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Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE April 2024 Running Related Injuries: Should we rethink the use of treadmill biomechanical analysis? by Karen Napierala MS, AT, PT, CAFS What would you do? A 54 yo runner with persisting L knee lateral knee pain presents after running a 10k race with hills two months ago. His normal weekly running volume was three times/week for two to three miles. Once he warms up his knee soreness resolves but then symptoms exacerbate sometimes by late in the run but definitely within hours of finishing, sometimes lasting into the next day. PMH includes L ITB syndrome and also recurrent (L) ankle sprains and associated chronic stiffness. The patient denies any catching or giving way in his knee. He has tenderness at the ITB over the LFC, no joint effusion, no joint line tenderness, (-) McMurray’s and Thessaly tests, and pain with single leg squatting. Plain films show diffuse mild grade I degenerative changes. I would prescribe… Rest from running for two weeks along w/NSAID’s Physical Therapy for ITBS including a treadmill running biomechanics analysis MRI to R/O lateral meniscus pathology with FU in two weeks Home exercises handout including ITB stretches, other LE stretches, balance and step up exercises along with recommending cross training for two weeks and then gradually resume running. FU if symptoms persist. CURRENT EVIDENCE: Malisoux L, Gette P et al. Gait asymmetry in spatiotemporal and kinetic variables does not increase running-related injury risk in lower limbs: a secondary analysis of a randomized trial including 800 recreational runners. BMJ Open Sport Exerc Med. 2024; 10(1) E001787 *** We modified the Newsletter format to better match your time constraints. The more in-depth “Peak Perspective” will now be contained below in more “summary” form. We invite you to reach out to us at PT@peakptrochester.com or call our office at 585-218-0240 to further discuss this article or specific patient needs if you wish. The abstract can be found after the case study. PEAK PERSPECTIVE SUMMARY Studies show that up to 79% or more runners sustain lower extremity injuries. Orthopedic, primary care, and podiatric physicians along with physical therapists will see these athletes frequently for evaluation and determining best treatment approach. This often has included the recommendation for a biomechanical running analysis, assessing for both general abnormality in mechanics/style but importantly also determining any key asymmetries present that may underlie overuse patterns. This study by Malisoux and Gette et al on the surface may seem to suggest that running gait analysis based asymmetry may not be the correct variable/factor actually underlying running injuries. A deeper assessment of the study may caution providers to be slower in foregoing traditional treadmill running gait analysis for a number of reasons. As with so many studies there is more than meets the eye from reviewing the abstract alone! This study prospectively examined 874 recreational runners, as a part of a primary study looking at two different shoes cushioning sneaker types, and found 107 injuries over the 6 month study follow-up period, noting that there were no difference between leg asymmetries in kinetics or spatiotemporal variables measured for the injured runners group. They concluded that gait asymmetries with spatiotemporal and kinetic variables were not associated with increased injury risk. Consider for a moment the analogy of MRI findings with degenerative meniscal tears, or degenerative rotator cuff or lumbar disc pathology or even osteoarthritis. While past thinking early on revolved around identifying these abnormalities as definitive of injury and often receiving surgical treatment, current thinking has evolved based on newer research and better appreciation for the role MRI plays, and does not play, in defining a patient’s condition. We now know there are (+) MRI findings in asymptomatic people or on the contralateral side that caution “over-reading” the importance. The MRI, now more than ever before, is taken as key information but kept in context with the entirety of the history and clinical exam findings. Gait analysis according to this study is a similar case. Kinetics alone, (GRF, COG displacement, step length) did not correlate or predict those recreational athletes that became injured during this running time period. So, yes, this study suggests we take more caution in calling (certain) kinetic and spatiotemporal variable asymmetries between limbs as critical factors. Does this study then make them unimportant? Much like the vast number of MRI studies (+) for abnormality in contralateral limbs and asymptomatic populations - the answer is no, it is not unimportant. But we must take it all in context. Asymmetry of those variables may not be the key factor. Consider a runner with symmetrically excessive stride length causing poor heel strike and braking forces up the kinetic chain. This study would not find that because there’s no “asymmetry” noted. Same for the entire host of variables measured, which only looked for spatiotemporal and kinetic “asymmetry” - with the underlying hypothesis being that it is asymmetry that is the causative factor to eventual injury. Other studies have certainly demonstrated that asymmetry (i.e. unilateral weakness or tightness) can be related to injury and also poor performance. Running studies in particular have also demonstrated the biomechanics differences between novices and more expert/experienced runners. These kinetics based biomechanical findings also exist within each individual runner’s own kinematics factors and injury history, making even symmetric kinetic abnormalities “experienced” asymmetrically. Even if these kinetic measurements are not a direct predictor of injury, they are certainly not irrelevant. A key consideration not studied is how the forces of running (through the measured kinetics) are then absorbed and/or produced across the various joints and muscle groups. Kinematic variables like this would help define the percentage of load, including any asymmetry present, with how the ankle, knee, and hip handled those forces. This is also true for the triplanar nature of authentic function. This study viewed sagittal plane variables yet we know that frontal and transverse plane function is also simultaneously occurring, whether that be from a “stabilization” demand or a force production/reduction standpoint. Malisoux and Gette et al did not control for training load progressions, possibly the largest factor in expected injury. The fact this data also involves the participants testing and training using different shoes than they normally wear, potentially impacting running style but also introducing a key shock absorption variable into the kinetics and spatiotemporal factors attempting to be studied. “Injury” was also defined as causing a restriction or stopping of training for 7 days or more - meaning athletes who had to modify for shorter times and then able to resume, but then had symptoms return again may not have been included as having an “injury”. Our treadmill running analysis utilizes 2D video to capture not only sagittal plane but also frontal plane views for assessing kinetic (AND SPATIOTEMPORAL) variables. This study reminds us to be cautious of placing excessive importance on asymmetry but because of the various limitations falls short of proving kinetic analysis unimportant or unnecessary. Like MRI findings, the treadmill analysis becomes part of a larger battery of tests that help identify potential factors affecting the patient’s symptoms/function, leading to clinical decision making. The use of functional weight bearing mobility, dynamic balance, strength, deceleration, and power testing provides some level of kinematics related information that helps paint a fuller picture of how that injured runner developed their condition and thus identifies targeted areas for functional rehab. THE PEAK PERFORMANCE EXPERIENCE Jack said: “After two weeks of doing the ankle and hip stretches, I am starting to run again! My knee feels looser.” History: Left ITB pain at knee, not on the joint line. Running 2-3 /wk no more than 3 miles. Subjective: L knee pain with heel contact thru foot flat. Able to warm up and run through pain with increase in pain once cooled down. Sore to touch on the ITB and was also painful with over 5 miles of biking at a time. Objective: (*=pain) Initial Eval Re-Eval 6 wks Ankle dorsiflexion squat L 19 / R 10 L 21 / R 17 Single leg squat knee angle L 65 / R 85 L 78 / R 90 Calf raise in 15 sec L 25/ R 14 L 25 / R 14 3” quad dom step down (eccentric) 2-10# DB FRONT RACK L 24 / R 27 L 27 / R 28 Hip flexion L 85 / R 110 L 110 / R 120 Hip ER L 30 / R 48 deg L 42 / R 50 IKDC 59% 79 % Key Findings: Right ankle loss of dorsiflexion. Left hip limitations in external rotation and flexion. Left calf and quad weakness. Tender palpation ITB at the joint line. Gait analysis using 2D spark motion software revealed an increased step length on the L side and an increased tibial contact angle indicating increased GRF thru the L leg. Frontal plane analysis revealed L hip drop increase in foot flat and increased knee valgus compensation. Calcaneal eversion was the same, but the midfoot appeared to evert more on the L. Treatment: Hip external rotation/flexion stretch and hip mobilization for posterior capsule. Hip external rotation stretches with active frontal plane hip motion for strengthening and simultaneous posterior hip active stretch developing increased hip motion/concurrent strengthening in all planes. Standing ankle dorsiflexion active stretch with knee flexion for soleus (rather than gastroc) stretch. Progressive strengthening for left calf and quadriceps, quad dominant including step downs at 3 inches. Standing hip external rotation strengthening using bands for low row (eccentric external rotation control from hip to foot). Outcome: Strength and ROM measures significantly improved. Symptoms reduced to the point that the patient was running 3 miles 3/week pain free after four weeks of work. His biking increased gradually to 8-10 miles 2/week pain free as long as he stretched. ABSTRACT Background: Gait asymmetries in lower limbs during running are thought to generate differences in mechanical stress in a bilateral comparison and may expose runners to a higher injury risk. There is no current consensus on ‘normal’ levels of asymmetry and when an asymmetry will create an injury. We know that, when running, there is a wide variety of asymmetry in kinetic measurements such as stride length, ground Rx force, vertical displacement distance. This study indicates that these kinetic measures alone are not associated with higher injury risk. Also the variability between involved and uninvolved limbs in runners who sustained an injury was not correlated to the injury. Purpose: To investigate asymmetry in spatiotemporal and kinetic variables in 800+ recreational runners identifying determinants of asymmetry. Is greater asymmetry related to greater running injury risk with the kinetic variables between involved and uninvolved limb at baseline with treadmill analysis and a self-selected pace. Type: Secondary analysis biomechanical running analysis at baseline and 6 month follow up on running exposure comparing two running shoe prototypes with different cushioning properties. Methods: 874 recreational runners who were injury free from 18-65 years old and who had run without orthopedic insoles for 12 months volunteered for the study. They randomly received one of two running shoes differing only in their cushioning properties. They were tested on a treadmill at their self-declared preferred running speed. Three-dimensional ground reaction force (GRF) data was collected (step length, contact time, flight time, vertical oscillation of Centre of mass, peak GRF, peak braking force and propulsive force). During the 6 month follow-up running related overuse injury was defined as “a running-related musculoskeletal pain in either of the lower limbs that caused a restriction in distance, speed, or duration, or stopping of running for 7 days or more. Findings: 107 participants reported at least one running-related injury using the predefined definition of injury (any musculoskeletal pain that causes a restriction in distance, speed or duration, or stoppage of running practice over the previous month). Although leg length and other asymmetries were found, no between-limb differences were observed in runners having sustained an injury. Author's Conclusion: Gait asymmetry was not associated with higher injury risk for investigated spatiotemporal and kinetic variables. 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 March 2024 Clinical Decision Making: Utility of Physical Therapy for Glenohumeral Osteoarthritis Cases with Varying Radiographic Severity by Mike Napierala, PT, SCS, CSCS, FAFS What would you do? A 72 yr old golfer comes for evaluation of chronic progressive shoulder pain with associated loss of motion that has led to increased disability during ADL, yardwork, fitness, and golf. Clinical exam shows moderate limitation of elevation ROM asymmetrically, along with all other ranges tested. Strength is minimally affected but painful in most directions and producing palpable/audible crepitus especially with resisted abduction and abducted rotations. Plain films show mild-moderate severity osteoarthritis on one side and moderate-severe on the other side, , correlating to his asymmetric symptoms. The patient wishes to avoid any surgery as long as possible but does want to remain active. . I would do the following … Perform an intra-articular corticosteroid injection on at least the most severe shoulder and FU in 2-3 wks to consider physical therapy referral. Prescribe NSAID’s and topical Voltaren gel along with a home program sheet of ROM drills, FU in 4-6 wks. Prescribe physical therapy to include Class IV laser and joint mobilization along with exercise, FU in 4-6wks. Recommend viscosupplementation vs biologic injection options and proceed per patient choice. CURRENT EVIDENCE Bauman AB, Indermuhle T, et al. Comparing outcomes after referral to physical therapy for patients with glenohumeral osteoarthritis based on radiographic osteoarthritis severity: A retrospective analysis. Cureus. 15(8), 2023. https://assets.cureus.com/uploads/original_article/pdf/173193/20230905-28062-n725ly.pdf *** We modified the Newsletter format to better match your time constraints. The more in-depth “Peak Perspective” will now be contained below in more “summary” form. We invite you to reach out to us at PT@peakptrochester.com or call our office at 585-218-0240 to further discuss this article or specific patient needs if you wish. The abstract can be found after the case study. PEAK PERSPECTIVE SUMMARY Radiographic signs of glenohumeral (GH) osteoarthritis have been seen in 17-20% of adults over age 65. As physicians seeing increasing numbers of the aging population for shoulder pain and disability being aware of current best practices based on available evidence is not only necessary but helps in clinical decision making beyond “standards of care” that may have been developed years or decades earlier that were based on less available quality studies or on residency/fellowship practices habits primarily. While there is a significant amount of literature examining the efficacy of injections for glenohumeral osteoarthritis (GHOA) there remains a very limited amount of data available to discern the efficacy of conservative care based physical therapy. The American Physical Therapy Association (APTA) has developed a Clinical Practice Guideline (CPG) for GHOA in conjunction with representatives from AAOS and also AAPMR. (https://academic.oup.com/ptj/article/103/6/pzad041/7146561). Unfortunately higher levels for “strength of evidence” only exist for limited aspects of GHOA care decision making. Rene Dubois has been quoted as saying “The measurable drives out the important” - a statement considered inflammatory and a bit hyperbolic and overgeneralizing by some, yet holds some critical truth as well. Beyond the more variable and bias-risked world of case study and professional experience level evidence, the “truths” of orthopedics and rehabilitation are hoped by most to lie in evidence that reaches randomized clinical trial (RCT) levels of study and scrutiny. As studies are done exploring “mechanisms” and measuring “outcomes” the collective results are intended to drive clinical decision making. But what about when a topic has not been well studied…or studied thoroughly? Then what? This is the case to a great extent for GHOA. There simply is a lack of high level data to help physicians and PT’s alike make determinations on best practices. The fact remains that many, in fact, most patients with GHOA are not presently at a level that requires escalation to total shoulder arthroplasty (TSA) or a reverse-TSA. A common non-operative treatment of choice has been corticosteroid injections (CSI). There is at least some controversy over the use, especially repeated use, of CSI - while acutely helpful oftentimes, also has some evidence suggesting potentially negative downstream impact. Some studies, particularly in the knee, have even demonstrated a risk of early progression to arthroplasty from CSI. Additionally, some evidence exists suggesting biologics, like PRP, may show better/longer (+) changes for GHOA patients than standard steroid injection (Saif et al, Egyptian Rheumatology and Rehabilitation, 2018). This presents some dilemma and challenge since steroid injections are covered by insurance while PRP is not and can only be done as an added cash based service, meaning the majority of patients will choose CSI first when given options. Patients often indicate that PRP was never even discussed as an option despite the evidence suggesting mainly short term benefits and a potentially concerning risk profile of CSI in combination with at least some (+) evidence for PRP. Some would suggest this begs the question of whether treatment decision making is being based more on tradition/habit or truly evidence based rationales. Bauman et al provide some low level evidence that, like physical therapy for more common OA conditions of the hip and knee, shoulder OA can benefit from physical therapy as well. While certainly no conservative treatments have been proven to literally restore normal chondral anatomy and function, the evidence does show that patients receiving physical therapy can reduce symptoms and increase function with a low cost and very low risk treatment (PT) that also actively involves them in positively affecting their own care and outcomes. Their retrospective review of 220 patient cases divided between no GHOA (n=104), mild radiographic GHOA (n=61) and moderate/severe GHOA (n=55) referred to PT for shoulder pain were measured for pain (VAS), AROM into abduction, and Quick DASH scores. Post hoc testing showed no difference between groups for pain improvement, for abduction AROM, or for Quick DASH findings. While they showed only small (but statistically significant) short term improvements in pain, AROM, and disability across the varying severity levels of GHOA there was no significant association of the magnitude of change with severity. Only the mild GHOA patient group experienced clinically meaningful pain reduction (mean 2.4 pts reduction vs 1.4 no GHOA and 1.5 mod/severe GHOA). The mod/severe GHOA group actually showed the highest abduction AROM mean improvement (19.80 vs no GHOA 15.20 and mild OA 8.30). While surgical care for severe shoulder OA has trended upward significantly over the past decade with advances in technology and surgical techniques there does not appear to be an associated significant rise in the