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I came to Peak with a knee issue that had caused me to lose of lot of functionality and sidelined me from basketball. Mike and Rachele got me on the right track to return to play, and to regain confidence in my knee and ability to stay healthy! Many thanks to both of them for getting me back on the court….and pushing me to perform! Thomas “Tommy” Eastman

I initially injured my knee a few years ago and never sought treatment. After starting to be more active and working out regularly, the pain was intense to the point normal walking was very uncomfortable and I could not work out like I wanted to. I finally sought out treatment and was fairly discouraged after my MRI that there was not a more specific diagnosis. I was referred to Peak Performance and was extremely skeptical that PT would help my situation. My mind was instantly changed after my first visit when Andrew was able to determine that my knee pain was related to my IT band. I finally saw light at the end of the tunnel after receiving his diagnosis! After working the program Andrew gave me, I am now able to perform normal daily activities virtually pain free, and am regularly working out 4 to 5 times a week. I have my occasional flare-up, but now feel I have the tools to know how to alleviate the pain. Thank you, Andrew! Sarah Rosenberg

My right knee was replaced in 2006. My left knee was replaced in 2012. My right knee could only be bent at 600 due to adhesions. After 6 or 7 years with not being able to fully bend, I started to have back pain along with a loss of tightness in my right hamstring. Working with Karen was great! She gave me stretching exercises for my back and hamstring. Within a month of working with her and doing the exercises, I have significantly increased my mobility both in normal circumstances and in playing golf! I know it’s a long process that I will continue to have to do. However, I already feel better, walk taller, and am generally pain free. I appreciate all of the instruction and positive reinforcement. Thanks to all at Peak Performance (especially Karen) for caring so much and making a difference! William “Bill” Radford

Getting old is hard! After Andrew great assisted with getting me back on my feet a few years ago following hip surgery, I returned for assistance with my knee. Arthritis and a removed meniscus caused pain that interfered with my normal activities lacrosse officiating. Cortisone shots didn’t help. Andrew’s spot-on assessment and program to strengthen the knee and loosen the hip did wonders to enable full movement and full confidence in myself! I also had the bonus of working with his intern, Margaret, who in the future will elevate to PT Rock Star status like Andrew! The Peak PT folks are knowledgeable, patient and hands-on to ensure the individual feels important and achieves mutually established goals. I have total confidence and admiration for the work Andrew and the rest of the Peak Performance team provide. Thanks for your help! Charles Lamb May 21, 2019

I am 71 and still run. For the last year, during races and training runs, especially long ones, I was having knee pain around mile 7. As the race progressed, I eventually had to drop back to walking. I ran through 2 halves and a full marathon with that. My chiropractor finally determined it was IT band issues and recommended Peak Performance. I started working with Andrew and Margaret at the beginning of March, doing stretches and strengthening exercises. They gradually increased the variety of both and finally added weights to the strength exercises. Andrew was especially helpful because he is also a runner and understood my issues. He examined my shoes and inserts and put inserts under both feet. My first race since seeing Andrew was in early April: a 10-mile race in Washington, D.C. I ran my strongest race in more than a year! I had no IT band issues and no knee pain. I cannot say enough about the support and knowledge that Andrew and Margaret gave me! I will be training for another marathon this fall and the exercises they designed for me are now an integral part of my training and workouts. ~ Kathleen Fuller May 8, 2019

I am 71 and still run. For the last year, during races and training runs, especially long ones, I was having knee pain around mile 7. As the race progressed, I eventually had to drop back to walking. I ran through 2 halves and a full marathon with that. My chiropractor finally determined it was IT band issues and recommended Peak Performance. I started working with Andrew and Margaret at the beginning of March, doing stretches and strengthening exercises. They gradually increased the variety of both and finally added weights to the strength exercises. Andrew was especially helpful because he is also a runner and understood my issues. He examined my shoes and inserts and put inserts under both feet. My first race since seeing Andrew was in early April: a 10-mile race in Washington, D.C. I ran my strongest race in more than a year! I had no IT band issues and no knee pain. I cannot say enough about the support and knowledge that Andrew and Margaret gave me! I will be training for another marathon this fall and the exercises they designed for me are now an integral part of my training and workouts. ~ Kathleen Fuller May 8, 2019

