, you
know, the right job.
So, um, you know, we appreciatepeople like yourself in all that
you do.
Um, this might have been themost educational, uh, podcast
episode I think I've had so far.
Um, which, which would justyour, your brilliance raining
(38:11):
down.
Holly, I feel like we solvedsome pro problems today.
I think we did.
I think we did.
So
Holly (38:17):
Oh, good.
Mike (38:19):
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 thatlike strength and conditioning
facilities are guilty of thistoo.
Not to go off on a tangent hereat the end, but like, man, we,
we got like super, super intopower.
Right.
Like it's, we, you know, thelast decade or so and Glu glu
(38:41):
glute and not hamstring,hamstring, hamstring a lot.
So you, you, you said the flipwhere, you know, we're focusing
too much on the hamstring andnot on the others.
I, I think if you look at a lotof the youth, they're squatting
and deadlifting a ton andthey're not doing a lot of
isolated hamstring.
Holly (38:54):
Absolutely, I could not agree more.
And I see that a lot,particularly like in my kind of
high level, like 14 to 18 yearold group.
And I could not agree more.
And this is where I plead, likewith the coaches, it's like, let
us help you like just take alittle dose of this.
We're only asking for a lot ofthis dynamic stuff.
We're lucky.
We're asking for about a 28minute commitment a week.
(39:15):
And if you kind of stratify thatthrough the calendar and if
that's gonna.
Some of your best playersavailable to you in the
post-season.
It is such a win-win, you know?
So, um, yeah.
And, uh, and on the strength andconditioning side, it's like,
yeah, sometimes we, we try toget a little too clever and
sometimes we don't need to bethat, that crafty or that that
creative or that unique, we cankind of stick with some of the
(39:35):
basics because they work andlike dedicated hamstring work
absolutely has to be a, a.
Primary component of everythingbecause a lot of the sports
will, um, you know, just byvirtue of competition and
playing and participating, yourquads are gonna stay pretty darn
strong.
And it's, it's the posteriorchain that we really have to
make sure we're, we're involvingas well.
Mike (39:57):
Right.
And who knows what we caninfluence with the youth as
they're growing and they'readopting their, their, their,
you know, their, their, theirgrowth spurts and all these
things, uh, with the musclearchitecture.
I, I, I think you're completelyright.
I think, I think that isprobably gonna be our next area
that we have, have to eemphasize the most.
So, um, uh, amazing stuff.
Holly, this was awesome.
(40:17):
Uh, before I let you go, I gottaend with our high five, five
quick questions that I'm, I'meager to hear your answers.
I think you're gonna have great.
Five quick questions, five quickanswers.
Learn a little bit about you andyour brain, how you think, but
first question, what are youcurrently working on for your
own professional development,not teaching us, but what are
you learning yourself?
Holly (40:38):
You know, I have to say I love reading, like I, I, my, my
Twitter feed is like, I, I useTwitter to.
Follow things that I wouldn'tnormally feed, like read things
outside the box.
Like I follow, um, oncology, Ifollow I read anything, I'm, I'm
a bit of a geek obviously.
I think you probably picked thatup in the last 45 minutes.
But, um, I'll, I read anythingand everything, reading about
(41:00):
long covid reading about um, uh,you know, novel treatments.
Cuz I think anything you learnto extrapolate, um, one might
help you help a patient likeinadvertently, 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 upand making things, um, you know,
(41:24):
sometimes difficult on myselfbecause I think that makes me
better at what I do overall.
Mike (41:29):
Yeah.
I love it.
That's a great one.
What's one thing that you'verecently changed your mind
about?
Holly (41:35):
Um, and this isn't super recent, but, uh, one of the
things, oh, uh, uh, well wetalked a little bit about like
looking at gluten and nottotally 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 (41:58):
I love the excitement.
I love this.
I love hip flexors too.
Holly (42:02):
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 issuesaway.
And now I have like completelyabandoned that thought and now I
am like, we are going tostrengthen these issues away.
So that has been a real slip andI love explaining that to
patients because that's been abit of dogma.
Like, I have tight hip flexorsand I was like, yeah, the reason
(42:23):
you do that because you sit in acorporate job for like, you
know, nine hours a day and we'regonna kind of work your way out
of it and this is what we'regonna.
Mike (42:30):
Yeah, that's a great one.
I think that's great and you'veseen success with that.
Holly (42:33):
Yes, yes.
Well, and the stretchingmatters.
I'm not, I, maybe I overstatedthat a bit, but I think like
oftentimes they're weak.
Use your dynamometers and figureit out.
Like, are they weak?
You
Mike (42:42):
that's a good, that's a, yeah.
Very well said.
I like that.
Uh, what's your favorite pieceof advice that you give
students?
Holly (42:48):
Oh, you know, just stay hungry.
I mean, you know, I've beendoing this for 23 years and
it's, if I've been doing it forone, I am.
I just like you.
I love what I do.
And if you're not happy in yourcurrent job situation, then find
a way.
Maybe it's just that particularsituation, like volunteer.
I, I can't tell you how manyphilanthropic hours I have done
throughout my career, and it hasled me to some of the most
(43:11):
rewarding.
Career and life experiences thatI 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 findrelationships and network and
conversations, but alsovolunteer cause some of the most
fruitful things you mightexperience, not only
professionally, but personally,uh, maybe of a genuine surprise
(43:34):
to you,
Mike (43:35):
I love it.
That was gold.
I like that.
That was a good one.
Uh, what's coming up next foryou?
I'm sure you get a bunch what'scoming
Holly (43:41):
Oh yeah.
Well, loving the N F L stuff.
Continuing.
Some work with M L D, which Ialso love.
This is a funny question orfunny quick story if you have a
second.
Um, when I first started gettinginvolved in MLB and we were on a
call with multiple teams and wewere in the height, this is many
years ago when there was likethis big rise in, uh, um,
Hamstring incidents and, um,one, I won't name any names, but
(44:03):
there was a team member oraffiliate member from, uh, one
of the clinical staff and an MLBteam.
And he's like, and all duerespect, like, you're a soccer
person.
Like, what do you know aboutbaseball?
And I'm like, I'll have, youknow, I was a mean.
Third base, little leagueplayer,
Mike (44:17):
There you go.
Holly (44:18):
I said, so I would say one of my things I say obviously
being a woman and not being ableto play, you know, high level
baseball.
I played softball, but, um, or,uh, uh, football.
But I, I would say, um, beopen-minded in terms of people's
experiences.
Like, um, some of the bestcoaches in the world weren't the
greatest players, and I thinkthat goes for like our
(44:38):
profession as well.
You don't necessarily have toplay the sport, but, but be well
versed.
I immerse myself and try, I knowevery position and I know, you
know, watching my nephews playthroughout the year.
