Sami Karam

After working as an assistant and then as an Osteopath for 6 years at the Peakhurst Sports Medicine Clinic begining in 1999, Dr Sami Karam started the Parramatta branch of the Sports Medicine Clinic in 2005. In 2001 he was the head physician for the Petersham Soccer Club, then from 2002-2004 he was the head physician for the Southern Star Sharks Soccer Club in the NSW State League. In 2005 Sami became the head physician for the St George Crows AFL Club in the NSW Premier League, and acts as a consultant till the present day. During his many years of practice, Dr. Sami Karam has had the opportunity to travel to Europe and work with elite athletes at the highest level. He is currently a consultant for the Barcelona Total Tennis Academy and Catania Football Club (FC) in the Italian Seria A. He has a special interest in Strength Training for the athletes that he treats and uses the same model in rehabilitating common injuries that present in the clinics. Dr Sami Karam was a guest lecturer at the University of Western Sydney Osteopathy program and is a fully registered AHPRA practitioner and a member of the Osteopathy Australia.

A Pain In The Elbow: Golfer’s Elbow

09/18/202104/19/2020 by Sami Karam

Hand or elbow issues? It could be Golfer’s Elbow. Gripping things with your hands is about a basic human function as you can get. So when you get pain associated with gripping, the impact it has on what you can or can’t do is directly associated with how useful you are as a person. And since we all want to be useful (most of us), we need to address some of the main conditions that cause pain with gripping.

Such is the importance of the gripping function, people with amputated hands, fingers and/or nerve damage that reduces their gripping are often deemed “disabled.” Now before you go and start using the disabled car spaces, let’s just discuss how you’re able to overcome one of the main causes of painful gripping.

One of the common conditions that cause pain on the inside of the elbow is known as Golfer’s Elbow. The medical term for this is medial epicondylitis. This is generally characterised with pain that’s quite tender and achy and bruised to touch. It also feels quite tender and achy to grip and use your forearm.

Disclaimer: This is for Educational Purposes Only

Let me take a quick intercession to inform you as to the nature of our advice. We are experienced, healthcare clinicians. We wish to share our experience with you on topics to do with your health. We may be a little colourful in doing so, but at the heart of what we do is in-the-trenches experience. Whilst we have achieved academic success and understand the evidence, we are not solely evidence-based. We are, however, EVIDENCE INFORMED.

We find that the evidence is usually 10-15years (at minimum) behind what we are seeing in the clinic. We see real people, with real problems, and we’ve made a great living out of offering real solutions.

If all you’re after is the researched evidence, you can find some on Google Scholar, or you can very easily look for more on Google. We want to give you real-life advice, most of which you may not find in the research.

There is no way that this document can replicate or replace expert assessment and guidance given by a qualified registered healthcare practitioner who has seen you personally. I am sure you’re aware that I have no knowledge of your personal medical history or how you take care of your body. If you require care from a qualified practitioner, you would be best served by seeing someone who can empathise with your situation and treat you accordingly.

I’m sure you understand that I disclaim any and all responsibility for anything you do as a result of reading this document. And by reading this article, you accept 100% responsibility for the actions of you or anyone under your care.

So the movement that actually causes this is gripping. The main concern has to do with gripping and using your elbow and your wrist whilst you’re gripping. Movements like gripping and twisting, gripping and pulling, gripping and hammering, gripping and chopping will aggravate the inflammation. Anything that uses your wrist and your elbow whilst you’re gripping will tend to put strain on the tendons and cause them to get really swollen, inflamed and cause some pain at your elbow.

What happens is all these tendons on the inside of your forearm – the ones that close your fingers – attach onto one point on the inside of your elbow, called the Common Flexor Origin. As those tendons get tighter and tighter, and they pull on that bone, the bone will actually become inflamed. That will then add to your pain as well.

If you have had a Golfer’s Elbow condition for a relatively short period of time (2-6 weeks) the condition is considered to be fairly fresh and can be treated using some basic guidelines. This advice mainly relates to people who are suffering from this condition for a short period of time, and how they can help themselves or how we can help them to improve that condition.

The treatment that we may use for Golfer’s Elbow involves looking at this problem from a few different angles.