Before coming to Peak, any slight running, no matter the activity, would cause pain in my ankles, shins and knees. After just a few weeks of working with Andrew and company, I was able to do my favorite activities with little to no pain. Now I can do just about anything with no pain and all thanks to Andrew, Margaret and Jenna (his interns) for helping me to get to where I am. ~ William Rauber May 4, 2019

I tore my ACL and had surgery. My experience at Peak Performance was great! Andrew and everyone else that helped him out with my PT were very helpful. After a while I stopped doing my PT for a while, which was a big mistake. Andrew talked to me about it and it really encouraged me to get back to doing my PT and after that I was really good about it. Now I am feeling really good and am back to playing soccer again. I am doing well and my knee also feels good. I really want to thank Andrew and Peak Performance for helping me get back to playing soccer! Michael LoIacono April 28, 2019

Transformational. That best describes the competent and compassionate care and coaching I received at Peak Performance from Andrew, who is engaging and supportive. I arrived with knee pain and hoped to alleviate the pain, avoid surgery, and return to full function. Andrew not only accomplished all three goals, but also diagnosed the instability in my left ankle as secondary to a foot problem and implemented orthotics, which totally fixed the issue! Under Andrew’s care, my knee is comfortable and functional, my balance is vastly improved, and I am definitely stronger for all activities. Thanks, Andrew—and the entire staff—for improving my life and developing a strategy of exercise to maintain my knees, balance, and strength. I enthusiastically endorse the philosophy and techniques at Peak Performance! Christine Platt April 25, 2019

I was referred to your organization, after rotator cuff surgery, by a trainer at Penfield Fitness who knew of your work. I was assigned to Andrew and that turned out to be a really good choice. I’d had this surgery 10 years before, but I must not have coalesced adequately, resulting in a more severe problem. I had neither strength nor range of motion in that shoulder when I met him. Andrew advised me intelligently, humorously, cajoling me to what will be a near-complete recovery. I can now wash my hair with that arm, scratch my back and lift weights overhead that I was unable to lift! During that time I also experienced a knee problem, so we soon transitioned to the other end of my 77-year-old frame. Same outcome…Andrew gave me exercises that have led to pain-free and flexible walking without surgery. I admit, he’s a better therapist than I am a patient, but his encouragement makes following through with his program less of a task and more of a healthy routine. Andrew is results-oriented, clearly knows his “stuff,” and is a true professional. Thank you, man! ~ Arthur North

I had been to another physical therapy place, but it seemed to only improve my situation a little. A friend had recommended that I try Peak Performance. I had knee surgery for a torn meniscus in August, so I started PT with Karen in September. She was exactly what I needed! She was easy to talk to and very encouraging, but could also be tough when I sometimes complained about the exercises. She knew exactly what I needed to improve my range of motion, strengthen and straighten my knee and recover my ability to go up and down the stairs more easily. Karen not only address my knee, but looked at all my issues (well, the physical ones anyway J). She also helped with my right foot and made some other suggestions regarding my health. I am now walking straighter and with little to no pain in my knee. I am very grateful to Karen! She is kind, caring, and adds humor to her PT sessions! I appreciate her encouragement and belief in me. Thank, you, Karen, for your compassion, your expertise and especially your patience with me! I will miss you…but not our PT sessions! J Dianne C.

When I first came to Peak Performance I was a MESS. I had already been through a broken hip replacement and broken femur, due to two separate falls; now I was seeing Andrew after a knee replacement to correct a deformity. I felt like a MESS, not only physically but also emotionally/spiritually too. I credit Andrew with my vast improvement. He not only helped me to improve my physical movements and strength, but he helped me to gain confidence. It’s not easy to “just go for a walk,” perform everyday tasks, or enjoy physical activity, when you have been told never to fall again…and you do. Through all these injuries, I experienced many PT sessions. So when the doctor said, “one more operation (other knee),” I knew just who to see: Andrew. Sometimes, when I feel down because I still use a cane, I hear Andrew’s voice, “But Jackie, look how far you’ve come”; or, when I think I’m too tired to do those “darn exercises,” I hear, “You want to keep up the progress you’ve made, don’t you.” Andrew was not only my physical therapist, but I thought of him as my personal cheerleader, too. Now on those days when I still feel like a MESS, I think of Peak Performance and Andrew cheering me on, and I stand up a little taller, hold my head a little higher, put on a smile and…go for a walk. J Jackie P.

