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Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE (September, 2023) New RCT data on Patellofemoral Pain Best Practices: When Knee Rehab Is So Much More Than Just the Knee by Allison Pulvino, PT, MSPT, CMP, FAFS Clinical Scenario…What would you do? A 45 year old female runner comes in for evaluation of anterior and medial knee pain that began 3 months ago as she gradually ramped up her running mileage in preparation for a half marathon in two months. She’d been running 5k races prior to that and training a total of 12-15 mi/wk over 4 days. She has tenderness along the medial patellar border, no effusion, does have mild PF crepitus, (-) McMurrays meniscal maneuvers, and non-tender at her joint lines and quad/patellar tendons. Squat depth is painful/limited, noting mild early ipsilateral heel rise. She also demonstrates mild asymmetry of dynamic valgus/rotation during squatting, submax anterior mini lunge, and vertical/anterior hopping. Plain films show very mild lateral tracking symmetrically with Merchant views. I would… Give her our group’s PFP Home Exercises sheet to do and FU in 1 month. Advise her to “wait and see” for 4 wks and do cross-training because the symptoms may resolve and allow a return to running by then. Prescribe rest and NSAID’s x 3 wks and gradual return to running, FU 4-6 wks. Prescribe physical therapy including biomechanical screening and any appropriate hip & knee exercises, orthotics consideration, and manual therapy as indicated - FU 6 wks. Order an MRI to R/O chondral lesions or degenerative meniscus involvement. FU in 3-4 wks once test results back and determine POC. CURRENT EVIDENCE Neal BS et al. “Six Treatments Have Positive Effects at 3 Months for People With Patellofemoral Pain: A Systematic Review With Meta-Analysis”. Journal of Orthopedic & Sports Physical Therapy. 52 (11). Nov 2022, 750-768. (We’d love to hear your professional insights on this topic. Let me know your thoughts after reading this summary at PT@PeakPTRochester.com or if you have a patient case you'd like to discuss) Summary: Patellofemoral pain (PFP) is a common cause of knee pain seen by physicians, affecting both active and sedentary lifestyle people across all age spectrums. Although PFP is agreed in most cases to be at least initially a non-operative condition, determining the most effective treatments based on high quality research has left physicians and therapists alike with limited guidance. This systematic review and meta-analysis demonstrate that effective treatments for PFP do exist and that a “wait and see” approach should therefore not be used. This meta-analysis of 65 RCT’s includes treatments commonly included in traditional ortho/sports PFP care. Unfortunately most studies examine short term outcomes and there is a lack of long term follow up data to prove more lasting efficacy. The authors looked for studies showing pain and/or function measure changes, using a multilevel evaluating system for “proof of efficacy”. Primary proof of efficacy in the short term was shown for both Knee-targeted exercises as well as combined interventions over wait and see for pain and function, for foot orthotics on GROC score, and lower extremity manual therapy over wait and see for function. Secondary proof for short term efficacy was shown for Hip & Knee targeted ex vs knee targeted exercise for pain and function, knee exercise + perineural dextrose injection vs knee exercise for pain and function. Superiority was shown for Combined Interventions vs Knee exercise at short term follow up for pain and function. Hip targeted vs knee exercise was equivalent for pain and function. Foot orthoses vs hip exercise also showed equivalence having neither show a (+) GROC score. Adding foot orthoses to combined interventions showed no added benefit. Adding dry needling to hip & knee exercise added no benefit for pain or function. Vibration therapy did not show added benefit vs hip & knee exercise alone. There was no indication of efficacy for hyaluronic acid injection added to hip & knee exercise or sham injections. Foot orthoses showed no efficacy over sham orthotics in medium and long term follow ups. Lower extremity manual therapy showed no efficacy compared to wait and see over the short term for pain. Dry needling showed no efficacy over sham needling for pain or function short term. Many other treatments were considered inadequately tested. These interventions are all based on a short-term follow-up and are very global in their descriptions. When considering “best practices” a shortcoming to remember for such studies and reviews is that application of given treatments based on the condition/diagnosis alone is not how real world physical therapy functions…or should function. Physicians should expect that therapists are performing very thorough examinations that lead to customizing treatments based on specific individualized findings both for local tissue needs as well as importantly for kinetic chain