This problem needs to be considered as an upper limb condition.
This means that you don’t just look at the elbow, you need to look at the wrist, the elbow, the shoulder, and the thoracic spine, and make sure that mechanically they’re all working well together.
The second strategy is you need to manage inflammation.
We can use ice, and we can use movement to actually help drain out inflammation and reduce inflammation in that area if we need to.
A third strategy that we need to implement is called load management. So we need to manage the kind of loads that we put on it.
We can’t overload it otherwise it will just keep getting inflamed and the process will repeat itself, but we can’t underload it because it will get weak.

So what you need to do is you need to find a point where you can do the work that you need to do, but not overload it. And then you gradually increase that load bit by bit, generally from week to week. Over time, that should help improve the actual condition. As the muscles don’t get weak, you can still function and the inflammation should die down gradually.

Now, some people will speak to me and say, “Well, look, I’ve had this problem for a good 3-4 months, it just doesn’t go away. I’ve seen a lot of people about it, it’s been going on for a long time, and I just can’t shake it.”

In these particular circumstances, there may be a lot of microtrauma at that particular area on the inside of your elbow, which means that every time you use it, you increase that microtrauma.

The strategy that we need to implement to actually overcome this is quite painful. It’s not nice, and it requires that we go in there and actually really work hard on the inside of that elbow and create some hyper inflammation. What that will do is it will bring on a cascade of events where your body will actually try and heal that area.

So previously, your body was in a state of chronic inflammation and some kind of tissue thickening that it just wasn’t getting out of. When we go in there, we beat it up, your body thinks that you’ve just hurt yourself, and that starts to repair the area. So we need to be a little bit firmer with you, and maybe a little bit painful, but we get to a point where it’s really hyper inflamed and it’s really swollen and then we ice it back down.

We basically get you to the point where the strategies I discussed earlier with you when this is a short term problem become applicable. When that happens, the tissue should repair quite well and you’ll find that your pain reduces quite significantly. No need for forearm straps, wraps or any kind of device.

Follow these Golfer’s Elbow guidelines when you feel that pain on the inside of your elbow is making you less useful than you’d like to be. Because we’d prefer that you be useful, and not take the disabled car spaces from those people who actually need them.

If you feel that any of the information we’ve given you here resonates with you and you feel we are in a position to help, please BOOK ONLINE as we would welcome the opportunity. If you feel that we can help you in any other way, please reach out to us via our CONTACT PAGE.

Dr. Sami Karam, Osteopath

I’ve been a qualified Osteopath since 2004. I’ve been playing football ever since I could remember and I have a passion for it. I’ve played at the highest level in the NSW State League at both Youth and Senior levels, and have also been Head Physician at numerous State League Clubs. I’ve travelled internationally and consulted with Sports academies in Barcelona and Italy. I have a special interest in Strength and Conditioning for footballers, as I believe it gives them an edge in their physical competition. My passion involves bringing all of this knowledge into every single treatment that I provide for all athletes. If you feel that I can help you and want to reach out to me, contact me.

More about Osteopath Dr. Sami Karam

Getting Your Pillow Right

07/10/202104/12/2020 by Sami Karam

One of the major obstacles to improving the upper back and neck pain that people often complain about, is getting their pillow right. Waking up in the morning with a stiff aching neck is not the first thing you want to be feeling after opening your eyes in the morning.

A lot of people ask us to tell them what the best pillow is for them, and here I will attempt to at least explain to you what a good pillow should do and also, some of the problems we encounter when helping people get a better night’s sleep.

Disclaimer: This is for Educational Purposes Only

Now it’s important that I discuss with you some of the sleeping patterns we find people get into. These patterns will generally tell us how comfortable you are at night – in your bed and on your mattress – and it will also add to our knowledge as to why you have these aches and pains in your neck.

The first pattern is people sleeping on their backs.
The second one is people sleeping on their side.
And the third one, the one that we don’t recommend, is people sleeping on their stomachs.

The reason why we don’t recommend that is that when you sleep on your stomach, you have to extend and rotate your neck to be able to breathe and fall asleep. That’ll put a lot of tension on your upper back and neck and you will find that that is something that you will not recover from really well because you’re doing it for eight hours a night.

This is one of the main problems that I encounter when I’m trying to help people find a better night’s sleep. They often complain that the only position they could fall asleep in is on their stomach.

The two main reasons why people do this is:

They’ve just been accustomed to it for so long, and
There’s generally an underlying mechanical or postural problem in their upper back and neck that needs addressing or treatment.

