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Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE (August 2023) Functional Rehabilitation for Greater Trochanteric Pain Syndrome: Thinking Beyond Traditional Isometrics and Isotonics by Andrew Neumeister, PT, DPT, FAFS, Certified Running Gait Analyst Clinical Scenario - What would you do? Your patient comes into your clinic with complaints of localized hip pain and tenderness at the greater trochanter. They have an overall reduction in function and ADL ability due to pain with weight bearing activities as well as side lying and certain sitting positions. You’ve assessed the problem and concluded the patient has greater trochanteric pain syndrome (GTPS). My clinical thinking is… A. Tell them to rest and restrict activity while taking N-SAIDS for pain relief? B. Prescribe generic physical therapy for hip strengthening with basic and nonfunctional isometric and isotonic exercises? C. Refer them to an orthopedic specialist for possible imaging and cortisone injection? D. Order specialized physical therapy with focus on assessing underlying biomechanical pitfalls and treating with indicated functional mobility and strengthening (nwb/wb) and Class IV laser? CURRENT EVIDENCE Clifford, Christopher, et al. "Isometric versus isotonic exercise for greater trochanteric pain syndrome: a randomised controlled pilot study." BMJ open sport & exercise medicine 5 (1): 1-9, (2019) http://dx.doi.org/10.1136/bmjsem-2019-000558 SUMMARY: Greater Trochanteric Pain Syndrome (GTPS) is a common cause of lateral hip pain affecting up to 24% of females and 9% of males aged 50-79 years of age. GTPS involves pathology of the gluteus medius and minimus tendons and less frequently the trochanteric bursae. The authors sought to determine the effectiveness of isotonic and isometric exercises for individuals with GTPS. Primary care physicians and orthopedists are likely the first contact for diagnosis and treatment recommendations for this condition. Various treatment options can be utilized for treating this pathology ranging from rest from activity with or without NSAID and traditional physical therapy treatment for strengthening the lateral hip muscles, specifically the gluteus minimus, medius, and maximus. PCP’s also may consider referral to an orthopedist for further assessment. Considerations include cortisone injections and possible imaging to determine severity of the condition and how much involvement of the GT bursae vs. possible tendon tears of the medius and minimus. Clifford et al examined the effectiveness of isometric and isotonic strengthening of the lateral hip complex as a means of treatment for GTPS. Although the results of the study do report that reduction of pain and self-reported functional ability increased in the subjects, we must be careful to NOT take this study as “best practice” for conservative treatment of GTPS. For some, this study may provide low level “evidence” to include these exercises in the treatment plans; however, as professionals we must also appreciate what was not studied. Simple and traditional strengthening isometric and isotonic exercises, while physiologically stimulating the local involved tissues, do not specifically treat biomechanical pitfalls that have subsequently resulted in this condition. We propose an approach that, while including appropriate isometric, isotonic, concentric and/or eccentric emphasized exercise stimuli of the local involved hip muscles, also focuses heavily on finding and identifying potential or likely causative factors. The fact that lateral hip tissues were overloaded and ultimately “failed” does not in any way mean exclusively that they were at fault or weak/insufficient. Other factors such as leg length, ipsilateral or contralateral lower extremity asymmetries, including things like asymmetric anteversion or overpronation but also asymmetric ADL/work/sport postures and body mechanics all could be causative of the otherwise normal hip’s overload. Treating only the “symptom” of the overload may temporarily be effective but misses the mark in the long term. (We’d love to hear your professional insights on this topic. Let me know your thoughts after reading this summary at PT@PeakPTRochester.com or if you have a patient case you'd like to discuss) Background: GTPS is a common diagnosis of lateral hip pain consisting of possible tendinopathy of the gluteus minimus and/or medius, and less frequently the greater trochanteric bursae. Limited evidence exists when comparing isometric and isotonic exercises for treatment of GTPS to determine what best practice may be. Methods: This pilot study consisted of 30 individuals with GTPS separated into 2 groups. Subjects were separated into 2 groups and prescribed either isometric or isotonic progressive home exercises for 12 weeks with 8 individual physical therapy sessions. Results were documented primarily using the Victorian Institute of Sports Assessment-Gluteal (VISA-G), the Numerical Pain Scale Rating (0-10), and an 11-point Global Rating of Change Scale. Inclusion criterion required