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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

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

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

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

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

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

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

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

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

Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE March 2023 Improving Clinical Decision Making on Scapular Dyskinesis with Subacromial Shoulder Pain by Mike Napierala, PT, SCS, CSCS, FAFS Clinical Scenario...What would you do? A 50 yr old female with chronic shoulder pain and stiffness comes to the office for a consult after failing two prior bouts with physical therapy and numerous injections. Recent MRI shows RC tendinopathy and small labral tearing. She is not in acute distress but limited significantly with ADL and fitness/recreational activities. AROM into elevation and abd’d rotations is most restricted along with neutral ER. She has painful weakness with RC testing but no signs of frank tearing. Scapular dyskinesis noted during descent from flexion and with resisted flexion at 1300. She did have prior dx of Adhesive Capsulitis and did not recover fully but did not feel PT was helping. She demonstrated a typical PT HEP routine of GH stretches and scapular retraction, serratus protraction/plus, and RC PRE. My clinical thinking is: Consider arthroscopy since PT and injections failed. Consider MUA to recover ROM unable to be attained through standard PT care and compliant HEP. Refer to PT for more thorough manual therapy and customized exercise including specifically serratus work to reduce scapular dyskinesis contributing to ongoing RC overload/irritation. Refer for deep tissue work with LMT to attempt ROM recovery and then send back to PT. CURRENT EVIDENCE Tangrood ZJ, Sole G, Riberio DC. Is there an association between changes in pain or function with changes in scapular dyskinesis: A prospective cohort study. Musculoskeletal Science and Practice. (48) 2020. 1-7. https://doi.org/10.1016/j.msksp.2020.102172 (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: Shoulder pain is a common diagnosis seen by physicians/orthopedists. Oftentimes scapular dyskinesis (SD) may be present. Testing for SD using reliable methods and determining potential meaningfulness contribute to clinical decision making regarding treatment recommendations, especially in the case of “failed” conservative care where more invasive procedures are not called for or necessary yet. Current data has both variable and contradictory findings surrounding SD and the related serratus anterior and/or lower trapezius involvement, along with a lack of clear causal level relationships to pain and/or injury. Tangrood et al demonstrated an association over 8 weeks in a group of 44 participants with shoulder pain that improvements in scapular dyskinesis testing was associated with improved PSFS self-report function scores. One confounding variable included that 65% of those completing all testing were receiving physical therapy and 35% were not. These groups were not separately analyzed which may have shed more light on causes for improvement. Common SD approaches in physical therapy often involve activation of the serratus anterior (SA) that utilizes a “plus” movement (i.e. protraction). While the SA certainly does and can protract the shoulder this risks activation of the pec minor as well with the ongoing risk of facilitating a protraction posturing that otherwise has been identified as a potential risk factor for shoulder pain. In overhead activities the scapula must tilt posteriorly while upward rotating. Many traditional methods of testing and training for SD also utilize long lever positions that painful shoulders struggle in. Authentic biomechanics approaches are necessary to promote scapular integrity via medial border stabilization (superior through inferior angles) along with upward rotation without compromising biceps or rotator cuff tendons or labral structures. A physician’s ability to identify SD in clinical exams in order to prescribe and monitor appropriate PT is often key in achieving optimal outcomes. Background: Scapular dyskinesis (SC) is a debated topic and it is unclear whether it is causative of shoulder dysfunction and subacromial pain or a consequence of symptoms, and, whether the presence of and changing of SD affects function or pain. Purpose: To assess the association of changes in subacromial shoulder pain or function with SD changes over time. Methods: Observational, prospective, cohort study of 44 participants (37 who completed baseline and 8 wk follow up testing), with 24 receiving physical therapy and 13 no treatment, using Numeric Pain Rating Scale (NPRS) 0-10 scale for “at rest” and “during movement” , self-report Patient Specific Functional Scale (PSFS), and the scapular dyskinesis test (0=normal scapular movement and 6= highest scapular dyskinesis, summing using Kibler et al system scoring). Findings: Improvement in function showed a fair association with improved SD (correlation coefficient = -0.4) while no associations found for pain at rest or pain with movement to changes in SD. 89% of patients showed subtle to obvious SD at baseline. Participants showed no changes in “pain at rest”, medium improvements of “pain during movement”, and large function improvements (28.0 mean PSFS score difference w p=0.000) but no significant SD changes. Author's Conclusion: Improved function in patients with subacromial pain was associated with improvements in scapular dyskinesis. Future studies needed to determine causal effects. THE PEAK PERFORMANCE PERSPECTIVE Shoulder pain is one of the most common orthopedic complaints seen by orthopedists and PCP’s alike. One of the most frequent diagnoses includes some form of RC syndrome (tendinitis, tendinosis, tears, impingement, etc.) which contributes to subacromial shoulder pain. Physicians discerning best practices for non-operative care recommendations are often tasked with determining obvious contributing factors they expect to be addressed in physical therapy. Understanding and testing for scapular dyskinesis underlies prescribing practices for these patients and especially for cases of “failed care” where more simple protocol based therapy approaches have not worked. It is also potentially a great example of the concept “because a muscle can doesn’t mean that it does” - in regard to how we classically test and exercise in comparison to how it actually functions. Directing care for shoulder pain of various sorts, whether it be tendon related, bursal, labral, or instability related can be difficult when considering there are few or even no clear truly “BEST practices” approaches that have been proven clearly superior to others. Many studied are more so “only practices” or “doing this happens to work” versus actually finding “bests” in treatment. That makes prescribing care and designing rehab difficult. Certainly there is a blending of science with “art”/experience etc. Secondarily, other kinetic chain contributing factors, whether local to the scapulothoracic articulation, the thoracic spine, or even related to more distal/distant joints (especially when considering complex body movements such as overhead athlete mechanics or total body lifting/reaching ADL demands) have construct validity but often lack clear “evidence” in the literature. Scapular dyskinesis (SD) is one of those entities that has been identified but suffers from conflicting evidence as to its contribution and meaningfulness. Nevertheless, it may be one of those important factors for physicians to consider when prescribing physical therapy. Physicians must therefore consider how SD should be assessed in the office and how are therapists/athletic trainers addressing this through exercises. Kibler et al (2013) and others have identified abnormal scapular mechanics, or scapular dyskinesis, as a potential contributing factor. Kibler proposed a four pattern grading system with Pattern I being inferior angle prominence (tipping), Pattern II being medial border prominence (winging), Pattern III being early scapular elevation or excessive upward rotation (elevation), and Pattern IV being normal rhythm. In-office measurement of scapular dyskinesis can be done utilizing the scapular dyskinesis test (SDT) by Kibler. Arms are raised into flexion to maximum elevation and lowered 3-5x (adding 3-5# to each hand for up to 10 repetitions may be used to accentuate abnormal findings). Most often altered motion occurs during the eccentric descent. Ramiscal et al (Clin Shoulder & Elb 2022) showed grouping Patterns I-III as a “yes” and Pattern IV as a “no” resulted in intra-rater reliability kappa of 0.92 and inter-rater values of 0.85 for expert PT’s with asymptomatic individuals. This sort of chunking certainly reduces potential for reliability errors related to the challenge of ensuring consistency with limited/poor objective measurable means of determining when exactly a “winging” event at the respective scapular reference points has occurred. Break tests of flexion at 1300, abduction at 130-1500, and extension with arms at the side - looking for significant scapular movement should also be done. Kibler wisely has reminded (Int J Sports PT 2022) that lack of research agreement is, in part, related to multiple muscles attaching to the scapula allow for simultaneous and synchronous activation and stabilization during arm movement” causing variability in how individuals perform the same task, thoracic anatomy and varied muscle fiber orientation does not allow for single plane scapular movement - scapular motion involves complex translations/rotations w coupled muscle activation. He differentiates “neurologic” winging that remains disconnected through ascent and descent phases while “altered scapular positioning” is more so evident in descent phases. This differentiation on the surface would seem plausible, however, length-tension relationships, impacts of tissue tightness at different arm positions, and nuances of force couples may otherwise explain why the dyskinesis of abnormal scapular movement often occurs with eccentric phases only or more so than during concentric phases. Causal effects of scapular dyskinesis to pain and/or injury has not been clearly established Finally, Kibler also cautions that scapular dyskinesis is not a “diagnosis” in medical terms but an impairment therefore clinical utility, measuring diagnostic accuracy, is difficult and even inappropriate when no gold standard exists for comparison. Tangrood et al provide some evidence of an association of scapular dyskinesis reduction with improved shoulder function on self-report PSFS questionnaire responses. Repeated measures correlation coefficient showed 16% of the variability in PSFS score changes is explained by scapular dyskinesis changes. Strength of findings are weakened because confounding factors (symptom duration, physical demands, etc.) were not controlled for, especially the fact that 65% of those completing all testing participated in physical therapy (without known parameters) while 35% did not, creating a heterogeneous sample. Data was not analyzed for differences between these groups. Since blinding was not done the risk of examiner bias cannot be ruled out. Subtle dyskinesis made up 57% of the baseline group test findings. Measurement properties make determining change for these subjects more difficult to ascertain. Clinically speaking we find not only for a high percentage of shoulder pain patients that SD is present in some manner but that especially for many of the “failed PT” cases we see that this has not been addressed in rehab or maybe more importantly was only addressed with simple protraction exercises. One consideration is determining the authentic function of a muscle in ADL or sport. Again, we would caution that “because a muscle can doesn’t mean that it does” in regard to certain tests traditionally done or exercises utilized. During elevation function so often related to shoulder overloads and pain the scapula does need to upward rotate but that is coupled with posterior tipping/adduction especially for cocking positions of overhead athletics. The majority of SD exercises, owing to the classically viewed Serratus Anterior role in its capacity to protract the scapula, are most often pre-engaged or emphasized by intentional or forceful protraction. We would contend that in many typical ADL and athletic arm movements the authentic biomechanics necessary contradict coupling upward rotation with anterior tipping/abduction (ie protraction). Yes, that “works” and “fatigues” the Serratus Anterior, leading to a self-fulfilling prophecy of sorts that the exercise is effective. Functional biomechanics would seem to differ with that conclusion. In unique demands of pushing and throwing/propelling the arm and related objects forward certainly serratus function protracting the scapula is an absolute necessity. Relegating the majority of serratus anterior training for the sake of reducing SD though may be oversimplifying muscle function. Because it can doesn’t mean that it is…in this movement or case. Most testing and exercises related to SD factors (i.e. serratus and lower traps) tend to place the arm in longer lever positions. While this creates loads that may quickly increase lever arm effects and identify inadequacies it also risks eliciting pain in inflamed or damaged tissues that causes inhibition of otherwise potentially normal muscles. This is especially true for the “T” and “Y” tests and exercises so often done to address SD. We attempt to approach SD with a functional biomechanics mindset that we are seeking scapular integrity on the thoracic cage wall, with whatever posterior or anterior tipping required, and with adequate and not excessive upward rotational mechanics. While this is not easy to measure objectively or to isolate to singular muscles, due in part to the related pain generating tissue implications noted above, it leads to what we believe is a more authentic approach to scapular dyskinesis through “de-winger” thinking versus promotion of protraction dominated successful activation of serratus anterior that risks over stimulus of pec minor and what would otherwise be abnormal posturing. Kinetic chain biomechanics involving facilitation of thoracolumbar coupling, for example, into same sided rotation and side bending along with extension during cocking phases for overhead athletes, must be addressed if scapular positioning is to be optimized. This involves testing for and addressing Type I and Type II spinal mechanics along with other core and hip function. Too often we see patients having failed traditional PT approaches because classic exercises essentially rely on long lever arm loading into at-risk positions that cause pain of the irritated rotator cuff tendons or labral injury. Care must be taken in many cases of shoulder pain to customize loading of the Serratus Anterior and/or Lower Trapezius to achieve scapular integrity while avoiding symptom exacerbation. The case below involves a patient who had scapular dyskinesis as a contributing factor that required careful attention in testing and exercise. THE PEAK PERFORMANCE EXPERIENCE Holli said: “I had tried a couple of rounds of physical therapy elsewhere with not a lot of improvement in my shoulder after two years of pain. I’m so happy I was finally able to get my range of motion back and not be in pain all day!” History: 50 yr old female nurse fell in 2020 injuring her wrist and then developing L non-dominant shoulder pain. She had PT at a local hospital based outpatient clinic and transitioned to HEP but developed adhesive capsulitis and was then seen for PT several more months. Pt had a total of 4 corticosteroid injections. Now presenting two years after the original fall to address ongoing issues. Subjective: 6/10 max pain with reported function at 80%. Symptoms aggravated by elevation ADL, unable to sleep L sidelying, unable to do pushups and other fitness exercises, cannot kayak. Objective: (*=pain) Eval 5 mo DC ReEval Flexion AROM 1330 / 1660 1670 900 Abd IR AROM 130 / 300 350 900 Abd ER AROM 950 / 1200 NT Wall Serratus Anterior test L @ 4 / 5 with < moderate winging 5- / 5 Pec minor Scapular Retraction (hand @ head) Mod L tight < Min Flexion isometric 1.8 kg * (24%) 5.5 kg (74%) OH reaching (pressing) 5# 33x ( < 66%) 12# 12x (71%) 800 Abd w 900 ER test NT 8# 76% painfree Key Findings: At evaluation Pt had limited elevation AROM along with posterior RC/capsule restriction in Horz Abd and Abd IR. Isometric testing revealed weak/painful elevation and Abd ER along w weak Serratus Anterior during wall scapular integrity resistive test - showing scapular winging medial border. Thoracic L rotation was asymmetrically limited. Impingement / RC tendonitis special tests were (+). Treatment: Manual therapy emphasis to pec minor release, thoracic rotation mobilizations, and especially GH jt mob’s for all motions and capsular restrictions using holding style techniques vs std oscillation approach. Sustained stretching HEP initiated including for pec minor and thoracic L rotation combined with AROM integration drills immediately following. Scapular dyskinesis addressed with Serratus drills in both NWB and WB environments, focusing on “de-winging” emphasis of maintaining scapular integrity during related modified lever arm loaded LUE movements to optimize successful maintenance of scapular positioning…first accomplished in scapular plane and increasingly loaded in sagittal plane. These were eventually moved to upright 900 and then overhead demand positions to mimic authentic biomechanics necessary for ADL and fitness needs. Progressive shoulder/scapular PRE were done moving from BID high reps/low load toward eventual TIW 3x10-12 reps work and including functional considerations for fitness goal movements. Outcome: Pt happy with her progress and wanted to continue remaining work on her own with (I) HEP only. She had had challenges with regular attendance due to other life and work schedule demands. Holli rated function at 90% with Quick DASH 7% and Sport rating 24%. 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 February 2023 A “new” Low Cost Treatment for Knee/Hip OA Without NSAID and Tylenol Side Effect Risks and Downstream Medical Costs… by Karen Napierala MS, AT, PT, CAFS What would you do? A 67 yo female enters your office with pain in her L anterior thigh traveling up into her anterior hip/groin. She has pain on heel strike and late stance phase of gait, which is visibly shortened. She can stand 30 minutes maximum while leaning forward to prepare meals at the counter, but can only stand upright < 10 minutes socializing at a family gathering. Hip flexion for tying her shoe is painful and limited. Hip scouring is (+) for pain and limited motion. All hip AROM and PROM are limited, especially with loss of IR, Faber’s, and hip ext. Plain films confirm moderately severe L hip DJD. The Pt’s goals are to resume WNL ADL, watching grandchildren BIW for 5 hr each, fitness class BIW 45min and occasional doubles pickleball. I would prescribe… A. A normal course of NSAID’s along with continued usual activity until 6 wk FU B. A normal course of paracetamol along with continued usual activity until 6 wk FU C. Surgical consult for THR consideration D. Customized PT to include Class IV laser, manual therapy, biomechanical exercise with FU 6 wks E. Provide handout of simple HEP drills for ROM and light strengthening with FU 6-8 wks F. Intra-articular corticosteroid injection with FU 4 wks CURRENT EVIDENCE Weng Q, Goh SL et al. Comparative efficacy of exercise therapy and oral nonsteroidal antiinflammatory drugs and paracetamol for knee or hip osteoarthritis: a network meta-analysis of randomized controlled trials. BJSM, Jan 2, 2023(online). https://bjsm.bmj.com/content/early/2023/01/02/bjsports-2022-105898 SUMMARY: Osteoarthritis is one of the most common orthopedic conditions seen by physicians. Clinical decision making often initially includes pharmaceutical management for control of pain and inflammation along with other potential treatment options. NSAID’s and paracetamol are commonly prescribed medicines but their cost-benefit analysis regarding potential adverse effects and comorbidity profiles (Tuhina Neogi , Amer College of Rheumatology) may make these drugs inappropriate. Exercise is a recommended treatment for restoring ROM, strength, balance, and overall function but pain reduction is more so considered a secondary benefit. Weng et al performed a network meta-analysis that included 152 RCT studies with a total of 17,431 participants with hip or knee OA comparing the efficacy, directly or indirectly, of exercise vs oral NSAID’s and paracetamol for pain and function. The results showed that exercise was comparably effective vs NSAID’s and paracetamol in reducing pain and improving physical function at 4 weeks, 8 weeks, and 24 weeks comparisons. It was also superior to “usual care” (ie. continued daily activities). Exercise may present some challenges regarding the delayed benefit of symptom reduction, requiring compliance by patients, the challenge in slowing down “over-exercisers”, and that oftentimes we find (especially for “failed PT” cases we see) specific biomechanical adjustments and considerations are necessary beyond traditional PT approaches in order to produce successful outcomes. The use of medications, however, does not produce the same expected gains in needed ROM, strength/endurance, and balance these patients require to optimize function and quality of life. Patients relying mainly on continued dosing of NSAID’s and Tylenol also are habituating into a mindset reinforcing quick fixes to symptom control and return