Search the Community

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.

Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE (December, 2022) What Constitutes “Passing” When ACLR Return to Play Tests Disagree? by William Slapar, PT, DPT, OCS, CMTPT, CAFS Clinical Scenario...What would you do? A 21 yr old female competitive college soccer player underwent ACLR 7.5 mo ago and has progressed through jog-walk - - - > running- - - >sprinting work and agility progressions. She is presently at an estimated 90% intensity with her functional training. The patient was performing rehab at a facility near her home over the summer and has returned late August to college locally to continue rehab and resume soccer. Updated ReEvaluation testing locally showed the following: Isometric Quads at 600 angle 90% and at 300 was 65% Anterior Stepdown (toes off + posterior lean) @ 6” with front racked 20# DB’s was 65% with mild asymmetric dynamic valgus tendency SLB 6” cones rotational no touches test 70% with asymmetric overpronation tendency > dynamic valgus and delayed resupination action 900 rotational timed hop testing was 75% with mild asymmetric overpronation and dynamic valgus tendency but no frank instability sx reported 3x Ant crossover hop 85% with visible asymm opp leg swing and poorer 3rd hop landing (~ 300 stiff legged vs healthy limb ~ 500 knee flexion dampening) Her PT from home indicated she’d be starting practices at 50% effort and volume and expect to transition to full 100% intensity within 2-3 weeks. At your FU visit the Lachmans’ and Pivot Shift are (-), she has very mild inferior pole tenderness and only a trace effusion. She is eager to resume and confirms a subjective 90% function rating. After reviewing the above local PT ReEval findings you recommend: The knee is doing great and she should proceed with her home PT’s recommendations for a progressive 50% - - - >100% intensity college soccer practices return. Ortho FU 4 wks. The knee is steadily advancing - - keep doing intensive rehab focusing on Quad and Hamstring strength and retest in 3 wks just prior to next ortho FU to reassess RTP potential The knee is improving nicely - - - more strength/power and dynamic control needed before safe to resume soccer play beyond (I) ball drills. Continue functional rehab progression including dynamic valgus control PRE and reactive stability training, retest and FU ortho visit in 3-4 wks. The knee is doing great and she should continue PT work and then proceed with her home PT’s recommendations in 2 wks for a progressive 50% - - - >100% intensity college soccer practices return. Ortho FU in 6 wks. CURRENT EVIDENCE Thompson X.D, Bruce A.S, et al. Disagreement in Pass Rates Between Strength and Performance Tests in Patients Recovering From Anterior Cruciate Ligament Reconstruction, The Journal of Sports Medicine, 2022;50(8):2111-2118 SUMMARY: Many physicians, surgeons, physical therapists, athletic trainers and even personal trainers deal with patients with an ACL injury. A critical discussion between all has been passing rates on tests related to return to play (RTP) criteria for athletes after ACLR. In this article, Thompson et al did a cross sectional study on ACLR subjects that are 5-12 months post-surgical. They utilized a commonly suggested/referenced limb symmetric index (LSI) of 90% for the battery of return to play test and isokinetic testing as return to play criteria. They compared outcomes with quadriceps isokinetic testing vs single leg (SL) maximum distance single hop and triple hop. The authors hypothesized pass rates would be non-uniformly distributed comparing gender, activity levels, and that more would pass hop than strength testing. The authors found 36.5% disagreement between non-weightbearing isokinetic 900/sec quad strength (peak torque) and SL hop test LSI pass rates. For those passing hopping but failing isokinetic testing, a greater portion included patients with higher pre-injury activity ratings, approximately 7 months post-op having more difficulty passing strength tests than hop tests, which they had hypothesized correctly. The key issue then becomes determining why we have so many not passing the strength pass rates and how dynamic hop testing is being passed when the quadriceps, a key power production muscle for the concentric and eccentric demands of hopping, remains significantly weak as defined by isokinetic measures. A potential source of error when using limb symmetry postoperatively as the key indicator of recovery is the integrity of the non-operative limb, which we now know from studies, does underperform most often compared to pre-surgical status. That risks falsely elevating limb symmetry scores for the post-operative side, in this case, the ACLR knee, and giving passing grades prematurely, thereby exposing patients to potentially greater re-injury risk. Making pre-op measurements either (i.e. pre-season test battery) prior to injury or prior to surgery (which would likely exclude a significant portion of patients whose injured knee may not allow safe hop test performance of the uninjured limb) would improve accuracy of subsequent RTP tests use LSI of 90% as the criteria for passing. While isokinetic strength testing is very good at isolating concentric knee extensor muscle force production and is considered very reliable as a measurement property, it does lack great authenticity of the WB demands the knee and quads must deal with performing at-risk activities of hopping, cutting, jumping, agility etc. While a SL hop has the advantages of measuring a much more global and authentic movement demand associated with sport, its weakness is that no single muscle group deficit can be identified with such testing. Multi-joint tests like these must have some constraints in order to minimize obvious or excessive compensatory actions. For example, in this study, while isokinetic testing operationally controlled for excessive UE involvement by crossing arms the hop test description did not contain any clear language indicating control over arm swing or opposite limb swing, leaving substantial potential for the expected poorer ACLR knee/limb to perform acceptably due not to excellent capacity of the quads/knee necessarily but due to asymmetric arm and/or opposite leg swing during testing. It is critical that physical therapists/athletic trainers be hypervigilant during all types of testing, but especially during final rehab stage RTP testing as false (+) passing on LSI scoring can lead to patients resuming higher risk activities. Physicians likewise have a key role in discerning the types and accuracy of RTP testing being utilized as they discern progressive activity allowances. While quad strength and sagittal plane/vertical force based hop testing is a key and valuable measure we believe it is critical that frontal and transverse plane capacities must also be scrutinized as these are known contributors to the mechanism of injury, yet too often are ignored with clinical RTP testing. A crossover triple hop can begin to identify some of this frontal/transverse plane control required however we advocate intentional plane dominant side-side and also rotary timed hop testing as well. (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: ACL re-injury rates at 29.5% (30.4% ipsilateral and 69.6% contralateral knee) after returning to physical activity. Clinicians, whether surgeons or PT’s/ATC’s, have difficulty in determining the correct test criteria to follow on functional performance and strength tests especially when there is disagreement in scoring. Purpose: The purpose of this study is to show a comparison of the pass rates between strength (isokinetic peak torque) and SL hop and triple hop tests comparing results among men and women as well as to compare lower versus higher preinjury activity levels (Tegner). Authors hypothesized that the pass rates would be non-uniformly distributed among gender, and activity levels, and that more subjects would pass hop tests over strength tests. Methods: Testing completed by a total of 299 participants (146 Men; 153 women) at a mean of 6.8 +/-1.4 months on unilateral/uncomplicated ALCR. Isokinetic testing at 900/s and 1800/s was used for quadriceps strength, while single leg (SL) hop and triple hop test was measured in cm for jump distance. The measurements were evaluated and compared via the Limb symmetry index (LSI), passing defined as 90% . Findings: Pass rates were found to be non-uniformly distributed between the SL HOP test and 900/sec isokinetic test (p<.001). Of the 299 subjects, 36.5% (102/299) failed the strength test while passing the SL HOP test, and also reported that there was no difference between men and women with pass rates. A higher portion of those passing hop testing but failing strength testing reported higher preinjury Tegner activity levels. Author's Conclusion: Patients with ACLR who had higher activity levels prior to surgery were more likely to pass hop testing despite failing strength testing, likely through movement compensations to achieve jump symmetry despite the presence of weak quadriceps. THE PEAK PERFORMANCE PERSPECTIVE ACL reconstruction remains a “hot topic” across multiple medical field journals, whether it is through biomechanics, surgery/orthopedics, or sports medicine. Surgeons and rehab professionals are tasked with deciding when a patient recovering from ACLR is ready to begin jogging progressions and agility/jumping work and eventually when return to play (RTP) to actual athletics/recreational activities can safely begin. Since re-injury rates are considered unacceptably high it is imperative that high quality testing be used as a basis for these key decisions. Paterno M. et al 2014, showed re-injury rates near 30% overall, with 30% being to the ipsilateral knee and nearly 70% to the contralateral knee on a 24 month follow-up study of ACLR. It’s initially surprising to many that a 70% contralateral knee injury rate could exist on the knee that did not have disuse atrophy or painful inhibition of the quadriceps muscle. Might this implicate underlying contralateral limb biomechanical risk factors, poor technique tendencies, or post-operative deconditioning effects on the “normal” leg…or might it suggest an abnormal reliance on the “healthy/normal” leg due to incomplete rehab and/or premature return to sports placing excess demands on the post-operative side? Statistics like these are the cause for both surgeons and PT’s/ATC’s to take notice and explore deeper understanding of contributing factors so we each can be more effective in our responsibilities working to optimize outcomes and reduce re-injury. Functional performance and strength tests are used as a guide to both measure progress of