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  2. Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE April 2024 Running Related Injuries: Should we rethink the use of treadmill biomechanical analysis? by Karen Napierala MS, AT, PT, CAFS What would you do? A 54 yo runner with persisting L knee lateral knee pain presents after running a 10k race with hills two months ago. His normal weekly running volume was three times/week for two to three miles. Once he warms up his knee soreness resolves but then symptoms exacerbate sometimes by late in the run but definitely within hours of finishing, sometimes lasting into the next day. PMH includes L ITB syndrome and also recurrent (L) ankle sprains and associated chronic stiffness. The patient denies any catching or giving way in his knee. He has tenderness at the ITB over the LFC, no joint effusion, no joint line tenderness, (-) McMurray’s and Thessaly tests, and pain with single leg squatting. Plain films show diffuse mild grade I degenerative changes. I would prescribe… Rest from running for two weeks along w/NSAID’s Physical Therapy for ITBS including a treadmill running biomechanics analysis MRI to R/O lateral meniscus pathology with FU in two weeks Home exercises handout including ITB stretches, other LE stretches, balance and step up exercises along with recommending cross training for two weeks and then gradually resume running. FU if symptoms persist. CURRENT EVIDENCE: Malisoux L, Gette P et al. Gait asymmetry in spatiotemporal and kinetic variables does not increase running-related injury risk in lower limbs: a secondary analysis of a randomized trial including 800 recreational runners. BMJ Open Sport Exerc Med. 2024; 10(1) E001787 *** We modified the Newsletter format to better match your time constraints. The more in-depth “Peak Perspective” will now be contained below in more “summary” form. We invite you to reach out to us at PT@peakptrochester.com or call our office at 585-218-0240 to further discuss this article or specific patient needs if you wish. The abstract can be found after the case study. PEAK PERSPECTIVE SUMMARY Studies show that up to 79% or more runners sustain lower extremity injuries. Orthopedic, primary care, and podiatric physicians along with physical therapists will see these athletes frequently for evaluation and determining best treatment approach. This often has included the recommendation for a biomechanical running analysis, assessing for both general abnormality in mechanics/style but importantly also determining any key asymmetries present that may underlie overuse patterns. This study by Malisoux and Gette et al on the surface may seem to suggest that running gait analysis based asymmetry may not be the correct variable/factor actually underlying running injuries. A deeper assessment of the study may caution providers to be slower in foregoing traditional treadmill running gait analysis for a number of reasons. As with so many studies there is more than meets the eye from reviewing the abstract alone! This study prospectively examined 874 recreational runners, as a part of a primary study looking at two different shoes cushioning sneaker types, and found 107 injuries over the 6 month study follow-up period, noting that there were no difference between leg asymmetries in kinetics or spatiotemporal variables measured for the injured runners group. They concluded that gait asymmetries with spatiotemporal and kinetic variables were not associated with increased injury risk. Consider for a moment the analogy of MRI findings with degenerative meniscal tears, or degenerative rotator cuff or lumbar disc pathology or even osteoarthritis. While past thinking early on revolved around identifying these abnormalities as definitive of injury and often receiving surgical treatment, current thinking has evolved based on newer research and better appreciation for the role MRI plays, and does not play, in defining a patient’s condition. We now know there are (+) MRI findings in asymptomatic people or on the contralateral side that caution “over-reading” the importance. The MRI, now more than ever before, is taken as key information but kept in context with the entirety of the history and clinical exam findings. Gait analysis according to this study is a similar case. Kinetics alone, (GRF, COG displacement, step length) did not correlate or predict those recreational athletes that became injured during this running time period. So, yes, this study suggests we take more caution in calling (certain) kinetic and spatiotemporal variable asymmetries between limbs as critical factors. Does this study then make them unimportant? Much like the vast number of MRI studies (+) for abnormality in contralateral limbs and asymptomatic populations - the answer is no, it is not unimportant. But we must take it all in context. Asymmetry of those variables may not be the key factor. Consider a runner with symmetrically excessive stride length causing poor heel strike and braking forces up the kinetic chain. This study would not find that because there’s no “asymmetry” noted. Same for the entire host of variables measured, which only looked for spatiotemporal and kinetic “asymmetry” - with the underlying hypothesis being that it is asymmetry that is the causative factor to eventual injury. Other studies have certainly demonstrated that asymmetry (i.e. unilateral weakness or tightness) can be related to injury and also poor performance. Running studies in particular have also demonstrated the biomechanics differences between novices and more expert/experienced runners. These kinetics based biomechanical findings also exist within each individual runner’s own kinematics factors and injury history, making even symmetric kinetic abnormalities “experienced” asymmetrically. Even if these kinetic measurements are not a direct predictor of injury, they are certainly not irrelevant. A key consideration not studied is how the forces of running (through the measured kinetics) are then absorbed and/or produced across the various joints and muscle groups. Kinematic variables like this would help define the percentage of load, including any asymmetry present, with how the ankle, knee, and hip handled those forces. This is also true for the triplanar nature of authentic function. This study viewed sagittal plane variables yet we know that frontal and transverse plane function is also simultaneously occurring, whether that be from a “stabilization” demand or a force production/reduction standpoint. Malisoux and Gette et al did not control for training load progressions, possibly the largest factor in expected injury. The fact this data also involves the participants testing and training using different shoes than they normally wear, potentially impacting running style but also introducing a key shock absorption variable into the kinetics and spatiotemporal factors attempting to be studied. “Injury” was also defined as causing a restriction or stopping of training for 7 days or more - meaning athletes who had to modify for shorter times and then able to resume, but then had symptoms return again may not have been included as having an “injury”. Our treadmill running analysis utilizes 2D video to capture not only sagittal plane but also frontal plane views for assessing kinetic (AND SPATIOTEMPORAL) variables. This study reminds us to be cautious of placing excessive importance on asymmetry but because of the various limitations falls short of proving kinetic analysis unimportant or unnecessary. Like MRI findings, the treadmill analysis becomes part of a larger battery of tests that help identify potential factors affecting the patient’s symptoms/function, leading to clinical decision making. The use of functional weight bearing mobility, dynamic balance, strength, deceleration, and power testing provides some level of kinematics related information that helps paint a fuller picture of how that injured runner developed their condition and thus identifies targeted areas for functional rehab. THE PEAK PERFORMANCE EXPERIENCE Jack said: “After two weeks of doing the ankle and hip stretches, I am starting to run again! My knee feels looser.” History: Left ITB pain at knee, not on the joint line. Running 2-3 /wk no more than 3 miles. Subjective: L knee pain with heel contact thru foot flat. Able to warm up and run through pain with increase in pain once cooled down. Sore to touch on the ITB and was also painful with over 5 miles of biking at a time. Objective: (*=pain) Initial Eval Re-Eval 6 wks Ankle dorsiflexion squat L 19 / R 10 L 21 / R 17 Single leg squat knee angle L 65 / R 85 L 78 / R 90 Calf raise in 15 sec L 25/ R 14 L 25 / R 14 3” quad dom step down (eccentric) 2-10# DB FRONT RACK L 24 / R 27 L 27 / R 28 Hip flexion L 85 / R 110 L 110 / R 120 Hip ER L 30 / R 48 deg L 42 / R 50 IKDC 59% 79 % Key Findings: Right ankle loss of dorsiflexion. Left hip limitations in external rotation and flexion. Left calf and quad weakness. Tender palpation ITB at the joint line. Gait analysis using 2D spark motion software revealed an increased step length on the L side and an increased tibial contact angle indicating increased GRF thru the L leg. Frontal plane analysis revealed L hip drop increase in foot flat and increased knee valgus compensation. Calcaneal eversion was the same, but the midfoot appeared to evert more on the L. Treatment: Hip external rotation/flexion stretch and hip mobilization for posterior capsule. Hip external rotation stretches with active frontal plane hip motion for strengthening and simultaneous posterior hip active stretch developing increased hip motion/concurrent strengthening in all planes. Standing ankle dorsiflexion active stretch with knee flexion for soleus (rather than gastroc) stretch. Progressive strengthening for left calf and quadriceps, quad dominant including step downs at 3 inches. Standing hip external rotation strengthening using bands for low row (eccentric external rotation control from hip to foot). Outcome: Strength and ROM measures significantly improved. Symptoms reduced to the point that the patient was running 3 miles 3/week pain free after four weeks of work. His biking increased gradually to 8-10 miles 2/week pain free as long as he stretched. ABSTRACT Background: Gait asymmetries in lower limbs during running are thought to generate differences in mechanical stress in a bilateral comparison and may expose runners to a higher injury risk. There is no current consensus on ‘normal’ levels of asymmetry and when an asymmetry will create an injury. We know that, when running, there is a wide variety of asymmetry in kinetic measurements such as stride length, ground Rx force, vertical displacement distance. This study indicates that these kinetic measures alone are not associated with higher injury risk. Also the variability between involved and uninvolved limbs in runners who sustained an injury was not correlated to the injury. Purpose: To investigate asymmetry in spatiotemporal and kinetic variables in 800+ recreational runners identifying determinants of asymmetry. Is greater asymmetry related to greater running injury risk with the kinetic variables between involved and uninvolved limb at baseline with treadmill analysis and a self-selected pace. Type: Secondary analysis biomechanical running analysis at baseline and 6 month follow up on running exposure comparing two running shoe prototypes with different cushioning properties. Methods: 874 recreational runners who were injury free from 18-65 years old and who had run without orthopedic insoles for 12 months volunteered for the study. They randomly received one of two running shoes differing only in their cushioning properties. They were tested on a treadmill at their self-declared preferred running speed. Three-dimensional ground reaction force (GRF) data was collected (step length, contact time, flight time, vertical oscillation of Centre of mass, peak GRF, peak braking force and propulsive force). During the 6 month follow-up running related overuse injury was defined as “a running-related musculoskeletal pain in either of the lower limbs that caused a restriction in distance, speed, or duration, or stopping of running for 7 days or more. Findings: 107 participants reported at least one running-related injury using the predefined definition of injury (any musculoskeletal pain that causes a restriction in distance, speed or duration, or stoppage of running practice over the previous month). Although leg length and other asymmetries were found, no between-limb differences were observed in runners having sustained an injury. Author's Conclusion: Gait asymmetry was not associated with higher injury risk for investigated spatiotemporal and kinetic variables. You can trust the Physical Therapists at PEAK PERFORMANCE to do a thorough evaluation, to search for related but underlying contributing factors to kinetic chain dysfunction, and to design exercise progressions that both respect tissue healing and creatively use biomechanics principles to prevent symptoms and optimize carryover to your patients' functional goals. Call us at 218-0240 to discuss your patient's specific needs. Peak Performance is just minutes away from your patients in Penfield, Fairport, Pittsford, Brighton, Rochester and, of course, East Rochester. We promise Individualized, hands-on and biomechanically appropriate Physical Therapy for your patients. No "one-size-fits-all" approaches. We WILL go the extra mile and "dig deeper" to discover underlying causes for injury risk and delayed recovery using the most advanced Evidence Based methods available and, we’re able to make unique adjustments to exercise prescriptions to speed the return to function and to minimize or prevent symptoms from interfering. No surprises. No hassles. Confident your patient is in the right place. COME VISIT US AT 161 E Commercial St Just 1 mile off 490 exit (585) 218-0240 www.PeakPTRochester.com
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  4. Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE March 2024 Clinical Decision Making: Utility of Physical Therapy for Glenohumeral Osteoarthritis Cases with Varying Radiographic Severity by Mike Napierala, PT, SCS, CSCS, FAFS What would you do? A 72 yr old golfer comes for evaluation of chronic progressive shoulder pain with associated loss of motion that has led to increased disability during ADL, yardwork, fitness, and golf. Clinical exam shows moderate limitation of elevation ROM asymmetrically, along with all other ranges tested. Strength is minimally affected but painful in most directions and producing palpable/audible crepitus especially with resisted abduction and abducted rotations. Plain films show mild-moderate severity osteoarthritis on one side and moderate-severe on the other side, , correlating to his asymmetric symptoms. The patient wishes to avoid any surgery as long as possible but does want to remain active. . I would do the following … Perform an intra-articular corticosteroid injection on at least the most severe shoulder and FU in 2-3 wks to consider physical therapy referral. Prescribe NSAID’s and topical Voltaren gel along with a home program sheet of ROM drills, FU in 4-6 wks. Prescribe physical therapy to include Class IV laser and joint mobilization along with exercise, FU in 4-6wks. Recommend viscosupplementation vs biologic injection options and proceed per patient choice. CURRENT EVIDENCE Bauman AB, Indermuhle T, et al. Comparing outcomes after referral to physical therapy for patients with glenohumeral osteoarthritis based on radiographic osteoarthritis severity: A retrospective analysis. Cureus. 15(8), 2023. https://assets.cureus.com/uploads/original_article/pdf/173193/20230905-28062-n725ly.pdf *** We modified the Newsletter format to better match your time constraints. The more in-depth “Peak Perspective” will now be contained below in more “summary” form. We invite you to reach out to us at PT@peakptrochester.com or call our office at 585-218-0240 to further discuss this article or specific patient needs if you wish. The abstract can be found after the case study. PEAK PERSPECTIVE SUMMARY Radiographic signs of glenohumeral (GH) osteoarthritis have been seen in 17-20% of adults over age 65. As physicians seeing increasing numbers of the aging population for shoulder pain and disability being aware of current best practices based on available evidence is not only necessary but helps in clinical decision making beyond “standards of care” that may have been developed years or decades earlier that were based on less available quality studies or on residency/fellowship practices habits primarily. While there is a significant amount of literature examining the efficacy of injections for glenohumeral osteoarthritis (GHOA) there remains a very limited amount of data available to discern the efficacy of conservative care based physical therapy. The American Physical Therapy Association (APTA) has developed a Clinical Practice Guideline (CPG) for GHOA in conjunction with representatives from AAOS and also AAPMR. (https://academic.oup.com/ptj/article/103/6/pzad041/7146561). Unfortunately higher levels for “strength of evidence” only exist for limited aspects of GHOA care decision making. Rene Dubois has been quoted as saying “The measurable drives out the important” - a statement considered inflammatory and a bit hyperbolic and overgeneralizing by some, yet holds some critical truth as well. Beyond the more variable and bias-risked world of case study and professional experience level evidence, the “truths” of orthopedics and rehabilitation are hoped by most to lie in evidence that reaches randomized clinical trial (RCT) levels of study and scrutiny. As studies are done exploring “mechanisms” and measuring “outcomes” the collective results are intended to drive clinical decision making. But what about when a topic has not been well studied…or studied thoroughly? Then what? This is the case to a great extent for GHOA. There simply is a lack of high level data to help physicians and PT’s alike make determinations on best practices. The fact remains that many, in fact, most patients with GHOA are not presently at a level that requires escalation to total shoulder arthroplasty (TSA) or a reverse-TSA. A common non-operative treatment of choice has been corticosteroid injections (CSI). There is at least some controversy over the use, especially repeated use, of CSI - while acutely helpful oftentimes, also has some evidence suggesting potentially negative downstream impact. Some studies, particularly in the knee, have even demonstrated a risk of early progression to arthroplasty from CSI. Additionally, some evidence exists suggesting biologics, like PRP, may show better/longer (+) changes for GHOA patients than standard steroid injection (Saif et al, Egyptian Rheumatology and Rehabilitation, 2018). This presents some dilemma and challenge since steroid injections are covered by insurance while PRP is not and can only be done as an added cash based service, meaning the majority of patients will choose CSI first when given options. Patients often indicate that PRP was never even discussed as an option despite the evidence suggesting mainly short term benefits and a potentially concerning risk profile of CSI in combination with at least some (+) evidence for PRP. Some would suggest this begs the question of whether treatment decision making is being based more on tradition/habit or truly evidence based rationales. Bauman et al provide some low level evidence that, like physical therapy for more common OA conditions of the hip and knee, shoulder OA can benefit from physical therapy as well. While certainly no conservative treatments have been proven to literally restore normal chondral anatomy and function, the evidence does show that patients receiving physical therapy can reduce symptoms and increase function with a low cost and very low risk treatment (PT) that also actively involves them in positively affecting their own care and outcomes. Their retrospective review of 220 patient cases divided between no GHOA (n=104), mild radiographic GHOA (n=61) and moderate/severe GHOA (n=55) referred to PT for shoulder pain were measured for pain (VAS), AROM into abduction, and Quick DASH scores. Post hoc testing showed no difference between groups for pain improvement, for abduction AROM, or for Quick DASH findings. While they showed only small (but statistically significant) short term improvements in pain, AROM, and disability across the varying severity levels of GHOA there was no significant association of the magnitude of change with severity. Only the mild GHOA patient group experienced clinically meaningful pain reduction (mean 2.4 pts reduction vs 1.4 no GHOA and 1.5 mod/severe GHOA). The mod/severe GHOA group actually showed the highest abduction AROM mean improvement (19.80 vs no GHOA 15.20 and mild OA 8.30). While surgical care for severe shoulder OA has trended upward significantly over the past decade with advances in technology and surgical techniques there does not appear to be an associated significant rise in the frequency of preoperative physical therapy utilization that might be expected. Physicians and orthopedic surgeons are at risk for assessing that patients with moderate and severe GHOA may be too advanced in their condition to benefit from physical therapy. Even for patients who likely may eventually need TSA or R-TSA there remains the need to optimize pain relief and function at low cost and low side effects. Bauman et al, albeit only providing low level retrospective analysis level data, demonstrate that even with more advanced GHOA physical therapy can be effective. One concern regarding the design and data presentation is that physical therapy was allowed to be “real world” in regard to its variability. There were no minimums or provider skill levels noted for manual therapy, no parameters for type and extent of exercises done, HEP compliance was not monitored, and a more typical bout of PT care for longer time period was not required - this study’s inclusion was only > 2 PT visits. All of these lead to the risk of “watering down” the efficacy all while still lumping in results as being definitive of “physical therapy care.” Nevertheless, this “real world” design strengthens the findings to some extent since despite this variability significant changes were nevertheless produced by treatments. It likewise produces a caution in believing that “only” minor changes can be made with physical therapy for GHOA. Our experience is certainly that skilled manual therapy is key in these cases along with very careful customized therapeutic exercise. So often we see failed PT cases who eventually do very well but initially were provided standardized shoulder ROM and strengthening protocol sheets to follow, without adequate regard for their biomechanical nuances needed. Obviously further quality studies are needed to provide better evidence. The limited number of mod/high quality studies left the APTA’s CPG for GHOA non-operative care guidelines reliant on clinical expertise level recommendations rather than moderate or high quality evidence for many of the areas of care relevant to decision making. Where specific GHOA data may be lacking the literature demonstrating beneficial outcomes of manual therapy and exercise for hip and knee OA may be considered supportive. And like hip and knee OA, shoulder OA, due at least in part to the expected ROM limitations/barriers that exist, become very reliant on effectively identifying kinetic chain needs - in this case, for especially scapular and thoracic function. Traditional PT approaches focusing on local shoulder needs and approaches often fail then to identify key needs of pectoralis minor restrictions to elevation ROM ease or of thoracic extension and rotation function necessary for UE reaching in ADL or work and recreational activities. The case below illustrates the efficacy possible with skilled PT care in a unique case of a patient with (B) GHOA at differing severities. THE PEAK PERFORMANCE EXPERIENCE John said: “I’m feeling much better now, I’ve got less crepitus, and I played 18 holes of golf without any issues!” History: 71 yr old male with 6+ yr gradual onset of L shoulder pain w fitness wt lifting but also had R shoulder partial RC tear debridement in 2007. After Covid based concerns he returned to the gym in mid-2023. Subjective: Initial verbal pain scale max was L 2/10 and R 1/10 with associated function ratings of L 80% and R 90%. CC included pain and limitation with dressing, OH reaching ADL especially limited with any loading, playing accordion, sleep disturbance and AM symptoms. Objective: (*=pain) Initial Eval L/R Re-Eval 9 wks L/R Quick DASH 20% 7% L 5% R Thor Rot sitting 500/580 630590 Pec Minor (Retraction in Elev) Max/Min+ Mod/< Min AROM flexion 1150 */1450* 1280/1620 IR up back L2*/T12* T12/T10 Neut ER 150/330 300/600 Abd ER 600/750 720/780 Isometric Jobe 3.3kg*/4.4 kg 5.6/6.4 kg Isometric Neut IR 6.7kg/10.5kg 15.1/16.5 kg Isometric Abd ER 4.4kg/6.4 kg 9.4/9.9kg Fxn - OH reach (L 70” and R 75.5”) 5# > 50x ea w ↑ IR 12# L 12x, R 25x Fxn - Row pulley @ 1mo 50# 22x/32x 50# cable 37x/40x Key Findings: Pec minor length significantly limited L > R w upward rotated scapula, mod+ crepitus L and minimal R. All AROM was limited and most were painful. Isometrics were initially symptomatic only with L flexion and Jobe though all were weak. Thoracic extension only min limited but asymmetrically limited in R > L