This was my second full knee replacement. I came to Peak Performance for my first replacement last year and returned because I could not imagine going anywhere else. Once again Andrew, along with Karen and Mark (their intern), did an awesome job helping me get through my recovery. I greatly appreciated the attention to detail in each exercise to ensure that I got the maximum benefit for the work involved. Their extensive knowledge, expertise and encouraging support was always evident in all they did and in my successful recovery. I can now go up and down stairs properly, I no longer need a cane to walk my dog, I can walk faster and longer than before, and I can do more daily tasks than I could for the past five years! My sincere thanks to Andrew and the staff at Peak Performance for all they did through my recovery. I will continue to highly recommend them to anyone in need of physical therapy. Bonnie Stiggins

Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE October 2018 Hop-Testing Asymmetry: Frontal & Transverse Plane CURRENT EVIDENCE Wren TA, Mueske NM, et al. Hop Distance Symmetry Does NOT indicate normal landing biomechanics in adolescent athletes with recent ACL reconstruction. JOSPT. 2018; 48(8): 622-629. by Mike Napierala, PT, SCS, CSCS, FAFS NOTE: This is a Part II following last month’s review by Karen Napierala, PT, ATC, MS, CAFS in which she focused mainly on the sagittal plane findings, which are the majority and main focus of Wren et al’s study. You can review Karen’s update HERE. Background: This study’s purpose was to compare operative limb single-leg hop biomechanics following ACLR to both the contralateral non-operative limb and a normal knee control group. They wanted to determine whether the gold standard of 90% hop distance symmetry should be used for return-to-sport readiness following ACLR surgeries in adolescents, and if it is associated with normalized biomechanics. Method: Forty-six 12-to-18-year-old patients along with 38 age-matched contralateral controls participated. ACLR patients were at a mean of 7.2 months post-op. Single Anterior Hop test (best of three) along with 3-D motion-analysis data were recorded at initial contact and between initial foot contact and maximum weight-bearing limb knee flexion on landing. Thirty-eight controls of the same age, who participated in 3/week sporting activities, with no injury history, were tested to provide normative data. Patients were grouped for data analysis based on limb symmetry index (LSI) as symmetric (> 90%) or asymmetric (< 90%). The control group was pared down to 24 of the 38 based on those exhibiting 90% LSI(72% of group), since relative symmetry is considered a target for normal function. Results: Here I’ll focus on the frontal/transverse plane findings. The authors reported that both symmetric and asymmetric patients had lower average external knee adduction moments, reaching statistical significance for both limbs for symmetric patients and the operative limb of asymmetric patients. Additionally, the authors later indicated that “only minor differences were noted in the frontal/transverse plane” regarding symmetric patients. No comments were made regarding the asymmetric patients group. In the Discussion they do caution that the Vicon plug-in gait model has been shown to have high intersubject variance.” I’ll expand below on some of the findings Wren et al failed to emphasize. Maximum hip adduction angle was 4.10 for controls, 5.20 for symmetric/operative limb and 4.90 for asymmetric/operative side while only 1.90 and 1.40 for non-operative symmetric and asymmetric sides respectively – not apparently reaching statistical significance. Minimum knee adduction angle was 1.50 for controls, but 0.40 and 0.20 respectively for symmetric non-op and operative limbs while asymmetric limbs were -0.60 and -0.90 respectively for non-op and operative limbs – again, apparently not reaching statistical significance. Average external knee adduction moment was lower for symmetric and asymmetric patients and was significantly less vs controls (0.098 units) for symmetric patients both non-operative (0.071) and operative side (0.056), and for asymmetric operative limbs (0.06). Conclusion: Symmetric patients achieved symmetry by, in part, hopping shorter on the non-operative opposite leg. Both symmetric and asymmetric patients off loaded their operative side. Hop distance symmetry may not be an adequate indicator of single leg function