Like I, I, I definitely am astudent of the game.
I'm a student of life, but I ama student of the game and I
turn, I,
Mike (44:57):
I'm picking up
Holly (44:57):
it's very important.
Mike (44:58):
I'm, I'm picking up on that.
I feel, I feel like you're oneof those people that got very
little work done during theWorld Cup, right?
Are you in, are you in you inthat boat?
Holly (45:07):
It's fascinating.
That was a fascinating World Cupfor a variety of reasons.
That might be our next podcast.
Mike
Mike (45:12):
Yeah, exactly right.
Awesome.
All right.
Well, how, how can people learnmore about you?
I know, I know you justmentioned Twitter.
Um, do you have, do you have,but like what's the best places
for people to learn more aboutyou and your research and all
the stuff
Holly (45:23):
I'm, I'm more active on Twitter than Instagram.
Maybe that's sort of uncool ofme.
But, um, that's the facts, Andthen, um, I have a website.
Um, it's just my small clinicalpractice, but I post things
about like our, our newest.
Uh, sort of research anythingthat's getting published.
And then, um, and I, and Iretweet things that I think are
really important to ourprofession.
(45:44):
Um, whether it's on like the A PT A or sports section, political
side, or, you know, ways to stayinvolved.
Um, opportunities that I thinkmight be of interest to my
former self, you know, 20 yearsago.
Um, but I just think.
If I can just give a little bitof advice to young clinicians.
It's just read, read, read, andread from a variety of sources
in terms of, um, and I thinkTwitter and, and social media
(46:06):
has made that so much easier nowand palatable because it's just
like, it's, you can design yourown news, source your newsfeed,
which is phenomenal.
Mike (46:15):
Yeah, it's a great opportunity and it's a great
opportunity to get to interactwith people like yourself,
right?
I mean, like, think about that.
That's crazy.
I can't, I'm sure you, yourespond to people.
I mean, that, that's amazingthat you can do that nowadays.
So, um, you know, re reallyappreciate everything you do for
the profession, um, and takingsome time out to come here and,
um, probably give the mostinformation per second on, on
(46:38):
the podcast history if we.
If we look at a ratio ofbrilliance per second.
But thank you so much, Holly.
We love it.
Um, I, I feel like we, we gottado an ACL one in the future,
but, but thanks so much and uh,and I hope to see you soon.
Thank you again.
Holly (46:51):
my pleasure.
Thank you for the invitation.
Really a blast.
Thank you.
On this episode of the sportsphysical therapy podcast, I'm
joined by Holly silvers.
Holly's a PT PhD in SantaMonica, California.
She's a member of the U S soccermedical team and chair of the
MLS soccer research committee.
We talk about her work onhamstring strains, why they're
so common and often recurrent,and some of the things we may be
missing when trying to preventin rehab these injuries.
Mike (00:35):
Hey Holly, how's everything going?
Welcome to the podcast.
Holly (00:38):
Thank you.
Pleasure to be here.
Thanks for the.
Mike (00:41):
Oh, I know, my pleasure.
Um, and I, you know, I've beensaying this a lot on the podcast
lately, but, um, it's superselfish just because I want to
talk to you, right.
And I wanna learn from you.
So, um, I, I love having guestson 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 yourbrilliance, I think are just,
(01:02):
are just so cool and you have alot of neat things to share with
people.
So I'm really excited for thisepisode.
Holly (01:07):
Well, thank you.
Very flattering.
Likewise, feelings.
Mutual.
Mike (01:11):
That, that, that's awesome.
I, I think a to a ton of peoplesee 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 coolopportunities, things that you
got, um, uh, you get to workwith.
I think a lot of people arejealous.
Right.
And, and they'd love to do that.
(01:31):
And a lot of early careerprofessionals want to, to, to
kind of hear a little bit aboutyour career arc.
So tell me about that.
You spend time, you know,obviously you, you, you must
love soccer, um, but now you'reworking football, you're working
in baseball, like all thesethings like, tell, tell us about
your journey.
Holly (01:47):
Okay, great.
Yeah, a little unorthodox too.
I mean, and some of it'sserendipitous, maybe a splash of
nepotism too, which I'll explainSo I,
Mike (01:55):
that
Holly (01:56):
I grew up I grew up in, uh, Kearney, New Jersey, which,
um, We have been dubbed SuckerTown, 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, wewere all first generation kids.
My dad's from Ireland, mymother's from London.
(02:18):
Um, we had the Portuguese andSpanish section.
We had the Italian section, youhad the Polish section, and we
all played soccer.
Um, my U seven to U 12 coachplayed for Celtic
Mike (02:30):
Oh my God,
Holly (02:31):
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 coachplayed professionally at U
seven.
Um, but, but, and then, um,interestingly, like we just, you
know, when US Soccer was gettingback on the map internationally
and like the late eighties,like, so in 1990, we had not
(02:53):
qualified for a World Cup in 52years.
So, Uh, current brother-in-lawwas my sister's boyfriend at the
time, was the goalkeeper forthat team, uh, leading up.
And he was a, like a, it wasbasically a glorified NCAA
standout team, which we the, weassembled and they qualified for
(03:13):
Italy in 1990.
And so, Um, this is kind ofspeaking to the culture of the
town.
When I told my high schoolprincipal at the time, like, I'm
going to the World Cup, I needto, to uh, take exams early.
He's like, of course you are.
And there were like several ofus doing that.
My very good friend Carolyn Mirae there were many of us doing it
cuz they, that was like revered.
So my brother-in-law is TonyMila.
(03:35):
It's full disclosure, and partof the reason I got into the a c
L world is because, um, during aUS Mexico match, we were kind
of, they were playing in Aztecaand, uh, winning and, um, he
just, he had a collision earlieron in the game, probably
sustained a concussion, nojudgment, was back in the game
(03:55):
and, uh, took a punt, a goalkick, and, um, collapsed to the
ground.
We're all quizzically lookingand I was finishing graduate
school at the time, I was in mylast year of PT school and I was
like, oh my God.
And then, you know, obviouslykind of surmising what happened.
And then he had surgery with,uh, Dr.
(04:17):
Burt Mandelbaum, who was a teamphysician at the time.
And, um, I wound up going out toone of his follow up visits with
him and meeting Bert and, uh,Bert said, you know, well, I was
literally graduating a monthlater.
He's like, what are youinterested in doing?
I said, We need to prevent ACLinjuries.
I said it sort of flippantly.
He's like, well come over onTuesday morning.
(04:38):
We meet at 6 45 every Tuesdayand let's just kind of discuss
this.
So I met with them for a coupleof months and then we got an
opportunity to apply for a grantto the LA 84 Foundation, which
was founded after the 84Olympics.
Cause there was a lot of moneyleft over in a, in a good way.