thoracic rotation. Pt’s subjective pain reporting and function ratings were out of proportion to the symptoms noted and extent of limitation on objective testing. Treatment: Manual therapy: Pec minor release/mobilization and GH joint mob’s for L > R shoulder. Exercise: PROM stretching program following mob’s and done as HEP BID-TID for all major motions/directions/planes of shoulder…L > R. Customizing paths was necessary to avoid impingement sx often with elevation especially and with Abd’d IR. PRE were added once ROM work was fully in place. Pulling and rotational work was advanced before elevation work. Elevation PRE began with multi-joint incline pressing before long lever work was done in order to control extension/adduction moments at the shoulder. Functional rotational combination trunk drills done especially regarding golf concerns. Outcome: Pt successfully resumed 18 holes golfing and increased fitness wt lifting and ADL. Though his subjective ratings were only L 80% - - - > 80% and R 90- - - >98% his gross shoulder Quick DASH changed from 20% global to L 7% and R 5%, indicating with regard to rating the same activity categories he did, in fact, note significant changes in both shoulders, including the more moderately arthrtitic L shoulder. ABSTRACT Background: Glenohumeral osteoarthritis (GHOA) is a common cause for musculoskeletal pain and disability. Conservative care choices, including physical therapy, sometimes depend on radiographic severity of the GHOA. Purpose: This retrospective analysis aimed to examine how physical therapy impacts outcomes for patients with varying degrees of GHOA severity radiographically. Type: Retrospective analysis. Methods: Patients attending outpatient physical therapy between 2016 and 2022 for shoulder pain who had radiographs within two years of the initial PT visit, had at least one PT follow up visit following evaluation, and no history of shoulder surgery had charts reviewed for outcome measures of pain, abduction AROM, and Quick DASH scores. The 220 patients were divided into No GHOA (n=104), Mild GHOA (n=61), and Mod/Severe GHOA (n=55) groups based on radiographic findings. Findings: The mean age was 62.2 yrs and mean number of PT sessions 7.8x. Post hoc analysis showed no significant difference between any of the three groups’ improvements in pain, magnitude of AROM gain, or Quick DASH improvements based on the severity of radiographic GHOA. Author's Conclusion: Patients with GHOA have small but statistically significant short term improvements in pain, abduction AROM, and disability regardless of GHOA severity and no association between magnitudes of improvement with radiographic severity. Only patients with mild OA showed clinically significant improvements in pain. You can trust the Physical Therapists at PEAK PERFORMANCE to do a thorough evaluation, to search for related but underlying contributing factors to kinetic chain dysfunction, and to design exercise progressions that both respect tissue healing and creatively use biomechanics principles to prevent symptoms and optimize carryover to your patients' functional goals. Call us at 218-0240 to discuss your patient's specific needs. Peak Performance is just minutes away from your patients in Penfield, Fairport, Pittsford, Brighton, Rochester and, of course, East Rochester. We promise Individualized, hands-on and biomechanically appropriate Physical Therapy for your patients. No "one-size-fits-all" approaches. We WILL go the extra mile and "dig deeper" to discover underlying causes for injury risk and delayed recovery using the most advanced Evidence Based methods available and, we’re able to make unique adjustments to exercise prescriptions to speed the return to function and to minimize or prevent symptoms from interfering. No surprises. No hassles. Confident your patient is in the right place. COME VISIT US AT 161 E Commercial St Just 1 mile off 490 exit (585) 218-0240 www.PeakPTRochester.com
  5. Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE February 2024 Clinical Decision Making: Diagnostic Accuracy of an Updated 2-test Cluster for Greater Trochanteric Hip Pain…reducing time, patient discomfort, and costs for lateral hip pain by Allison Pulvino, PT, MSPT, CMP, FAFS What would you do? A 57 yr old female pickleball player comes for evaluation of lateral L hip pain of gradual onset over the past 2+ months after the start of her doubles pickleball season. She is R handed and moved up a level to more competitive play and from one to two days/wk. She already has been on a therapeutic dose of NSAIDs with only slight symptom reduction and rested for 3+ weeks earlier in the season but symptoms recurred after gradually returning to play again. She denies any frank trauma and has never had ecchymosis at the hip nor been substantially debilitated w ADL. Stairs are painful with mild compensation the day after playing. Early evaluation shows ambulation is WNL without any Trendelenberg sign. Hip AROM is WNL. Plain films show very mild symmetric early degenerative changes at both hips. Hip scour was only subtly uncomfortable at inguinal region symmetrically. Suspicion is for Greater Trochanteric Pain Syndrome with gluteal tendinopathy and/or bursitis. Lumbar screening was unremarkable for potential radicular/referred pain to the hip. I would do the following hip tests to assess for GTPS….. Palpate gluteal tendons/bursa and perform FABER, resisted Abd, resisted ER, resisted external de-rotation, Ober, Trendelenberg standing tests Order an MRI to more clearly assess gluteal/bursa tissues Perform standing single leg squat test, 30sec single stance test, palpate gluteal tendons/bursa, resisted IR Palpate gluteal tendons/bursa and perform resisted Abd Do diagnostic US and consider doing bursa injection if indicated CURRENT EVIDENCE Kinsella R et al. Diagnostic Accuracy of Clinical Tests for Assessing Greater Trochanteric Pain Syndrome: A Systematic Review With Meta-Analysis. Journal of Ortho & Sports PT. January 2024. Volume 54. Number 1. 26-49. PEAK PERSPECTIVE SUMMARY Lateral hip pain due to greater trochanteric pain syndrome (GTPS) is a common complaint seen by physicians, affecting up to 25% of the population, with greater risk from increased age, female sex, low back pain, and greater adiposity. It is highly beneficial to be able to determine the diagnosis in a timely manner and with the least number of painful provocative testing needed for diagnosing the condition and deciding on best treatment options, especially when a patient is in the more painful/reactive acute or subacute stage of symptoms. While imaging can be helpful, plain films are of limited value outside of grading OA changes, which often show varying correlation to actual symptoms or function. MRI and US tests, while being expensive in addition to clinical exams, also have a higher than desired rate of false positive findings regarding abnormalities found in asymptomatic people. The ability to be able to quickly and accurately rule in or rule out certain diagnoses, in this case GTPS, using clinical testing while minimizing the cumulative discomfort we put the patient through is highly valuable and also can improve physician and therapist efficiency in managing busy caseloads. Kinsella et al. did a systematic review looking at diagnostic accuracy studies for GTPS that had 6 of 858 studies meet the criteria for inclusion. There were 272 total subjects (252 with symptoms and 20 without) with 314 hips assessed. Across all studies there were 15 different tests used. These were compared against reference MRI findings. Statistical analysis showed the best combination of positive likelihood ratio (LR) and negative LR for shifting the probability of a positive test confirming GTPS or a negative test ruling out GTPS showed the 2-test cluster of greater trochanteric palpation pain and pain with resisted hip abduction to be best. It was the only combination of tests whose + LR and -LR both shifted the probability of an accurate diagnosis significantly. Others had sensitivity and specificity values that were high on one and moderate or low on the other, same with LR’s. Some of these tests included the 30-second single leg stance, Trendelenburg sign, FABER, and resisted hip external de-rotation testing. The (+) LR for many tests include higher scores such as 30-second single leg stance and Trendelenburg sign, but not necessarily an acceptable (-)LR. Kinsella et al concluded both greater trochanter palpation testing (+ LR 2.62 and -LR 0.25) as well as resisted hip abduction tests (+LR 6.09 and -LR 0.45) as best for patients with GTPS lateral hip pain. Utilizing this 2-test cluster limits the manual manipulation and provocative testing required in a clinical exam of a patient’s hip through painful movements and stresses. One limitation of the study is the use of MRI as the “gold standard” since results can be positive for abnormal findings in asymptomatic patients. This study’s conclusions can assist with saving patients both time and money and also improve clinician efficiency. When the diagnosis is confirmed, the severely symptomatic patient may seek immediate relief with treatments such as cortisone or oral medications, however, in the majority of cases addressing the root underlying cause of the symptoms remains key. In the clinic we often see patients who have had good symptomatic control of their pain and temporarily improved function through various means, whether that be injection, NSAIDs, rest, activity modification etc. but without any specific evaluation of biomechanical/orthopedic issues contributing to the abnormal loading of lateral hip structures. In these cases patients too often exacerbate again upon return to activity because the very same loading patterns and inadequacies exist despite temporarily reduced pain and inflammation. Thorough detailed kinetic chain functional movements and manual assessments done as part of a physical therapy evaluation are necessary to identify limitation patterns in patients with lateral hip pain or a diagnosis from a physician confirming GTPS. The most common findings in PT exams can be hip flexion contractures, lack of functional hip capsular adduction with a common varus deformity (not just typical IT band tension) and/or a lack of functional hip IR mobility - both causing increased lateral tissues tensile loading…but also can be related to excessive hip adduction and/or IR, such as with anteversion or proximal effects of overpronation and dynamic knee valgus that may happen due to foot deformities or even as a compensation due to limited talocrural dorsiflexion (with squatting or lunging) . Others include especially the long leg side of a leg length discrepancy via repetitive tensile loading from always being “on stretch” to the shortened side having abnormal ITB tightness that causes tensile loading (or bursal compression) stresses with various wb activity positions. Hip abductor and external rotator weakness is another area of more obvious causative factors. Scoliosis compensations can also impact demands on the pelvis/hip region and must be assessed. Addressing both these local hip factors and also importantly the other adjacent or even contralateral kinetic chain issues is critical in optimizing long term success for GTPS patients. A focus on Applied Functional Science © approaches using authentic wb proprioceptive input and forces helps ensure the body can effectively transfer those exercise induced training effects into real-life ADL, sport, work, and recreational use. Too often traditional therapy hip exercises involving various NWB stimuli can be highly performed but the disconnect to authentic WB function leaves the hip still overloaded. Oftentimes even a simple correction of foot alignment with OTC, and less often custom, orthotics is helpful/necessary. A thorough functional biomechanics based approach is a key step in optimizing chances the patient can return to activity successfully long term and prevent the need for more invasive procedures down the road. THE PEAK PERFORMANCE EXPERIENCE Mary said: “I’ve had up to 8/10 pain and now I can walk a ton and use the stairs as many times as I want!” History: Chronic L lateral hip pain with hx of multiple cortisone injections in trochanteric bursa, and even recent tenex procedure 2 weeks before starting PT. Subjective: Pain gets up to 8/10. Unable to sit > 15min, pain with any stairs with ascending stairs more painful, unable to cross legs or sidelie in bed, and pain wakes her up at night. Objective: (*=pain) Initial Eval Re-Eval 8 wks Ober’s test Positive Negative Thomas test Positive Negative Squatting Not tested d/t pain Full depth and painfree S/L hip abduction test Unable* L 20x, R 16 (No pain/fatigued) SLB endurance Unable* 12 sec Sit-stand Pain* Pain-free Key Findings: Lack of hip extension, adduction and ER mobility, decreased hip abd strength with pain, lack of hamstring flexibility, midfoot pronation collapse in WB B, lack of spinal extension with only 20% and reversal of lordosis, significant gastroc tension affecting foot alignment, L > R hip flexor weakness, femoral IR alignment in WB. Treatment: Manual therapy: Anterior hip glide mobs in NWB and WB, hip ER jt mobs with passive stretching, WB hip mobs into adduction to assist WS in stance phase. Exercise: hip abductor strength progression from gravity eliminated AROM to standing hip OKC abduction to against gravity OKC hip abd to SL balance loading in static and then dynamic phases. Squat progression from bridging with hip abd strap to WB modified range squats to full depth. Lateral stepping progression starting with assist from SG and TR plane stepping drills. Hip flexor stretching and eccentric loading in WB with opp LE fwd stepping/reaching drills. Outcome: Pt able to sit > 30 min, transfers all pain free, walking as long as she would like w/o limitation, stairs pain free multiple times a day. Pain only up to 3/10 with extended periods of WB and advanced tasks such as lifting and carrying. (All progress documented after only 8 weeks of PT). ABSTRACT Background: There are numerous clinical tests that exist that can be performed during hip exams, but determining which are the most accurate can save the clinician time and help arrive at an appropriate diagnosis in less time with more certainty. Purpose: This study aimed to evaluate the accuracy of hip clinical tests that are used to diagnose greater trochanteric pain syndrome. Type: Systematic review with meta-analysis Methods: Literature search using key words mapped to diagnostic test accuracy for GTPS. Risk of bias was assessed using QUADAS-2 tool. And certainty of evidence GRADE framework. MetaDTA “R” random-effects models were used to summarize both individual and pooled data, including sensitivity, specificity, likelihood ratios and pretest-posttest probabilities. Findings: Of 858 studies, 23 full tests were assessed. 6 studies were included for review that involved 15 tests and 272 participants. In participants reporting lateral hip pain, a negative gluteal tendon (GT) palpation test followed by a negative resisted hip abduction test significantly reduced the posttest probability of GTPS from 59% to 14%. In those with a positive GT palpation test followed by a positive resisted hip abduction test, the posttest probability of GTPS significantly shifted from 59% to 96%. Author's Conclusion: Prior use of MRI for diagnosing GTPS is debated due to positive findings in asymptomatic individuals. This study finds a clinical test cluster that can accurately help confirm or refute the presence of GTPS in individuals reporting lateral hip pain. You can trust the Physical Therapists at PEAK PERFORMANCE to do a thorough evaluation, to search for related but underlying contributing factors to kinetic chain dysfunction, and to design exercise progressions that both respect tissue healing and creatively use biomechanics principles to prevent symptoms and optimize carryover to your patients' functional goals. Call us at 218-0240 to discuss your patient's specific needs. Peak Performance is just minutes away from your patients in Penfield, Fairport, Pittsford, Brighton, Rochester, and, of course, East Rochester. We promise Individualized, hands-on and biomechanically appropriate Physical Therapy for your patients. No "one-size-fits-all" approaches. We WILL go the extra mile and "dig deeper" to discover underlying causes for injury risk and delayed recovery using the most advanced Evidence Based methods available and, we’re able to make unique adjustments to exercise prescriptions to speed the return to function and to minimize or prevent symptoms from interfering. No surprises. No hassles. Confident your patient is in the right place. COME VISIT US AT 161 E Commercial St Just 1 mile off the 490 exit (585) 218-0240 www.PeakPTRochester.com
  6. Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE January 2024 Biomechanical Pitfalls Promoting Achilles Tendonitis in Recreational Runners by Andrew Neumeister, PT, DPT, FAFS, Certified Running Gait Analyst Clinical Scenario…What would you do? A 41 yr old male recreational runner with R achilles area pain developing gradually over the past 6 wks comes in for evaluation. Plain films are (-) and clinical exam shows tenderness on the R achilles tendon (AT) several cm above and down to the calcaneal insertion, painful vertical hopping and standing plantarflexion raising. Bilateral squat testing reveals limited ankle wb dorsiflexion while single leg squat shows asymmetric dynamic valgus and overpronation compared to the L side. He reports recently increasing weekly mileage from 20- - - >30 miles over his 4 days/week running frequency. I would … Order an MRI to confirm suspected achilles tendinopathy and R/O other possible causes. FU in 2 wks after starting a course of OTC NSAID’s to check progress and decide a plan of care. Advise rest from running for 4-6 weeks with a change to non-impact cross training options and FU in 4 wks. Prescribe a customized, biomechanical PT evaluation along with a running analysis to establish a customized functional exercise program geared to address any running pathomechanics. To include manual therapy, therapeutic taping trial, and Class IV laser therapy as indicated. Provide handout of standard calf stretching and ankle tubing resisted PF strengthening PRE with orders to reduce running mileage by 50% and frequency to BIW-TIW. Refer for custom orthotics evaluation and management along with non-impact cross training. FU in 4 wks. CURRENT EVIDENCE Skypala J, Hamill J et al. Running-Related Achilles Tendon Injury: A Prospective Biomechanical Study in Recreational Runners. J Appl Biomech. 2023 (online Jul 7), 39(4):237-245. https://journals.humankinetics.com/view/journals/jab/39/4/article-p237.xml We invite you to reach out to us at PT@peakptrochester.com or call our office at 585-218-0240 to further discuss this article in further detail if you wish. The abstract can be found after the case study. PEAK PERFORMANCE PERSPECTIVE Orthopedists and PCP’s often evaluate runners presenting with achilles tendon symptoms, easily discernible through palpation and painful resisted plantar flexion in weight bearing. Achilles tendonitis/tendinopathy (AT) is among one of the most common running related injuries (RRI), occurring up to 22% in recreational runners and has been shown to decrease running performance in up to 66% of runners during the first year after injury. Recommending treatment involves more than simply “routine” physical therapy as studies show that a running analysis can be helpful/necessary and contributing factors can easily be missed when simple “stretching and strengthening exercises'' PT concepts are ordered and employed. The study’s regression analysis showed that knee flexion angle increases at initial contact(IC) and midstance (MS) resulted in greater risk of AT - for every 1° of knee flexion angle increase; there was a 15% rise in AT risk. The authors hypothesized this may be related to alterations in the effective mechanical advantage of the gastroc complex. Dorsiflexion was also significantly greater at midstance. Foot strike patterns were not found to contribute. Clinically speaking we find that AT must involve a thorough biomechanical evaluation as there are numerous potential contributing factors, most of which were not analyzed or data not shown in this study. There are also many possible underlying reasons why a runner might exhibit this increased knee flexion angle at IC and MS. Merely being aware this finding is present does not indicate the actual cause that must be addressed with physical therapy. While coaching/cueing generic running form or cadence changes may temporarily alter symptoms and performance it is paramount that causative factors be identified so that tightness and/or weakness etc. are properly addressed so the compensatory abnormal knee flexion no longer is necessary in the first place. Further Details… Skypala 2023 et al. conducted a prospective biomechanical study in recreational runners to assess which mechanics during phases of running have influence on the RRI of AT. The authors reported that many previous cross sectional and retrospective studies conclude runners with AT have greater ankle dorsiflexion and eversion during the loading phase of running, and also noting conflicting reports showing either increased and decreased knee flexion during stance phase. These studies, however, were performed on runners already having AT, therefore do not confirm causal relationships but may reveal compensatory patterns due to pain. Skypala et al. set out to determine whether biomechanical variables were related to the incidence of RRI AT for one year in low-volume runners. The authors defined an AT RRI as pain in the AT region requiring medical evaluation or resulting in limited/cease of running for at least 7 days or 3 consecutive running sessions. Of the 318 original participants who met the inclusion criteria were 108 recreational runners aged 18 - 65 yr old with a weekly mileage under 51 km/wk and were free of musculoskeletal lower extremity injuries 6 months prior to the study. A 10 camera motion analysis biomechanical assessment using 24 markers while using a self-selected speed (for 45 min run pace) over a 17m force plate runway while wearing provided “neutral” running shoes was done, analyzing R side mechanics for this study. The authors reported that 26 (15 males and 11 females) or 25% of the final 103 participants completing the study had R sided AT within one year after biomechanical analysis, with 18 runners (17%) developing (B) AT. Biomechanical predictors that were associated with development of RRI AT were an increased knee flexion angle at initial contact (OR=1.146, P = .034) and midstance phase (OR=1.143, P=.037). Therefore, a 1° increase of knee flexion at initial contact (IC) and midstance (MS) was associated with a 15% increase in risk of developing RRI of AT. Runners with AT also showed significantly increased dorsiflexion (P=.010, ES=0.630) during stance phase and at baseline had lower body fat % (P=.041, ES=0.491) and reported more mod-vigorous activity (P=.048, ES=0.630). Foot strike pattern was not a risk factor (OR=0.997, P=.807). Effective mechanical advantage (EMA) of the medial and lateral gastroc reduce as the increase in both the knee and ankle flexion angles causes larger external flexion moments which then require greater muscle force to decelerate and then propel the body. The authors proposed this as a potential mechanism for the achilles overloading. Skypala et al’s study does have some important limitations that must be considered. As an endurance runner myself, it can often take time to establish your preferred speed in a study like this where runners were crossing a 17m over 6 minutes and stop/starting at each end. Simply cueing someone to run at a “45 min running pace” cannot simply be established in 6 minutes of inconsistent running. Runners used a “neutral” running shoe which does not account for each individual's preferred footwear during testing, thus potentially causing modifications from their otherwise typical running mechanics but also is then not the same footwear used during the subsequent year of running for the study. Foot dynamics were not assessed during the study thus no data regarding pronation and supination mechanics, with any over-the-counter orthotics, “pronation control”, or minimalist footwear used during training were analyzed. DF angles during IC and MS may be altered depending on different heel drop heights between shoes. The amount of calcaneal eversion can also be variable in control depending on orthotic design or the footwear itself. All of those factors above can influence the stress on the AT during running that was not accounted for during motion analysis in the lab. Regarding foot strike patterns it would require further analysis as to whether an adequate variability and number of participants having differing foot strike tendencies to power finding significant differences were present in the study. Why does any of this matter when recommending an appropriate treatment plan? It is not as simple to tell your patient to reduce their DF and knee flexion angle while on a run to reduce mechanical stress. The data suggests that reducing peak knee flexion and dorsiflexion angle reduces tension on the achilles tendon through improvement in their biomechanics, however does not address how to take this knowledge and then apply it to appropriate treatment methods. It is not inherent for patients and many therapists to know how to provide proper functional treatment while rehabilitating AT taking account of the dynamic activity which caused them to seek medical attention. A specific biomechanical evaluation assessing running form and technique using 2D motion analysis allows for the therapist and patient to visualize where external joint angles can increase stress on the entire lower extremity system contributing to AT pain and other common running injuries at each of the ankle, knee, and hip complexes. Ankle/foot mechanics need to also be assessed to determine where limitations in mobility or pronation control could exist as biomechanical pitfalls. Correction utilizing an appropriate orthotic can aid in reducing stress to the system caused by ground up tibial internal rotation and subsequent dynamic valgus. A functionally trained physical therapist with knowledge of running biomechanics can establish a return to running program with necessary cues to reduce impact stress during the stance phase from start to finish. Anderson et al. reported that increasing cadence has been shown to have a large effect on reducing peak ankle DF and knee flexion angles. Through an appropriate biomechanical evaluation and treatment geared specifically to the runner’s goals, results can be obtained quicker by addressing specific biomechanical results. While Skypala et al. used a large group prospectively to better understand commonalities among runners developing AT, it must also be remembered that each individual runner brings unique physical abilities and limitations that potentially affect risk of developing AT. More in-depth biomechanical kinetic chain assessments must be included for effective physical therapy care beyond merely utilizing group findings such as from this study, especially considering the variety of kinetic and kinematic information not analyzed here. A variety of limitations such as limited ankle DF, abnormal foot mechanics leading to prolonged overpronation during propulsion phase, poor contralateral propulsion or swing phase function, proximal hip Abductor and/or ER’s weakness, and weak quadriceps among others have all been findings we’ve noted that potentially have contributed to AT cases in runners. THE PEAK PERFORMANCE EXPERIENCE A 1° increase of knee flexion at initial contact (IC) and midstance (MS) was associated with a 15% increase in risk of developing RRI of AT. At a cadence of 150-160, the peak knee flexion ankle at midstance is 50°. Below are images of the author running at 7.5 mph speed at 8 different cadences ranging from: 150 steps/min to 220 steps/min increasing by 10’s respectively. A reduction of knee peak knee flexion reduces as cadence increases, down to 32° at 220 steps/min. 1. 