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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 (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 November 2021 Finding Alternative Therapies for Arthritic Patients: Effective Natural Anti-infammatory Option RCT by Mike Napierala, PT, SCS, CSCS, FAFS CURRENT EVIDENCE Deutsch L. Evaluation of the Effect of Neptune Krill Oil on Chronic Inflammation and Arthritic Symptoms. J of Amer College of Nutrition. 26(1). 2007. 39-48. (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) What would you do? Clinical Scenario..... A 65 yr old female c/o 7 yrs of L knee pain w/o obvious trauma, worsening over the past 6 mo with mild swelling, crepitus, and sometimes painful giving way during her favorite activity of doubles pickle ball and also descending stairs. She has used OTC NSAID's regularly over the past 2-3 yrs with limited success. She does have a h/o GI disorders and varying adverse reactions to attempted doubling of OTC ibuprofen or naproxen. She presently uses Tylenol for pain control. Plain radiographs show moderately advanced medial compartment knee degenerative changes. Clinical exam shows asymmetric mild varus deformity L knee and AROM reduced to 7-125deg (R 2-135deg). Single squat is limited/painful with audible crepitation. Patient's goal is avoiding surgery and continuing with fitness and pickle ball with her friends. She inquires if there are any dietary or supplement changes that could help. I would... Start with prescription NSAID's course, allow her to continue playing and reassess in 4 wks. Start with prescription NSAID's course but advise to DC playing for 3-4 wks and then reassess. Encourage anti-inflammatory diet and trial with supplement options such as krill oil or turmeric before considering NSAID's, plus order Physical Therapy. Begin viscosupplementation injection therapy. Order an MRI to R/O symptomatic degenerative meniscal tear. SUMMARY: Deutsch examined the use of a proprietary blend of krill oil (Neptune Krill OilTM ) vs a placebo in an RCT comparing 44 and 43 patients, the majority of whom had osteoarthritis or rheumatoid arthritis (40 of 44 Group A and 38 of 43 Group B placebo). The 30 day trial showed significant reductions in CRP within 7 days and continued decreases over the 30 days compared to the placebo group. “Rescue” acetaminophen use was reduced significantly by the krill oil group and WOMAC scores were more significantly improved for the NKOTM group. Many patients with arthritic symptoms looking for immediate symptom control either prefer non-pharmacologic options, have had GI issues in the past already from prolonged NSAID use, or have comorbidities making them at risk for adverse events with continued NSAID use. This study provides both inflammatory marker and functional WOMAC scale evidence for the (+) impacts related to NKOTM supplementation. While NSAID prescription and OTC use recommendations are commonplace in medicine/orthopedics this provides encouraging alternatives for consideration by physicians looking for effective alternatives to help reduce symptoms and improve function short term, at least, for arthritis sufferers wanting reduced GI and cardiac risks. The case study presents a patient who was preparing for TKA who, through manual therapy and functional exercise, was able to improve adequately to resume goal activities and delay/avoid surgery. Background: C-reactive protein (CRP) has been a strong predictor of future cardiovascular events per the Framingham risk score and it’s production in arthritic joints reflective of proinflammatory cytokines essential to cartilage degradation. A strong association has been shown between CRP and clinical severity of patients with knee or hip OA. Dietary intake of Omega-3 vs Omega-6 fatty acids is critical to inflammatory processes. Neptune Krill Oil is extracted from zooplankton in the Antarctic Ocean and has high EPA and DHA fatty acids and potent antioxidants, especially astaxanthin. Numerous studies have demonstrated the anti-inflammatory properties of these compounds. With increasing evidence of adverse events related to NSAID’s use, the otherwise gold standard for chronic inflammation care, safe alternatives need to be found. Methods: Prospective double blinded RCT with 90 patients from PCP offices in Ontario, Canada randomly assigned to Group A (300mg qd morning NKOTM) or Group B (neutral placebo). NKO contained 17% EPA, 10% DHA and Omega-3:6 ratio of 15 to 1. Fasted blood testing done at baseline (after 1 wk washout) and then at 7, 14, and 30 days. Patients kept a diary of any “rescue” acetaminophen use to maximum of 1-2 capsules q8hr. Forty four patients completed Group A and 43 patients Group B care. Mean age was 54.6 and 55.3 yrs respectively with 55.6% males in Group A and 48.9% in Group B. To avoid