And we applied for this ACLprevention.
(04:58):
and here I am 23 years later.
Mike (05:01):
I know, right?
It just And what, and, and it,it kept growing.
I mean, you've done so much inthe 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 thatyou love soccer, right?
And you're, you're, you're,you're passionate about it, and
you got to pursue a job thatgets to work in that realm.
(05:23):
And I mean, that's the dream,right?
Like you're, you're, you'repassionate about it Every day,
you, you combine medicine in thesport that you love, and, uh,
you know, it, it's a home run.
So, congrats.
That's,
Holly (05:33):
Thank you.
Yeah, and I, I, you know,similar to you, I feel blessed.
There are a lot of people thatgo to work every day and sort of
do it because they need to.
I like fully love what I do andI, 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?
(05:54):
What could be better, likeloving 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 abrother-in-law that made a
couple of introductions for me.
But I always say the joke andhe's like, well, I'm glad
tearing my a c l is major careerout of lemons.
But, but I say like, it got mein the door.
It doesn't keep you in the door,but you, I obviously, um, Have
(06:15):
done some hard work and, andit's the work I enjoy doing.
So my, my level of dedication isa hundred percent.
Um, so I, I, but I wouldn'tdiscourage anyone from trying to
get in if you don't have afamily relationship.
But, um, um, like to, to your,to your earlier point, uh, How,
because I get a lot of emailslike this or like, Hey, how, how
(06:35):
do I get in?
Like make a way in?
And now with, with whether it'ssoccer or baseball or, or, or
football, I always say start outthe community level.
Cause I did that too.
You know, I worked with like U12 teams and helped them for
dynamic warmups.
And I, I volunteered, I, myfirst seven years at mls, I was
a volunteer in it.
So I, I, I, I, Fully giving ofmy time because it was something
(06:59):
I loved.
It was a passion project, so Ididn't feel like work to me.
But I know for some people thatmight be difficult.
But, um, I would just say evenif the grassroots community
level, a high school, likevolunteering, helping, because
most.
organizations areunder-resourced.
Um, I'm sure you can speak tothat as well.
So I think if you are willing togive your time, your energy,
(07:19):
your expertise, um, without alot of tentacles attached to
that, I think a lot of peoplewill be very, very receptive to
that.
Mike (07:27):
Yeah, and, and I love when people combine their passions,
so the sport they played andthen this newfound knowledge
that they got with with medicineor performance or that type of
thing.
Um, I, I almost feel like it's aduty of ours to give it back to
the grassroots, to the kids andthe parents and the coaches, and
to teach them the things thatwe've learned.
So, um, I couldn't agree more,and I'm gonna give you a little
(07:48):
more credit.
Those, um, they, they didn'thelp you get through that door.
They opened the door for you,but you're the one that took
those steps through it, youknow, and, and you get to think
about that.
Yes, it's, it's nice to havedoors open, but you have to have
that, that desire to take thosesteps through the door too.
And not everybody does.
Holly (08:06):
Yeah.
Thank you.
Yeah, it, yeah, I agree.
Um, it's, it's been a journey oftimes 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 obstaclesalways, I, I'm reflective on
those and oftentimes thoseobstacles have, uh, built more
character and, and have pushedme even harder than maybe I knew
(08:28):
I had that sixth or seventh gearavailable to me.
So
Mike (08:31):
That's a great way of, of thinking of it.
I love that.
Well, so te, tell me a littlebit about a day in the life of
Holly, right?
Because I, I feel like you wearmultiple hats
Holly (08:39):
Mm-hmm.
Mike (08:40):
obviously there's soccer, there's you're consulting with
football and baseball.
Tell me a little bit about theday in the life of, of, of you.
Holly (08:45):
Sure.
Okay.
So it varies a bit, but I havea, I have a full-time clinical
practice.
Like I see, like I do at least30 hours of clinical work a
week.
And I absolutely love it.
I love it in that, um, myhusband maybe doesn't love it
all the time cause I'm a littlebit overtaxed, but, uh, uh, but
I, I.
Honest to God, even when I wasfinishing my PhD at University
(09:06):
of Delaware and Lynn SnyderMackler, who I adore was my PhD
advisor and she said, um, youknow, what are you doing this
for?
I said, to be better at, to be abetter clinician.
And I really didn't have any,um, grandiose.
Concepts of like, going intoacademia, academia that didn't
really appeal to me.
I like to teach, but more onthe, um, sort of uh, lecture
(09:30):
circuit in terms of like, oh,let's do a course here and
there.
I don't think I would love to bea full-time academic.
Um, but what also has beenwonderful about getting a PhD
has that opened a few more doorsbecause as we know in our world,
Tend to matter.
And I'll give you one quicklittle example of that.
I was probably, I was workingwith Dr.
Mandelbaum for about 10 yearsand I was presenting at A O S S
(09:54):
M, um, and this is a while back,and one of the orthopedic
orthopedic surgeons said to melike, oh, you only have a
master's.
It's like, oh well, I'm stillkind 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.
(10:15):
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 conversationswith Lynn and like, I was like,
you know what, I'm gonna go backand do this.
So I, I was practicing for 17years before I went back and did
a PhD.
Mike (10:30):
Oh, I didn't realize that.
Holly (10:32):
yeah.
And then had a baby in, in theinterim too, which is, um, you
know, I don't recommend that,but But, uh, that, but, but, uh,
but But having said that, I, Ireally, I loved, like I came in
armed with so many ideas andlike at that point I had been
researching for a while and Ijust, I felt like, uh, in a lot
(10:52):
of ways, um, I almost couldadvise myself in the sense like
I had so many ideas andclinically I was the way I
thought about my PhD.
I am absolutely corroboratingeverything I've thought of for
the last 17.
It was like a, I was, yeah.
And it was, I was so grateful togo back, cuz I think, I don't
know if you had this experience,but when I was doing, when I was
(11:12):
in PT school, I was just likelooking forward to the end so I
could get out there and do ourthing.
And this was so different cuz Iwas relishing, I'm like, oh.
Education is wasted on the youthWe, we should like, uh, here I
am.
I was like almost approachingFlorida and I'm like, this is
amazing.
Like, I could not be happierdoing this right now.
Cause this is just the, thewonderful way of like almost
(11:35):
going back and doingsabbaticals.
I think it's like a great ideafor everybody.
Obviously it doesn't fit intoeveryone's life path, but, um,
that was.
That was really great for me.
But anyway, so like I do theclinical steps, so each week's a
little bit different based onwhat's going on.
Like I had a research CO allearlier today I'm the research
chair for Major League Soccer,which I love.
(11:55):
And so depending on the week,like right now we're in a little
bit of a low, we had our annualmeeting and then we haven't
started preseason physicals yet,but we're also ramping up.