or return to sport readiness. The authors neglected to address frontal plane findings in their conclusion statement. I would add that there were small but statistically significant differences with a trending toward knee abd moments for both knees of symmetric patients and the operative limb of asymmetric patients, with both limbs of the operative limb trending toward knee abd angles. THE PEAK PERFORMANCE PERSPECTIVE Karen covered many pertinent concepts regarding this article’s overall kinetic chain implications in terms of compensatory tendencies noted, the inadequacy of post-operative limb symmetry index scoring as a valid comparison to normal pre-injury function (due to subsequent decline of non-operative limb performance also), and the sagittal plane dominant perspectives regarding hip, knee, and ankle loading. We advocate for return to play (RTP) functional testing that demands authentic activity stressors rather than focusing solely on the more easily measured and observed exclusive sagittal plane traditional power indicators, which too often happen to the mutual exclusion of the quality and quantity measures of frontal and transverse plane dynamic stability. Cutting, change of direction, unexpected twisting/bending, either based on sport reactions or contact from another player, all require control of frontal and transverse plane forces. The ability to powerfully hop in just one direction is valuable but very limited. For example, two functional hop tests we utilize are a frontal plane single leg timed side-side hop and also a timed rotational (450 up to 1200 depending on pt status and goal activity ). Both provide useful insights into more authentic demands on the ACLR knee (and a host of other LE injuries as well). In turn, the rehabilitation progression of proprioception, dynamic stability, strength and power training, and agility all reflect that understanding. Too often patients, especially athletes, exercise in sagittal plane restricted motions despite their ultimate goal activity containing substantial amounts of frontal and transverse plane deceleration/acceleration requirements. Exercises aimed at training muscle groups like the hip ER’s and abd’s or Tib Posterior or gluteals/hamstrings must be consistent enough with typical use for the body to quickly apply this newfound ability directly into functional tasks. An example would be the common “clamshell” exercise…generally designed to stimulate the hip abductors/ER’s. Regardless of the loading used, which typically is body weight alone or ankle/cuff wts, the disconnect for the body we’d propose has more to do with proprioceptive inconsistencies – the fact that those muscles never see substantial loading for NWB actions but rather are loaded in ADL and athletics by superincumbent body weight via gravity and inertial loading. The “leap of faith” if you will, that must occur for a clamshell trained hip to then perform with excellence in a hop landing or a cutting move are seemingly massive. The post-operative ACLR hop tests most commonly referenced in the literature are a 3x Anterior Hop, a 3x Anterior Crossover Hop, and a 6m Timed Anterior Hop. While these tests remain sagittal plane dominant they do at minimum require multiple acceleration-deceleration efforts. An advantage of the Crossover hop is the hybrid demand of decelerating forward momentum with simultaneous frontal plane stresses into both genu varum (knee adduction) or genu valgum (knee abduction). Dynamic valgus has been identified in numerous studies over the past decade or more as a key risk factor for ACL injury. Knees collapsing into valgus during landing events have greater risk of subsequent ACL injury. Knee abduction is a natural kinetic chain extension of the lower extremity landing mechanics that begin with foot pronation. Subtalar joint pronation, via talus adduction contributes to kinetic chain proximal tibial IR, knee abduction, femoral IR, hip adduction/flexion. This is one means of producing dynamic valgus. Landing with the foot ER’d can also cause the proximal knee segment to drive medially into valgus/abduction as well. Proximally driven “top-down” mechanics ot a trunk/pelvis segment turning away from the landing limb may also produce dynamic valgus. Wren et al did attempt to examine frontal plane knee biomechanics but they oddly chose to measure “knee adduction” angles and external moments, directly in contrast to the other lower extremity measures taken, which, as