 Carlos Jimenez, Carlos is currently works at the U.S. Soccer Federation as the head physical therapist for the women's national team, not a bad team to work for. Originally from Caracas, Venezuela, Carlos enrolled at the Miami's Florida International University and earned his bachelor's in health science and a doctorate of physical therapy. He has worked for the Venezuela's men's U-20 soccer team as well as soccer teams in Poland. Welcome Carlos. Hi my name is Carlos Jimenez and today I would like to share with you guys a rehab continuum for hamstring injuries and I'm currently working as the physical therapist for the U.S. women's national soccer team. Before moving on I wanted to put this disclaimer up there that informs you that the views thoughts and opinions expressed in this presentation belong to me and not necessarily to the U.S. Soccer Federation at all. The objectives of this presentation is to give you context at the national team level, introduce you to the multi disciplinary team and the communication within our team, give you a framework to treat an acute hamstring injury and just to share a few final thoughts in my rehab philosophy. So I'm lucky to be able to work with great like-minded people and we are lucky to have a couple of M.D.s and orthopedic doctors that will travel with us during the camps. Also working with Steve Strieker, the head athletic trainer and then the head sports scientist Ellie Maybury and Julian Hyde and then we have a few volunteers to travel with us and supporting the team during these trips. So working at the national team level with the U.S. women's soccer team we have a unique scenario here because we have to be proactive and have an intimate relationship with reactivity because anything can happen and we have limited time working with these players. Then also we have reduced hours of work with these players and ultimately they only with us for a few couple weeks and they go back to their clubs and then we have to do the best we can while they're with us. Before I move on I wanted to touch bases first with the communication and relationship within a team. I feel like if this line of communication from Dr. Athletic Trainer, PT, sports scientist and going back and forward it's healthy then the success of your rehab plan and any other problem will be solved just because this communication right here is key. So I wanted to spend a little bit of time talking about your multidisciplinary team and the communication with the team. I wanted to put reference on this research that was done in Europe and they asked a simple question to their clubs, top club elite clubs in that region, basically asking them what was the relationship and communication style within their teams, within their sportsmen, sports scientists and coaching staff and they were ready from one to five and they saw this relationship that those teams that had good communication styles within their staff was able to show less injuries incidents throughout the year. So this brings to my attention that you know you can have the best framework for returning to sports or returning to play but if you don't have a good team to work with and if the communication is broken then definitely nothing is going to get done and everything's going to fall in the cracks. In this slide I just want to bring up to your attention that I'm always thinking in this process and every part of the team should be thinking of tissue healing, timing for the next game, if the athlete can be replaced by another player. What kind of rehab strategies are we going to use? What exercise can they tolerate? What about the injury history? If they can train with a team, if they're a key player, all of these things are going to make a difference when you're taking a decision when the athlete can go back to their team and play eventually. So we know that we're going to be looking at the research and we're going to tie these two past experience. So we know that already this injury was related to a confirm with an ultrasound that it was a great one, a soft tissue injury that we feel confident that this injury won't take the athlete too long to go back on the field. And we should never forget about how the athlete feels about this injury because if they have any doubts in their head that this injury is worse than we think, we need to reassure the athlete gives an input in the injury. So we have to make sure that the athletes are confident with our approach and that the athlete already has a buy in our treatment approach and rehab approach. Next, once we finish with this part right here where we're communicating well, we are all taking into consideration this part right here. We're always taking this into consideration and we move up to the athlete's view. Now we're looking into is the athlete ready to return to practice? Yes, if yes, so we're going to be looking at different clinical presentations. We're going to look at the acute chronic ratio. If you have it, we look at the lower strength if they're able to have a high speed, more than 70%. And then limited training. These are the things that we're looking at to return the athlete to practice. So I've used this rehab update continuum. And it's basically a quick clinical assessment for the clinician that they can use to kind of assess how severe the injury was with clinical objective data. So if you see the athlete with