I took an advisory role with theNFL last year or a year and a
half ago, basically trying tocreate ACL mitigation programs
with the nfl and that's.
So fun because that's obviouslya sport I did not play, but I
(12:16):
respect and enjoy.
And I al always think like froma biomechanical perspective,
like if, you know biomechanics,you can, you can analyze
anything, right?
So, um, but that's been reallyfun and, and really fun.
Um, Getting to know a whole newgroup of clinicians, but also,
um, understanding theirobstacles, right?
Because we all have our unique,uh, boundaries in place in terms
(12:40):
of whether it's the league orlegal or the players
association, and how that is sodifferent.
So that's been a fascinatinglike learning experience for me
too, um, is how you navigate,um, through different cultures
and subsets of cultures withindifferent sports within our
country.
And I'm sure you could speak tothat with baseball as well.
Mike (12:59):
Absolutely.
Yeah.
I mean, it's, it's diverse inthat manner.
Um, it's neat, but I, I likethat 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, Ilike how you're keep.
Been that trend.
So, um, I, I, I know we can talka c l and I, I, I'd be excited
to talk a c l but I'm beingsuper selfish here and I wanna
(13:23):
continue some of the pastconversations that you and I
have had in person at dinnerabout hamstrings, because I love
hamstrings and that's probablyafter a c l that's probably your
second thing, right?
Holly (13:34):
No, I love hamstrings too.
I have an equal love forhamstrings.
Mike (13:38):
Oh, that's, that's, that's, that's so nice for
hamstring.
Um, I, I, I, I, I, I know youspend a lot of time in this and
this, this is kind of funny.
Holly and I were kind oflaughing before we hit record on
this podcast, but this might bethe shortest amount of questions
that have prepared for apodcast, but they're big
questions, right?
So I'm gonna hit you with someof these big, juicy ones.
So, first one to, to me is like,I know you're spending a lot of
(14:00):
time on hamstring trains.
Holly (14:01):
Yeah.
Mike (14:02):
Why, why are hamstring strains so common?
And again, what an open-endedquestion.
I'm just gonna say that, butlike, but what, why on earth?
Because they're, I think notonly 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 (14:16):
yeah.
Great question.
And then honestly, if.
If you follow, I would recommendfollowing young tran's work cuz
he's one of the leaders from,from a, from an Amer uh, from
soccer, uh, you know, Europeanfootball perspective.
He does all the uafa analysis ofall the Champions League data.
And the numbers not only are,um, still high, they're going
(14:37):
up, which is, you know, Kind ofeats at my core.
Um, um, and I think part of it,part of my, uh, thought process
here is that there's a categoryor subset of these hamstrings
that are being, um, perhapswrongly identified and
undertreated, right?
Not looking at this.
(14:57):
In a macro way in treating it ina micro way.
And we can kind of talk aboutthat in a second.
Cause I've certainly seenathletes like that have put in
that category.
I mean, and when you look atthese regression analyses, you
know, like, well the riskfactors are like, okay, prior
injury and age, well that's sortof redundant Cause if they're
getting more exposure, wellsure.
Um, so that doesn't tell us verymuch.
(15:18):
Um, you know, you can look atthe mechanisms like the
mechanism.
I find so fascinating cuz it's,it's probably one of the
cleanest in terms of thediversity and mechanisms as
opposed to American football andsoccer because it's a lot of
it's bass riding, right?
Going from home plate to firstbase and either on the reach or
step outta the box.
And I think that's been, um,really.
(15:38):
Coolly illuminated in the lastdecade or so by a bunch of
authors.
But for from soccer, it's ournumber one injury in Major
League soccer.
It's our biggest time lossinjury by far.
And it continues to lead thatcharge since I've been, uh,
involved with mls and that'sover, you know, 18 years now,
which is frustrating.
So we've tackled it from, I canspeak to Major League Soccer.
(16:01):
The way we've tackled this islike, Building our stakeholders,
so like incorporating all of ourteams and saying, Hey, we
recognize it's a problem.
um, do you recognize it as aproblem?
That's question one.
Um, and secondly like, what areyou 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 helpyou and like, what can we do?
(16:22):
And as you know, working inprofessional sports, so many
people, so many teams and um,institutions are very reluctant
to get involved in any type ofcohort or R c T study.
It's just.
you know, and for a lot of verygood reasons.
Um, so a lot of the data we'vetried to pull, like is from the
NCAA and try to looselyextrapolate that to the pros,
(16:43):
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'rereally successful into December,
and then you have an incomingrookie.
Cause in mls it's interesting, alot of our rookies are immensely
(17:03):
vulnerable to injury hamstringin particular.
Um, it's because we basicallytripled 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 ofthe, the late World Cup, but
the, the season goes throughDecember.
I mean, it's wildly long.
Um, not unlike baseball.
So, um, I say I think a lot ofit is like, We, we are like, um,
(17:28):
Brian Hirschfeld in Wisconsin'sdoing some amazing work.
Um, looking at, I don't knowthat we even know the fact, the
variables that we need to berecognizing.
Um, so there's a lot of work,like on the regression side that
needs to be done and is beingdone.
Um, but I think some of theathletes that I've seen that
have had like recurrent, like ontheir fifth and sixth and
seventh episodes, One of thethings that I had noticed is
(17:52):
that, wow, maybe the hamstringsnot the deficit.
It might be the glute like, andthat was an interesting
phenomenon that I found with acouple of very high level
notable, um, um, US nationalteam members and or MLS players.
Um, and the same goes for gasjock too.
We were kind of seeing thatphenomenon like, are we, are we.
And, and the other fascinatingthing is when we were testing
(18:15):
some of these players, is thatthe strength parameters were
looking good, optimal normative,uh, some of their movement
patterns and uh, performancevariables were looking
normative.
But then when I started doingEMG analyses on these people, we
were seeing some deficits andwas this some sort of cortical.
Element at play here and like,were we not seeing that until
(18:36):
there was a little bit of afatigue element or, and I don't
necessarily mean physiologicalfatigue, but could be some upper
cortical fatigue there.
So, It is super complex.
I think it's more complicatedthan acl, honestly.
in a lot of ways.
Yeah, because um, um, and thenthe other element is like, okay,
(18:56):
there are some things in place.
You look at the efficacy of theNordics and some of these
eccentric capturing type.
Exercises, whether using Nordboard and uh, Russian, um, the
snake, whatever variants youwanna use.
But then we look at this game ofattrition where, what is the
adherence in compliance?
And that's what the extra shown,like these champions, league
level teams, you're looking at a12 to 16% adherence rate.
(19:20):
So, yeah, very low.
You know?
And those were, those were,yeah, very surprising.
Very surprising.
Mike (19:28):
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 ifthey're not compliant?