factors likely contributing to the symptoms (i.e. foot orthotics only when substantial foot dysfunction noted and considered relevant vs applying foot orthotics to all PFPS patients…same for taping or hip exercises etc.). This study concludes that more research is necessary to look into long-term follow-up prognoses, as well as more individualized treatment parameters in the exercise specialty should be investigated. Systematic reviews like this one do provide some helpful information toward clinical decision making but their usefulness is limited by too many studies with low strength of evidence, the multifactorial nature of PFP, and a lack of enough studies applying treatments only for tested limitations rather than to an entire group (that may not need that treatment). Background: Patellofemoral pain (PFP) affects 29% of active adolescents, and 23% of both active and sedentary adults, and there is no general consensus on how PFP is best managed. Nonsurgical treatment has been determined to be best for this diagnosis, but it remains unclear which nonsurgical treatments have the highest efficacy. Methods: A Meta-analysis of 65 randomized control trials was performed to include 3796 participants for median symptom duration of 43 months. The trials investigated exercise therapies, electrotherapies, manual therapies, foot orthoses, dry needling/acupuncture, injection therapies, taping techniques, combined interventions (hip-and-knee-targeted exercise therapy, vastus medialis oblique biofeedback, soft tissue stretching, patellar taping), blood flow restriction training, and psychological therapies. Findings: Knee-targeted exercise therapy vs wait-and-see control confirmed high-certainty evidence of large effect that knee-targeted exercises are most effective for pain relief and moderate certainty of a large effect improving function at short-term follow-up over wait and see approach. Combined interventions for pain and function, foot orthotics for global rate of change (GROC), and lower extremity manual therapy for function all showed primary efficacy. Combined therapies confirmed higher efficacy together included hip-and-knee targeted exercises combined with perineural dextrose injection have secondary efficacy. Combined interventions produced superior outcomes compared to just knee-targeted exercises. Author’s Conclusion: Wait-and-see care should not be an option due to many interventions proving there are benefits in pain control and improved function, at least within short-term follow-up testing. These include knee exercises, combined interventions, manual therapy, foot orthoses, hip and knee exercises and knee exercise combined with perineural dextrose injection. THE PEAK PERFORMANCE PERSPECTIVE Patellofemoral pain is one of the most common knee related reasons people seek out a healthcare professional, commonly their primary care or orthopedic specialist. Patients sometimes fear they may even need surgery based on the level of pain they’re having that they believe cannot simply be due to stiffness or weakness. Studies unfortunately show that 50% of PFP patients report pain still 5 years after treatment. Physicians prescribing treatment for PFP often look toward not only RCT level evidence but the “totality” of current thinking via systematic reviews and meta-analyses to help shape decision making. Neal, et al in this study astutely reminds that PFP is multifaceted and variable in its etiology. Therefore, conservative care cannot approach PFP with a one-size-fits-all protocol or philosophy. The large number of different types of interventions studied over decades to potentially help PFP supports the concept that we should not take a “protocol” type approach because clearly no singular cause exists that can be treated with a simple uniform treatment approach. This review clearly demonstrated that RCT’s do show knee exercise, combined interventions (hip & knee exercise plus taping, biofeedback, soft tissue work etc.), and lower extremity manual therapy all to be more effective than “wait and see” approaches. Foot orthotics were effective short term over sham orthotics. A key takeaway here is that various treatments do exist that should be considered/prescribed in lieu of having patients simply rest and/or wait. Patients often don’t understand that despite their pain levels and frequency it may not require invasive interventions. This study helps validate the efficacy of especially exercise based interventions so that physicians can confidently begin the education process at their office visit prior to referring to PT. Patients are encouraged knowing that their condition need not be permanent. Expectations and compliance can be influenced positively when physicians inform them prior to PT that it often just takes the correct exercises and treatments to get back to normal function without pain. Clinically speaking, we find education on any biomechanical reasoning behind their particular pain helps patients feel optimistic and have understanding regarding