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Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE (December 2023) Clinical Decision Making with PFPS: RCT Evidence for Utility of High-Intensity Laser Therapy by William Slapar, PT, DPT, OCS, FAFS, CMTPT, CAFS Clinical Scenario...What would you do? A 20 yr old competitive female college soccer player with L PFPS for 6 weeks duration has not improved significantly after working with her athletic trainers comes for evaluation and treatment recommendations. She has mild symmetric lateral tracking with plain film Merchant view. There is peripatellar tenderness along medial > lateral border, without inferior pole tenderness. Squatting is limited/painful with slightly asymmetric dynamic valgus/rotation noted. Single hopping is moderately reduced and painful. WB ankle DF is asymmetrically reduced ipsilaterally and prone rotation PROM (IR >> ER) suggests asymm larger L anteversion. The patient has 5 wks remaining before soccer season begins and prefers to avoid repeating traditional rehab (typical simple LE stretches, step ups, leg press, clamshell and abd-add machine hip work, TKE quad bench strengthening) due to the lack of prior efficacy. My clinical thinking is: Obtain an MRI since the patient is not improving and little time left before the season. FU 2 wks for treatment plan. Provide with PF stabilization brace, order continued rehab work with ATC’s but doing more advanced exercise progressions for returning to soccer, allowing < 3/10 sx max Order custom orthotics and Physical Therapy to include nwb hip Abd and ER PRE. Prescribe customized biomechanical PT including specific functional exercise per evaluation findings, Class IV laser photobiomodulation therapy, trial w/elastic therapeutic taping, and joint mobilization for ankle DF. CURRENT EVIDENCE Qayyum HA, Arsalan SA, Tanveer F, Ahmad A, Javaria, Gilani SA. Role of High Power Laser Therapy on Pain Reduction in Patients with Patellofemoral Pain Syndrome. Pakistan Journal of Medical and Health Sciences. 2022;16(6):9-12. doi:https://doi.org/10.53350/pjmhs221669 *** We are modifying the Newsletter format to better match our physicians’ time constraints. The previously more in-depth “Peak Perspective” will now be contained below in more “summary” form. We invite you to reach out to us at PT@peakptrochester.com or call our office at 585-218-0240 to further discuss this article in further detail if you wish. The abstract can be found after the case study. PEAK PERSPECTIVE & SUMMARY: PCP’s and orthopedists often evaluate patients presenting with anterior knee pain that is suspicious for Patellofemoral Pain Syndrome (PFPS) and must determine the optimal treatment regimen to prescribe. Over the past years Class IV therapeutic laser has become more popularized as a treatment option for musculoskeletal conditions. Numerous journals are dedicated to investigating the efficacy of laser (Lasers in Medical Science, Lasers in Surgery and Medicine, Laser Therapy…etc.). Class IV laser becomes a key consideration for physicians considering current evidence and best practices for PFPS cases. Qayyum 2022 et al. performed a randomized control trial (RCT) to determine the effects of High Intensity Laser Therapy (HILT) on pain reduction in patients with PFPS. They compared HILT + “standard” therapy exercises to a control group using the same physical therapy exercises alone over 4 weeks. They found a significant VAS reduction in both groups but by the 4th week there was a statistically significant greater reduction in VAS pain scores in the experimental group compared to the control group. This was maintained through the 8 weeks of the study. While often mistakenly overgeneralized or referred to as chondromalacia, PFPS remains a very common diagnosis in orthopedics and sports medicine. Common treatments including various stretching and strengthening have been proposed. It is now understood to be a multifactorial condition and thus less appropriate for “protocol” based approaches but more so deserving of customized care dependent on the contributing factors discovered on testing. High-Intensity Laser Therapy (HILT) is an important option shown to produce analgesic, anti-inflammatory, and tissue healing effects for musculoskeletal disorders (MSD). This works through a process deemed photobiomodulation. This is where photons are absorbed by proteins in the mitochondria, which then increase ATP production, reactive oxygen species, and nitric oxide to help with tissue healing, cell energy, and improving inflammatory effects. Newer models of Class IV laser therapy, specifically using 25W and even more recently 40W power have greater capacity for more immediate analgesic effects. Especially for those who may have exhausted safe NSAIDs use or who have comorbidities precluding medications assistance with pain/inflammation reduction, this study adds to the body of evidence showing Class IV laser can be not only an effective component to PFPS rehab but, importantly, it can produce superior pain reduction more quickly. It must be noted this study used only a 10W HILT laser while now more powerful Class IV lasers utilizing up to 25W are used in the clinic and have the capacity for deeper penetration and quicker, more significant analgesic effects. The “routine” physical therapy that included standardized LE stretches, patella mobilizations along with strengthening of quads (DB squats and wall squats, SLR), hamstring strengthening (not specified), hip abduction and adduction (not specified) - all done 4 days/wk at 5-10 repetitions for strengthening exercises, is grossly inadequate and as common with many studies was not “high level” therapy, also due in nature to failing to customize exercises to evaluation findings. This is critical because it means some patients were doing stretches that were unnecessary while other important limitations (e.g. hamstrings or soleus) were not addressed. The protocol used also focused solely on sagittal and frontal plane work but appears to have neglected transverse/rotational planes of function. Biomechanical based approaches must include consideration of foot-ankle mechanics influences, proximal hip influences, and even contralateral limb issues that can produce abnormal forces on an involved PFPS knee via kinetic chain effects. We often find that manual therapy techniques are necessary in PFPS cases, whether that be soft tissue mobilization (STM) or joint mobilization work (e.g. ankle DF). The study would be stronger had the authors included objective measures of performance (such as rotational balance ability and control, squat depth, hop