frequency of preoperative physical therapy utilization that might be expected. Physicians and orthopedic surgeons are at risk for assessing that patients with moderate and severe GHOA may be too advanced in their condition to benefit from physical therapy. Even for patients who likely may eventually need TSA or R-TSA there remains the need to optimize pain relief and function at low cost and low side effects. Bauman et al, albeit only providing low level retrospective analysis level data, demonstrate that even with more advanced GHOA physical therapy can be effective. One concern regarding the design and data presentation is that physical therapy was allowed to be “real world” in regard to its variability. There were no minimums or provider skill levels noted for manual therapy, no parameters for type and extent of exercises done, HEP compliance was not monitored, and a more typical bout of PT care for longer time period was not required - this study’s inclusion was only > 2 PT visits. All of these lead to the risk of “watering down” the efficacy all while still lumping in results as being definitive of “physical therapy care.” Nevertheless, this “real world” design strengthens the findings to some extent since despite this variability significant changes were nevertheless produced by treatments. It likewise produces a caution in believing that “only” minor changes can be made with physical therapy for GHOA. Our experience is certainly that skilled manual therapy is key in these cases along with very careful customized therapeutic exercise. So often we see failed PT cases who eventually do very well but initially were provided standardized shoulder ROM and strengthening protocol sheets to follow, without adequate regard for their biomechanical nuances needed. Obviously further quality studies are needed to provide better evidence. The limited number of mod/high quality studies left the APTA’s CPG for GHOA non-operative care guidelines reliant on clinical expertise level recommendations rather than moderate or high quality evidence for many of the areas of care relevant to decision making. Where specific GHOA data may be lacking the literature demonstrating beneficial outcomes of manual therapy and exercise for hip and knee OA may be considered supportive. And like hip and knee OA, shoulder OA, due at least in part to the expected ROM limitations/barriers that exist, become very reliant on effectively identifying kinetic chain needs - in this case, for especially scapular and thoracic function. Traditional PT approaches focusing on local shoulder needs and approaches often fail then to identify key needs of pectoralis minor restrictions to elevation ROM ease or of thoracic extension and rotation function necessary for UE reaching in ADL or work and recreational activities. The case below illustrates the efficacy possible with skilled PT care in a unique case of a patient with (B) GHOA at differing severities. THE PEAK PERFORMANCE EXPERIENCE John said: “I’m feeling much better now, I’ve got less crepitus, and I played 18 holes of golf without any issues!” History: 71 yr old male with 6+ yr gradual onset of L shoulder pain w fitness wt lifting but also had R shoulder partial RC tear debridement in 2007. After Covid based concerns he returned to the gym in mid-2023. Subjective: Initial verbal pain scale max was L 2/10 and R 1/10 with associated function ratings of L 80% and R 90%. CC included pain and limitation with dressing, OH reaching ADL especially limited with any loading, playing accordion, sleep disturbance and AM symptoms. Objective: (*=pain) Initial Eval L/R Re-Eval 9 wks L/R Quick DASH 20% 7% L 5% R Thor Rot sitting 500/580 630590 Pec Minor (Retraction in Elev) Max/Min+ Mod/< Min AROM flexion 1150 */1450* 1280/1620 IR up back L2*/T12* T12/T10 Neut ER 150/330 300/600 Abd ER 600/750 720/780 Isometric Jobe 3.3kg*/4.4 kg 5.6/6.4 kg Isometric Neut IR 6.7kg/10.5kg 15.1/16.5 kg Isometric Abd ER 4.4kg/6.4 kg 9.4/9.9kg Fxn - OH reach (L 70” and R 75.5”) 5# > 50x ea w ↑ IR 12# L 12x, R 25x Fxn - Row pulley @ 1mo 50# 22x/32x 50# cable 37x/40x Key Findings: Pec minor length significantly limited L > R w upward rotated scapula, mod+ crepitus L and minimal R. All AROM was limited and most were painful. Isometrics were initially symptomatic only with L flexion and Jobe though all were weak. Thoracic extension only min limited but asymmetrically limited in R > L thoracic rotation. Pt’s subjective pain reporting and function ratings were out of proportion to the symptoms noted and extent of limitation on objective testing. Treatment: Manual therapy: Pec minor release/mobilization and GH joint mob’s for L > R shoulder. Exercise: PROM stretching program following mob’s and done as HEP BID-TID for all major motions/directions/planes of shoulder…L > R. Customizing paths was necessary to avoid impingement sx often with elevation especially and with Abd’d IR. PRE were added once ROM work was fully in place. Pulling and rotational work was advanced before elevation work. Elevation PRE began with multi-joint incline pressing before long lever work was done in order to control extension/adduction moments at the shoulder. Functional rotational combination trunk drills done especially regarding golf concerns. Outcome: Pt successfully resumed 18 holes golfing and increased fitness wt lifting and ADL. Though his subjective ratings were only L 80% - - - > 80% and R 90- - - >98% his gross shoulder Quick DASH changed from 20% global to L 7% and R 5%, indicating with regard to rating the same activity categories he did, in fact, note significant changes in both shoulders, including the more moderately arthrtitic L shoulder. ABSTRACT Background: Glenohumeral osteoarthritis (GHOA) is a common cause for musculoskeletal pain and disability. Conservative care choices, including physical therapy, sometimes depend on radiographic severity of the GHOA. Purpose: This retrospective analysis aimed to examine how physical therapy impacts outcomes for patients with varying degrees of GHOA severity radiographically. Type: Retrospective analysis. Methods: Patients attending outpatient physical therapy between 2016 and 2022 for shoulder pain who had radiographs within two years of the initial PT visit, had at least one PT follow up visit following evaluation, and no history of shoulder surgery had charts reviewed for outcome measures of pain, abduction AROM, and Quick DASH scores. The 220 patients were divided into No GHOA (n=104), Mild GHOA (n=61), and Mod/Severe GHOA (n=55) groups based on radiographic findings. Findings: The mean age was 62.2 yrs and mean number of PT sessions 7.8x. Post hoc analysis showed no significant difference between any of the three groups’ improvements in pain, magnitude of AROM gain, or Quick DASH improvements based on the severity of radiographic GHOA. Author's Conclusion: Patients with GHOA have small but statistically significant short term improvements in pain, abduction AROM, and disability regardless of GHOA severity and no association between magnitudes of improvement with radiographic severity. Only patients with mild OA showed clinically significant improvements in pain. You can trust the Physical Therapists at PEAK PERFORMANCE to do a thorough evaluation, to search for related but underlying contributing factors to kinetic chain dysfunction, and to design exercise progressions that both respect tissue healing and creatively use biomechanics principles to prevent symptoms and optimize carryover to your patients' functional goals. Call us at 218-0240 to discuss your patient's specific needs. Peak Performance is just minutes away from your patients in Penfield, Fairport, Pittsford, Brighton, Rochester and, of course, East Rochester. We promise Individualized, hands-on and biomechanically appropriate Physical Therapy for your patients. No "one-size-fits-all" approaches. We WILL go the extra mile and "dig deeper" to discover underlying causes for injury risk and delayed recovery using the most advanced Evidence Based methods available and, we’re able to make unique adjustments to exercise prescriptions to speed the return to function and to minimize or prevent symptoms from interfering. No surprises. No hassles. Confident your patient is in the right place. COME VISIT US AT 161 E Commercial St Just 1 mile off 490 exit (585) 218-0240 www.PeakPTRochester.com

Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE (October 2023) Reducing Knee Adduction Moment During Gait via PT Exercises: What does the newest evidence say? by Mike Napierala, PT, SCS, CSCS, FAFS Clinical Scenario...What would you do? A 59 yr old female with a 7 year h/o progressive L > R medial knee pain and swelling/stiffness, with no recent trauma episodes, comes in for evaluation and treatment recommendations. Plain films show IKDC Grade C (2-4mm jt space) degenerative changes in medial compartment and mild Grade B changes in lateral compartment. She has a 1+ jt effusion and AROM on L knee is 5-1250 vs R knee at 2-1400 with L PROM ext only to 20. Meniscus provocation maneuvers are (-). Single squat is L 350 limited by pain with palpable crepitus and R is 55° without pain. Her L knee shows mild varus asymmetry vs the R. The patient’s goals are avoiding TKA for as long as possible, resuming doubles pickle ball and bowling (R handed), playing with her 5 and 3 yr old grandchildren, and travelling with her husband including light hiking. My clinical thinking is: Begin NSAID’s, instruct regarding activity modification and FU in 4 wks. Prescribe PT - providing sheet of local providers for ease of proximity. Perform cortisone injection and FU in 4 wks. Prescribe customized PT including biomechanical assessment and exercises, manual therapy, and laser trial. Recommend viscosupplementation injection/series - initiate insurance authorization request if pt agrees. CURRENT EVIDENCE: Cottmeyer DF, Hoang BH et al. Can exercise interventions reduce external knee adduction moment during gait? A systematic review and meta-analysis. Clinical Biomechanics. (109) 2023. 1-8. https://www.clinbiomech.com/article/S0268-0033(23)00195-X/pdf (We’d love to hear your professional insights on this topic. Let me know your thoughts after reading this summary at PT@PeakPTRochester.com or if you have a patient case you'd like to discuss) SUMMARY: Physicians frequently see patients with medial joint OA and associated varus deformity for evaluation and treatment recommendations. Aside from general OA clinical decision making surrounding early handling of which treatment approach makes sense research relevant to this population has considered whether knee adduction forces can be altered with physical therapy. To the extent varus forces are considered a precursor to medial degeneration and not simply a result, these studies become pertinent in this clinical decision making. Cottymeyer et al in the above systematic review and meta-analysis attempt to discern the body of literature on this topic. A first read of their findings easily leads physicians and therapists alike to the conclusion that knee adduction moment (KAM) during gait is not significantly altered by physical therapy exercise; however, in females there may be some effective KAM reduction possible. Only one of the nine final accepted studies showed a significant KAM reduction vs control groups and that one utilized ankle proprioceptive training compared to TENS/hot packs. These conclusions could easily mislead physicians and therapists to ignore more in-depth evaluation and biomechanical treatment approaches in favor of simple, generic “exercise” that fails to address those KAM forces contributing to ongoing pain and deterioration. Like many studies, systematic reviews, and meta-analyses, caution must be used in reading and accepting conclusions as a basis for directing clinical decision making. The authors here, I believe, have overgeneralized the term “exercise” and the included studies did not specifically utilize targeted/customized approaches aimed specifically at evaluation based findings for those patients. Exercises were generic in nature. They mainly focused on strengthening rather than efforts at restoring joint mobility through manual therapy and ROM/stretching of biomechanically relevant pathways that would promote knee abduction capacity (i.e., reversal of existing KAM forces). The hypothesis that generic strengthening, whether at the knee, locally or including hip/ankle muscles as well as a means to alter KAM fails to address the more obvious biomechanical influences directly impacting KAM. The knee cannot experience increased lateral joint loading (i.e. medial unloading) without the hip’s frontal plane adduction and transverse plane IR capacity being available. The same is true for subtalar joint eversion/foot pronation. These ranges of motion are necessary biomechanically for knee abduction directed forces to occur. Physical therapy for medial knee OA cases with and without visible KAM deformity, based on our experience in the clinic with these patients, is often far more successful when biomechanically authentic exercise focused on medial unloading is used. This must include restoration/improvement of hip and ankle frontal/transverse plane capacity that allows for potential knee abduction directed loading. Many failed cases we see that have not improved with more generic therapy approaches utilized in the studies examined above do, in fact, see significant progress when more customized biomechanical approaches are used. Therefore, in this case, I would urge caution in too quickly accepting the conclusions of Cottymeyer et al’s study, which failed to more carefully define that generic strengthening exercises are inadequate at improving KAM with gait, a subtle but critical distinction that can have important impacts on clinical treatment decisions for patients. Background: Knee adduction moment (KAM) is considered a contributing factor in medial knee OA progression and a potential focus of treatment interventions, especially physical therapy exercise intentions. Purpose: This systematic review and meta-analysis is aimed at determining if exercise interventions are effective at reducing KAM during gait. Methods: Nine RCT studies published up until May 2023 met inclusion criteria and yielded 24 effect sizes for exercise vs control groups utilizing numerous subgroups (sex, BMI, exercise type, muscle group targeting, training volume, PT supervision). Findings: The effect size of exercise interventions on KAM during gait was similar to controls (ES=0.004, P=0.946). Subgroup analysis showed studies with females only did show a positive effect size versus those with combined sexes. Author's Conclusion: Exercise may not be effective in altering KAM during gait. Clinicians should consider alternative treatment options for decreasing KAM in patients with medial knee OA and need to explore further the mechanisms for females having a more positive response. THE PEAK PERFORMANCE PERSPECTIVE Physicians frequently see patients with knee OA issues that require careful evaluation and assessment of the best course of treatment. Medial joint degenerative changes are most common and these are often associated with knee adduction deformity. Sharma et al found that knee varus was not only associated with development of incident knee OA compared to valgus deformity but that the risk of progressing medial joint degeneration was greater in the presence of knee varus or adduction. The question arises as to whether non-operative measures prior to TKA or HTO can have any significant influence on knee adduction forces. This study by Cottmeyer et al reviewed existing data on exercise interventions via physical therapy based care and its impact on measured knee adduction moment (KAM) during gait. While their efforts are admirable and valuable to the body of knowledge this study represents another example of how great care must be taken before making sweeping or generalized conclusions about a given modality such as “exercise” because it significantly influences the decision making of both referring physicians along with physical therapists themselves, possibly to the detriment of the patient. Studies up until May 2023 measuring KAM during level walking after exercise interventions were found, involving patients with diagnosed knee OA, and included control groups receiving passive care or no treatment. Out of an initial 1272 studies eventually 9 RCT studies met criteria for meta-analysis. Hedges g Effect Size was calculated. Moderator variables examined included sex, muscle groups targeted, type of exercise (strength vs neuromuscular) , PT presence (supervision) level, BMI, and training volume of intervention group. Hip and ankle targeted exercise approaches were too few to be included in ES assessment. Of the 15 “intervention groups” subsets of data developed there were 10 performing exercise supervised by a PT and 5 without a PT. Adherence/attendance varied from not reported up to 100%. Cottmeyer et al’s meta-analysis found only one of the nine studies showing significant reduction of KAM - found with 1st and 2nd peaks during gait for the ankle proprioception training group vs the TENS/hot packs control group. The subgroup analysis showed sex, specifically only females, had significant ES vs studies with males + females. No other moderator variables were found significant. The authors concluded that while exercise in general does not appear effective at reducing KAM during gait that it may reduce KAM for females specifically. While on the surface this study seems in line with prior published literature indicating KAM cannot be altered by exercise interventions (ie PT) these conclusions break the rules surrounding external validity in a significant way that can negatively impact physicians’ perspectives on the potential value of PT in OA cases and also may serve to hasten the tendency toward higher level medical interventions that also themselves have limited efficacy based on current research evidence and also carry with them greater costs and sometimes risk profiles. Careful reading leads us to pumping the brakes on their conclusions in the several important ways. The studied groups were not standardized regarding the amount of knee varus malalignment they began with for entry into the study. Varying levels of knee angulation certainly can impact the lever arm potentiation of greater varus/adduction moment that would increasingly be expected to have lesser potential for modification during or through exercise and resultantly with gait. Another very key factor is that exercise types were highly variable and generic in nature. They did not specifically target contributory or causative areas toward the knee adduction moment - specifically attempting to address optimizing hip adduction, hip internal rotation, and subtalar joint eversion capacities in order to reduce knee varus/adduction tendency. Without these adjacent limb/joint capacities a knee joint cannot be expected to shift loading toward the lateral compartment since the limb is biomechanically tending toward varus alignment without them. The only mediating factor then becomes proximal trunk lean in the frontal plane. The studies did not expressly involve added manual therapy to promote quicker or more effective restoration of those typically reduced ROM areas noted above, nor specific stretching/PROM exercises to that same effect. Knee varus deformity patients consistently, in the clinic based on our experience, demonstrate significant ROM loss in one and often all of those areas. Approaches that lack specific targeting, much like generic PT programs, may help some limited percent of patient cases but will likely miss another substantial subset who did have good rehab potential but were not addressed with customized and biomechanically based approaches. I would caution orthopedists and