2. 3. 4. 5. 6. 7. 8. (angles are calculated by (180° - X deg. below) Skypala J, Hamill J et al. Running-Related Achilles Tendon Injury: A Prospective Biomechanical Study in Recreational Runners. J Appl Biomech. 2023 (online Jul 7), 39(4):237-245. Abstract Background: Few running studies have attempted to prospectively identify biomechanical risk factors associated with Achilles tendonitis injuries. Many studies have been done retrospectively on individuals with AT and have not identified if the results are mere correlation and not causation. Purpose: The authors set out to determine what potential factors there may be associated with developing AT in healthy recreational runners. Type: Prospective Study Methods: 103 healthy recreational runners had their kinematics and kinetics assessed with a motion analysis system at a self selected running speed. They then completed weekly questionnaires at home for the following year to determine if they had developed AT per the authors definition of the running related injury. Findings: A more flexed knee at initial contact and at the midstance phase were significant predictors for developing the Running Related Injury of AT. Runners who had a significantly greater maximal ankle dorsiflexion during the stance phase also were found to be a risk factor for developing AT. Author's Conclusion: The incidence of running related AT over a 1-year prospective evaluation was 30%. Participants with AT RRI ran with greater angles of knee flexion and dorsiflexion during stance phase. This potential risk factor could be attributed to a mechanical disadvantage of the gastrocnemius complex with a flexed knee. The effective mechanical advantage is reduced as external moment arms increase at the knee angle ankle with individuals exhibiting greater knee flexion and ankle DF. (Citation for evidence regarding the effect of cadence on running kinematics) 2. Anderson LM, Martin JF, Barton CJ, Bonanno DR. What is the Effect of Changing Running Step Rate on Injury, Performance and Biomechanics? A Systematic Review and Meta-analysis. Sports Med Open. 2022 Sep 4;8(1):112. doi: 10.1186/s40798-022-00504-0. PMID: 36057913; PMCID: PMC9441414. You can trust the Physical Therapists at PEAK PERFORMANCE to do a thorough evaluation, to search for related but underlying contributing factors to kinetic chain dysfunction, and to design exercise progressions that both respect tissue healing and creatively use biomechanics principles to prevent symptoms and optimize carryover to your patients' functional goals. Call us at 218-0240 to discuss your patient's specific needs. Peak Performance is just minutes away from your patients in Penfield, Fairport, Pittsford, Brighton, Rochester and, of course, East Rochester. We promise Individualized, hands-on and biomechanically appropriate Physical Therapy for your patients. No "one-size-fits-all" approaches. We WILL go the extra mile and "dig deeper" to discover underlying causes for injury risk and delayed recovery using the most advanced Evidence Based methods available and, we’re able to make unique adjustments to exercise prescriptions to speed the return to function and to minimize or prevent symptoms from interfering. No surprises. No hassles. Confident your patient is in the right place. COME VISIT US AT 161 E Commercial St Just 1 mile off 490 exit (585) 218-0240 www.PeakPTRochester.com
  7. Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE (December 2023) Clinical Decision Making with PFPS: RCT Evidence for Utility of High-Intensity Laser Therapy by William Slapar, PT, DPT, OCS, FAFS, CMTPT, CAFS Clinical Scenario...What would you do? A 20 yr old competitive female college soccer player with L PFPS for 6 weeks duration has not improved significantly after working with her athletic trainers comes for evaluation and treatment recommendations. She has mild symmetric lateral tracking with plain film Merchant view. There is peripatellar tenderness along medial > lateral border, without inferior pole tenderness. Squatting is limited/painful with slightly asymmetric dynamic valgus/rotation noted. Single hopping is moderately reduced and painful. WB ankle DF is asymmetrically reduced ipsilaterally and prone rotation PROM (IR >> ER) suggests asymm larger L anteversion. The patient has 5 wks remaining before soccer season begins and prefers to avoid repeating traditional rehab (typical simple LE stretches, step ups, leg press, clamshell and abd-add machine hip work, TKE quad bench strengthening) due to the lack of prior efficacy. My clinical thinking is: Obtain an MRI since the patient is not improving and little time left before the season. FU 2 wks for treatment plan. Provide with PF stabilization brace, order continued rehab work with ATC’s but doing more advanced exercise progressions for returning to soccer, allowing < 3/10 sx max Order custom orthotics and Physical Therapy to include nwb hip Abd and ER PRE. Prescribe customized biomechanical PT including specific functional exercise per evaluation findings, Class IV laser photobiomodulation therapy, trial w/elastic therapeutic taping, and joint mobilization for ankle DF. CURRENT EVIDENCE Qayyum HA, Arsalan SA, Tanveer F, Ahmad A, Javaria, Gilani SA. Role of High Power Laser Therapy on Pain Reduction in Patients with Patellofemoral Pain Syndrome. Pakistan Journal of Medical and Health Sciences. 2022;16(6):9-12. doi:https://doi.org/10.53350/pjmhs221669 *** We are modifying the Newsletter format to better match our physicians’ time constraints. The previously more in-depth “Peak Perspective” will now be contained below in more “summary” form. We invite you to reach out to us at PT@peakptrochester.com or call our office at 585-218-0240 to further discuss this article in further detail if you wish. The abstract can be found after the case study. PEAK PERSPECTIVE & SUMMARY: PCP’s and orthopedists often evaluate patients presenting with anterior knee pain that is suspicious for Patellofemoral Pain Syndrome (PFPS) and must determine the optimal treatment regimen to prescribe. Over the past years Class IV therapeutic laser has become more popularized as a treatment option for musculoskeletal conditions. Numerous journals are dedicated to investigating the efficacy of laser (Lasers in Medical Science, Lasers in Surgery and Medicine, Laser Therapy…etc.). Class IV laser becomes a key consideration for physicians considering current evidence and best practices for PFPS cases. Qayyum 2022 et al. performed a randomized control trial (RCT) to determine the effects of High Intensity Laser Therapy (HILT) on pain reduction in patients with PFPS. They compared HILT + “standard” therapy exercises to a control group using the same physical therapy exercises alone over 4 weeks. They found a significant VAS reduction in both groups but by the 4th week there was a statistically significant greater reduction in VAS pain scores in the experimental group compared to the control group. This was maintained through the 8 weeks of the study. While often mistakenly overgeneralized or referred to as chondromalacia, PFPS remains a very common diagnosis in orthopedics and sports medicine. Common treatments including various stretching and strengthening have been proposed. It is now understood to be a multifactorial condition and thus less appropriate for “protocol” based approaches but more so deserving of customized care dependent on the contributing factors discovered on testing. High-Intensity Laser Therapy (HILT) is an important option shown to produce analgesic, anti-inflammatory, and tissue healing effects for musculoskeletal disorders (MSD). This works through a process deemed photobiomodulation. This is where photons are absorbed by proteins in the mitochondria, which then increase ATP production, reactive oxygen species, and nitric oxide to help with tissue healing, cell energy, and improving inflammatory effects. Newer models of Class IV laser therapy, specifically using 25W and even more recently 40W power have greater capacity for more immediate analgesic effects. Especially for those who may have exhausted safe NSAIDs use or who have comorbidities precluding medications assistance with pain/inflammation reduction, this study adds to the body of evidence showing Class IV laser can be not only an effective component to PFPS rehab but, importantly, it can produce superior pain reduction more quickly. It must be noted this study used only a 10W HILT laser while now more powerful Class IV lasers utilizing up to 25W are used in the clinic and have the capacity for deeper penetration and quicker, more significant analgesic effects. The “routine” physical therapy that included standardized LE stretches, patella mobilizations along with strengthening of quads (DB squats and wall squats, SLR), hamstring strengthening (not specified), hip abduction and adduction (not specified) - all done 4 days/wk at 5-10 repetitions for strengthening exercises, is grossly inadequate and as common with many studies was not “high level” therapy, also due in nature to failing to customize exercises to evaluation findings. This is critical because it means some patients were doing stretches that were unnecessary while other important limitations (e.g. hamstrings or soleus) were not addressed. The protocol used also focused solely on sagittal and frontal plane work but appears to have neglected transverse/rotational planes of function. Biomechanical based approaches must include consideration of foot-ankle mechanics influences, proximal hip influences, and even contralateral limb issues that can produce abnormal forces on an involved PFPS knee via kinetic chain effects. We often find that manual therapy techniques are necessary in PFPS cases, whether that be soft tissue mobilization (STM) or joint mobilization work (e.g. ankle DF). The study would be stronger had the authors included objective measures of performance (such as rotational balance ability and control, squat depth, hop function, or quadriceps anterior stepdown strength), to provide better objective proof of improved outcomes. Patient centered outcome scales of performance also were not measured. Scales such as a LEFS or KOOS or IKDC would show evidence of actual performance improvement vs. simply symptom reduction without verifying a return to higher level activity demands. An easily missed finding in Qayyum et al study is that it took four weeks of laser therapy to produce the significantly better VAS reductions. Oftentimes patients can be easily discouraged by slow outcomes with conditions such as PFPS, especially when an impending goal timelines or demand is nearing. This serves as a reminder to PTs and physicians to educate patients that laser efficacy may require weeks of consistent treatment to produce superior outcomes rather than using only a few sessions or two weeks as a litmus test of sorts. Finally, the overall exercise portion in this study was lacking. It is important to consider that PFPS can include contributions from multiple joints via kinetic chain biomechanics. With there being multiple factors involved and needing change to occur to produce symptom relief and improved performance there may be a need for time to pass until the pain/cause of the abnormal mechanics is reduced. Having the necessary patience is not easy for many patients. The case below illustrates a patient who benefited from incorporating Class IV Laser into his program with a diagnosis of PFPS to recover from chronic anterior knee pain to strength training with less symptoms. The patient is still in physical therapy for further treatment. THE PEAK PERFORMANCE EXPERIENCE Brian said: “The right knee is so much better after performing laser, squatting is more manageable and I can perform reciprocating steps down stairs.” History: 36 y/o male with chronic right anterior knee pain with L knee most recent MCL sprain from picking up tennis and twisting right with left leg being planted. Pt had right anterior knee pain for years in which has tried PT before but with not too much of a difference and stairs and squatting motions tend to be more painful and unable to reciprocate descending stairs. Subjective: 6/10 pain with jumping, running, squatting, stair negotiation, getting in and out of a chair Objective: (*=pain) Initial Eval (R/L) After laser demo (RLE) 1 mo ReEval AROM knee flexion 120*/130* (deg) 134 deg 140 B step downs ( 2 inch) quad dom. x8*( DKV moderate)/x15* 10* ( no DKV) 4/10*→2/10* 8# 4 inch x10, x14 SL squat ( knee flexion) 55 */ 85* (deg) squat: 95 deg (4/10*) to 100 deg (2/10*) 100*/ 105 (deg) Ant lunge R= ant knee pain with reduced DF no pain and knees over toes WB StJn DF (knee flexed) 23/25 (deg) 26/ 30 (deg) Step up: 8# R= 4 inch L=6 inch x20*/ x20 R=3/10*→2/10* 15# R=4 inch x22 L=6 inch x18 Prone hip IR 20 deg B 28/25 deg Key Findings: At evaluation pt had pain in the bilateral knees with the right being a chronic case and the other being an MCL sprain from a recent tennis injury. Pt showed having more reduction in strength and function on the right side compared to the left, which could have made the right side compensate more for the right LEs faults. Pt shows reduction in hip internal rotation. Treatment: Pt treatment started with Class IV laser, with manual to address hypomobilities in the ankle, soft tissue mobilization to address TrPs in the quadriceps. Stretching for hip Irs and then addressing movement quality with hip rotation exercises in standing to address sport specific motions. Pt worked on strengthening the hip extensors to improve loading for tennis specific motions. Pt also performed quadriceps strengthening, step downs with post OH reach for quad angulation, which shows a moderate dynamic knee valgus. Outcome: The patient after a laser demo was able to perform more squat motion and stair negotiation ability as well with less pain. The step down also improved in mechanics of no longer having dynamic knee valgus (DKV). Pt is now able to split squat and reach near the floor with 2/10 pain, with increasing loads and depths on functional and sport specific movements to help rehab him to sport. Pt still shows deficits in hip and quadriceps strength comparison and depth which is still coming to PT but there are vast improvements in just one month with having a chronic status of a diagnosis. ABSTRACT Background: PFPS is a very common MSD in which affects 23% of the general population and high prevalence in elite athletes. There are very many biomechanical factors that can be causing pain at the knee, whether it be weakness, reduction in ROM or abnormal structure of a specific joint in the LE kinetic chain. HILT has shown positive impacts in reducing pain in other MSD. HILT shows having effects on inflammation, tissue healing, and pain reduction. Purpose: To determine if HILT will reduce knee pain in with patients with PFPS Methods: Sixty-six subjects from 2 groups, control group of routine physical therapy (PT), and the experimental group of HILT and routine PT. Pain was interpreted using the VAS scale Findings: The data shows that there was a within group significant difference for each assessment of pain for routine PT and routine PT + HILT. At week 4 and 8 between groups shows a significant difference in the mean showing HILT + PT shows superior results in reduction in pain. Author's Conclusion: There is a reduction in pain when using HILT for patients with PFPS. You can trust the Physical Therapists at PEAK PERFORMANCE to do a thorough evaluation, to search for related but underlying contributing factors to kinetic chain dysfunction, and to design exercise progressions that both respect tissue healing and creatively use biomechanics principles to prevent symptoms and optimize carryover to your patients' functional goals. Call us at 218-0240 to discuss your patient's specific needs. Peak Performance is just minutes away from your patients in Penfield, Fairport, Pittsford, Brighton, Rochester and, of course, East Rochester. We promise Individualized, hands-on and biomechanically appropriate Physical Therapy for your patients. No "one-size-fits-all" approaches. We WILL go the extra mile and "dig deeper" to discover underlying causes for injury risk and delayed recovery using the most advanced Evidence Based methods available and, we’re able to make unique adjustments to exercise prescriptions to speed the return to function and to minimize or prevent symptoms from interfering. No surprises. No hassles. Confident your patient is in the right place. COME VISIT US AT 161 E Commercial St Just 1 mile off 490 exit (585) 218-0240 www.PeakPTRochester.com
  8. Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE November 2023 The Effects of Power Training Frequency on Muscle Power and Functional Performance in Older Women: A Randomized Controlled Trial by Karen Napierala MS, AT, PT, CAFS What would you do? A 72 year old woman comes to PT with a history of falling over the past year. Her primary CC is a painful R knee along with lumbar DJD symptoms also. She underwent L THR three years prior and reports good function without hip pain. She wants to play in the yard with her grandchildren, who are under 10 yrs old, but feels unsure of her footing on the grass and at times is apprehensive due to occurrences of a “step in the wrong direction” causing sudden knee pain and associated giving way. Plain films show > moderate DJD of her R knee. R knee AROM is 5-1150, single leg squat is moderately decreased vs L, and SLB control is minimally reduced with static testing. I would prescribe… A. “RICE”, NSAIDs, and gradual activity return as able over 2-4 wks - call if problems persist. B. Obtain a knee MRI and lumbar plain films. Prescribe NSAID’s and recommend Physical Therapy (providing a geographic based list of options). C. Customized biomechanical PT to include Class IV laser, manual therapy, customized exercise/balance training progressing to include “speed/power” training - FU 6 wks. CURRENT EVIDENCE The Effects of Power Training Frequency on Muscle Power and Functional Performance in Older Women: A Randomized Controlled Trial, Katsoulis, Konstantina; Amara, Catherine Et al., Journal of Strength and Conditioning Research 37(11): p 2289-2297, November 2023. *** We are modifying the Newsletter format to better match our physicians’ time constraints. The previously more in-depth “Peak Perspective” will now be contained below in more “summary” form. We invite you to reach out to us at PT@peakptrochester.com or call our office at 585-218-0240 to further discuss this article in further detail if you wish. The abstract can be found after the case study. PEAK PERSPECTIVE & SUMMARY Physicians frequently see older patients with orthopedic conditions causing movement limitations, ranging from difficulty with simple ADL (such as walking and sit-stand or stairs) all the way up to higher demand athletic endeavors. While the worst of these cases involve actual falling and fall risks, a majority of older patients will complain of loss of quicker movement ability, reduced pace of activity, excessive perceived exertion with low demand activity, and also reduced ability to react to losses of balance…etc. Traditional physical therapy, despite its focus on typical ROM/flexibility, balance, and strength training, often neglects purposeful speed of movement focus (i.e., power). Physicians prescribing physical therapy must determine best practices for expectations and prescription habits surrounding these less customary but critical speed of motion components related to the patient’s goals and also determine appropriate DC criteria. Buford et al (2010) showed we lose 3-8% of muscle mass/yr as we age. Postmenopausal women lose more muscle mass per pound of body weight than men during aging, which is proportionally fast > slow twitch fibers (Fontera, et al 2000 Cell Physiology; Purves et al). This is consistent with the fall risk concerns of aging, where a component includes rapid deceleration capacity and acceleration qualities. Strength is important but inadequate itself in securing the capacity for rapid force generation. Muscle power training tends to be underutilized in physical therapy care but must be considered as part of a standard rehab progression if function is to be optimized. Low intensity power training has been used as an effective method to improve power and functional performance in these older adults in the gym, but it is underutilized in Physical Therapy. The RCT by Katsoulis and Amara studied the frequency of power training (1, 2 or 3 days per week) for 12 weeks on various power and strength measures in older women. Their “power” exercises focused solely on the concentric power in sagittal plane dominant exercise movements. Measures included 1 RM leg press, isokinetic knee extension, stair climbing , sit stands in 30 seconds and 400 m walk among several others. Functional tests such as leg press, sit stand, 4 m walk improved in the power training (PT) groups with 1-3 sessions/wk anywhere from 6-12%. Leg press 1 RM increased 23% pre to post. Rate of perceived exertion (RPE) for the 400 M walk was significantly improved over the controls in all groups. The BIW trained women improved in the stair climb test over the 12 week period. Chair sits to stand improved 10-19% in all PT groups. An 11-13 % improvement was seen in the 4 M walk. While significant power changes in 1, 2, and 3 times/week training groups were noted for isokinetic knee extension, the 3/wk power training group had four times more gains. This type of resistance training with quick motion and lower weight is crucial for functional results. Not only does weight training enhance muscle function, but the power or quick motion enhances fast twitch fibers necessary for reactive movements and power movements of getting up from the ground unassisted and climbing stairs, or even chasing grandchildren. While this study was done on otherwise healthy > 65 yr old females and external validity prevents us from directly applying the results in orthopedic patients we can still use this data to help frame important considerations for this population. Our patients are dealing with one or more painful joints that need to be addressed before moving into more progressive balance/strengthening and functional exercise activities intended to truly move the needle toward safer and higher function. We know that true strength takes at least 6 weeks to see results but changes related to the efficiency of the nervous system are occurring in the first weeks of training. Unfortunately, especially in this era of efficiency of care and early independence efforts and cost containment we often see patients following up with their physicians at a six week checkup who “feel better” but who still have significant disparities in strength and function still present, yet are oftentimes