how the physical therapy care will address these underlying causes and reduce the chance for recurrence. And it may also help them understand why the exercises given by a friend or family member or generic routines found on the internet weren’t helping relieve their symptoms, and even sometimes making it worse. Neal, et al include six treatments that have a positive effect on PFP. They go on to say that PFP requires treatment based on expert clinical reasoning from the provider and the exact interventions that should be included need to be based on how each individual presents. The SR/MA found knee targeted and hip & knee targeted exercises to be effective, along with lower extremity manual therapy and foot orthotics A challenge patients and clinicians face with foot orthotics for example, is that despite any positive or immediate changes induced,, the strength and neuromuscular control must still be optimized through exercise vs just the passive support alone. Similarly, although, as in this study perineural dextrose injections were found helpful, when medications or an injection brings immediate symptom relief it can lead to mutually dismissing the need to address the underlying flexibility, strength, neuromuscular, or other mechanics related factors. Prefacing and education regarding the necessity of thorough care is critical. An in-depth biomechanically minded evaluation is a key first step. In patients we see due to “failed care” too often cursory testing with a few traditional ROM or strength measures were taken and then canned protocols applied. That thorough evaluation of each patient’s individual contributing factors allows a customized plan to be developed. While a “PFP homework” sheet does check the box of “keeping things simple” for patients and providers, it fails to take into account those multifactorial aspects of PFP noted by these and many other researchers. One key shortcoming of many meta-analyses and systematic reviews is that while high quality studies (e.g. by research design standards, such as a RCT) may have been used they do not necessarily take into account the clinical relevance of the study design. Too often a specific treatment modality (i.e. stretching the ITB or strengthening the vastus medialis, or using foot orthotics) is applied to an entire group of patients who actually have a wide variety of underlying contributing factors. This waters down potential efficacy as otherwise potentially “good treatments” get applied to patients not needing that specific intervention. Physicians should expect that PFP patients receive an in-depth evaluation that informs customized exercises, manual therapy, and other interventions. Giving everyone orthotics if they slightly pronate or giving all patients isolated isotonic quad or hip strengthening should be test based decisions, rather than a standardized treatment approach or protocol. That testing must include authentic function demands and observation. For example, NWB DF may be “WNL” at 15° but then be grossly abnormal in WB at 30° vs 20° in a squat type test. A foot may show an asymmetric forefoot varus but in WB, despite some mild overpronation, actually show good control allowing some pronation for force attenuation and then the ability to re-supinate - thus no orthotic being necessary. Another patient may have a similar small to moderate FF varus and shows poor control in WB or even worse may have asymmetric anteversion contributing to significant asymmetric overpronation - making orthotics an appropriate consideration. Functional tests such as an anterior step down, various types of lunges, or hopping all can help identify real-life mechanics issues present during their primary activity concerns that affecting a patient’s PFP. In the case of dynamic valgus/rotation (knee abd + femoral IR) we may find WNL NWB strength tests of the hip abductors and ER’s but then find WB testing asymmetries that lead us to intentional exercise for that patient. Other common impairments that can warrant a different approach to treating PFP is a leg length discrepancy that may need to be corrected due to compensatory overpronation leading to abnormal tibiofemoral mechanics and patellar forces. Another example is psoas and rectus femoris adaptive shortening from years of sitting at a desk. The traditional quad exercises (open-chain), especially full range Quad bench extension, often tend to be the worst options for localized pressure to the undersurface of the patella in PFP cases. Even simple nuances like specifically testing TKE vs 90-60° ranges can help identify the best NWB arc to train the quads through to avoid pain and minimize crepitus and stress over damaged articular surfaces. Likewise customizing depths and loads for WB training is often even more critical because stairs, for example, are commonly a primary source of pain with PFP cases. When indicated, changing the femoral and tibial (and hence the patellar) alignment when pre-positioning a lower extremity can change the load to be