Now when we transition people from laying on their stomachs to laying on their backs, or when we transition people from laying on their stomachs to laying on their side, we need to use pillows as props to stop them from moving one way or the other.

So when you go from laying on your stomach to laying on your back, you need a pillow under your neck. You need a pillow under your knees. You also need a pillow on either side of your arms to stop you from rolling over.

When you’re going from laying on your stomach to trying to sleep on your side, you need a pillow under your neck, you need a pillow in between your knees, and you should have a pillow underneath your top armpit that you hug that stops you from rolling forward back onto your stomach. Now, if you persevere through that for a few nights, 3-4-5 nights, that along with the treatment that we’re offering you should help you then transition from sleeping on your stomach to a better sleeping pattern either on your back or on your side.

With regards to sleeping on your back, a good pillow should allow your head to sit back comfortably into the pillow and facilitate that backward curve of the neck. You should feel it more so supporting your neck and less on the back of your head. If you find that your pillow is pushing you too far forward or your head is too far forward, you might find that the pillow is too thick.

If you find the opposite, that your pillow allows your head to go too far backward or extend, then you might find the pillow is too thin, and you’ll have to make sure you test out for that.

With regards to people who sleep on their side, a good pillow should fill the gap between your neck and your shoulders. That’ll stop your head from tilting one way or the other when you’re asleep at night. If you find that you have broader shoulders, you might need to thicker pillow. If you find that you have narrow shoulders, you might need a thinner pillow. Again, you have to add that to your testing.

Now with regards to buying a pillow, if you’re spending more than $100 on a pillow, you’re generally paying for marketing or for gimmicky tempura memory foam nonsense that you just don’t need. A good pillow shouldn’t be more than $100. We often test people here at the clinic and help them find the right pillow. So if you need our help with that, just ask us.

So when choosing the right pillow for you, do some testing. First, make sure you’re sleeping either on your back or side. Second, check that the pillow supports your neck in a neutral position, and third, don’t fall for gimmicky marketing. A good pillow will be affordable. Enjoy your night’s sleep

Dr. Sami Karam, Osteopath

More about Osteopath Dr. Sami Karam

Getting Your Mattress Right

07/10/202104/05/2020 by Sami Karam

One of the main questions I often get asked in the clinic is what kind of bed should I buy. Should I buy a firm bed a medium bed or a soft bed? Before I answer that question, I’m going to discuss with you some of the things you may feel when your bed is actually contributing to your aches and pains.

The first one is if you’re waking up in the morning, with aches, pains and stiffness, and you’re otherwise generally healthy, you have a generally healthy spine, that may be an indication that your bed is contributing to those aches and pains.
The second one, is if you can’t find a comfortable position to sleep in if you’re constantly tossing and turning. And there’s physical discomfort – doesn’t have to be a huge amount of pain – just discomfort, that may also be an indication that your bed is contributing to your aches and pains.
The third, one and the dead giveaway, is if you go to bed and you start to feel yourself sinking into the bed within about 20 minutes. It’s probably time to get your bed replaced.

Disclaimer: This is for Educational Purposes Only

Now when you combine this information with the age of the bed and we generally recommend 5-7 years, it will give you an indication if you need to replace your bed or not. Most mattresses come with 10-year warranties, but that just means they’re not going to fall apart in 10 years. It does not mean that it will do its job of contributing to good spinal health.

Okay, now you’ve decided to buy a new mattress, what kind of mattress should you buy? Well let’s get one point clear first. Don’t fall for all that memory foam tempura, bamboo foam, gimmicky nonsense that they’ve got out there. They don’t help and they don’t offer anything that is worth the extra money you spend on them. One more thing they don’t do is they don’t offer any kind of recovery for your spine at night. They just conform to all the compression that you’ve built up through the day.

Traditional spring-loaded mattresses will actually offer some kind of relief because they will help change your spine at night as you’re sleeping, in a good way.

And this is why a traditional spring-loaded FIRM mattress is generally better for you. This can be applied to roughly 80% of the population based on the feedback and results we see in the clinic. The reason why a firm spring-loaded mattress is better for you, is because it offers traction at night when you’re laying down.