Holly (19:38):
it's complicated.
But I would say from thechampions lead level data like
that was um, almost a little bitsurprising on how low that is.
And that was even partialadherence.
So we have a paper coming out,um, actually in MLB cuz we did
a, we did a really niceintervention study with an
entire organization, which waskind of a unique opportunity
cause we don't typically havethose.
(19:58):
And we were able to inter use anintervention with a lot of
eccentric.
It was multifactorial.
And I think when we're designingproject projects for pros, we're
doing the same thing with theNFL right now.
So instead of something like wewould design typically for the
youth, um, and this is some ofthe other programs I've been
involved with, whether it waslike the PEPPER L 11 plus, which
was interestingly effective forhamstring mitigation as well.
(20:20):
Um, those are kind of.
Uh, dynamic warmups design cuzit's like packaged right?
We only have access to some ofthese kids three times a week.
So dynamic warmup, you kind ofprepare them for movement and
you know, hopefully we seeinjury mitigation as a result.
At the pros it's very differentcuz we have to kind of seed this
in and um, I think oftentimesthat's harder from an adherence
(20:43):
compliance perspective.
Not packaged in such a tidy way.
So, and then you have to kind ofreally, um, work collaboratively
with strength and conditioningand on, you know, the fitness
performance side to make sure,well, this is something they
accept as well.
There's, so there's morestakeholders at play.
Sometimes youth sports iseasier.
in some ways, you know, and tonot as sort of bureaucratic if
(21:06):
you'll, um, with full respect tostrength and conditioning and
performance.
I don't say that
Mike (21:11):
Yeah.
And, and now, now imagine thebaseball season too, because,
and you know, the, our, our bigthing is that we play every day,
right?
We, we actually compete everyday.
Holly (21:22):
yeah.
When do you do it?
Yeah.
Mike (21:23):
Yeah, I mean, you, you have 20 games in a row, like 20
days in a row with some daygames and travel, like mixed in
on there.
Um, it, it makes it even harderin, in, in our games.
So, um, I, I definitely see, Idefinitely see a bit of the
hurdles right in not a lot ofteams wanna travel with the nor
board, so Yeah, of course youcan, you can do Nordics in other
(21:44):
ways, right?
But it's, it's, it's just a,it's a different vibe.
Um, well, I'm super excited thatyou talked about the EMG because
you, I, you probably remember,but that's the part of our
conversation we had over thesummer or last year that I was
super excited about.
Cause that's interesting.
And, and I like how you broughtup the glutes.
I like you brought up the calfs.
So you were saying essentiallythat deficits in the in in the
(22:05):
glutes, deficits in the calvesmight be part of what's going on
with the hinging.
That's why we're.
So much, uh, just, just likemyopically on the hamstring.
Maybe we're, we're missing thoseother things that are, that are
changing the force, but thenalso the emg.
I, I think we gotta elaborate onthat, Holly.
I mean, that's, I, to me, to methat's some good stuff.
(22:25):
Tell me a little bit about,let's start with the, the glute
and the calf.
What, what specifically did youfind that made you start to say
like, oh gosh, we missed.
Holly (22:35):
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 thinkingabout it more on the biomechanic
side because we think wequantify, um, moments and like a
total support moment, right?
So when we're lookingspecifically see, like, need
alga, well it's like, wellwhat's, what's the ankle doing?
What's the hip doing and whatare the percentages of what
(22:56):
they're doing?
Right?
And I'm like, well, why aren'twe doing this for muscle?
Right.
That just kinda seems likekinda.
Like, okay, so, so I had onenational team member and I had
just, I have, uh, approval todiscuss his case.
Um, specifically it's Jodi AlCador and Josie Wa um, is a
phenomenal still playing.
I think he's in his 18th seasonin New England at the Revs.
(23:19):
And, um, he, um, you know, someof you may know if you watch the
Brazil World Cup within, youknow, the first eight minutes
against Ghana making this, he'sincredibly explosive, incredibly
fast.
He's making.
Incredible rundown the leftlength and kind of goes into,
you know, to make a right.
Um, he's being defended, ofcourse, closely by g Ghanaian
(23:41):
player and uh, um, and justpulls up and just grabs his left
hamstring.
I'm like, oh no, here we go.
Right?
So I hadn't seen Josie prior tothat, but then after Brazil, I
did a teeny bit of work with himand then, I think he was in
Toronto at the time.
And then, um, and then he had asecond and a third and then a
(24:01):
fourth, and then I started doinga little bit more work with him.
And what was fascinating withhim when we tested him pretty
extensively, I'm like hishamstrings, his strength, his
mg, like are all.
Optimal.
And what was so fascinating isthat his glutes were grossly
underactive and he's um, has apretty extensive lordotic
(24:22):
stance.
He's got that anterior pelvictill.
So even in standing, hishamstrings 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, bitof dynamic effort for certainly
at the level of what she needsto do at a World Cup, you know,
(24:45):
performance is that one.
He's either already slightlyfatigued.
From a hamstring perspective cuzthey're working so hard just in
standing.
And secondly, his glutes are sounderperforming that, um, from a
posterior chain, if we'relooking at this ratio of like
hip flexion, quad anterior tibto glutes, hamstrings, gas jock,
(25:06):
and our soleus, um, we are at amassive imbalance here, like
massive.
And with those forces and those.
It's highly unlikely that anyonecan perform at that level
without having multiple strains.
So we have to walk all thisback.
Yeah.
So, so, yeah.
Mike (25:24):
I mean, it's, it's, it's a good way to think of it that
not, I think sometimes we, wemiss the boat because we're just
our, we, we have this tunnelvision and you think, I'm just
gonna, I'm just gonna work onthis over and over again.
But everybody's posturaladaptations are different.
Everybody's, you know, the waythey use their bodies different.
You have to think outside thebox.
And maybe, maybe, you know,again, with these re.
(25:45):
Issues.
Right?
I mean, this is probably one ofthe most recurrent injuries out
there, right?
And, and maybe, maybe we aremissing the boat.
Um, tell me a little bit moreabout the EMG now, because
that's the part that I was superexcited about is that they're
super strong, but EMGs off what?
Tell me about that
Holly (25:59):
I, and Josie knows this, I fully credit him with my,
like, complete likemetamorphosis of how I think of
this injury.
Like I, and that, that is why Ilove to treat, like, cause I,
cause if I'm in an academicoffice, I'm
Mike (26:12):
Yeah, you'd
Holly (26:13):
my hypotheses, you know,
Mike (26:14):
You'd mi you'd miss that for sure.
Holly (26:16):
have to drag me outta my clinic at 85 or something.
But, um, but, um, until I gettoo irrelevant.
But, um, uh, But, so after him,Wow.