to activity that will not serve them long-term regarding their need to modify activity and actively participate in restorative/preventative exercise. Downstream costs for patients relying on these medications also have been shown to increase significantly over time, including due to adverse effects on numerous body systems. The other risk is that patients will contribute unknowingly to accelerated degenerative changes as they medicate their way “successfully” through impact activities that are deleterious to their joint health long term. Expert physical therapy should include specific customizing intended to off-load the compartment mainly effected via specific reaching/shifting maneuvers to allow pain-free/minimized functional strengthening work. Prescriptions should also order kinetic chain evaluation and exercise/manual therapy to address contributing factors (ie., lack of hip IR and ITB length both contributing to varus knee tendency and subsequent medial joint loading). Simple traditional therapy exercises for knee and hip OA do not take these biomechanical considerations into account. (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) Purpose: Comparing analgesic benefits of exercise vs NSAID’s and paracetamol in hip and knee OA patients. Study Design: Network meta-analysis Methods: Studies included were: 1. RCT’s, 2. Participants with knee or hip OA, 3. Comparisons of exercise with oral NSAIDs , 4. Studies comparing exercise therapy with any common comparator that may be shared with NSAID’s (i.e. usual care/no treatment/waiting list control, glucosamine sulfate/chondroitin/intra-articular hyaluronic acid, topical NSAID’s, acupuncture), and 5. Studies reporting pain or function. Any study with less than 1 week follow up, use of a cross-over design, or postoperative pain were excluded. The full texts of 2738 potentially eligible articles were reviewed. There were 152 studies (17,431 participants) meeting the inclusion criteria. There were 49 studies with data available at or nearest to four weeks, two studies had data available at eight weeks and nine studies at 24 weeks. Most trials recruited participants with knee OA, while 12 studies investigated hip OA and 13 studies were both. Results: For pain relief there was no difference between oral NSAID’s and Tylenol at or nearest to 4, 8, and 24 weeks. Similar findings were noted for function as well. Authors Conclusion: Exercise has similar positive benefits to oral NSAID’s and Tylenol for pain relief and function. Since exercise has an excellent safety profile it should be given more prominence in clinical care, especially for older patients with comorbidity or higher adverse event risks related to NSAID or Tylenol use. THE PEAK PERFORMANCE PERSPECTIVE: Osteoarthritis is one of the most common orthopedic conditions seen by physicians. Clinical decision making often initially includes pharmaceutical management for control of pain and inflammation along with other potential treatment options. With pain relief ultimately comes the expectation that function will be improved significantly as well, optimizing quality of life. NSAID’s and paracetamol are among the most commonly prescribed medicines used for OA, however, the cost-benefit analysis for these medicines presents some challenges for physicians due to both potential adverse effects and comorbidity profiles (ie. Tuhina Neogi , Amer College of Rheumatology) that may make these drugs inappropriate long term or at all. Exercise is often considered a valuable treatment for restoring ROM, strength, balance, and overall function. Pain reduction is often more so thought of as a secondary benefit. Prescribed physical therapy to include formal supervised exercise is frequently delayed until more significant losses of function (i.e., ROM and strength deficits evident on clinical exam) are noted. Boston rheumatologist Jean Liew, MD noted that over 50% of patients receive NSAID’s and the same percent were given an opioid prescription when diagnosed with OA (American College of Rheumatology Convention 2021). Liew, updating their group’s findings looking at patterns of NSAID, opioid, and physical therapy (PT) use among more than 30,000 newly diagnosed patients with knee or hip OA found 9% had NSAID contraindications and 22% had NSAID precautions. This begs the question: Are NSAID’s and paracetamol being prescribed too frequently for hip and knee OA? Weng et al performed a network meta-analysis that included 152 RCT studies with a total of 17,431 participants comparing the efficacy, directly or indirectly, of exercise vs oral NSAID’s and paracetamol for pain and function knee or hip OA. The results not only showed that exercise was a clinically effective treatment (better than usual care) for reducing pain and improving physical function in people with knee or hip OA, but it was comparable in efficacy to NSAID’s and paracetamol at 4 weeks, 8 weeks, and 24 weeks comparisons. NSAID’s, for example, while effective for control of that knee/hip OA pain and inflammation, have been associated with gastrointestinal, renal, and cardiovascular complications, especially in older adults with comorbidities, There are also patients whose comorbidities deem NSAID’s as strictly contraindicated. Together these facts leave physicians and patients in a difficult position regarding ideal options if left to typical medications alone. Exercise, on the other hand, has the multi-faceted benefits of decreasing pain, increasing range of motion, increasing balance and strength - thus improving function, without the ongoing cost or risks associated with medications. Does exercise have some limitations also? There remains no absolute agreed protocols or best practices based on the evidence, however, this also should be viewed in the light that even heterogeneous “exercise” has been shown not only in this study but in numerous others to nevertheless be effective. Numerous orthopedic and rheumatology organizations have included exercise as strongly recommended based on review findings.. Three particular difficulties must be considered and addressed with prescribing exercise, especially if chosen over NSAID’s and paracetamol alone. One, the patient's desire to do the least and get the most results. We live in a society where people often “want results yesterday, not four weeks from now!” If I am told that I can take a pill today and do nothing, or I can go to PT and exercise, but it will probably take four to six weeks to work, what would I do? If I knew that I would get stronger, get off the ground easier, climb stairs better after exercise, and not just relieve the pain, patients would be more likely to follow those orders. Educating patients about these “long term” expectations and benefits fosters the compliance needed for good outcomes. Secondly, patients unaccustomed to exercise may struggle with commitment to an exercise program. There are patients who will flat out refuse to put the effort in. Third, is slowing down those who are avid exercisers. We have to be careful not to overdose, or allow exercise that will overload the joints. Many patients become their own “worst enemy” as they swing the exercise pendulum in the direction of excess, be it volume, frequency, or oftentimes intensity (especially for impact related activities). One study corroborated that the exercise for 8 weeks was very effective, but the effect of exercise gradually decreased when reassessed a year from the original study. We must approach such facts with caution, however, as the same would be true for medications taken for 6 weeks and not expecting patients to remain substantially better one year later. Exercise is a treatment that must be continued to have maximum results. Siew-LiGoh et al (Sports Medicine, 2019) compared a variety of exercises with “usual care” (i.e. continuing normal daily activity without other treatment). They found that aerobic, flow and pattern exercise, strength and coordination exercises all reduced the pain in knee and hip OA subjects. The question for physicians remains - if exercise, as shown in this and other studies, can be as effective at pain control as NSAID’s and paracetamol, have positive effects on increased function, strength, movement, coordination, and potential decrease risk in falls, and, lack the adverse effects and downstream medical costs associated with those side effects, then why would exercise not be used with every patient that presents with knee or hip OA in the office? The final but not least important points about exercise prescribing and treatment is that the RIGHT exercise will bring the BEST results. Careful attention to detail is necessary for many OA patients to succeed with exercise. Many patients will appear to succeed early on using simple NWB exercises. Unfortunately that often leaves a large “gap to bridge” to more authentic functional demands. For many of these cases, sometimes becoming “failed PT” cases, although finding effective pain-free/minimized PWB and WB functional strength methods can be a much more daunting task, it provides a more effective impact on day to day life. Expert Physical Therapy applies understanding of key biomechanics in order to both intentionally load healthier portions of articular surfaces and also in order to address key kinetic chain shortcomings that are contributing to joint overload. For example, in a common knee medial joint OA case, where the knee is in a varus presentation, PT exercise should focus on unloading the medial knee joint especially via the frontal plane but also the transverse plane. Specific reaching and shifting during otherwise typically painful exercises like split squats or step ups/downs etc can significantly reduce or abolish symptoms, allowing patients to more effectively strengthen. Key biomechanical shortcomings related to having caused the genu varum or that will perpetuate those forces such is poor hip IR, poor ITB length, poor STJ eversion all should be assessed and custom exercises done to treat. These are not approaches common to traditional physical therapy for knee/hip OA. The following case illustrates an example of simple/traditional exercises not working for his case of knee OA. THE PEAK PERFORMANCE EXPERIENCE: Mark said: “ I came to Peak after other physical therapy didn’t work for me. I was on the verge of needing surgery that I didn't want. I came to a Peak PT knee arthritis workshop. After starting PT I I know what to do, and I’m doing it. I can get through work and vacations now pain free!” History: Mark is a 64 year old male who had prior physical therapy and tried to exercise on his own, but was finding the things that he usually did created medial knee pain. He tried NSAIDs for a few months with some relief, but decided that he didn't see that as a long term solution. His job requires climbing ladders and stairs, squatting and carrying. By the end of the day his R > L medial knee is painful. He knows there is some OA on films, but he is not ready to think about a knee replacement yet. Subjective: He complained of knee pain and stiffness that limited walking, climbing ladders for work, and by the start of PT that his knees “hurt all the time.” Objective: (*=pain) Initial Eval Re-Eval Knee extension R knee 50 10 Single leg squat knee angle L 400/ R Unable ** L 650/R 500 Hip IR standing L 150/R 120 L 300 / R 250 2” quad dom step down (eccentric ) painful * 10 # front racked with ant lateral op toe reach ( inc valg at knee) L 24x / R 15x Step up 6” w 10# wts doing P-L opp foot reach ($ knee valgus for med jt unload) L 5x / R painful** L 16x / R 12x Sit stand to seat 15 sec 7x 12x Single leg balance rotation 15 sec painful ER L 15x R 13x WOMAC 41 % 16 % Key Findings: Poor knee ext and flex ROM, lacking hip IR (B) - slightly worse on R, poor tol of WB rotation, limited/painful squat function Treatment: Mark needed to regain as much knee extension as possible initially before moving into flexion exercises. This immediately decreased his pain with walking. He also worked on his limited hip IR NWB and then he progressed to functional WB methods to improve ADL and work applications. He began strengthening with PWB squats (using 0-300 and 60-950 pain-free depths) that were hip and ankle dominant to offload the knee. He used hands holding onto a stationary pole to unweight using arms also. A small yoga ball between his knees allowed Mark to maintain valgus alignment at the knees, thereby unloading his painful medial joint. All sagittal knee motions such as squats, split squats, step ups, and step downs were modified to decrease forces on the medial compartment of the knee. Frontal plane motion into valgus, and increased pronation or tibial IR were allowed as this relieved symptoms. When Mark was able to progress to impacting he began with crossover lunges focusing on valgus force from the foot up. Even once he progressed to lateral lunges, medial joint unloading was maintained by landing laterally on a wedge. Mark also received 6 sessions of Class IV Laser treatments on his R knee. The pain relief for him was immediate and lasting. This allowed faster progressions and improved his functional status quicker. After 6 weeks: Mark was ambulating at 3.0 mph pain free for 30 min, and could sit stand easily and was pain- free up and down ladders at work. He knows he has a limit for the total amount of weight bearing and work during each day, but has kept himself well under that. Outcome: Pt was DC’d to an (I) HEP, pain-free, able to remain at work full duty performing all tasks w/o troubles, walking and sitting were WNL, and he was able to go on vacation as well. 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 January 2023 New Evidence on PRP Use in UCL Throwing Injuries by Rachele Jones, PTA, ATC, CAFS Clinical Scenario…What would you do? A 21 yr old male college baseball pitcher is FU with you after Fall short season due to persisting medial elbow pain. He’d developed symptoms after a small “pop” he felt on an errant throw after pitching 5 innings. The college’s team physician diagnosed a Gr II UCL injury after a physical exam and MRI. He’s been rehabbing with the team’s athletic trainers but progressing slowly. He’s eager to prepare for the Spring season where he was expected to be in the starting rotation. Valgus testing now shows 1+ laxity with good end feel; elbow ROM is WNL and pain free, manual resistance is good in all relevant muscle groups. A review of his exercise routine confirms local elbow/forearm/wrist traditional rehab stretches and PRE which he does consistently. I would: Advise him to continue the same course of care since he is progressing adequately. Recommend Physical Therapy evaluation with focus on biomechanical testing to determine underlying contributing factors affecting throwing mechanics, including a video throwing assessment. Recommend PRP injection as adjunct to simulate healing further, prior to including a formal Physical Therapy evaluation and rehabilitation program collaboration with his team’s ATC’s. Discuss surgical reconstruction options since long term likelihood of remaining successful non-operatively as a pitcher is low. Advise a position change due to anticipated long term challenges with pitching Current Evidence Aakash Chauhan, et al. Nonoperative Treatment of Elbow Ulnar Collateral Ligament Injuries with and without Platelet-Rich Plasma in Professional Baseball Players. The American Journal of Sports Medicine 2019; 47 (13) 3107-3119. SUMMARY: Ulnar Collateral Ligament (UCL) injuries are common for throwing athletes especially, but can also occur in other overhead sport athletes as well. Physicians and surgeons must determine best treatment recommendations for these cases, considering both non-operative as well as surgical options. PRP has become increasingly used to promote healing in especially tendon tissue injury but data is lacking regarding its efficacy with throwing athletes. Chauhan et al retrospectively studied 544 professional MLB and MiLB position players and pitchers diagnosed with UCL injury over four years who elected for non-operative care. While 54% of those players did RTP, the PRP group’s return to throwing (RTT) was delayed two weeks, they RTP at a lower rate and also had RTP delayed by 5 weeks vs the non-PRP group. Matching analysis showed MLB and MiLB pitchers in the non-PRP group had faster RTT and MiLB pitchers a faster RTP. Survivorship analysis was trending but not significantly different at 54- - - 44% non-PRP and 43- - ->37% for PRP groups over the subsequent three years before re-injury or UCLR became necessary. This study does not support the use of PRP for non-operative treatment of UCL injuries in high level throwers. These findings, however, are limited in applicability due to varied nature of the PRP injections, heterogeneity of physical therapy provided, and other lack of controls over factors that would need more constraint and/or grouping in a future RCT study. While survivorship was examined, the levels of performance compared to pre-injury were not closely examined and may be an important factor. Non-operative therapy was effective at helping UCL injured throwers back to playing 54% of the time, supporting its use as a key component to recovery from UCL injury. Quality therapy should include specialized biomechanical evaluation of not only local throwing body segments (elbow, shoulder…) but also key kinetic chain areas including the scapula, thoracic spine, hips and ankle/subtalar joints. Addressing key findings must be a part of skilled care in order to reduce abnormal stresses on the medial elbow. (We’d love to hear your professional insights on this topic. Let me know your thoughts after reading the summary at PT@PeakPTRochester.com or if you have a patient case you'd like to discuss) Background: Elbow ulnar collateral ligament (UCL) injuries are very commonly diagnosed in professional baseball players due to the repetitive valgus stresses and high level throwing. Orthobiologics, such as platelet-rich plasma (PRP) have shown promising results in nonoperative treatment, however, no studies have been performed on the benefit of non-operative treatment with or without PRP on professional baseball players. Method: Five hundred forty-four professional baseball (including major and minor league players) players were retrospectively selected out of the Major League Baseball Health and Injury Tracking System that were being treated for an UCL injury non-operatively within a 4 year span. Of these, 133 players received PRP injections before starting non-operative treatment. Player outcomes and Kaplan-Meier survival analysis (using a 1:1 comparison, matched by age, position, throwing side, and MLB or MiLB league status) were compared between the PRP group and non-PRP group. A single radiologist of extensive experience in MRI interpretation viewed and analyzed 243 MRI’s where location and severity of grade scale were provided. Results: Overall 54% of non-operative treatment players returned to play (RTP). Players that received PRP, however, had a longer return to throwing (RTT) by an average of two weeks, a lower percent of RTP (46% vs 57%), and 5 weeks delayed RTP (25wks vs 20wks) compared to the non-PRP group. The matched cohort showed MLB and MiLB pitchers in the non-PRP group had a faster RTT & MiLB pitchers a faster RTP. The use of PRP, MRI grade, and tear location were not statistically significant predictors for RTP or progression to surgery. The survivorship of non-operative treatment was not significantly different between PRP and non-PRP groups (54- - - >44% for non-PRP and 43- - ->37% for PRP groups over 1 - - >3 years). Author’s Conclusion: In this retrospective matched comparison study of pitchers and position players from both MLB and MiLB treated non-operatively the addition of PRP injection prior to treatment did not show any improvement in return to play (RTP) or ligamentous survivorship. While matching was possible regarding comparison of player positions, throwing side, age, and severity grade there was excessive variability with the preparation of the PRP, the time of injury to injection, injection protocols, and rehabilitation programs. The location and grade of the tear did not significantly affect the RTP outcomes of progression to surgery. Further prospective study is necessary to better define best practices for PRP use with UCL injury treatment in elite throwing athletes. The Peak Performance Perspective Physicians and Orthopedists frequently see throwing sport related elbow ulnar collateral ligament (UCL) injuries. Most of these are likely high school/college athletes or post-collegiate adult league players, along with local professional players possibly. With the advancement and increased awareness of orthobiologics for the treatment of various orthopedic injuries, PRP likewise becomes a potentially viable option in addition to non-operative physical therapy for UCL elbow injuries. This study provides some insight to assist in clinical decision making around non-operative treatment. Ulnar collateral ligament injuries are most common in “overhead” athletes, usually with throwing sports such as: baseball, softball, javelin, and also paddle/racquet sports. Pitchers are the most frequent player position affected due to the increased dynamic and repetitive valgus stress on the elbow. Two interventions most commonly implemented are physical therapy or surgery. With the advancement of orthobiologics, platelet rich plasma (PRP), rich in proteins with healing and growth factors, which when administered to tissues that are injured and especially when less vascular (such as a UCL), is expected to produce a faster recovery by stimulating healing. The findings of Chauhan et al were not as expected. Results did not support improved outcomes with inclusion of PRP to non-operative rehabilitation, however, it did demonstrate that non-operative physical therapy, despite the admitted heterogeneity in this retrospective study, was effective at helping up to 