When you’re laying down at night, your spine is like a flattened out S curve. with gravity acting down on that S curve, it’ll pull the ends apart and cause traction on all those little ligaments, discs and muscles throughout your spine. We want that because that’s good for recovery when you’re sleeping at night. Most of you through the day, when you’re sitting or standing, gravity is acting on your spine in a compressive way, there’s compression squeezing all those spinal structures together. When you’re sleeping at night, you want traction. Traction tends to somewhat reverse or help recover some of that compressive load that’s happened throughout the day. So again, the main point to take away, look for a traditional spring-loaded mattress that’s firm. That’ the recommendation that we have given to our clients when they ask us, and it has served them well over the years.

And what about your pillow? Here’s how to get your pillow right.

Dr. Sami Karam, Osteopath

More about Osteopath Dr. Sami Karam

Cleaning Out Your Knee

03/19/202303/25/2020 by Sami Karam

Having sharp pains in your knee every which way you turn is neither fun nor sustainable. If you enjoy being active, having a knee that’s painful, but otherwise stable, is really annoying. You just want the damn pain to go away! Most people would go to their GP who would then recommend them to a surgeon and they would recommend that they “clean your knee out,” otherwise known as an arthroscope. Now you have a decision to make. Do I do the surgery and tidy up whatever it is in there that’s giving me pain? Or do I ride it out and maintain my knee cartilage? This is actually a bigger decision than you might think.

What is Arthroscopic knee surgery?

Arthroscopic knee surgery is usually performed so as to clean and tidy up the internal knee joint. Nothing is actually repaired. Meaning that they will generally cut out bits of the knee cartilage that are suspected of causing the knee pain. A good surgeon will be able to clean and tidy the cartilage and keep as much of the cartilage as they can.

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What Causes Heel Pain?

How Custom Orthotics Can Help You Walk Better

What is bursitis?

Ingrown Toenails

Meniscal cartilage knee surgery

The cartilage that we are discussing here is meniscal cartilage. It’s the cushioning cartilage in your knee. It’s softer and more prone to cuts and tears from compressive and rotational forces. We call it the Meniscus. There are two kidney-shaped menisci in each knee, a medial and lateral meniscus.

They absorb the shock in your knee and protect the articular cartilage, the shiny lining on top of your bones inside the joint. Once your articular cartilage wears out, you generally need a knee replacement, which is why we like to keep the meniscus as intact as possible.

The surgery is actually quite simple when you think about it. They open two 1cm holes at the front of your knee. They insert a mini camera in one hole, and a shaver or scraper instrument through the other hole. The skill with the surgeon lies in how they can use those tools to tidy up the tearing by removing as little meniscus as possible.

How long will knee surgery take?

The whole process usually lasts about 30 minutes, then you wake up and they give you a sandwich and juice. Hopefully, the surgeon visits you once you wake up and gives you the all-clear to go home the same day. Done well, you should be able to hobble out of there on some crutches, and you should be walking around more comfortably within a couple of days.

Disclaimer: This is for Educational Purposes Only Let me take a quick intercession to inform you as to the nature of our advice. We are experienced, healthcare clinicians. We wish to share our experience with you on topics to do with your health. We may be a little colourful in doing so, but at the heart of what we do is in-the-trenches experience. Whilst we have achieved academic success and understand the evidence, we are not solely evidence-based. We are, however, EVIDENCE INFORMED. We find that the evidence is usually 10-15 years (at minimum) behind what we are seeing in the clinic. We see real people, with real problems, and we’ve made a great living out of offering real solutions. If all you’re after is the researched evidence, you can find some here (link to evidence page), or you can very easily look for more on Google. We want to give you real-life advice, most of which you may not find in the research. There is no way that this document can replicate or replace expert assessment and guidance given by a qualified registered healthcare practitioner who has seen you personally. I am sure you’re aware that I have no knowledge of your personal medical history or how you take care of your body. If you require care from a qualified practitioner, you would be best served by seeing someone who can empathise with your situation and treat you accordingly. I’m sure you understand that I disclaim any and all responsibility for anything you do as a result of reading this document. And by reading this article, you accept 100% responsibility for the actions of you or anyone under your care.

What is bursitis?

How to diagnose, treat and prevent Hamstring Strains

Diagnosing, treating and preventing Hamstring Strains

What is an ankle sprain?