rehabilitation and for RTP criteria. Not only which tests to use but what criteria to base the ‘passing score’ on varies highly and is in disagreement between clinicians. Common tests include isolated (typically quads, NWB isokinetic) muscle strength, SL hop or triple hop along with crossover triple hop, vertical jumping, and/or agility tasks. Side-side comparison, typically with a “passing score” as 90% is used for the limb symmetry index (LSI). As a surgeon or orthopedist, when do you know that your patient has met RTP criteria? Do you have specific criteria you adhere to? Are you strict in using those passing grades as requirements or how often do other factors play a role in approving RTP despite the patient not yet passing RTP testing? How confident are we, as both surgeons/orthopedists and rehab professionals, that the tests used are highly likely to be effective tools in reducing re-injury rate? Unfortunately, the current literature suggests we’re not tremendously effective on a consistent basis. For return to sport or work it would be ideal if we had and used specific details about expected demands, chose specific tests based on those functional requirements, and had agreed criteria passing grades rather than a singular “RTP battery” used as a standard for all. Because no one job or sport is the same, they are all unique and require different skills. Thompson et al show there is difficulty in patients reaching this “passing score” on isokinetic strength testing in the knee extensors. Quadriceps strength is necessary for all knee surgeries and for ACLR’s we all can agree is a must. Studies have shown it is one of the top factors relating to satisfaction after surgery and level of activity performed. Returning to running and sport a person must be able control impact on a single leg repetitively in succession and for cutting/agility movements certainly larger sudden, unexpected larger impact loads. These are without a doubt where we can start when looking at RTP. In this study Thompson et al showed that SL HOP and quad strength pass rates do not line up uniformly at an average 7 month mark of rehabilitation. SL HOP metric was passed more than isokinetic quad strength tests using the 90% LSI criteria. Even though that is what they should have done for the past 7 months is work on quad strength. But we have to look at how the quadriceps was tested in strength and how it was actually strengthened. In the study they used an isokinetic machine in which the patient was performing a kicking motion at 180 and 900/s. While this is a very reliable measure it does have some controversy or debate associated with it based on the “authenticity” criteria - real life demands of the quads in work, recreation, and sport most often involve gravity based body weight demands through squat motions and injury most often occurs during deceleration phases. It is critical to remember these often involve combined planes of motion into the frontal and/or transverse plane as well, and not simply just sagittal plane performance. Isokinetics would be most authentic for things like kicking a ball where distal limb loading occurs, however, even then those loads are minimal and rapid contractile forces produce acceleration prior to any external load where force is generated. Isokinetic devices show acceleration (and some also eccentric deceleration measures as well) limited to the sagittal plane only. Great care in how to facilitate the quadriceps must be performed early in rehab to diminish likelihood of compensations by the short toe and ankle flexors or the hip extensors for motions or squatting, lunging, and stair negotiation. This is performed by understanding the biomechanics, carefully watching form, use of surface EMG biofeedback, and knowing how to target the quadriceps through functional movements. Too often what are thought to be “closed chain” or “functional” training methods become facilitators of abnormal neurologic habituation/compensation patterns. Anterior step downs with the distal foot off the box, and other similar quad dominating techniques, are key in stimulating the weak quads during ACLR rehab and testing. This provides the opportunity to more authentically stimulate and measure quad performance in WB environments while minimizing compensatory muscle activation that clouds the validity of test results. We often see patients perform NWB isometric knee extension testing well only to grossly underperform on WB testing. Therefore we never rely mainly on nwb test findings. While this study did not look at frontal and transverse planes, which together contribute to the dynamic valgus mechanism of the injury, this must be a key focus of rehab. Careful considerations of dorsiflexion loss, hip weakness of the abductors and ERs, overpronation foot mechanics, and femoral anteversion make rehab very multifactorial. Specifically testing for and addressing these dynamic valgus factors, rather than oversimplifying strengthening of the quadriceps and hips in general is a key aspect to high level functional rehabilitation. One of the key issues with the Thompson et al study here is the lack of clear control over arm swing and opposite leg swing during hop testing. While arms contribution during isokinetic testing was controlled they do not address arm/leg swing as confounding factors during hop testing. This leaves room for the “apparent” success (i.e. passing) of SL hop and triple hop findings to not have been due to excellent quad/knee performance but potentially due to momentums generated from elsewhere. We believe strongly in hop testing and find it very useful in discerning when the patient is ready for the next step. Using the SL Hop shows the sagittal plane well but there must be more standardization of this test to really show that the LEs are what are providing the power and distance rather than other influencers, upper extremities or the contralateral extremities. We need to avoid allowing a false (+) passing test which could actually put someone on the field with an actual increased risk. Thompson et al. did state that here were compensatory movement patterns used to pass the hop tests but was not clear on what. The fact that higher Tegner activity patients pre-op were most often the ones who passed hop testing but failed isokinetics may speak to proprioceptive/neurologic aptitude and their ability to compensate with high performing remaining “triple extension” hip and ankle power sources. This likely needs more study but we find a “cleaner” testing method of hands remaining on hips simply removes arm swing as a variable, thereby isolating true LE power more clearly. Cueing and observation to ensure hop performance is due to actual hop efforts and not contralateral leg swing is key. Quality assessment of final landing is critical as well - focusing on willingness of the knee to tolerate dampening forces into knee flexion vs weaker patients using a “peg leg” style landing. Of course frontal and transverse plane control must also be visualized and considered. Finally, opposite limb training must be included in formal rehab and home programming in order to avoid false (+) pass rates due to underperformance of the healthy limb occurring over time based on deconditioning effects. This also may have played some role in the Thompson et al results but is not clear how it differently may have affected isokinetic vs hop outcomes. The battery of tests must consider the sport/activity that the individual wants to return to but more importantly any known MOI that occurred, and its biomechanical contributors. While the single hop and triple hop sagittal plane tests are useful some other examples are lateral SL hop, vertical hop, triple cross-over hop, rotational hops, SL squatting ability under load, Anterior step down test with toes off…etc. These tests are biomechanically and proprioceptively more consistent with the functional demands and MOI prevention considerations of most patients. THE PEAK PERFORMANCE EXPERIENCE Justin said: “I never knew how much went into an ACL rehab. I definitely have more confidence in my knee now than I did prior to surgery with squatting and lunging. I never liked lunges because my knee hurt.” History: Justin is a ski instructor and trainer for the youth US ski team. During a ski session he fell and his ski did not come off. He felt a “pop” in his knee during his fall. He came to Peak for pre-hab and then post-op for his ACLR with partial lateral meniscectomy. Objective: (*=pain) 6 mo ReEval 7 mo ReEval Isometric 600 Quad 74% 89% 6” cone 600 pron - 600 sup rotational no touches 20sec 48% 62% SL squats 15sec 78%, fatigue shows consistent DKV @ last 5 sec 89%, inconsistent DKV happening rarely 3x Crossover Ant Hops 9’11” w/ reduced knee flexion and more hip flexion, contr leg swing, min DKV 10’2” w/ improved knee flexion (but still reduced), less contraleg swing, min DKV 900 Rotational Hops 10sec (30 unit radius) 4x (67%) (50 unit radius) 8x (80%) WB Quads Anterior (toes off) Stepdown 6” 10# DB’s 12x (75%) 15# DB’s 15x (75%) Key Findings: ALCR in which there was a lateral meniscectomy. Pt is in the intermediate phase of treatment showing weakness still in the quadriceps functionally and isometrically. Pt has inconsistent anterior pelvic tilting during such as well. The hopping test shows hip flexion compensation during lands of hops with minimal dynamic knee valgus. During rotational hops there was less speed from time of impact to lift but very minimal to no dynamic knee valgus during both trials. Treatment: In this intermediate phase dynamic frontal and transverse planes were worked on to really minimize the dynamic valgus and enhance the stability of the lower extremity. Squatting on incline board was done to mimic transfer of forces at angles with dumbbell hang position for skiing efforts. Unstable surface SL squatting was performed to improve overall stability of force absorption with a noncompliant surface. Toes off anterior step downs were still used with a posterior lean for quadriceps strengthening through function with a cross reach to minimize DKV while overloading the muscles. Speed training to improve fast twitch fiber reaction on unstable and slated surfaces for proper ground reaction to sport. Justin required fast small impact drills to mimic the oscillatory action of skiing downhill. The Vibeplate also helped with Single legged balance training for the nervous system at high levels for return to fast oscillatory motions as well. Outcome: Pt is still working through physical therapy to start skiing soon with small slopes. Pt shows great determination to get back to it with consistent work on HEP and shows changes weekly. 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

Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE April 2022 Key Mistakes in ACLR Return to Sports Decision Making: Can We Trust Hop Testing Data? by Mike Napierala, PT, SCS, CSCS, FAFS Clinical Scenario...What would you do? A 27 yr old male semi-pro developmental league football wide receiver sustained a non-contact deceleration injury during a cutting move and has an MRI confirmed isolated ACL tear. He underwent autologous patellar tendon ACL reconstruction and has been participating in BIW - - > weekly post-operative physical therapy. He has progressed very well and is presently at the 12+ month mark. Subjectively he is painfree. On clinical exam he has (-) Lachmans and Pivot Shift test findings. Your quick MMT of quads and hamstrings sitting on table are very good and painfree. He is eager and confident in his readiness to resume football practices. He reports performing progressive agility and plyometric drills at PT. His PT Re-Evaluation report did not yet make it through for review. He wants your approval to resume non-contact practices including route running and change of direction drills w defender, blocking drills…progressing to full contact scrimmaging and play over the next 4 weeks. My clinical thinking is: He needs to wait until at least the 9 month mark to reduce risks of contralateral knee ACL injury. He is doing well. He may return gradually now and progress his participation based on his comfort level and coaching feedback on movement quality. Perform in-office single leg squats, vertical and rotary hop testing observation and then decide. Call PT to discuss Re-Eval findings while Pt is in office or wait to obtain test findings before final decision. Counsel patient on risk management and call back with orders once testing reviewed. CURRENT EVIDENCE Kotsifaki A, et al. Symmetry in Triple Hop Distance Hides Asymmetries in Knee Function After ACL Reconstruction in Athletes at Return to Sports. Am J Sports Med, 50:2, 2022, 441-450. https://journals.sagepub.com/doi/pdf/10.1177/03635465211063192 SUMMARY: ACLR recovery risks becoming a “routine” for both surgeons, therapists, and patients alike. As a surgeon/physician how do you really know an athlete is ready and safe to return to sports (RTS)? Are you certain they’ve prepared properly and thoroughly in their rehab? Key decision making centers around the quality of rehabilitation especially in the intermediate phase leading up to return to function progressions and eventual testing used to determine return to play. Recent data on recovery from ACLR regarding return to prior sports participation is disappointing. Some evidence suggests that only 65% return to prior levels of sports participation and risks of a second ACL injury have been reported up to 29% (Australian football/rugby showing rates of even 40%). . Limb symmetry index (LSI) is often used for RTS testing of strength and hop performance among others. Consensus is, however, lacking regarding the “best practices” on specific tests and scoring to optimize successful return and reduce future injury risk to the ipsilateral or contralateral knee. Some data suggests that LSI values alone do not accurately reflect the function and biomechanical performance properties of the ACLR knee and limb. Kosifaki et al performed 3D motion analysis during a triple anterior hop test comparing 23 healthy male controls with 24 post-op ACLR male athletes who were cleared for RTS(ages 18-35, Tegner > 7). Among inclusion criteria were quads LSI > 90% and hop battery tests LSI > 90%. They used 42 reflective markers with a 14-camera system and force plate, requiring hands remain on hips and a 2 second hold upon final landing. The ACLR group had 97.1% LSI . The ACLR group showed the involved limb landed with greater hip flexion, trunk flexion, anterior tilt and peak knee flexion angle was less as well as less knee flexion moments. ACLR involved limbs also showed knee work absorption LSI of 80% with second rebound and final landing but only 51% and 66% for work generation LSI during first and second rebound take offs. Hip work was higher and ankle work lower for the involved ACLR group. In controls and uninvolved limbs alike the knee plays a greater role during the abslorption or typical “injury” phase than in the propulsion phase thought to create the distance of the hop test findings. It is imperative that surgeons and therapists be critical about not only the RTS phase of recovery but the intermediate phase preceding that. This phase oftentimes is considered “routine” and merely a “putting in the work” mindset by both clinicians and patients. But it is this foundational strength and power development phase that can set up the knee-quads and lower extremity for success or for compensation based “false success” noted in mere LSI based testing. Traditional PT rehab exercises involving triple extension, while being functional, also risk setting up the ACLR athlete for compensatory patterning with the hip extensors from early on. The ability to “isolate” the quads during integrated functional patterning is critical. Unfortunately it’s all too often a missed or lost art in rehab clinics across the world. That may be the reason that despite such extensive therapy so many ACLR studies show persistent quad weakness, and, that quad weakness remains one of the key limiting factors to successful RTS. This study also did not examine frontal and transverse plane issues with landing mechanics regarding “dynamic valgus” risk factors. These also must be appreciated and addressed during testing performance, beyond simple LSI numerics. Surgeons and physicians during the post-operative phase remain in a critical role because they must discern if the rehab being done is appropriate and thorough enough to confidently trust that desired outcomes will be achieved. Routine care and mere protocol adherence is likely to fail. The literature certainly demonstrates that as a total collective the health care system is not presently producing high outcomes for our ACLR patients. Below are further details regarding key approaches that distinguish biomechanically authentic methods of approaching Quad rehab and hop testing beyond traditional approaches for the sake of optimizing function and reducing re-injury risk. Background: ACLR return to sport (RTS) and second injury rates are both unacceptable. Limb symmetry index (LSI) with hop testing is commonly used as a means of assessing readiness for sport but some data suggests kinetics/kinematics may not be normal despite symmetry of distance measures. Purpose: To determine if restoration of lower limb biomechanics during triple hop for distance testing is ensured by passing discharge criteria post-ACLR. Methods: Controlled clinical lab study using 3D motion analysis of 24 male athletes after ACLR who were cleared to RTS (LSI > 90% for quad strength and hop battery testing) compared to 23 healthy male athletes (participants 18-35 yr ). A 14-camera + force plate, using 42 body markers, was used to collect data. Findings: Despite reaching 97% LSI for ACLR involved side distances, the absorption work LSI was 80% and work generation were only 51% and 66% for first and second rebounds respectively. The relative knee work was less for involved limbs and hip work larger (P < 0.001) for all phases vs uninvolved and control limbs. Hip, pelvis, trunk compensations were noted with ACLR involved side limb testing. Author's Conclusion: Triple hop limb symmetry masked important knee deficits in knee joint work which were more prominent during work generation (concentric push off) than absorption (eccentric landing). THE PEAK PERFORMANCE PERSPECTIVE Surgeons and physicians caring for post-op ACLR patients are most often comfortable with familiar rehabilitation protocols they have often used for years. These oftentimes have been introduced during fellowship training or possibly through interaction with “experts in the field” via publications or conferences. ACLR recovery risks becoming a “routine” task for both clinicians and patients alike, especially for surgeons who perform numerous ACLR’s monthly even upwards to 150+ per year. For patients, physical therapists, and athletic trainers the multiple visits weekly process also risks a “routine” feeling that can undermine the appreciation for subtle biomechanical factors that must be addressed if the RTS phase is to go well. The real question at hand is are we all being scrutinizing enough? Are we discerning the subtle details as best possible in order to optimize recovery and reduce reinjury risks? The literature would suggest we are not! As a surgeon/physician how do you know your patient is ready to RTS? Do you carefully scrutinize the test reports sent by PT’s and ATC’s? How often do you recommend delaying RTS or has it become routine to approve progression based more so on time than supportive data? While there is no consensus or clear answers as to the “right” thing to do the successful return to sport data and second injury data are both disappointing to say the least. While individual experiences may be different the collective data suggest that surgeons and therapists/trainers are too often failing to ensure optimal recovery, including for those allowed to RTS. Over 30% of those undergoing the long recovery process of ACLR never make it back to their prior and expected level of sports participation. One in five sustain a second ACL injury. Surgeons sit at the healm of decision making in terms of protocols used