pain with walking, how much tender to patient they had was the strength of the hamstring muscle at 15-30 degrees of knee flexion. Then you also want to look at the manual maximal supine after the knee extension, comparing left and right. And then you look at single leg bridges, long lever. And if you can do a little reps to look for more endurance. Since we know in this case she or he was a grade one strain, we know that they might only have a couple of these that might appear during our clinical presentation. So this athlete is going to be able to go from here all the way down here, meaning this athlete is going to start with some type of Asclean Rehab Program, some eccentrics as soon as they can. But then also some submaximal isometric exercises to start working on that tissue and pain tolerance. Once the athlete jumps down here to phase two, then we can think of more sport specific rehab within tolerance. And then we can add some of the Mendigucha type of protocol to help the athlete have a standard rehab progression. Then as they progress, they're going to go to a phase three progression, meaning they're going to use heavy high level of isometric movement based rehab, meaning to high plios, high-level eccentric emphasis, and then obviously sport specific and retest again. We're also going to use some of map taverns controlled to chaos to kind of like having a more objective criteria to move on to the next phase. When you see an objective data to measure the strength of the athlete, if you're using normal strength, hopefully you have historical data that you can check and see where the athlete falls, because it's very valuable. Some answers might be asymmetric, but there might be a normal asymmetry for the athlete. But then also you want to look at it as a whiskers box plot, and you will see where they're falling within their team, and maybe it might be useful to use these two graphs to have an idea how to rehab the athlete and when to be feel confident that the athlete will be ready to tolerate the load on the field. So I wanted to show you the guys, this graph from Team Gavid, and using the Q chronic workload, basically he, but if using the past, if you already know, if you have enough information from your athlete, and you know that 100% from the past week, you know, they're loading, so if they're been off for like, about five or seven days, and they missed a few sessions, you know, the load will not be the same as they was before they were injured. So taking this into consideration will make your rehab a little more objective and return to play easier. When we are progressing towards more sport specific, and looking at a limited training session, I've always looked at what can the athlete do as a part of the conditioning aspect, and also looking if they're going to use the ball on the ball. In this case, if you have an athlete with a strain one in this hypothetical case, I've used a combination of this with the sports scientists, you always make sure that they're okay with this as well. And then change your direction with without the ball. And you're looking at some acceleration and deceleration preparation. You can use progression of technical skills if you use a ball on a ball. But these are look good really easy parameters to use to be able to track how the athlete is checking some boxes and if they're ready to move on to the next stage of rehab. Now that the athlete has been able to return to practice after making sure the athlete was able to tolerate practices, then we're ready to move up to the next part. So we're almost ready here. Once the athlete is able to return to practice, we're going to be able to get them back to return to play phase. Now we're still looking at the clinical presentation acute current ratio, normal strength, that's what we spoke earlier. The high speed running should be hitting about 90%. And then axle to the cell intensity should be increased. And the training of this session should be filled positionally specific. So this is something that you should be working closely with your sports scientists in the future. And I feel like as these are markers that are the hitting and all of this is being taken care that he had this in a good path to return to play. Here we can see how we're using this for return to play. Basically using a speed as your metric also using running speed more than 90%. And you're using all their metrics acceleration, deceleration, we want this more positional. So basically the athlete is able to train with the team and being used in their position and being able to tolerate that demand, hopefully in the session. So we feel confident to be able to let the athlete play in the next game. And here I wanted to share with you guys a few final thoughts. I want to say that rehab is an art because it's about managing a situation with what science is actually telling us. Also, we need to keep in mind that I do not think that one exercise fits all and also injuries I didn't treat in reality they are managed. And a couple of things that I want to show you is that empathy is key, but you must guide yourself with rational thoughts, not your heart. Otherwise, you will make a mistake. And to finish, you should guide your athlete with recommendations as well as confidence, but we do not have a magic one. In conclusion, I also want to show you guys how we work at the national team level.