Total Knee Replacements: Why, What & When

Knee Pain and Squats

Knee surgery rehabilitation

The rehabilitation process is not complicated:

Surgeon guidelines and wound healing

Follow the surgeon’s guidelines for wound healing. Ice and elevate if necessary. You want to regain full knee extension as quickly as possible, and return to a normal walking pattern as quickly as possible, whilst respecting the healing process. This is best done in partnership with your Osteopath so they can guide you.

Knee movement and range of motion

Get onto an exercise bike and start moving the knee through a full range of motion. Keep getting your quadriceps and hamstrings worked on by your therapist. You can begin engaging your knee within the squat and deadlift movements (done correctly), provided there is no pain.

Movement and pain-free knees

Keep engaging those movements until they are full range and pain-free. Now you can start loading them. You should be at about the 6-week mark post-op. Once you’ve regained sufficient strength in your knee that resembles pre-op strength, you can start doing some straight-line running, if that is your desire. Anything extra from here on would require specific programming based on your specific goals.

So you’ve just read about the process of cleaning out your knee. A fairly routine surgical process these days. What is more important is the decision you need to make about whether you should actually get it done or not. This decision has become easier given recent evidence. The evidence suggests that a cleanout of your knee does not have any long term benefits and that it will actually accelerate your need for a knee replacement.

If your feet are also causing you pain and balance issues, you should talk to a Podiatrist and investigate custom orthotics.

Why get knee surgery?

So then why do people still get them, and why do surgeons still do them? Well, some surgeons will do them when there is acute locking of the knee. This is an undesirable scenario where the knee locks and inflames. It can lead to a whole myriad of complications, including serious ones like blood clots. Some surgeons will also do them for specific people who have specific goals. Like if you’re a football player earning $50 million dollars a year, you’d probably take a jackhammer to the knee if it means getting you back out on the pitch in the short term. These athletes suffer into their older adult life, but who cares when you have $500 million in the bank. And then you get some surgeons who do them because they’re butchers, stay away from them.

Does knee surgery help?

Usually, the surgery helps in the short term, but the pain comes back. And as you get older….arthritis and degeneration speed up and you’re now looking at a knee replacement. Fortunately, we now know better. We don’t recommend these surgeries unless absolutely necessary.

So if you’re just an average Joe or Jane, and you have some knee pain from a torn meniscus, don’t get the surgery done. Get it looked at by your Osteopath because they will have some tricks up their sleeve to help you. Get the knee stronger, build some muscle around it. It will slow the arthritic process and hopefully, you may not need it replaced. And if you do need it replaced, you won’t need it done as soon.

What is bursitis?

Total Knee Replacements: Why, What & When

Knee Pain and Squats

Dr. Sami Karam, Osteopath

More about Osteopath Dr. Sami Karam

ACL Rehab Done Right!

07/10/202103/22/2020 by Sami Karam

We’ve all either seen (and heard it happen), seen it on T.V, or had it happen to ourselves. Tearing an Anterior Cruciate Ligament (ACL) in the knee is one of those injuries where you just know it’s bad. If you’re an athlete, you can already see yourself sitting out the season, and if you’re Jane Average, the shock and trauma of having it happen to you is a little unbelievable. The sound is like a gunshot going off, and the pain is sharp and knife like through the whole knee. Up until that point in time, it’s likely that you would not have experienced such pain. Nothing can prepare you, and nothing can be done then and there…. YOU’RE OUT!

As soon as you hear the letters ACL about your favourite athlete, you know they’re out for the season.

As a practitioner, the connections we make with people are the things we value the most. So when we get an opportunity to help someone rehab after ACL surgery, we know there will be potential for a bond that will last a lifetime. As much as we are devastated for the person in front of us, we cherish the opportunity to help. And “help” is actually a light word in this situation. You’re doing much more than helping. When the trauma is so high, like the phoenix, the rise from the ashes is magnificent! It’s an honour and a privilege to bear a huge responsibility for that. You’re REBUILDING, RESHAPING and IMPACTING the whole person.

I do though want to make this point. What I’m about to describe to you is the way we do this particular ACL rehab for this injury. We believe it’s the best way forward. You may have done your ACL rehab differently with someone else, and the results you’ve gotten will be based on that. We are just giving you our experience.