function, or quadriceps anterior stepdown strength), to provide better objective proof of improved outcomes. Patient centered outcome scales of performance also were not measured. Scales such as a LEFS or KOOS or IKDC would show evidence of actual performance improvement vs. simply symptom reduction without verifying a return to higher level activity demands. An easily missed finding in Qayyum et al study is that it took four weeks of laser therapy to produce the significantly better VAS reductions. Oftentimes patients can be easily discouraged by slow outcomes with conditions such as PFPS, especially when an impending goal timelines or demand is nearing. This serves as a reminder to PTs and physicians to educate patients that laser efficacy may require weeks of consistent treatment to produce superior outcomes rather than using only a few sessions or two weeks as a litmus test of sorts. Finally, the overall exercise portion in this study was lacking. It is important to consider that PFPS can include contributions from multiple joints via kinetic chain biomechanics. With there being multiple factors involved and needing change to occur to produce symptom relief and improved performance there may be a need for time to pass until the pain/cause of the abnormal mechanics is reduced. Having the necessary patience is not easy for many patients. The case below illustrates a patient who benefited from incorporating Class IV Laser into his program with a diagnosis of PFPS to recover from chronic anterior knee pain to strength training with less symptoms. The patient is still in physical therapy for further treatment. THE PEAK PERFORMANCE EXPERIENCE Brian said: “The right knee is so much better after performing laser, squatting is more manageable and I can perform reciprocating steps down stairs.” History: 36 y/o male with chronic right anterior knee pain with L knee most recent MCL sprain from picking up tennis and twisting right with left leg being planted. Pt had right anterior knee pain for years in which has tried PT before but with not too much of a difference and stairs and squatting motions tend to be more painful and unable to reciprocate descending stairs. Subjective: 6/10 pain with jumping, running, squatting, stair negotiation, getting in and out of a chair Objective: (*=pain) Initial Eval (R/L) After laser demo (RLE) 1 mo ReEval AROM knee flexion 120*/130* (deg) 134 deg 140 B step downs ( 2 inch) quad dom. x8*( DKV moderate)/x15* 10* ( no DKV) 4/10*→2/10* 8# 4 inch x10, x14 SL squat ( knee flexion) 55 */ 85* (deg) squat: 95 deg (4/10*) to 100 deg (2/10*) 100*/ 105 (deg) Ant lunge R= ant knee pain with reduced DF no pain and knees over toes WB StJn DF (knee flexed) 23/25 (deg) 26/ 30 (deg) Step up: 8# R= 4 inch L=6 inch x20*/ x20 R=3/10*→2/10* 15# R=4 inch x22 L=6 inch x18 Prone hip IR 20 deg B 28/25 deg Key Findings: At evaluation pt had pain in the bilateral knees with the right being a chronic case and the other being an MCL sprain from a recent tennis injury. Pt showed having more reduction in strength and function on the right side compared to the left, which could have made the right side compensate more for the right LEs faults. Pt shows reduction in hip internal rotation. Treatment: Pt treatment started with Class IV laser, with manual to address hypomobilities in the ankle, soft tissue mobilization to address TrPs in the quadriceps. Stretching for hip Irs and then addressing movement quality with hip rotation exercises in standing to address sport specific motions. Pt worked on strengthening the hip extensors to improve loading for tennis specific motions. Pt also performed quadriceps strengthening, step downs with post OH reach for quad angulation, which shows a moderate dynamic knee valgus. Outcome: The patient after a laser demo was able to perform more squat motion and stair negotiation ability as well with less pain. The step down also improved in mechanics of no longer having dynamic knee valgus (DKV). Pt is now able to split squat and reach near the floor with 2/10 pain, with increasing loads and depths on functional and sport specific movements to help rehab him to sport. Pt still shows deficits in hip and quadriceps strength comparison and depth which is still coming to PT but there are vast improvements in just one month with having a chronic status of a diagnosis. ABSTRACT Background: PFPS is a very common MSD in which affects 23% of the general population and high prevalence in elite athletes. There are very many biomechanical factors that can be causing pain at the knee, whether it be weakness, reduction in ROM or abnormal structure of a specific joint in the LE kinetic chain. HILT has shown positive impacts in reducing pain in other MSD. HILT shows having effects on inflammation, tissue healing, and pain reduction. Purpose: To determine if HILT will reduce knee pain in with patients with PFPS Methods: Sixty-six subjects from 2 groups, control group of routine physical therapy (PT), and the experimental group of HILT and routine PT. Pain was interpreted using the VAS scale Findings: The data shows that there was a within group significant difference for each assessment of pain for routine PT and routine PT + HILT. At week 4 and 8 between groups shows a significant difference in the mean showing HILT + PT shows superior results in reduction in pain. Author's Conclusion: There is a reduction in pain when using HILT for patients with PFPS. You can trust the Physical Therapists at PEAK PERFORMANCE to do a thorough evaluation, to search for related but underlying contributing factors to kinetic chain dysfunction, and to design exercise progressions that both respect tissue healing and creatively use biomechanics principles to prevent symptoms and optimize carryover to your patients' functional goals. Call us at 218-0240 to discuss your patient's specific needs. Peak Performance is just minutes away from your patients in Penfield, Fairport, Pittsford, Brighton, Rochester and, of course, East Rochester. We promise Individualized, hands-on and biomechanically appropriate Physical Therapy for your patients. No "one-size-fits-all" approaches. We WILL go the extra mile and "dig deeper" to discover underlying causes for injury risk and delayed recovery using the most advanced Evidence Based methods available and, we’re able to make unique adjustments to exercise prescriptions to speed the return to function and to minimize or prevent symptoms from interfering. No surprises. No hassles. Confident your patient is in the right place. COME VISIT US AT 161 E Commercial St Just 1 mile off 490 exit (585) 218-0240 www.PeakPTRochester.com