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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 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

When I first came to Peak Performance, I could barely walk. It hurt to stand and do any activities. I missed almost all of my school soccer season. After coming to see Karen, we started addressing the pain I was experiencing. After a few weeks of strengthening exercises, I started to feel less and less pain, and continued to get stronger. Now I can walk, run, and stand for as long as I need to. I’m regaining my strength and I’m back to soccer! Kathryn “Kate” Schell