primary care physicians who may have read systematic reviews like this one or other RCT’s suggesting similar conclusions to be wary of falling into the trap of fully trusting the authors’ conclusions. Deeper questioning often reveals carelessness in overgeneralizing results that can negatively impact how you care for your patients and the outcomes achieved. I’d submit that a better conclusion would have been that “in knee OA cases where variable amounts of KAM in gait are treated with only generic knee exercises do not show clear evidence of significant KAM reduction in gait except potentially for females only - further study is needed for biomechanically based custom targeted approaches that include more clinical care consistent based hybrid/encompassing approaches such as manual therapy/PROM-stretching/strengthening/neuromuscular/functional exercise based care. We frequently find that even acutely during exercise portions, specifically for squat based WB quad strengthening drills, where OA based knee pain is most frequently problematic, that utilizing biomechanically sound movement principles can immediately alter symptoms and afford patients less or no symptoms during mini lunges, split squats, step ups, step downs, leg press, wall/hangback squat etc. type drills. For example, a medial knee OA case will typically have fewer symptoms when lateral loading can be increased and medial loading decreased. This is accomplished in numerous ways by trial and error but often involve trunk lean ipsilaterally, ER of the foot/leg, mild medial drifting of the knee, BUE support across midline, pelvic shifting contra laterally, lateral wedging heel among others. These frontal and transverse plane adjustments, while non-traditional, implement sound biomechanical principles toward the goal of unloading the painful and sensitive medial joint. We often find that in “failed cases” of non-operative OA knee care, these approaches are highly beneficial to the patient in optimizing function and reducing symptoms. The case below illustrates a recent example of this approach. The case below illustrates an example of the opposite issue; predominant lateral joint pain issues with radiographic OA findings plus MRI confirmed degenerative meniscus issues. The same biomechanical principles underlying KAM and preferred lateral joint loading efforts are mutually reversed in this patient’s case. They were found very effective at optimizing comfort during WB squat based strengthening drills and ultimately promoted a dramatic increase in her squat function and resulting ADL capacity. This case demonstrates the value of both a patient focused customized biomechanically authentic treatment, and especially exercise based, program along with ongoing supervised care versus premature transition to a simple HEP alone. THE PEAK PERFORMANCE EXPERIENCE Basilike said: “My pain has really decreased and now I can do stairs more easily and I walked 5 miles in NYC on a recent trip without any pain!!” HX: 78 yr old female with 2+ yrs of progressive (B) knee pain, slightly worse on L, had two prior bouts with physical therapy but only very limited benefit. Several cortisone injections provided up to 2 mo relief and recent gel injections provided only 10% reported net improvement. Subjective: L knee 8/10 and R 7/10 max sx with reported fxn of 25% L and 35% R. CC is desc>asc stairs, walking 1 lap @ Cobbs Hill Reservoir, getting up after sitting 5min. WOMAC 44%. Objective: (*=pain) Eval 6 mo ReEval Flexion AROM 1290 / 1250 1370/1350 Extension AROM 10 / 40 00/10 Isometric Quads 14.2*/16.9* kg 22.2/23.7 kg Ober TFL Mod R> L Very min Hip rot PROM IR>> ER NT Calcaneal Eversion WNL NT Squat 300/400 * (B) 700/600 * (R) SLB Static - R STJ control ↓ Rot’s: F+ control (B) Anterior Stepdowns NT 4” w 5# wts 20x/17x *(R) only Key Findings: R>L lateral joint line tenderness more so than medial jt line along with R knee ITB at LFC as well. Both knees lacked good flexion ROM but extension was mostly limited only on the R knee. Hip PROM rot’s showed IR > ER consistent with retroversion influence but ER was 120/200. TFL tightness was worse on R. Her squat fxn was painful/limited L > R but biomechanical testing for sx reduction showed L improved with frontal + transverse plane knee adduction stimulus via UE reaching/trunk positioning and R w transverse plane knee add stimulus (via opp cross reach) - both consistent with lateral joint unloading techniques. WB DF was slightly limited on R. Treatment: BIW early frequency included manual therapy joint mobilization for R TCJ DF, R knee extension, and prone hip ER. Stretching/ROM work included knee flexion (B), R knee ext, hip ER, functional TFL and R soleus/gastrocnemius. SLB rotational control work promoting pronation deceleration for general foot-ankle control was initiated, consistent also with desire to minimize knee abd forces due to predominant lateral knee sx. A key component in early strengthening was PWB - - - > FWB- - -> eventually externally loaded squat-based PRE. These were consistently found to be pain-free or pain-minimized by producing knee adduction or varus forces utilizing pelvic shift-trunk tipping and rotational pre-positioning of either the foot or opposite UE in order to promote medial joint WB. NWB quad PRE were also incorporated. Outcome: Pt was able to advance from BIW to q1-2wk FU visits and ratings of 80% L and 70% R knee function, including 5 mi walk in NYC w/o issues, improved stairs function, and reduced pain max to L 3/10 and R 3.5/10 at reduced frequencies. WOMAC reduced to 21%. Pt is being DC in the next few wks to her (I) HEP. 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, 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 (August 2023) Functional Rehabilitation for Greater Trochanteric Pain Syndrome: Thinking Beyond Traditional Isometrics and Isotonics by Andrew Neumeister, PT, DPT, FAFS, Certified Running Gait Analyst Clinical Scenario - What would you do? Your patient comes into your clinic with complaints of localized hip pain and tenderness at the greater trochanter. They have an overall reduction in function and ADL ability due to pain with weight bearing activities as well as side lying and certain sitting positions. You’ve assessed the problem and concluded the patient has greater trochanteric pain syndrome (GTPS). My clinical thinking is… A. Tell them to rest and restrict activity while taking N-SAIDS for pain relief? B. Prescribe generic physical therapy for hip strengthening with basic and nonfunctional isometric and isotonic exercises? C. Refer them to an orthopedic specialist for possible imaging and cortisone injection? D. Order specialized physical therapy with focus on assessing underlying biomechanical pitfalls and treating with indicated functional mobility and strengthening (nwb/wb) and Class IV laser? CURRENT EVIDENCE Clifford, Christopher, et al. "Isometric versus isotonic exercise for greater trochanteric pain syndrome: a randomised controlled pilot study." BMJ open sport & exercise medicine 5 (1): 1-9, (2019) http://dx.doi.org/10.1136/bmjsem-2019-000558 SUMMARY: Greater Trochanteric Pain Syndrome (GTPS) is a common cause of lateral hip pain affecting up to 24% of females and 9% of males aged 50-79 years of age. GTPS involves pathology of the gluteus medius and minimus tendons and less frequently the trochanteric bursae. The authors sought to determine the effectiveness of isotonic and isometric exercises for individuals with GTPS. Primary care physicians and orthopedists are likely the first contact for diagnosis and treatment recommendations for this condition. Various treatment options can be utilized for treating this pathology ranging from rest from activity with or without NSAID and traditional physical therapy treatment for strengthening the lateral hip muscles, specifically the gluteus minimus, medius, and maximus. PCP’s also may consider referral to an orthopedist for further assessment. Considerations include cortisone injections and possible imaging to determine severity of the condition and how much involvement of the GT bursae vs. possible tendon tears of the medius and minimus. Clifford et al examined the effectiveness of isometric and isotonic strengthening of the lateral hip complex as a means of treatment for GTPS. Although the results of the study do report that reduction of pain and self-reported functional ability increased in the subjects, we must be careful to NOT take this study as “best practice” for conservative treatment of GTPS. For some, this study may provide low level “evidence” to include these exercises in the treatment plans; however, as professionals we must also appreciate what was not studied. Simple and traditional strengthening isometric and isotonic exercises, while physiologically stimulating the local involved tissues, do not specifically treat biomechanical pitfalls that have subsequently resulted in this condition. We propose an approach that, while including appropriate isometric, isotonic, concentric and/or eccentric emphasized exercise stimuli of the local involved hip muscles, also focuses heavily on finding and identifying potential or likely causative factors. The fact that lateral hip tissues were overloaded and ultimately “failed” does not in any way mean exclusively that they were at fault or weak/insufficient. Other factors such as leg length, ipsilateral or contralateral lower extremity asymmetries, including things like asymmetric anteversion or overpronation but also asymmetric ADL/work/sport postures and body mechanics all could be causative of the otherwise normal hip’s overload. Treating only the “symptom” of the overload may temporarily be effective but misses the mark in the long term. (We’d love to hear your professional insights on this topic. Let me know your thoughts after reading this summary at PT@PeakPTRochester.com or if you have a patient case you'd like to discuss) Background: GTPS is a common diagnosis of lateral hip pain consisting of possible tendinopathy of the gluteus minimus and/or medius, and less frequently the greater trochanteric bursae. Limited evidence exists when comparing isometric and isotonic exercises for treatment of GTPS to determine what best practice may be. Methods: This pilot study consisted of 30 individuals with GTPS separated into 2 groups. Subjects were separated into 2 groups and prescribed either isometric or isotonic progressive home exercises for 12 weeks with 8 individual physical therapy sessions. Results were documented primarily using the Victorian Institute of Sports Assessment-Gluteal (VISA-G), the Numerical Pain Scale Rating (0-10), and an 11-point Global Rating of Change Scale. Inclusion criterion required participants to be >or equal to 18 years old, lateral hip pain >3 months, sx with direct palpation, and one other of 5 provocative pain tests described by Grimaldi et al. Exclusion of participants if they had physical therapy within 6 months of study, cortisone INJ if past 3 months, unable to ABD hip in side lying, Sx with scour testing and XR showing OA, and had previous hip/spine surgery within 12 months. Treatment of both isometric and isotonic exercise began with no external resistance before progressing to “progressive therapeutic bands” individualized working intp a pain scale up to 5/10 as long as Sx eased after. Isometric - non-weight bearing (NWB) sidelying hip ABD to 30 deg then held for 6x30sec with 60s rest between. WB exercise consisted of moving opposite LE through ABD/ADD 3x10 repetitions with isometric holds of gluteal muscles. Time under tension (TUT) where time of which tendons were held under load was 6 min daily. Isotonic - NWB side lying hip ABD raising to 30 deg then returning to midline. WB hip ABD slide where the affected leg slid into ABD and returned while holding anteriorly for support with bilat UEs. Non-affected hip allowed to flex knee to 45 deg during activity. Both Ex 3x10 with 6 sec duration (3s eccentric and 3s concentric) with TUT 6 min daily. Simple analgesia was allowed at home but participants were asked to refrain from other means of sx relief. Findings: Out of the 30 participants starting the trial, only 23 completed the 12 week trial. Outcome measures were taken at baseline, 4 weeks, and 12 weeks. VISA-G was the primary outcome measure with secondary measures of numeric pain rating scale (NPRS), global rating of change (GROC), pain catastrophizing scale, hip disability and OA outcome scale, The Euro QoL, and lastly the International Physical Activity Questionnaire Short Form. Both groups had similar progress in VISA-G, NPRS, and GROC, although not all participants did not meet MCID. NPRS- 55% isometric and 58% isotonic reached MCID at 12 weeks GROC- 64% isometric and 75% reached MCID at 12 weeks All other questionnaires showed no significant difference between both groups and had minimal changes. Author's Conclusion: Compliance of HEP completed 50% or so of daily HEP and 70% isometric and 58% isotonic participants attended 80+% of physical therapy sessions. MCID was met for both groups for VISA-G, NPRS, and GROC. Both programs show improvement in function and pain however no statistical differences exist. THE PEAK PERFORMANCE PERSPECTIVE Although this study claims that there were improvements in pain and “function” when utilizing both isometrics and isotonic exercises for lateral hip strengthening in GTPS, a deeper dive into the evidence would show the multiple limitations of this study that may go unnoticed with an abbreviated glance looking at the results and conclusions reported on the abstract. For perspective it must be remembered first what was studied and what was not studied. There was no control group to compare exercise with which calls to question whether individuals who went on with ADL etc. for the same duration of the study might also show both reduction in pain and improvement in function simply through natural history. The total number of subjects starting the study was 30, and at the conclusion only 23 remained. Both isotonic and isometric exercise showed improvement in the NPRS scale and increased function per GROC scale greater than the MCID, however less than 60% of subjects reached the MCID. Regarding functional improvements, at 4 weeks both groups had less than 50% of subjects statistically improving and at 12 weeks 64% and 75% of subjects had increased function for isotonic and isometric respectively. Most importantly, the types of exercises studied were limited to a single WB and NWB option for each group, without objective data acquired demonstrating improved strength of the lateral hip musculature which is the point one would perform strengthening exercises. Although the study sought to define whether isotonic and isometric exercises would help patients with GTPS, no objective data regarding strength was reported, so how can we infer that improved strength would improve symptoms? Primary care more often and orthopedic physicians are often the first line of providers assessing patients for GTPS to make appropriate treatment recommendations including the referral to skilled physical therapy. Given the choice between standard abductor exercises and a biomechanical functional treatment plan, the former may be the most common choice, however, the latter biomechanical approach at least attempts to both identify root causes rather than symptoms only and also considers authentic biomechanical demands with strengthening progression drills. The intention would be to create the smallest “leap of faith” from the body’s exercise stimulus in PT to the real-world demands of ambulation, ADL, work, and sport/recreation possible. Why strengthen someone’s hip primarily with static isometric NWB exercises when that individual needs to improve their ability of locomotion? It would be prudent to not accept the article above as “best practice” for treating lateral hip pain when the study does not provide its subjects with any functional exercises despite measuring function as one of its primary outcomes assessed. Subjects were asked to perform both NWB and WB “strength” exercises however the thoroughness (ie compliance) of completing the exercises on to the level prescribed and progressions of loading (self-determined but the subject via band color) were primarily on the individual and their home exercise program with minimal assistance from a therapist 8 sessions in total. Specific parameters were advised by the therapist in terms of side lying leg raises to approx 300 and completed for a total time under tension (TUT) of 6 minutes. Isotonic exercises included 3x10 reps with timed concentric and eccentric directives. Left to their own devices, individual subjects were asked to complete exercises without professional assistance for form and technique reported both compliance and noncompliance. 100% of those who completed their exercise diaries and completed more than 50% of daily exercise. Only 70% of the isometric group completed 80% of in person sessions compared to only 58% of isotonic subjects limiting the ability to provide appropriate feedback to exercise technique. The authors may have failed to isolate the glute medius and minimus during WB isotonic slides as the affected LE was asked to slide laterally with load as the stationary unaffected leg bent to 450 deg flexion at the knee. Despite the claims of this to emphasize lateral hip stimulus, assessing where center of mass is and joint positioning during activity creates an abductor moment controlled primarily with pelvic adductors and not the abductors for both eccentric and concentric return. Understandings like this are paramount in accelerating return to functional capacity as it acts to more effectively stimulate the muscles needed to increase strength and load accepting forces through locomotion. The lack of assessment of other potential biomechanical pitfalls that have contributed to the onset of GTPS should be addressed when designing an individualized rehabilitation program. The “simple” exercises studied by Clifford et al. may be hurting the PT population if prescribed by a provider advising to rest and do common leg raises or single leg stance drills. The incidence of GTPS can increase due to overloading the demand or stress of the lateral hip as it functions to accept load bearing forces. Hip Abductors and external rotators have to eccentrically decelerate hip adduction and internal rotation upon impact of the lower limb. The control of dynamic valgus at the knee can be addressed through strategic exercise planning to attack the problem from the adjacent hip and ankle. Weakness of the glute med/min may not decelerate the femur effectively through loading of the limb; however the foot may exhibit overpronation either from biomechanical faults of the joint unlocking the midfoot excessively in WB without poor deceleration by the posterior tibialis. If the foot/ankle complex fails to control dynamic valgus at the knee, the lateral hip must take up larger stress demands than necessary contributing to the onset of GTPS. Leg length discrepancy is another possible contributor to strain on the glute medius and minimus as a larger hip adduction moment is necessary to drop the contralateral pelvis down so that the shorter leg may accept body weight during functional mobility. A tight IT band can also provide increased stress and friction to the greater trochanter and bursae commonly seen with individuals with GTPS. Skilled functional rehabilitation can identify these underlying factors that can increase the stress on the lateral hip tendons and bursae. Simply completing NWB abduction leg raises and single leg stance or lateral slides may improve pain in a limited studied population but effectively identifying kinetic chain factors resulting in hip Adduction and/or IR overload as well as 3D methods of authentically loading/strengthening not only the affected hip