discharged from formal care to “keep doing your home program on your own” sort of thinking. Optimizing pace of movement and reactive ability, both for safety and performance/quality of life, are best done using speed based exercise movement drills vs simply traditional load based drills. Nevertheless, adequate strength must be developed first. Patients often are happy with the changes they’ve noticed already without appreciating the limitations their lack of speed capacity for deceleration/acceleration and perceived exertion are going to have. We utilize a “speed day” akin to this study’s intentions, however, importantly include or even focus on eccentric/deceleration based stimuli instead of just concentric power production. This is a known key to injury prevention. This often looks like 50% loads of their typical 8-12 reps training loads on a “strength” day workout but done with faster pacing usually over a short time of 10-20 seconds. Since many limitations and injuries come from the inability to control the forces of gravity while slowing down the body in motion, stopping, or especially reactively catching oneself after a slip or trip the eccentric “power” component is critical. This is often ignored in traditional therapy and as a requirement by physicians prior to discharge. Another key shortcoming in this study was the sagittal plane only training. In real-world function the frontal and transverse planes must be developed both in a dynamic stabilization sense during more frequent sagittal plane activities but also through motion also for activities like tennis, golf, and playing with grandchildren as even a few examples. The case below illustrates a patient who benefited greatly from incorporating this “speed day” training to optimize their recovery toward safer and higher level performance. THE PEAK PERFORMANCE EXPERIENCE Jody said: “I finally feel comfortable on the grass, and in the woods. I’m moving faster and my husband doesn't have to wait for me!” History: Jody is 84 and has (B) THA and a L TKA. She remained sluggish in her movement following her h/o DJD and the replacements but was also concerned about her “good” R knee’s progressive symptoms with stair. She struggled to get down on the ground to clean and needed a chair to help her up. Subjective: “I never felt like I fully got back to my activities. It took me much longer to get my housework done. I really want to take a walk on a path with my husband and keep up with the grandkids!” Objective: (*=pain) Initial Eval Re-Eval 6 wks Re eval 12 wks Sit -Stand 15 seconds 6x 7x 9 x Single leg squat knee angle L 550/ R 50 ** L 650/R 550 L75/R 67 Calf raise in 15 sec L 10/R 8 L 13 / R 10 L/R 16 3” quad dom step down (eccentric ) Unable * L 8x / R 7x L 16/ 14 TUG 20’ 16 sec 14 sec 12 sec Timed SLB rotations 15 sec Unable L 12x R 9x L 13x R 10x IKDC 32% 54% 79% Key Findings: Jody had 50 degrees knee flexion in a squat with pain at her patellofemoral joint. Split squat depth was 8 inches off the floor L forward. She had difficulty controlling ER’s on the R>L hip, and her R.L quad were weak. Calf weakness, especially soleus, was evident on the R side. Her balance was poor B in a single leg stance where she was unable to stand for more than 1-2 seconds at a time. Treatment: Jody has been in PT at Peak PT before and after each of her total hip surgeries. She has always been discharged after 6 -8 weeks of PT because she “felt better” and seemed capable of basic ADL. She is now realizing her “better” was actually not as strong as she needed to be and that she lacked the ability to move more quickly playing with her grandkids, carry loads down stairs, or hike on uneven terrain comfortably. After 3 weeks of lower level modified quads work (to avoid sx noted with a more flexed knee) Jody increased to resistive training into squats/ lunges/ and rotational/frontal plane assisted motion ensuring use of knee, ankle and hip muscles. By 6 weeks she was able to begin her light locomotion based agility program and also a “speed day” utilizing 50% of her typical loads for faster reps over 3 x 15 sec sets. The depth or ROM were adjusted as needed to optimize pace, maintain excellent technique and avoid symptoms. Keeping in line with this study's results she incorporated “speed/agility” day no more than 1-2/ week sandwiched in between her strength days. Outcome: Jody was doing well with only strength work but the addition of power and speed took her to the next functional level. She was finally able to move faster, feeling more secure and without falling. This is the best she has performed and felt in the past three years. ABSTRACT Background: It is known that muscle mass and strength decline with age but studies also show that power or dynamic strength capacities also decrease disproportionately for women vs men. Power training, where the load is substantial but significantly lighter than traditional strength training intensities, and the concentric phase is quick, is a form of exercise that is not frequently used in the older population but has been shown effective in improving muscle power and functional performance in older adults. Older adults often also feel more comfortable and willing to exercise with lighter loads. Purpose: To determine the efficacy of a low intensity (i.e. load), high speed exercise program done 1, 2, or 3 d/wk on lower body power and total body functional performance indicators. Type: Noninferiority RCT Methods: Fifty four healthy independent, active women over 70 yr of age were randomized into 1,2, or 3 d/wk of Power Training (PT) or the control group (CON) for 12 weeks. There were three testing sessions - baseline, midpoint, and 12 weeks as the dependent variables. Subjects were given four sessions of sub-max testing to prepare for the maximal effort tests. Measures included: Biodex maximal knee extension isokinetic test, leg press 1 RM, 30 second chair sit-stand , stair climbing power and timed 13 step stair climbing, 400 m walk, and a short physical performance battery (balance, 4m usual pace walk, 5 chair sit-stands). Findings: No differences were found between 1, 2, and 3 d/wk training frequency groups in leg press 1 RM, isokinetic knee extension power, or functional performance after 12 weeks. Leg press 1 RM increased 20-33% across all PT groups. Isokinetic power increased by 10% for 2 d/wk and 12% for 3 d/wk PT groups. All PT groups showed significant improvements in 30sec chair stands and in the Short Physical Performance Battery (6-22%). The 1 d/wk and 3 d/wk groups improved 400m walk times while the 2 d/wk PT group improved over controls in stair climbing power and stair climb time (4-7%). RPE was also significantly improved over controls. Author's Conclusion: In healthy older females incorporating low-intensity power training at 40% 1RM at 1,2,or 3 sessions/ week will improve the muscle strength and functional performance and training 2-3 d/wk may be required to improve both power and functional performance. You can trust the Physical Therapists at PEAK PERFORMANCE to do a thorough evaluation, to search for related but underlying contributing factors to kinetic chain dysfunction, and to design exercise progressions that both respect tissue healing and creatively use biomechanics principles to prevent symptoms and optimize carryover to your patients' functional goals. Call us at 218-0240 to discuss your patient's specific needs. Peak Performance is just minutes away from your patients in Penfield, Fairport, Pittsford, Brighton, Rochester, and, of course, East Rochester. We promise Individualized, hands-on and biomechanically appropriate Physical Therapy for your patients. No "one-size-fits-all" approaches. We WILL go the extra mile and "dig deeper" to discover underlying causes for injury risk and delayed recovery using the most advanced Evidence Based methods available and, we’re able to make unique adjustments to exercise prescriptions to speed the return to function and to minimize or prevent symptoms from interfering. No surprises. No hassles. Confident your patient is in the right place. COME VISIT US AT 161 E Commercial St Just 1 mile off 490 exit (585) 218-0240 www.PeakPTRochester.com
  9. Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE (October 2023) Reducing Knee Adduction Moment During Gait via PT Exercises: What does the newest evidence say? by Mike Napierala, PT, SCS, CSCS, FAFS Clinical Scenario...What would you do? A 59 yr old female with a 7 year h/o progressive L > R medial knee pain and swelling/stiffness, with no recent trauma episodes, comes in for evaluation and treatment recommendations. Plain films show IKDC Grade C (2-4mm jt space) degenerative changes in medial compartment and mild Grade B changes in lateral compartment. She has a 1+ jt effusion and AROM on L knee is 5-1250 vs R knee at 2-1400 with L PROM ext only to 20. Meniscus provocation maneuvers are (-). Single squat is L 350 limited by pain with palpable crepitus and R is 55° without pain. Her L knee shows mild varus asymmetry vs the R. The patient’s goals are avoiding TKA for as long as possible, resuming doubles pickle ball and bowling (R handed), playing with her 5 and 3 yr old grandchildren, and travelling with her husband including light hiking. My clinical thinking is: Begin NSAID’s, instruct regarding activity modification and FU in 4 wks. Prescribe PT - providing sheet of local providers for ease of proximity. Perform cortisone injection and FU in 4 wks. Prescribe customized PT including biomechanical assessment and exercises, manual therapy, and laser trial. Recommend viscosupplementation injection/series - initiate insurance authorization request if pt agrees. CURRENT EVIDENCE: Cottmeyer DF, Hoang BH et al. Can exercise interventions reduce external knee adduction moment during gait? A systematic review and meta-analysis. Clinical Biomechanics. (109) 2023. 1-8. https://www.clinbiomech.com/article/S0268-0033(23)00195-X/pdf (We’d love to hear your professional insights on this topic. Let me know your thoughts after reading this summary at PT@PeakPTRochester.com or if you have a patient case you'd like to discuss) SUMMARY: Physicians frequently see patients with medial joint OA and associated varus deformity for evaluation and treatment recommendations. Aside from general OA clinical decision making surrounding early handling of which treatment approach makes sense research relevant to this population has considered whether knee adduction forces can be altered with physical therapy. To the extent varus forces are considered a precursor to medial degeneration and not simply a result, these studies become pertinent in this clinical decision making. Cottymeyer et al in the above systematic review and meta-analysis attempt to discern the body of literature on this topic. A first read of their findings easily leads physicians and therapists alike to the conclusion that knee adduction moment (KAM) during gait is not significantly altered by physical therapy exercise; however, in females there may be some effective KAM reduction possible. Only one of the nine final accepted studies showed a significant KAM reduction vs control groups and that one utilized ankle proprioceptive training compared to TENS/hot packs. These conclusions could easily mislead physicians and therapists to ignore more in-depth evaluation and biomechanical treatment approaches in favor of simple, generic “exercise” that fails to address those KAM forces contributing to ongoing pain and deterioration. Like many studies, systematic reviews, and meta-analyses, caution must be used in reading and accepting conclusions as a basis for directing clinical decision making. The authors here, I believe, have overgeneralized the term “exercise” and the included studies did not specifically utilize targeted/customized approaches aimed specifically at evaluation based findings for those patients. Exercises were generic in nature. They mainly focused on strengthening rather than efforts at restoring joint mobility through manual therapy and ROM/stretching of biomechanically relevant pathways that would promote knee abduction capacity (i.e., reversal of existing KAM forces). The hypothesis that generic strengthening, whether at the knee, locally or including hip/ankle muscles as well as a means to alter KAM fails to address the more obvious biomechanical influences directly impacting KAM. The knee cannot experience increased lateral joint loading (i.e. medial unloading) without the hip’s frontal plane adduction and transverse plane IR capacity being available. The same is true for subtalar joint eversion/foot pronation. These ranges of motion are necessary biomechanically for knee abduction directed forces to occur. Physical therapy for medial knee OA cases with and without visible KAM deformity, based on our experience in the clinic with these patients, is often far more successful when biomechanically authentic exercise focused on medial unloading is used. This must include restoration/improvement of hip and ankle frontal/transverse plane capacity that allows for potential knee abduction directed loading. Many failed cases we see that have not improved with more generic therapy approaches utilized in the studies examined above do, in fact, see significant progress when more customized biomechanical approaches are used. Therefore, in this case, I would urge caution in too quickly accepting the conclusions of Cottymeyer et al’s study, which failed to more carefully define that generic strengthening exercises are inadequate at improving KAM with gait, a subtle but critical distinction that can have important impacts on clinical treatment decisions for patients. Background: Knee adduction moment (KAM) is considered a contributing factor in medial knee OA progression and a potential focus of treatment interventions, especially physical therapy exercise intentions. Purpose: This systematic review and meta-analysis is aimed at determining if exercise interventions are effective at reducing KAM during gait. Methods: Nine RCT studies published up until May 2023 met inclusion criteria and yielded 24 effect sizes for exercise vs control groups utilizing numerous subgroups (sex, BMI, exercise type, muscle group targeting, training volume, PT supervision). Findings: The effect size of exercise interventions on KAM during gait was similar to controls (ES=0.004, P=0.946). Subgroup analysis showed studies with females only did show a positive effect size versus those with combined sexes. Author's Conclusion: Exercise may not be effective in altering KAM during gait. Clinicians should consider alternative treatment options for decreasing KAM in patients with medial knee OA and need to explore further the mechanisms for females having a more positive response. THE PEAK PERFORMANCE PERSPECTIVE Physicians frequently see patients with knee OA issues that require careful evaluation and assessment of the best course of treatment. Medial joint degenerative changes are most common and these are often associated with knee adduction deformity. Sharma et al found that knee varus was not only associated with development of incident knee OA compared to valgus deformity but that the risk of progressing medial joint degeneration was greater in the presence of knee varus or adduction. The question arises as to whether non-operative measures prior to TKA or HTO can have any significant influence on knee adduction forces. This study by Cottmeyer et al reviewed existing data on exercise interventions via physical therapy based care and its impact on measured knee adduction moment (KAM) during gait. While their efforts are admirable and valuable to the body of knowledge this study represents another example of how great care must be taken before making sweeping or generalized conclusions about a given modality such as “exercise” because it significantly influences the decision making of both referring physicians along with physical therapists themselves, possibly to the detriment of the patient. Studies up until May 2023 measuring KAM during level walking after exercise interventions were found, involving patients with diagnosed knee OA, and included control groups receiving passive care or no treatment. Out of an initial 1272 studies eventually 9 RCT studies met criteria for meta-analysis. Hedges g Effect Size was calculated. Moderator variables examined included sex, muscle groups targeted, type of exercise (strength vs neuromuscular) , PT presence (supervision) level, BMI, and training volume of intervention group. Hip and ankle targeted exercise approaches were too few to be included in ES assessment. Of the 15 “intervention groups” subsets of data developed there were 10 performing exercise supervised by a PT and 5 without a PT. Adherence/attendance varied from not reported up to 100%. Cottmeyer et al’s meta-analysis found only one of the nine studies showing significant reduction of KAM - found with 1st and 2nd peaks during gait for the ankle proprioception training group vs the TENS/hot packs control group. The subgroup analysis showed sex, specifically only females, had significant ES vs studies with males + females. No other moderator variables were found significant. The authors concluded that while exercise in general does not appear effective at reducing KAM during gait that it may reduce KAM for females specifically. While on the surface this study seems in line with prior published literature indicating KAM cannot be altered by exercise interventions (ie PT) these conclusions break the rules surrounding external validity in a significant way that can negatively impact physicians’ perspectives on the potential value of PT in OA cases and also may serve to hasten the tendency toward higher level medical interventions that also themselves have limited efficacy based on current research evidence and also carry with them greater costs and sometimes risk profiles. Careful reading leads us to pumping the brakes on their conclusions in the several important ways. The studied groups were not standardized regarding the amount of knee varus malalignment they began with for entry into the study. Varying levels of knee angulation certainly can impact the lever arm potentiation of greater varus/adduction moment that would increasingly be expected to have lesser potential for modification during or through exercise and resultantly with gait. Another very key factor is that exercise types were highly variable and generic in nature. They did not specifically target contributory or causative areas toward the knee adduction moment - specifically attempting to address optimizing hip adduction, hip internal rotation, and subtalar joint eversion capacities in order to reduce knee varus/adduction tendency. Without these adjacent limb/joint capacities a knee joint cannot be expected to shift loading toward the lateral compartment since the limb is biomechanically tending toward varus alignment without them. The only mediating factor then becomes proximal trunk lean in the frontal plane. The studies did not expressly involve added manual therapy to promote quicker or more effective restoration of those typically reduced ROM areas noted above, nor specific stretching/PROM exercises to that same effect. Knee varus deformity patients consistently, in the clinic based on our experience, demonstrate significant ROM loss in one and often all of those areas. Approaches that lack specific targeting, much like generic PT programs, may help some limited percent of patient cases but will likely miss another substantial subset who did have good rehab potential but were not addressed with customized and biomechanically based approaches. I would caution orthopedists and primary care physicians who may have read systematic reviews like this one or other RCT’s suggesting similar conclusions to be wary of falling into the trap of fully trusting the authors’ conclusions. Deeper questioning often reveals carelessness in overgeneralizing results that can negatively impact how you care for your patients and the outcomes achieved. I’d submit that a better conclusion would have been that “in knee OA cases where variable amounts of KAM in gait are treated with only generic knee exercises do not show clear evidence of significant KAM reduction in gait except potentially for females only - further study is needed for biomechanically based custom targeted approaches that include more clinical care consistent based hybrid/encompassing approaches such as manual therapy/PROM-stretching/strengthening/neuromuscular/functional exercise based care. We frequently find that even acutely during exercise portions, specifically for squat based WB quad strengthening drills, where OA based knee pain is most frequently problematic, that utilizing biomechanically sound movement principles can immediately alter symptoms and afford patients less or no symptoms during mini lunges, split squats, step ups, step downs, leg press, wall/hangback squat etc. type drills. For example, a medial knee OA case will typically have fewer symptoms when lateral loading can be increased and medial loading decreased. This is accomplished in numerous ways by trial and error but often involve trunk lean ipsilaterally, ER of the foot/leg, mild medial drifting of the knee, BUE support across midline, pelvic shifting contra laterally, lateral wedging heel among others. These frontal and transverse plane adjustments, while non-traditional, implement sound biomechanical principles toward the goal of unloading the painful and sensitive medial joint. We often find that in “failed cases” of non-operative OA knee care, these approaches are highly beneficial to the patient in optimizing function and reducing symptoms. The case below illustrates a recent example of this approach. The case below illustrates an example of the opposite issue; predominant lateral joint pain issues with radiographic OA findings plus MRI confirmed degenerative meniscus issues. The same biomechanical principles underlying KAM and preferred lateral joint loading efforts are mutually reversed in this patient’s case. They were found very effective at optimizing comfort during WB squat based strengthening drills and ultimately promoted a dramatic increase in her squat function and resulting ADL capacity. This case demonstrates the value of both a patient focused customized biomechanically authentic treatment, and especially exercise based, program along with ongoing supervised care versus premature transition to a simple HEP alone. THE PEAK PERFORMANCE EXPERIENCE Basilike said: “My pain has really decreased and now I can do stairs more easily and I walked 5 miles in NYC on a recent trip without any pain!!” HX: 78 yr old female with 2+ yrs of progressive (B) knee pain, slightly worse on L, had two prior bouts with physical therapy but only very limited benefit. Several cortisone injections provided up to 2 mo relief and recent gel injections provided only 10% reported net improvement. Subjective: L knee 8/10 and R 7/10 max sx with reported fxn of 25% L and 35% R. CC is desc>asc stairs, walking 1 lap @ Cobbs Hill Reservoir, getting up after sitting 5min. WOMAC 44%. Objective: (*=pain) Eval 6 mo ReEval Flexion AROM 1290 / 1250 1370/1350 Extension AROM 10 / 40 00/10 Isometric Quads 14.2*/16.9* kg 22.2/23.7 kg Ober TFL Mod R> L Very min Hip rot PROM IR>> ER NT Calcaneal Eversion WNL NT Squat 300/400 * (B) 700/600 * (R) SLB Static - R STJ control ↓ Rot’s: F+ control (B) Anterior Stepdowns NT 4” w 5# wts 20x/17x *(R) only Key Findings: R>L lateral joint line tenderness more so than medial jt line along with R knee ITB at LFC as well. Both knees lacked good flexion ROM but extension was mostly limited only on the R knee. Hip PROM rot’s showed IR > ER consistent with retroversion influence but ER was 120/200. TFL tightness was worse on R. Her squat fxn was painful/limited L > R but biomechanical testing for sx reduction showed L improved with frontal + transverse plane knee adduction stimulus via UE reaching/trunk positioning and R w transverse plane knee add stimulus (via opp cross reach) - both consistent with lateral joint unloading techniques. WB DF was slightly limited on R. Treatment: BIW early frequency included manual therapy joint mobilization for R TCJ DF, R knee extension, and prone hip ER. Stretching/ROM work included knee flexion (B), R knee ext, hip ER, functional TFL and R soleus/gastrocnemius. SLB rotational control work promoting pronation deceleration for general foot-ankle control was initiated, consistent also with desire to minimize knee abd forces due to predominant lateral knee sx. A key component in early strengthening was PWB - - - > FWB- - -> eventually externally loaded squat-based PRE. These were consistently found to be pain-free or pain-minimized by producing knee adduction or varus forces utilizing pelvic shift-trunk tipping and rotational pre-positioning of either the foot or opposite UE in order to promote medial joint WB. NWB quad PRE were also incorporated. Outcome: Pt was able to advance from BIW to q1-2wk FU visits and ratings of 80% L and 70% R knee function, including 5 mi walk in NYC w/o issues, improved stairs function, and reduced pain max to L 3/10 and R 3.5/10 at reduced frequencies. WOMAC reduced to 21%. Pt is being DC in the next few wks to her (I) HEP. You can trust the Physical Therapists at PEAK PERFORMANCE to do a thorough evaluation, to search for related but underlying contributing factors to kinetic chain dysfunction, and to design exercise progressions that both respect tissue healing and creatively use biomechanics principles to prevent symptoms and optimize carryover to your patients' functional goals. Call us at 218-0240 to discuss your patient's specific needs. Peak Performance is just minutes away from your patients in Penfield, Fairport, Pittsford, Brighton, Rochester, and of course, East Rochester. We promise Individualized, hands-on and biomechanically appropriate Physical Therapy for your patients. No "one-size-fits-all" approaches. We WILL go the extra mile and "dig deeper" to discover underlying causes for injury risk and delayed recovery using the most advanced Evidence Based methods available and, we’re able to make unique adjustments to exercise prescriptions to speed the return to function and to minimize or prevent symptoms from interfering. No surprises. No hassles. Confident your patient is in the right place. COME VISIT US AT 161 E Commercial St Just 1 mile off 490 exit (585) 218-0240 www.PeakPTRochester.com