more medial or lateral during WB strengthening drills , thus reducing symptoms and optimizing the training effect. Oftentimes PFP patients are “overpronators” where the 3D AFS (Applied Functional Science) approach really makes a difference - a dominant sagittal plane hinge joint such as the knee is placed into a position in the frontal and/or transverse plane(s) to externally rotate the femur and/or supinate the foot, creating more comfort with closed chain lunges or flexed knee loading. These examples illustrate just some of the clinically noted potential PFP related factors that after addressing them individually we’ve found the majority of patients having positive outcomes. These specific findings can be tested and re-tested to establish before and after-care functional performance measures - this both helps to validate our evaluation based treatment hypotheses and the efficacy of the various exercises and other treatments chosen. THE PEAK PERFORMANCE EXPERIENCE Mallory said: “I ran the whole 5K on Saturday and felt fine!” History: Mallory is a 14 y/o female presenting to PT with a chronic hx of B knee pain surrounding the patella when running. She previously ran track and Cross Country through the pain and only came into PT for medial foot pain from L post tib tendinitis which had her donning a boot it was so painful to walk or run on. Objective: Initial Exam Re-evaluation Knee extension WNL WNL Knee flexion WNL WNL SL squat test valgus each LE Fair hip ER control each LE SLB midfoot pronation each LE neutral foot w/ orthotics SL forward hop unable good control hip/knee/foot Anterior step down unable/pain foot/knee 4” step down w 5# DBs SL calf raise unable/B LEs only 20x with 10# DB in L hand Key Findings: Lack of hip ER, midfoot pronation collapse in any WB, lack of toe flex/ext strength, unable to fully WB L with poor control R LE SLB/squat, pain ant/med B knees and medial L foot in WB flexion loading, weak glute med B Treatment: Class IV therapeutic laser treatment to medial L foot 6 treatments, tubing inversion and PF isotonic exercises, intrinsic toe flexion exercises, standing lunges with hip ER/supination biased pre-positioned stance, glute med isolation exercise in SLB with contralateral loading drills, TR plane pivot drills in SLB to re-supinate and ER femur with tubing and progressed to dumbbell rotations. Agility: Lateral shuffle cued to grip/load medial foot, running drill in FR plane bias with wider leaps/hops, dynamic fwd/bkwd shuffle with green loop tube above knees for femoral ER control, multi-plane SL up with femoral ER assistance with cross arm reaches. Outcome: Pain-free running in both ankles and knees; Full return to P.E. classes and Cross Country meets! You can trust the Physical Therapists at PEAK PERFORMANCE to do a thorough evaluation, to search for related but underlying contributing factors to kinetic chain dysfunction, and to design exercise progressions that both respect tissue healing and creatively use biomechanics principles to prevent symptoms and optimize carryover to your patients' functional goals. Call us at 218-0240 to discuss your patient's specific needs. Peak Performance is just minutes away from your patients in Penfield, Fairport, Pittsford, Brighton, Rochester and, of course, East Rochester. We promise Individualized, hands-on and biomechanically appropriate Physical Therapy for your patients. No "one-size-fits-all" approaches. We WILL go the extra mile and "dig deeper" to discover underlying causes for injury risk and delayed recovery using the most advanced Evidence Based methods available and, we’re able to make unique adjustments to exercise prescriptions to speed the return to function and to minimize or prevent symptoms from interfering. No surprises. No hassles. Confident your patient is in the right place. COME VISIT US AT 161 E Commercial St Just 1 mile off 490 exit (585) 218-0240 www.PeakPTRochester.com

Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE September 2021 Patellar Tendinopathy: Eccentrics May Not Be The Way to Go! by Karen Napierala MS, AT, PT, CAFS CURRENT EVIDENCE “Effectiveness of progressive tendon-loading exercise therapy in patients with patellar tendinopathy: a randomized clinical trial. Breda SJ, et al. Br J Sports Med 2021; 55:501–509. “ (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: Eccentric exercise has been the key form of exercise prescribed by physicians/surgeons and used by therapists and trainers during rehab for tendinopathy conditions. Breda et al in BJSM present important data that contradicts this reliance and focus on eccentrics. Instead their study demonstrated that a HEP based program of progressive loading/strengthening outperformed an eccentric based program in a RCT of patellar tendinopathy patients, 82% of which had failed prior care, in self report pain/function/sport questionnaire after 24 weeks and also showed a trend toward higher return to sport (43% vs 27%) . Despite concerns about generally low compliance with this HEP based