We are, I always, I joke, I'mlike, half of orthopedics is
neurology, isn't it?
You know, we, and I think, andthe other interesting thing,
(26:38):
like what I started to do issimultaneously is testing.
Okay?
So we have this like magicthreshold of, um, okay, what's
normative?
Like quad hamstring ratio, uh,quad glue.
Um, what?
Well, but is that normal or isthat just what we.
Accept because in normals we'restill having high occurrences,
so should we accept that asnormal?
(26:59):
So there's that question.
And then the second issue is,um, what happens with, okay,
once they clear or we, we, wehave this sort of theoretical
acceptance of return totraining, uh, return to contact,
return to full competition,return to play.
Is there recidivism?
Keep testing.
(27:20):
Right?
So what we notice is that, andthis, I'm seeing this a lot on
the ACL side and definitely onthe hamstring side is like,
okay, we'll, we'll, we'll kindof get this cortical output that
we're expecting either on thestrength and or EMG side.
And then, um, and then there,there's this slide back, right?
There's this recidivism back toa baseline that these players
(27:42):
have gotten super comfortablewith and have mastered, right?
They're all.
and there's this fascinatingthing.
Keep yourself honest by, youknow, pull them back in if you
have the opportunity every fourto six weeks and do a retest.
Now the cool thing istechnology's gotten really
inexpensive.
Like, no, I don't have anyalliance to any EMG company.
(28:03):
I just happen to use an Mtrigger.
They're like$400.
Which is amazing for, like, youraverage clinical practice can
probably swing that in additionto a really good dynamometer.
So, you know, so we sh we, it'sincumbent upon us to like, make
sure we're testing both, um,because I have been.
um, pleasantly surprised andsometimes un unpleasantly
(28:24):
surprised looking at likestrengthen EMG DA data that oh,
they're, they're sort ofcorresponding and they're,
they're correlated and sometimesthey're not.
And so we, yeah.
So I think, um, I'm not makingany false hypotheses here and
making any false conclusionspredicated on what I think is
happening based on a performanceor their ability to load.
(28:46):
So I, I do think there's anincredible.
um, uh, there's some incredibleassets involved in continuing to
test from the strength side.
Obviously from the performanceand biomechanics movement side,
but then also from theneurological side, um, the EMG
side.
Um, and the cool thing is likethese are all very portable
(29:06):
units and you can do them duringdynamic movements and then the
treatment that the assessmentbecomes the treatment cuz it
serves as a biofeedback.
Mike (29:14):
Right,
Holly (29:15):
And that's where I think we get real motor planning.
Um, sh.
Mike (29:19):
so walk me through that, because I think a lot of people
get testing right now.
You think, I even think, youknow, they, they understand even
the positions to test ahamstring in, in, in various
positions.
But walk me through how, how,how do you use MG to test?
What, what do you do formovements?
How do you use it?
Holly (29:34):
Oh, sure thing.
Yeah.
And you can be, you're onlylimited by your own creativity,
quite frankly.
So I kind of make it sportsspecific.
So we'll do like the basicstandard test because oftentimes
I'll check a strength and an EMGat the same time.
So, um, m trigger, again, I haveno financial relationship with,
but they have a really craftytest built into their, their
app.
And it's a five second repeated.
(29:55):
NBC basically, and you're, and Ido that in, um, I have just this
like, setup onto one of myhighlight tables and they, you
can do it either in prone or inseated at 45 and or I might test
the player, like if it was aninsertional tendonopathy versus
a mid bely or like depending, Imight test them at different
angles.
(30:15):
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 beltzor, you know, It doesn't need to
be expensive.
Um, and then, um, what I willalso do is strength test in
those same positions.
So if we come up with anythingor we see a deficit or
imbalance, Between sides, um,uh, then we can train in those
(30:37):
specific areas.
We can get highly specific, butI would say don't get too highly
specific.
Cause you wanna make sure, youknow, you're, like I say in one
hand you wanna do things like, Ithink a really good example is
like this whole toss up of likewhat's the most effective is
centric.
And if you look at some of theEMG data on looking at a Nordic
versus a Russian versus.
(30:58):
any other type of, um, what'sinteresting when you have that
sort of concentric eccentriccomponent of a, of a, of a
Russian, um, uh, you get alittle bit more semi
involvement, right?
You'll see some semi semitinvolvement and gracilis.
Um, And then where unlike theNordic, they're getting a little
bit more bicep fems.
Um, do them both.
(31:19):
You know?
Why not?
And I, you know, and I love theutility of working varying
ranges.
The concentric, eccentric,eccentric alone.
Um, so then, and then, so fromthe MG perspective, it's like,
okay.
So then let's do some moresports specific stuff.
Let's look at them on atreadmill.
Let's put them at speed.
And, and I just watched the feedlive.
And then we can capture certainsegments at certain speeds and
(31:41):
then do a right and leftcomparison, whether we're
looking at biceps, fem, uh, youwanna compare the biceps to the
semis.
Um, you could do that contra,um, again, It's um, I think you
clinically think through it andyou think of, okay, where is
this um, uh, player or thisathlete's major deficit?
And then you kind of work fromthere.
(32:01):
But again, kind of, I think thecommon thread to this whole
discussion is like, think macro,not micro.
Like don't overly get specificbecause 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 interms of preparation for a
(32:22):
player to going back to, andlike I talked about it earlier,
but I have a very, um, likemethodical return to train, uh,
and then return to training withsome like friendly contact.
And that's usually a coach oranother athlete who has been
injured recently, and thenreturn to full contact in a
training and then return to fullplay in competition with some
(32:43):
minute, um, allotments obviouslyand some requirements.
Mike (32:48):
That's great.
So, so, so I think we, I thinkyou talked a lot there about why
recurrent hamstrings happen, andI think we can extrapolate a lot
of that to saying, okay, we needto improve our rehab programs,
you know, based on some of thesemacro things that we just talked
about.
Um, what, what, what aboutpreventing though, I, I mean,
let's, let's go back topreventing just for a hot second
here and say, yeah, what, what,what are we, what do you think
(33:09):
we're missing preventing?
Is it, is it still using thatsame thing?
Do.
Trained all of our players thisway, right?
To assure that we're having allthis stuff happen, or what do
you think is our lowest hangingfruit for preventing these
injuries in the first place?
Holly (33:23):
Yeah, that's a great question.
And I think if we got super, soif we're talking like a thousand
feet up, I'd say, okay, let'sjust talk the basics of having
people adhere or comply Likelet's just do something
Mike (33:35):
I guess so, right?
Holly (33:37):
and be relatively consistent.
Okay.
Mike (33:39):
a good point.
Holly (33:40):
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, havingthese conversations with coaches
like this happened in the NFLstudy.