57% of non-op treated players back to playing again. The PRP group as a whole did have a two week delay (7.3 weeks vs 9.1 weeks) in return to throwing (RTT) and five week delay from 20.1 to 25.4 weeks for return to play (RTP). Some inherent delay was due to post-injection rest orders and not simply a poorer recovery. Being a retrospective analysis, the rehab protocols used were not standardized, which is a weakness of the study but also a strength of sorts, lending external validity to real-world variability within physical therapy and athletic training. The lack of true “best practices” rehab progressions for non-op UCL care and RTT/RTP guidelines does contribute to the inability to optimally compare the data in these groups. Variability also existed in PRP type, timing, and volume. For athletes in the semi-professional and professional sports, timelines are crucial to either keeping their jobs or advancing them to post-season depending on their position and string status. From this study by Chauhan et al the most significant predictor of those having re-injury or subsequent UCLR was those > 25yo, MLB pitchers and players in the MLB. Those players' best option of return to play was those with less severity of tear at proximal site and those under 25yo. Over three years of non-operative care in the PRP treatment group the survival rates were 43% (1yr), 37% (2yr), 37% (3yr). The survival rate of non-PRP group over three years was 54% (1yr), 47% (2yrs), 44% (3yr). Position/field players had a better overall return to play and less incidence of re-injury or surgery compared to pitchers. Other studies have shown a 67-95% RTP rate following UCLR. The study did an excellent job going beyond simple group comparisons and included matching as a one to one comparison with position of player, severity of injury (grade), location of injury, age of athlete, and level of performance (whether major league or minor league player) to reduce confounding variables from affecting statistical findings (e.g. MLB players tend to be older, therefore having more “reps” on that elbow, more potential for recurrent/chronic UCL injury vs a younger player in MiLB). It may have been under-powered, however, in the low numbers for matching, especially regarding RTP and eventual UCLR. As mentioned above, the heterogeneity of physical therapy does mimic the real world in rehabilitation. Unfortunately, as a study, with one desired goal being that it could be reproduced if need be, the heterogeneous PT approach fails to define the exercises and types utilized, progression standards, frequency, use of manual therapy, and use of modalities done with these players. It is also not clear the extent of differences between PRP and non-PRP physical therapy. Variability can be great, acceptable and necessary, providing freedom to individualize treatments based on specific findings and contributing factors noted in one athlete that are not present across the board. The authors’ inclusion of MiLB players also provides somewhat more relevant data when physicians are considering their more typical patient profile seen locally in Rochester - high school/college aged players. Those younger players in the study typically have less “mileage” of throwing on the elbow and fewer prior injuries to the elbow, throwing arm and body - making them a better comparison group for typical UCL patients here in Rochester versus the MLB player group. Future studies will require being more specific/consistent in their biologics details (types of injection, how many injections, timeframe from injury to injection…etc.) along with at least some rehab and RTT/RTP guidelines for physicians and therapists to consider when applying to real world patients seen in the office. Athletes and providers alike are seeking the best but oftentimes also the fastest means to an excellent outcome of getting them back on the field. This study does not give any parameters on performance. It is unknown if they were able to resume a normal velocity and number of throws or pitches, have fewer errors, hit cutoffs, throw all the various pitches like prior, have an acceptable or even better ERA, number of strikeouts per inning or game, RBI’s, and batting average among others. Most players will look to the fastest means back to playing. While the PRP group did show a delayed RTT/RTP it would provide some counter-argument if their performance were better improved. Unfortunately the PRP group showed a higher reinjury/eventual UCLR rate though not statistically significant. As physicians and certainly therapists we should ask “What is the leading cause of UCL injuries?” There is no muscle in the elbow that solely prevents a valgus load in the frontal plane that can simply be “strengthened” in rehab with the expectation of excellent prevention of abnormal UCL forces. Is it merely in the overuse of velocity forces/torques? To what extent do poor mechanics play a role for this athlete? Does the player exhibit underlying kinetic chain limitations affecting optimal mechanics and force generation/deceleration? It’s critical that therapists examine the kinetic chain of the throwing/overhead athletes - including a 3D functional shoulder, wrist, scapula, thoracic spine, hip/pelvis, and foot-ankle assessment. Physicians and surgeons should expect these as a standard part of excellent care. In some cases, specifying these on the prescription may be necessary. Early opening of the trunk, lead leg foot plant alignment, poor trunk and hip mobility-strength-power among others all can lead to “all arm” mechanics and other faulty movements that overload elbow valgus, creating UCL overload. Some of these may best be captured by assessing throwing video the athlete already has or can be done using our Spark Motion Analysis in the clinic. Throwing mechanics issues can often be traced back to those underlying kinetic chain limitations noted above. The pectoralis minor length, serratus anterior stabilizing capacity, posterior cuff/capsule status, thoracic rotation ROM especially, hip rotational ability, and STJ eversion abilities all directly relate to throwing mechanics needed for each of the phases. Late cocking and acceleration must especially be examined due to being the most provocative to the UCL, causing the most valgus strain on the elbow because the UCL is most stretched at 30 deg flex and 120 deg of elbow extension are when the tissue is most taught where injury is more likely. Once areas of need are identified then a functional biomechanical exercise progression can be determined and initiated. Class IV laser therapy also can be an excellent treatment to stimulate tissue healing. Manual therapy is often useful/necessary along with therapeutic taping techniques. The case below illustrates a baseball thrower who did undergo a PRP injection prior to his physical therapy program. The Peak Performance Experience Victor said: “My elbow is now pain free and I’ve started my return to throwing program to become a 3rd baseman.” History: 20 yo male baseball pitcher injured self approximately one year ago while pitching in a game. He felt a pop in his medial elbow and had had significant pain 6/10. This has been an ongoing issue since May 2021 and pt has received PT intermittently for the last year and a half between school baseball seasons. Pt received a PRP injection November 23, 2022 (10wks ago). Subjective: Patient reported intermittent medial elbow pain 2/10. Symptoms are increased by throwing and opening a tight jar. Patient self reports being at 90% overall function and Quick DASH scale 23% limitation Quick DASH Sport 25% & work 6% limitation. Objective: Patient showed decreased pectoral minor, hip and trunk mobility, rotator cuff and scapular weakness. See below re Eval and Re-Eval findings. Initial Evaluation (L/R) ReEval 4wks (Pre-PRP inj) ReEval - 10wks (post PRP inj) Self Rating 90% overall function 100% Quick DASH 23% 0% Quick Dash Sport 25% 0% Pain scale 2/10 max 1/10 max 0/10 pec Minor moderate moderate DNT Thoracic Rotation 38 deg / 42deg 52 deg / 45 deg 51 deg / 35 deg Hip IR prone ROM DNT 33 deg / 32 deg DNT Hip ER ROM 20 deg / 17 deg DNT Isometric strength nER 12.8 kg / 11.6 kg nIR. 13.7 kg / 12.6 Kg nER 12.0 kg/ 12.3 kg nIR 16.2 kg/ 16.3 kg nER 10.9 kg nIR 11.2 kg AbdER 11.3kg to 12 kg Functional strength: biceps 20# 26x 24x 25# 23x /24x 25# 8x Cable Row 50# 36x 30x 50# 20x 19x OH press 12# 36x 32x 12# 28x 25x Treatment: Exercise - Mobility, strengthening, explosive, speed/ reactionary function. Kinetic chain stretching of hip IR & ER, Thoracic Rot & Ext, Pec Minor, Shld IR, Calcaneal Eversion. PRE’s including open and closed chain with resistance tubing & medicine balls, weights. Impact/speed based drills - utilizing multiple angles in a dynamic arcing pattern and static angles (Included: diagonal chops & lifts, rebounder, perturbations/ rhythmics stabs @ multiple angles for scapular stabilizers with internal and external forces i.e.: body blade, or therapist perturbations). Outcome: Interestingly, the patient has progressed to subjectively being pain free and now able to advance to a graduated return to throw program despite some of his testing parameters actually not yet reaching pre-PRP levels. These measures have, however, continued improving since the decline that followed during the rest period post-PRP injection. A throwing program has been implemented, week 1 of 6. Additionally, the Pts throwing program has changed as he transitions from a pitcher to 3rd baseman. 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 (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 November 2022 Knee OA Injection Therapy: New Evidence on Best Options for Improving Pain & Function by Allison Pulvino, PT, MSPT, CMP, FAFS Clinical Scenario…What would you do? A 57 year old female with a 5 yr h/o L knee pain medially has noted progressive worsening over the past 6 months, especially with long walking and hikes with her friends. Plain films show moderate joint space narrowing medially and only slight changes in the lateral and patellofemoral compartments. She has mild genu varum asymmetric on the L knee noted with WB exam. She wishes to continue TIW fitness exercise (cardio, weights, classes) and has been controlling symptoms with OTC NSAID’s for the past several years. She was seen in PT 2.5 yrs ago for three visits in PT and taught a HEP, which she remained compliant with. She demonstrated common knee exercises as her main HEP activities (SLR’s, Hip Abd clamshells, bridging, static balance on foam pad, 8” step ups, band walks for abd’s - band at ankles, full range quad bench PRE). I would prescribe… Customized physical therapy with 6 wk FU to discuss corticosteroid injection option depending on symptom and function status. Corticosteroid injection with 2 wk FU to discuss physical therapy option. Customized physical therapy w 6 wk FU to discuss HA injection option. Customized physical therapy w 6 wk FU to discuss PRP injection option. Begin HA injection series and begin customized physical therapy one week following 1st injection. CURRENT EVIDENCE Singh et al. Relative Efficacy of Intra-articular Injections in the Treatment of Knee Osteoarthritis. The American Journal of Sports Medicine. 2022; 50 (11): 3140-3148. Summary: Knee OA is a commonly seen condition for physicians, surgeons and physical therapists. Among the treatment considerations physicians often consider is injection therapy. Singh et al did a systematic review examining pain and function status 6 months after steroid(CS), HA, PRP, plasma rich in growth factor (PRGF), or placebo injection therapy. PRP demonstrated the best outcomes compared to others for pain and function findings. All injections except CS showed statistically significant improvements vs placebo. Steroid and HA injections anecdotally appear to be the most frequently used injections here locally in Rochester for these cases. This evidence for PRP efficacy may provide compelling support for physicians/surgeons making recommendations to patients for optimal injection therapy options. PRP presents a unique challenge since it is not yet approved by third party payers. This is likely a key factor for physicians and patients when choosing CS or HA injections first. One risk physicians and patients must be aware of is the tendency for early symptom relief following injections to dissuade appropriate consideration of physical therapy. Addressing ROM and strength/balance needs will not only optimize function but lessen the likelihood of symptom reactivity to ADL and recreational activities. Another factor in knee OA treatment prescribing may be physician or patient based past experiences with “failed PT.” We often find this is due to a lack of biomechanical considerations applied to especially key WB strengthening. Careful consideration should allow physical therapists to most often intentionally unload symptomatic knee compartments. While not part of traditional approaches, this biomechanical technique can be an effective means of promoting pain-minimized or pain-free strength gains, leading to more successful squat ADL and stairs or recreational participation. Expectations are that IA injection combined with excellent physical therapy should produce optimal outcomes not only acutely but for many months or even years to come in most cases. (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: Intra-articular (IA) knee injections for knee OA has been a topic of increasing interest, as well as which type of injections most benefit patients long term in regards to pain and function. Methods: A systematic review and meta-analysis utilizing 23 RCT’s meeting the inclusion/exclusion criteria was performed to obtain information regarding pain and function at a 6-month follow-up after either Corticosteroid (CS), Hyaluronic acid (HA), platelet-rich plasma (PRP), or a plasma rich in growth factor (PRGF) injection, or a placebo. Findings: All IA treatments except CS were found to have statistically significant outcome improvements when compared to a placebo. PRP demonstrated the greatest results in function-related gains. In regards to pain, function and both combined, PRP was found to possess the highest probability of efficacy and CS as the last followed by the placebo. Author’s Conclusion: When comparing various IA injections, PRP had the most significant outcomes, followed by PRGF, HA, CS and then placebo for treatment of knee OA at a 6-month follow-up. Other non-operative treatments were not included in this study, including NSAIDS and physical therapy. THE PEAK PERFORMANCE PERSPECTIVE As a physician/surgeon, knee OA is likely a common diagnosis seen in the clinic. Conservative measures are key options for early treatment, including NSAIDs and physical therapy. Another frequent consideration is injection therapy. Quality research forms a critical foundation helping physicians and surgeons determine treatment recommendations. While as providers we all appreciate the value and necessity of optimizing function, for patients their top-of-mind concern is typically symptom control. Many but not all patients with knee OA will respond positively to OTC or prescription medications, at least temporarily. A majority will see significant improvements in pain, ROM, strength, and function with quality physical therapy. Additionally, intra-articular (IA) injection therapy is a potentially helpful treatment option, for some used as a primary stand-alone treatment and for others as an important part of a multi-faceted approach to thorough OA care. The question remains: Which type of injection is most effective and indicated for this patient? The evidence on comparing outcomes for various injections has been limited. Practice standards and habits had traditionally utilized IA corticosteroid (CS) as the first-line injection type. Over the past decades “gel” injections using hyaluronic acid (HA) and biologics (PRP, stem cells…) have become more available and had variable increasing evidence, however, most are short term studies. Singh et al. discovered in their Systematic Review and Meta-analysis that PRP really produces the best results, with PRGF and HA outperforming CS injection therapy, when they looked at longer 6-month follow-ups for pain and function outcomes. One risk for patients and physicians alike regarding injection therapy is that when highly effective early on, the motivation to actively participate in physical therapy to restore ROM and strength may be diminished. Patients often take a “It’s feeling good now so I’m gonna see how things go like this” sort of mentality, being unintentionally lured into complacency by their immediate post-injection symptom relief (typically after CS injection). We remind patients it is important to “get beyond feeling better to being better” - i.e., restoring mobility, strength, balance etc. in order to optimize function. Regarding the Singh et al. findings, locally we do not see PRP used often for knee OA cases. Certainly a lack of comparative outcomes data to support treatment recommendations of PRP over other options may be a primary reason for this. PRP is also presently a cash-based treatment, making a trial with CS injection initially the potentially more logical option since it is typically covered by insurance. The findings of this Singh et al study will probably provide some convincing data to support future trials with PRP, despite the higher expense to the patient, as doctors and surgeons evaluate the best treatment suggestions for knee OA aside from oral drugs and physical therapy. Also, there remains some limit on the frequency/volume of CS that can be injected before potential negative effects are noted within the joint - making PRP additionally appealing as an option. While we clinically have seen variable outcomes from IA injections (both HA and CS) ranging from no relief to full relief, these results are often temporary in nature, sometimes lasting for weeks to months but then requiring further injections. Research has shown physical therapy to be effective at reducing symptoms and increasing function for knee OA. While it is often prescribed it remains underutilized, possibly in part due to a perception that therapy itself cannot alter the degenerative chondral changes themselves. When NSAID’s or injection therapies, especially CS, are successful that also, as mentioned above, tends to dissuade some patients from the work therapy entails. For patients with knee OA, the loss of motion and strength both negatively affect not only day to day function but clearly contribute to worsening symptoms. This also contributes to increasing compensation patterns and too often symptoms developing in adjacent body parts such as the hip or lower back. For example, we see patients unable to squat their knee effectively tending to bend over from their spine which is more than ideal. Flexion sensitive LBP sometimes then develops. Knee OA physical therapy too often is mistakenly perceived to have “failed” in the eyes of the patient and the physician as well. This scenario begs the question - is physical therapy itself an ineffective tool for this patient/case or was the specific therapy provided ineffective/inappropriate/limited in nature? Just as a poorly done procedure or non-compliance with recommended medication dosages/frequency may yield less than favorable outcomes, physical therapy must be biomechanically appropriate, problem solving based and most often include manual therapy to optimize outcomes. While “cookie-cutter, simple” home programs may appear a great starting point for most patients, it presents the challenge that for too many patients (who have already waited too long to engage with health care professionals) that unimpressive results with early physical therapy risks being perceived as ineffective. These failures may be avoidable but require physical therapists to utilize deeper understandings of biomechanics rather than reliance on “keeping it simple” to such an extent that customized needs of each OA case are missed. From a physician’s standpoint it may help to prescribe something like “biomechanical adjustments prn with squat PRE.” The knee’s dominance as a primary sagittal plane functioning joint brings a double edged sword of sorts. Focused manual therapy and exercise efforts to gain full functional extension and/or flexion of an arthritic knee can greatly impact functional WB activities like ambulation and stairs; however, strengthening exercises dominating that same sagittal plane are most often the source of most patients’ chief complaints. Many knee OA situations involve one compartment being significantly worse than the other. Asymmetric loading of the arthritic chondral surfaces then occurs with traditional “closed chain” exercise attempts to strengthen. This is especially where deeper biomechanical understandings can significantly benefit patients attempting to regain quad strength for sit-stand function and stairs. Preferential loading and unloading of the medial or lateral compartment can be accomplished with a variety of different “tweaks” utilizing the frontal and/or transverse plane biomechanics of the knee and lower extremity. This involves in some way reversing the biomechanical patterns of how that degenerative compartment gets overloaded in the frontal and/or transverse plane to begin with. An overpronated foot elicits tibial IR or an anteverted hip likewise femoral IR, either being contributors to dynamic knee valgus and increased lateral compartment stresses (likewise reducing medial compartment compressive loading). Conversely a supinated foot, retroversion, a tight ITB, or even lacking pronation or femoral IR can all lead to a dynamic varus knee alignment which increases medial and decreases lateral compartment stresses. Thoughtful PT exercise plans work toward optimizing symptom-minimized knee status to promote more optimal exercise intensity and eventual strength gains. Utilizing various body “drivers” or movement stimuli meant to promote a given movement pattern or body positioning in order to reverse those damaging stresses. Thus, a hand reach or body tip/lean or altered foot position affecting the frontal and/or transverse plane can work to increase loading on the healthier or asymptomatic side during otherwise typically painful squat based WB strengthening exercises. This Applied Functional Science (AFS ®) based approach is a critical means of helping the majority of “previously ‘failed PT’ “cases and otherwise deemed “low rehab potential” cases to do well. Singh et al admit that physical therapy wasn’t addressed in this study. Injection therapy can be an important component to OA treatment especially because many patients struggle with pain limiting exercises. We would suggest that a comprehensive approach includes targeted, customized physical therapy using biomechanical approaches. The case below illustrates an example of effective conservative knee OA care with successful outcomes. THE PEAK PERFORMANCE EXPERIENCE Alice said: “I had the last shot 7 days ago and I feel improvement!” History: Alice has had moderate pain in her L knee for over 2 years, off and on. Has previously had a series of 3 cortisone injections without relief > a few months. Recent HA injections have provided improved ability to tolerate WB as well as PT ex’s to gain more extension ROM and functional strength. Objective: Initial Exam Re-evaluation Knee extension -10deg (flexion contracture) -2deg Knee flexion 120deg 130deg FABER test Pos Pos Ober’s test Pos Neg Thomas test Pos Neg Anterior step down L unable/fear of buckling 2” step down w 8# DB Pivoting for directional change L fear of instability No fear/no issue Sit-stand UE assist/stiffness 10x w/o UE assist Key Findings: L knee flexion contracture, lack of full knee flexion with pain as compared to opp knee, limited with all WB transfers, inability to descend any height step, valgus deformity, very limited hamstring length, lack of ankle DF and lack of hip extension Treatment: Manual joint mobs for ankle DF, knee extension with distraction and distal femoral ER to realign, hip extension mobs in WB, patellar mobs, hip ER mobs in WB. Stretching knee extension in prone, ankle DF WB stretching, hamstring and hip flexor stretching in WB, NWB hip ER stretching. Strengthening consisted of SLRs, quad control in L WB knee extended opp LE toe reaches, knee flexed DF loading toe reaches, progressing to 2 inch step downs with ipsilat pelvic rot for femoral ER control, SLB with ipsilateral rotation R crossover touches for valgus correction, assisted squats with L toeing in for alignment correction. Outcome: Pt was able to gain almost full knee extension, was able to ascend/descend steps without pain with UE assist, sit to stand transfers pain free without increased time needed, and ambulating short distances without AD. 