and in discernment over where rehabilitation is done. Therapists and trainers are daily making treatment decisions that impact the training effect achieved…whether that be potentially reinforcing compensation patterns or optimizing more authentic normal neuromuscular function. We all have a hand in these mediocre outcomes. We all want excellence though. Kotsifaki et al demonstrated that despite 97% limb symmetry with triple anterior hop testing that important biomechanical performances were significantly still abnormal/asymmetric compared to the uninvolved limb and control limbs. Knee work was less, especially for concentric push off following an absorption (ie, plyometric type “rebound” effect”) though still only 80% for the typical injury phase eccentric absorptions. Proximal segment compensation from hip/trunk extensors was evident on involved limbs as well. Symmetry on triple hop distances was clearly NOT achieved because the “knee” itself was normal and symmetric! Underlying this subpar performance at the knee, even in just these sagittal plane indicators, is quad strength deficits. Traditional post operative protocols and real-life rehabilitation programming often attempt to utlize what are thought to be “functional” approaches to exercise advancements, with the intention of stimulating the neuromuscular system and mimicking real-life demands for activities like stair climbing that will eventually evolve into decelerating a cut or landing a jump. That means “triple extension” based exercises that intend to stimulate the hip-knee-ankle activation used for successful squating maneuvers. Typically that involves squats, leg presses, split squats, lunges, step downs, step ups, sled pulls and pushes and eventually impact based drills for jumping and hopping…etc. Unfortunately post operative pain and effusion disproportionately effects quadriceps performance more so than other related muscle groups in squat function. That open door for compensation, especially from the hip extensor hamstrings and glutes, more often than the short plantarflexors means that PT’s and ATC’s doing ACLR rehab must be keenly aware of how to recruit quads preferentially. Otherwise the risk is that too early or too casual or careless an “advancement” to functional ADL prep training exercises like stepdowns or step ups etc will produce significant compensation patterns that become harder to undo later down the road. Avoiding these mistakes requires attention to detail and personalized/customized exercise programming and cueing. The use of surface EMG biofeedback can be helpful but the real key is understanding biomechanics and carefully observing exercise techniques during squatting drills. While in one hand we appreciate and desire the “protective” effect of hamstring co-activation regarding it’s potential to reduce anterior shear forces we also need care in habituating quad inhibition and inadequacy during strength training drills. We don’t believe the answer is merely a focus on seated NWB quad extensions to isolate the quad but generic “functional” exercises like lunges and stepdowns done incorrectly can facilitate quad avoidance that will lead to poor declaration mechanics down the road. While this study did not examine frontal and transverse plane mechanics risk factors (ie. Dynamic valgus/IR) which is well known and accepted, these are key areas of focus during ACLR rehab. Since this is a multifactorial issue there is not a singular protocol-based approach or exercise that can simply be done to address dynamic valgus control or deceleration. Focused testing for anteversion, abnormal foot mechanics leading to overpronation issues, hip weakness issues of the abductors and/or external rotators, and dorsiflexion loss are some of the key underlying causes that we find related to dynamic valgus/IR that can be addressed with proper physical therapy care. We do perform hop testing and find it valuable. Normative data tells us that significant asymmetry is not normal. Yet, we also know from Kotsifaki et al’s data and others that mere LSI symmetry is also not enough information to prove normal function. Without expensive research level testing equipment clinical testing relies on keen observation skills and qualitative assessment beyond simple number crunching. But the well studied sagittal plane dominated tests used over the past decades in ACLR research we believe are lacking in their authenticity to real-world mechanism of injury biomechanics where frontal and transverse plane forces also occur. We utilize side-side hopping tests along with rotational hopping tests to force the knee to prove it can handle/decelerate and stabilize dynamic valgus/rotational type loading. Many PT exercise programs post ACLR also maintain a prolonged focus on “knee over the foot” directional intention for landing drills. While this is necessary and safe early on during healing concern time frames it is deleterious to neuromuscular training of authentic biomechanics loading forces the athletes will incur when they do return to the court or field and must contend with multiplanar knee and lower extremity loading. A key consideration is whether rehab has taught that knee and LE to successfully decelerate and reverse dynamic valgus/rotational inertial loading. The reality is that these forces WILL happen to athletes knees during sport. Excellent rehab does not pretend that conscious control of intended ideal paths will always be the norm. It must progress to contending with the original MOI and prove that safe dynamic stabilization and progression of the intended sports movement can happen. Below is a case study of my son’s ACLR experience at Peak Performance. Unfortunately the demands of work and parenthood altered his ideal rehab consistency further into his recovery but his excellent progress in the early formative months post op set him up for his return to football practices and soon to be game play. THE PEAK PERFORMANCE EXPERIENCE Jordan said: “I feel faster than I was before I got hurt. I'm making cuts in practice, getting open and catching the ball. I’m not 100% yet but I’m feeling good!" HX: 29 yr old male sustained a change of direction R knee giving way injury doing a wide receiver route in practice on turf in March 2021. He underwent autologous patellar tendon ACLR 3.29.21 and initiated rehab 2 days later. Subjective: At 7 month ReEval patient reported 1/10 max sx, 70% subjective function. By his 9 month ReEval he reported less frequency of symptoms but not yet painfree, likely due to his progression of activity and reducing HEP and PT compliance (new baby). Subjective function 80% , able to do sprinting, light route running and catching, IKDC 90%. Objective: (*=pain) 7 mo ReEval 9 mo ReEval Isometric 600 Quad 56% 78% 6” cone 900 pron - 600 sup rotational no touches 20sec Prior testing 114%...NT NT Vertical Hop 70% 550/470 3x Crossover Ant Hops 18’3” w reduced knee ant excursion and min excess trunk/hip flexion 19’0’ (97%) w improved knee and trunk mechanics + no abn Dyn Valg 900 Rotational Hops 10sec (40 unit radius) 9x (100%) (60 unit radius) 10x (111%) WB Quads Anterior (toes off) Stepdown 6” 40# DB’s 20x (71%) 50# DB’s 24x (86%) Key Findings: During intermediate phase mild increased hip flexion (ant tilting pelvis) often occurred during intended quad dominant squat PRE type drills and excessive trunk incline (hip extensor compensation) along with limited anterior knee excursion would occur during lunges and split squats. Frontal and transverse plane control had become excellent by 3 months post op and was advanced accordingly but did not require the typical extra attention often noted. Compliance became an increasing issue with PT visits falling off and HEP reducing significantly with birth of first child during at the 8 month post op mark. Treatment: During intermediate phase rehab dynamic frontal and transverse plane proprioceptive/stability drills were advanced via single leg balance drills including use of VibePlate plus reduced visual feedback (eye/eyes closed) work and distraction/perturbation techniques with ball passing and manual perturbations, eventually leading into “on-impact” mini squats with perturbations producing dynamic valgus type loading forces for deceleration/stabilization. Early on reliance on hip extensors and plantarflexors to assist squat function triple extension drills were gradually transitioned into Quad dominant stimuli using “front rack” (upright trunk) DB’s positioning, toes off Ant stepdowns with posterior trunk lean and posterior pelvic tilt cueing and lunging drills with toes off ¾” plywood landings to optimize knee flexion moments for quad recruitment. Impact drills were progressed into single leg push offs for power, single leg landings in place - - - > with distance excursion …and then multiplanar landings. Eventually proximal kinetic chain demands with inertial loading into diagonal patterns producing dynamic valgus replications of sport-like demands were included and then finally with reactive catching medicine balls into “at-risk” positions of the trunk-BUE. Plyometrics and agility drills proceeded as well with intention transition into combined frontal-transverse plane demands. Outcome: Pt has continued HEP inconsistently and returned to weekly (9+ mo mark) - - - >biweekly football practices and now at one year post op has done full contact scrimmaging and preparing for first official team scrimmage out of town. 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