  10. Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE (September, 2023) New RCT data on Patellofemoral Pain Best Practices: When Knee Rehab Is So Much More Than Just the Knee by Allison Pulvino, PT, MSPT, CMP, FAFS Clinical Scenario…What would you do? A 45 year old female runner comes in for evaluation of anterior and medial knee pain that began 3 months ago as she gradually ramped up her running mileage in preparation for a half marathon in two months. She’d been running 5k races prior to that and training a total of 12-15 mi/wk over 4 days. She has tenderness along the medial patellar border, no effusion, does have mild PF crepitus, (-) McMurrays meniscal maneuvers, and non-tender at her joint lines and quad/patellar tendons. Squat depth is painful/limited, noting mild early ipsilateral heel rise. She also demonstrates mild asymmetry of dynamic valgus/rotation during squatting, submax anterior mini lunge, and vertical/anterior hopping. Plain films show very mild lateral tracking symmetrically with Merchant views. I would… Give her our group’s PFP Home Exercises sheet to do and FU in 1 month. Advise her to “wait and see” for 4 wks and do cross-training because the symptoms may resolve and allow a return to running by then. Prescribe rest and NSAID’s x 3 wks and gradual return to running, FU 4-6 wks. Prescribe physical therapy including biomechanical screening and any appropriate hip & knee exercises, orthotics consideration, and manual therapy as indicated - FU 6 wks. Order an MRI to R/O chondral lesions or degenerative meniscus involvement. FU in 3-4 wks once test results back and determine POC. CURRENT EVIDENCE Neal BS et al. “Six Treatments Have Positive Effects at 3 Months for People With Patellofemoral Pain: A Systematic Review With Meta-Analysis”. Journal of Orthopedic & Sports Physical Therapy. 52 (11). Nov 2022, 750-768. (We’d love to hear your professional insights on this topic. Let me know your thoughts after reading this summary at PT@PeakPTRochester.com or if you have a patient case you'd like to discuss) Summary: Patellofemoral pain (PFP) is a common cause of knee pain seen by physicians, affecting both active and sedentary lifestyle people across all age spectrums. Although PFP is agreed in most cases to be at least initially a non-operative condition, determining the most effective treatments based on high quality research has left physicians and therapists alike with limited guidance. This systematic review and meta-analysis demonstrate that effective treatments for PFP do exist and that a “wait and see” approach should therefore not be used. This meta-analysis of 65 RCT’s includes treatments commonly included in traditional ortho/sports PFP care. Unfortunately most studies examine short term outcomes and there is a lack of long term follow up data to prove more lasting efficacy. The authors looked for studies showing pain and/or function measure changes, using a multilevel evaluating system for “proof of efficacy”. Primary proof of efficacy in the short term was shown for both Knee-targeted exercises as well as combined interventions over wait and see for pain and function, for foot orthotics on GROC score, and lower extremity manual therapy over wait and see for function. Secondary proof for short term efficacy was shown for Hip & Knee targeted ex vs knee targeted exercise for pain and function, knee exercise + perineural dextrose injection vs knee exercise for pain and function. Superiority was shown for Combined Interventions vs Knee exercise at short term follow up for pain and function. Hip targeted vs knee exercise was equivalent for pain and function. Foot orthoses vs hip exercise also showed equivalence having neither show a (+) GROC score. Adding foot orthoses to combined interventions showed no added benefit. Adding dry needling to hip & knee exercise added no benefit for pain or function. Vibration therapy did not show added benefit vs hip & knee exercise alone. There was no indication of efficacy for hyaluronic acid injection added to hip & knee exercise or sham injections. Foot orthoses showed no efficacy over sham orthotics in medium and long term follow ups. Lower extremity manual therapy showed no efficacy compared to wait and see over the short term for pain. Dry needling showed no efficacy over sham needling for pain or function short term. Many other treatments were considered inadequately tested. These interventions are all based on a short-term follow-up and are very global in their descriptions. When considering “best practices” a shortcoming to remember for such studies and reviews is that application of given treatments based on the condition/diagnosis alone is not how real world physical therapy functions…or should function. Physicians should expect that therapists are performing very thorough examinations that lead to customizing treatments based on specific individualized findings both for local tissue needs as well as importantly for kinetic chain factors likely contributing to the symptoms (i.e. foot orthotics only when substantial foot dysfunction noted and considered relevant vs applying foot orthotics to all PFPS patients…same for taping or hip exercises etc.). This study concludes that more research is necessary to look into long-term follow-up prognoses, as well as more individualized treatment parameters in the exercise specialty should be investigated. Systematic reviews like this one do provide some helpful information toward clinical decision making but their usefulness is limited by too many studies with low strength of evidence, the multifactorial nature of PFP, and a lack of enough studies applying treatments only for tested limitations rather than to an entire group (that may not need that treatment). Background: Patellofemoral pain (PFP) affects 29% of active adolescents, and 23% of both active and sedentary adults, and there is no general consensus on how PFP is best managed. Nonsurgical treatment has been determined to be best for this diagnosis, but it remains unclear which nonsurgical treatments have the highest efficacy. Methods: A Meta-analysis of 65 randomized control trials was performed to include 3796 participants for median symptom duration of 43 months. The trials investigated exercise therapies, electrotherapies, manual therapies, foot orthoses, dry needling/acupuncture, injection therapies, taping techniques, combined interventions (hip-and-knee-targeted exercise therapy, vastus medialis oblique biofeedback, soft tissue stretching, patellar taping), blood flow restriction training, and psychological therapies. Findings: Knee-targeted exercise therapy vs wait-and-see control confirmed high-certainty evidence of large effect that knee-targeted exercises are most effective for pain relief and moderate certainty of a large effect improving function at short-term follow-up over wait and see approach. Combined interventions for pain and function, foot orthotics for global rate of change (GROC), and lower extremity manual therapy for function all showed primary efficacy. Combined therapies confirmed higher efficacy together included hip-and-knee targeted exercises combined with perineural dextrose injection have secondary efficacy. Combined interventions produced superior outcomes compared to just knee-targeted exercises. Author’s Conclusion: Wait-and-see care should not be an option due to many interventions proving there are benefits in pain control and improved function, at least within short-term follow-up testing. These include knee exercises, combined interventions, manual therapy, foot orthoses, hip and knee exercises and knee exercise combined with perineural dextrose injection. THE PEAK PERFORMANCE PERSPECTIVE Patellofemoral pain is one of the most common knee related reasons people seek out a healthcare professional, commonly their primary care or orthopedic specialist. Patients sometimes fear they may even need surgery based on the level of pain they’re having that they believe cannot simply be due to stiffness or weakness. Studies unfortunately show that 50% of PFP patients report pain still 5 years after treatment. Physicians prescribing treatment for PFP often look toward not only RCT level evidence but the “totality” of current thinking via systematic reviews and meta-analyses to help shape decision making. Neal, et al in this study astutely reminds that PFP is multifaceted and variable in its etiology. Therefore, conservative care cannot approach PFP with a one-size-fits-all protocol or philosophy. The large number of different types of interventions studied over decades to potentially help PFP supports the concept that we should not take a “protocol” type approach because clearly no singular cause exists that can be treated with a simple uniform treatment approach. This review clearly demonstrated that RCT’s do show knee exercise, combined interventions (hip & knee exercise plus taping, biofeedback, soft tissue work etc.), and lower extremity manual therapy all to be more effective than “wait and see” approaches. Foot orthotics were effective short term over sham orthotics. A key takeaway here is that various treatments do exist that should be considered/prescribed in lieu of having patients simply rest and/or wait. Patients often don’t understand that despite their pain levels and frequency it may not require invasive interventions. This study helps validate the efficacy of especially exercise based interventions so that physicians can confidently begin the education process at their office visit prior to referring to PT. Patients are encouraged knowing that their condition need not be permanent. Expectations and compliance can be influenced positively when physicians inform them prior to PT that it often just takes the correct exercises and treatments to get back to normal function without pain. Clinically speaking, we find education on any biomechanical reasoning behind their particular pain helps patients feel optimistic and have understanding regarding how the physical therapy care will address these underlying causes and reduce the chance for recurrence. And it may also help them understand why the exercises given by a friend or family member or generic routines found on the internet weren’t helping relieve their symptoms, and even sometimes making it worse. Neal, et al include six treatments that have a positive effect on PFP. They go on to say that PFP requires treatment based on expert clinical reasoning from the provider and the exact interventions that should be included need to be based on how each individual presents. The SR/MA found knee targeted and hip & knee targeted exercises to be effective, along with lower extremity manual therapy and foot orthotics A challenge patients and clinicians face with foot orthotics for example, is that despite any positive or immediate changes induced,, the strength and neuromuscular control must still be optimized through exercise vs just the passive support alone. Similarly, although, as in this study perineural dextrose injections were found helpful, when medications or an injection brings immediate symptom relief it can lead to mutually dismissing the need to address the underlying flexibility, strength, neuromuscular, or other mechanics related factors. Prefacing and education regarding the necessity of thorough care is critical. An in-depth biomechanically minded evaluation is a key first step. In patients we see due to “failed care” too often cursory testing with a few traditional ROM or strength measures were taken and then canned protocols applied. That thorough evaluation of each patient’s individual contributing factors allows a customized plan to be developed. While a “PFP homework” sheet does check the box of “keeping things simple” for patients and providers, it fails to take into account those multifactorial aspects of PFP noted by these and many other researchers. One key shortcoming of many meta-analyses and systematic reviews is that while high quality studies (e.g. by research design standards, such as a RCT) may have been used they do not necessarily take into account the clinical relevance of the study design. Too often a specific treatment modality (i.e. stretching the ITB or strengthening the vastus medialis, or using foot orthotics) is applied to an entire group of patients who actually have a wide variety of underlying contributing factors. This waters down potential efficacy as otherwise potentially “good treatments” get applied to patients not needing that specific intervention. Physicians should expect that PFP patients receive an in-depth evaluation that informs customized exercises, manual therapy, and other interventions. Giving everyone orthotics if they slightly pronate or giving all patients isolated isotonic quad or hip strengthening should be test based decisions, rather than a standardized treatment approach or protocol. That testing must include authentic function demands and observation. For example, NWB DF may be “WNL” at 15° but then be grossly abnormal in WB at 30° vs 20° in a squat type test. A foot may show an asymmetric forefoot varus but in WB, despite some mild overpronation, actually show good control allowing some pronation for force attenuation and then the ability to re-supinate - thus no orthotic being necessary. Another patient may have a similar small to moderate FF varus and shows poor control in WB or even worse may have asymmetric anteversion contributing to significant asymmetric overpronation - making orthotics an appropriate consideration. Functional tests such as an anterior step down, various types of lunges, or hopping all can help identify real-life mechanics issues present during their primary activity concerns that affecting a patient’s PFP. In the case of dynamic valgus/rotation (knee abd + femoral IR) we may find WNL NWB strength tests of the hip abductors and ER’s but then find WB testing asymmetries that lead us to intentional exercise for that patient. Other common impairments that can warrant a different approach to treating PFP is a leg length discrepancy that may need to be corrected due to compensatory overpronation leading to abnormal tibiofemoral mechanics and patellar forces. Another example is psoas and rectus femoris adaptive shortening from years of sitting at a desk. The traditional quad exercises (open-chain), especially full range Quad bench extension, often tend to be the worst options for localized pressure to the undersurface of the patella in PFP cases. Even simple nuances like specifically testing TKE vs 90-60° ranges can help identify the best NWB arc to train the quads through to avoid pain and minimize crepitus and stress over damaged articular surfaces. Likewise customizing depths and loads for WB training is often even more critical because stairs, for example, are commonly a primary source of pain with PFP cases. When indicated, changing the femoral and tibial (and hence the patellar) alignment when pre-positioning a lower extremity can change the load to be more medial or lateral during WB strengthening drills , thus reducing symptoms and optimizing the training effect. Oftentimes PFP patients are “overpronators” where the 3D AFS (Applied Functional Science) approach really makes a difference - a dominant sagittal plane hinge joint such as the knee is placed into a position in the frontal and/or transverse plane(s) to externally rotate the femur and/or supinate the foot, creating more comfort with closed chain lunges or flexed knee loading. These examples illustrate just some of the clinically noted potential PFP related factors that after addressing them individually we’ve found the majority of patients having positive outcomes. These specific findings can be tested and re-tested to establish before and after-care functional performance measures - this both helps to validate our evaluation based treatment hypotheses and the efficacy of the various exercises and other treatments chosen. THE PEAK PERFORMANCE EXPERIENCE Mallory said: “I ran the whole 5K on Saturday and felt fine!” History: Mallory is a 14 y/o female presenting to PT with a chronic hx of B knee pain surrounding the patella when running. She previously ran track and Cross Country through the pain and only came into PT for medial foot pain from L post tib tendinitis which had her donning a boot it was so painful to walk or run on. Objective: Initial Exam Re-evaluation Knee extension WNL WNL Knee flexion WNL WNL SL squat test valgus each LE Fair hip ER control each LE SLB midfoot pronation each LE neutral foot w/ orthotics SL forward hop unable good control hip/knee/foot Anterior step down unable/pain foot/knee 4” step down w 5# DBs SL calf raise unable/B LEs only 20x with 10# DB in L hand Key Findings: Lack of hip ER, midfoot pronation collapse in any WB, lack of toe flex/ext strength, unable to fully WB L with poor control R LE SLB/squat, pain ant/med B knees and medial L foot in WB flexion loading, weak glute med B Treatment: Class IV therapeutic laser treatment to medial L foot 6 treatments, tubing inversion and PF isotonic exercises, intrinsic toe flexion exercises, standing lunges with hip ER/supination biased pre-positioned stance, glute med isolation exercise in SLB with contralateral loading drills, TR plane pivot drills in SLB to re-supinate and ER femur with tubing and progressed to dumbbell rotations. Agility: Lateral shuffle cued to grip/load medial foot, running drill in FR plane bias with wider leaps/hops, dynamic fwd/bkwd shuffle with green loop tube above knees for femoral ER control, multi-plane SL up with femoral ER assistance with cross arm reaches. Outcome: Pain-free running in both ankles and knees; Full return to P.E. classes and Cross Country meets! You can trust the Physical Therapists at PEAK PERFORMANCE to do a thorough evaluation, to search for related but underlying contributing factors to kinetic chain dysfunction, and to design exercise progressions that both respect tissue healing and creatively use biomechanics principles to prevent symptoms and optimize carryover to your patients' functional goals. Call us at 218-0240 to discuss your patient's specific needs. Peak Performance is just minutes away from your patients in Penfield, Fairport, Pittsford, Brighton, Rochester and, of course, East Rochester. We promise Individualized, hands-on and biomechanically appropriate Physical Therapy for your patients. No "one-size-fits-all" approaches. We WILL go the extra mile and "dig deeper" to discover underlying causes for injury risk and delayed recovery using the most advanced Evidence Based methods available and, we’re able to make unique adjustments to exercise prescriptions to speed the return to function and to minimize or prevent symptoms from interfering. No surprises. No hassles. Confident your patient is in the right place. COME VISIT US AT 161 E Commercial St Just 1 mile off 490 exit (585) 218-0240 www.PeakPTRochester.com
  11. Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE (August 2023) Functional Rehabilitation for Greater Trochanteric Pain Syndrome: Thinking Beyond Traditional Isometrics and Isotonics by Andrew Neumeister, PT, DPT, FAFS, Certified Running Gait Analyst Clinical Scenario - What would you do? Your patient comes into your clinic with complaints of localized hip pain and tenderness at the greater trochanter. They have an overall reduction in function and ADL ability due to pain with weight bearing activities as well as side lying and certain sitting positions. You’ve assessed the problem and concluded the patient has greater trochanteric pain syndrome (GTPS). My clinical thinking is… A. Tell them to rest and restrict activity while taking N-SAIDS for pain relief? B. Prescribe generic physical therapy for hip strengthening with basic and nonfunctional isometric and isotonic exercises? C. Refer them to an orthopedic specialist for possible imaging and cortisone injection? D. Order specialized physical therapy with focus on assessing underlying biomechanical pitfalls and treating with indicated functional mobility and strengthening (nwb/wb) and Class IV laser? CURRENT EVIDENCE Clifford, Christopher, et al. "Isometric versus isotonic exercise for greater trochanteric pain syndrome: a randomised controlled pilot study." BMJ open sport & exercise medicine 5 (1): 1-9, (2019) http://dx.doi.org/10.1136/bmjsem-2019-000558 SUMMARY: Greater Trochanteric Pain Syndrome (GTPS) is a common cause of lateral hip pain affecting up to 24% of females and 9% of males aged 50-79 years of age. GTPS involves pathology of the gluteus medius and minimus tendons and less frequently the trochanteric bursae. The authors sought to determine the effectiveness of isotonic and isometric exercises for individuals with GTPS. Primary care physicians and orthopedists are likely the first contact for diagnosis and treatment recommendations for this condition. Various treatment options can be utilized for treating this pathology ranging from rest from activity with or without NSAID and traditional physical therapy treatment for strengthening the lateral hip muscles, specifically the gluteus minimus, medius, and maximus. PCP’s also may consider referral to an orthopedist for further assessment. Considerations include cortisone injections and possible imaging to determine severity of the condition and how much involvement of the GT bursae vs. possible tendon tears of the medius and minimus. Clifford et al examined the effectiveness of isometric and isotonic strengthening of the lateral hip complex as a means of treatment for GTPS. Although the results of the study do report that reduction of pain and self-reported functional ability increased in the subjects, we must be careful to NOT take this study as “best practice” for conservative treatment of GTPS. For some, this study may provide low level “evidence” to include these exercises in the treatment plans; however, as professionals we must also appreciate what was not studied. Simple and traditional strengthening isometric and isotonic exercises, while physiologically stimulating the local involved tissues, do not specifically treat biomechanical pitfalls that have subsequently resulted in this condition. We propose an approach that, while including appropriate isometric, isotonic, concentric and/or eccentric emphasized exercise stimuli of the local involved hip muscles, also focuses heavily on finding and identifying potential or likely causative factors. The fact that lateral hip tissues were overloaded and ultimately “failed” does not in any way mean exclusively that they were at fault or weak/insufficient. Other factors such as leg length, ipsilateral or contralateral lower extremity asymmetries, including things like asymmetric anteversion or overpronation but also asymmetric ADL/work/sport postures and body mechanics all could be causative of the otherwise normal hip’s overload. Treating only the “symptom” of the overload may temporarily be effective but misses the mark in the long term. (We’d love to hear your professional insights on this topic. Let me know your thoughts after reading this summary at PT@PeakPTRochester.com or if you have a patient case you'd like to discuss) Background: GTPS is a common diagnosis of lateral hip pain consisting of possible tendinopathy of the gluteus minimus and/or medius, and less frequently the greater trochanteric bursae. Limited evidence exists when comparing isometric and isotonic exercises for treatment of GTPS to determine what best practice may be. Methods: This pilot study consisted of 30 individuals with GTPS separated into 2 groups. Subjects were separated into 2 groups and prescribed either isometric or isotonic progressive home exercises for 12 weeks with 8 individual physical therapy sessions. Results were documented primarily using the Victorian Institute of Sports Assessment-Gluteal (VISA-G), the Numerical Pain Scale Rating (0-10), and an 11-point Global Rating of Change Scale. Inclusion criterion required participants to be >or equal to 18 years old, lateral hip pain >3 months, sx with direct palpation, and one other of 5 provocative pain tests described by Grimaldi et al. Exclusion of participants if they had physical therapy within 6 months of study, cortisone INJ if past 3 months, unable to ABD hip in side lying, Sx with scour testing and XR showing OA, and had previous hip/spine surgery within 12 months. Treatment of both isometric and isotonic exercise began with no external resistance before progressing to “progressive therapeutic bands” individualized working intp a pain scale up to 5/10 as long as Sx eased after. Isometric - non-weight bearing (NWB) sidelying hip ABD to 30 deg then held for 6x30sec with 60s rest between. WB exercise consisted of moving opposite LE through ABD/ADD 3x10 repetitions with isometric holds of gluteal muscles. Time under tension (TUT) where time of which tendons were held under load was 6 min daily. Isotonic - NWB side lying hip ABD raising to 30 deg then returning to midline. WB hip ABD slide where the affected leg slid into ABD and returned while holding anteriorly for support with bilat UEs. Non-affected hip allowed to flex knee to 45 deg during activity. Both Ex 3x10 with 6 sec duration (3s eccentric and 3s concentric) with TUT 6 min daily. Simple analgesia was allowed at home but participants were asked to refrain from other means of sx relief. Findings: Out of the 30 participants starting the trial, only 23 completed the 12 week trial. Outcome measures were taken at baseline, 4 weeks, and 12 weeks. VISA-G was the primary outcome measure with secondary measures of numeric pain rating scale (NPRS), global rating of change (GROC), pain catastrophizing scale, hip disability and OA outcome scale, The Euro QoL, and lastly the International Physical Activity Questionnaire Short Form. Both groups had similar progress in VISA-G, NPRS, and GROC, although not all participants did not meet MCID. NPRS- 55% isometric and 58% isotonic reached MCID at 12 weeks GROC- 64% isometric and 75% reached MCID at 12 weeks All other questionnaires showed no significant difference between both groups and had minimal changes. Author's Conclusion: Compliance of HEP completed 50% or so of daily HEP and 70% isometric and 58% isotonic participants attended 80+% of physical therapy sessions. MCID was met for both groups for VISA-G, NPRS, and GROC. Both programs show improvement in function and pain however no statistical differences exist. THE PEAK PERFORMANCE PERSPECTIVE Although this study claims that there were improvements in pain and “function” when utilizing both isometrics and isotonic exercises for lateral hip strengthening in GTPS, a deeper dive into the evidence would show the multiple limitations of this study that may go unnoticed with an abbreviated glance looking at the results and conclusions reported on the abstract. For perspective it must be remembered first what was studied and what was not studied. There was no control group to compare exercise with which calls to question whether individuals who went on with ADL etc. for the same duration of the study might also show both reduction in pain and improvement in function simply through natural history. The total number of subjects starting the study was 30, and at the conclusion only 23 remained. Both isotonic and isometric exercise showed improvement in the NPRS scale and increased function per GROC scale greater than the MCID, however less than 60% of subjects reached the MCID. Regarding functional improvements, at 4 weeks both groups had less than 50% of subjects statistically improving and at 12 weeks 64% and 75% of subjects had increased function for isotonic and isometric respectively. Most importantly, the types of exercises studied were limited to a single WB and NWB option for each group, without objective data acquired demonstrating improved strength of the lateral hip musculature which is the point one would perform strengthening exercises. Although the study sought to define whether isotonic and isometric exercises would help patients with GTPS, no objective data regarding strength was reported, so how can we infer that improved strength would improve symptoms? Primary care more often and orthopedic physicians are often the first line of providers assessing patients for GTPS to make appropriate treatment recommendations including the referral to skilled physical therapy. Given the choice between standard abductor exercises and a biomechanical functional treatment plan, the former may be the most common choice, however, the latter biomechanical approach at least attempts to both identify root causes rather than symptoms only and also considers authentic biomechanical demands with strengthening progression drills. The intention would be to create the smallest “leap of faith” from the body’s exercise stimulus in PT to the real-world demands of ambulation, ADL, work, and sport/recreation possible. Why strengthen someone’s hip primarily with static isometric NWB exercises when that individual needs to improve their ability of locomotion? It would be prudent to not accept the article above as “best practice” for treating lateral hip pain when the study does not provide its subjects with any functional exercises despite measuring function as one of its primary outcomes assessed. Subjects were asked to perform both NWB and WB “strength” exercises however the thoroughness (ie compliance) of completing the exercises on to the level prescribed and progressions of loading (self-determined but the subject via band color) were primarily on the individual and their home exercise program with minimal assistance from a therapist 8 sessions in total. Specific parameters were advised by the therapist in terms of side lying leg raises to approx 300 and completed for a total time under tension (TUT) of 6 minutes. Isotonic exercises included 3x10 reps with timed concentric and eccentric directives. Left to their own devices, individual subjects were asked to complete exercises without professional assistance for form and technique reported both compliance and noncompliance. 100% of those who completed their exercise diaries and completed more than 50% of daily exercise. Only 70% of the isometric group completed 80% of in person sessions compared to only 58% of isotonic subjects limiting the ability to provide appropriate feedback to exercise technique. The authors may have failed to isolate the glute medius and minimus during WB isotonic slides as the affected LE was asked to slide laterally with load as the stationary unaffected leg bent to 450 deg flexion at the knee. Despite the claims of this to emphasize lateral hip stimulus, assessing where center of mass is and joint positioning during activity creates an abductor moment controlled primarily with pelvic adductors and not the abductors for both eccentric and concentric return. Understandings like this are paramount in accelerating return to functional capacity as it acts to more effectively stimulate the muscles needed to increase strength and load accepting forces through locomotion. The lack of assessment of other potential biomechanical pitfalls that have contributed to the onset of GTPS should be addressed when designing an individualized rehabilitation program. The “simple” exercises studied by Clifford et al. may be hurting the PT population if prescribed by a provider advising to rest and do common leg raises or single leg stance drills. The incidence of GTPS can increase due to overloading the demand or stress of the lateral hip as it functions to accept load bearing forces. Hip Abductors and external rotators have to eccentrically decelerate hip adduction and internal rotation upon impact of the lower limb. The control of dynamic valgus at the knee can be addressed through strategic exercise planning to attack the problem from the adjacent hip and ankle. Weakness of the glute med/min may not decelerate the femur effectively through loading of the limb; however the foot may exhibit overpronation either from biomechanical faults of the joint unlocking the midfoot excessively in WB without poor deceleration by the posterior tibialis. If the foot/ankle complex fails to control dynamic valgus at the knee, the lateral hip must take up larger stress demands than necessary contributing to the onset of GTPS. Leg length discrepancy is another possible contributor to strain on the glute medius and minimus as a larger hip adduction moment is necessary to drop the contralateral pelvis down so that the shorter leg may accept body weight during functional mobility. A tight IT band can also provide increased stress and friction to the greater trochanter and bursae commonly seen with individuals with GTPS. Skilled functional rehabilitation can identify these underlying factors that can increase the stress on the lateral hip tendons and bursae. Simply completing NWB abduction leg raises and single leg stance or lateral slides may improve pain in a limited studied population but effectively identifying kinetic chain factors resulting in hip Adduction and/or IR overload as well as 3D methods of authentically loading/strengthening not only the affected hip but also those contributory segments is key to both a successful short term and long term recovery. THE PEAK PERFORMANCE EXPERIENCE Jacqueline said: “I ran this morning and it felt totally fine!” History: Pt is a 51 y.o. female who is an avid runner with 4 workouts a week up to 4 miles at a time. She presents with L hip trochanteric bursitis and dual small labral tear, contributing to deep anterior hip pain, but which the orthopedist does not think there is any alarm for concern. Subjective: Pain reports unable to run along with severe discomfort while sitting with pain at worst rated a 6/10 at lateral hip with self-functional rating of 60% out of 100% baseline. Lower extremity functional questionnaire (LEFS) scored 58% functional. Objective: (*=pain) Initial Eval Re-Eval Pelvis and leg length L LE long leg (high trochanter) with posterior rotated innominate Corrected with small lift under RLE and SIJ muscle energy techniques with reduction of anterior hip pain Hip flexion PROM 115/130 (88%) 123/134 (92%) Isometric hip flexion 22.4kg/25.7 (87%) 22.3/22.3 (100%) WB DF (STJn) 11/16 (69%) 20/18 (111%) SL Squat (knee flexion deg.) 60/69 (87%) 65/70 (93%) SLB rotation Minimal INCR pronation INCR control pronation into supination Anterior hop 2x INCR femur IR (dynamic valgus) Reduction but still present dynamic valgus Isometric Abduction Supine 14.0/11.5 kg 26.1/21.2 Key Findings: Upon evaluation, pt presented with a longer left leg length discrepancy contributing to INCR stress and demand of the lateral hip complex to control WB hip ADD upon impact when running - this was corrected with a heel lift. ITB tightness was greater on LLE than RLE. SIJ dysfunction was also present and anterior hip pain subsided following osteopathic muscle energy techniques to correct for her asymmetrically. Reduced DF can produce compensatory overpronation leading to INCR dynamic valgus that mutually produces excessive hip ADD/IR, increasing strain on gluteal muscles to decelerate impact on the left LE. Weakness noted in the LLE via SL squat testing for depth. Treatment: Correction of the LLD with heel lift and corresponding pelvic “correction” via manual then self-muscle energy techniques. Ankle DF ROM improved with functional manual reaction (FMR) to improve talocrural joint mobility in a STJn position and reinforced with self gastroc and soleus stretching. IT Band flexibility promoted in WB to reduce lateral hip tension. Hip flexion PROM improved with self stretching NWB. Left hip abductors (minimus and medius) strengthened initially with NWB lateral leg raises due to pain with WB before transitioning to WB anterior slides with the nondominant moving anterior. This promotes the LLE transitioning from initial impact in hip flexion progressing to extension before take off with focus on maintaining L hip position controlling hip ADD. Increased lateral hip strengthening in SL stance with anterior/posterior RLE marches to stimulate running stress of LLE. Care taken with all WB hip drills to improve dynamic valgus control as pt had poor tolerance to resisted ECC hip external rotator stimulation secondary to Sx. SL squatting improved via single leg squatting with glute emphasis via hip flexion moments to aid in control of dynamic valgus with INCR external rotators in the sagittal plane. SLB resupination/pronation control addressed with toe tapping with RLE with LLE IR/ER movements with modifications initially maintain a neutral to supinated position before advancing to controlling pronation to supination experienced at initial contact/impact on landing and progression of gait cycle to a rigid and supinated and locked on midfoot. Outcome: Upon reevaluation, the patient's lateral hip pain had dropped from 6/10 to 2/10 and was deemed more tightness than sharp. Pt was able to resume running from 1.5 to 3 miles without Sx whereas before she had to cease running altogether. Self FNXL rating improved from 60% to 70% and LEFS questionnaire from 58% to 86%. Anterior hip pain had improved much, reducing Sx while sitting and was attributed to correction of leg length discrepancy and pelvic asymmetry in the sagittal plane. Pt did undergo a cortisone injection after reevaluation due to concern she had of improvement however not eliminated Sx and reported to PT further reduction of pain to negligible afterwards. You can trust the Physical Therapists at PEAK PERFORMANCE to do a thorough evaluation, to search for related but underlying contributing factors to kinetic chain dysfunction, and to design exercise progressions that both respect tissue healing and creatively use biomechanics principles to prevent symptoms and optimize carryover to your patients' functional goals. Call us at 218-0240 to discuss your patient's specific needs. Peak Performance is just minutes away from your patients in Penfield, Fairport, Pittsford, Brighton, Rochester and, of course, East Rochester. We promise Individualized, hands-on and biomechanically appropriate Physical Therapy for your patients. No "one-size-fits-all" approaches. We WILL go the extra mile and "dig deeper" to discover underlying causes for injury risk and delayed recovery using the most advanced Evidence Based methods available and, we’re able to make unique adjustments to exercise prescriptions to speed the return to function and to minimize or prevent symptoms from interfering. No surprises. No hassles. Confident your patient is in the right place. COME VISIT US AT 161 E Commercial St Just 1 mile off 490 exit (585) 218-0240 www.PeakPTRochester.com
  12. Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE July 2023 Optimizing In-office Testing for Hip Labral Tears: Two New Tests Examined for Clinical Utility by Mike Napierala, PT, SCS, CSCS, FAFS Clinical Scenario…What would you do? A 47 yr old male comes to his PCP for c/o L hip pain that has been increasing gradually for the past 4 months, now w sharp pains and reduced function, especially with deep squatting, quick change of direction, and getting in and out of his car. He notes some clicking/snapping but cannot recall a specific traumatic episode as a MOI. Plain films show mixed FAI findings. PROM is limited > painful in flexion-Abd-ER and in flexion-Add-IR but resistive testing with isometrics is only painful and slightly weak for hip flexors. I would... Assume a hip labral tear and begin with an outpatient physical therapy trial for 4-6 wks. Assume a hip labral tear and begin with an intra-articular steroid injection and then possibly physical therapy 2 weeks later. Order MRI and FU in 2-3 wks. Order MRA and FU in 2-3 wks. Perform Arlington, twist, FADIR tests for labral involvement, then decide regarding need for orthopedic consult. CURRENT EVIDENCE: Adib F, Hartline J et al. Two Novel Clinical Tests for the Diagnosis of Hip Labral Tears. AJSM 51(4), 1007-1014, 2023. https://journals.sagepub.com/doi/10.1177/03635465221149748?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed (We’d love to hear your professional insights on this topic. Let me know your thoughts after reading this summary at PT@PeakPTRochester.com or if you have a patient case you'd like to discuss) SUMMARY: Physicians routinely see patients with hip pain where femoracetabular impingement (FAI) and labral tears are considered key differential diagnoses to be addressed with the clinical exam. Unfortunately to date there is a lack of validated clinical tests for labral pathology. MR technology has advanced and with MRA there is good sensitivity and specificity data, however, this testing is expensive and invasive. There also remains the consideration that a significant amount of asymptomatic hips can present with positive radiographic labral and FAI findings, complicating the clinical decision making following these tests. Adib et al examined two novel hip labral clinical tests developed/advanced by their group, the Arlington test (FABER - - - > FADIER w oscillating IR-ER) and the twist test (bilateral - - - > single wb IR-ER via body twisting), on 283 patients between 13–77 yrs of age via retrospective chart review. MRA was used as the reference standard and the flexion-adduction-IR (FADIR) was also assessed. They found sensitivity for the Arlington test to be 0.94 but specificity only 0.33 while the twist test had sensitivity of 0.68 and specificity of 0.72. These tests appear to be useful additions to clinical practice since the sensitivity of the Arlington was higher than the often used FADIR and the specificity of the twist test was significantly better than the FADIR. Combining the two new tests did not improve clinical utility compared to separate values noted. Accurate clinical exams are needed for diagnosis of hip labral pathology for numerous reasons. Determining more confidently whether labral pathology is likely may allow for treatment decision making without more expensive MRI/MRA (also invasive) testing early on. This is important based on the challenge of interpreting the meaningfulness of imaging findings based on the known prevalence among asymptomatic populations. For PCP’s this may swing the pendulum toward an orthopedic consult to further ascertain hip labral and/or FAI decision making. For orthopedists, (+) labral clinical tests likewise contribute to advanced imaging considerations but also may provide a pause for routine MR imaging and arthroscopy consideration. Less expensive and invasive options such as injection therapy and physical therapy may be appropriate starting points, leaving advanced imaging for failed cases requiring surgical consideration. Determining diagnostic accuracy in this study may have been affected also by the choice to consider “chondromalacia” MRA findings as part of labral pathology versus being its own separate diagnostic entity. While a “syndrome” of sorts with degenerative joint changes of both articular cartilage and labral tissues may occur, with or without associated FAI, this clustering may have impacted the accuracy as to whether these two new tests would be positive in cases of chondral changes when no labral tear was found on MRA. The authors acknowledged the lack of varied diagnoses also, which impacts the ability to study specificity and predictive values. Nevertheless, the Arlington’s sensitivity and twist test’s specificity values exceed those of the more common FADIR and may warrant inclusion as part of orthopedic hip testing when labral pathology is suspected or needs to be ruled out. Background: There is a lack of well-studied clinical tests at the hip for diagnosing labral tears. Accurate in-office examination is critical for determining the necessity of advanced imaging and surgical consideration. Methods: Cohort study with retrospective chart review examined 283 patients (13–77 yo) who were prospectively identified as suspected labral tear and had MRA done. Clinical exams included the Arlington, twist, and FADIR tests. Findings: The Arlington test had 0.94 sensitivity and 0.33 specificity. The twist test had 0.68 sensitivity and 0.72 specificity. The FADIR test had 0.43 sensitivity and 0.56 specificity. The Arlington was significantly more sensitive than the FADIR and the twist was more significantly specific than the FADIR. Author's Conclusion: The Arlington test demonstrates high clinical sensitivity for detecting labral tears. The twist test shows promising specificity. These tests can complement traditional testing for hip labral pathology. THE PEAK PERFORMANCE PERSPECTIVE Hip pain is a common complaint evaluated by both orthopedic and primary care physicians. Labral tears are one of the key differential diagnoses that clinical testing attempts to identify, however, at this time the available in-office tests for labral pathology do not demonstrate high sensitivity or specificity. While magnetic resonance (MR) technology allows for evaluation of labral tissues, the more ideal advanced MRA test, despite both good sensitivity and specificity, is invasive and expensive – making it inappropriate for routine use. Numerous studies and systematic reviews have also confirmed the significant prevalence of labral tears (and FAI findings) among asymptomatic populations. This complicates current clinical decision making when oftentimes historically arthroscopic procedures may have otherwise been more quickly chosen as the preferred treatment. A relevant question regarding hip pain care is whether diagnosing a labral tear automatically moves a patient toward surgical care. While this is a highly contextual situation, there is evidence demonstrating successful outcomes with non-operative physical therapy for labral tears (Hyland et al, Scientific Reports 2023; Yazbek et al, JOSPT 2011; Scott et al, J Arthroplasty, 2020) and for FAI (Mallets et al, IJSPT 2019; Mansell et al, AJSM 2018; Wright et al, J Sci Med Sport 2016). An accurate in-office exam provides a solid starting point for clinical decision making. Adib et al examined two novel hip labral clinical tests developed/advanced by their group, the Arlington test (FABER - - - > FADIER w oscillating IR-ER) and the twist test (bilateral - - - > single wb IR-ER via body twisting) – (images showing tests - https://www.semanticscholar.org/paper/Two-Novel-Clinical-Tests-for-the-Diagnosis-of-Hip-Adib-Hartline/5db1ff974407e5054217314640ae9608b7e7770d). They studied 283 patients between 13–77 yrs of age via retrospective chart review. MRA was used as the reference standard and the flexion-adduction-IR (FADIR) was also assessed. They found sensitivity for the Arlington test to be 0.94 but specificity only 0.33 while the twist test had sensitivity of 0.68 and specificity of 0.72. Developing a trustworthy series of clinical tests is paramount in providing excellent in-office care and in supporting treatment choices. Both of these tests proved useful in terms of diagnostic accuracy in comparison to the often used FADIR test – with the Arlington having higher sensitivity and the twist test better specificity. Combining the two new tests did not improve clinical utility compared to separate values noted. Further studies are needed to confirm diagnostic accuracy especially utilizing a broader group of diagnoses for determining specificity and predictive values. For PCP’s having a more accurate clinical exam for labral pathology may be more compelling in moving toward an orthopedic consult but may also help provide confidence in ordering physical therapy early without the need for MRI/MRA. For orthopedists, the addition of the Arlington and twist tests, if (+) as labral pathology indicators, likewise contributes to advanced imaging considerations but also may provide a pause for expensive routine MR imaging and arthroscopy consideration based on some of the prevalence issues associated with labral and FAI diagnosis. Less expensive and invasive options such as injection therapy and physical therapy may be appropriate starting points, leaving advanced imaging for failed cases requiring surgical consideration. The authors chose to consider “chondromalacia” on the MRA as a part of labral pathology and rather than its own separate entity. This certainly is one factor that might impact diagnostic accuracy assessment. While a “syndrome” of sorts with degenerative joint changes of both articular cartilage and labral tissues may occur, with or without associated FAI, this clustering may have impacted the accuracy as to whether these two new tests would be positive in cases of chondral changes when no labral tear was found on MRA. The authors acknowledged the lack of varied diagnoses also, which impacts the ability to study specificity and predictive values. Nevertheless, the Arlington’s sensitivity and twist test’s specificity values exceed those of the more common FADIR and may warrant inclusion as part of orthopedic hip testing when labral pathology is suspected or needs to be ruled out. Certainly from a non-operative or post-operative care standpoint the quality and nature of physical therapy provided can be highly impactful on outcomes. One weakness of many studies including physical therapy is the simplicity and continuity maintained in the approaches studied. Just as all FAI surgery or labral repair work across all surgeons cannot be equated, due to technique differences and skill level/experience differences that may influence outcomes, the discerning of non-operative or post-operative care should not be viewed as a commodity-like, one size fits all approach. Biomechanical considerations must be applied to better understand both adjacent and more distant joint kinematic influences on the involved hip. Manual therapy is often a key element in successful treatment but often neglected or too limited/standardized in many studies – producing underwhelming outcomes. The following case represents a patient with chronic hip pain who underwent arthroscopic labral repair and FAI work following similar procedure on the other hip previously. THE PEAK PERFORMANCE EXPERIENCE Jared said: “Now I’m playing two-on-two basketball for up to two hours and working out again with no troubles!” History: 36 yr. old male had A’scopic L hip labral repair and FAI work done after persisting sx w biking, driving, sitting, and athletics that worsened while recovering from R hip A’scopy. Subjective: Post-op sx @ 3 days only 2/10. Objective: MEASURE (*=pain) L / R 1st ReEval (8 wks) ReEval (4 mo) AROM hip flex (deg.) 1000/ NT 1080/1020 AROM Abd (deg.) 500/NT 580/500 FABER (cm to table.) 6/10 cm 7/7cm PROM hip flex (deg.) 1120/NT 1200/1120 PROM prone IR (deg.) 230/290 320/310 Isometric hip flexion (kg) 84% 89% Isometric Abd (kg) 89% 75% but ↑ Isometric ER (kg) 93% 93% Step ups 4” w 0# 14/10x 6” w 10# 10/10 WB IR (deg) 110/170 150/220 FWB hip ext opp Ant toe reach (units) 43/48 50/52 Key Findings: Pt had persisting limitations still from his prior R hip A’scopy (rehab completed elsewhere). ROM was restricted significantly still and squat type strength was especially lacking on the R prior surgery LE. Treatment: Joint Mobilizations used for both the recent post-op L hip as well as the R. Ankle TCJ mob’s for DF necessary also, to promote squat function. Joint mob’s progressed from NWB - - - > WB style for more functional carryover. Simple isolated post-op strength drills moved toward complex multi-joint work such as lunges, step downs, step ups and rotational movements utilizing the principle of “dominating” vs “isolating” to foster functional carryover while still targeting key muscle groups and actions. Patient advanced towards functional light impact and agility work. His attendance became challenging due to work and family responsibilities along with a temporary focus on shoulder issues that continued to bother him. His last formal FU was at 5 mo post op, unplanned but due to work/family time demands and based on successes occurring. Outcome: At 4 mo ReEval pt reported L hip 60% and R hip 85% function while LEFS was 68%. By phone call FU at 7 mo post op mark pt reported up to two hrs of basketball along with fitness workouts “going well” and felt ready to DC. You can trust the Physical Therapists at PEAK PERFORMANCE to do a thorough evaluation, to search for related but underlying contributing factors to kinetic chain dysfunction, and to design exercise progressions that both respect tissue healing and creatively use biomechanics principles to prevent symptoms and optimize carryover to your patients' functional goals. Call us at 218-0240 to discuss your patient's specific needs. Peak Performance is just minutes away from your patients in Penfield, Fairport, Pittsford, Brighton, Rochester, and of course, East Rochester. We promise Individualized, hands-on and biomechanically appropriate Physical Therapy for your patients. No "one-size-fits-all" approaches. We WILL go the extra mile and "dig deeper" to discover underlying causes for injury risk and delayed recovery using the most advanced Evidence Based methods available and, we’re able to make unique adjustments to exercise prescriptions to speed the return to function and to minimize or prevent symptoms from interfering. No surprises. No hassles. Confident your patient is in the right place. COME VISIT US AT 161 E Commercial St Just 1 mile off 490 exit (585) 218-0240 www.PeakPTRochester.com