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 (October 2022) New Findings for Degenerative Meniscal Tears: A’scopy vs Non-op…1st year joint space narrowing outcomes! by Mike Napierala, PT, SCS, CSCS, FAFS Clinical Scenario...What would you do? A 54 yr old male comes in for a 2nd opinion consult for his L knee. He’s had a h/o various knee injuries in the past with some periodic bouts of stiffness and swelling especially with impact activities if not careful of volume and intensity. Five weeks ago he was getting off the floor while playing with his grandchild and felt a small snap/click in his knee and suddenly had sharp pain with weight-bearing and difficulty extending his knee. His PCP referred him for an orthopedic consult. Mild DJD noted on plain films in the medial > lateral compartment. MRI was done on suspicion of a degenerative medial meniscus tear and found (+). Recommendations were to have Arthroscopic partial meniscectomy. He was assured it would have no bearing on arthritic progression since the torn meniscus was not functioning properly now. His lack of full extension was explained as part of the reason he needed A’scopy. He prefers non-op if possible but does not want to make his knee worse by avoiding surgery. He’s presently doing OTC NSAIDs and prn Tylenol. Findings showed AROM 5-1250 (vs 1350 on R) and extension PROM stiff/painful at 30, with the patient commenting that it had been 100 short just 2 wks ago. Medial joint line is very tender and there is a > 1+ effusion present. McMurrays is (+) with varus/ER especially, reproducing an asymmetric snap in the knee. Single leg squat is painful at 300 vs R 550 and Thessaly WB test is (+) for pain/snap also. My clinical thinking is: A’scopy will more quickly resolve his pain and restore extension for WB with generally very low risks. Recommend A’scopy. ROM has been steadily improving. He already has a mild DJD present on plain films. Leave the meniscus in if he can progress back to asymptomatic with near normal or normal function. Continue non-operative care - prescribe Physical Therapy including Class IV laser and customized biomechanical exercises for 4-6 wks and then reassess. Recommend a steroid injection to reduce inflammation first and reassess in 2-3 wks regarding continuing non-op care with PT vs doing A’scopy. Aspirate the fluid, begin prescription NSAIDs, advising general rest from activity and FU in 2 wks to reassess for surgery vs formal PT. CURRENT EVIDENCE Santana DC, Oak SR et al. Increased Joint Space Narrowing After Arthroscopic Partial Meniscectomy: Data From the Osteoarthritis Initiative. AJSM 50(8): 2075-2082. 2022 03635465221096790 SUMMARY: The question of how to appropriately treat degenerative meniscus tears of the knee remains a clinical challenge. On one hand, experience has shown many physicians and surgeons that immediately remove the damaged meniscus seems to provide earlier pain relief and restore normal motion and function more quickly. Leaving damaged tissue in a joint to potentially impact chondral stresses and even contribute to loose body development may be another rationale for some in addressing these surgically sooner than later. On the other hand numerous orthopedic organizations have recommended against routine degenerative meniscus arthroscopy based on outcome findings in comparison to non-operative rehab at 6 and 12 months. Karen last month shared a JAMA Network Open study from July 2022 showing a 5 year follow up in the ESCAPE RCT showing exercise based physical therapy non-inferior to Arthroscopic Partial Meniscectomy (APM). But another consideration not studied well is the joint space width (JSW) narrowing status comparing APM with non-operative treatment of meniscus tears vs normal knee. Santana et al, using the Osteoarthritis Initiative cohort (4796 adults 45-79 yr old from 4 centers in US who had or were high risk for tibiofemoral OA), looked at 144 patients undergoing APM and having > 12 months of follow ups vs 144 with meniscal tears not undergoing APM and also 144 knees without a meniscus tear - matched by age, sex, Kellgren-Lawrence (KL) arthritis grade and FU time. Minimum medial joint space width was calculated from radiographs taken annually or semiannually following all knees having an MRI at baseline. The authors found the rate of JSW decline over the first 12 months to be 27x greater than the non-operative group and 5x greater than the no tear group. From 12-72 months showed no differences between groups. JSW at baseline vs 72 months was significantly different for the APM group compared to others (P < 0.001) but not between the non-surgical and no-tear groups. Clinically speaking this is a challenging topic, in part because many times patients want a quicker answer for their pain and limitations than non-operative care can bring. A consideration is certainly, however, to do no harm. While further evidence would be needed to confirm these findings, there is some other published evidence that APM leads to an increased rate of TKA. We find non-operative care most often, though not always, effective at resolving symptoms and restoring function in these cases. Two factors that should be considered and require further study but we see regularly on an anecdotal basis is the efficacy of our Class IV 25W laser and customizing especially squat based strengthening exercises to unload the specific meniscus tear side. That is not part of traditional physical therapy approaches. This greater attention to utilizing biomechanics to alter medial and lateral joint forces can literally allow an otherwise painful knee to perform valuable step down or split squat etc. strengthening through effective ranges when traditional technique causes pain that prevents continuing. We find that simply using otherwise deemed “functional” strengthening methods with simple step ups or downs (...etc.) contributes to the appearance for patients and physicians of “failed conservative care” and may lead prematurely to APM and the accelerated degenerative changes noted by Santana et al. Careful consideration by referring physicians of how customized and detailed rehab is for even just a “routine degenerative meniscus tear” case can significantly influence patient outcomes. Background: APM is a widely performed treatment option for patients with degenerative meniscus tears. Recent evidence has produced debate whether APM accelerates progression of OA. Purpose: To compare tibiofemoral joint space width (JSW) across three groups - patients undergoing APM, those with meniscus tears treated non-operatively, and those without a tear. The hypothesis was JSW would be least in those undergoing APM and greatest in those without a tear. Methods: Cohort design using the Osteoarthritis Initiative cohort, inclusion and exclusion criteria identified 144 patients having undergone APM having at least 12 months follow up and no prior knee surgery along with matched (by age, sex, Kellgren-Lawrence grade and follow-up time) 144 each in the meniscus tear without APM and the no meniscus tear groups. Baseline MRI used and then annual or biannual radiographs used to calculate the minimum medial compartment JSW. Linear regressions done. Findings: All groups had comparable 4.33 - 4.38mm JSW at baseline. The rate of JSW decline for the APM group was 27x greater during the first 12 months than the non-surgical tear group and 5x greater than the no tear group. No differences present in the rate of JSW decline between 12 and 72 month follow ups between groups. There was a significant difference in JSW from baseline to 72 months for the APM group vs the other groups (P < 0.001). Author's Conclusion: APM results in a faster rate of joint space narrowing during the first 12 months postoperatively than nonsurgical management of meniscal tears. Comparable rates of OA progression occur between 12 and 72 months regardless of treatment approach. Untreated meniscus tears do not hasten radiographic progression of OA as measured by JSW narrowing. THE PEAK PERFORMANCE PERSPECTIVE Orthopedists, whether non-operative specialists or surgeons, and family practice physicians alike often see patients in the 40+ age range with complaints of sudden onset knee pain and swelling. This is oftentimes accompanied by a lack of motion, catching/snapping symptoms and sometimes frank or pseudo-locking symptoms. With no frank trauma implicating ligament injury, along with joint line tenderness and a (+) McMurray’s, Appley’s or Thessaly sign this is typically considered a degenerative meniscus tear until proven otherwise. MRI is most often utilized to confirm the diagnosis if needed. The question then becomes “what is the next right step for care?” Oftentimes it’s patients themselves who are looking for the “quick fix” of arthroscopy also. Historically, a decade or more ago, these cases were moved to arthroscopic partial meniscectomy (APM). Typically patients have a fairly short recovery and their pain/mechanical symptoms are effectively treated - a seemingly good outcome. The costs and albeit infrequent adverse events related to even a “minor” arthroscopic procedure, among other considerations, led the responsible orthopedic community to study efficacy and alternatives further. I was a lead on the PT care side while at University Sports Medicine in the 90’s of a study done by the Sports Medicine Dept by several surgeons on non-operative care for MRI diagnosed degenerative meniscus tears that began as a 6 wk treatment program. The majority of participants did so well the study was extended. During that time and following, numerous other studies started being published lauding the merits of non-surgical care for degenerative meniscus tears. Various orthopedic societies and organizations have published position statements suggesting routine APM is no longer recommended. Other authors have cited that despite all these recommendations the rate of APM has not significantly dropped (Rongen 2018). There are certainly some percentage of patients with meniscus tears who are good candidates for APM for numerous reasons that may be unique to their situation and life demands, timing needs etc. Clearly this is true for frank locking of the knee due to the tear. Less clear is the “slow to recover non-operatively” knee case. We don’t know how long is “too long” before the benefits outweigh the risks and costs of APM versus waiting longer for the hoped benefits of non-operative care to manifest. One consideration some have indicated is whether leaving the torn, and less effective, meniscus in the joint would impact OA progression or produce risk of further injury. The ESCAPE Trial that Karen’s last newsletter reported on from JAMA Open Network reviewed 5 year follow up results vs APM and noted non-operative care to be non-inferior to APM long term. Obviously these non-op approaches inherently cost less and carry less risk of adverse event than APM. In this study, by Santana et al, joint space narrowing (JSN) was specifically assessed. APM having produced a 27x greater rate of decline in joint space vs non-operative meniscus tear approach weighs significantly into the basis for deciding on APM as an option. While not the standard, and yet to be well studied or an algorithm determined for identifying at-risk patients, we have personally seen numerous times patients with reported “mild to moderate, but not bone-on-bone” plain film radiographic findings who undergo APM for meniscus tear having a very negative post-op course of recovery and eventually have a much earlier than expected TKA done. The question remains, how much pre-existing OA can be tolerated by a joint undergoing APM and not have degradation accelerated to a point more further procedures are needed compared to having left the degenerative meniscus alone? While non-operative physical therapy care will, of course, not “heal” the tear or smooth over rough edges of torn meniscus this study by Santana et al supports the findings of many studies before it that physical therapy care for these cases produces good results very often, allowing patients to forego otherwise anticipated necessity for APM and the associated costs and risks of having a procedure. It also established that leaving a torn degenerative meniscus tear in the joint did not contribute to significant further abnormal narrowing in the first 12 months, and that comparable progression of OA still does occur over ensuing years comparable to that of an intact meniscus knee with OA. The JAMA Open paper did, of course, as expected, reveal that some percentage of non-operative care cases will eventually move on to surgery. Certainly not all meniscus tear cases begun in physical therapy alone will be fully successful in resolving symptoms and restoring full function. The key to recovery from a degenerative meniscus appears though not to be dependent on removal of the tear or rough margins. It often means reduction of pain and inflammation, and recovery of ROM and strength - common pursuits of typical physical therapy care. And now there is mounting evidence suggesting that “fixing” the torn meniscus may bring with it unwanted accelerated adverse effects. What is not typical in non-op care of these cases, however, is the unique demand for biomechanical “respect” for the painful tear side of the joint. Traditional PT does not teach or espouse a keen focus on “unloading techniques” for the painful tear side during typical WB strength or balance exercises. Yes…squats and leg presses, lunges and step downs or step ups, these all can be part of a functional strengthening regime of PT exercises. But done in standard “PT fashion” they oftentimes will requires unnecessary reductions in training ROM and/or loading due to pain issues (without advanced biomechanical approaches being used). The problem is that most degenerative meniscus patients have pain, sometimes very sharp debilitating pain, during these exercises. If one were to employ only NWB quad bench strengthening, even if it were pain-free (which it often is not in these cases), I’d submit we wouldn’t remotely see the effectiveness that studies show for non-op care. We see even better results utilizing biomechanical considerations to unload the painful knee side via frontal and/or transverse plane pre-positioning or reaching techniques that allow needed stimulus of the Quads, for example, but reduce the compressive pain over the meniscus tear. Consider this example - a posterior horn medial meniscus tear on the R knee may be especially loaded in WB by varus (knee adduction) and tibial ER (compression of posterior horn). While not exclusive we often find that patients unable to squat at all for effective strengthening exercise can suddenly perform (happily) through pre-positioning with the R hand reaching down or out to the R (tipping R, creating gapping on the medial knee) or by IR the foot slightly. The use of customized frontal and transverse plane adjustments allows us to identify unique positions for effective strengthening. Another key consideration is the kinetic chain biomechanics. For example, a varus knee with a MM tear must have the ability to internally rotate the hip, pronate the subtalar joint, and adduct the hip (limited by ITB tightness) addressed if there is any chance to reduce the magnified loading of the medial joint biomechanically. These are parts of our Applied Functional Science (AFS ©) training that are not part of traditional PT approaches. Our Class IV 25W laser has also been a key tool in reducing pain and inflammation. Last year I had a typical degenerative meniscus event…simply picking up my leg to dry off in the shower, felt a click. Within an hour the knee was swollen, I was unable to fully extend, ambulation was limited and painful, and flexion was reduced probably 15-200 also. These episodes typically would take me 2-4 wks to recover from. With only 3 laser treatments I was feeling 75% better in just three days! In less than a week I was fully recovered as if nothing had happened, able to do stairs, workout w wts, and golf. The case below illustrates a patient who had plain film confirmed DJD but sharp pain with clunking on McMurrays suggestive of also having a degenerative LM tear. MRI was never done to confirm findings but clinically speaking he presented with findings beyond typical knee OA alone or an ITB syndrome. THE PEAK PERFORMANCE EXPERIENCE Ken said: “Now my knee feels like it’s 95% of normal! I walked 18 holes of golf 3x in one week without trouble.” HX: 68 yr old male retired engineer and recreational golfer developed R knee pain laterally over the prior month especially with descending stairs, sit-stand ADL, and getting out of the car. He was referred by his PCP with plain films apparently showing DJD changes. He had just finished a 5 day steroid dose pack which helped. Subjective: Max sx 3/10 and self-rating function at 70%. WOMAC 28%. CC is pain w stairs (desc > asc), getting out of car, twisting activities, had to change to taking a golf cart to avoid walking hills with reduced golf. Objective: 1+ joint effusion, tender lateral joint line + ITB @ LFC, (+) McMurrays all four combinations w sharp pain and clunk noted @ lateral knee. (*=pain) Eval 6wk DC ReEval Knee ext AROM (L/R) 0/2.00 0/2-30 Knee ext PROM R 20 1-20 hyperext Knee flex AROM (L/R) 135/1320 NT/1430 Isometric Quads @ 300 89% w * 98% Isometric Hams @ 200 87% w * > 100% Single squat 74/650 * NT/750 SLB rotations <5sec/>10sec 7sec/NT FWB hip flexion (glutes/hams fxn) 30/300 45/540 WB hip IR 26/300 40/400 Quads Anterior (toes off) Stepdown 4” w 12# wts NT 35x/35x (100%) Key Findings: (+) McMurrays w lateral sharp pain and clunk consistent w R/O degenerative LM tear. Pt had weakness in Quads/Hams NWB w pain at lat/posterolateral knee, limitation and sx w squat function. WB hip IR restricted (B) - an issue for golf demands (ie, if hip unable to adequately rotate then forces at knee increased) , and poor function of hip extensors as assist w squat function. Treatment: Manual therapy joint mob’s for knee extension + sustained stretch after. Flexibility/ROM work to improve R TFL/ITB and hip IR WB (B) along w knee flex PROM. US utilized at lateral knee/ITB. Class IV laser demo done but pt chose to not purchase package for treatment (was already improving significantly). SLB work done to improve rotational control and tolerance - especially due to being a CC, despite actually better performance at RLE on IE testing than LLE. Functional squat based strengthening for quads/thigh utilized frontal plane unloading during Ant stepdowns initially (tipping trunk L to unload lateral joint - ie, reducing compression forces at LM…attempt to unload potential ITB as primary source via tipping to R worsened sx), tipping L via LUE reach table also utilized during split squats to allow deeper and heavier training. Outcome: Pt progressively reported increasing stairs/squat function and ability to tolerate rotation. Eventually he resumed walking golf, playing even 3x in one week w/o sx prior to his ReEval. WOMAC reduced to 5% and self-report score 95% at 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 ext (585) 218-0240 www.PeakPTRochester.com

Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE September 2022 Five Year Follow-up on Physical Therapy vs Arthroscopic Partial Meniscectomy for Degenerative Meniscal Tears: ESCAPE RCT Results by Karen Napierala MS, AT, PT, CAFS What would you do? A 52 year old male limps into your office after stepping on an uneven muddy surface, slipping, and feeling pain in his medial knee. He is lacking full knee extension by 50 degrees with a springy empty end feel. End range flexion is painful/limited, as is full weight bearing. He denies any frank locking symptoms. A small effusion is present and tenderness is isolated to the medial joint line, especially posteromedially. Plain films show very mild joint space narrowing. McMurray’s provocative testing reproduces pain with tibial ER + varus compression. The patient is eager to return to hiking, and outdoor activities as soon as possible. I would prescribe… “RICE”, NSAIDs, and gradual activity return as able over 2-4 wks - call if problems persist. Order MRI for suspected medial meniscus tear. NSAID’s and 3x PT visits based on ease of location for HEP training. Intra-articular steroid injection and reassess in 2 weeks. Customized biomechanical PT to include Class IV laser, manual therapy as needed, customized exercise for off-loading medial knee. FU 4-6 weeks. Refer for or schedule knee Arthroscopy for expected partial medial meniscectomy and chondral debridement. CURRENT EVIDENCE Rhon DI, Fraser JJ. et al.“.Effect of Physical Therapy vs Arthroscopic Partial Meniscectomy in People with Degenerative Meniscal Tears: Five-Year Follow-up of the ESCAPE Randomized Clinical Trial, JAMA Network open, 2022:5(7), 2022, 2021; 619-27. SUMMARY: Meniscectomies for degenerative meniscal tears are performed throughout the United States but more recently have been recommended less routinely than in the past due to numerous studies showing no clear clinical benefit over non-operative care in the first two years. Debate is ongoing, however, regarding the implications that arthroscopy vs rehabilitation choices may have on subsequent cartilage degeneration over a longer period of time. Some have suggested that addressing unstable meniscal tissue will reduce the potential for abnormal stresses on the articular cartilage. A multicenter randomized clinical trial (RCT) on arthroscopy vs exercise therapy for degenerative meniscus tears (ESCAPE Trial) was conducted in the orthopedic departments of 9 hospitals in the Netherlands. Recruited subjects had symptomatic, MRI confirmed degenerative meniscus tears - 321 patients aged 45 - 70 years participated between 2013 and 2020. Patients were randomly assigned to arthroscopic surgery + written HEP or 16 sessions of exercise based PT. The study was non-inferiority RCT after 5 years following up on the original ESCAPE Trial group of which 278 of 321 patients completed the study. Neither IKDC nor radiographic knee OA indicators (OARSI and Kellgren-Lawrence scales) showed statistically significant differences at five year follow up. It should be noted also that as-treated analysis also showed no differences, with 32% of the PT group subjects’ crossing over to delayed surgery but still never achieved significant improvements over the PT-only group for function. Comparable rates of progression of radiographic knee osteoarthritis were noted between treatments. Noorduyen et al concluded that exercise-based PT remained non-inferior to arthroscopic partial meniscectomy for patient-reported knee function and radiographic knee OA during the following five years. They concluded that “PT should therefore be the preferred treatment over surgery for degenerative meniscal tears”. While the PT program that included simple ROM and generic squats, step-ups and lunges was as helpful as the surgery. There was a significant amount of patients from the PT groups that were unsuccessful. Our experience has shown that numerous biomechanical factors must be considered to optimize and expedite patient recovery. These focus both on potential underlying contributing factors that accentuate forces through the medial or lateral joint and also include specific techniques used to off-load the medial or lateral joint tissues during otherwise limited and painful squat based WB strengthening exercises. These are not commonly addressed in traditional physical therapy programs. The addition of Class IV laser has also proven helpful for many patients having degenerative meniscal tear diagnoses. (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: Recommendations for care of degenerative meniscus tears has changed toward non-operative PT/exercise based on studies comparing arthroscopic partial meniscectomy (APM) outcomes over two years. A significant reduction in APM, however, has not been seen. Neither surgery nor conservative treatment (exercise) necessarily prevents the development of OA. Conversely, some studies have shown APM in these degenerative knees to accelerate this articular degenerative process. Purpose: This study looked to compare patient-reported knee function at the 5 year follow-up mark after APM and exercise-based PT in patients with a degenerative meniscal tear. Secondarily, it looked to assess the radiographic progression of knee OA. Their hypothesis was that exercise-based PT is non-inferior to arthroscopic partial meniscectomy after 5 years. Type: Non-inferiority RCT Methods: This study followed up on the ESCAPE Trial or “Cost-effectiveness of Early Surgery versus Conservative Treatment” begun in 2013. In this study, 321 patients aged 45-70 were recruited who had MRI confirmed degenerative meniscus tears. They were randomized to APM within four weeks or PT exercise groups within two weeks of injury. APM included a written HEP (after 8 weeks access to PT only for delayed recovery) and PT was BIW x 8 wks + HEP training for 16 sessions of supervised exercise. IKDC self-report instrument was the primary outcome, checked at 3.6.9.12. 18 and 24months and secondary outcomes were radiographic knee OA measures (OARSI and KL scores). At 3 month patients visited the outpatient department for physical examination. At 24 months plain films were obtained. A follow-up questionnaire, exam, and radiograph were also obtained at 60 months. Knee locking or subsequent trauma, or failure to progress in PT were grounds to consider APM surgery. Findings: Of the 321 patients (mean age=58 yr), 278 completed the 5-year follow-up. The mean IKDC improvement was 29.6 points in the APM group and 25.1 in the PT group. The crude between group differences was 3.5 in both which did not exceed the non-inferiority measure of 11 points on the IKDC. Radiographic OA changes were not statistically significantly different between groups at 5-year follow up. In a previous study, those who received physical rehab between 8 and 12 weeks had 1.97 greater odds of recurrence compared to those who received immediate physical rehab within 4 weeks. Author's Conclusion: Exercise-based PT remained non-inferior to APM for patient-reported knee function. PT should therefore be the preferred treatment over surgery for degenerative meniscal tears of non-obstructive nature. THE PEAK PERFORMANCE PERSPECTIVE: My last doctor's newsletter also focused on long term health care costs being reduced with PT vs arthroscopy for degenerative meniscal tears. Historically speaking, meniscal surgery is the most performed orthopedic surgical intervention with 30,000 procedures annually (van Arkel ERA, Van Essen, et al) in 2013 the U.S. There was a 49% increase in arthroscopic partial meniscectomies (APM) between 1996 and 2006 (Kim S Bosque, et al). Half of these were performed in patients over 45 years old. These numbers continue to rise since the proportion of the population over 60 years will double from 11% to 22% between 2000 and 2050 (WHO). APM therefore contributes significantly to healthcare costs. Meniscal surgeries range from $5,000 to $30,000 depending on insurance coverage status. Sudden onset knee pain with some swelling and painful/limited knee motion in patients over 35 years without significant associated trauma is a common finding and often considered a potential degenerative meniscus tear until proven otherwise. Physicians and surgeons see these patients frequently for evaluation. Clinical decision making has changed over the years regarding best practices for these cases. First, I really want to stress that although cost can be a large factor driving decisions, quality of healthcare is of primary influence here at Peak. Noorduyn et al showed here that both surgery or exercise yield similar outcomes on the IKDC and regarding radiographic changes in knee osteoarthritis following 5 years after a meniscus injury, based on their non-inferiority RCT with 278 patients following up (87%) at 9 centers over that time. While APM has decreased in popularity (due to research supporting non-operative care - Herrli and, Hallander et al NEJM 2013; Kise and Risberg et al, BMJ 2016) in the past years, there remain some physicians/surgeons and certainly patients who would tend to prefer surgery over formal PT/exercise. In cases when symptoms persist or in cases of mechanical obstruction (locking and limited range of motion) APM has been proven to be an effective treatment to restore knee function. Although arthroscopy for obstructive meniscal tears in patients over 50 are widely accepted, knee derangement symptoms may be triggered by meniscal tears, or by early onset osteoarthritis (OA). A study by Englund (2008) identified meniscal tears on MRI in 61% of nearly 1000 asymptomatic volunteers over 50 years old. If treatment of non-obstructive meniscal tears focuses primarily on reducing symptoms, first the symptom producing tissue needs to be idefined. Are we really sure that knee pain is from the meniscus, or is it generated from the chondral bone below, or other innervated structures? Shvonen et al looked at the long term changes in osteoarthritis of the injured knee joint and showed slightly increased risk of radiographic knee OA following APM compared with exercise therapy. Katz et al found a 5 times higher risk for total knee replacement after surgery vs an exercise-based PT program. While a subset of patients with degenerative meniscus tears initiated with non-operative care do move on to arthroscopy we also have seen cases as described above, where an otherwise routine and “minor” APM and associated chondral debridement led to an exacerbation of DJD symptoms and in a number of cases resulted in far earlier than expected transition to TKA. Faster progression to OA will lead to more patients desiring to stop the pain thru knee replacement (which results in more medical cost). Preventing this acceleration of OA may result in people with increased function, independence, and less chance for early total knee surgeries. This will trigger a substantial reduction of costs of healthcare while maintaining patients' outcomes and independent lifestyles. Traditional physical therapy, while proven effective in many studies for degenerative meniscus tears, often neglects key components that can shorten the time needed to move to an effective independent HEP. This is based on customized PT utilizing Applied Functional Science (AFS ®) biomechanical approaches being able to adjust body/limb segment postures and paths/directions during especially WB exercises to lessen medial or lateral compartment stresses. For a medial meniscus injury, for example, oftentimes traditional PT squat based exercises like common step ups or step downs or various lunges would be limited and painful, delaying recovery. Utilizing biomechanical approaches, however, AFS trained PT’s would likely find foot ER, tipping the ipsilateral hand / shoulders down laterally and drifting the opposite foot 15-200 off midline all serve to decompress the medial joint and typically allow patients to train their quads and squatting like movements much earlier and much more effectively. Let's consider that same patient who has a medial meniscal tear. There are other biomechanical factors that can accentuate medial joint loading that must be addressed. Typical step ups, step downs, lunges often continue to produce discomfort or must be constrained to very shallow depths due to symptoms. Tight ITB/TFL will contribute to knee varus tendencies, as will retroversion or lack of hip IR (tightness of ER’s). At the foot, a lack of calcaneal eversion and general foot pronation, or a short leg can add to varus knee forces that may enhance medial joint forces and thus pain at the degenerative meniscus and related subchondral bone and/or synovial area. If the foot allows, a neutral or 2 degree valgus forefoot/rearfoot wedge may be used to unload the medial knee joint. The opposite idea, yet the same biomechanics can be applied to the lateral joint issues with the focus being on limiting the causation of pronation from the foot to the hip. THE PEAK PERFORMANCE EXPERIENCE: Nicolas said: “After 5 years I am still out in the wilderness leading boy scouts and leaders. Just last month I was out kayaking across Greenland with kayak portages and climbing mountains! I have no pain in my knee joint as of today!” History: Nicolas was a 50 year old Boy Scout leader who spent many weekends roughing it in the wild and training other leaders. He went out with his son training for a marathon when he felt knee pain. He suspected 26 miles was too much but he really wanted to do this with his son. After a few weeks of training his medial knee was painful to stand on. Subjective: It began with a small ache, and after a week more of running, he could barely walk. Objective: (*=pain) Initial Eval Re-Eval Knee extension R knee 50 Full extension Single leg squat knee angle L 650/ Unable ** L 750/R 650 Calf raise L 240/R 20 L 260 / R 240 3” quad dom step down (eccentric ) Unable * 15 # front racked L 24x / R 15x Single leg hop 10 sec L 14x / R unable ** L 16x / R 5x ** Knee Flexion R 700 R 1250 Single leg balance rotation 15 sec Unable L 12x R 9x IKDC 32% 64% Treatment: Nicolas presented with limited ROM due to pain. He had limited calcaneal eversion R >L. R forefoot valgus was 50, while L is 30. His PT began with restoring ROM as able. Once he could fully extend his knee, he was able to do weight bearing activities beginning with B at 50% WB on the leg and progressing to SL weight bearing as able. He received mobilization to his calcaneus to increase available eversion and reduce his varus knee force on each step. To decrease WB forces on the medial meniscus, Nicolas used a 4 degree lateral forefoot and 2 degree lateral rearfoot wedge in his R shoe. He had limited hip IR to 15 degrees B. Hip IR stretching NWB was added in, as well as hip extension. His exercise program progressed to upright hip ext and IR stretches and then small range strengthening of the ER’s and hip extensors. As symptoms allowed he also began quad dominant step downs, ant medial lunges to facilitate a valgus force at the knee, and calf raises. After 3 weeks: Pt ambulating at 2.5 mph with no pain. Outcome: By controlling the knee varus through his shoe posting, and allowing him freer calcaneus, hip, and knee frontal plane motion, Nicolas was able to return slowly to prior activities. It took him 3 months to return to walking on even surfaces, and almost 6 months before uneven surface and small hiking, (specially downhill) felt good. I interviewed him last week, and after five years he is hiking, portaging (carrying) his canoe/kayak, climbing mountains, and getting on and off the ground with no pain. Jumping and landing on the R leg alone will bring on some discomfort (1-2/10), as will planting R and cutting L if he isn’t careful. He has returned to his full activities with no complaints. 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.