treatment of independent exercise progression (40-49% compliance) and low overall return to sport rates after 6 months the study does still demonstrate that eccentric focused rehab approaches are not superior to progressive loading based approaches. The low compliance also suggests more formal care from a therapist is warranted since reliance on patients following a HEP progression without regular follow ups produced mediocre outcomes, however, this group was a mostly “failed care” group to begin with. Our experiences and successes with tendinopathy also suggest that kinetic chain biomechanics must be well understood and evaluated/addressed, that in-depth appreciation of subtle exercise adjustments for proper loading combined with control of symptoms, and the use of other treatment modalities such as Class IV laser all play an important role in effectively treating patellar tendinopathy. Meticulous appreciation for and attention to optimal ranges for training the extensor mechanism, for optimizing Quad recruitment while avoiding sx typical of traditional rehab exercises, and limiting recruitment of compensatory muscle groups during attempted strengthening are all key factors we see in failed PT/conservative care cases referred for advanced rehab. Background: Studies note that 45% of elite jumping athletes and up to 58% of those with physically demanding work/sports activities at some time experience patellar tendinopathy. The term tendinopathy has replaced the commonly referred “tendinitis” based on numerous studies showing histopathologic tissue changes and only minimal inflammatory cells in these cases. Anti inflammatories alone are thought to be not recommended. Research has demonstrated the effectiveness of eccentric overload to enhance tendon strength and recovery, however, is pain-provoking and especially a concern for in-season athletes. This study compared progressive tendon loading exercises (PTLE) with the eccentric exercise therapy (EET) over 24 wks on clinical outcome measures. Methods: Seventy-six patients (18-35 years old) who participated in sports at least 3/wk with diagnosed patellar tendinopathy based on local tenderness, structural changes on Doppler, and <80 score on the Victorian Institute of Sports Assessment for Patellar Tendons (VISA-P) were randomly assigned into the EET or the PTLE group for 24 weeks of an independent exercise program. Median symptom length prior to the study was 2 years. 82% had failed prior PT. The EET group was instructed to perform pain provoking single leg decline squat (eccentric only) on a 24 0slant board with body weight at 2/day x 12 weeks with a maximum pain level of 5/10 (VAS, visual analog scale). They progressed to loaded single leg squat and then to sports specific exercises over the next 12 weeks as able. The PTLE group started with isometric leg press at 60 0 or a body weight wall squat with 70% max voluntary contraction 45 seconds x 5 reps. They moved to isometrics plus isotonic leg press 4 x 6 reps the following day. Their maximum pain allowed was 3/10 on the VAS scale. Step ups or lunges were added on the isotonic day when able. They progressed to day three jumping, split squat jumps, box jumps with the isometric and isotonic exercise on day one and two, respectively. Finally, sports specific activities such as running, cutting, and their actual sports were slowly resumed. They maintained a < 3/10 pain level using the VAS and progressed as tolerated through this sequence over 24 weeks. Both groups were also assessed for open chain hamstring, gastrocnemius and quadriceps flexibility. They noted their WB squat dorsiflexion soleus length and had isometric hip abductors and quad strength measured. The program and the targeted flexibility / strength exercises were given to each of the participants via a pamphlet. Videos were included and the participants met at baseline, 12 weeks and 24 weeks for retesting. All exercise groups performed their programs independently of each other and of tester feedback. Findings: The primary outcome was the VISA-P questionnaire (100 point maximum as no pain, maximal function and unrestricted return to play). It was self -administered at baseline, 12 and 24 weeks. Secondary outcomes were the return to sports rate, exercise adherence (% of sessions registered) , and patient satisfaction. VISA-P score improved significantly from 56 to 84 at 24 wks in PTLE. And from 57 to 75 in the EET group. After 24 weeks 87% in the PTLE group (32 patients) and 77% in the EET group (23 patients) achieved the 13 point MCID or better. In the PTLE group 21% returned to the desired sports at preinjury level after 12 weeks and 43% after 24 weeks. In the EET group, only 7% after 12 weeks and 27% after 24 weeks returned to pre-injury levels. Percent of patients with an excellent satisfaction rating was 38% in PTLE and10% in EET. After 24 weeks and 23 patients in the EET group achieved the MCID (Visa score increased 13 points minimally. In the PTLE group, 21% (n=7) returned to the desired