Disclaimer: This is for Educational Purposes Only

The Surgery

I’ll keep this short, simple and as easy to understand as I can make it. The ACL along with the PCL (Posterior Cruciate Ligament) make up a cross (X) like formation inside the knee and hold the knee together. The ACL stops the lower bone of the leg (tibia) from gliding too far forward from the upper bone of the leg (femur).

The surgery basically involves the surgeon drilling holes in both the upper and lower leg towards the inside of the knee, cutting out a roughly 20cm chunk of your hamstring, looping it over 4 times and inserting it into the drilled holes, replacing the torn ACL. They then screw that in and bone grafts around it to keep it stable.

Sounds nasty right? Well, it can be, depending on the surgeon. We have dealt with many of these injuries and rehabilitated thousands. And as routine as this surgery has become, there are still only a handful of surgeons in Sydney who I would trust with my own knee. The ACL rehab process is significantly easier in terms of time and quality of improvement when the surgery is clean and without complication. Ideally, the surgeon should be able to match the reconstructed knee as closely as possible to the feel of the healthy knee. Too loose, and the knee is unstable and likely to re-rupture, too tight and the rehabilitation is long, tough and painful. This means the surgeon needs to be highly experienced in the quantity of knees, but also getting a great quality of outcome. The operating procedures will look seamless and effortless, just as if he were performing a routine he has performed everyday, like brushing his teeth.

Providing you are fortunate enough to have this quality, the ACL rehab process should also flow seamlessly and you should see progress from day-to-day. If unfortunately, you have a poor surgical experience, your quality of the outcome will be reduced, as no amount of ACL rehab can hide a poorly reconstructed knee.

The ACL Rehab

The purposes of this article is to give you the information we have accumulated via our experience regarding the ACL rehab process after a knee reconstruction. The rehabilitation process is widely understood. There are many protocols and templates out there that pretty much follow the same path. These are generally evidence based and outline the return to sport based on a timeline, given that you reach your goals. We recommend the ACL Rehabilitation Protocol given by the North Sydney Orthopaedic Research Group, led by Associate Professor Leo Pinczewski, who is our preferred surgeon when it comes to the knee joint.

At the heart of this protocol, and this is why we advocate it, is this statement: “We recognize that GOAL based rehabilitation is far superior to TIME based rehabilitation…but biological healing must also be respected.”

We agree with this statement as it respects the body’s healing mechanism and understands that this healing of tissue is best achieved through reaching goals that are individualised. Time, being the same for everyone, is not individualised and what one person can do in 6 months another can’t do in 12 months. This rehabilitation protocol available for download, anyone can access it, but the information contained in it, is not the subject of our discussion today. What we are discussing today is the WAY this protocol is applied, and the considerations we take into account when figuring out HOW to apply it.

There are many patients who we have seen, that when looking at their protocol, one would think they would have a well rehabilitated knee. But upon examination, they are well short of their goals and expected outcomes, with associated pain, discomfort and weakness. This is not the fault of the protocol, but of the applicator, who has failed to apply the protocol within the framework of respecting the mechanics of the whole body, and respecting the tissue healing process.

Whilst the protocol we have advocated contains 6 phases, these phases are not distinct from each other. For example, Strength & Co-ordination begins in phase 2, but realistically, strength and coordination begins from phase 0 and is constantly continuing. So the applicator must allow these phases to seamlessly flow and understand when the components accelerate or back off. This might sound like a complicated task, but it need not be. If you’re using some basic principles to guide you, then the process becomes simpler and more effective.

Phased ACL Rehab principles

There are 2 major principles to consider when considering the phase progression:

Are we respecting the tissues and where they are in the healing process? (Respecting the Tissue)
Are we respecting the structure and function of the knee as it relates to the individual it’s attached to? (Structure & Function)
If these 2 principles are the first questions we ask ourselves each time we consult, then the process becomes simple and effective.