noted above, are collectively consistent with the pattern of dynamic valgus that is a known ACL risk indicator. Their data does indicate (-) knee adduction angle values for asymmetric patients both non-operative and operative knees….ie, knee abduction. Both knees of symmetric ACLR patients and the operative side of asymmetric ACLR patients also had statistically significant reductions of knee adduction moment, or in other terms – trending toward knee abduction moments. It remains to be seen why Wren et al’s study did not demonstrate the same dynamic valgus in either controls or ACLR patients that have been noted in other studies. They do indicate that the gait model they used tends to result in high intersubject variance of frontal plane variables. Based on the known dynamic valgus concerns for landing/hopping mechanics it appears Wren et al missed an important opportunity to gather accurate valuable data to help us better understand differences in this kinematic variable for symmetric and asymmetric hoppers. Finally, the Wren et al group use control group data for comparison. We must remember that this group may or may not reflect our ideal physically. It is unknown which people in the control group are actually an at risk group based on other factors – such as dynamic valgus landing mechanics or strength profiles or balance function. Wren et al also chose to define “control” only as the 62% who were within 10% between L-R for Anterior Hop Test performance. It is worth noting that over 1/3 of all “normals” in fact had > 10% asymmetry in hop testing, and that was evenly split between their pre-defined “dominant” and “nondominant” side being superior. The case study below demonstrates some of the hop testing utilized at Peak Performance for a patient who underwent ACLR. THE PEAK PERFORMANCE EXPERIENCE Becca stated: “My ACL and meniscus tears had me sitting out all the activities I love--mountain biking, swing dancing, and hiking--now I am ready to start racing and performing again with full confidence.” History: 25 yr old female swing dancer and mountain biker had non-contact twisting mechanism to (L) knee while kicking a ball at recreational league soccer practice. MRI was (+) for torn ACL and MM tear. Underwent ACLR + PMM and began outpatient PT three days later. Subjective: Pt reported 2/10 pain max at post-op PT evaluation. Was using Toradol and Percocet post op. IKDC was 30%. Pt employed as engineer. Goals were returning to competitive mountain biking and swing dance. Objective: TEST Eval 4 mo Re-eval DC @ 7mo Knee ROM PROM: Ext 10hyper, flex 570 AROM: 0-1360 1-1400 Quad 600 isometric NT 37.7kg (78%) 49.8 kg (88%) Hams 200 isometric NT 24.6kg (95%) 27.0kg (116%) SLB rotational “no touch” test 20sec NT 14x (88%) 20x (120%) (excellent decel Dyn Valg/Pron) Quads Ant Stepdown NT 5.25” 12lb wts 64% 5.25” 20lb wts 89% 3x Ant Hop NT Submax 1x Ant = Fair 103% Side-side 10sec hops NT NT 100% 900 Rotational Hops NT NT 80% Outcome: At DC re-eval Pt reported max 1/10 sx only after hours of mountain biking or heavy wt lifting. She self-reported 99% function and IKDC was 89%. She also resumed swing dancing but felt she was not quite fully WNL yet with all dance moves. Treatment: Exercise: After early post-op care phase once pt FWB she was advanced through functional exercise approach with primarily WB based strengthening focusing on quadriceps, hamstrings/gluteals, plantarflexors and as healing time passed increasingly including especially supinators and hip abductors and ERs . Proprioception/Dynamic Stability: Early simple single-leg balancing (SLB) progressed with visual challenges (dominant and both eye closed) along with plane-based challenges using both upper and contralateral lower limbs to promote deceleration toward right rotation and knee abduction stresses (dynamic valgus). Vibration platform was utilized for increased neuromuscular stimulus. Impact based demands were later included. Manual therapy: Ankle joint mobilization to restore dorsiflexion. Functional Training: Impact progression drills beginning with stabilization landings and explosive push offs into (B) landings were initiated. Over time she progressed into multidirectional leaping and single leg hopping drills along with agility stepping/change of direction work to prepare for her swing dance demands. 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. Mike Napierala, PT, SCS, CSCS, FAFS 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