but also those contributory segments is key to both a successful short term and long term recovery. THE PEAK PERFORMANCE EXPERIENCE Jacqueline said: “I ran this morning and it felt totally fine!” History: Pt is a 51 y.o. female who is an avid runner with 4 workouts a week up to 4 miles at a time. She presents with L hip trochanteric bursitis and dual small labral tear, contributing to deep anterior hip pain, but which the orthopedist does not think there is any alarm for concern. Subjective: Pain reports unable to run along with severe discomfort while sitting with pain at worst rated a 6/10 at lateral hip with self-functional rating of 60% out of 100% baseline. Lower extremity functional questionnaire (LEFS) scored 58% functional. Objective: (*=pain) Initial Eval Re-Eval Pelvis and leg length L LE long leg (high trochanter) with posterior rotated innominate Corrected with small lift under RLE and SIJ muscle energy techniques with reduction of anterior hip pain Hip flexion PROM 115/130 (88%) 123/134 (92%) Isometric hip flexion 22.4kg/25.7 (87%) 22.3/22.3 (100%) WB DF (STJn) 11/16 (69%) 20/18 (111%) SL Squat (knee flexion deg.) 60/69 (87%) 65/70 (93%) SLB rotation Minimal INCR pronation INCR control pronation into supination Anterior hop 2x INCR femur IR (dynamic valgus) Reduction but still present dynamic valgus Isometric Abduction Supine 14.0/11.5 kg 26.1/21.2 Key Findings: Upon evaluation, pt presented with a longer left leg length discrepancy contributing to INCR stress and demand of the lateral hip complex to control WB hip ADD upon impact when running - this was corrected with a heel lift. ITB tightness was greater on LLE than RLE. SIJ dysfunction was also present and anterior hip pain subsided following osteopathic muscle energy techniques to correct for her asymmetrically. Reduced DF can produce compensatory overpronation leading to INCR dynamic valgus that mutually produces excessive hip ADD/IR, increasing strain on gluteal muscles to decelerate impact on the left LE. Weakness noted in the LLE via SL squat testing for depth. Treatment: Correction of the LLD with heel lift and corresponding pelvic “correction” via manual then self-muscle energy techniques. Ankle DF ROM improved with functional manual reaction (FMR) to improve talocrural joint mobility in a STJn position and reinforced with self gastroc and soleus stretching. IT Band flexibility promoted in WB to reduce lateral hip tension. Hip flexion PROM improved with self stretching NWB. Left hip abductors (minimus and medius) strengthened initially with NWB lateral leg raises due to pain with WB before transitioning to WB anterior slides with the nondominant moving anterior. This promotes the LLE transitioning from initial impact in hip flexion progressing to extension before take off with focus on maintaining L hip position controlling hip ADD. Increased lateral hip strengthening in SL stance with anterior/posterior RLE marches to stimulate running stress of LLE. Care taken with all WB hip drills to improve dynamic valgus control as pt had poor tolerance to resisted ECC hip external rotator stimulation secondary to Sx. SL squatting improved via single leg squatting with glute emphasis via hip flexion moments to aid in control of dynamic valgus with INCR external rotators in the sagittal plane. SLB resupination/pronation control addressed with toe tapping with RLE with LLE IR/ER movements with modifications initially maintain a neutral to supinated position before advancing to controlling pronation to supination experienced at initial contact/impact on landing and progression of gait cycle to a rigid and supinated and locked on midfoot. Outcome: Upon reevaluation, the patient's lateral hip pain had dropped from 6/10 to 2/10 and was deemed more tightness than sharp. Pt was able to resume running from 1.5 to 3 miles without Sx whereas before she had to cease running altogether. Self FNXL rating improved from 60% to 70% and LEFS questionnaire from 58% to 86%. Anterior hip pain had improved much, reducing Sx while sitting and was attributed to correction of leg length discrepancy and pelvic asymmetry in the sagittal plane. Pt did undergo a cortisone injection after reevaluation due to concern she had of improvement however not eliminated Sx and reported to PT further reduction of pain to negligible afterwards. You can trust the Physical Therapists at PEAK PERFORMANCE to do a thorough evaluation, to search for related but underlying contributing factors to kinetic chain dysfunction, and to design exercise progressions that both respect tissue healing and creatively use biomechanics principles to prevent symptoms and optimize carryover to your patients' functional goals. Call us at 218-0240 to discuss your patient's specific needs. Peak Performance is just minutes away from your patients in Penfield, Fairport, Pittsford, Brighton, Rochester and, of course, East Rochester. We promise Individualized, hands-on and biomechanically appropriate Physical Therapy for your patients. No "one-size-fits-all" approaches. We WILL go the extra mile and "dig deeper" to discover underlying causes for injury risk and delayed recovery using the most advanced Evidence Based methods available and, we’re able to make unique adjustments to exercise prescriptions to speed the return to function and to minimize or prevent symptoms from interfering. No surprises. No hassles. Confident your patient is in the right place. COME VISIT US AT 161 E Commercial St Just 1 mile off 490 exit (585) 218-0240 www.PeakPTRochester.com

Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE July 2023 Optimizing In-office Testing for Hip Labral Tears: Two New Tests Examined for Clinical Utility by Mike Napierala, PT, SCS, CSCS, FAFS Clinical Scenario…What would you do? A 47 yr old male comes to his PCP for c/o L hip pain that has been increasing gradually for the past 4 months, now w sharp pains and reduced function, especially with deep squatting, quick change of direction, and getting in and out of his car. He notes some clicking/snapping but cannot recall a specific traumatic episode as a MOI. Plain films show mixed FAI findings. PROM is limited > painful in flexion-Abd-ER and in flexion-Add-IR but resistive testing with isometrics is only painful and slightly weak for hip flexors. I would... Assume a hip labral tear and begin with an outpatient physical therapy trial for 4-6 wks. Assume a hip labral tear and begin with an intra-articular steroid injection and then possibly physical therapy 2 weeks later. Order MRI and FU in 2-3 wks. Order MRA and FU in 2-3 wks. Perform Arlington, twist, FADIR tests for labral involvement, then decide regarding need for orthopedic consult. CURRENT EVIDENCE: Adib F, Hartline J et al. Two Novel Clinical Tests for the Diagnosis of Hip Labral Tears. AJSM 51(4), 1007-1014, 2023. https://journals.sagepub.com/doi/10.1177/03635465221149748?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed (We’d love to hear your professional insights on this topic. Let me know your thoughts after reading this summary at PT@PeakPTRochester.com or if you have a patient case you'd like to discuss) SUMMARY: Physicians routinely see patients with hip pain where femoracetabular impingement (FAI) and labral tears are considered key differential diagnoses to be addressed with the clinical exam. Unfortunately to date there is a lack of validated clinical tests for labral pathology. MR technology has advanced and with MRA there is good sensitivity and specificity data, however, this testing is expensive and invasive. There also remains the consideration that a significant amount of asymptomatic hips can present with positive radiographic labral and FAI findings, complicating the clinical decision making following these tests. Adib et al examined two novel hip labral clinical tests developed/advanced by their group, the Arlington test (FABER - - - > FADIER w oscillating IR-ER) and the twist test (bilateral - - - > single wb IR-ER via body twisting), on 283 patients between 13–77 yrs of age via retrospective chart review. MRA was used as the reference standard and the flexion-adduction-IR (FADIR) was also assessed. They found sensitivity for the Arlington test to be 0.94 but specificity only 0.33 while the twist test had sensitivity of 0.68 and specificity of 0.72. These tests appear to be useful additions to clinical practice since the sensitivity of the Arlington was higher than the often used FADIR and the specificity of the twist test was significantly better than the FADIR. Combining the two new tests did not improve clinical utility compared to separate values noted. Accurate clinical exams are needed for diagnosis of hip labral pathology for numerous reasons. Determining more confidently whether labral pathology is likely may allow for treatment decision making without more expensive MRI/MRA (also invasive) testing early on. This is important based on the challenge of interpreting the meaningfulness of imaging findings based on the known prevalence among asymptomatic populations. For PCP’s this may swing the pendulum toward an orthopedic consult to further ascertain hip labral and/or FAI decision making. For orthopedists, (+) labral clinical tests likewise contribute to advanced imaging considerations but also may provide a pause for routine MR imaging and arthroscopy consideration. Less expensive and invasive options such as injection therapy and physical therapy may be appropriate starting points, leaving advanced imaging for failed cases requiring surgical consideration. Determining diagnostic accuracy in this study may have been affected also by the choice to consider “chondromalacia” MRA findings as part of labral pathology versus being its own separate diagnostic entity. While a “syndrome” of sorts with degenerative joint changes of both articular cartilage and labral tissues may occur, with or without associated FAI, this clustering may have impacted the accuracy as to whether these two new tests would be positive in cases of chondral changes when no labral tear was found on MRA. The authors acknowledged the lack of varied diagnoses also, which impacts the ability to study specificity and predictive values. Nevertheless, the Arlington’s sensitivity and twist test’s specificity values exceed those of the more common FADIR and may warrant inclusion as part of orthopedic hip testing when labral pathology is suspected or needs to be ruled out. Background: There is a lack of well-studied clinical tests at the hip for diagnosing labral tears. Accurate in-office examination is critical for determining the necessity of advanced imaging and surgical consideration. Methods: Cohort study with retrospective chart review examined 283 patients (13–77 yo) who were prospectively identified as suspected labral tear and had MRA done. Clinical exams included the Arlington, twist, and FADIR tests. Findings: The Arlington test had 0.94 sensitivity and 0.33 specificity. The twist test had 0.68 sensitivity and 0.72 specificity. The FADIR test had 0.43 sensitivity and 0.56 specificity. The Arlington was significantly more sensitive than the FADIR and the twist was more significantly specific than the FADIR. Author's Conclusion: The Arlington test demonstrates high clinical sensitivity for detecting labral tears. The twist test shows promising specificity. These tests can complement traditional testing for hip labral pathology. THE PEAK PERFORMANCE PERSPECTIVE Hip pain is a common complaint evaluated by both orthopedic and primary care physicians. Labral tears are one of the key differential diagnoses that clinical testing attempts to identify, however, at this time the available in-office tests for labral pathology do not demonstrate high sensitivity or specificity. While magnetic resonance (MR) technology allows for evaluation of labral tissues, the more ideal advanced MRA test, despite both good sensitivity and specificity, is invasive and expensive – making it inappropriate for routine use. Numerous studies and systematic reviews have also confirmed the significant prevalence of labral tears (and FAI findings) among asymptomatic populations. This complicates current clinical decision making when oftentimes historically arthroscopic procedures may have otherwise been more quickly chosen as the preferred treatment. A relevant question regarding hip pain care is whether diagnosing a labral tear automatically moves a patient toward surgical care. While this is a highly contextual situation, there is evidence demonstrating successful outcomes with non-operative physical therapy for labral tears (Hyland et al, Scientific Reports 2023; Yazbek et al, JOSPT 2011; Scott et al, J Arthroplasty, 2020) and for FAI (Mallets et al, IJSPT 2019; Mansell et al, AJSM 2018; Wright et al, J Sci Med Sport 2016). An accurate in-office exam provides a solid starting point for clinical decision making. Adib et al examined two novel hip labral clinical tests developed/advanced by their group, the Arlington test (FABER - - - > FADIER w oscillating IR-ER) and the twist test (bilateral - - - > single wb IR-ER via body twisting) – (images showing tests - https://www.semanticscholar.org/paper/Two-Novel-Clinical-Tests-for-the-Diagnosis-of-Hip-Adib-Hartline/5db1ff974407e5054217314640ae9608b7e7770d). They studied 283 patients between 13–77 yrs of age via retrospective chart review. MRA was used as the reference standard and the flexion-adduction-IR (FADIR) was also assessed. They found sensitivity for the Arlington test to be 0.94 but specificity only 0.33 while the twist test had sensitivity of 0.68 and specificity of 0.72. Developing a trustworthy series of clinical tests is paramount in providing excellent in-office care and in supporting treatment choices. Both of these tests proved useful in terms of diagnostic accuracy in comparison to the often used FADIR test – with the Arlington having higher sensitivity and the twist test better specificity. Combining the two new tests did not improve clinical utility compared to separate values noted. Further studies are needed to confirm diagnostic accuracy especially utilizing a broader group of diagnoses for determining specificity and predictive values. For PCP’s having a more accurate clinical exam for labral pathology may be more compelling in moving toward an orthopedic consult but may also help provide confidence in ordering physical therapy early without the need for MRI/MRA. For orthopedists, the addition of the Arlington and twist tests, if (+) as labral pathology indicators, likewise contributes to advanced imaging considerations but also may provide a pause for expensive routine MR imaging and arthroscopy consideration based on some of the prevalence issues associated with labral and FAI diagnosis. Less expensive and invasive options such as injection therapy and physical therapy may be appropriate starting points, leaving advanced imaging for failed cases requiring surgical consideration. The authors chose to consider “chondromalacia” on the MRA as a part of labral pathology and rather than its own separate entity. This certainly is one factor that might impact diagnostic accuracy assessment. While a “syndrome” of sorts with degenerative joint changes of both articular cartilage and labral tissues may occur, with or without associated FAI, this clustering may have impacted the accuracy as to whether these two new tests would be positive in cases of chondral changes when no labral tear was found on MRA. The authors acknowledged the lack of varied diagnoses also, which impacts the ability to study specificity and predictive values. Nevertheless, the Arlington’s sensitivity and twist test’s specificity values exceed those of the more common FADIR and may warrant inclusion as part of orthopedic hip testing when labral pathology is suspected or needs to be ruled out. Certainly from a non-operative or post-operative care standpoint the quality and nature of physical therapy provided can be highly impactful on outcomes. One weakness of many studies including physical therapy is the simplicity and continuity maintained in the approaches studied. Just as all FAI surgery or labral repair work across all surgeons cannot be equated, due to technique differences and skill level/experience differences that may influence outcomes, the discerning of non-operative or post-operative care should not be viewed as a commodity-like, one size fits all approach. Biomechanical considerations must be applied to better understand both adjacent and more distant joint kinematic influences on the involved hip. Manual therapy is often a key element in successful treatment but often neglected or too limited/standardized in many studies – producing underwhelming outcomes. The following case represents a patient with chronic hip pain who underwent arthroscopic labral repair and FAI work following similar procedure on the other hip previously. THE PEAK PERFORMANCE EXPERIENCE Jared said: “Now I’m playing two-on-two basketball for up to two hours and working out again with no troubles!” History: 36 yr. old male had A’scopic L hip labral repair and FAI work done after persisting sx w biking, driving, sitting, and athletics that worsened while recovering from R hip A’scopy. Subjective: Post-op sx @ 3 days only 2/10. Objective: MEASURE (*=pain) L / R 1st ReEval (8 wks) ReEval (4 mo) AROM hip flex (deg.) 1000/ NT 1080/1020 AROM Abd (deg.) 500/NT 580/500 FABER (cm to table.) 6/10 cm 7/7cm PROM hip flex (deg.) 1120/NT 1200/1120 PROM prone IR (deg.) 230/290 320/310 Isometric hip flexion (kg) 84% 89% Isometric Abd (kg) 89% 75% but ↑ Isometric ER (kg) 93% 93% Step ups 4” w 0# 14/10x 6” w 10# 10/10 WB IR (deg) 110/170 150/220 FWB hip ext opp Ant toe reach (units) 43/48 50/52 Key Findings: Pt had persisting limitations still from his prior R hip A’scopy (rehab completed elsewhere). ROM was restricted significantly still and squat type strength was especially lacking on the R prior surgery LE. Treatment: Joint Mobilizations used for both the recent post-op L hip as well as the R. Ankle TCJ mob’s for DF necessary also, to promote squat function. Joint mob’s progressed from NWB - - - > WB style for more functional carryover. Simple isolated post-op strength drills moved toward complex multi-joint work such as lunges, step downs, step ups and rotational movements utilizing the principle of “dominating” vs “isolating” to foster functional carryover while still targeting key muscle groups and actions. Patient advanced towards functional light impact and agility work. His attendance became challenging due to work and family responsibilities along with a temporary focus on shoulder issues that continued to bother him. His last formal FU was at 5 mo post op, unplanned but due to work/family time demands and based on successes occurring. Outcome: At 4 mo ReEval pt reported L hip 60% and R hip 85% function while LEFS was 68%. By phone call FU at 7 mo post op mark pt reported up to two hrs of basketball along with fitness workouts “going well” and felt ready to DC. You can trust the Physical Therapists at PEAK PERFORMANCE to do a thorough evaluation, to search for related but underlying contributing factors to kinetic chain dysfunction, and to design exercise progressions that both respect tissue healing and creatively use biomechanics principles to prevent symptoms and optimize carryover to your patients' functional goals. Call us at 218-0240 to discuss your patient's specific needs. Peak Performance is just minutes away from your patients in Penfield, Fairport, Pittsford, Brighton, Rochester, and of course, East Rochester. We promise Individualized, hands-on and biomechanically appropriate Physical Therapy for your patients. No "one-size-fits-all" approaches. We WILL go the extra mile and "dig deeper" to discover underlying causes for injury risk and delayed recovery using the most advanced Evidence Based methods available and, we’re able to make unique adjustments to exercise prescriptions to speed the return to function and to minimize or prevent symptoms from interfering. No surprises. No hassles. Confident your patient is in the right place. COME VISIT US AT 161 E Commercial St Just 1 mile off 490 exit (585) 218-0240 www.PeakPTRochester.com

Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE (June 2023) The Underlying Precursor to Many Orthopedic Injuries ...Optimizing Best Practices for Fall Prevention by Karen Napierala, MS, AT, PT, CAFS Clinical Scenario…What would you do? John, a 67 year old golfer, presents in your office with a painful and weak L non-dominant shoulder. He reports stumbling over a threshold while getting up to use the bathroom at night, causing him to catch himself on his L hand at the countertop. He heard a small “pop” or a “snap” sound and noted difficulty with elevation ADL the next morning along with pain locally in the shoulder. Upon further questioning about his stumble, he admits to increasing frequency of falls this past 6 months but has had no other major injuries. Plain films are (-) for fracture but he does show mild DJD at the GH and AC joints. Clinical exam reveals elevation AROM limited to ~ 1500 with pain, Jobe/Abd > flexion and neutral ER MMT are 3+/5 and painful. IR, ext and adduction are strong. My clinical thinking is… Order an MRI to R/O a RC tear and determine if surgery necessary. Perform intra-articular subacromial cortisone injection and FU in 2 wks to consider starting PT. Likely partial RC tear. Non-dominant arm may not require surgery with his present ROM and rehab potential. Prescribe shoulder PT and FU in 4 wks for possible MRI if not improving adequately. Likely partial RC tear. Non-dominant arm may not require surgery with his present ROM and rehab potential. Prescribe shoulder PT plus Silver Sneakers or other similar balance program - FU in 4 wks for possible MRI if not improving adequately. Likely partial RC tear. Non-dominant arm may not require surgery with his present ROM and rehab potential. Prescribe shoulder PT + customized fall prevention including Reactive Balance Training to address underlying risk factors for re-injury - FU in 4 wks for possible MRI if not improving adequately. CURRENT EVIDENCE: Okubo Y, Sturnieks D et al. Effect of Reactive Balance Training Involving Repeated Slips and Trips on Balance Recovery Among Older adults: A Blinded Randomized Controlled Trial. J of Gerontology. Series A, 74(9), 2019, 1489-1496. SUMMARY: Falls due to slips and trips, especially in older people, can result in fractures and other injuries that potentially cause significant decline in independence. Finding safe and effective, and ideally measurable, ways to minimize this trend is crucial. Physicians play a key role in identifying patients where both a fall may have contributed to injury but also that fall risk is present moving forward and needs to be addressed. Okubo et al utilized locomotion based reactive balance training (RBT) via induced slips and trips on a 10m walkway to determine its training/preventive effect on perturbation -induced falls. Secondarily, they examined how reactive balance training effects balance recovery kinematics. Slips involved sliding tiles within the floor track while trips involved tripping boards that would spring up. Training reduced perturbation-induced falls in the lab by 60% (Rate ratio RR = 0.40). Physicians determining and prescribing care for patients with injuries related to fall risk should consider ordering RBT where indicated. Because overhead harness systems are infrequently or rarely available in outpatient clinics to match the lab conditions of studies like this, it is imperative that therapists be well versed in alternative methods for training dynamic balance including perturbation responsiveness. (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: Falls in older people can lead to serious injury that may trigger and overall decrease of function and then independence. Use of mechanical postural perturbations has been proposed as a training method to improve reactive balance toward the goal of reducing falls. Mansfield and Wong et al found this type of training may reduce falls by 46-48%. It is important that training regulate predictive behavior (gait cadence) and then superimpose unpredictable perturbations (slips and trips). Prior studies have used perturbations generated using a low friction plate on a walkway, treadmill accelerations, waist or ankle cable pulls, but all of those perturbations usually occur at a fixed location which results in loss of “unpredictability”. Gait alterations that only involve trips only or slip only are not as effective in creating balance changes. Also, to maximize learning of reactive balance control (the final defense against falls in everyday life), training should regulate predictive behavior (gait cadence) and then superimpose unpredictable perturbations. This group developed a walkway that would allow gait at a static cadence and unpredictable slips and trips. Purpose: This study examined whether reactive balance training thru exposure to slips and trips could improve balance recovery and reduce perturbation-induced falls among older adults. The authors were examining whether these patients would develop predictive locomotor strategies to the various conditions. Methods: Forty-four adults aged 65-90 were recruited thru a flyer in their community center and participated in this blinded randomized control trial study. Subjects all were exercising for at least 90 min / week over at minimum the past three months and could walk for 20 minutes without an aid. Exclusion criteria included h/o fractures or total joint arthroplasty within the past 12 months. Subjects walked on a 10m perturbation walkway (strapped into an overhead harness system to prevent actual falls) that was equipped with sensors along with a trip inducing board that sprung up as well as a movable tile that could slide up to 70cm on foot contact. Step length and cadence were regulated. The 14 cm tall tripping obstacle was triggered 50ms before the foot was to land in that sensor. Each of three sessions (trip, slip, combination of both) performed over 2 days included six trials on the walkway (< 40 min total). At the end of the sessions perceived anxiety and difficulty levels were assessed and confirmed to create a reaction. A trip or slip was defined as the load thru the harness that exceeded 30% of BW. The entire session was recorded and kinematic data was collected. The margin of stability (MOS) was calculated - with a (+) number indicating a stable body and (-) number indicating increased magnitude of COG motion. The control group undertook sham “target step training” on the same walkway without perturbations while still in a harness for safety. The final assessment was conducted after a 1 hour lunch break from the final slip and trip or sham training session. Findings: Fifty-one falls were recorded at post-assessment (23 slips, 27 trips). RBT reduced perturbation-induced falls by 60%. During a recovery step from a trip, the intervention group’s COM position was less anterior. The recovery stepping foot was higher and the trunk sway was smaller than that of the control group. Authors Conclusion: Results indicate that RBT decreased falls induced by trips and slips in the laboratory by 60%. The lower reduction rate observed here may indicate reactive balance is harder to train than predictive gait strategies, and more sessions may be required to lower fall rates further. THE PEAK PERFORMANCE PERSPECTIVE: Whether you are a primary care/family practice or internal medicine physician, an orthopedist, neurologist, or even a sports medicine specialist there’s a good chance that you will see patients over 60 years old. Falls in this population can be dangerous. For people over age 60 studies show that 30% will fall yearly and these risk percentages will rise quickly with each passing year. One way this is often missed is that patients may engage with health professionals over the result of the fall(s), thus leading to the key focus being the fracture or tear/strain/sprain or contusion they’ve suffered. Patients often are also embarrassed to admit they are knowingly struggling with balance control or may be in some denial and therefore miss the “connection” between increasing balance issues and their injury. A key consideration for physicians becomes the hybrid demand for treatment planning and recommendations that address the injury/condition itself but also discovery of and specific prescribing related to addressing the balance dysfunction underlying their main reason for seeking a physician. With age it is normal to lose more fast twitch muscle fibers. These muscle fibers play a key role in the body’s response to various perturbations – contributing to effective “reaction time.” Oftentimes traditional balance training will focus on static holds or intentional or pre-planned movements as training challenges designed to improve balance. While these can be effective the incorporation of more fast twitch fiber stimulating activities, like those noted in this study by Phi Yam, Bhatt.et al can be utilized to improve and maintain reactivity. Reactive Balance Training (RBT) in this study, accomplished via unexpected “slip” and “trip” occurrences during locomotion were shown to be advantageous for preventing falls. Their RBT was particularly impressive in that only 3 < 40 min sessions were adequate in affecting dynamic balance and fall prevention. Traditional balance training must start with static balance (for safety reasons) and progress to dynamic movement patterns to create a conscious competency of moment. The basis of these movement patterns is a foundation of strength that helps later on tolerate quicker and eventually reactive movements to an unexpected perturbation of the COG relative to the base of support (BOS). During the aging process, after a stroke, or with neurologic disease these proprioceptive and neuromuscular capacities are compromised. This can leave a patient unable to access movements quickly enough to prevent a fall. Rasmossen et al found that slips that occur in the early stance phase occur faster and are harder to recover from than those in the late phase of gait. As with any sport, practicing these patterns will produce a wide array of movement strategies available to cope with changing needs during activities. Also as with sports, there are times where the unexpected happens, and we expect that our bodies will be able to handle them and keep our center of gravity close to home so that we don’t fall. Reactive Balance Training (RBT) appears to be more advantageous for prevention of slips, trips, and falls than traditional balance training. RBT incorporates unconscious reactions to stimulus that are unknown creating a pattern of coping with losses of balance. Rosenblatt and Hunt et al noted studies that show a 21% reduction in falls a year later after only 4 sessions of RBT! While the method of RBT used in this study was appropriate and effective in its focus on ambulation related stimuli and training, it does have some clinical shortcomings. First, they utilize an overhead safety harness to prevent injury. This brings some external validity concerns to the findings because most patients/clinics do not have access to such a safety device. Also, it is possible that the patients’ normal gait patterns and tendencies were altered knowing the harness was there ready to protect them. This study does not provide evidence that alternative means to create a RBT environment would be comparably effective in falls reduction. Outpatient clinicians would creatively provide other means of inducing a perturbation stimuli and training opportunity. That requires a second person to be involved at home to produce the external perturbations. The partner would thus have to be physically capable of producing an adequate stimulus while still being capable of not producing an actual fall where no harness safety system was available. It must be remembered also that all falls do not occur during locomotion but also during other ADL such as reaching or lifting or simple change of direction. Referring physicians have four key considerations to be appreciated in these cases. First, foundational abilities must be trained not only in proprioception/static balance but also in adequate movement capacity and functional strength. For example, a person experiencing a LOB who trips or stumbles may need to utilize a lunge movement to catch themselves. Training reactively cannot adequately be done without prior lunge strength in this case which then allows for faster movements. This also includes appreciation for training vestibular and visual systems as well. A second consideration or progression must involve training in all three planes in order to prepare the joints/tissues but also global body for life demands that include stumbles or trips that may involve sideways or twisting movements and not merely sagittal plane only. The third is intentional fast twitch muscle performance training – we call this “speed day” for patient home programs. Using lighter loads through quick movement patterns optimizes fast twitch stimuli for these patients, many of whom may even do fitness work slowly with weights but have lost higher speed contraction ability, especially for deceleration needs. Finally, it is critical that RBT be authentic to a patient’s needs. This, for even basic human movement needs, will consider head/upper body driven motions and also ipsi or contralateral lower extremity driven stimuli – progressing to external perturbations thru the trunk/arms and eventually to uneven surfaces (often incorporated early on in traditional approaches, prior to adequate foundational work being done). These are first predictable and then eventually reactive or unpredictable with external bands, various wobble boards, reactions to verbal or physical cues, or using technology like BlazePods. The case below illustrates the benefits of using a 3D functional approach to dynamic balance training where an overhead harness treadmill system was not available yet profound improvements were generated. THE PEAK PERFORMANCE EXPERIENCE: Eleanor said: “I feel like my balance is improving. I don’t feel like I’ll fall anymore inside, or on the tennis court. I can get to the ball more often now also!” History: over the years, her balance has slowly deteriorated. An ankle sprain during tennis two years ago left her with a pattern of avoidance on the L side. Subjective: She states that she felt an inability to try to get certain balls on the tennis court, and at night she was often tentative at foot placement and uses her hands on the walls and furniture for safety. She likes a fully clean house with no throw rugs or shoes lying around. If things were messy, her level of fear of falling increased. Objective: (*=pain) Initial Eval Reeval (6 weeks) Hip extension R/L 20/15 25/22 Single leg squat knee angle R/L 40/60 55/68 Ankle dorsiflexion 11/15 18/22 Single leg balance static R/L sec 7/0 sec 12/5 sec Sit stand to seat 15 sec 9 12 Single leg balance with trunk rotation 15 sec R/L 2/0 13/5 Calf raises R/L 10/6 25/15 Key Findings: Eleanor didn’t even realize that she had an avoidance strategy on the L side until static and dynamic training were initiated. Treatment: Static balance, especially on the L had to be achieved first and then visual disturbances, head turns, and body movements were added on. She began a lunge “matrix” in a star pattern with single stepping, double stepping, and various hand reach patterns. After four weeks of strengthening, she was able to include external perturbations using the Airex foam pad via single leg balancing with added leaning in lateral and forward directions to move her COM out of her BOS enough to generate a stepping response. External forces with bands were also used to generate top-down (proximal - - - >distal) perturbations. Outcome: Eleanor is now proficient with reacting to stimuli that force her to step on her L foot quickly. She can stand on her left leg easily now, and is feeling very confident walking even when her head is turned to one side instead of straight. She hasn’t reported any falls or trips in over 6 months! 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 March 2023 Improving Clinical Decision Making on Scapular Dyskinesis with Subacromial Shoulder Pain by Mike Napierala, PT, SCS, CSCS, FAFS Clinical Scenario...What would you do? A 50 yr old female with chronic shoulder pain and stiffness comes to the office for a consult after failing two prior bouts with physical therapy and numerous injections. Recent MRI shows RC tendinopathy and small labral tearing. She is not in acute distress but limited significantly with ADL and fitness/recreational activities. AROM into elevation and abd’d rotations is most restricted along with neutral ER. She has painful weakness with RC testing but no signs of frank tearing. Scapular dyskinesis noted during descent from flexion and with resisted flexion at 1300. She did have prior dx of Adhesive Capsulitis and did not recover fully but did not feel PT was helping. She demonstrated a typical PT HEP routine of GH stretches and scapular retraction, serratus protraction/plus, and RC PRE. My clinical thinking is: Consider arthroscopy since PT and injections failed. Consider MUA to recover ROM unable to be attained through standard PT care and compliant HEP. Refer to PT for more thorough manual therapy and customized exercise including specifically serratus work to reduce scapular dyskinesis contributing to ongoing RC overload/irritation. Refer for deep tissue work with LMT to attempt ROM recovery and then send back to PT. CURRENT EVIDENCE Tangrood ZJ, Sole G, Riberio DC. Is there an association between changes in pain or function with changes in scapular dyskinesis: A prospective cohort study. Musculoskeletal Science and Practice. (48) 2020. 