I tore my ACL and had surgery. My experience at Peak Performance was great! Andrew and everyone else that helped him out with my PT were very helpful. After a while I stopped doing my PT for a while, which was a big mistake. Andrew talked to me about it and it really encouraged me to get back to doing my PT and after that I was really good about it. Now I am feeling really good and am back to playing soccer again. I am doing well and my knee also feels good. I really want to thank Andrew and Peak Performance for helping me get back to playing soccer! Michael LoIacono April 28, 2019

Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE October 2018 Hop-Testing Asymmetry: Frontal & Transverse Plane CURRENT EVIDENCE Wren TA, Mueske NM, et al. Hop Distance Symmetry Does NOT indicate normal landing biomechanics in adolescent athletes with recent ACL reconstruction. JOSPT. 2018; 48(8): 622-629. by Mike Napierala, PT, SCS, CSCS, FAFS NOTE: This is a Part II following last month’s review by Karen Napierala, PT, ATC, MS, CAFS in which she focused mainly on the sagittal plane findings, which are the majority and main focus of Wren et al’s study. You can review Karen’s update HERE. Background: This study’s purpose was to compare operative limb single-leg hop biomechanics following ACLR to both the contralateral non-operative limb and a normal knee control group. They wanted to determine whether the gold standard of 90% hop distance symmetry should be used for return-to-sport readiness following ACLR surgeries in adolescents, and if it is associated with normalized biomechanics. Method: Forty-six 12-to-18-year-old patients along with 38 age-matched contralateral controls participated. ACLR patients were at a mean of 7.2 months post-op. Single Anterior Hop test (best of three) along with 3-D motion-analysis data were recorded at initial contact and between initial foot contact and maximum weight-bearing limb knee flexion on landing. Thirty-eight controls of the same age, who participated in 3/week sporting activities, with no injury history, were tested to provide normative data. Patients were grouped for data analysis based on limb symmetry index (LSI) as symmetric (> 90%) or asymmetric (< 90%). The control group was pared down to 24 of the 38 based on those exhibiting 90% LSI(72% of group), since relative symmetry is considered a target for normal function. Results: Here I’ll focus on the frontal/transverse plane findings. The authors reported that both symmetric and asymmetric patients had lower average external knee adduction moments, reaching statistical significance for both limbs for symmetric patients and the operative limb of asymmetric patients. Additionally, the authors later indicated that “only minor differences were noted in the frontal/transverse plane” regarding symmetric patients. No comments were made regarding the asymmetric patients group. In the Discussion they do caution that the Vicon plug-in gait model has been shown to have high intersubject variance.” I’ll expand below on some of the findings Wren et al failed to emphasize. Maximum hip adduction angle was 4.10 for controls, 5.20 for symmetric/operative limb and 4.90 for asymmetric/operative side while only 1.90 and 1.40 for non-operative symmetric and asymmetric sides respectively – not apparently reaching statistical significance. Minimum knee adduction angle was 1.50 for controls, but 0.40 and 0.20 respectively for symmetric non-op and operative limbs while asymmetric limbs were -0.60 and -0.90 respectively for non-op and operative limbs – again, apparently not reaching statistical significance. Average external knee adduction moment was lower for symmetric and asymmetric patients and was significantly less vs controls (0.098 units) for symmetric patients both non-operative (0.071) and operative side (0.056), and for asymmetric operative limbs (0.06). Conclusion: Symmetric patients achieved symmetry by, in part, hopping shorter on the non-operative opposite leg. Both symmetric and asymmetric patients off loaded their operative side. Hop distance symmetry may not be an adequate indicator of single leg function or return to sport readiness. The authors neglected to address frontal plane findings in their conclusion statement. I would add that there were small but statistically significant differences with a trending toward knee abd moments for both knees of symmetric patients and the operative limb of asymmetric patients, with both limbs of the operative limb trending toward knee abd angles. THE PEAK PERFORMANCE PERSPECTIVE Karen covered many pertinent concepts regarding this article’s overall kinetic chain implications in terms of compensatory tendencies noted, the inadequacy of post-operative limb symmetry index scoring as a valid comparison to normal pre-injury function (due to subsequent decline of non-operative limb performance also), and the sagittal plane dominant perspectives regarding hip, knee, and ankle loading. We advocate for return to play (RTP) functional testing that demands authentic activity stressors rather than focusing solely on the more easily measured and observed exclusive sagittal plane traditional power indicators, which too often happen to the mutual exclusion of the quality and quantity measures of frontal and transverse plane dynamic stability. Cutting, change of direction, unexpected twisting/bending, either based on sport reactions or contact from another player, all require control of frontal and transverse plane forces. The ability to powerfully hop in just one direction is valuable but very limited. For example, two functional hop tests we utilize are a frontal plane single leg timed side-side hop and also a timed rotational (450 up to 1200 depending on pt status and goal activity ). Both provide useful insights into more authentic demands on the ACLR knee (and a host of other LE injuries as well). In turn, the rehabilitation progression of proprioception, dynamic stability, strength and power training, and agility all reflect that understanding. Too often patients, especially athletes, exercise in sagittal plane restricted motions despite their ultimate goal activity containing substantial amounts of frontal and transverse plane deceleration/acceleration requirements. Exercises aimed at training muscle groups like the hip ER’s and abd’s or Tib Posterior or gluteals/hamstrings must be consistent enough with typical use for the body to quickly apply this newfound ability directly into functional tasks. An example would be the common “clamshell” exercise…generally designed to stimulate the hip abductors/ER’s. Regardless of the loading used, which typically is body weight alone or ankle/cuff wts, the disconnect for the body we’d propose has more to do with proprioceptive inconsistencies – the fact that those muscles never see substantial loading for NWB actions but rather are loaded in ADL and athletics by superincumbent body weight via gravity and inertial loading. The “leap of faith” if you will, that must occur for a clamshell trained hip to then perform with excellence in a hop landing or a cutting move are seemingly massive. The post-operative ACLR hop tests most commonly referenced in the literature are a 3x Anterior Hop, a 3x Anterior Crossover Hop, and a 6m Timed Anterior Hop. While these tests remain sagittal plane dominant they do at minimum require multiple acceleration-deceleration efforts. An advantage of the Crossover hop is the hybrid demand of decelerating forward momentum with simultaneous frontal plane stresses into both genu varum (knee adduction) or genu valgum (knee abduction). Dynamic valgus has been identified in numerous studies over the past decade or more as a key risk factor for ACL injury. Knees collapsing into valgus during landing events have greater risk of subsequent ACL injury. Knee abduction is a natural kinetic chain extension of the lower extremity landing mechanics that begin with foot pronation. Subtalar joint pronation, via talus adduction contributes to kinetic chain proximal tibial IR, knee abduction, femoral IR, hip adduction/flexion. This is one means of producing dynamic valgus. Landing with the foot ER’d can also cause the proximal knee segment to drive medially into valgus/abduction as well. Proximally driven “top-down” mechanics ot a trunk/pelvis segment turning away from the landing limb may also produce dynamic valgus. Wren et al did attempt to examine frontal plane knee biomechanics but they oddly chose to measure “knee adduction” angles and external moments, directly in contrast to the other lower extremity measures taken, which, as noted above, are collectively consistent with the pattern of dynamic valgus that is a known ACL risk indicator. Their data does indicate (-) knee adduction angle values for asymmetric patients both non-operative and operative knees….ie, knee abduction. Both knees of symmetric ACLR patients and the operative side of asymmetric ACLR patients also had statistically significant reductions of knee adduction moment, or in other terms – trending toward knee abduction moments. It remains to be seen why Wren et al’s study did not demonstrate the same dynamic valgus in either controls or ACLR patients that have been noted in other studies. They do indicate that the gait model they used tends to result in high intersubject variance of frontal plane variables. Based on the known dynamic valgus concerns for landing/hopping mechanics it appears Wren et al missed an important opportunity to gather accurate valuable data to help us better understand differences in this kinematic variable for symmetric and asymmetric hoppers. Finally, the Wren et al group use control group data for comparison. We must remember that this group may or may not reflect our ideal physically. It is unknown which people in the control group are actually an at risk group based on other factors – such as dynamic valgus landing mechanics or strength profiles or balance function. Wren et al also chose to define “control” only as the 62% who were within 10% between L-R for Anterior Hop Test performance. It is worth noting that over 1/3 of all “normals” in fact had > 10% asymmetry in hop testing, and that was evenly split between their pre-defined “dominant” and “nondominant” side being superior. The case study below demonstrates some of the hop testing utilized at Peak Performance for a patient who underwent ACLR. THE PEAK PERFORMANCE EXPERIENCE Becca stated: “My ACL and meniscus tears had me sitting out all the activities I love--mountain biking, swing dancing, and hiking--now I am ready to start racing and performing again with full confidence.” History: 25 yr old female swing dancer and mountain biker had non-contact twisting mechanism to (L) knee while kicking a ball at recreational league soccer practice. MRI was (+) for torn ACL and MM tear. Underwent ACLR + PMM and began outpatient PT three days later. Subjective: Pt reported 2/10 pain max at post-op PT evaluation. Was using Toradol and Percocet post op. IKDC was 30%. Pt employed as engineer. Goals were returning to competitive mountain biking and swing dance. Objective: TEST Eval 4 mo Re-eval DC @ 7mo Knee ROM PROM: Ext 10hyper, flex 570 AROM: 0-1360 1-1400 Quad 600 isometric NT 37.7kg (78%) 49.8 kg (88%) Hams 200 isometric NT 24.6kg (95%) 27.0kg (116%) SLB rotational “no touch” test 20sec NT 14x (88%) 20x (120%) (excellent decel Dyn Valg/Pron) Quads Ant Stepdown NT 5.25” 12lb wts 64% 5.25” 20lb wts 89% 3x Ant Hop NT Submax 1x Ant = Fair 103% Side-side 10sec hops NT NT 100% 900 Rotational Hops NT NT 80% Outcome: At DC re-eval Pt reported max 1/10 sx only after hours of mountain biking or heavy wt lifting. She self-reported 99% function and IKDC was 89%. She also resumed swing dancing but felt she was not quite fully WNL yet with all dance moves. Treatment: Exercise: After early post-op care phase once pt FWB she was advanced through functional exercise approach with primarily WB based strengthening focusing on quadriceps, hamstrings/gluteals, plantarflexors and as healing time passed increasingly including especially supinators and hip abductors and ERs . Proprioception/Dynamic Stability: Early simple single-leg balancing (SLB) progressed with visual challenges (dominant and both eye closed) along with plane-based challenges using both upper and contralateral lower limbs to promote deceleration toward right rotation and knee abduction stresses (dynamic valgus). Vibration platform was utilized for increased neuromuscular stimulus. Impact based demands were later included. Manual therapy: Ankle joint mobilization to restore dorsiflexion. Functional Training: Impact progression drills beginning with stabilization landings and explosive push offs into (B) landings were initiated. Over time she progressed into multidirectional leaping and single leg hopping drills along with agility stepping/change of direction work to prepare for her swing dance demands. 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. Mike Napierala, PT, SCS, CSCS, FAFS 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