I came to Allison after tearing my ACL for the second time. I was unable to do anything. After 10 months, I was able to return to playing sports (football and basketball) with complete confidence. I have had PT before on the first knee and Peak Performance was different than any other place! I feel great and better than I ever have. Thank you for allowing me to get back to football. Thank you, Allison! Timothy"Tim" Reilich November 13, 2018

I came to see Karen at Peak Performance due to swelling and pain in my knee after standing at a concert. Karen helped to strengthen my quad/knee so the swelling was gone in just two visits! However, I wanted to be able to do a really good “child pose” so now we have been working on not only strengthening, but also flexibility in my quad. Thank you for challenging me and keeping me healthy and in good shape. You rock! Michelle C. October 28, 2018

I came to Peak Performance after having a meniscus repair surgery. After 8 weeks in a knee immobilizer, my leg muscles had significant atrophy. I had confidence issues since my meniscus tear occurred within 3 months of a prior meniscus removal surgery. Mike patiently coached me to build my muscles and confidence back. I was able to build strength to walk properly, do steps and start hiking again. After a lot of hard work and guidance from Mike, I am back to doing all my home activities and am enjoying hiking in the Adirondacks and other national parks. Thanks, Mike! Greg Hoffman October 16, 2018

I came to Peak Performance after having a meniscus repair surgery. After eight weeks in a knee immobilizer, my leg muscles had significant atrophy. I had confidence issues since my meniscus tear occurred within three months of a prior meniscus removal surgery. Mike patiently coached me to build my muscles and confidence back. I was able to build strength to walk properly, do steps and start hiking again. After a lot of hard work and guidance from Mike, I am back to doing all my home activities and am enjoying hiking in the Adirondacks and other national parks. Thanks, Mike! Greg Hofmann October 18, 2018

Prior to knee replacement surgery, the pain, swelling AND reduced range of motion changed my ability to perform my normal daily activities. I could no longer play golf, bike, climb a ladder, go shopping or even walk more than 2/10th of a mile. As time went on, it became increasingly difficult to climb stairs, stand up from a seated position, get in and out of a car, get off the floor or even put my shoes and socks on. Having had two prior surgeries with follow-up PT at another practice, I found myself discouraged and frustrated that general PT didn’t seem to help me improve. I felt like my questions were just dismissed and that the pre-established “cookie cutter” worksheets were falling short of reasonable expectations for me. Following knee replacement surgery, I have had such a different and wonderful physical therapy experience at Peak Performance. From Day 1 the program and exercises were designed around my individual needs and abilities. Karen and the entire staff treated me with dignity, compassion and professionalism. My questions were happily answered and I was an active participant in setting reasonable goals. Now that I’ve completed my PT, I am no longer in any pain, I have maximized my range of motion and improved my flexibility and strength. I have met and exceeded my goals and expectations. I have been able to resume playing golf, riding a bike, climbing ladders, shopping, and I am able to walk several miles! I no longer struggle with climbing stairs, getting in and out of a car or chair, getting up off the floor or putting my socks and shoes on. I couldn’t be happier with my progress! It’s also had a surprising positive impact on my overall outlook of staying much more active throughout my lifetime. I am incredibly satisfied with my experience with Karen and Peak Performance. There are two things that stand out to me that make Peak Performance FAR superior to other practices: 1. Having my program tailored to my individual situation and needs instead of adhering to a “cookie cutter” pre-established routine was hands down more efficient and maximized my improvement. The flexibility to detour and adapt as issues came up was a big factor in my recovery. 2. I have watched other practices give preferential treatment to athletes and young people, while treating aging folks and non-athletes as second rate or not as deserving of individualized attention. That is not the case at Peak Performance! I have watched the entire staff treat every person with dignity and respect regardless of athletic ability, gender, race, weight or age! It is something that in my experience, sets them apart from other practices. Thank you Karen and all at Peak Performance for getting me back on my feet! Beth Markell October 18, 2018

This spring I developed bursitis in my knee. My clavicle also started to protrude. My orthopedist specializes in knees so didn’t address the clavicle but sent me to PT. I chose Peak because my daughter benefited so much from coming here. Andrew and Karen helped me so much! Karen is the first person who looked at all my “parts” together and found two curves in my spine. She worked with me on all these issues which helped my knee, back and hips. I love to garden, hike and work out at the gym, and I’ve learned how to move better and stay safe and healthy. These guys are awesome professionals! Annette B. October 1, 2018

Before PT, I had difficulty bending my knee and putting weight on it. Now, after working with Karen my knee is much stronger, closer to right knee strength and my balance has improved. Susan M. September 20, 2018

My left knee was painful before surgery. After my operation I came to Peak Performance and was greeted with open arms by the staff and my PT, Doc Andrew! The program that Andrew created for me was great! It has strengthened my left knee as well as my right. I will always be grateful for the care and encouragement Andrew and the Peak Performance staff have given me. Thank you! James F. September 20, 2018

I was having trouble doing my breastroke kick, due to an injury I sustained while doing the breastroke. My coach called the injury “breastroker’s knee.” Before I came to Peak Performance, I couldn’t do 25 yards without my knee giving me a problem. After just a couple of weeks with Mike, I could do longer distances faster than I did before. I don’t know where I would be without Peak Performance. Daniel R. October 8, 2018