1-7. https://doi.org/10.1016/j.msksp.2020.102172 (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: Shoulder pain is a common diagnosis seen by physicians/orthopedists. Oftentimes scapular dyskinesis (SD) may be present. Testing for SD using reliable methods and determining potential meaningfulness contribute to clinical decision making regarding treatment recommendations, especially in the case of “failed” conservative care where more invasive procedures are not called for or necessary yet. Current data has both variable and contradictory findings surrounding SD and the related serratus anterior and/or lower trapezius involvement, along with a lack of clear causal level relationships to pain and/or injury. Tangrood et al demonstrated an association over 8 weeks in a group of 44 participants with shoulder pain that improvements in scapular dyskinesis testing was associated with improved PSFS self-report function scores. One confounding variable included that 65% of those completing all testing were receiving physical therapy and 35% were not. These groups were not separately analyzed which may have shed more light on causes for improvement. Common SD approaches in physical therapy often involve activation of the serratus anterior (SA) that utilizes a “plus” movement (i.e. protraction). While the SA certainly does and can protract the shoulder this risks activation of the pec minor as well with the ongoing risk of facilitating a protraction posturing that otherwise has been identified as a potential risk factor for shoulder pain. In overhead activities the scapula must tilt posteriorly while upward rotating. Many traditional methods of testing and training for SD also utilize long lever positions that painful shoulders struggle in. Authentic biomechanics approaches are necessary to promote scapular integrity via medial border stabilization (superior through inferior angles) along with upward rotation without compromising biceps or rotator cuff tendons or labral structures. A physician’s ability to identify SD in clinical exams in order to prescribe and monitor appropriate PT is often key in achieving optimal outcomes. Background: Scapular dyskinesis (SC) is a debated topic and it is unclear whether it is causative of shoulder dysfunction and subacromial pain or a consequence of symptoms, and, whether the presence of and changing of SD affects function or pain. Purpose: To assess the association of changes in subacromial shoulder pain or function with SD changes over time. Methods: Observational, prospective, cohort study of 44 participants (37 who completed baseline and 8 wk follow up testing), with 24 receiving physical therapy and 13 no treatment, using Numeric Pain Rating Scale (NPRS) 0-10 scale for “at rest” and “during movement” , self-report Patient Specific Functional Scale (PSFS), and the scapular dyskinesis test (0=normal scapular movement and 6= highest scapular dyskinesis, summing using Kibler et al system scoring). Findings: Improvement in function showed a fair association with improved SD (correlation coefficient = -0.4) while no associations found for pain at rest or pain with movement to changes in SD. 89% of patients showed subtle to obvious SD at baseline. Participants showed no changes in “pain at rest”, medium improvements of “pain during movement”, and large function improvements (28.0 mean PSFS score difference w p=0.000) but no significant SD changes. Author's Conclusion: Improved function in patients with subacromial pain was associated with improvements in scapular dyskinesis. Future studies needed to determine causal effects. THE PEAK PERFORMANCE PERSPECTIVE Shoulder pain is one of the most common orthopedic complaints seen by orthopedists and PCP’s alike. One of the most frequent diagnoses includes some form of RC syndrome (tendinitis, tendinosis, tears, impingement, etc.) which contributes to subacromial shoulder pain. Physicians discerning best practices for non-operative care recommendations are often tasked with determining obvious contributing factors they expect to be addressed in physical therapy. Understanding and testing for scapular dyskinesis underlies prescribing practices for these patients and especially for cases of “failed care” where more simple protocol based therapy approaches have not worked. It is also potentially a great example of the concept “because a muscle can doesn’t mean that it does” - in regard to how we classically test and exercise in comparison to how it actually functions. Directing care for shoulder pain of various sorts, whether it be tendon related, bursal, labral, or instability related can be difficult when considering there are few or even no clear truly “BEST practices” approaches that have been proven clearly superior to others. Many studied are more so “only practices” or “doing this happens to work” versus actually finding “bests” in treatment. That makes prescribing care and designing rehab difficult. Certainly there is a blending of science with “art”/experience etc. Secondarily, other kinetic chain contributing factors, whether local to the scapulothoracic articulation, the thoracic spine, or even related to more distal/distant joints (especially when considering complex body movements such as overhead athlete mechanics or total body lifting/reaching ADL demands) have construct validity but often lack clear “evidence” in the literature. Scapular dyskinesis (SD) is one of those entities that has been identified but suffers from conflicting evidence as to its contribution and meaningfulness. Nevertheless, it may be one of those important factors for physicians to consider when prescribing physical therapy. Physicians must therefore consider how SD should be assessed in the office and how are therapists/athletic trainers addressing this through exercises. Kibler et al (2013) and others have identified abnormal scapular mechanics, or scapular dyskinesis, as a potential contributing factor. Kibler proposed a four pattern grading system with Pattern I being inferior angle prominence (tipping), Pattern II being medial border prominence (winging), Pattern III being early scapular elevation or excessive upward rotation (elevation), and Pattern IV being normal rhythm. In-office measurement of scapular dyskinesis can be done utilizing the scapular dyskinesis test (SDT) by Kibler. Arms are raised into flexion to maximum elevation and lowered 3-5x (adding 3-5# to each hand for up to 10 repetitions may be used to accentuate abnormal findings). Most often altered motion occurs during the eccentric descent. Ramiscal et al (Clin Shoulder & Elb 2022) showed grouping Patterns I-III as a “yes” and Pattern IV as a “no” resulted in intra-rater reliability kappa of 0.92 and inter-rater values of 0.85 for expert PT’s with asymptomatic individuals. This sort of chunking certainly reduces potential for reliability errors related to the challenge of ensuring consistency with limited/poor objective measurable means of determining when exactly a “winging” event at the respective scapular reference points has occurred. Break tests of flexion at 1300, abduction at 130-1500, and extension with arms at the side - looking for significant scapular movement should also be done. Kibler wisely has reminded (Int J Sports PT 2022) that lack of research agreement is, in part, related to multiple muscles attaching to the scapula allow for simultaneous and synchronous activation and stabilization during arm movement” causing variability in how individuals perform the same task, thoracic anatomy and varied muscle fiber orientation does not allow for single plane scapular movement - scapular motion involves complex translations/rotations w coupled muscle activation. He differentiates “neurologic” winging that remains disconnected through ascent and descent phases while “altered scapular positioning” is more so evident in descent phases. This differentiation on the surface would seem plausible, however, length-tension relationships, impacts of tissue tightness at different arm positions, and nuances of force couples may otherwise explain why the dyskinesis of abnormal scapular movement often occurs with eccentric phases only or more so than during concentric phases. Causal effects of scapular dyskinesis to pain and/or injury has not been clearly established Finally, Kibler also cautions that scapular dyskinesis is not a “diagnosis” in medical terms but an impairment therefore clinical utility, measuring diagnostic accuracy, is difficult and even inappropriate when no gold standard exists for comparison. Tangrood et al provide some evidence of an association of scapular dyskinesis reduction with improved shoulder function on self-report PSFS questionnaire responses. Repeated measures correlation coefficient showed 16% of the variability in PSFS score changes is explained by scapular dyskinesis changes. Strength of findings are weakened because confounding factors (symptom duration, physical demands, etc.) were not controlled for, especially the fact that 65% of those completing all testing participated in physical therapy (without known parameters) while 35% did not, creating a heterogeneous sample. Data was not analyzed for differences between these groups. Since blinding was not done the risk of examiner bias cannot be ruled out. Subtle dyskinesis made up 57% of the baseline group test findings. Measurement properties make determining change for these subjects more difficult to ascertain. Clinically speaking we find not only for a high percentage of shoulder pain patients that SD is present in some manner but that especially for many of the “failed PT” cases we see that this has not been addressed in rehab or maybe more importantly was only addressed with simple protraction exercises. One consideration is determining the authentic function of a muscle in ADL or sport. Again, we would caution that “because a muscle can doesn’t mean that it does” in regard to certain tests traditionally done or exercises utilized. During elevation function so often related to shoulder overloads and pain the scapula does need to upward rotate but that is coupled with posterior tipping/adduction especially for cocking positions of overhead athletics. The majority of SD exercises, owing to the classically viewed Serratus Anterior role in its capacity to protract the scapula, are most often pre-engaged or emphasized by intentional or forceful protraction. We would contend that in many typical ADL and athletic arm movements the authentic biomechanics necessary contradict coupling upward rotation with anterior tipping/abduction (ie protraction). Yes, that “works” and “fatigues” the Serratus Anterior, leading to a self-fulfilling prophecy of sorts that the exercise is effective. Functional biomechanics would seem to differ with that conclusion. In unique demands of pushing and throwing/propelling the arm and related objects forward certainly serratus function protracting the scapula is an absolute necessity. Relegating the majority of serratus anterior training for the sake of reducing SD though may be oversimplifying muscle function. Because it can doesn’t mean that it is…in this movement or case. Most testing and exercises related to SD factors (i.e. serratus and lower traps) tend to place the arm in longer lever positions. While this creates loads that may quickly increase lever arm effects and identify inadequacies it also risks eliciting pain in inflamed or damaged tissues that causes inhibition of otherwise potentially normal muscles. This is especially true for the “T” and “Y” tests and exercises so often done to address SD. We attempt to approach SD with a functional biomechanics mindset that we are seeking scapular integrity on the thoracic cage wall, with whatever posterior or anterior tipping required, and with adequate and not excessive upward rotational mechanics. While this is not easy to measure objectively or to isolate to singular muscles, due in part to the related pain generating tissue implications noted above, it leads to what we believe is a more authentic approach to scapular dyskinesis through “de-winger” thinking versus promotion of protraction dominated successful activation of serratus anterior that risks over stimulus of pec minor and what would otherwise be abnormal posturing. Kinetic chain biomechanics involving facilitation of thoracolumbar coupling, for example, into same sided rotation and side bending along with extension during cocking phases for overhead athletes, must be addressed if scapular positioning is to be optimized. This involves testing for and addressing Type I and Type II spinal mechanics along with other core and hip function. Too often we see patients having failed traditional PT approaches because classic exercises essentially rely on long lever arm loading into at-risk positions that cause pain of the irritated rotator cuff tendons or labral injury. Care must be taken in many cases of shoulder pain to customize loading of the Serratus Anterior and/or Lower Trapezius to achieve scapular integrity while avoiding symptom exacerbation. The case below involves a patient who had scapular dyskinesis as a contributing factor that required careful attention in testing and exercise. THE PEAK PERFORMANCE EXPERIENCE Holli said: “I had tried a couple of rounds of physical therapy elsewhere with not a lot of improvement in my shoulder after two years of pain. I’m so happy I was finally able to get my range of motion back and not be in pain all day!” History: 50 yr old female nurse fell in 2020 injuring her wrist and then developing L non-dominant shoulder pain. She had PT at a local hospital based outpatient clinic and transitioned to HEP but developed adhesive capsulitis and was then seen for PT several more months. Pt had a total of 4 corticosteroid injections. Now presenting two years after the original fall to address ongoing issues. Subjective: 6/10 max pain with reported function at 80%. Symptoms aggravated by elevation ADL, unable to sleep L sidelying, unable to do pushups and other fitness exercises, cannot kayak. Objective: (*=pain) Eval 5 mo DC ReEval Flexion AROM 1330 / 1660 1670 900 Abd IR AROM 130 / 300 350 900 Abd ER AROM 950 / 1200 NT Wall Serratus Anterior test L @ 4 / 5 with < moderate winging 5- / 5 Pec minor Scapular Retraction (hand @ head) Mod L tight < Min Flexion isometric 1.8 kg * (24%) 5.5 kg (74%) OH reaching (pressing) 5# 33x ( < 66%) 12# 12x (71%) 800 Abd w 900 ER test NT 8# 76% painfree Key Findings: At evaluation Pt had limited elevation AROM along with posterior RC/capsule restriction in Horz Abd and Abd IR. Isometric testing revealed weak/painful elevation and Abd ER along w weak Serratus Anterior during wall scapular integrity resistive test - showing scapular winging medial border. Thoracic L rotation was asymmetrically limited. Impingement / RC tendonitis special tests were (+). Treatment: Manual therapy emphasis to pec minor release, thoracic rotation mobilizations, and especially GH jt mob’s for all motions and capsular restrictions using holding style techniques vs std oscillation approach. Sustained stretching HEP initiated including for pec minor and thoracic L rotation combined with AROM integration drills immediately following. Scapular dyskinesis addressed with Serratus drills in both NWB and WB environments, focusing on “de-winging” emphasis of maintaining scapular integrity during related modified lever arm loaded LUE movements to optimize successful maintenance of scapular positioning…first accomplished in scapular plane and increasingly loaded in sagittal plane. These were eventually moved to upright 900 and then overhead demand positions to mimic authentic biomechanics necessary for ADL and fitness needs. Progressive shoulder/scapular PRE were done moving from BID high reps/low load toward eventual TIW 3x10-12 reps work and including functional considerations for fitness goal movements. Outcome: Pt happy with her progress and wanted to continue remaining work on her own with (I) HEP only. She had had challenges with regular attendance due to other life and work schedule demands. Holli rated function at 90% with Quick DASH 7% and Sport rating 24%. 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 February 2023 A “new” Low Cost Treatment for Knee/Hip OA Without NSAID and Tylenol Side Effect Risks and Downstream Medical Costs… by Karen Napierala MS, AT, PT, CAFS What would you do? A 67 yo female enters your office with pain in her L anterior thigh traveling up into her anterior hip/groin. She has pain on heel strike and late stance phase of gait, which is visibly shortened. She can stand 30 minutes maximum while leaning forward to prepare meals at the counter, but can only stand upright < 10 minutes socializing at a family gathering. Hip flexion for tying her shoe is painful and limited. Hip scouring is (+) for pain and limited motion. All hip AROM and PROM are limited, especially with loss of IR, Faber’s, and hip ext. Plain films confirm moderately severe L hip DJD. The Pt’s goals are to resume WNL ADL, watching grandchildren BIW for 5 hr each, fitness class BIW 45min and occasional doubles pickleball. I would prescribe… A. A normal course of NSAID’s along with continued usual activity until 6 wk FU B. A normal course of paracetamol along with continued usual activity until 6 wk FU C. Surgical consult for THR consideration D. Customized PT to include Class IV laser, manual therapy, biomechanical exercise with FU 6 wks E. Provide handout of simple HEP drills for ROM and light strengthening with FU 6-8 wks F. Intra-articular corticosteroid injection with FU 4 wks CURRENT EVIDENCE Weng Q, Goh SL et al. Comparative efficacy of exercise therapy and oral nonsteroidal antiinflammatory drugs and paracetamol for knee or hip osteoarthritis: a network meta-analysis of randomized controlled trials. BJSM, Jan 2, 2023(online). https://bjsm.bmj.com/content/early/2023/01/02/bjsports-2022-105898 SUMMARY: Osteoarthritis is one of the most common orthopedic conditions seen by physicians. Clinical decision making often initially includes pharmaceutical management for control of pain and inflammation along with other potential treatment options. NSAID’s and paracetamol are commonly prescribed medicines but their cost-benefit analysis regarding potential adverse effects and comorbidity profiles (Tuhina Neogi , Amer College of Rheumatology) may make these drugs inappropriate. Exercise is a recommended treatment for restoring ROM, strength, balance, and overall function but pain reduction is more so considered a secondary benefit. Weng et al performed a network meta-analysis that included 152 RCT studies with a total of 17,431 participants with hip or knee OA comparing the efficacy, directly or indirectly, of exercise vs oral NSAID’s and paracetamol for pain and function. The results showed that exercise was comparably effective vs NSAID’s and paracetamol in reducing pain and improving physical function at 4 weeks, 8 weeks, and 24 weeks comparisons. It was also superior to “usual care” (ie. continued daily activities). Exercise may present some challenges regarding the delayed benefit of symptom reduction, requiring compliance by patients, the challenge in slowing down “over-exercisers”, and that oftentimes we find (especially for “failed PT” cases we see) specific biomechanical adjustments and considerations are necessary beyond traditional PT approaches in order to produce successful outcomes. The use of medications, however, does not produce the same expected gains in needed ROM, strength/endurance, and balance these patients require to optimize function and quality of life. Patients relying mainly on continued dosing of NSAID’s and Tylenol also are habituating into a mindset reinforcing quick fixes to symptom control and return to activity that will not serve them long-term regarding their need to modify activity and actively participate in restorative/preventative exercise. Downstream costs for patients relying on these medications also have been shown to increase significantly over time, including due to adverse effects on numerous body systems. The other risk is that patients will contribute unknowingly to accelerated degenerative changes as they medicate their way “successfully” through impact activities that are deleterious to their joint health long term. Expert physical therapy should include specific customizing intended to off-load the compartment mainly effected via specific reaching/shifting maneuvers to allow pain-free/minimized functional strengthening work. Prescriptions should also order kinetic chain evaluation and exercise/manual therapy to address contributing factors (ie., lack of hip IR and ITB length both contributing to varus knee tendency and subsequent medial joint loading). Simple traditional therapy exercises for knee and hip OA do not take these biomechanical considerations into account. (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) Purpose: Comparing analgesic benefits of exercise vs NSAID’s and paracetamol in hip and knee OA patients. Study Design: Network meta-analysis Methods: Studies included were: 1. RCT’s, 2. Participants with knee or hip OA, 3. Comparisons of exercise with oral NSAIDs , 4. Studies comparing exercise therapy with any common comparator that may be shared with NSAID’s (i.e. usual care/no treatment/waiting list control, glucosamine sulfate/chondroitin/intra-articular hyaluronic acid, topical NSAID’s, acupuncture), and 5. Studies reporting pain or function. Any study with less than 1 week follow up, use of a cross-over design, or postoperative pain were excluded. The full texts of 2738 potentially eligible articles were reviewed. There were 152 studies (17,431 participants) meeting the inclusion criteria. There were 49 studies with data