participants to be >or equal to 18 years old, lateral hip pain >3 months, sx with direct palpation, and one other of 5 provocative pain tests described by Grimaldi et al. Exclusion of participants if they had physical therapy within 6 months of study, cortisone INJ if past 3 months, unable to ABD hip in side lying, Sx with scour testing and XR showing OA, and had previous hip/spine surgery within 12 months. Treatment of both isometric and isotonic exercise began with no external resistance before progressing to “progressive therapeutic bands” individualized working intp a pain scale up to 5/10 as long as Sx eased after. Isometric - non-weight bearing (NWB) sidelying hip ABD to 30 deg then held for 6x30sec with 60s rest between. WB exercise consisted of moving opposite LE through ABD/ADD 3x10 repetitions with isometric holds of gluteal muscles. Time under tension (TUT) where time of which tendons were held under load was 6 min daily. Isotonic - NWB side lying hip ABD raising to 30 deg then returning to midline. WB hip ABD slide where the affected leg slid into ABD and returned while holding anteriorly for support with bilat UEs. Non-affected hip allowed to flex knee to 45 deg during activity. Both Ex 3x10 with 6 sec duration (3s eccentric and 3s concentric) with TUT 6 min daily. Simple analgesia was allowed at home but participants were asked to refrain from other means of sx relief. Findings: Out of the 30 participants starting the trial, only 23 completed the 12 week trial. Outcome measures were taken at baseline, 4 weeks, and 12 weeks. VISA-G was the primary outcome measure with secondary measures of numeric pain rating scale (NPRS), global rating of change (GROC), pain catastrophizing scale, hip disability and OA outcome scale, The Euro QoL, and lastly the International Physical Activity Questionnaire Short Form. Both groups had similar progress in VISA-G, NPRS, and GROC, although not all participants did not meet MCID. NPRS- 55% isometric and 58% isotonic reached MCID at 12 weeks GROC- 64% isometric and 75% reached MCID at 12 weeks All other questionnaires showed no significant difference between both groups and had minimal changes. Author's Conclusion: Compliance of HEP completed 50% or so of daily HEP and 70% isometric and 58% isotonic participants attended 80+% of physical therapy sessions. MCID was met for both groups for VISA-G, NPRS, and GROC. Both programs show improvement in function and pain however no statistical differences exist. THE PEAK PERFORMANCE PERSPECTIVE Although this study claims that there were improvements in pain and “function” when utilizing both isometrics and isotonic exercises for lateral hip strengthening in GTPS, a deeper dive into the evidence would show the multiple limitations of this study that may go unnoticed with an abbreviated glance looking at the results and conclusions reported on the abstract. For perspective it must be remembered first what was studied and what was not studied. There was no control group to compare exercise with which calls to question whether individuals who went on with ADL etc. for the same duration of the study might also show both reduction in pain and improvement in function simply through natural history. The total number of subjects starting the study was 30, and at the conclusion only 23 remained. Both isotonic and isometric exercise showed improvement in the NPRS scale and increased function per GROC scale greater than the MCID, however less than 60% of subjects reached the MCID. Regarding functional improvements, at 4 weeks both groups had less than 50% of subjects statistically improving and at 12 weeks 64% and 75% of subjects had increased function for isotonic and isometric respectively. Most importantly, the types of exercises studied were limited to a single WB and NWB option for each group, without objective data acquired demonstrating improved strength of the lateral hip musculature which is the point one would perform strengthening exercises. Although the study sought to define whether isotonic and isometric exercises would help patients with GTPS, no objective data regarding strength was reported, so how can we infer that improved strength would improve symptoms? Primary care more often and orthopedic physicians are often the first line of providers assessing patients for GTPS to make appropriate treatment recommendations including the referral to skilled physical therapy. Given the choice between standard abductor exercises and a biomechanical functional treatment plan, the former may be the most common choice, however, the latter biomechanical approach at least attempts to both identify root causes rather than symptoms only and also considers authentic biomechanical demands with strengthening progression drills. The intention would be to create the smallest “leap of faith” from the body’s exercise stimulus in PT to the real-world demands of ambulation, ADL, work, and sport/recreation possible. Why strengthen someone’s hip primarily with static isometric NWB exercises when that individual needs to improve their ability of locomotion? It would