sports at preinjury level after 12 weeks and 43% (n=16) after 24 weeks. In the EET group, 7% (n=2) returned to the desired sports at preinjury level after 12 weeks and 27% (n=8) after 24 weeks. The VAS for pain related to tendon-specific exercises at 24 weeks was significantly lower in the PTLE group than in the EET group with an estimated mean of 2 vs 4 (adjusted mean between- group difference: 2 (95% CI 1 to 3); p=0.0 Author's Conclusion: In the largest clinical trial in patients with patellar tendinopathy (PT) to date, progressive tendon-loading exercises (PTLE) resulted in a clinically relevant benefit compared with pain-provoking eccentric exercise therapy (EET) after 24 weeks follow-up. THE PEAK PERFORMANCE PERSPECTIVE The use of eccentric based strengthening exercises for tendinopathy has for some time now been accepted “best practices” in prescribing conservative care for these cases. Numerous prior studies had shown the efficacy of eccentrics,which usually includes an intentional pain-provoking aspect, especially with achilles tendinopathy. The challenge does remain, however, that most athletes who develop tendinopathy symptoms do so gradually and with a period of ‘working through symptoms” that eventually did not result in resolution but likely, in part, contributed to their “overuse” stresses. It can be difficult for providers and patients alike to have certainty over those levels of intentionally produced symptoms that are actually therapeutic. This study reminds us how common failed tendinopathy cases can be. Failed cases present a unique task for referring physicians who are charged with determining possibly why prior PT failed or what more thorough or advanced conservative care may be called for since surgical procedures here are the very last resort and rarely necessary. The participant’s limited/poor compliance and the low return to play rates do suggest that “keeping it simple” with easy-to-do home program recommendations is inadequate. ... The question must always be asked “What exactly was the actual cause of their tendinopathy?” While referring physicians generally are and should be less concerned with this question it is incumbent on therapists and athletic trainers to be not only concerned about this but equipped to test and assess in ways that give athletes confidence the right changes have been induced that will prevent recurrence upon return. Athletes often are confused that the entire team is jumping or cutting, yet only they or a few ever developed tendon symptoms. Very frequently both lower extremities are experiencing essentially the same bilateral or reciprocating stresses with a sport, making identification of the “overuse” more challenging and oftentimes uncertain or illogical, since the opposite knee tolerated the very same “overuse” without trouble. In other cases there are clear asymmetric loading patterns that occur such as in soccer kicking (plant leg and kick leg each) or basketball (layups) or high/long jumping. In all cases it is critical to discern any biomechanical factors such as leg length discrepancy that produce asymmetric loading. Other issues such as asymmetric anteversion, overpronation, loss of ankle dorsiflexion, hip extensor weakness all are examples of commonly seen contributing factors consistent with potential overloading of the patellar tendon/extensor mechanism. Oftentimes “protocol” driven mindsets or “one-size fits all” approaches may address gradual tissue loading and training but never end up in having addressed what may be the real underlying mechanism - leaving patients “treated” but never really rehabilitated. This study by Breda et al had 82% of the cases happened to be failed prior PT situations. This itself is cause for concern regarding traditional PT approaches. . The direct correlation according to this author is not known. Whether internal biomechanics, or external overload, the tendon needs to be restored to its full strength to handle the loads of the activity. Breda et al’s randomised controlled clinical trial showed the PTLE approach provided superior clinical outcomes compared with EET after 24 weeks follow-up. Additionally PTLE showed a trend towards a higher return to sports rate compared with EET (43% vs 27%) and that the exercises were significantly less painful to perform (VAS 2/10 vs 4/10). While this study itself is not enough to completely disregard all the prior evidence supporting eccentrics it does present some compelling evidence that even with an unsupervised independent home routine approach that progressive loading approaches do not require “eccentric only/emphasized” design to reduce symptoms and improve function. Since only 27 - 43% of the patients in either group returned to sport over the 6 month period, the overall perspective should not be that the treatment approach used was a success. Based on our experience with similar cases we would suggest that the treatment approach itself was inadequate, the limited compliance contributed to mediocre outcomes, and/or