I came to Allison after tearing my ACL for the second time. I was unable to do anything. After 10 months, I was able to return to playing sports (football and basketball) with complete confidence. I have had PT before on the first knee and Peak Performance was different than any other place! I feel great and better than I ever have. Thank you for allowing me to get back to football. Thank you, Allison! Timothy"Tim" Reilich November 13, 2018

From the first appointment I had, Mike was there to correct my form, which may have contributed to my ACL injury. Post-op, he was there to guide me in my recovery by adjusting ACL surgery recovery to accommodate my body’s reaction to the surgery. He never rushed me through my program and was able to spend the quality time I needed to aid in my recovery. It helps to know that Mike is not only there to fix my current injury but also to prevent future injury. Before PT I was mostly immobile due to surgery and Mike has helped me progress through his custom rehab program. Although I have not fully recovered yet, I believe Mike has started me on a great road to recovery. I am thankful that Mike took the time to help me find a new PT in Connecticut (where I am moving to). Mary D. May 31, 2018

I came to Peak Performance after I tore my ACL skiing in Switzerland. I had trouble walking, going upstairs and carrying heavy things. Going to physical therapy before and after surgery improved my knee and built my confidence in my knee back up. Mike made physical therapy fun and extremely helpful. Almost a year after my injury, I am ready to get back to sports. I can now run, cut, and carry a heavy weight load again. I feel almost stronger than I was before my injury, thanks to Mike and Peak Performance! Jennifer A. March 16, 2018

While coaching wrestling in a “live” situation, my right knee popped out and completely tore my ACL in half. After surgery, Andrew started working with me and I couldn’t be happier with the progress I’ve made. Coming to PT was my favorite part of the week. I am back to coaching wrestling and very thankful to the staff at Peak Performance. Thanks, guys! Michael M. December 28, 2017

On a ski trip to Canada, I tore my ACL and MCL in a wipeout. I worked with Andrew before surgery to build up strength and after to repair. I’m now back to full function and back to running. I’m looking forward to ski season! Laurie Z. October 30, 2017

When I was 14 years old, I tore my ACL and had reconstructive surgery on my knee. I’ve had trouble with it for the last 30 years (!), and had rehab 3-4 times with varying degrees of success. When I re-injured my knee this past February, I thought I would need surgery for sure. It turns out I didn’t and just needed more rehab. After 3 months at Peak Performance, my knee feels as good as it ever has and I’m looking forward to getting back to my hobbies of backpacking and playing soccer. This has hands down been the best rehab experience of my life. Thank you, Mike! Trent H.

I had never had a lower body injury in my life, let alone an ACL tear. The injury was devastating at the time, but Mike assured me that, with hard work and diligence, my strength would be regained. Along my PT journey, Mike pushed me beyond my limits and out of my comfort zone. I trusted Mike’s elite knowledge of ACL recovery the entire time, and that pushed me even more when I was working on my own. During my time here, Mike taught me skills regarding attention to detail, diligence and patience that I will carry with me forever. I will never forget my first visit after surgery; I was terrified and nearly passed out! 7 months later, I’m nearing a full recovery and working towards being back on the basketball court. I would not be where I am today without Mike help and encouragement, and for that I’m forever grateful! Ben S.

My ACL and meniscus tears had me sitting out all of the activities I love: Mountain biking, swing dancing, and hiking. After working with Mike, I am ready to start racing and performing again with full confidence. Thank you, Peak Performance! Rebecca W.

Peak Performance was amazing. I tore my ACL playing soccer and I had surgery and had to stay in bed for 1-2 weeks. I was on crutches for months, and have had knee pain for 6-8 months. I started PT not even being able to climb stairs or get in the shower without help. Now, I’m back to playing high-intensity contact soccer at RIT. Also, I’m 100% back to lifting (squats, deadlifts, lunges, etc.). Going from trouble walking to jumping, cutting and sprinting again is incredible. I’m so thankful for Peak Performance and all Mike has done for me! Marcus D.

I came to PT to experience a recovery process from my ACL at a more rigorous level than at the Westfall Facility. Starting with a new ACL the bar is quite low as to activity levels. I wanted to, and with Mike’s help, was able to methodically improve my strength and agility. I still have improvements to make but I know what I have to do and have the tools and skills to do it. Mark S. October 18, 2016

After having ACL and meniscus surgery as well as a case of patellar tendonitis, I was having a hard time walking, going up and down stairs and even performing simple daily tasks. Due to the help of Mike and the whole PPPT staff, I slowly but surely got back to doing everything I was able to do prior to my injury with no pain! I am excited to be able to start playing soccer again in the near future! Morgan L. August 24, 2016