available at or nearest to four weeks, two studies had data available at eight weeks and nine studies at 24 weeks. Most trials recruited participants with knee OA, while 12 studies investigated hip OA and 13 studies were both. Results: For pain relief there was no difference between oral NSAID’s and Tylenol at or nearest to 4, 8, and 24 weeks. Similar findings were noted for function as well. Authors Conclusion: Exercise has similar positive benefits to oral NSAID’s and Tylenol for pain relief and function. Since exercise has an excellent safety profile it should be given more prominence in clinical care, especially for older patients with comorbidity or higher adverse event risks related to NSAID or Tylenol use. THE PEAK PERFORMANCE PERSPECTIVE: Osteoarthritis is one of the most common orthopedic conditions seen by physicians. Clinical decision making often initially includes pharmaceutical management for control of pain and inflammation along with other potential treatment options. With pain relief ultimately comes the expectation that function will be improved significantly as well, optimizing quality of life. NSAID’s and paracetamol are among the most commonly prescribed medicines used for OA, however, the cost-benefit analysis for these medicines presents some challenges for physicians due to both potential adverse effects and comorbidity profiles (ie. Tuhina Neogi , Amer College of Rheumatology) that may make these drugs inappropriate long term or at all. Exercise is often considered a valuable treatment for restoring ROM, strength, balance, and overall function. Pain reduction is often more so thought of as a secondary benefit. Prescribed physical therapy to include formal supervised exercise is frequently delayed until more significant losses of function (i.e., ROM and strength deficits evident on clinical exam) are noted. Boston rheumatologist Jean Liew, MD noted that over 50% of patients receive NSAID’s and the same percent were given an opioid prescription when diagnosed with OA (American College of Rheumatology Convention 2021). Liew, updating their group’s findings looking at patterns of NSAID, opioid, and physical therapy (PT) use among more than 30,000 newly diagnosed patients with knee or hip OA found 9% had NSAID contraindications and 22% had NSAID precautions. This begs the question: Are NSAID’s and paracetamol being prescribed too frequently for hip and knee OA? Weng et al performed a network meta-analysis that included 152 RCT studies with a total of 17,431 participants comparing the efficacy, directly or indirectly, of exercise vs oral NSAID’s and paracetamol for pain and function knee or hip OA. The results not only showed that exercise was a clinically effective treatment (better than usual care) for reducing pain and improving physical function in people with knee or hip OA, but it was comparable in efficacy to NSAID’s and paracetamol at 4 weeks, 8 weeks, and 24 weeks comparisons. NSAID’s, for example, while effective for control of that knee/hip OA pain and inflammation, have been associated with gastrointestinal, renal, and cardiovascular complications, especially in older adults with comorbidities, There are also patients whose comorbidities deem NSAID’s as strictly contraindicated. Together these facts leave physicians and patients in a difficult position regarding ideal options if left to typical medications alone. Exercise, on the other hand, has the multi-faceted benefits of decreasing pain, increasing range of motion, increasing balance and strength - thus improving function, without the ongoing cost or risks associated with medications. Does exercise have some limitations also? There remains no absolute agreed protocols or best practices based on the evidence, however, this also should be viewed in the light that even heterogeneous “exercise” has been shown not only in this study but in numerous others to nevertheless be effective. Numerous orthopedic and rheumatology organizations have included exercise as strongly recommended based on review findings.. Three particular difficulties must be considered and addressed with prescribing exercise, especially if chosen over NSAID’s and paracetamol alone. One, the patient's desire to do the least and get the most results. We live in a society where people often “want results yesterday, not four weeks from now!” If I am told that I can take a pill today and do nothing, or I can go to PT and exercise, but it will probably take four to six weeks to work, what would I do? If I knew that I would get stronger, get off the ground easier, climb stairs better after exercise, and not just relieve the pain, patients would be more likely to follow those orders. Educating patients about these “long term” expectations and benefits fosters the compliance needed for good outcomes. Secondly, patients unaccustomed to exercise may struggle with commitment to an exercise program. There are patients who will flat out refuse to put the effort in. Third, is slowing down those who are avid exercisers. We have to be careful not to overdose, or allow exercise that will overload the joints. Many patients become their own “worst enemy” as they swing the exercise pendulum in the direction of excess, be it volume, frequency, or oftentimes intensity (especially for impact related activities). One study corroborated that the exercise for 8 weeks was very effective, but the effect of exercise gradually decreased when reassessed a year from the original study. We must approach such facts with caution, however, as the same would be true for medications taken for 6 weeks and not expecting patients to remain substantially better one year later. Exercise is a treatment that must be continued to have maximum results. Siew-LiGoh et al (Sports Medicine, 2019) compared a variety of exercises with “usual care” (i.e. continuing normal daily activity without other treatment). They found that aerobic, flow and pattern exercise, strength and coordination exercises all reduced the pain in knee and hip OA subjects. The question for physicians remains - if exercise, as shown in this and other studies, can be as effective at pain control as NSAID’s and paracetamol, have positive effects on increased function, strength, movement, coordination, and potential decrease risk in falls, and, lack the adverse effects and downstream medical costs associated with those side effects, then why would exercise not be used with every patient that presents with knee or hip OA in the office? The final but not least important points about exercise prescribing and treatment is that the RIGHT exercise will bring the BEST results. Careful attention to detail is necessary for many OA patients to succeed with exercise. Many patients will appear to succeed early on using simple NWB exercises. Unfortunately that often leaves a large “gap to bridge” to more authentic functional demands. For many of these cases, sometimes becoming “failed PT” cases, although finding effective pain-free/minimized PWB and WB functional strength methods can be a much more daunting task, it provides a more effective impact on day to day life. Expert Physical Therapy applies understanding of key biomechanics in order to both intentionally load healthier portions of articular surfaces and also in order to address key kinetic chain shortcomings that are contributing to joint overload. For example, in a common knee medial joint OA case, where the knee is in a varus presentation, PT exercise should focus on unloading the medial knee joint especially via the frontal plane but also the transverse plane. Specific reaching and shifting during otherwise typically painful exercises like split squats or step ups/downs etc can significantly reduce or abolish symptoms, allowing patients to more effectively strengthen. Key biomechanical shortcomings related to having caused the genu varum or that will perpetuate those forces such is poor hip IR, poor ITB length, poor STJ eversion all should be assessed and custom exercises done to treat. These are not approaches common to traditional physical therapy for knee/hip OA. The following case illustrates an example of simple/traditional exercises not working for his case of knee OA. THE PEAK PERFORMANCE EXPERIENCE: Mark said: “ I came to Peak after other physical therapy didn’t work for me. I was on the verge of needing surgery that I didn't want. I came to a Peak PT knee arthritis workshop. After starting PT I I know what to do, and I’m doing it. I can get through work and vacations now pain free!” History: Mark is a 64 year old male who had prior physical therapy and tried to exercise on his own, but was finding the things that he usually did created medial knee pain. He tried NSAIDs for a few months with some relief, but decided that he didn't see that as a long term solution. His job requires climbing ladders and stairs, squatting and carrying. By the end of the day his R > L medial knee is painful. He knows there is some OA on films, but he is not ready to think about a knee replacement yet. Subjective: He complained of knee pain and stiffness that limited walking, climbing ladders for work, and by the start of PT that his knees “hurt all the time.” Objective: (*=pain) Initial Eval Re-Eval Knee extension R knee 50 10 Single leg squat knee angle L 400/ R Unable ** L 650/R 500 Hip IR standing L 150/R 120 L 300 / R 250 2” quad dom step down (eccentric ) painful * 10 # front racked with ant lateral op toe reach ( inc valg at knee) L 24x / R 15x Step up 6” w 10# wts doing P-L opp foot reach ($ knee valgus for med jt unload) L 5x / R painful** L 16x / R 12x Sit stand to seat 15 sec 7x 12x Single leg balance rotation 15 sec painful ER L 15x R 13x WOMAC 41 % 16 % Key Findings: Poor knee ext and flex ROM, lacking hip IR (B) - slightly worse on R, poor tol of WB rotation, limited/painful squat function Treatment: Mark needed to regain as much knee extension as possible initially before moving into flexion exercises. This immediately decreased his pain with walking. He also worked on his limited hip IR NWB and then he progressed to functional WB methods to improve ADL and work applications. He began strengthening with PWB squats (using 0-300 and 60-950 pain-free depths) that were hip and ankle dominant to offload the knee. He used hands holding onto a stationary pole to unweight using arms also. A small yoga ball between his knees allowed Mark to maintain valgus alignment at the knees, thereby unloading his painful medial joint. All sagittal knee motions such as squats, split squats, step ups, and step downs were modified to decrease forces on the medial compartment of the knee. Frontal plane motion into valgus, and increased pronation or tibial IR were allowed as this relieved symptoms. When Mark was able to progress to impacting he began with crossover lunges focusing on valgus force from the foot up. Even once he progressed to lateral lunges, medial joint unloading was maintained by landing laterally on a wedge. Mark also received 6 sessions of Class IV Laser treatments on his R knee. The pain relief for him was immediate and lasting. This allowed faster progressions and improved his functional status quicker. After 6 weeks: Mark was ambulating at 3.0 mph pain free for 30 min, and could sit stand easily and was pain- free up and down ladders at work. He knows he has a limit for the total amount of weight bearing and work during each day, but has kept himself well under that. Outcome: Pt was DC’d to an (I) HEP, pain-free, able to remain at work full duty performing all tasks w/o troubles, walking and sitting were WNL, and he was able to go on vacation as well. 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 (October 2022) New Findings for Degenerative Meniscal Tears: A’scopy vs Non-op…1st year joint space narrowing outcomes! by Mike Napierala, PT, SCS, CSCS, FAFS Clinical Scenario...What would you do? A 54 yr old male comes in for a 2nd opinion consult for his L knee. He’s had a h/o various knee injuries in the past with some periodic bouts of stiffness and swelling especially with impact activities if not careful of volume and intensity. Five weeks ago he was getting off the floor while playing with his grandchild and felt a small snap/click in his knee and suddenly had sharp pain with weight-bearing and difficulty extending his knee. His PCP referred him for an orthopedic consult. Mild DJD noted on plain films in the medial > lateral compartment. MRI was done on suspicion of a degenerative medial meniscus tear and found (+). Recommendations were to have Arthroscopic partial meniscectomy. He was assured it would have no bearing on arthritic progression since the torn meniscus was not functioning properly now. His lack of full extension was explained as part of the reason he needed A’scopy. He prefers non-op if possible but does not want to make his knee worse by avoiding surgery. He’s presently doing OTC NSAIDs and prn Tylenol. Findings showed AROM 5-1250 (vs 1350 on R) and extension PROM stiff/painful at 30, with the patient commenting that it had been 100 short just 2 wks ago. Medial joint line is very tender and there is a > 1+ effusion present. McMurrays is (+) with varus/ER especially, reproducing an asymmetric snap in the knee. Single leg squat is painful at 300 vs R 550 and Thessaly WB test is (+) for pain/snap also. My clinical thinking is: A’scopy will more quickly resolve his pain and restore extension for WB with generally very low risks. Recommend A’scopy. ROM has been steadily improving. He already has a mild DJD present on plain films. Leave the meniscus in if he can progress back to asymptomatic with near normal or normal function. Continue non-operative care - prescribe Physical Therapy including Class IV laser and customized biomechanical exercises for 4-6 wks and then reassess. Recommend a steroid injection to reduce inflammation first and reassess in 2-3 wks regarding continuing non-op care with PT vs doing A’scopy. Aspirate the fluid, begin prescription NSAIDs, advising general rest from activity and FU in 2 wks to reassess for surgery vs formal PT. CURRENT EVIDENCE Santana DC, Oak SR et al. Increased Joint Space Narrowing After Arthroscopic Partial Meniscectomy: Data From the Osteoarthritis Initiative. AJSM 50(8): 2075-2082. 2022 03635465221096790 SUMMARY: The question of how to appropriately treat degenerative meniscus tears of the knee remains a clinical challenge. On one hand, experience has shown many physicians and surgeons that immediately remove the damaged meniscus seems to provide earlier pain relief and restore normal motion and function more quickly. Leaving damaged tissue in a joint to potentially impact chondral stresses and even contribute to loose body development may be another rationale for some in addressing these surgically sooner than later. On the other hand numerous orthopedic organizations have recommended against routine degenerative meniscus arthroscopy based on outcome findings in comparison to non-operative rehab at 6 and 12 months. Karen last month shared a JAMA Network Open study from July 2022 showing a 5 year follow up in the ESCAPE RCT showing exercise based physical therapy non-inferior to Arthroscopic Partial Meniscectomy (APM). But another consideration not studied well is the joint space width (JSW) narrowing status comparing APM with non-operative treatment of meniscus tears vs normal knee. Santana et al, using the Osteoarthritis Initiative cohort (4796 adults 45-79 yr old from 4 centers in US who had or were high risk for tibiofemoral OA), looked at 144 patients undergoing APM and having > 12 months of follow ups vs 144 with meniscal tears not undergoing APM and also 144 knees without a meniscus tear - matched by age, sex, Kellgren-Lawrence (KL) arthritis grade and FU time. Minimum medial joint space width was calculated from radiographs taken annually or semiannually following all knees having an MRI at baseline. The authors found the rate of JSW decline over the first 12 months to be 27x greater than the non-operative group and 5x greater than the no tear group. From 12-72 months showed no differences between groups. JSW at baseline vs 72 months was significantly different for the APM group compared to others (P < 0.001) but not between the non-surgical and no-tear groups. Clinically speaking this is a challenging topic, in part because many times patients want a quicker answer for their pain and limitations than non-operative care can bring. A consideration is certainly, however, to do no harm. While further evidence would be needed to confirm these findings, there is some other published evidence that APM leads to an increased rate of TKA. We find non-operative care most often, though not always, effective at resolving symptoms and restoring function in these cases. Two factors that should be considered and require further study but we see regularly on an anecdotal basis is the efficacy of our Class IV 25W laser and customizing especially squat based strengthening exercises to unload the specific meniscus tear side. That is not part of traditional physical therapy approaches. This greater attention to utilizing biomechanics to alter medial and lateral joint forces can literally allow an otherwise painful knee to perform valuable step down or split squat etc. strengthening through effective ranges when traditional technique causes pain that prevents continuing. We find that simply using otherwise deemed “functional” strengthening methods with simple step ups or downs (...etc.) contributes to the appearance for patients and physicians of “failed conservative care” and may lead prematurely to APM and the accelerated degenerative changes noted by Santana et al. Careful consideration by referring physicians of how customized and detailed rehab is for even just a “routine degenerative meniscus tear” case can significantly influence patient outcomes. Background: APM is a widely performed treatment option for patients with degenerative meniscus tears. Recent evidence has produced debate whether APM accelerates progression of OA. Purpose: To compare tibiofemoral joint space width (JSW) across three groups - patients undergoing APM, those with meniscus tears treated non-operatively, and those without a tear. The hypothesis was JSW would be least in those undergoing APM and greatest in those without a tear. Methods: Cohort design using the Osteoarthritis Initiative cohort, inclusion and exclusion criteria identified 144 patients having undergone APM having at least 12 months follow up and no prior knee surgery along with matched (by age, sex, Kellgren-Lawrence grade and follow-up time) 144 each in the meniscus tear without APM and the no meniscus tear groups. Baseline MRI used and then annual or biannual radiographs used to calculate the minimum medial compartment JSW. Linear regressions done. Findings: All groups had comparable 4.33 - 4.38mm JSW at baseline. The rate of JSW decline for the APM group was 27x greater during the first 12 months than the non-surgical tear group and 5x greater than the no tear group. No differences present in the rate of JSW decline between 12 and 72 month follow ups between groups. There was a significant difference in JSW from baseline to 72 months for the APM group vs the other groups (P < 0.001). Author's Conclusion: APM results in a faster rate of joint space narrowing during the first 12 months postoperatively than nonsurgical management of meniscal tears. Comparable rates of OA progression occur between 12 and 72 months regardless of treatment approach. Untreated meniscus tears do not hasten radiographic progression of OA as measured by JSW narrowing. THE PEAK PERFORMANCE PERSPECTIVE Orthopedists, whether non-operative specialists or surgeons, and family practice physicians alike often see patients in the 40+ age range with complaints of sudden onset knee pain and swelling. This is oftentimes accompanied by a lack