View this email in your browser Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE September 2018 Return-to-play hop testing: Are we being fooled? CURRENT EVIDENCE Wren TA, Mueske NM, et al. Hop Distance Symmetry Does NOT indicate normal landing biomechanics in adolescent athletes with recent ACL reconstruction. JOSPT. 2018; 48(8): 622-629. by Karen Napierala, PT, AT, MS, CAFS Background: The purpose of this study is to compare single-leg hop biomechanics following ACLR to both the contralateral non-operative limbs and a normal knee control group. They wanted to determine whether the gold standard of 90% hop distance symmetry should be used for return to sport readiness following ACLR surgeries in adolescents, and if it is associated with normalized biomechanics. Method: Forty-six 12-to-18-year-old patients along with 38 age-matched contralateral controls. ACLR at mean average following surgery of 7.2 months. Single Anterior Hop test (best of three) along with 3-D motion-analysis data were recorded in all three planes at initial contact and between initial foot contact and maximum knee flexion of the weight-bearing limb on landing. All subjects were tested before being cleared for full return to play. Thirty-eight controls of the same age, who participated in 3/week sporting activities, with no injury history, were tested to provide normative data. Patients were grouped for data analysis based on limb symmetry index (LSI) as symmetric (> 90%) or asymmetric (< 90%). Results: Thirty-eight percent of all patients tested were asymmetric hoppers, having similar contralateral non-operative hop distances to controls but significantly reduced hop on the reconstructed limb. The average LSI for asymmetric patients was 77%. The symmetric hop group, despite an LSI > 90%, only hopped an intermediate distance on both the operative and non-operative limbs. Asymmetric patients had lower operative side knee flexion moments and knee energy absorption compared with their contralateral side and with uninjured limbs. They also had lower peak hip and knee flexion angles on the operative side compared with their contralateral side and both sides of symmetric patients, greater plantar flexion at initial contact compared with contralateral side and controls. Peak dorsiflexion was less than both limbs of the symmetric hop group of patients. Symmetric patients had lower knee flexion moments (vs contralateral and controls) and lower knee energy absorption (vs contralateral). Symmetric patients had greater hip flexion angles and moments bilaterally (vs controls) and hip energy absorption. Both symmetric group limbs and operative limb of asymmetric patients showed lower average knee adduction moments (vs controls). The conclusion was that they used more ankle, and less knee on landing post operatively, and thus landed more stiffly after their surgeries. Take-off mechanics showed lower peak knee and hip flexion ROM on the operative side compared with the contralateral side. THE PEAK PERFORMANCE PERSPECTIVE ACLR is not uncommon in sports these days. At our clinic alone we have seen more than 200 such cases in the past 13 years. According to research, 7.7% of ACLR patients have revisions in the first 6 years, and 6% have contralateral ACL injuries (Hetrich et al AJSM 2013). The return to play (RTP) decision making factors following ACLR can include strength, endurance, proprioception/balance, dynamic stability, power. Objectively measuring these variables is crucial. A common example is hop testing. Wren et al chose the single Anterior Hop Test. We prefer the three-hop or three-hop crossover tests to better assess multiple acceleration/deceleration episodes for both distance and quality. However, Wren et al found that 8 of 11 patients who went on to second ACL injuries had passed 90% LSI criteria for Anterior Hop Test with the comparison only to contralateral limb post operatively. Is the contralateral leg that has been only semi-active for six months a valid comparison? Is the athlete’s ability to safely control landing mechanics of greater or lesser importance than pure distance values (i.e. LSI)? Wren et al addressed both the numeric distance comparisons along with a number of objective “quality” measures. In this study, the landing on a force plate allowed for calculating the quality measures above (kinetics/kinematics). Some key weaknesses remain that potentially cloud this data. Without proper verbal cuing, we see athletes, and the risk remains in studies like Wren's, which don’t specify that they used specific verbal cuing. The athlete may use opposite leg swing, or the bilateral arm swing can easily be used to gain distance. If not controlled for this, it could easily affect the LSI. Wren et al’s study did NOT indicate that these were controlled for. At Peak, hop tests are performed with the patient's hands on their hips to limit arm swing and verbal cuing to limit trunk and opposite leg swing. Wren et al’s study clearly shows that all ACLR patients (whether symmetric or asymmetric) hoppers compensate. We