acute inflammation cases CRP measured weekly - those > 1mg/dl (no fluctuations > 0.5mg) blindly randomized for treatment and testing. WOMAC completed for those with arthritic disease along with Likert 5-point scale (0 best and 4 worst) for outcome. Findings: No differences between groups at baseline for concomitant medications, CRP levels or three WOMAC scores (pain, stiffness, functional impairment). Patients in Group A taking NKO reduce rescue med’s by 31.6% by 30 days vs Group B placebo only 5.6% reduction (p=0.012). After 7 days of treatment Group A reduced CRP by 19.3% vs 15.7% increase in Group B(p=0.049). CRP further reduced by 29.7% and 30.9% in Group A by 14 and 30 days respectively while Group B increased by 32.1% by 14 days and then reduced by 25.1% at 30days. NKOTM group WOMAC pain scores significantly reduced more than Group A at all three visits as did stiffness and functional impairment. Author's Conclusion: NKOTM at 300mg daily may inhibit inflammation with 7—14 days by reducing CRP and significantly alleviate symptoms caused by OA and RA. THE PEAK PERFORMANCE PERSPECTIVE Arthritis is one of the most common musculoskeletal diagnoses seen in physician’s offices. The routine care of these patients includes consideration of pharmacologics that can be used to quickly control symptoms to improve quality of life. The CDC reports in 2013-2015 22.7% of US adults had some form of arthritis (OA, RA, gout, lupus , fibromyalgia) with 44% reporting some related activity limitation. By 2025 it is projected that 67 million US adults will have an arthritis related diagnosis. In 2013 arthritis attributable wage losses were $164 billion in the US. (https://www.cdc.gov/arthritis/data_statistics/arthritis-related-stats.htm) Physicians are faced with the challenge oftentimes of patients with risk factors for GI adverse events ( > 65 yrs , h/o peptic ulcer, concomitant aspirin or anticoagulant use, alcohol or tobacco use, and others) as well as risks for cardiovascular, renal, or other reported side effects concerns. NSAID users have been shown to have 4-5x relative risk of peptic ulcer vs nonusers (Sostres et al, Arthritis Res Ther 2013)(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3890944/). A 2016 article in British Journal of General Practice cited NSAID’s were responsible for 30% of hospital admissions for adverse drug reactions. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4809680/) These facts along with increasing interest by patients for non-pharmacologic alternatives and/or supportive nutritional supplements that reduce inflammation, makes these findings by Deutsch very pertinent in musculoskeletal care. While as a standalone study it would be inappropriate to fully alter clinical practices regarding NSAID use these findings do add to the body of evidence that options do exist for those needing or wanting to avoid/minimize NSAID use for various reasons. In this study the Neptune Krill Oil (NKOTM) use allowed Group A participants to reduce “rescue” acetaminophen use by 30% from baseline vs only 6% in the placebo group over the 30 days. CRP levels were significantly reduced within 7 days and throughout the 30day testing period and also vs the placebo group mean CRP levels. WOMAC scores for pain were significantly reduced vs placebo Group B scores, as were the change scores for stiffness and functional limitation as well. These positive indicators all clearly support consideration of NKOTM for arthritic symptoms. Although no adverse events were reported in the short 30 day treatment/testing period further research into safety and dosing is certainly necessary. Also, these findings cannot be generalized to all krill oil supplements and require additional testing to determine what minimal and optimal levels of EHA and DPA, anti-oxidant, and/or omega-3 to omega-6 ratios are necessary for therapeutic benefits. As Physical Therapists we are able to give generic nutritional advice but cannot prescribe or recommend specific dietary or supplement intakes to patients. However, many patients also are disinterested or unwilling to formally see a registered dietician or clinical nutritionist for guidance. Nevertheless, patients do often inquire about any diet based or nutritional supplements they might take for anti-inflammatory purposes. The access to information on the internet obviously leaves the public with an endless resource of material ranging from completely unfounded conjecture all the way to excellent expert opinion to peer reviewed studies. For those lacking formal background and training to discern fact from fiction there remains a need for guidance. Physicians remain in an excellent position to share these supplement options with their patients. Conservative care remains the first and most necessary step in the treating of osteoarthritis. Physical