Meet Michelle Ober, a workout fanatic and our Peak Performer of the Month for August 2022. Hopefully her story inspires you... Michelle slipped on ice Super Bowl weekend, February 2022 and badly broke her arm which required surgery to repair the extensive fractures of her humerus and radius. Allison went above and beyond to contact physicians to help Michelle get seen as soon as possible. Michelle now has a lot of hardware in her arm and her rehab was an uphill battle. Michelle says: 'I had to look for the ways that God was working in my circumstances, and to see the humor in things. I started with no elbow movement and was barely able to lift one pound. My kids had to help me dress! Now I almost have all of my strength and motion back. Thank you Allison for all of the stretching and being a cheerleader in each victory of my recovery!' Allison says: 'Wow, Michelle is serious about working out! Every time she gained range of motion, she would jump up and down and cheer! She had a goal to get back to plyo workouts including planks and push ups, and she did every thing I told her and more to get there. Michelle just had her six month follow up with her doctor and he was so impressed with her range of motion that he took pictures for her chart. I wish all patients could tap into Michelle's energy and drive! You're the bomb girl!!!' Peak Performance makes a $50 donation in honor the work of our Peak Performers of the Month to a charity of their choosing. Michelle chose the Bethany House. Congratulations Michelle and way to go!!

Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE (July 2022) Clinical Decision Making on Reducing Dynamic Knee Valgus-rotation …It’s not always the hip! by William Slapar, PT, DPT, OCS, CMTPT, CAFS Clinical Scenario...What would you do? A 16 year old female comes in for follow-up four weeks after evaluation for persistent left medial patellar pain that developed during running and lacrosse without any specific trauma. She’d already been seeing a personal trainer and has continued working on hip Abd’s and ER’s strengthening drills related to asymmetric dynamic valgus noted on your initial exam. Rest from running/sports x 2 weeks and gradual return to activity was prescribed. She was able to continue strength training with her hip stabilizers but symptoms returned as she resumed interval runs and 50% effort and volume lacrosse practice. Single leg squat observation shows no change of dynamic knee valgus/rotation vs eval findings. Ober’s (-) . Merchant view plain films showed mild but symmetric lateral patellar tilt and glide and Insall-Salvati ratio was (-) for patella alta. Patient is a junior who is eager to get back to lacrosse participation especially for upcoming exposure tournaments and scouting camps to attend this summer. My clinical thinking is: Course of prescription NSAID’s, painfree cross training and no practice, and order MRI to further assess and R/O chondral pathology - FU in 2 wks. Order patellofemoral buttress stabilizer brace and do gradual return to lacrosse. FU 2-3 wks. Refer to sports-ortho Physical therapy including biomechanical eval including distal factors (since hip work thus far not effective controlling dynamic valgus/rotation) - BIW x 4 wks allowing gradual activity return per symptom status. FU 4 wks. Refer for instrument assisted soft tissue mobilization of especially ITB/ lateral structures along with dry needling. CURRENT EVIDENCE Ban R., Yang F. “ Preliminary study on acute effects of an intervention to increase dorsiflexion range of motion in reducing medial knee displacement.” Clinical Biomechanics, 95, 2022; 2-6. SUMMARY: Dynamic Knee Valgus (DKV) is a commonly seen biomechanical failure that can lead to various different knee injuries, from as minor as an MCL sprain or patellar subluxation event to as severe as an ACL tear. Physicians ordering Physical Therapy must consider if they trust a thorough biomechanical screening and care plan will be performed. Key concerns may need to be emphasized on prescription orders for initial care episodes, in post-op cases, and especially changes in therapy providers following failed early rehab attempts when surgery is not yet indicated. There are many different biomechanical factors that may contribute to DKV. Most often physicians/physical therapists/trainers focus on the proximal influence, the hip. This article by Ban and Yang shows that there is an oftentimes missed distal influence as well, limited dorsiflexion, that is amenable to treatment that mutually reduces DKV. This pilot study tested 8 healthy participants (18-32 yo, 6 female, 2 males) presenting with DKV, or medial knee displacement(MKD) (measured as an outcome for DKV), during an overhead squat, where the MKD was reduced by a heel lift. Dorsiflexion ROM was measured in 3 different static forms (passive straight knee, passive bent knee, and lunge). Their intervention (foam roll, static stretching, PF/inversion strength exercise and single leg squats) increased DF ROM and resulted in a reduction in MKD, thus decreasing DKV. Dorsiflexion loss, while a distal sagittal plane restriction, causes a proximal compensatory transverse and frontal plane effect at the knee resulting in DKV. Limited DF can result in a compensatory strategy of talus Internal rotation that unlocks the MTJ to produce needed “DF” but at the midfoot. Kinetic chain biomechanics dictate that talar motion will induce tibial Internal rotation and abduction, leading to femoral internal rotation and adduction - all resulting in DKV. The body often seeks the path of least resistance, here, with the midfoot’s available DF becoming the resource when the ankle proper (TCJ) DF is limited. While that mechanism may produce DKV, likewise, the frontal/transverse plane knee may become it’s own “path” for shock absorption and adaptation to ground changes through DKV when the foot-ankle are not compliant with adequate eversion. This study did not examine all factors contributing to DKV, therefore DF loss alone cannot be assumed the cause of DKV/MKD. Therapists must test all possible contributing factors to DKV to optimize patient outcomes. High quality care goes beyond the simple treatments used in this study to include manual therapy and more biomechanically authentic exercise options to optimize neuromuscular integration for ADL and athletic use. Nevertheless, there was a measurable benefit from a single care episode in reducing MKD/DKV. Depending on the severity of the restriction this may normally take weeks for a difference on DKV. Because traditional therapy often assumes a proximal cause when DKV is present physicians may need to specify “assess and treat knee valgus prox/distal factors” for initial PT scripts. For “failed” cases, it may be beneficial to review with patients specifically what exercises were done to determine if therapists/trainers had discovered and addressed distal factors or not. Background: Dynamic Valgus, medial knee displacement, which has been an important biomechanical failure we see in athletes, especially females, has been associated as a risk factor in lower extremity injury, especially ACL tears. Loss of dorsiflexion (DF) has recently been shown to contribute to medial knee displacement (MKD). Purpose: (1) to explore an intervention to increase ankle dorsiflexion range of motion during the three static measurements (2) to test if increasing dorsiflexion ROM could reduce MKD in individuals who demonstrated MKD corrected by a heel lift in squatting. Methods: Eight healthy participants (18-32 yo, 6 female, 2 males) who displayed dynamic valgus in an overhead squat that was alleviated by a 2 inch heel lift were included Treatment included foam rolling, knee flexed and extended slant board stretch, tubing inversion and WB PF raises in IR, plus single squats for integration - all done in single session. The dorsiflexion was assessed in 3 different ways statically: passive straight-knee, passive bent-knee, and weight-bearing lunge. Findings: A single session of interventions targeting dorsiflexion ROM increased dorsiflexion in all three static positions (all P < 0.01 with moderate effect sizes) and a significant reduction in medial knee displacement (P =0.02) during an overhead squat. Author's Conclusion: The intervention protocol used was beneficial in improving dorsiflexion limitations for those showing MKD on squat testing related to apparent DF restriction and that addressing DF ROM may be helpful in reducing MKD as a a risk factor for ACL injuries. THE PEAK PERFORMANCE PERSPECTIVE Physicians treating knee injuries commonly see Anterior Cruciate Ligament (ACL) tears but also other conditions and injuries that often may experience common overload positioning, whether as microtrauma or as a sudden event, that involve dynamic valgus/rotation. Patellar dislocations and instability, MCL injuries, and meniscal injuries are among these. Early decision making on treatment choices and ensuring risk factors have been properly identified and are being addressed is critical. Physicians making initial treatment orders or especially in cases of “failed care” are tasked with identifying key factors that may require specific emphasis on prescriptions they write to ensure Physical Therapists/Athletic Trainers address biomechanical issues properly in rehab. Anterior cruciate injuries are one of the most common injuries in sports. The fact that this injury is most often a non-contact injury and occurs with between 600-2300 N of force shows that there are numerous factors that we must consider before treating a patient to prevent/reduce the risk of this injury. One well studied and accepted concept related to risk is dynamic valgus/rotation, the biomechanical failure that leads to the increased stress/tensile load on the ACL along with other structures. Ban and Yang provide an important piece of work in connecting the loss of DF with abnormal MKD-DKV during squatting and the ability for even a single session of therapy exercises to significantly influence DKV. We define dynamic knee valgus as being a combination of excessive femoral adduction along with internal rotation in combination with tibial abduction and internal rotation. It is commonly measured via the resultant “medial knee displacement” for objective testing in research or clinical observation. Most often physicians and therapists/trainers alike risk assuming the source is commonly referenced proximal factors at the hip. This results in exercises to strengthen and neuromuscularly train the hip abductors and external rotators. While these are critical considerations and often effective methods careful evaluation is needed in the rehab setting to ensure the primary and ALL key influences potentially contributing to DKV have been identified. Too often a “protocol-like” approach is taken that automates a series of hip based exercises without specific objective evaluation to determine underlying factors. Ban and Yang do a great service to orthopedic and rehab professionals in identifying that a lack of dorsiflexion could be causing a distal or “bottom-up” mechanical compensation into knee dynamic valgus/rotation. However, while this can definitely be true we must then evaluate the other parts of the lower kinetic chain. Each of the reasons listed below requires its own unique treatment path toward the goal of reducing the severity and frequency of DKV, with the end goal of reducing abnormal loading on the at-risk tissues surrounding or in the knee. Strength and motion of the hips are certainly critical, but sometimes it is a bony anomaly, such as anteversion that is pre-loading the system. The foot, not only regarding DF, but also other foot mechanics as the first body part dealing with ground reaction forces that induce kinetic chain loads is critical. Sometimes orthotic intervention is necessary to reduce abnormal forces and to optimize the ability of the neuromuscular system to then improve dynamic stability control actively through exercises. High quality knee rehabilitation must include a substantial checklist to determine the most significant and likely issues for a patient presenting with DKV/MKD. Common deficits we see with patients who have DKV are: Lack of dorsiflexion: this often results in either early heel rise, which reduces the contact area and thus stability within the lower extremity or very often we see this sagittal plane TCJ restriction causing overpronation at the STJ which unlocks the MTJ to obtain the necessary sagittal dorsiflexion for force absorption eccentrically…resulting in the tibial IR distally that contributes to DKV or MKD along with reduced distal stability in general Foot alignment/structure: abnormal foot mechanics issues, including rearfoot and forefoot varus “deformities” can result in compensatory overpronation; this results in tibial IR forces that contribute to DKV tendencies Limited calcaneal eversion: the STJ needs to be able to evert for proper adaptation to the uneven ground and force absorption as a part of our body’s deceleration process; Limited calcaneal eversion can cause excessive compensatory MTJ collapse into general foot pronation and/or kinetic chain demands on the knee to adapt to the frontal/transverse plane absorption normally dealt with by the STJ Hip anteversion: this is a huge disadvantage to DKV, and other joints, due to the anatomy having an increased tendency to femoral internal rotation, displacing the knee medially Weak hip ABD and ER: strength deficits of these are commonly accepted contributors proximal causes of DK, allowing for excessive femoral frontal and transverse plane collapse medially due to ground reaction forces and superincumbent body weight loading Quadriceps weakness: since force dampening/absorption involves the pronation kinetic chain pattern including tibial and femoral IR especially, quad weakness may result in poorer control of knee flexion and a tendency for the knee to collapse medially (far more often than excessive lateral movement) The case below illustrates an example of an athlete who had DF limitations that contributed to abnormal knee dynamic valgus who was helped by specific functional manual therapy and customized therapeutic exercise progressions where proximal factor approaches alone would have missed key contributing factors she needed addressed. THE PEAK PERFORMANCE EXPERIENCE Allison said: “I was able to play my tournaments all weekend long (4 games) and did not have any knee pain on either knee” History: Allison is a Junior in high school who has been playing lacrosse all season and now getting scouted during the summer. She has to run/sprint, cut, play defense,using all three planes of movement at all times during her play. Her knee pain came about as a repetitive overuse nature. She had R sided knee pain that with rest ordered from an Orthopedist resolved but then her opposite L side started to bother her two weeks later. Objective: (*=pain) Eval 4 week Re-Eval STJN WB DF R=250 L=150 R=280 L=250 6” Anterior step down L= * 1st rep, w/ mod. DKV, R= 15x, min-mod DKV increases with reps L=15x (fatigue with 1/10 pain) min. DKV R=x20(fatigue), min. DKV SLB rotations L=stays in pronation, lacking resupination R=5th digit WB with resupination L= min. resupination, LOB R=mod resupination ability Single legged hop 10 sec L= 1x *, mod DKV, with immediate RLE touch down R= mod DKV, LOB L=min DKV, min frontal trunk sway to regain balance R=min DKV, SLB mini-squats L = Mod DKV and * R=mod DKV L=min DKV R=mod DKV Prone Hip PROM (IR/ER) R=55/300 L=53/300 NT Key Findings: LE Posture: squinting patella B with overpronation B; anteversion of B hips, anterior step down shows anterior pelvic tilting of the hips with shaking of the tested leg due to quad inability to descend body weight eccentrically with proper control in sagittal and frontal plane. Hamstring imbalance, ABD and ER strength was near symmetrical based on handheld dynamometer. Treatment: Manual FMR DF mobilization in wb/function followed by STJ neutral stretching of the soleus and calf, supination drills to improve overall foot mechanics in the rearfoot for supination efforts and forefoot for pronation control. Anterior step downs 4-6” with toes off box to isolate the quads better, Hamstring strengthening in functional weight bearing 3D movements. Lunges for all planes with different foot positions during landings to mimic natural lifting patterns. Deceleration exercises through multiple planes at foot positions to mimic on-field play for cutting/agility, multiplanar landings for single legged hips and multiple hops with turns, Blaze Pod reactivity lacrosse drills, and progression of multiplanar speed drills to achieve working in two or more planes at once. Outcome: Pt was able to achieve a personal goal of competing in summer tournaments and scouting camps while being in PT for just 3 sessions and starting speed days within 2 weeks of PT evaluation.Pt is a continuing PT to complete her 3D functional exercise progressions to further optimize the ability to control abnormal DKV in order to improve performance and reduce risk. Pt has difficulties in the frontal plane with more than just sagittal movements. Also increasing proximal kinetic chain work to further improve physical performance.

Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE June 2022 Using 2D Video Testing with Runners - Analyzing Biomechanics to Treat and Prevent Injury CLINICAL SCENARIO…What do you think? A 35 year old runner comes in with L lateral knee pain gradually developing and worsening over time as running mileage has increased and hilly terrains have been added to workouts of 4-5d/wk running. She has (B) mild squinting patella in resting standing, worsened slightly in single leg stance, over pronation L > R in single leg balance, painful single squat from ~ 150 - 400, (-) Ober’s and McMurray’s, unremarkable plain films, and local tenderness over the ITB at the lateral femoral condyle. You refer her for ITBS with orders to evaluate and treat. She’s returning for a 4 week FU and here’s what she tells you about her PT experience so far … A. Did a 10min evaluation and provided her with the clinic’s ITB Syndrome exercise sheet including 3 different ITB stretches, 4” step ups, clam shells. No major changes yet. Sore after step ups but PT said it may hurt for a few weeks and then should begin reducing pain. B. Did a 45 minute evaluation and found less L knee valgus/femoral IR/pronation with medial posting an OTC insert, noted L STJ neutral squat DF loss (prior ankle sprain hx) - doing ankle mob’s and soleus stretching, customized depth of step downs to 1” box to avoid pain during quads training, doing Class IV laser now, working hip ER’s in wb. Sx 40-50% reduced now. Treadmill assessment planned once sx reduced to allow jogging. C. Did 20min evaluation and began with instrument assisted “scraping” technique tissue mobilization to ITB, ultrasound, resistance band walks, NWB inversion tubing to strengthen foot along with towel toe scrunches for intrinsics. Sx 10-20% better. PT requesting script for iontophoresis. What would you decide for each case? 1. Determine the therapy is not specific/customized enough, the eval was too cursory and treatments are not biomechanically focused. Consider allowing 2 -3 more weeks of care before changing (or change now) to a PT/clinic doing more in-depth biomechanical testing and customized exercise. 2. The treatments are appropriate and on track. Happy with present status. Advise to continue PT. 3. Concerned about the lack of more thorough evaluation and use of generic and assumed local ITB approaches (stretches, soft tissue work) despite no (+) ITB tightness findings. Contact the PT to discuss the case and to question if underlying causes/factors identified and what further testing is planned. 4. Order an MRI to R/O a degenerative lateral meniscus tear or small chondral lesion that may be causing the lateral knee pain. Summary: Physicians and physical therapists frequently see runners for their most common issue, lower extremity injuries. If “overuse” is really to blame, knowing running is a bilateral reciprocating activity, then why are these injuries so often unilateral? Physicians routinely send runners for physical therapy. The real key is what happens next. As a physician, do you really know? Is a patient who comes back “feeling better” truly better? How do we get beyond simply treating the pain/inflammation and actually identifying biomechanical causes or technique based issues that may be contributing to the diagnosis made? Is the naked eye adequate in identifying these issues with treadmill or on-ground running analysis? The use of 2D video testing can help identify areas needing further biomechanical and orthopedic assessment for tightness or weakness or poor neuromuscular control. They also provide excellent feedback for possible technique cues runners can implement to alter the abnormal forces being produced. The gold standard in visual recordings to understand the biomechanics during running can be done utilizing expensive 3D (sagittal, frontal/coronal, and transverse plane views) cameras/software but this must include the right operational setting, which is unobtainable by most therapists and their patients. More recently, 2D (sagittal and frontal plane) analysis has been increasing in availability as a practical way to help providers and runners observe individualized mechanics and form during running. This can aid to help better understand the faulty biomechanics potentially leading to the “overuse” injuries we hear patients report in the clinic. Martinez et al. compared sagittal plane 2D and 3D analysis of running kinematics and determined that the 2D measurements 2-50 from the gold standard 3D counterparts and can serve as an effective way to record qualitative and quantitative information that could not be seen easily by the naked eye alone. Maykut et al. in similar fashion looked at 2D vs. 3D in the frontal plane focusing on pelvis-hip-knee relationships and also found good validity and reliability vs 3D. In the mode of “practice what I preach”, I used 2D analysis on myself with the SPARK MOTION ™ app available at Peak Performance to analyze my running mechanics, helping to better understand what I may be doing well, and more obviously not well and perhaps identify reasons for the knee pain I get with increasing training and mileage. (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) CURRENT EVIDENCE Martinez, Caitlyn, et al. "Comparison of 2-D and 3-D Analysis of Running Kinematics and Actual Versus Predicted Running Kinetics." International Journal of Sports Physical Therapy 17.4 (2022): 566-573. Background: It is crucial to have a tool such as 2D kinematic motion analysis to predict kinematic measurements in distance runners and is needed to compare accuracy vs 3D gold standard as well as measured and estimated kinetic variables. Method: 30 runners averaging at least 20 miles/wk ran on an instrumented treadmill at their preferred training pace for 6 minutes before having kinematic data measured by markers placed on anatomical landmarks on left LE then data collected on both 2D and 3D camera systems. Ground reaction forces (GRF) were also recorded as kinetic data to compare against published kinetic prediction formulas vs 2D and 3D measurements. Results: Significant difference did exist between 2D and 3D kinematic measurements however average difference for all 2D kinematic data was within 2-50. Previously published kinetic prediction equations were supported by both 2D and 3D measurements for GRF and loading rate. Author’s Conclusion: Accurate predictions of kinetic variables can be made using spatiotemporal and 2D kinematic variables. Maykut, Jennifer N et al. “Concurrent validity and reliability of 2d kinematic analysis of frontal plane motion during running.” International journal of sports physical therapy vol. 10,2 (2015): 136-46. Background: Due to temporal and financial constraints, concurrent reliability and validity need to be assessed for 2D analysis of runners in the frontal plane. Method: 24 collegiate cross country runners completed a protocol on a treadmill at a self selected speed with frontal plane (FP) data collected using 3D and 2D motion analysis systems. Variables of interest were contra-lateral pelvic drop (CPD) peak hip adduction angle (HADD), and peak knee abduction angle (KABD). Results: 2D analysis demonstrated excellent intra-rater reliability for peak HADD and CPD. Moderate correlations between HADD were noted between 2D and 3D of bilateral LEs and KABD on the left. No statistical significance between CPD between analysis however a strong correlation was present between HADD and CPD. Author’s Conclusion: The ease of 2D running analysis in capturing FP variables can be effective when assessing HADD and with close relations to CPD. THE PEAK PERFORMANCE PERSPECTIVE Andrew Neumeister, DPT, FAFS, CAFS, Certified Running Gait Analyst Physicians must scrutinize what the best options are for the treatment of runners with lower extremity pain. Simply addressing local symptoms with modalities along with rest and gradual return to activity may provide short term relief but not address underlying causes or reduce likelihood of recurrence. Biomechanical based testing, both from a local and global on-ground movement performance basis but also from a functional task analysis (i.e. treadmill or ground) of running itself can be a necessary tool in directing treatment needs. Runners are often considered a different “breed” l because from the external perspective…who enjoys running for the sake of running? But talking to and working with these individuals gives you an appreciation for the dedication they have towards their sport and the oftentimes stress that is willingly put on their bodies. Many runners end up with short or long term recurring injuries that are not easily improved with rest or general stretching. I have been fortunate enough to have had a fairly injury free running career transitioning from sprinting and 400m hurdles to the marathon and ultra-marathon distance post collegiate. As the evidence base for 2D running analysis has grown, it was time to practice what I preach and see what biomechanical flaws I may have with my running form and shed light on a fortunate brief battle with R knee IT band syndrome. Utilization of 2D analysis can provide a skilled practitioner with more specific biomechanical data to assist in both evaluating and treating the patient to more quickly hit the ground running… Martinez et al. accomplished some of the hypotheses they set out to test in the sagittal plane in regards to comparing 2D analysis against the gold standard of 3D. Despite statistical differences noted between leg angles, strong correlations were found between the variables. Variables of interest assessed for the left LE included shoe angle at initial contact, tibia to vertical at initial contact, knee flexion angle at initial contact and mid-stance and vertical position of center of mass at mid-stance and double float. The average difference between 2D and 3D variables were 1.4-4.90 depending on which kinematic angle measured which can provide benefit when assessed by a seasoned biomechanical clinician by assessing for kinetic flaws or potential pitfalls in the injured runner. With an acceptable mean of <50 difference between an affordable 2D analytic system and an impractical 3D motion capture setup for the clinic environment, abnormalities can be discovered that are not otherwise observed with the naked eye in real time. It thus becomes a powerful tool for evaluating and making treatment choices in order to counter biomechanical and/or technique shortcomings. Maykut et al. conducted a similar study to the one above, however looked at the frontal plane positions of the pelvis, femur, and tibia relative to each other and vertical. Again, the authors concluded that no statistical correlation was found between 2D and 3D analysis for pelvic drop and knee abduction, however, peak hip ADD had a strong correlation found and that HADD correlated with CPD. Intra-rater reliability was also found using 2D software and this knowledge allows a clinician to be confident in their observations to make sound decisions to better expedite recovery and return to activity. Peak Performance and Spark Motion™ Technology It is easy to glance over the results or discussion pieces in current literature and see that the authors failed to find statistical significance between certain variables and dismiss the data. Although 2D and 3D analysis is statistically different for many kinetic variables, moderate correlation was found for HADD in the frontal plane which is commonly associated with increased triplanar dynamic valgus (knee abduction, femoral IR, knee flexion). Almost all clinicians will agree that reducing dynamic valgus stress at the knee throughout impact and loading is pivotal for reducing risk of injury. The use of 2D motion capture technology gives clinicians the capability to slow down or even freeze frame and draw vectors to compare asymmetrical loading during a reciprocating activity. Being able to show someone who is having pain while running their own biomechanics and comparing left to right and/or versus normal mechanics is an extremely powerful tool to guide treatment of pathologies. This can be especially true for those with “overuse” injury because the asymmetries or abnormalities in their inherent biomechanics of running technique can be so small they are not otherwise evident. The images of me below are depicting commonly measured variables during 2D analysis in the frontal and sagittal planes performed in our office. One of these pictures may stand out more than the others when assessing running form and body positioning during initial contact, mid stance, and heel off. It may seem trivial when noticing the extent of abnormality/asymmetry when asked to pick it out of this collection below; however would this clear visual have been found without 2D running analysis??? How fast can you spot my mechanical pitfall that contributes to IT syndrome? Being able to “connect the dots” biomechanically is critical in not only helping patients overcome their present issue but also in providing confidence to patients and providers alike that the risk of recurrence has been greatly reduced! R Hip ADD Mid-stance L Hip ADD Mid-stance L Hip Extension Toe Off Tibial Inclination IC Knee Flexion IC 9 Deg DF Mid-stance 9 Deg Knee Flexion Mid-stance 35 Deg

Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE May 2022 Hip Osteoarthritis Clinical Decision Making: New Evidence Affecting Treatment Recommendations by Allison Pulvino, PT, MSPT, CMP, FAFS Clinical Scenario…What would you do? A 62 yr old male with 6+ months of progressive hip pain seen for ortho consult referred by PCP. Pt had been taking NSAID’s for 6 weeks and attending physical therapy for 4 wks with limited improvements in pain, ROM, and overall function. Plain films show Gr III-IV degenerative changes in the R painful hip joint and Gr II-III changes on the pain free L side. He enjoys fitness classes including low to moderate impact drills, playing golf and tennis, and hiking with his wife, including mild-moderate elevations. Clinical exam shows NWB A/PROM asymmetric R hip limited in flexion, IR, extension more so than other directions. I would... Recommend 3 series gel injection and reassess in 3-4 months. Advise to continue HEP given by PT and limit activity to non and low-impact only. Recommend patient stop impact activity and switch to pool exercise and cycling for exercise for 2 months and then FU to consider other options such as injection. Update PT prescription or change providers to include BIW manual therapy (+ advancing exercise for ROM and functional strengthening) for at least 4-6 wks before considering HA gel injections. Perform single cortisone injection. Potentially controversial but presently acceptable since only one recent study showed (-) effects on potential rapid degeneration. Change NSAID’s and advise the patient to continue the present PT program for 4 more weeks. CURRENT EVIDENCE Shepherd, et al. “The Influence Of Manual Therapy Dosing On Outcomes In Patients With Hip Osteoarthritis: A Systematic Review”. Journal of Manual & Manipulative Therapy. (2022) 10. 1080/10669817.2022.2037193 Summary: Hip OA is a common ailment causing symptoms and limiting function. While joint mobilization techniques have been shown to be helpful and clinical practice guidelines have formally recommended them, there is a lack of clear dosing parameters known to produce best outcomes. This systematic review initially found 4,675 potential studies on the topic but only 33 were eligible for further review, with only 10 meeting all criteria - this included being an RCT, measuring outcomes, and having specific dosing parameters reported. Of the 768 total participants, it was noted that sessions were most frequently 2-3x/wk, patients had a mean of 6-12 sessions over 1-12 wks, with manual therapy performed in 7 sessions. Effect sizes ranged from small to large depending on the variable measured (pain, ROM, function). While no clear dosing parameter could be recommended based on findings, there were ranges noted that can serve as evidence based starting point. Hip arthritis care, for patients as well as for providers, risks being viewed as an accepted “routine” and “keep it simple” care model mentality. Many experienced physicians may be relying on evidence based “best practices” from studies published many years or even a decade or more ago. Physicians seeing patients themselves and who are training upcoming physicians in residency or fellowship may be unaware of newer evidence published in recent years around the use of joint mobilization efficacy with hip OA. This is a key factor when considering treatment recommendations and prescription content for physical therapy, along with specific recommendations vs a “wherever is most convenient” thinking that is intended to ease the burden on patients but may unintentionally lack discernment regarding extent of manual therapy performed. Often patients have been told prior to PT that “they’ll show you some stretches to do at home” - setting patients up for expectations about PT that may not be consistent with best practices. This study did not find a specific set of parameters supported by the evidence that can be applied “across the board” for joint mobilization in hip OA cases. The heterogeneity of the mobilization parameters does, however, support the idea that there is no single parameter that needs to be followed to achieve results. It suggests that knowledgeable, skilled PTs have the ability to make clinical judgments regarding the customization of techniques used, application of force, directions, and volume/frequency of treatment that result in (+) outcomes. Physicians should know, when ordering PT, that manual therapy techniques lasting 10-30minutes, 2-3x/week, for 6-12 sessions are an evidence based part of appropriate hip OA care. (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: Hip OA is a common cause of pain and limitation with functional activities for many older adults. There currently is good evidence that joint mobilization is effective in improving pain, ROM, and function however there is not documented well studied specific dosing recommendations for hip OA manual therapy treatment parameters. This review study attempts to establish more specific treatment guidelines for this diagnosis based on RCT level evidence. Methods: This is a systematic review that included randomized controlled trials (RCTs) and utilized joint-focused manual therapy. Inclusion criteria were detailed dosing parameters of manual therapy type, direction of force, session duration, frequency of interventions, and numbers of sessions, were published between January 2000 and December of 2021, and met the criteria for hip OA according to the American College of Rheumatology. Findings: Within 4,675 studies, 33 were eligible and 10 were included meeting all the criteria. There were 768 participants with treatments performed by physical therapists and two chiropractors. A variety of manual therapy interventions were performed, including the Mulligan concept (MWM), long-axis high-velocity low-amplitude thrust (LA-HVLAT) mobilization, and non-thrust mobilizations. Parameters used ranged widely. Risk of bias assessment was also done along with outcome-level certainty using the GRADE approach. The most common MT type used was LA-HVLAT. The most common directions of non-thrust mobilizations were lateral and caudal glides with some form of hip IR. Long-axis distraction was used in 7/10 studies. All forms of MT when compared to a control group, improved hip ROM in the short term. Quality of life improvements were documented as medium and large between-group effects after 6 weeks of treatment but small after one year, with regards to the HOOS QoL subscale. Five studies assessed functional performance including walk speed, step-count or a walk test, and large between-group effects were found with walk-test improvements. The largest between-group effect sizes were seen for pain and ROM using MWM into hip flexion and IR when compared to a sham, no-force intervention. Author’s Conclusion: There were some trends that clinicians can consider from this study. The largest within-group effects for pain and ROM and self-reported functional gains were from LA-HVLAT, specifically performing thrust techniques (up to 9 times) and for longer durations of three to six sets (30-45 seconds). When considering non-thrust mobilizations LADM for 10 minutes with 30 second bouts. If hip flexion and IR ROM are limited, then MWM into these motions was shown to have the greatest improvements. There was a lack of specific dosing parameters for many studies so further research is recommended to allow for MT frequency and techniques to be more concisely recommended. Clinical trials should also include baseline sensory and pain neurophysiology assessments, as well as psychosocial assessments as they can influence clinical outcomes. THE PEAK PERFORMANCE PERSPECTIVE Hip OA is a common diagnosis that both primary care and orthopedic physicians see in the office routinely. The pain, progressive loss of motion, and weakness that negatively impact function require consideration of what the best options for treatment recommendations are. Physical therapy has been shown effective in the care of hip OA but physicians considering best practices are oftentimes uncertain regarding the specific recommendations to make on therapy prescriptions and in educating patients about what to expect. Shepherd et al, in this systematic review, analyzed RCT’s to discern if there were specific treatment parameters with manual therapy treatments for hip OA that could be identified for purposes of understanding best practices related to optimizing outcomes. This is critical for both referring physicians writing prescriptions and educating patients regarding therapy expectations. Physicians are also discerning next steps when a patient is apparently “failing” an episode of therapy and the adequacy of care provided must be assessed before deciding if different therapy or escalating care to injections or surgery is called for. And of course these dosing parameters would be critical for practicing therapy providers to understand. While the question on dosing parameters is a good one, this study, like many others, may suffer from the challenge we all see as clinicians. The attempt at a homogeneous answer for the sake of minimizing variability in treatments of the “same condition/diagnosis” is admirable and logical but often ignores the heterogeneity of the patients themselves. Also, many diagnoses have multifactorial considerations. Sometimes evidence exists demonstrating a common approach or parameter that can be consistently used. But, there also exists significant variability within our patients’ lives and bodies that impacts treatment decision making, often leaving linear, singular treatment decisions inappropriate or non-specific to this case. External validity factors in applying research recommendations are often forgotten or neglected too often. Clinical judgment based on both evidence and experience, leaving a “range” of options vs a singular algorithm-like, mathematical equation-like answer that every single provider could and should arrive at equally, is a key portion of our day to day practice as providers. Manual therapy is an effective and necessary component of hip OA care but the evidence does not support a strict and specific dosing parameter that is “one-size-fits-all” in nature. That is not a “bad” finding but speaks to the “art and science” of clinical practice. Our patients are unique - they come with a variety of preconceptions. Oftentimes they verbalize their own expectations of what therapy will entail and will do for them. We have heard requests of massaging the tightness away or to provide them with three or four “easy exercises” to help get them back to where they were years ago or just a quick morning “stretch routine” that can be done daily. Some, of course, say they’ll do whatever it takes to perform their favorite activity again. Many are under the impression or have been expressly told by their physician that physical therapy will be a few short weeks only to learn a home routine. While evidence from the past has certainly demonstrated the efficacy of simple ROM and strengthening exercises with hip OA cases there can sometimes be an unawareness of what the newest research and clinical practice experiences show regarding the efficacy of other treatments in optimizing hip OA outcomes. That can contribute to physicians having mistaken paradigms and providing patients with inaccurate expectations of what physical therapy will include and the length of time likely for formal care. For patients, the disconnect that happens when the PT’s treatment recommendations differ sometimes significantly from their own preconceptions or physician’s advice can sabotage their confidence and trust in therapy, their “buy-in” to the treatment process, and their compliance. It’s helpful, therefore, for physical therapists to share important evidence and experience based updates with referring physicians to update current thinking on best practices in hip OA care. What we as therapists typically do is often different from what physicians and patients expect, both in terms of the extent of biomechanical considerations within the evaluation as well as the variety of treatment options available within therapy. Many patients may have already looked up information from Google that there are the “3 best movements” for everyone’s arthritic hip or have a sheet of six exercise pictures from a friend or other PT or even a physician. Most of the time patients become pleasantly surprised when therapists educate them on all the ways therapy will help them achieve their goals, and it’s much more than exercise. Good evidence exists and clinical practice guidelines now formally recommend the use of manual therapy, especially joint mobilization and/or thrust techniques, for the benefit of pain reduction, ROM gains, and eventual function improvements. While stretching and strength are very important components to be able to move comfortably, it is specifically manual therapy (MT) techniques that decrease pain the fastest and assist in movements with more fluidity and ease, as well as decreasing someone’s compensatory strategies causing pain onset in other joints or even the opposite extremity. Shepherd et al found trends in MT techniques that show the most gains in ROM and pain control, mentioning mobilization with movement techniques (MWM) and long axis high velocity low amplitude thrust (LA-HVLAT) techniques among others, consisting of 10-30 minutes of treatment, 2-3 times per week, for a duration of care from 2-6 weeks as the ranges noted in the RCT’s examined where (+) outcomes were noted using manual therapy to reduce pain, increase ROM, and or function was examined. That is a general suggestion but also needs to be based on individual presentations, level of current and past functional abilities, motivation, fear avoidance, and psychosocial status. All patients are individuals and we as providers need to treat them as they are. Very often a “simple” approach is considered a starting point for all patients. For many this can be appropriate. For many others the case is more complex or goals are loftier. That is where customization of treatment planning comes in…starting with a thorough biomechanical/orthopedic evaluation. We often find that the “regional interdependence” considerations of the kinetic chain result in the need to address other body parts affecting or being affected by the arthritic hip. If one’s goal is to walk 3 miles per day and there is a significant hip flexion contracture, there is a high likelihood of compensations into the spine or opposite knee or hip as that person’s ipsilateral stride is shortened from lack of hip extension. The lumbar spine often hyperextends to take up the lack of extension, potentially contributing to low back pain but also forcing the opposite extremity to be overloaded on impact over time. Carefully assessing the functional mechanics of gait and other ADL, work, or sport movements is key. Many hip OA cases likely require manual joint mobilizations to assist increasing ROM and reducing pain where there hasn’t been correct mobility and mechanics in months or even years. Multi-plane functional hip mobility exercises in all three planes in standing, as well as ankle and knee mobility will all be incorporated into a patient’s treatment plan. Once patients start to feel more comfortable, functional strength and dynamic stability has to be applied through patient specific therapeutic exercises to control their newly achieved hip ROM, thus allowing for functional gains in ADLs and recreational activities. THE PEAK PERFORMANCE EXPERIENCE Diane said: “I feel so great walking, it’s not catching anymore like it used to!” History: Diane was coming into PT for c/o L buttock pain, anterior L hip pain and knee stiffness and pain. She is a nurse and stated she required assistance to help her even walk without limping. She couldn’t quite figure out why she was limping so significantly, but has a history of back, pelvic/SI joint and hip/knee issues on that L leg. Objective: Diane fell off of a step onto her L knee in 2015 initially injuring L knee. She also had been in a MVA in 2000 with c/o L posterior hip pain ever since as well as posterior pelvic pain. She was unable to sit > 20 min, standing > 20 was painful, and any walking was painful at the time of PT exam. Bending forward and squatting was painful as well. Pain could get up to 4/10 and at times was constant. Initial Exam Re-evaluation Hip extension -10deg (flexion contracture) 10deg Prone hip ER 25deg 30deg Prone hip IR 45deg 45deg FABER test Pos Neg O’ber’s test Pos Neg Thomas test Pos Neg Hip Scour Pos Neg Pivoting for directional change L fear of instability No fear/no issue Anterior step down L unable/fear of buckling 2” step down w 8# DB Sit-stand UE assist/stiffness 10x w/o UE assist Key Findings: Diane had a L knee flexion contracture and almost no L hip ER and extension and also was observed to have her L leg longer than her R. She was limping and almost falling into her R leg during gait and her tolerance to any walking was limited (facial grimacing). Treatment: Diane received manual therapy treatment for at least 15 min at the start of every treatment consisting of L hip lateral and caudal (long axis) distraction with a mobilization belt, with 10-20 oscillations followed by 20 sec holds, as well as MWM hip extension and ER mobs 2x10 each direction, each visit. She was also advised to get fitted for a custom external shoe lift as her LLD was of much significance. She performed self SI joint correction, hip ER stretching, elevated hip flexor stretching followed then by resistance band ER pivot step outs and hip flexor loading in/out of extension with sliding discs in WB for ease of increased stride in gait. Other exercises performed including hip adductor stretching and lateral weighted lunges loading adductors instead of abductors, and SLB with transverse plane top-down loading, eccentric step downs for quad loading, incline side planks in/out of hip adduction for ease of WS in gait. Outcome: Diane can walk, squat and negotiate stairs as well as complete all transfers without pain limiting her. She is very happy with her progress and soon to be discharged from PT to live an active lifestyle. 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

Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE September 2020 Rachele Jones PTA, ATC, CAFS You decide…. Patient Scenario: A high school soccer athlete comes to you for what they think is a strain in their hamstring. While playing they felt a small “twang” or “pop” in their mid-belly at the posterior thigh and are having pain with completing knee extension, especially in sitting, with bending over, taking long strides, and cannot jog. Your clinical exam is consistent with a biceps femoris muscle strain. You’re ordering Physical Therapy. Clinical Decision Making… How do I decide where to send the patient? Will their rehab be essentially the same wherever they go? Are generic HS exercises adequate or will they customize exercise stresses for my patient to target specific injured tissue for functional demands? Will proximal kinetic chain factors be tested and addressed to handle underlying risk factors? Summary: Physicians regularly are charged with making decisions on best practices regarding hamstring strains for overall care, specifying prescription orders vs releasing full trust to the PT to “figure things out and do what’s best”, and how referrals to PT are decided. The authors present data that shows in a group of male soccer athletes over 1.5 seasons there was a 20% reduction in HS strains for those sprinting with 10% greater gluteal activity during early front swing phase and 6% reduction for those with greater trunk/core activity during backswing phase of sprinting during pre-season testing. The general concept is that proximal activation of those muscles/groups appears to be at least somewhat protective against HS strains and therefore must be considered as a potentially important component of rehabilitation. It is surprising they found no significant differences for late swing and early contact phase, where the HS forces would intuitively be higher and at greater risk of strain. It must be remembered that EMG demonstrates neurologic activation but is not proportional necessarily to actual force production. The study does fail to indicate how exactly these findings can be put into practical application during Physical Therapy. This would require specific research to determine any best practices on specific exercises that promote EMG evidenced activation along with experimental cause-effect determination if injuries are, in fact, prevented using specific training practices and if reinjury is avoided using similar concepts during rehab. Current Evidence: Joke Schuermans, et al. Proximal Neuromuscular Control protects against hamstring injuries in male soccer players. The American Journal of Sports Medicine 2017; 45 (6) 1315- 1325. Background: Hamstring injuries remain the highest incidence and the most detrimental functional repercussion in male soccer athletes. Proximal neuromuscular control (“core stability”) is considered to be a key importance to primary and secondary hamstring prevention although scientific evidence is currently nonexistent. Method: Sixty amatuer soccer players participated in pre-season testing using multi-muscle surface electromyography (sEMG), assessing medial/lateral hamstrings, gluteals, and trunk erector spinae and int/ext obliques(later analyzed as a group) during maximal acceleration to full speed sprinting. Time frame of 1.5 seasons was evaluated and athletes would self-report. Follow up of the hamstrings, gluteals, and trunk muscle activity during airborne and stance phases of acceleration were evaluated and statistically explored for possible causal association with self-reported injury occurrence and absence from sport during follow up. Results: Players that did not experience a self-reported injury to the hamstring, showed an increase in gluteal muscle activity during (early) front swing phase and higher trunk muscle activity during backswing of sprinting. The risk of hamstring injury lowered by 20% from A 10% increase in gluteal activity during front swing and decreased by 6% with a 10% increase in trunk muscle activation during backswing. AUTHOR’S Conclusion: Higher amounts of gluteal and trunk activity were shown during airborne phases during sprinting which was associated with lowering the risk of hamstring injuries. This provides a basis for improvement on rehabilitation and prevention focusing on the increasing neuromuscular control of the glut and trunk muscles during sport specific activities ( sprinting drill, and agility drills). Peak Perspective: Looking at the anatomy and physiology of the hip, the hamstrings ( bicep femoris, semimembranosus, semitendinosus), gluteus maximus, and the adductor magnus are all muscles that produce hip extension or decelerate hip flexion. Hip extension force occurs with deceleration of late swing knee extension and hip flexion, early stance phase as a hip extensor to produce forward propelling momentum, and in early backswing as hip extension and knee flexion occur. While not actually defined by Schuermans et al, back swing is the moment from toe off until the leg reaches maximum extension behind the body. Front swing is the moment when the leg begins to swing forward and ends just before heel strike. One would expect the greatest demand on hamstrings to be late swing and early stance phase. This study showed that those who eventually reported hamstring strains showed sprint function tendencies for lesser gluteal and trunk activation during NWB swing phases (back swing and early front swing). This may warrant modifying current rehab practices if these findings were to be confirmed with further research. Until then it is likely premature. Examining pre-injury functional patterns for potential risk factors is valuable. The limited size of this study and number of injuries reported along with the fact injuries were self-reported, and especially that the mechanism was not specified as sprinting related necessarily all contribute to uncertainty whether this really does rise to the level of evidence driving a change in physician treatment expectations of physical therapists and athletic trainers for hamstring injury care. For example, what if the strain was related to a misstep or slide tackle contact or unexpected perturbation during a “50-50 ball”? It would become a bigger leap of faith that sprinting sEMG findings were reflective of greater risk during that injury mechanism. One issue is no reporting as to when the athlete's injury occurred, what was the mechanism of injury, (whether during running or contact with another player), the severity of the injury, and what made them more susceptible to injury. With this information being withheld was can not correlate what areas to concentrate on whether more linear patterns or the unexpected which would be best for prevention or quicker return to play status. As a measure of nerve activation, sEMG, in this study, resulted in findings opposite of what we would have expected, showing that the hamstring was most responsive in the backswing and early swing phases. Even if that were accepted to be true - studies have not been done to demonstrate which exercises are best employed to activate the gluteals and proximal trunk/core during swing phase, preferentially to other muscles, for prevention and return to play training. Then a “causal” relationship would need to be shown between whatever specific activation drills might be done, the effective improvement of gluteal and core activation in sprinting, and a reduction in hamstring strains. The authors seem a bit quick here to accept correlational level findings as likely causal in their conclusion and recommendations. Regardless, the findings suggest physicians and therapists might consider more open chain exercises for stimulating gluteal and trunk/core activation for swing phase (rather than a main focus on WB hamstring work), in order to improve the timing activation of these muscles/groups in running like positions/movements for swing phase. This is an area we need to give further consideration to and develop exercise strategies for. Since these findings, however, remain too early to be prescriptive for “best practices” of hamstring strain recovery, the biomechanically relevant considerations of understanding when the hamstring is under maximal tension (nearing and at heel strike) and when the greatest contractile demands and lever arm loads are occurring can and should remain a key principle to rehab and to treatment expectations from physicians. At Peak Performance we find that using a “hamstring strain” protocol or exercise series consistent across all patients is not effective. Strains may be more medial or lateral. They may involve more proximal fibers vs more mid-belly or even distal muscle-tendon junction. Customizing each exercise to the deficits and symptoms of the patient and to the demands of what activity/sports they want to resume are critical. All three planes of motion must be tested and considered to thoroughly retrain an injured hamstring. Transitioning into specific speed-power exercises is necessary for rapid acceleration and deceleration muscle performance and helps prepare for sport specific drills and eventual return to sports. Since this study found sprinting based swing phase muscle activation to account for some risk factor, open chain loading and neuromuscular type exercises would also be appropriate. The VibePlate, a vibration platform designed to stimulate the neural system, is one tool we use oftentimes during hamstring strain recovery. A popular exercise is the Nordic Hamstring curl. While a very demanding exercise and having some limited evidence basis, aside from being very challenging and therefore stimulating, it functionally trains the hamstring’s ability to decelerate a thigh extending over a fixed lower leg. That is not typically consistent with athletic function nor definitively with injury mechanisms. Functional loading with multidirectional lunges incorporating an anterior reach with weights trains the hip extensors’ ability to effectively decelerate as would occur in planting and changing direction or using implements reaching for a ball (lacrosse, tennis, field hockey, hockey..etc). Tubing resisted terminal swing phase directly trains the hamstrings as an eccentric decelerator of knee extension + hip flexion in prep for heel strike. RDL’s and tubing based horizontal pulling based stepping drills train early stance phase hip extensor ability. All of these are also customized to include multiple planes in consideration of multilateral sport movement demands or also based specifically on injury mechanism. The case below demonstrates a patient where many of these principles were utiilzed, despite not specifically incorporating the backswing and early swing phase gluteal/core activation referenced in Schuermans' study, and this patient did extremely well - the objective tests show gluteal, hamstring and core have all improved to >100% of the uninjured side. Peak Experience: “ I feel a lot better. There’s more flexibility in my leg and I didn’t notice it at all with soccer tryouts!” “ I was able to do half field sprints, all drills and have been able to do short runs now.” HX: 15 yo female soccer player injured 5 months prior, reporting pain in the ischial tuberosity and right hamstring due to increased running mileage of 3 miles a day/ 5 days a week. Subjective: Pt reports intermittent 3/10 pain in R hamstring and ischial tuberosity after increasing mileage in preparation for the upcoming soccer season. Symptoms are increased by seated hamstring stretch , cartwheels, walking up a hill, squatting, ascending stairs, and any duration of running. Patient self reports being at 70% overall function and Lower Extremity Functional Scale 88% function Objective: Patient showed decreased overall hip mobility, ankle mobility, calf tightness, and decreased hamstring strength on contralateral limb. Hamstring range of motion significantly decreased on R. See below re Eval and Re-Eval findings. *pain Initial Evaluation (L/R ) ReEvaluation 8+ wks (L/R) Self Rating 70% overall function 90% Overall function LEFS Scale 88% 90% Pain scale max 3/10 max 3/10 - only deep squat Supine 90/90 HS length 12deg/23deg 8deg/7deg DF ROM knee extend’d 0deg/10deg 11deg/13deg Prone Single Leg FA plank NT L WB 4 sec / R WB 7 sec SL Squat - - - -> hop Squat: R* > L dyn valgus SL hop: Dyn valgus = HS isometric 9.0 kg/11.0 kg 10.7 kg/11.0 kg 6” Step up test 10# DB’s NT 30x/30x Treatment: Exercise - Mobility, strengthening, power, function… Kinetic chain stretching of hip, hamstring (HS), STJ, and calf including mulitplanar. PRE’s including NWB, WB, Impact/speed based drills, and agility - utilizing multiple angles and a proximal- - >distal and distal- - >proximal directed movement loading approaches. (Included: SL bridges, 6” step ups (gluts focus), tube resisted stepback to pull thru hip extensions in 3 paths, SLB with UE reaching for medial and lateral HS stimulus) Core work including: Incline single arm side plank with Ant-Post LE stepping, prone incline plank w LE knee hip cross to opposite hip, SLB on the Vibe Plate w weighted UE running arms for additional strength, and running progressions. Agility progressed to SL hopping in multiple directions, and incline demand during treadmill. 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