Phased ACL Rehab groups

I will summarise the phases into 3 groups:

Acute healing and Return to walking
- Here we are interested in reducing swelling and helping the wounds heal. So we use strategies like icing and elevation. We also follow the instructions from the surgeon as to wound care. We also must consider the hamstring that has been cut out, so we can begin some light activation of that tissue (Respecting the Tissue).
- Walking properly requires that we gain full knee extension at heel strike, so we must encourage full knee extension. This can be done by the therapist and can also be done at home by the patient (structure & function). It is imperative that you regain the full locking mechanism of the knee before moving forward (structure and function). This is where most rehab strategies fall apart. They move forward before full knee extension is achieved.
Improving Strength & Agility
- If you regain full extension of the knee, you are then able to fully recruit the quadricep muscles at full contraction, and recruit the hamstring eccentrically. Although strength has already started in return to walking, you can now accelerate the strength phase because you have respected where the tissues are in healing and you have regained a vital function of the knee joint.
- You can progress through strength based on pain feedback (Respecting the Tissue), by progressing through to multi-joint movements surrounding the knee (structure and function). Why do we do this? Because that’s the way the body works, in a system, not in isolated parts. So, you can begin squatting and deadlifting, using correct technique, progress through the movements based on pain feedback. You do the movement until it hurts, then BACK OFF a little to where it doesn’t hurt. The key here is that you the therapist, you move the joint a little more than previous and then you get the patient to engage that movement. Then the next time they see you, you go a little further. You respect the process and principles until you can do a full range squat and deadlift, then you begin loading.
- You then apply the same principles to agility. You begin slow and progress in pain-free range. By now the hamstring should have some solid healing and strength. Once you’re able to load a full range squat and deadlift, then you can begin running. The same principles apply here. Speed and direction will be based on pain feedback. Notice that pain is the feedback and not discomfort. Moving through new ranges will be uncomfortable for your body and your mind. But if the process has been followed, your strength and joint integrity will be better than your confidence will allow.
Return to Sport
- Whilst we appreciate that individual sports have their specific requirements, we believe that strength is strength. There is no football strong, or tennis strong. There is just STRONG relative to your body weight. Once you get strong, you then go and express that strength within your sport. So you need to have a certain amount of neuromuscular strength (Respecting the Tissue) before thinking about a return to sport or sport like activities.
- Most protocols require that you have at least 90% strength in the operated leg vs non operated leg. But if you were a weakling before your injury, you’re likely to be a weakling after it. So we want you to actually be of sufficient strength (structure and function) for your sport before attempting to go back.
- Just like strength training, you begin doing sports drills based on your tolerance levels. We want discomfort, but not pain. This will not only retrain motor patterns but also help you regain confidence. These drills should be sufficiently programmed so that there are incremental increases that move you to a return to full training capacity.
- Once you have trained enough to regain full confidence in your abilities to handle game situations (Respecting the Tissue), you may then consider competitive return to sport. But this full confidence must extend to strength, conditioning, and skill performance. If either of these are lacking, then a delay is advised (structure and function). This means that if you can’t perform all the tasks and skills required of you at full capacity, at the level required in that event, don’t play! You have no business returning to sport until you can.

The phases I have described will flow and melt into each other. If you follow the principles outlined, there should not be a backwards step. If you find that you have had to back off, then attention has not been paid to the tissues and the structure and function of the individual has not been considered before moving forward.

The last thing we want to see is a patient in the clinic, 2 years on from a knee reconstruction, with a knee that has limited extension and significantly reduced muscle mass… and they’re playing. That’s asking for trouble and a greater risk of re-injury.

This is a painful, painful injury, not to be taken lightly. The effects are on-going and long lasting. It is something you want to take seriously and make a priority. You definitely don’t want a weak, unstable knee moving into later adult life, and you certainly don’t want a second surgery. The difference between these things will be down to the quality of the surgery, of which you have less control, and the quality of the ACL rehab, of which you have more control over. Please see someone that is not just following a template. See someone who has sound principles that guide their treatment and whether you move forward or not. That will protect you. It could mean the difference between an old good knee and a bad one.

Dr. Sami Karam, Osteopath

More about Osteopath Dr. Sami Karam

Dr. Sami Karam, Osteopath

Dr. Sami Karam, Osteopath

Dr. Sami Karam, Osteopath

What is Arthroscopic knee surgery?

Meniscal cartilage knee surgery

How long will knee surgery take?

Knee surgery rehabilitation

Surgeon guidelines and wound healing

Knee movement and range of motion

Movement and pain-free knees

Why get knee surgery?

Does knee surgery help?

Dr. Sami Karam, Osteopath

The Surgery

The ACL Rehab

Phased ACL Rehab principles

Phased ACL Rehab groups

Acute healing and Return to walking

Improving Strength & Agility

Return to Sport

Dr. Sami Karam, Osteopath

Parramatta Clinic

Peakhurst Clinic