be prudent to not accept the article above as “best practice” for treating lateral hip pain when the study does not provide its subjects with any functional exercises despite measuring function as one of its primary outcomes assessed. Subjects were asked to perform both NWB and WB “strength” exercises however the thoroughness (ie compliance) of completing the exercises on to the level prescribed and progressions of loading (self-determined but the subject via band color) were primarily on the individual and their home exercise program with minimal assistance from a therapist 8 sessions in total. Specific parameters were advised by the therapist in terms of side lying leg raises to approx 300 and completed for a total time under tension (TUT) of 6 minutes. Isotonic exercises included 3x10 reps with timed concentric and eccentric directives. Left to their own devices, individual subjects were asked to complete exercises without professional assistance for form and technique reported both compliance and noncompliance. 100% of those who completed their exercise diaries and completed more than 50% of daily exercise. Only 70% of the isometric group completed 80% of in person sessions compared to only 58% of isotonic subjects limiting the ability to provide appropriate feedback to exercise technique. The authors may have failed to isolate the glute medius and minimus during WB isotonic slides as the affected LE was asked to slide laterally with load as the stationary unaffected leg bent to 450 deg flexion at the knee. Despite the claims of this to emphasize lateral hip stimulus, assessing where center of mass is and joint positioning during activity creates an abductor moment controlled primarily with pelvic adductors and not the abductors for both eccentric and concentric return. Understandings like this are paramount in accelerating return to functional capacity as it acts to more effectively stimulate the muscles needed to increase strength and load accepting forces through locomotion. The lack of assessment of other potential biomechanical pitfalls that have contributed to the onset of GTPS should be addressed when designing an individualized rehabilitation program. The “simple” exercises studied by Clifford et al. may be hurting the PT population if prescribed by a provider advising to rest and do common leg raises or single leg stance drills. The incidence of GTPS can increase due to overloading the demand or stress of the lateral hip as it functions to accept load bearing forces. Hip Abductors and external rotators have to eccentrically decelerate hip adduction and internal rotation upon impact of the lower limb. The control of dynamic valgus at the knee can be addressed through strategic exercise planning to attack the problem from the adjacent hip and ankle. Weakness of the glute med/min may not decelerate the femur effectively through loading of the limb; however the foot may exhibit overpronation either from biomechanical faults of the joint unlocking the midfoot excessively in WB without poor deceleration by the posterior tibialis. If the foot/ankle complex fails to control dynamic valgus at the knee, the lateral hip must take up larger stress demands than necessary contributing to the onset of GTPS. Leg length discrepancy is another possible contributor to strain on the glute medius and minimus as a larger hip adduction moment is necessary to drop the contralateral pelvis down so that the shorter leg may accept body weight during functional mobility. A tight IT band can also provide increased stress and friction to the greater trochanter and bursae commonly seen with individuals with GTPS. Skilled functional rehabilitation can identify these underlying factors that can increase the stress on the lateral hip tendons and bursae. Simply completing NWB abduction leg raises and single leg stance or lateral slides may improve pain in a limited studied population but effectively identifying kinetic chain factors resulting in hip Adduction and/or IR overload as well as 3D methods of authentically loading/strengthening not only the affected hip but also those contributory segments is key to both a successful short term and long term recovery. THE PEAK PERFORMANCE EXPERIENCE Jacqueline said: “I ran this morning and it felt totally fine!” History: Pt is a 51 y.o. female who is an avid runner with 4 workouts a week up to 4 miles at a time. She presents with L hip trochanteric bursitis and dual small labral tear, contributing to deep anterior hip pain, but which the orthopedist does not think there is any alarm for concern. Subjective: Pain reports unable to run along with severe discomfort while sitting with pain at worst rated a 6/10 at lateral hip with self-functional rating of 60% out of 100% baseline. Lower extremity functional questionnaire (LEFS) scored 58% functional. Objective: (*=pain) Initial Eval Re-Eval Pelvis and leg length L LE long leg (high trochanter) with posterior rotated innominate Corrected with small lift under RLE and SIJ muscle energy techniques with reduction of anterior hip pain Hip flexion PROM 115/130 (88%) 123/134 (92%) Isometric hip flexion 22.4kg/25.7 (87%) 22.3/22.3 (100%) WB DF (STJn) 11/16 (69%) 20/18 (111%) SL Squat (knee flexion deg.) 60/69 (87%) 65/70 (93%) SLB rotation Minimal INCR pronation INCR control pronation into supination Anterior hop 2x INCR femur IR (dynamic valgus) Reduction but still present dynamic valgus Isometric Abduction Supine 14.0/11.5 kg 26.1/21.2 Key Findings: Upon evaluation, pt presented with a longer left leg length discrepancy contributing to INCR stress and demand of the lateral hip complex to control WB hip ADD upon impact when running - this was corrected with a heel lift. ITB tightness was greater on LLE than RLE. SIJ dysfunction was also present and anterior hip pain subsided following osteopathic muscle energy techniques to correct for her asymmetrically. Reduced DF can produce compensatory overpronation leading to INCR dynamic valgus that mutually produces excessive hip ADD/IR, increasing strain on gluteal muscles to decelerate impact on the left LE. Weakness noted in the LLE via SL squat testing for depth. Treatment: Correction of the LLD with heel lift and corresponding pelvic “correction” via manual then self-muscle energy techniques. Ankle DF ROM improved with functional manual reaction (FMR) to improve talocrural joint mobility in a STJn position and reinforced with self gastroc and soleus stretching. IT Band flexibility promoted in WB to reduce lateral hip tension. Hip flexion PROM improved with self stretching NWB. Left hip abductors (minimus and medius) strengthened initially with NWB lateral leg raises due to pain with WB before transitioning to WB anterior slides with the nondominant moving anterior. This promotes the LLE transitioning from initial impact in hip flexion progressing to extension before take off with focus on maintaining L hip position controlling hip ADD. Increased lateral hip strengthening in SL stance with anterior/posterior RLE marches to stimulate running stress of LLE. Care taken with all WB hip drills to improve dynamic valgus control as pt had poor tolerance to resisted ECC hip external rotator stimulation secondary to Sx. SL squatting improved via single leg squatting with glute emphasis via hip flexion moments to aid in control of dynamic valgus with INCR external rotators in the sagittal plane. SLB resupination/pronation control addressed with toe tapping with RLE with LLE IR/ER movements with modifications initially maintain a neutral to supinated position before advancing to controlling pronation to supination experienced at initial contact/impact on landing and progression of gait cycle to a rigid and supinated and locked on midfoot. Outcome: Upon reevaluation, the patient's lateral hip pain had dropped from 6/10 to 2/10 and was deemed more tightness than sharp. Pt was able to resume running from 1.5 to 3 miles without Sx whereas before she had to cease running altogether. Self FNXL rating improved from 60% to 70% and LEFS questionnaire from 58% to 86%. Anterior hip pain had improved much, reducing Sx while sitting and was attributed to correction of leg length discrepancy and pelvic asymmetry in the sagittal plane. Pt did undergo a cortisone injection after reevaluation due to concern she had of improvement however not eliminated Sx and reported to PT further reduction of pain to negligible afterwards. You can trust the Physical Therapists at PEAK PERFORMANCE to do a thorough evaluation, to search for related but underlying contributing factors to kinetic chain dysfunction, and to design exercise progressions that both respect tissue healing and creatively use biomechanics principles to prevent symptoms and optimize carryover to your patients' functional goals. Call us at 218-0240 to discuss your patient's specific needs. Peak Performance is just minutes away from your patients in Penfield, Fairport, Pittsford, Brighton, Rochester and, of course, East Rochester. We promise Individualized, hands-on and biomechanically appropriate Physical Therapy for your patients. No "one-size-fits-all" approaches. We WILL go the extra mile and "dig deeper" to discover underlying causes for injury risk and delayed recovery using the most advanced Evidence Based methods available and, we’re able to make unique adjustments to exercise prescriptions to speed the return to function and to minimize or prevent symptoms from interfering. No surprises. No hassles. Confident your patient is in the right place. COME VISIT US AT 161 E Commercial St Just 1 mile off 490 exit (585) 218-0240 www.PeakPTRochester.com

Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE (May 2023) Improving Clinical Outcomes: Diagnostic Accuracy of Chronic Mid-body Achilles Tendinopathy Tests by William Slapar, PT, DPT, OCS, CMTPT, CAFS Clinical Scenario...What would you do? A 36 yr old recreational athlete who does Tae Kwan Do and running presents with L posterior ankle/heel and distal leg pain pointing to the achilles tendon area. She had overused the L wb leg two weeks ago while demonstrating R sided kicks through two consecutive classes and later that week had tried hill runs to break up the monotony of her distance running. She did have similar symptoms three years ago after progressing her first marathon training too fast but has been sx-free since then other than occasional stiffness. The achilles is tender to touch and slightly swollen but without frank crepitus during AROM PF-DF. Pain is reproduced with squatting and < 5x heel raises. Plain films are WNL. She does exhibit some asymmetric L overpronation in SLB standing/mini squats testing and has limited STJ neutral squat DF at approximately 15° L vs 25° R. She has an antalgic gait with poor push off of L foot and shortened R step length. She has iced and used ibuprofen OTC per bottle instructions with some relief. My clinical thinking is: She has achilles tendonitis. Advise to DC ibuprofen and continue with Tylenol for symptom control if needed. Temporary heel lifts x 2 weeks and FU to determine next course of action. Findings suspicious for achilles tendonitis but in-office US testing is indicated to confirm diagnosis before treatment can begin. She has achilles tendonitis. Delay US testing unless 3-4 week FU shows insignificant progress. Advise formal PT including biomechanical evaluation and Laser trial. Findings suspicious of achilles tendonitis but MRI indicated (due to prior hx to R/O more significant tendinopathy/degenerative tearing) including to assist in determining possible PRP recommendation. Initiate physical therapy. She has achilles tendonitis. Advise to continue ibuprofen. No other tests needed. Temporary walking boot x 2 weeks and FU to determine next course of action. CURRENT EVIDENCE Hutchison AM, Evans R, Bodger O, et al. What is the best clinical test for Achilles tendinopathy? Foot and Ankle Surgery. 2013;19(2):112-117. https://doi.org/10.1016/j.fas.2012.12.006 SUMMARY: Achilles tendinopathy can be a common complaint especially for active lifestyle and athletically active people. In the office it can present at different portions of the calf/ankle: insertional, mid body, or at the musculotendinous junction. This three joint muscle (knee, talocrural, subtalar joints) is key to normal function with roles at the knee and foot/ankle in both NWB and WB uses. There are numerous other differential diagnoses that can contribute to retro ankle pain, including retrocalcaneal bursitis, osteophytes and/or bony anomalies, complete or partial achilles tearing, tarsal tunnel syndrome, sural neuritis or neuroma, posterior tibial tendon dysfunction/rupture, arthritic conditions, plantar fasciitis, tenosynovitis of flexor hallucis longus, stress fracture, and/ or osteochondral lesions. Accurate diagnosis is a key starting point for clinical decision making. Many different tests are available to help improve our diagnostic accuracy of mid body achilles tendinopathy and numerous imaging options for more definitive tissue level assessment, however, these are variably expensive and must be weighed in each case regarding necessity. Hutchinson et al. reviewed and used 10 different common clinical diagnostic tests for chronic mid body achilles tendinopathy while using Ultrasound as a reference standard. The most valid tests are pain on palpation of the tendon, self-reported pain at 2-6 cm above insertion, and morning stiffness. The achilles transmits forces to and from the foot and leg/superincumbent body. While often considered a “heel raise” or “push off” muscle one of often neglected roles is to decelerate the advancing body/leg segment over the foot in mid- - - >late stance phase prior to push off. Following clinical testing PCP’s and orthopedists must then consider any further diagnostic testing needed. Utilizing valid existing clinical tests allows physicians to avoid or at least delay more costly tests that may not alter treatment recommendations. With a confident diagnosis of achilles tendinopathy treatment considerations typically include physical therapy. Excellent PT care will include in-depth biomechanical evaluation to assist in problem solving any modifiable contributing factors rather than simply addressing symptom reduction and gradual return to prior activity. Achilles symptoms may develop due to ipsilateral biomechanical factors but may also result from compensation due to contralateral limb deficiencies also. (We’d love to hear your professional insights on this topic. Let me know your thoughts after reading this summary at PT@PeakPTRochester.com or if you have a patient case you'd like to discuss) Background: Diagnosing chronic mid-body achilles tendinopathy is not straightforward due to amount of tissues in the surrounding area that can be inflamed or have pain associated with stressing them. But the diagnosis aspect is very important to providing the appropriate treatment. So having accurate clinical test that can improve such diagnosis is very helpful. Purpose: To evaluate the accuracy of clinical test in identifying chronic mid-body achilles tendinopathy. Using ultrasound as a reference standard Methods: Twenty-one subjects from three groups, with and without achilles tendinopathy, had an Ultrasound scan followed by ten clinical