expect that limiting some of these compensations may provide more accurate distance data and we the PTs can focus on the quality of the landing. This study showed that the non-operative limb failed to return to normal hop function performance based on control group comparisons. Without pre-injury reference data, this study confirms that there is a risk of a skewed comparison that leads to prematurely defining the operative limb as successful. That begs the question as to reliance on LSI for RTP decision making risks sending athletes back prematurely. Surgeons are dependent on PT testing data to contribute to RTP data. We need to be discerning. Clinically, without this force plate video, and EMG data, we have to rely on visual assessment to determine some of the quality measures that Wren et al described, as best as possible. Distance alone is inadequate. Even symmetric hoppers were not symmetric at their knee. That emphasizes the need to control for compensations during testing, and provide observational assessments. Other studies have shown dynamic valgus landing mechanics to be a risk factor. We commonly see this as over pronation, or increased femoral IR/ADDuction when we see athletes showing excellent hop distances, but abnormal mechanics. That must be understood as a risk factor for RTP and pointed out to the surgeons. (Wren et al pointed out that LSI has limited value.) Suggestions: All athletes should undergo pre-season hop testing that would provide excellent comparison for a true normal and comparisons down the road for a potential injury. We need to have an increasing awareness of the quality of the tests without such extreme reliance only on the numeric distance. While “hanging our hat” only on numbers, Wren et al show in their study that “symmetric” distances still don't equal normal performances at that limb. Even the control groups in this study had 38% or more than 1/3 showing greater than 10% asymmetry. While the single anterior hop test is an option, more demanding tests of three rep anterior hop, or the three rep anterior crossover version are better indicators of function. Because of the well-understood side-to-side twisting mechanisms reported for ACL injuries, we use side to side (frontal) and rotational (*transverse) hop testing to more specifically mimic the athletic demands needed on the field. These tests allow us to qualitatively, qualitatively assess the readiness for dealing with those forces. We find these key, and these are not reported in literature. This allows us to directly analyze the ability to decelerate or control landing mechanics involving at-risk positions that will be necessary when they return to the field or court. Rehab and testing in this specific manner increases the athlete's confidence when returning because they have been properly prepared for the forces and tasks necessary to play. THE PEAK PERFORMANCE EXPERIENCE Katie stated: “I was disappointed at first in not returning quicker, but now I know that I really needed the extra time to get my ACL leg able to control running, cutting and stopping. I feel so much more confident now, and sometimes i even forget that my leg was injured!” History: Katie underwent bone-patellar tendon-bone ACLR. She progressed steadily but slowly, with her quad function lagging behind slightly. As the 6-month mark rolled around, she assumed that she was ready. She knew it didn't feel right, but all her friends had returned at six months. But she was not ready. We tested her at seven months and then four weeks later: Before 4 weeks later 90 degree rotational hop for 15 seconds: L22 R 29 L 26 Step down 6” 20# weights L 16 R 30 L 25 Calf raise 15# L 25 R 31 L 29 Anterior hop and stick L 22 in. R 34 in. L 29 Triple hop and land L 42 in. R 67 in. L 57 Hop landings showed asymmetric over pronation and related dynamic valgus upon impact. Katie subjectively reported feeling the asymmetries in testing, which explained the difficulty she was having with cutting to the right while on the left leg and left leg deceleration. We set her goals and gave her four more weeks to get closer. After continuing intense physical therapy focused on quad strength, power, frontal and transverse stability, she was able to demonstrate the substantial differences in testing shown above. The quality and quantity of her testing improved enough that she was ready to progress to soccer practice. She felt more confident and and looked much more competent when in the clinic, and on the field. I saw her play the next year and she was quick and confident on the soccer field. This year, two years after her surgery, I watched her triple jump and high jump, and she is still pain free. 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. Karen Napierala, PT, AT, MS, CAFS 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 This email was sent to << Test Email Address >> why did I get this? unsubscribe from this list update subscription preferences Peak Performance Physical Therapy · 161 East Commercial Street · East Rochester, NY 14445 · USA