  13. Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE (June 2023) The Underlying Precursor to Many Orthopedic Injuries ...Optimizing Best Practices for Fall Prevention by Karen Napierala, MS, AT, PT, CAFS Clinical Scenario…What would you do? John, a 67 year old golfer, presents in your office with a painful and weak L non-dominant shoulder. He reports stumbling over a threshold while getting up to use the bathroom at night, causing him to catch himself on his L hand at the countertop. He heard a small “pop” or a “snap” sound and noted difficulty with elevation ADL the next morning along with pain locally in the shoulder. Upon further questioning about his stumble, he admits to increasing frequency of falls this past 6 months but has had no other major injuries. Plain films are (-) for fracture but he does show mild DJD at the GH and AC joints. Clinical exam reveals elevation AROM limited to ~ 1500 with pain, Jobe/Abd > flexion and neutral ER MMT are 3+/5 and painful. IR, ext and adduction are strong. My clinical thinking is… Order an MRI to R/O a RC tear and determine if surgery necessary. Perform intra-articular subacromial cortisone injection and FU in 2 wks to consider starting PT. Likely partial RC tear. Non-dominant arm may not require surgery with his present ROM and rehab potential. Prescribe shoulder PT and FU in 4 wks for possible MRI if not improving adequately. Likely partial RC tear. Non-dominant arm may not require surgery with his present ROM and rehab potential. Prescribe shoulder PT plus Silver Sneakers or other similar balance program - FU in 4 wks for possible MRI if not improving adequately. Likely partial RC tear. Non-dominant arm may not require surgery with his present ROM and rehab potential. Prescribe shoulder PT + customized fall prevention including Reactive Balance Training to address underlying risk factors for re-injury - FU in 4 wks for possible MRI if not improving adequately. CURRENT EVIDENCE: Okubo Y, Sturnieks D et al. Effect of Reactive Balance Training Involving Repeated Slips and Trips on Balance Recovery Among Older adults: A Blinded Randomized Controlled Trial. J of Gerontology. Series A, 74(9), 2019, 1489-1496. SUMMARY: Falls due to slips and trips, especially in older people, can result in fractures and other injuries that potentially cause significant decline in independence. Finding safe and effective, and ideally measurable, ways to minimize this trend is crucial. Physicians play a key role in identifying patients where both a fall may have contributed to injury but also that fall risk is present moving forward and needs to be addressed. Okubo et al utilized locomotion based reactive balance training (RBT) via induced slips and trips on a 10m walkway to determine its training/preventive effect on perturbation -induced falls. Secondarily, they examined how reactive balance training effects balance recovery kinematics. Slips involved sliding tiles within the floor track while trips involved tripping boards that would spring up. Training reduced perturbation-induced falls in the lab by 60% (Rate ratio RR = 0.40). Physicians determining and prescribing care for patients with injuries related to fall risk should consider ordering RBT where indicated. Because overhead harness systems are infrequently or rarely available in outpatient clinics to match the lab conditions of studies like this, it is imperative that therapists be well versed in alternative methods for training dynamic balance including perturbation responsiveness. (We’d love to hear your professional insights on this topic. Let me know your thoughts after reading this summary at PT@PeakPTRochester.com or if you have a patient case you'd like to discuss) Background: Falls in older people can lead to serious injury that may trigger and overall decrease of function and then independence. Use of mechanical postural perturbations has been proposed as a training method to improve reactive balance toward the goal of reducing falls. Mansfield and Wong et al found this type of training may reduce falls by 46-48%. It is important that training regulate predictive behavior (gait cadence) and then superimpose unpredictable perturbations (slips and trips). Prior studies have used perturbations generated using a low friction plate on a walkway, treadmill accelerations, waist or ankle cable pulls, but all of those perturbations usually occur at a fixed location which results in loss of “unpredictability”. Gait alterations that only involve trips only or slip only are not as effective in creating balance changes. Also, to maximize learning of reactive balance control (the final defense against falls in everyday life), training should regulate predictive behavior (gait cadence) and then superimpose unpredictable perturbations. This group developed a walkway that would allow gait at a static cadence and unpredictable slips and trips. Purpose: This study examined whether reactive balance training thru exposure to slips and trips could improve balance recovery and reduce perturbation-induced falls among older adults. The authors were examining whether these patients would develop predictive locomotor strategies to the various conditions. Methods: Forty-four adults aged 65-90 were recruited thru a flyer in their community center and participated in this blinded randomized control trial study. Subjects all were exercising for at least 90 min / week over at minimum the past three months and could walk for 20 minutes without an aid. Exclusion criteria included h/o fractures or total joint arthroplasty within the past 12 months. Subjects walked on a 10m perturbation walkway (strapped into an overhead harness system to prevent actual falls) that was equipped with sensors along with a trip inducing board that sprung up as well as a movable tile that could slide up to 70cm on foot contact. Step length and cadence were regulated. The 14 cm tall tripping obstacle was triggered 50ms before the foot was to land in that sensor. Each of three sessions (trip, slip, combination of both) performed over 2 days included six trials on the walkway (< 40 min total). At the end of the sessions perceived anxiety and difficulty levels were assessed and confirmed to create a reaction. A trip or slip was defined as the load thru the harness that exceeded 30% of BW. The entire session was recorded and kinematic data was collected. The margin of stability (MOS) was calculated - with a (+) number indicating a stable body and (-) number indicating increased magnitude of COG motion. The control group undertook sham “target step training” on the same walkway without perturbations while still in a harness for safety. The final assessment was conducted after a 1 hour lunch break from the final slip and trip or sham training session. Findings: Fifty-one falls were recorded at post-assessment (23 slips, 27 trips). RBT reduced perturbation-induced falls by 60%. During a recovery step from a trip, the intervention group’s COM position was less anterior. The recovery stepping foot was higher and the trunk sway was smaller than that of the control group. Authors Conclusion: Results indicate that RBT decreased falls induced by trips and slips in the laboratory by 60%. The lower reduction rate observed here may indicate reactive balance is harder to train than predictive gait strategies, and more sessions may be required to lower fall rates further. THE PEAK PERFORMANCE PERSPECTIVE: Whether you are a primary care/family practice or internal medicine physician, an orthopedist, neurologist, or even a sports medicine specialist there’s a good chance that you will see patients over 60 years old. Falls in this population can be dangerous. For people over age 60 studies show that 30% will fall yearly and these risk percentages will rise quickly with each passing year. One way this is often missed is that patients may engage with health professionals over the result of the fall(s), thus leading to the key focus being the fracture or tear/strain/sprain or contusion they’ve suffered. Patients often are also embarrassed to admit they are knowingly struggling with balance control or may be in some denial and therefore miss the “connection” between increasing balance issues and their injury. A key consideration for physicians becomes the hybrid demand for treatment planning and recommendations that address the injury/condition itself but also discovery of and specific prescribing related to addressing the balance dysfunction underlying their main reason for seeking a physician. With age it is normal to lose more fast twitch muscle fibers. These muscle fibers play a key role in the body’s response to various perturbations – contributing to effective “reaction time.” Oftentimes traditional balance training will focus on static holds or intentional or pre-planned movements as training challenges designed to improve balance. While these can be effective the incorporation of more fast twitch fiber stimulating activities, like those noted in this study by Phi Yam, Bhatt.et al can be utilized to improve and maintain reactivity. Reactive Balance Training (RBT) in this study, accomplished via unexpected “slip” and “trip” occurrences during locomotion were shown to be advantageous for preventing falls. Their RBT was particularly impressive in that only 3 < 40 min sessions were adequate in affecting dynamic balance and fall prevention. Traditional balance training must start with static balance (for safety reasons) and progress to dynamic movement patterns to create a conscious competency of moment. The basis of these movement patterns is a foundation of strength that helps later on tolerate quicker and eventually reactive movements to an unexpected perturbation of the COG relative to the base of support (BOS). During the aging process, after a stroke, or with neurologic disease these proprioceptive and neuromuscular capacities are compromised. This can leave a patient unable to access movements quickly enough to prevent a fall. Rasmossen et al found that slips that occur in the early stance phase occur faster and are harder to recover from than those in the late phase of gait. As with any sport, practicing these patterns will produce a wide array of movement strategies available to cope with changing needs during activities. Also as with sports, there are times where the unexpected happens, and we expect that our bodies will be able to handle them and keep our center of gravity close to home so that we don’t fall. Reactive Balance Training (RBT) appears to be more advantageous for prevention of slips, trips, and falls than traditional balance training. RBT incorporates unconscious reactions to stimulus that are unknown creating a pattern of coping with losses of balance. Rosenblatt and Hunt et al noted studies that show a 21% reduction in falls a year later after only 4 sessions of RBT! While the method of RBT used in this study was appropriate and effective in its focus on ambulation related stimuli and training, it does have some clinical shortcomings. First, they utilize an overhead safety harness to prevent injury. This brings some external validity concerns to the findings because most patients/clinics do not have access to such a safety device. Also, it is possible that the patients’ normal gait patterns and tendencies were altered knowing the harness was there ready to protect them. This study does not provide evidence that alternative means to create a RBT environment would be comparably effective in falls reduction. Outpatient clinicians would creatively provide other means of inducing a perturbation stimuli and training opportunity. That requires a second person to be involved at home to produce the external perturbations. The partner would thus have to be physically capable of producing an adequate stimulus while still being capable of not producing an actual fall where no harness safety system was available. It must be remembered also that all falls do not occur during locomotion but also during other ADL such as reaching or lifting or simple change of direction. Referring physicians have four key considerations to be appreciated in these cases. First, foundational abilities must be trained not only in proprioception/static balance but also in adequate movement capacity and functional strength. For example, a person experiencing a LOB who trips or stumbles may need to utilize a lunge movement to catch themselves. Training reactively cannot adequately be done without prior lunge strength in this case which then allows for faster movements. This also includes appreciation for training vestibular and visual systems as well. A second consideration or progression must involve training in all three planes in order to prepare the joints/tissues but also global body for life demands that include stumbles or trips that may involve sideways or twisting movements and not merely sagittal plane only. The third is intentional fast twitch muscle performance training – we call this “speed day” for patient home programs. Using lighter loads through quick movement patterns optimizes fast twitch stimuli for these patients, many of whom may even do fitness work slowly with weights but have lost higher speed contraction ability, especially for deceleration needs. Finally, it is critical that RBT be authentic to a patient’s needs. This, for even basic human movement needs, will consider head/upper body driven motions and also ipsi or contralateral lower extremity driven stimuli – progressing to external perturbations thru the trunk/arms and eventually to uneven surfaces (often incorporated early on in traditional approaches, prior to adequate foundational work being done). These are first predictable and then eventually reactive or unpredictable with external bands, various wobble boards, reactions to verbal or physical cues, or using technology like BlazePods. The case below illustrates the benefits of using a 3D functional approach to dynamic balance training where an overhead harness treadmill system was not available yet profound improvements were generated. THE PEAK PERFORMANCE EXPERIENCE: Eleanor said: “I feel like my balance is improving. I don’t feel like I’ll fall anymore inside, or on the tennis court. I can get to the ball more often now also!” History: over the years, her balance has slowly deteriorated. An ankle sprain during tennis two years ago left her with a pattern of avoidance on the L side. Subjective: She states that she felt an inability to try to get certain balls on the tennis court, and at night she was often tentative at foot placement and uses her hands on the walls and furniture for safety. She likes a fully clean house with no throw rugs or shoes lying around. If things were messy, her level of fear of falling increased. Objective: (*=pain) Initial Eval Reeval (6 weeks) Hip extension R/L 20/15 25/22 Single leg squat knee angle R/L 40/60 55/68 Ankle dorsiflexion 11/15 18/22 Single leg balance static R/L sec 7/0 sec 12/5 sec Sit stand to seat 15 sec 9 12 Single leg balance with trunk rotation 15 sec R/L 2/0 13/5 Calf raises R/L 10/6 25/15 Key Findings: Eleanor didn’t even realize that she had an avoidance strategy on the L side until static and dynamic training were initiated. Treatment: Static balance, especially on the L had to be achieved first and then visual disturbances, head turns, and body movements were added on. She began a lunge “matrix” in a star pattern with single stepping, double stepping, and various hand reach patterns. After four weeks of strengthening, she was able to include external perturbations using the Airex foam pad via single leg balancing with added leaning in lateral and forward directions to move her COM out of her BOS enough to generate a stepping response. External forces with bands were also used to generate top-down (proximal - - - >distal) perturbations. Outcome: Eleanor is now proficient with reacting to stimuli that force her to step on her L foot quickly. She can stand on her left leg easily now, and is feeling very confident walking even when her head is turned to one side instead of straight. She hasn’t reported any falls or trips in over 6 months! You can trust the Physical Therapists at PEAK PERFORMANCE to do a thorough evaluation, to search for related but underlying contributing factors to kinetic chain dysfunction, and to design exercise progressions that both respect tissue healing and creatively use biomechanics principles to prevent symptoms and optimize carryover to your patients' functional goals. Call us at 218-0240 to discuss your patient's specific needs. Peak Performance is just minutes away from your patients in Penfield, Fairport, Pittsford, Brighton, Rochester, and, of course, East Rochester. We promise Individualized, hands-on and biomechanically appropriate Physical Therapy for your patients. No "one-size-fits-all" approaches. We WILL go the extra mile and "dig deeper" to discover underlying causes for injury risk and delayed recovery using the most advanced Evidence Based methods available and, we’re able to make unique adjustments to exercise prescriptions to speed the return to function and to minimize or prevent symptoms from interfering. No surprises. No hassles. Confident your patient is in the right place. COME VISIT US AT 161 E Commercial St Just 1 mile off 490 exit (585) 218-0240 www.PeakPTRochester.com
  14. Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE (May 2023) Improving Clinical Outcomes: Diagnostic Accuracy of Chronic Mid-body Achilles Tendinopathy Tests by William Slapar, PT, DPT, OCS, CMTPT, CAFS Clinical Scenario...What would you do? A 36 yr old recreational athlete who does Tae Kwan Do and running presents with L posterior ankle/heel and distal leg pain pointing to the achilles tendon area. She had overused the L wb leg two weeks ago while demonstrating R sided kicks through two consecutive classes and later that week had tried hill runs to break up the monotony of her distance running. She did have similar symptoms three years ago after progressing her first marathon training too fast but has been sx-free since then other than occasional stiffness. The achilles is tender to touch and slightly swollen but without frank crepitus during AROM PF-DF. Pain is reproduced with squatting and < 5x heel raises. Plain films are WNL. She does exhibit some asymmetric L overpronation in SLB standing/mini squats testing and has limited STJ neutral squat DF at approximately 15° L vs 25° R. She has an antalgic gait with poor push off of L foot and shortened R step length. She has iced and used ibuprofen OTC per bottle instructions with some relief. My clinical thinking is: She has achilles tendonitis. Advise to DC ibuprofen and continue with Tylenol for symptom control if needed. Temporary heel lifts x 2 weeks and FU to determine next course of action. Findings suspicious for achilles tendonitis but in-office US testing is indicated to confirm diagnosis before treatment can begin. She has achilles tendonitis. Delay US testing unless 3-4 week FU shows insignificant progress. Advise formal PT including biomechanical evaluation and Laser trial. Findings suspicious of achilles tendonitis but MRI indicated (due to prior hx to R/O more significant tendinopathy/degenerative tearing) including to assist in determining possible PRP recommendation. Initiate physical therapy. She has achilles tendonitis. Advise to continue ibuprofen. No other tests needed. Temporary walking boot x 2 weeks and FU to determine next course of action. CURRENT EVIDENCE Hutchison AM, Evans R, Bodger O, et al. What is the best clinical test for Achilles tendinopathy? Foot and Ankle Surgery. 