test performed by two orthopedic surgeons and one senior physiotherapist. Each test accuracy and reproducibility were determined as well. Findings: For chronic mid-body achilles tendinopathy pain with palpation (sensitivity 84%, specificity 73%, Kappa .74-.96) and self-reported pain location from 2-6 cm above insertion (sensitivity 78%, specificity 77%, Kappa .75-.81) are the most accurate test in determining it as a diagnosis from others. Author's Conclusion: Only pain location and pain upon palpation were noted to be accurate and reliable in the diagnosis of chronic mid portion achilles tendinopathy. Further studies need to be conducted due to limitations of the study. THE PEAK PERFORMANCE PERSPECTIVE PCP’s and orthopedists alike deal with patients presenting with posterior distal leg and foot/ankle pain that is suspicious for achilles tendonitis or tendinopathy. Posterior ankle pain can be difficult to differential diagnose because of the many tissues potentially involved, including Achilles tendinopathy, retrocalcenal bursitis, os trigonum, neuritis of sural nerve, tenosynovitis of flexor hallucis longus, osteochondral lesions, etc.) which are stressed in particular ways more than others. Available clinical tests can vary significantly in their diagnostic value. Oftentimes, various imaging(i.e. US, MRI) is utilized by MDs to assess specific tissue quality and for higher sensitivity/specificity for diagnosing, however, these are more expensive and while providing more detailed information about tissue changes/quality may not alter non-operative treatment recommendations. Especially in these times of rising healthcare costs providers are expected by patients and insurers alike to control costs where possible without compromising quality of care. A common procedure is to plain films done to clear any osseus issues or other red flags that could affect treatment recommendations. Diagnostic ultrasound has become a more popular and less costly alternative to the MRI for assessing achilles tendonitis/tendinopathy. Hutchison 2012 et al clearly showed that providers can make an accurate diagnosis of chronic mid body Achilles Tendinopathy through palpation and the patient's subjective symptoms. Palpable tenderness locally showed 84% sensitivity and 73% specificity. “Active listening”for the patient’s local pain site description (being 2-6 cm above the Achilles insertion), is 78% sensitive and 77% specific to such a diagnosis. While these sensitivity or specificity values are adequate and not high, they are the highest of the 10 tested. London Royal test, the arc sign, single leg heel raise, and the hop test all have very poor sensitivity, all individually < 50%. Using “clusters” has been effective for other body parts to improve diagnostic accuracy but Hutchinson states that it is not justified since there were only very small gains in accuracy when using two of the top three most accurate tests: pain with palpation, morning stiffness, and self-reported pain. Hutchinson reminds also about test reproducibility/reliability as well. Consistency of test outcomes is a key component especially when different providers are examining patients. The three tests that were the most reproducible are once again, pain with palpation, self-reported pain, and morning stiffness. Limitations of this study was there was a low sample size with it only being 21 participants, no details on age range ( just 18+ y/o), or of gender. One of the patients from the Achilles tendinopathy group also had retrocalcaneal bursitis. Another potential limitation is the use of ultrasound as a reference standard (however, US has shown good accuracy compared to the gold standard, operative findings). Achilles tendinopathy is a very common diagnosis seen by physicians and PT’s/ATC’s alike. The mid portion/body type is the most common (vs insertional) and correlates to poorer vascularization and thus difficulty for the tendon to repair microtrauma. A key concern then is determining the reason for achilles microtrauma…especially in cases where a bilateral or reciprocating activity produced only a unilateral symptom. Most often a biomechanical deficiency is contributing to this asymmetric overloading - making identifying and addressing it properly crucial. Physicians making referrals for treatment should expect both local tissue recovery (reducing pain and inflammation and/or myofascial/scar issues) and addressing biomechanical faults related to the mechanism of injury (MOI) are being addressed in therapy. Specifying treatment orders can be difficult because there are a vast number of possible contributing factors to achilles overload. While the achilles/calf are certainly dominant sagittal plane loaded tissues there remain triplanar loading effects that must be considered. Common factors we note clinically include overpronation due to rearfoot and/or especially forefoot varus compensations, asymmetric anteversion causing dynamic valgus proximally and triplanar achilles strain distally, reduced dorsiflexion, and weak quads or hip extensors causing overload demands on the plantar