Peak Performance Physical Therapy & Sports Training PHYSICIAN UPDATENOVEMBER 2015 CURRENT EVIDENCE Ekegren CL et al, Reliability and Validity of Observational Risk Screening in Evaluating Dynamic Knee Valgus JOSPT 39(9) 2009. 665-674 Study Design: Nonexperimental methodological study Background: Hip neuromuscular control deficiency has been identified in non-contact ACL injuries as a key risk factor for postpubescent females. This manifests as valgus knee alignment during hip/knee flexion tasks. No scientifically tested clinical or on-field methods for screening dynamic valgus exist. Methods: Three PT’s used observation based risk-screening guidelines to rate 40 different teenage female soccer players for ACL injury risk using the amount of dynamic valgus noted during drop-jump landing. 3-D motion analysis was used for comparison to determine sensitivity and specificity. Results: Inter and intrarater reliability over time and between PT’s was consistent with Kappa coefficients 0.75 to 0.85. Sensitivity values ranged from 67% to 87% meaning that up to 1/3 of “truly high risk” players were missed. Specificity ranges from 60-72%, considered adequate for screening purposes. Conclusion: Observational risk screening for knee dynamic valgus with drop jump landings is practical and cost effective means of screening for ACL injury risk. Inter and intrarater reliability and specificity were acceptable but sensitivity was not adequate. Additional tests for other high risk characteristics may be needed in screening protocols beyond the drop jump landing. THE PEAK PERFORMANCE PERSPECTIVE Females are known to have 4-6 times higher incidence of non-contact ACL injuries versus their male counterparts. Numerous studies have shown through video analysis that females tend to land in drop-jump tasks with greater knee valgus. Also a prospective study by Hewett et al in AJSM in 2005 showed in adolescent females that increased knee valgus angles and moments were predictive of future ACL injuries. The commonly described “at risk” position of the knee at the time of a non-contact ACL mechanism of injury is knee abduction combined with femoral IR, in a position of slight knee flexion. This “collapsing inward” of the knee is a key component to injury risk and clinically is difficult to quantify without expensive and elaborate motion analysis equipment used with time consuming testing procedures. Oftentimes well studied functional performance based tests, such as the vertical hop or triple hop or others are utilized in post-operative ACLR cases to identify when someone is prepared to begin or transition further into or further along with sports related “functional” training programs entailing running progressions and agility/jumping work…and eventually increasing scrimmage and game play. Drop jump landing video analysis is commonly used but has some potential limitations that must be considered. In this case a 31cm box was used. Depending upon differences in height, limb length, body mass, and strength this 31cm landing load may have varied significantly between subjects. Landing bilaterally also substantially reduces the likelihood for abnormal knee dynamic valgus based on magnitude and types of loading present. The hip adduction moment experienced will certainly be reduced (that the landing limb’s hip abductors must oppose). Weakness of the Abductors may be seen as opposite side pelvic drop but may also be manifested in femoral collapse inward, ie hip adduction, leading to knee abduction or “valgus.” As ground reaction forces create a “bottom up” driver to the system, overpronation related transverse plane influences from the tibia and subsequently the femur become potential variables that can influence observed frontal plane knee valgus. Proximally, hip anteversion along with weakness of the hip External Rotators can contribute to increasing femoral IR moments, again contributing to dynamic knee valgus tendencies. One would expect both types of transverse plane moments to be reduced in a bilateral landing environment. In actual sport function, while there are certainly many instances were simultaneous bilateral landing from jumps occurs, this primarily happens in basketball and volleyball, and then also with soccer headers for females. Very often unilateral or asynchronous landings occur where one limb enters the ground alone or just prior to the other. This study’s findings cannot specifically be extrapolated to those sport situations, however, we would expect single limb landing mechanics may produce even greater dynamic valgus. In the clinic we observe both bilateral landings but also single leg performance. While quantity (height, distance, reps…etc) of various hop tests is a critical factor in determining if strength/power and deceleration capacity have been increased to adequate levels, the observed QUALITY of landing mechanics must be assessed and reported as well. In this study the “high risk” categorization was used when the patella moved inward medial to the hallux upon landing. We employ a similar visual assessment in the clinic for rating the quality of landing mechanics from jumps and hops, however, due to variations in anatomic alignment and deformities that may already position an athlete in a more “at risk” appearing position, we also visually assess the acceleration qualities of the dynamic valgus that occurs. This article’s evidence showed that up to 1/3 of actual “high risk” athletes may be labeled incorrectly as “low risk.” Our use of motion rather than just position alone, along with the type and demand of single leg tests employed are utilized in order to go beyond these limitations of bilateral drop landing testing. Many athletes having genu valgum and hip anteversion are likely to always have such mechanics and if strict criteria were employed they might otherwise be refused participation in sports if the ability to absolutely stop valgus (knee medial to hallux) were the requirement. In many cases it is observable that this “dynamic” valgus (at least 2-D occurrence) actually is decelerated nicely and there appears to be a measure of control the athlete either has innately or has developed. We are equally or more concerned about athletes who demonstrate a rapid acceleration toward dynamic valgus and who struggle upon change of direction rotational and frontal plane hop tests to reverse the pronating-dynamic knee abduction-IR collapse into a resupinating-knee adduction-ER pattern. Obviously the significance of this observation lies in the treatment choices that follow. Exercises addressing the characteristically weak Quads will not suffice in treating frontal and transverse plane motion control issues, though there is data that confirms increased stiffness of the Quad does produce some limiting effect on knee Frontal plane motion. Oftentimes we find it necessary to recommend OTC or custom foot orthotics if there are significant foot deformities impacting the timing, amount, or extent of motion at the foot-ankle. Frequently we employ “functional” WB exercise stimuli especially directed at the ER’s, Abd’s, and resupinators. A key next step is transitioning into controlled acceleration/deceleration training and multiplanar plyometrics in order to bridge the gap between strengthening exercises and higher level functional demands of cutting, agility, and jumping. STAY TUNED NEXT MONTH FOR PART TWO ON ACL DYNAMIC VALGUS CONSIDERATIONS IN REHAB. The Peak Performance Experience Hx: 14 year old female soccer player sustained non-contact ACL injury in soccer. Underwent ACLR. IE Subjective: 8/10 max pain at 2 day post-op visit, sx with ADL transfer and bed mobility, sleep positions. Using Percocet and ice/elevation. Patient’s goal was return to soccer at 6 months for school season. IE Objective: See table below. Treatment: Patient progressed through our standard ACLR post-op exercise programming with P/AROM and progressive strengthening and balance activities. Traditional and non-traditional exercises are employed with primary reliance on WB drills, including deceleration of foot-ankle pronation and limb dynamic valgus. At 5 month mark testing showed abn Dynamic Valgus on stepdown Anterior, lunging, and hop testing. Specific modifications were made during strengthening and proprioceptive training to optimize stimulus to the hip ER’s and Abd’s/Ext’s along with foot-ankle supinators. 3-D deceleration training tasks were fine tuned to enhance the deceleration of Dyn Valgus noted. Pt was not released to soccer practice/scrimmaging due to findings. DC Testing: Patient showed considerably reduced Dynamic Valgus during her stepdown and hop testing. Released to soccer scrimmaging and gradual play. Confirmed several weeks later that she played in final two games with high confidence and no complaints of instability or insecurity. MEASURE 3 mo RE- EVALUATION 5 mo RE-EVALUATION 6 mo DC RE-EVAL Single Squat 90/95 Isometric Quads @ 600 86% Isometric Hams @ 600 73% WB Quads Ant Stepdown 4” 20lb DB’s 83% 4” 10lb DB’s < 67% 6” 20lb DB’s 76% Showing abn Dyn Valgus Ant Hop to stabilization 78% but abn Dyn Valg Quad dom Squat hands OH L 750 R 800 (94%) SLB mini squats Eyes closed 96% (good control L) SLB Rotations hands OH 91% (good control L) Hip ABd’s wall test 20lb DB’s 95% Rotational Hop 10 sec 100% (good control L) 3x Anterior Hop L 14’ 2” Vertical hop 80% (mild Pron/Dyn valg) Katie stated: "Peak Performance has made me stronger and better than before. Thy have shown me how to get back up when you fall down. Thanks for making me wait until I was safe to play." 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, 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. Mike Napierala, PT, SCS, CSCS, FAFS Owner 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