the protocol did not address predisposing factors adequately - although they did attempt to address this with the additional testing and exercises provided. We find regularly that alternative rehab methods that include triplanar strengthening, using emphasized eccentrics at a lower pain scale, and progressive loading similar to Breda et al’s approach and also Class IV laser use are important aspects of effective tendinopathy care. The lack of regular professional supervision in this study left patients in a decision making position regarding technique, general program advancement, and load progression that is normally done by or in conjunction with the rehab professional. Training was designed to be 3/week for PTLE and 2 / week for EET, but the groups left to their own showed a low rate of compliance with 7-8 of the people not completing the testing, and all participants averaging .9 mean sessions of training over the 24 weeks. All exercises were performed without the benefit of skilled and knowledgeable feedback. The exercise program especially for the PTLE group was quite specific and extensive. Clinically, to foster progressions of this nature to be not only within the pain scale limitations and also to be mechanically correct with no substitutions, professional guidance is necessary. A HEP only approach risks a patient choosing to progress too quickly out of impatience and yet for others too slowly out of fear. A limited number of secondary contributing factors were assessed, but more extensive biomechanical examination was lacking. Thus while several stretches and non-functional strengthening exercises were included, they were not given based on individual test findings for need, and were very limited in scope. Another shortcoming was the singular resistance band for exercise loading. It would not likely provide either customized loading for each participant nor proper loading over a span of 24 weeks to be considered proper training stimulus. The participants were pre and post tested on their flexibility and vertical jump height. From baseline to 24 weeks there was literally no change in strength or jumping ability. There was some significant pain with single leg squat test where PTLE went from pain of 4.8/10 to 1.5 after 24 weeks, and EET group reduced from 4.9/10 pain to 2.7. THE PEAK PERFORMANCE EXPERIENCE: John said: “ I am back to skating in practice with no pain the next day. I'm looking forward to really playing hard in games soon!” History: John was a hockey player who had R > L patellar tendinopathy. He had pain for > 6 months that limited play until he finally had to discontinue athletics. Symptoms limited walking, sitting, and stairs. Objective: See below. Objective: (*=pain) Initial Eval Re-Eval STJn WB Dorsiflexion 13 R/ 15 L 17 R / 20 L Single leg squat R 10 * / L 22 * R 55 / L 70 Step ups 8" Unable * 15 # low reach R/25 L 32 3" quad dom step down( eccentric ) Unable * 10 # front racked R/ 22 L / 35 B squat proper form Pronates, heel rise R, lumbar flexion** 25# front racked 16 reps Lateral lunge Unable * 15# low reach R 17 L 21 Single leg bal rotation hands on hips 15 sec Unable R 5 L 7 Forefoot varus R 10deg L 7deg Corrected with superfeet and wedge posting 4-6 deg forefoot 2-3 degrees rearfoot Key Findings: Limited ankle dorsiflexion combined with forefoot varus producing compensatory overpronation and tibial IR producing abnormal loading at knee/patellar tendons with squatting activity. Treatment: John began stretching soleus in STJ neutral for late stance gait mechanics authenticity along w functional strengthening combination using opposite foot anterior foot reaches. Gradually he was able to begin squats at 50 % BW and progress to single leg quad dominant step downs. He also obtained SuperFeet OTC orthotics which were posted in the clinic accordingly to produce improved function on WB testing. Eccentric slow lowering was incorporated here with 2-3/10 max pain during this phase. By dominating the hip and transverse plane to accomplish strengthening he was able to overload his muscles, and also load his patellar tendon in two planes for added strength while avoiding tendon pain. While the tendon is primarily a sagittal plane worker, by loading in transverse and frontal planes, the strengthening could be progressed faster - with increasing tensile loading capacity while remaining still pain-free. At the same time, the hip ER’s were facilitated using tubing in the transverse plane upright. Hip flexion was increased during the ER for more authentic skating stimulus. He then began speed training to stimulate fast twitch fibers and start impact loading needed for running in gym class and life. After 6 weeks: He was able to begin skating 15 minutes at a time painfree. Outcome: He continues to improve his strength and stability. He uses the posted OTC Superfeet in his shoes and skates. He is now practicing 30-45 minutes at near maximum and is ready to progress to game status. 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