2013;19(2):112-117. https://doi.org/10.1016/j.fas.2012.12.006 SUMMARY: Achilles tendinopathy can be a common complaint especially for active lifestyle and athletically active people. In the office it can present at different portions of the calf/ankle: insertional, mid body, or at the musculotendinous junction. This three joint muscle (knee, talocrural, subtalar joints) is key to normal function with roles at the knee and foot/ankle in both NWB and WB uses. There are numerous other differential diagnoses that can contribute to retro ankle pain, including retrocalcaneal bursitis, osteophytes and/or bony anomalies, complete or partial achilles tearing, tarsal tunnel syndrome, sural neuritis or neuroma, posterior tibial tendon dysfunction/rupture, arthritic conditions, plantar fasciitis, tenosynovitis of flexor hallucis longus, stress fracture, and/ or osteochondral lesions. Accurate diagnosis is a key starting point for clinical decision making. Many different tests are available to help improve our diagnostic accuracy of mid body achilles tendinopathy and numerous imaging options for more definitive tissue level assessment, however, these are variably expensive and must be weighed in each case regarding necessity. Hutchinson et al. reviewed and used 10 different common clinical diagnostic tests for chronic mid body achilles tendinopathy while using Ultrasound as a reference standard. The most valid tests are pain on palpation of the tendon, self-reported pain at 2-6 cm above insertion, and morning stiffness. The achilles transmits forces to and from the foot and leg/superincumbent body. While often considered a “heel raise” or “push off” muscle one of often neglected roles is to decelerate the advancing body/leg segment over the foot in mid- - - >late stance phase prior to push off. Following clinical testing PCP’s and orthopedists must then consider any further diagnostic testing needed. Utilizing valid existing clinical tests allows physicians to avoid or at least delay more costly tests that may not alter treatment recommendations. With a confident diagnosis of achilles tendinopathy treatment considerations typically include physical therapy. Excellent PT care will include in-depth biomechanical evaluation to assist in problem solving any modifiable contributing factors rather than simply addressing symptom reduction and gradual return to prior activity. Achilles symptoms may develop due to ipsilateral biomechanical factors but may also result from compensation due to contralateral limb deficiencies also. (We’d love to hear your professional insights on this topic. Let me know your thoughts after reading this summary at PT@PeakPTRochester.com or if you have a patient case you'd like to discuss) Background: Diagnosing chronic mid-body achilles tendinopathy is not straightforward due to amount of tissues in the surrounding area that can be inflamed or have pain associated with stressing them. But the diagnosis aspect is very important to providing the appropriate treatment. So having accurate clinical test that can improve such diagnosis is very helpful. Purpose: To evaluate the accuracy of clinical test in identifying chronic mid-body achilles tendinopathy. Using ultrasound as a reference standard Methods: Twenty-one subjects from three groups, with and without achilles tendinopathy, had an Ultrasound scan followed by ten clinical test performed by two orthopedic surgeons and one senior physiotherapist. Each test accuracy and reproducibility were determined as well. Findings: For chronic mid-body achilles tendinopathy pain with palpation (sensitivity 84%, specificity 73%, Kappa .74-.96) and self-reported pain location from 2-6 cm above insertion (sensitivity 78%, specificity 77%, Kappa .75-.81) are the most accurate test in determining it as a diagnosis from others. Author's Conclusion: Only pain location and pain upon palpation were noted to be accurate and reliable in the diagnosis of chronic mid portion achilles tendinopathy. Further studies need to be conducted due to limitations of the study. THE PEAK PERFORMANCE PERSPECTIVE PCP’s and orthopedists alike deal with patients presenting with posterior distal leg and foot/ankle pain that is suspicious for achilles tendonitis or tendinopathy. Posterior ankle pain can be difficult to differential diagnose because of the many tissues potentially involved, including Achilles tendinopathy, retrocalcenal bursitis, os trigonum, neuritis of sural nerve, tenosynovitis of flexor hallucis longus, osteochondral lesions, etc.) which are stressed in particular ways more than others. Available clinical tests can vary significantly in their diagnostic value. Oftentimes, various imaging(i.e. US, MRI) is utilized by MDs to assess specific tissue quality and for higher sensitivity/specificity for diagnosing, however, these are more expensive and while providing more detailed information about tissue changes/quality may not alter non-operative treatment recommendations. Especially in these times of rising healthcare costs providers are expected by patients and insurers alike to control costs where possible without compromising quality of care. A common procedure is to plain films done to clear any osseus issues or other red flags that could affect treatment recommendations. Diagnostic ultrasound has become a more popular and less costly alternative to the MRI for assessing achilles tendonitis/tendinopathy. Hutchison 2012 et al clearly showed that providers can make an accurate diagnosis of chronic mid body Achilles Tendinopathy through palpation and the patient's subjective symptoms. Palpable tenderness locally showed 84% sensitivity and 73% specificity. “Active listening”for the patient’s local pain site description (being 2-6 cm above the Achilles insertion), is 78% sensitive and 77% specific to such a diagnosis. While these sensitivity or specificity values are adequate and not high, they are the highest of the 10 tested. London Royal test, the arc sign, single leg heel raise, and the hop test all have very poor sensitivity, all individually < 50%. Using “clusters” has been effective for other body parts to improve diagnostic accuracy but Hutchinson states that it is not justified since there were only very small gains in accuracy when using two of the top three most accurate tests: pain with palpation, morning stiffness, and self-reported pain. Hutchinson reminds also about test reproducibility/reliability as well. Consistency of test outcomes is a key component especially when different providers are examining patients. The three tests that were the most reproducible are once again, pain with palpation, self-reported pain, and morning stiffness. Limitations of this study was there was a low sample size with it only being 21 participants, no details on age range ( just 18+ y/o), or of gender. One of the patients from the Achilles tendinopathy group also had retrocalcaneal bursitis. Another potential limitation is the use of ultrasound as a reference standard (however, US has shown good accuracy compared to the gold standard, operative findings). Achilles tendinopathy is a very common diagnosis seen by physicians and PT’s/ATC’s alike. The mid portion/body type is the most common (vs insertional) and correlates to poorer vascularization and thus difficulty for the tendon to repair microtrauma. A key concern then is determining the reason for achilles microtrauma…especially in cases where a bilateral or reciprocating activity produced only a unilateral symptom. Most often a biomechanical deficiency is contributing to this asymmetric overloading - making identifying and addressing it properly crucial. Physicians making referrals for treatment should expect both local tissue recovery (reducing pain and inflammation and/or myofascial/scar issues) and addressing biomechanical faults related to the mechanism of injury (MOI) are being addressed in therapy. Specifying treatment orders can be difficult because there are a vast number of possible contributing factors to achilles overload. While the achilles/calf are certainly dominant sagittal plane loaded tissues there remain triplanar loading effects that must be considered. Common factors we note clinically include overpronation due to rearfoot and/or especially forefoot varus compensations, asymmetric anteversion causing dynamic valgus proximally and triplanar achilles strain distally, reduced dorsiflexion, and weak quads or hip extensors causing overload demands on the plantar flexors for deceleration. Traditional therapies usually implemented are eccentrics to help with the deceleration aspect but usually performed using a vertical force only instead of an angular force that respects horizontal forces of locomotion. Changing up different angles to provide stimulus towards the nature of function can help train more specific to the goals. Although eccentrics are helpful there is some data suggesting heavier loads strength training is key and less focus on isolated/emphasized eccentrics may be required. Of course a well-rounded approach involving manual therapy for joint and soft tissue mobilization is often necessary. Class IV laser therapy has also been a helpful modality to speed healing and reduce inflammation/pain. THE PEAK PERFORMANCE EXPERIENCE Sally said: ”The foot is feeling a lot better and and I’m able to walk farther, stand longer, and go to my grandson’s lacrosse games. I can go up and down stairs better also!” HX: 69 y/o female having progressive pain in the L posterior ankle with any weight bearing activities. Plain films are unremarkable. She was put in a walking boot for 6 weeks. Subjective: 8/10 pain with weight bearing activities, especially walking and going down stairs. Stairs is a one step at a time and walking stride is asymm. Objective: (*=pain) Initial Eval 1 mo ReEval Amb. Sx onset, asymm stride w/ antalgic type gait >15min, incr. *, near symm stride SLB , rotations Sx onset w/ rearfoot varus , no supination control 21 sec, vertical calcaneus, with min pro control and mod supination SL calf raise unable * 15x* (* at the 15th rep) Royal London Test (+) (-) NWB calc. Ev (AROM/ PROM) (0 deg /1deg) (2 deg / 3 deg) WB DF ( knee flexed) 5 degrees * 18 deg NWB DF ( knee ext) 8deg PF’d * 1 degree (100%+) Step down test unable , * 2”, 30x Palpation (TTP) Achilles ( 3cm above insertion), medial Gastroc( mod. to serve) minor TTP of med gastroc, Achilles Key Findings: At evaluation in standing, the patient shows a L foot rear foot varus, with deficits in side to side comparison of dec. calc everison. In ambulation, initial pain during all WB phases of gait of the L LE., due to lack of calc eversion. Unable to test strength due to increase in pain with all WB strength/functional testing. Lack of dorsiflexion in WB and NWB for the gastroc and soleus. Treatment: Pt treatment started with Class IV laser, with manual to address hypomobilities in the rear foot and ankle, soft tissue mobilization to address TrPs in the gastroc/ soleus structures. Using a wedge to improve tolerance of load on the achilles in a more Plantar Flexed position to reduce strain during load of the achilles. Then to reduce incline and plantar flexed ankle to a neutral or foot on floor during exercises. She worked on balance and gait training in the frontal plane first then transitioned into the Sagittal plane to reduce the amount strain in the beginning of the treatment. Balance exercises to improve pronation and calcaneal eversion control during weight acceptance of ambulation. Outcome: The patient is now able to walk without an onset of sx until 15 min of continuous walking, able to enjoy going to grandson lacrosse games, and starting back into a walking routine. Pt is able to go down the stairs in the morning with </=2/10 pain in the morning with reciprocal steps. Pt is still in Pt to continue strengthening for deceleration from elevated surfaces, increasing the endurance and strength of the plantar flexors for ambulation. Key Findings: At evaluation in standing the patient shows a L foot rear foot varus, with deficits in side to side comparison of dec. calc everison. In ambulation, initial pain during all WB phases of gait of the L LE., due to lack of calc eversion. Unable to test strength due to increase in pain with all WB strength/functional testing. Lack of dorsiflexion in WB and NWB for the gastroc and soleus. Treatment: Pt treatment started with Class IV laser, with manual to address hypomobilities in the rear foot and ankle, soft tissue mobilization to address TrPs in the gastroc/ soleus structures. Using a wedge to improve tolerance of load on the achilles in a more Plantar Flexed position to reduce strain during load of the achilles. Then to reduce incline and plantar flexed ankle to a neutral or foot on floor during exercises. She worked on balance and gait training in the frontal plane first then transitioned into the Sagittal plane to reduce the amount strain in the beginning of the treatment. Balance exercises to improve pronation and calcaneal eversion control during weight acceptance of ambulation. Outcome: The patient is now able to walk without an onset of sx until 15 min of continuous walking, able to enjoy going to grandson lacrosse games, and starting back into a walking routine. Pt is able to go down the stairs in the morning with </=2/10 pain in the morning with reciprocal steps. Pt is still in Pt to continue strengthening for deceleration from elevated surfaces, increasing the endurance and strength of the plantar flexors for ambulation. You can trust the Physical Therapists at PEAK PERFORMANCE to do a thorough evaluation, to search for related but underlying contributing factors to kinetic chain dysfunction, and to design exercise progressions that both respect tissue healing and creatively use biomechanics principles to prevent symptoms and optimize carryover to your patients' functional goals. Call us at 218-0240 to discuss your patient's specific needs. Peak Performance is just minutes away from your patients in Penfield, Fairport, Pittsford, Brighton, Rochester and, of course, East Rochester. We promise Individualized, hands-on and biomechanically appropriate Physical Therapy for your patients. No "one-size-fits-all" approaches. We WILL go the extra mile and "dig deeper" to discover underlying causes for injury risk and delayed recovery using the most advanced Evidence Based methods available and, we’re able to make unique adjustments to exercise prescriptions to speed the return to function and to minimize or prevent symptoms from interfering. No surprises. No hassles. Confident your patient is in the right place. COME VISIT US AT 161 E Commercial St Just 1 mile off 490 exit (585) 218-0240 www.PeakPTRochester.com
  15. Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE April 2023 Lachman’s Effectiveness Previously Overestimated...improving Diagnostic Accuracy for ACL Tears by Allison Pulvino, PT, MSPT, CMP, FAFS Clinical Scenario...What would you do? A 54 yr old male injured his L knee playing recreational softball with a deceleration change of direction non-contact MOI, hearing a “pop” and experiencing pain and then swelling within 30 minutes. Plain films are (-) for fracture. Gait is antalgic with 150 lack of extension and poor swing phase also. AROM is 12-1150 and he has a 100 SLR lag from resting 150. Clinical exam difficult due to guarding and large extremity size. Lachman’s is equivocal, anterior drawer 1+, posterior drawer (-), Apley’s (-), unable to perform McMurray’s due to pain/guarding, varus/valgus tests (-), ER/Dial tests (-) also. The patient works a remote job doing marketing research and his goals are walking and hiking with his wife, biking, recreational table tennis and possibly a return to softball at 1st base or outfield but is not concerned about hitting/running bases. Pt is inquiring if he has torn his ACL. He has a high deductible insurance and essentially self-pay at this time. He prefers to avoid an MRI if possible. You have determined his work and activity goals do not merit ACL reconstruction at this time and that he likely is a non-operative candidate. I would: 1. Order an MRI to confirm current partial ACL tear diagnosis and order Physical Therapy. 2. Prescribe NSAID’s and FU in 2 wks for re-exam to determine final diagnosis and plan of care. 3. Aspirate effusion and do diagnostic lidocaine injection to allow better clinical exam. 4. Perform Lever Test for ACL integrity to support diagnosis and plan for non-op care. Current Evidence: Sokal PA, Norris R et al. The diagnostic accuracy of clinical tests for anterior cruciate ligament tears are comparable but the Lachman test has been previously overestimated: a systematic review and meta-analysis. Knee Surg, Sports Traum, Arth. 30 ( ) , 3287-3303, 2022 https://link.springer.com/article/10.1007/s00167-022-06898-4 SUMMARY: ACL injury is common especially in athletics. Clinical diagnostic accuracy becomes paramount in determining both confident diagnoses and also resulting plans of care appropriate for each individual patient. The Lachman’s test, previously considered a “gold standard” of sorts regarding ACL examination, has supportive evidence based in numerous studies that allowed for concomitant knee ligament injury, calling into question if this diagnostic accuracy is as high in isolated ACL injury cases. Sokal et al in this systematic review and meta-analysis showed that the pivot shift and Lever (or Lelli) sign were the best tests for diagnositic accuracy of ruling in and ruling out ACL tear respectively. The Lever sign has also been proposed to indicate a functioning ligament in cases of a partial tear. This may contribute to decision making on non-operative care routes depending on the patient’s comorbidities/injury and goals. The Lever sign may also be useful for those with smaller hands/larger knee situations as well as for additional evidence when MRI pre-authorizations are required. The (-) Lever sign may provide evidence to support non-op care despite (+) Lachmans or Anterior Drawer testing in certain scenarios. (We’d love to hear your professional insights on this topic. Let me know your thoughts after reading this summary at PT@PeakPTRochester.com or if you have a patient case you'd like to discuss) Background: There have been several common longstanding tests performed by physicians and other medical providers to confirm or rule out ACL tear, however, many supportive studies included subjects with additional knee ligament injury. The Lachman’s test has previously been shown to have high diagnostic value. The Lever (or Lelli) sign demonstrates good diagnostic accuracy but has not been compared using the same inclusion/exclusion criteria Purpose: To report the diagnostic accuracy of clinical tests for ACL injury, both partial and complete, without concomitant knee ligament injury. Methods: A systematic review with a meta-analysis reporting sensitivity and/or specificity of clinical tests for ACL injury with or without a present meniscal injury. Diagnostic accuracy values, using bivariate random-effects modelling where possible, were calculated for the Lachman, anterior drawer, Lever sign and pivot shift tests overall and in acute (< 3 wks) or subacute (> 3 wks) settings. Results/Findings: Using a bivariate model for overall sensitivity and specificity respectively, pooled estimates include anterior drawer test at 83% and 85%, Lachman test at 81% and 85%, pivot shift test at 55% and 94%, and Lever sign test at 83% and 91%. For complete tears, Lachman test was 68% and 79%; post-acute injuries 70% and 77%. Authors Conclusion: The diagnostic accuracy of the Lachman test especially for post-acute presentations and complete tears was lower than previously reported. The pivot shift and Lever sign were the best tests overall for ruling in and ruling out ACL tear, respectively. Further research is recommended for the Lachman test in acute presentations and partial tears. THE PEAK PERFORMANCE PERSPECTIVE ACL injury screening, although commonplace in the orthopedic setting, has a variety of clinical diagnostic tests utilized by clinicians, each with the varying levels of reported diagnostic accuracy, that remain under scrutiny from further review and research. While the Lachman’s has often been considered a “gold standard” of sorts regarding clinical tests for ACL injury, there are several situations where this test can be difficult to perform well such as operator with small hands in comparison to a much larger knee-thigh-leg as well as acutely with greater swelling and pain that make relaxation difficult. There are also cases where non-operative care may be most appropriate despite a suspicion of ACL tear and further test cluster findings may help avoid the expense of an MRI in some cases. In other instances the addition of another accurate test may assist in supportive evidence when an MRI may be called for but insurance pre-approval is necessary. Sokal et al in this systematic review and meta-analysis found the Lachman test was not as accurate with ruling in or ruling out solely ACL tears as previously thought. One associated factor was many past studies showing positive results utilizing the Lachmans included concomitant knee ligament injury. This study also utilized bivariate random-effects modelling where able, rather than the typical univariate modelling, adding to the strength of the findings. The Lever sign is also thought to indicate in the cases of partial tear whether the intact fibers leave the ACL “functioning” regarding normal knee biomechanics. While not suggesting complete integrity the (-) Lever sign may suggest adequate fiber integrity to more confidently move forward with non-operative care in specific patient situations. With the positive findings for high sensitivity and specificity of the Lever sign, medical providers examining patients in acute settings, whether physicians and athletic trainers on the field or any provider assessing an injured knee within the first weeks when pain and swelling have settled in, may be able to obtain a more accurate diagnosis of an insufficient ACL and/or be able to have evidence that despite likely partial tearing that the integrity is adequate to entertain non-op care whereas Lachman’s tests alone sometimes are equivocal and then tend to merit more expensive MRI testing. While Sokal et al contribute to the evidence by looking at knees without other ligament injury also, this is mutually a weakness of the study. As they indicate, more than half of all ACL tears are accompanied by a medial or lateral ligament injury. Therefore, this improved diagnostic accuracy of the Lever sign may not apply in such cases. The test is simple to perform and very easy to measure the results. Below is a link explaining and demonstrating the Lever sign. https://www.youtube.com/watch?v=29JTT0uLubs While not replacing the Lachmans or other ACL tests this Lever sign may be a beneficial addition as well for the small operator hands/large knee scenario as well. Non-operative ACL injuries may still allow for patients to have a good quality of life, based on age and activity level of course. When PTs typically see a patient with an ACL injury, it usually is after decisions have already been formed, whether prehab is the focus, or this individual has chosen a non-operative route to get function and ROM back. Many patients don’t realize that despite their “knee” being injured that optimal recovery will involve addressing especially hip and foot-ankle function as these joints directly influence knee function and mechanics. The typical mechanism limitations are still present, whether it was a valgus deceleration non-contact trauma, or a hyperextension force from contact, there still exists some mobility loss and muscle atrophy occurring. The most common limitations we as PTs see in either post-op ACL reconstructive surgery or non-operative ACL trauma is some level of quad weakness, but also excessive femoral IR that leads to dynamic valgus mechanics. For some this is related to anteversion influences, for others it may be a lack of hip ER mobility or simply a weakness of the Abd’s-Er’s of the hip. A patient with overpronation, because of kinetic chain relationships, especially of the talus with the tibia-fibula, can also experience dynamic valgus-rotational tendencies that often mimic the MOI originally seen. While somewhat less critical for a short term pre-op care bout, those patients doing non-op PT care will have significant limitations in ADL/athletics if proximal and distal factors are not addressed adequately. Oftentimes traditional care will emphasize simple NWB and WB quads and hamstring strengthening and balance work, however care must be taken to identify each patient’s unique biomechanical issues It’s very common to see a patient gain better quad control without pain and increase their WB tolerance once these limitations throughout the entire kinetic chain are assessed and addressed. Whether it’s through manual joint mobilizations to the hip and rearfoot or myofascial work to one’s psoas, followed by dynamic hip transverse plane drills, and supination driven ankle stepping, each individual is unique and at a varying level of activity requiring frequent testing and re-testing of functional movements. Reducing dynamic valgus-rotational MOI-like tendencies can also significantly improve “dynamic stability” so that more intensive strengthening and neuromuscular drills can be implemented...leading to speed and impact training in preparation for return to recreational/athletic endeavors. The case below represents an example of a patient suffering an ACL re-injury following prior reconstruction who opted for non-op care due after only partial tear was confirmed. THE PEAK PERFORMANCE EXPERIENCE Kelle said: “I can play golf without any issue! Biking and walking on the beach is fine now!” History: 57 year old female with history of prior L ACL reconstruction and recent re-injury from downhill skiing requiring surgery for medial and lateral menisectomy and confirmed 30% ACL intact without reconstruction. Subjective: 5/10 pain random walking. Difficulty with descending stairs at times in morning and unable to run with new onset heel pain and history of intermittent L SI jt pain and L sided back pain. Objective: Initial Evaluation Re-eval Knee flexion 1430 1480 Knee extension -40 20 hyper Prone hip ER 250 250 Prone hip IR 500 550 Isometric Quad NT @ 900 89% Isometric Hams NT @ 450 105% SLB rotational NT ↑ pronation/IR w/o orthotic Gait L leg loading Flex’d knee mid stance Ext’d knee mid stance Key Findings: At initial evaluation, pt unable to ambulate without flexed knee during stance phase, minimal quad control with active SLR, unable to perform any step down depth, discomfort with end range knee extension anterior joint line with effusion. Positive special tests for decreased hip extension, decreased hip adduction and decreased foot/ankle control with pronation collapse in SLB. Treatment: Knee mobility focus first: Prone knee hang for TKE ROM, SLR long sitting for extension endurance for WB Manual therapy focus of hip: Anterior hip jt mobilizations for extension, passive hip joint ER stretching in standing hip flexor stretch, frontal plane hip abductor stretching for WS in gait Mobility/active stretching: gastroc and hip flexor stretching, hip ER stretching, functional abductor stretching with hip adduction drills in WB Strength: Anterior slide drills for terminal stance extension control at hip/ankle, TR plane supination assisted balance drills, SL calf raises for push off, Step down drill with L quad load in pelvic L rot for valgus prevention, L lateral hip loading with tubing with stepping drill for pelvic stability at abductors. Anterior step downs loading quad with DBs with pelvic L rotation assisted femoral ER/valgus prevention. Addition of Superfeet OTC arch supports with neutral sneaker. Outcome: Pt very happy with her knee sx’s for most ADLs. Recent re-eval demonstrates some diminished quad strength vs contralat knee, but able to go up/down stairs, walk on uneven ground without brace short durations, and bike and use elliptical > 20 min each, and walk at least 1 mile without sx’s onset. Further dynamic control at ankle and hip required for more advanced activity level.
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