Therapy is a most often effective means of both providing an intervention/treatment but also equipping the patient with proper self-help techniques and exercises to reduce symptoms and increase function. While traditional and simple regimens often have significant benefit we find for many patients that more substantial improvements or additional gains after “failed PT” occur when more in-depth biomechanical assessment and exercise/manual therapy approaches are employed. Due to the “regional interdependence” concept of the kinetic chain the appreciation for the impact limitations at adjacent and even distant body segments can have on a symptomatic arthritic joint cannot be overstated. The “failed PT” patients with OA that we see typically were given generic programs doing a rote series of common lower extremity stretches for large muscle group (hamstrings, quads, ITB etc) along with WB/NWB strengthening that is not customized to their ROM and/or symptom issues. There is commonly a lack of attention to less visible planes of motion (transverse plane) such as restoring hip IR for a hip or knee OA case developing progressive varus alignment, or with utilizing unique paths of movement to optimize loading through healthier portions of the articular surfaces (ie. promoting slight dyn valgus for medial knee OA to optimize lateral knee articular cartilage load dispersion). The case below illustrates a patient with knee OA who was able to avoid an anticipated TKA due to the extent of symptom relief and functional improvements he attained through Physical Therapy. THE PEAK PERFORMANCE EXPERIENCE Bud said: "My arthritic left knee was limiting my activities. Now I can mow my yard and walk my dog, and do the stairs better! I'm no longer thinking about a knee replacement." HX: 67 yr old male with 20+ yr h/o knee sx, underwent TKA 2013 R knee and presently c/o worsening L knee sx past 3-4 yrs. Plain films (+) for significant DJD. Pt indicated TKA being considered. Subjective: L knee 6/10 max sx w 75% self-report function. CC with walking dog on uneven surfaces/hills, walking 4-5mi, stairs, standing > 5min. WOMAC 40%. Key Findings: MEASURE ( *=pain) Evaluation Final ReEval @ 3mo AROM L knee ext (deg.) 50 20 AROM L knee flexion (deg.) 1230 1430 PROM hip IR L/R (deg.) 18/60 28 / 120 AROM STJ eversion (deg.) 4 / 80 NT Single leg balance L/R 5 / >15sec 15*/20 (75%) FWB knee ext (deg) 1680* /1830 1720 L knee(no sx) Squat L/R (deg) 400* / 580 65 / 580 WB DF (deg) 24 / 210 NT WB hip ext (deg) 80 flex / 00 10.1/9.6 (105%) Quad isometric 19.2 kg(83%) 30.6kg (94%) WB Ant Stepdown Quads 6” 15# NT >36x / 25x (>100%) Treatment: Pt began with BIW treatments focusing on manual therapy to improve L knee flexion and extension along with (B) hip IR and extension, as well as DF and eversion. Stretching/PROM HEP instructed to compliment mobilization work utilizing long duration 20-30sec sets. Neuromuscular re-integration movements were also used to optimize transfer into ADL use. Once simple single plane movements were successful then stretches were advanced toward multiplanar techniques to improve adaptability to patient’s frequent navigation of uneven surfaces in his large yard/property. Painfree strengthening especially for quads to enhance squat function were done using subtle path deviations to determine and optimize sx-free status throughout for stepdowns, stepups and “hangback” pole squats, attempting to increase loading preferentially to the lateral compartment to avoid medial joint overloading and symptoms. This was done using combinations of proximal and distal pre-positioning along with weight shifting to customize for patient response. Rotational balance work to promote use and control of femoral IR (unloading varus knee tendency) was done. Hip extension and combined ankle DF work of eccentric hip flexors and plantarflexors to normalize gait also included. Outcome: Pt reported sx overall reduced to max of L 3/10 and R 2/10 occurring ~ TIW frequency with walking his lawnmower through rough ground, carrying 40# for distances, sitting > 1 hr. He indicated stairs and getting off floor were much easier. WOMAC reduced to 18% and self-report function 90%. 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

Prior to coming to Peak Performance and working with Allison, I had trouble going up and down stairs, getting up from a chair and walking more than 10 yards without hip pain. I can now walk much better, get up and out of a chair 25 times without holding onto the chair! I have improved my balance with the addition of the exercise program that I have been doing here at Peak. I am looking forward to starting the golf season. I have greatly enjoyed my time here and look ahead to continue the process to better mobility with Allison and Peak Performance as my coach! Alan Tucker