Cause we have, and we areincluding a variable of the
eccentric hamstring into thisprogram that we're designing.
And one of the strength andconditioning coaches who is
absolutely amazing.
(34:00):
It's like, Holly, I'm gonna havea really hard time getting that
in.
Where do we insert it such thatthey're not going to be sore.
It won't impact any, likemidweek, like a Thursday night
game, a Sunday.
And um, is, is it best placedinto preseason?
But then the coaches will bedisappointed because then they
can't get onto their twoo daysbecause there's some soreness
(34:23):
quotient.
And I said, I know it is anabsolute conundrum, and my
answer is that hopefully you andI can inspire some young
clinicians out there to.
Almost combat the notion ofgetting to that level and not
having enough eccentric,capturing strength cuz it's been
introduced at the youth.
You know, these are, these areprinciples that we need to be,
(34:44):
um, these kids need to beengaged and knowing that this is
actually part of proper trainingand should be hopefully
introduced like, you know, theyouth in high school levels.
So there, there, there's that.
Mike (34:56):
That's awesome.
And, and I, I, you're right,maybe that is the future.
Right?
Um, we, we, we've seen so manypeople try their hardest and
players that aren't compliant inthe off-season with these
programs.
And then, you know, we expect'emto be there.
We have to unravel.
A little bit at the beginning inour pre-season and, and you
know, on-ramp, their sprintingon-ramp, their strength and, you
(35:17):
know, it just never goes wellonce you're behind the gun with
these things.
Cuz we, we have so manycompeting stresses.
Um, uh, wait, what, what aboutsprints?
You know, we talked a lot aboutstrength.
What about, what about, um, justdosage of like max velocity in,
in, in, in 10 full sprints.
Um, how much do you put thatinto your programs for prevent.
Holly (35:36):
Yeah.
Massively important.
Particularly your sport.
One, one little thing, if Iwanted to mention the one paper
we looked at, cause we did astudy with the Cape Cod League
in the North Woods League, andjust the establishing prevalence
of hamstring.
26% of those kids already had ahamstring.
And like this is ostensibly thefeeder, right?
For the minors.
And like, I'm like, oh boy.
(35:57):
And see that's where I thinkreally the heavy lifting has to
be done, no pun intended,
Mike (36:02):
Yeah.
Yeah.
Holly (36:03):
we need to get them early, right?
We can't have these young kidscoming in.
Um, they're all ostensiblyplaying high level D one, you
know, really competitivebaseball programs and it's.
Like, my God, if they're aquarter of them are already
afflicted and we're looking atage and recurrence as the
primary, um, risk factors we'rein a little bit of trouble.
But yeah, to your point on thesprint side, so like that would
(36:25):
be a little bit specific interms of like, for, for, for
soccer would be like, okay, whatare 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 ofyou are reading any of like the
(36:46):
arch, like looking at, um,hamstring architecture and the
classical morphology, I think wecan all agree that obviously
having, um, real, uh, the, thegranularity to which we're
understanding how morphology isreally important in hamstring
injury is, is.
Fascinating to me and how wetrain that.
Right.
So that's where the eccentricscan come in really, um, helpful
(37:08):
looking at ation angles andlooking at these dynamic
assessments with ultrasounds andhow that is important from a
performance side.
So we have to perform at lengthin order to not get injured at
length.
Mike (37:18):
Right, right.
And, and I, I think when you,when you start to think of it
from this fashion, you can seethat we have a lot of work to
do.
Holly (37:27):
Yeah.
Mike (37:28):
Um, and I think we're at the point now where you, people
like yourself have done so muchresearch to find a lot of these
things.
If we don't do the twocomponents, get the youth to do
'em before it's a problem, andthen to get people more
compliant in it.
We really are gonna have a hardtime assessing if all this hard
work you've put into it.
It worked, right?
(37:49):
It's, it's, it's unfair.
If nobody's, you know, ifcompliance is 16%, then you know
what, you know, it's, it's hardto say if we're doing, um, you
know, the right job.
So, um, you know, we appreciatepeople like yourself in all that
you do.
Um, this might have been themost educational, uh, podcast
episode I think I've had so far.
Um, which, which would justyour, your brilliance raining
(38:11):
down.
Holly, I feel like we solvedsome pro problems today.
I think we did.
I think we did.
So
Holly (38:17):
Oh, good.
Mike (38:19):
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 thatlike strength and conditioning
facilities are guilty of thistoo.
Not to go off on a tangent hereat the end, but like, man, we,
we got like super, super intopower.
Right.
Like it's, we, you know, thelast decade or so and Glu glu
(38:41):
glute and not hamstring,hamstring, hamstring a lot.
So you, you, you said the flipwhere, you know, we're focusing
too much on the hamstring andnot on the others.
I, I think if you look at a lotof the youth, they're squatting
and deadlifting a ton andthey're not doing a lot of
isolated hamstring.
Holly (38:54):
Absolutely, I could not agree more.
And I see that a lot,particularly like in my kind of
high level, like 14 to 18 yearold group.
And I could not agree more.
And this is where I plead, likewith the coaches, it's like, let
us help you like just take alittle dose of this.
We're only asking for a lot ofthis dynamic stuff.
We're lucky.
We're asking for about a 28minute commitment a week.
(39:15):
And if you kind of stratify thatthrough the calendar and if
that's gonna.
Some of your best playersavailable to you in the
post-season.
It is such a win-win, you know?
So, um, yeah.
And, uh, and on the strength andconditioning side, it's like,
yeah, sometimes we, we try toget a little too clever and
sometimes we don't need to bethat, that crafty or that that
creative or that unique, we cankind of stick with some of the
(39:35):
basics because they work andlike dedicated hamstring work
absolutely has to be a, a.
Primary component of everythingbecause a lot of the sports
will, um, you know, just byvirtue of competition and
playing and participating, yourquads are gonna stay pretty darn
strong.
And it's, it's the posteriorchain that we really have to
make sure we're, we're involvingas well.
Mike (39:57):
Right.
And who knows what we caninfluence with the youth as
they're growing and they'readopting their, their, their,
you know, their, their, theirgrowth spurts and all these
things, uh, with the musclearchitecture.
I, I, I think you're completelyright.
I think, I think that isprobably gonna be our next area
that we have, have to eemphasize the most.
So, um, uh, amazing stuff.
Holly, this was awesome.
(40:17):
Uh, before I let you go, I gottaend with our high five, five
quick questions that I'm, I'meager to hear your answers.
I think you're gonna have great.
Five quick questions, five quickanswers.
Learn a little bit about you andyour brain, how you think, but
first question, what are youcurrently working on for your
own professional development,not teaching us, but what are
you learning yourself?
Holly (40:38):
You know, I have to say I love reading, like I, I, my, my
Twitter feed is like, I, I useTwitter to.