flexors for deceleration. Traditional therapies usually implemented are eccentrics to help with the deceleration aspect but usually performed using a vertical force only instead of an angular force that respects horizontal forces of locomotion. Changing up different angles to provide stimulus towards the nature of function can help train more specific to the goals. Although eccentrics are helpful there is some data suggesting heavier loads strength training is key and less focus on isolated/emphasized eccentrics may be required. Of course a well-rounded approach involving manual therapy for joint and soft tissue mobilization is often necessary. Class IV laser therapy has also been a helpful modality to speed healing and reduce inflammation/pain. THE PEAK PERFORMANCE EXPERIENCE Sally said: ”The foot is feeling a lot better and and I’m able to walk farther, stand longer, and go to my grandson’s lacrosse games. I can go up and down stairs better also!” HX: 69 y/o female having progressive pain in the L posterior ankle with any weight bearing activities. Plain films are unremarkable. She was put in a walking boot for 6 weeks. Subjective: 8/10 pain with weight bearing activities, especially walking and going down stairs. Stairs is a one step at a time and walking stride is asymm. Objective: (*=pain) Initial Eval 1 mo ReEval Amb. Sx onset, asymm stride w/ antalgic type gait >15min, incr. *, near symm stride SLB , rotations Sx onset w/ rearfoot varus , no supination control 21 sec, vertical calcaneus, with min pro control and mod supination SL calf raise unable * 15x* (* at the 15th rep) Royal London Test (+) (-) NWB calc. Ev (AROM/ PROM) (0 deg /1deg) (2 deg / 3 deg) WB DF ( knee flexed) 5 degrees * 18 deg NWB DF ( knee ext) 8deg PF’d * 1 degree (100%+) Step down test unable , * 2”, 30x Palpation (TTP) Achilles ( 3cm above insertion), medial Gastroc( mod. to serve) minor TTP of med gastroc, Achilles Key Findings: At evaluation in standing, the patient shows a L foot rear foot varus, with deficits in side to side comparison of dec. calc everison. In ambulation, initial pain during all WB phases of gait of the L LE., due to lack of calc eversion. Unable to test strength due to increase in pain with all WB strength/functional testing. Lack of dorsiflexion in WB and NWB for the gastroc and soleus. Treatment: Pt treatment started with Class IV laser, with manual to address hypomobilities in the rear foot and ankle, soft tissue mobilization to address TrPs in the gastroc/ soleus structures. Using a wedge to improve tolerance of load on the achilles in a more Plantar Flexed position to reduce strain during load of the achilles. Then to reduce incline and plantar flexed ankle to a neutral or foot on floor during exercises. She worked on balance and gait training in the frontal plane first then transitioned into the Sagittal plane to reduce the amount strain in the beginning of the treatment. Balance exercises to improve pronation and calcaneal eversion control during weight acceptance of ambulation. Outcome: The patient is now able to walk without an onset of sx until 15 min of continuous walking, able to enjoy going to grandson lacrosse games, and starting back into a walking routine. Pt is able to go down the stairs in the morning with </=2/10 pain in the morning with reciprocal steps. Pt is still in Pt to continue strengthening for deceleration from elevated surfaces, increasing the endurance and strength of the plantar flexors for ambulation. Key Findings: At evaluation in standing the patient shows a L foot rear foot varus, with deficits in side to side comparison of dec. calc everison. In ambulation, initial pain during all WB phases of gait of the L LE., due to lack of calc eversion. Unable to test strength due to increase in pain with all WB strength/functional testing. Lack of dorsiflexion in WB and NWB for the gastroc and soleus. Treatment: Pt treatment started with Class IV laser, with manual to address hypomobilities in the rear foot and ankle, soft tissue mobilization to address TrPs in the gastroc/ soleus structures. Using a wedge to improve tolerance of load on the achilles in a more Plantar Flexed position to reduce strain during load of the achilles. Then to reduce incline and plantar flexed ankle to a neutral or foot on floor during exercises. She worked on balance and gait training in the frontal plane first then transitioned into the Sagittal plane to reduce the amount strain in the beginning of the treatment. Balance exercises to improve pronation and calcaneal eversion control during weight acceptance of ambulation. Outcome: The patient is now able to walk without an onset of sx until 15 min of continuous walking, able to enjoy going to grandson lacrosse games, and starting back into a walking routine. Pt is able to go down the stairs in the morning with </=2/10 pain in the morning with reciprocal steps. Pt is still in Pt to continue strengthening for deceleration from elevated surfaces, increasing the endurance and strength of the plantar flexors for ambulation. 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