Follow things that I wouldn'tnormally feed, like read things
outside the box.
Like I follow, um, oncology, Ifollow I read anything, I'm, I'm
a bit of a geek obviously.
I think you probably picked thatup in the last 45 minutes.
But, um, I'll, I read anythingand everything, reading about
(41:00):
long covid reading about um, uh,you know, novel treatments.
Cuz I think anything you learnto extrapolate, um, one might
help you help a patient likeinadvertently, 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 upand making things, um, you know,
(41:24):
sometimes difficult on myselfbecause I think that makes me
better at what I do overall.
Mike (41:29):
Yeah.
I love it.
That's a great one.
What's one thing that you'verecently changed your mind
about?
Holly (41:35):
Um, and this isn't super recent, but, uh, one of the
things, oh, uh, uh, well wetalked a little bit about like
looking at gluten and nottotally 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 (41:58):
I love the excitement.
I love this.
I love hip flexors too.
Holly (42:02):
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 issuesaway.
And now I have like completelyabandoned that thought and now I
am like, we are going tostrengthen these issues away.
So that has been a real slip andI love explaining that to
patients because that's been abit of dogma.
Like, I have tight hip flexorsand I was like, yeah, the reason
(42:23):
you do that because you sit in acorporate job for like, you
know, nine hours a day and we'regonna kind of work your way out
of it and this is what we'regonna.
Mike (42:30):
Yeah, that's a great one.
I think that's great and you'veseen success with that.
Holly (42:33):
Yes, yes.
Well, and the stretchingmatters.
I'm not, I, maybe I overstatedthat a bit, but I think like
oftentimes they're weak.
Use your dynamometers and figureit out.
Like, are they weak?
You
Mike (42:42):
that's a good, that's a, yeah.
Very well said.
I like that.
Uh, what's your favorite pieceof advice that you give
students?
Holly (42:48):
Oh, you know, just stay hungry.
I mean, you know, I've beendoing this for 23 years and
it's, if I've been doing it forone, I am.
I just like you.
I love what I do.
And if you're not happy in yourcurrent job situation, then find
a way.
Maybe it's just that particularsituation, like volunteer.
I, I can't tell you how manyphilanthropic hours I have done
throughout my career, and it hasled me to some of the most
(43:11):
rewarding.
Career and life experiences thatI 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 findrelationships and network and
conversations, but alsovolunteer cause some of the most
fruitful things you mightexperience, not only
professionally, but personally,uh, maybe of a genuine surprise
(43:34):
to you,
Mike (43:35):
I love it.
That was gold.
I like that.
That was a good one.
Uh, what's coming up next foryou?
I'm sure you get a bunch what'scoming
Holly (43:41):
Oh yeah.
Well, loving the N F L stuff.
Continuing.
Some work with M L D, which Ialso love.
This is a funny question orfunny quick story if you have a
second.
Um, when I first started gettinginvolved in MLB and we were on a
call with multiple teams and wewere in the height, this is many
years ago when there was likethis big rise in, uh, um,
Hamstring incidents and, um,one, I won't name any names, but
(44:03):
there was a team member oraffiliate member from, uh, one
of the clinical staff and an MLBteam.
And he's like, and all duerespect, like, you're a soccer
person.
Like, what do you know aboutbaseball?
And I'm like, I'll have, youknow, I was a mean.
Third base, little leagueplayer,
Mike (44:17):
There you go.
Holly (44:18):
I said, so I would say one of my things I say obviously
being a woman and not being ableto play, you know, high level
baseball.
I played softball, but, um, or,uh, uh, football.
But I, I would say, um, beopen-minded in terms of people's
experiences.
Like, um, some of the bestcoaches in the world weren't the
greatest players, and I thinkthat goes for like our
(44:38):
profession as well.
You don't necessarily have toplay the sport, but, but be well
versed.
I immerse myself and try, I knowevery position and I know, you
know, watching my nephews playthroughout the year.
Like I, I, I definitely am astudent of the game.
I'm a student of life, but I ama student of the game and I
turn, I,
Mike (44:57):
I'm picking up
Holly (44:57):
it's very important.
Mike (44:58):
I'm, I'm picking up on that.
I feel, I feel like you're oneof those people that got very
little work done during theWorld Cup, right?
Are you in, are you in you inthat boat?
Holly (45:07):
It's fascinating.
That was a fascinating World Cupfor a variety of reasons.
That might be our next podcast.
Mike
Mike (45:12):
Yeah, exactly right.
Awesome.
All right.
Well, how, how can people learnmore about you?
I know, I know you justmentioned Twitter.
Um, do you have, do you have,but like what's the best places
for people to learn more aboutyou and your research and all
the stuff
Holly (45:23):
I'm, I'm more active on Twitter than Instagram.
Maybe that's sort of uncool ofme.
But, um, that's the facts, Andthen, um, I have a website.
Um, it's just my small clinicalpractice, but I post things
about like our, our newest.
Uh, sort of research anythingthat's getting published.
And then, um, and I, and Iretweet things that I think are
really important to ourprofession.
(45:44):
Um, whether it's on like the A PT A or sports section, political
side, or, you know, ways to stayinvolved.
Um, opportunities that I thinkmight be of interest to my
former self, you know, 20 yearsago.
Um, but I just think.
If I can just give a little bitof advice to young clinicians.
It's just read, read, read, andread from a variety of sources
in terms of, um, and I thinkTwitter and, and social media
(46:06):
has made that so much easier nowand palatable because it's just
like, it's, you can design yourown news, source your newsfeed,
which is phenomenal.
Mike (46:15):
Yeah, it's a great opportunity and it's a great
opportunity to get to interactwith people like yourself,
right?
I mean, like, think about that.
That's crazy.
I can't, I'm sure you, yourespond to people.
I mean, that, that's amazingthat you can do that nowadays.
So, um, you know, re reallyappreciate everything you do for
the profession, um, and takingsome time out to come here and,
um, probably give the mostinformation per second on, on
(46:38):
the podcast history if we.
If we look at a ratio ofbrilliance per second.
But thank you so much, Holly.
We love it.
Um, I, I feel like we, we gottado an ACL one in the future,
but, but thanks so much and uh,and I hope to see you soon.
Thank you again.
Holly (46:51):
my pleasure.
Thank you for the invitation.
Really a blast.
Thank you.
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Therapy Gecko
An unlicensed lizard psychologist travels the universe talking to strangers about absolutely nothing. TO CALL THE GECKO: follow me on https://www.twitch.tv/lyleforever to get a notification for when I am taking calls. I am usually live Mondays, Wednesdays, and Fridays but lately a lot of other times too. I am a gecko.
The Joe Rogan Experience
The official podcast of comedian Joe Rogan.