of motion, catching/snapping symptoms and sometimes frank or pseudo-locking symptoms. With no frank trauma implicating ligament injury, along with joint line tenderness and a (+) McMurray’s, Appley’s or Thessaly sign this is typically considered a degenerative meniscus tear until proven otherwise. MRI is most often utilized to confirm the diagnosis if needed. The question then becomes “what is the next right step for care?” Oftentimes it’s patients themselves who are looking for the “quick fix” of arthroscopy also. Historically, a decade or more ago, these cases were moved to arthroscopic partial meniscectomy (APM). Typically patients have a fairly short recovery and their pain/mechanical symptoms are effectively treated - a seemingly good outcome. The costs and albeit infrequent adverse events related to even a “minor” arthroscopic procedure, among other considerations, led the responsible orthopedic community to study efficacy and alternatives further. I was a lead on the PT care side while at University Sports Medicine in the 90’s of a study done by the Sports Medicine Dept by several surgeons on non-operative care for MRI diagnosed degenerative meniscus tears that began as a 6 wk treatment program. The majority of participants did so well the study was extended. During that time and following, numerous other studies started being published lauding the merits of non-surgical care for degenerative meniscus tears. Various orthopedic societies and organizations have published position statements suggesting routine APM is no longer recommended. Other authors have cited that despite all these recommendations the rate of APM has not significantly dropped (Rongen 2018). There are certainly some percentage of patients with meniscus tears who are good candidates for APM for numerous reasons that may be unique to their situation and life demands, timing needs etc. Clearly this is true for frank locking of the knee due to the tear. Less clear is the “slow to recover non-operatively” knee case. We don’t know how long is “too long” before the benefits outweigh the risks and costs of APM versus waiting longer for the hoped benefits of non-operative care to manifest. One consideration some have indicated is whether leaving the torn, and less effective, meniscus in the joint would impact OA progression or produce risk of further injury. The ESCAPE Trial that Karen’s last newsletter reported on from JAMA Open Network reviewed 5 year follow up results vs APM and noted non-operative care to be non-inferior to APM long term. Obviously these non-op approaches inherently cost less and carry less risk of adverse event than APM. In this study, by Santana et al, joint space narrowing (JSN) was specifically assessed. APM having produced a 27x greater rate of decline in joint space vs non-operative meniscus tear approach weighs significantly into the basis for deciding on APM as an option. While not the standard, and yet to be well studied or an algorithm determined for identifying at-risk patients, we have personally seen numerous times patients with reported “mild to moderate, but not bone-on-bone” plain film radiographic findings who undergo APM for meniscus tear having a very negative post-op course of recovery and eventually have a much earlier than expected TKA done. The question remains, how much pre-existing OA can be tolerated by a joint undergoing APM and not have degradation accelerated to a point more further procedures are needed compared to having left the degenerative meniscus alone? While non-operative physical therapy care will, of course, not “heal” the tear or smooth over rough edges of torn meniscus this study by Santana et al supports the findings of many studies before it that physical therapy care for these cases produces good results very often, allowing patients to forego otherwise anticipated necessity for APM and the associated costs and risks of having a procedure. It also established that leaving a torn degenerative meniscus tear in the joint did not contribute to significant further abnormal narrowing in the first 12 months, and that comparable progression of OA still does occur over ensuing years comparable to that of an intact meniscus knee with OA. The JAMA Open paper did, of course, as expected, reveal that some percentage of non-operative care cases will eventually move on to surgery. Certainly not all meniscus tear cases begun in physical therapy alone will be fully successful in resolving symptoms and restoring full function. The key to recovery from a degenerative meniscus appears though not to be dependent on removal of the tear or rough margins. It often means reduction of pain and inflammation, and recovery of ROM and strength - common pursuits of typical physical therapy care. And now there is mounting evidence suggesting that “fixing” the torn meniscus may bring with it unwanted accelerated adverse effects. What is not typical in non-op care of these cases, however, is the unique demand for biomechanical “respect” for the painful tear side of the joint. Traditional PT does not teach or espouse a keen focus on “unloading techniques” for the painful tear side during typical WB strength or balance exercises. Yes…squats and leg presses, lunges and step downs or step ups, these all can be part of a functional strengthening regime of PT exercises. But done in standard “PT fashion” they oftentimes will requires unnecessary reductions in training ROM and/or loading due to pain issues (without advanced biomechanical approaches being used). The problem is that most degenerative meniscus patients have pain, sometimes very sharp debilitating pain, during these exercises. If one were to employ only NWB quad bench strengthening, even if it were pain-free (which it often is not in these cases), I’d submit we wouldn’t remotely see the effectiveness that studies show for non-op care. We see even better results utilizing biomechanical considerations to unload the painful knee side via frontal and/or transverse plane pre-positioning or reaching techniques that allow needed stimulus of the Quads, for example, but reduce the compressive pain over the meniscus tear. Consider this example - a posterior horn medial meniscus tear on the R knee may be especially loaded in WB by varus (knee adduction) and tibial ER (compression of posterior horn). While not exclusive we often find that patients unable to squat at all for effective strengthening exercise can suddenly perform (happily) through pre-positioning with the R hand reaching down or out to the R (tipping R, creating gapping on the medial knee) or by IR the foot slightly. The use of customized frontal and transverse plane adjustments allows us to identify unique positions for effective strengthening. Another key consideration is the kinetic chain biomechanics. For example, a varus knee with a MM tear must have the ability to internally rotate the hip, pronate the subtalar joint, and adduct the hip (limited by ITB tightness) addressed if there is any chance to reduce the magnified loading of the medial joint biomechanically. These are parts of our Applied Functional Science (AFS ©) training that are not part of traditional PT approaches. Our Class IV 25W laser has also been a key tool in reducing pain and inflammation. Last year I had a typical degenerative meniscus event…simply picking up my leg to dry off in the shower, felt a click. Within an hour the knee was swollen, I was unable to fully extend, ambulation was limited and painful, and flexion was reduced probably 15-200 also. These episodes typically would take me 2-4 wks to recover from. With only 3 laser treatments I was feeling 75% better in just three days! In less than a week I was fully recovered as if nothing had happened, able to do stairs, workout w wts, and golf. The case below illustrates a patient who had plain film confirmed DJD but sharp pain with clunking on McMurrays suggestive of also having a degenerative LM tear. MRI was never done to confirm findings but clinically speaking he presented with findings beyond typical knee OA alone or an ITB syndrome. THE PEAK PERFORMANCE EXPERIENCE Ken said: “Now my knee feels like it’s 95% of normal! I walked 18 holes of golf 3x in one week without trouble.” HX: 68 yr old male retired engineer and recreational golfer developed R knee pain laterally over the prior month especially with descending stairs, sit-stand ADL, and getting out of the car. He was referred by his PCP with plain films apparently showing DJD changes. He had just finished a 5 day steroid dose pack which helped. Subjective: Max sx 3/10 and self-rating function at 70%. WOMAC 28%. CC is pain w stairs (desc > asc), getting out of car, twisting activities, had to change to taking a golf cart to avoid walking hills with reduced golf. Objective: 1+ joint effusion, tender lateral joint line + ITB @ LFC, (+) McMurrays all four combinations w sharp pain and clunk noted @ lateral knee. (*=pain) Eval 6wk DC ReEval Knee ext AROM (L/R) 0/2.00 0/2-30 Knee ext PROM R 20 1-20 hyperext Knee flex AROM (L/R) 135/1320 NT/1430 Isometric Quads @ 300 89% w * 98% Isometric Hams @ 200 87% w * > 100% Single squat 74/650 * NT/750 SLB rotations <5sec/>10sec 7sec/NT FWB hip flexion (glutes/hams fxn) 30/300 45/540 WB hip IR 26/300 40/400 Quads Anterior (toes off) Stepdown 4” w 12# wts NT 35x/35x (100%) Key Findings: (+) McMurrays w lateral sharp pain and clunk consistent w R/O degenerative LM tear. Pt had weakness in Quads/Hams NWB w pain at lat/posterolateral knee, limitation and sx w squat function. WB hip IR restricted (B) - an issue for golf demands (ie, if hip unable to adequately rotate then forces at knee increased) , and poor function of hip extensors as assist w squat function. Treatment: Manual therapy joint mob’s for knee extension + sustained stretch after. Flexibility/ROM work to improve R TFL/ITB and hip IR WB (B) along w knee flex PROM. US utilized at lateral knee/ITB. Class IV laser demo done but pt chose to not purchase package for treatment (was already improving significantly). SLB work done to improve rotational control and tolerance - especially due to being a CC, despite actually better performance at RLE on IE testing than LLE. Functional squat based strengthening for quads/thigh utilized frontal plane unloading during Ant stepdowns initially (tipping trunk L to unload lateral joint - ie, reducing compression forces at LM…attempt to unload potential ITB as primary source via tipping to R worsened sx), tipping L via LUE reach table also utilized during split squats to allow deeper and heavier training. Outcome: Pt progressively reported increasing stairs/squat function and ability to tolerate rotation. Eventually he resumed walking golf, playing even 3x in one week w/o sx prior to his ReEval. WOMAC reduced to 5% and self-report score 95% at DC. You can trust the Physical Therapists at PEAK PERFORMANCE to do a thorough evaluation, to search for related but underlying contributing factors to kinetic chain dysfunction, and to design exercise progressions that both respect tissue healing and creatively use biomechanics principles to prevent symptoms and optimize carryover to your patients' functional goals. Call us at 218-0240 to discuss your patient's specific needs. Peak Performance is just minutes away from your patients in Penfield, Fairport, Pittsford, Brighton, Rochester and, of course, East Rochester. We promise Individualized, hands-on and biomechanically appropriate Physical Therapy for your patients. No "one-size-fits-all" approaches. We WILL go the extra mile and "dig deeper" to discover underlying causes for injury risk and delayed recovery using the most advanced Evidence Based methods available and, we’re able to make unique adjustments to exercise prescriptions to speed the return to function and to minimize or prevent symptoms from interfering. No surprises. No hassles. Confident your patient is in the right place. COME VISIT US AT 161 E Commercial St Just 1 mile off 490 ext (585) 218-0240 www.PeakPTRochester.com

Meet Michelle Ober, a workout fanatic and our Peak Performer of the Month for August 2022. Hopefully her story inspires you... Michelle slipped on ice Super Bowl weekend, February 2022 and badly broke her arm which required surgery to repair the extensive fractures of her humerus and radius. Allison went above and beyond to contact physicians to help Michelle get seen as soon as possible. Michelle now has a lot of hardware in her arm and her rehab was an uphill battle. Michelle says: 'I had to look for the ways that God was working in my circumstances, and to see the humor in things. I started with no elbow movement and was barely able to lift one pound. My kids had to help me dress! Now I almost have all of my strength and motion back. Thank you Allison for all of the stretching and being a cheerleader in each victory of my recovery!' Allison says: 'Wow, Michelle is serious about working out! Every time she gained range of motion, she would jump up and down and cheer! She had a goal to get back to plyo workouts including planks and push ups, and she did every thing I told her and more to get there. Michelle just had her six month follow up with her doctor and he was so impressed with her range of motion that he took pictures for her chart. I wish all patients could tap into Michelle's energy and drive! You're the bomb girl!!!' Peak Performance makes a $50 donation in honor the work of our Peak Performers of the Month to a charity of their choosing. Michelle chose the Bethany House. Congratulations Michelle and way to go!!

Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE August 2022 Optimizing Recovery from Lateral Epicondylitis by Rachele Jones, PTA, ATC, CAFS Clinical Scenario...What would you do? A 45 yr old female is in the office for the first time for 3 weeks now of lateral elbow pain related to paddle tennis. Plain films are deferred due to no indications based on history and presentation. She is locally tender at the common extensor origin at the LEP. AROM of the elbow/wrist/forearm are normal with some pain during wrist extension and flexion more than supination. Resisted digit III extension, wrist extension and grip > supination all reproduce her CC. I would… Order plain films to R/O any osteophytic changes or DJD and if (-) have her do two weeks w/NSAID’s and ice 15min BID and return for FU in 3 wks for re-assessment. Provide counterforce brace and have her attempt to return to play. Order physical therapy - to include Class IV laser, manual therapy, PRE including eccentrics, and other modalities as needed. To include biomechanical assessment of especially proximal joints. Offer and perform steroid injection to reduce inflammation and have her do a gradual return to activity over the next 7 days - return for FU if needed in 3 wks. CURRENT EVIDENCE MD Aminul Hoque Rasel, MD Obaidul Haque, et al. Functional Outcome of Lateral Epicondylitis Patients After Physiotherapy Interventions: - A Pretest & Posttest Study from Bangladesh. J Adv Sport Phys Edu 2021:4(8):193-197 SUMMARY: Lateral epicondylitis is a common overuse condition seen in family practice and orthopedic offices. Decision making on appropriate care often includes consideration of injections, NSAID’s, counterforce braces, rest/ice and activity modification and physical therapy. Clinical decision making is always best informed by updated research findings. In this study Rasel et al found that a multi-modal PT program was effective at reducing symptoms and increasing function for a group of 18 patients over the 6 week study period. While symptoms may be controlled adequately at least in the short term by NSAIDs, rest/ice, braces or injections, the inclusion or preference for Physical Therapy allows for use of modalities, manual therapy techniques, exercise, patient ownership and active participation in their recovery, patient education regarding modifying future risk factors of recurrence, - all with relatively low cost care and low/no risk of adverse events. This study does lack a control group, weakening the overall strength of the findings to some degree. It is clinically relevant though in that it demonstrates a multimodal approach being effective. Oftentimes studies attempt to single out specific treatments to prove efficacy. In real-world PT care patients would, in fact, typically have numerous therapeutic measures utilized to speed recovery. The use of Class IV laser has been an effective tool we also utilize for soft tissue overuse/tendonitis-tendinosis type cases. It is also critical for high quality therapy to include kinetic chain assessment of both distal hand-fingers function but also especially proximal thoracic cage, scapula and even core/hips/LE function since deficits in body positioning and capacity elsewhere can increase the demand at the elbow-forearm-hand during repetitive gripping and reaching activities. (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: Lateral Epicondylitis is a very common musculoskeletal condition experienced by more than 1-3% of people in the US each year. Lateral epicondylitis does not lead to gross disability but does limit function. The object of this study is to identify the functional outcomes that occur with a 6-week period of physical therapy intervention. Methods: Eighteen patients (aged 25 - 65 yr old, 10 males and 8 females) were selected by inclusion and exclusion criteria for 6 weeks of TIW frequency of visits (18 sessions), with a multi-modal approach of physical therapy incorporating, US, E-stim, deep tissue friction massage, stretches and strengthening. Assessment of pain and dysfunction were measured by the Numerical Pain Rating Scale (NPRS) and Patient Rated Tennis Elbow Evaluation (PRTEE) at initial visit and at 6 weeks. Findings: Results show significant reduction in pain between baseline and posttest, Three variables were looked at including: pain in the affected arm, specific activities, and usual activities. Overall pain in the affected arm, specific activities, and usual activities were all under p= 0.0001 and p= 0.000. At pretest distribution of pain was found at pretest for 6 ( 30%), specific activities 4 (20%), and usual activities 3 (17%)all of which were comparatively reduced after 6 weeks of PT care. Author's Conclusion: Six weeks of Physical Therapy interventions showed improved outcomes for pain and function. THE PEAK PERFORMANCE PERSPECTIVE Physicians in family practice and orthopedic clinics will oftentimes diagnose lateral epicondylitis as the primary cause of elbow pain. Numerous options exist for initial treatment. Clinical decision making often involves weighing options that may produce early and quick pain relief but do not address underlying weakness and/or stiffness issues versus the choice to prescribe physical therapy. This study by Rasel et al provides some guidance on the benefits of early physical therapy intervention as a key option. Lateral epicondylitis or “tennis elbow” is a common injury that affects 1-3% (Lai, et al, Open Access J SpMed, 2018) of the general population yearly, approximately 1 million people experiencing pain and functional limitations which could affect them for a few months up to a year or more depending on when treatment is implemented. The exacerbating issue is typically overuse and strain from repetitive gripping, wrist extension, radial deviation, and/or forearm supination activities. These may range from athletics, outdoor chores/gardening, fitness, ADL, work related, or recreational endeavors. This study broke down each of the participants by socio-demographic variables of occupation, age, gender, hand dominance, sight of pain. Occupations ranged from housewife (7 participants), service holder (4) to farmer (1 pt); 10 men, 8 women; and 13 of the 17 right hand dominant were affected on their right side, with 17 of the 18 had repetitive or forceful tasks or movements. This data shows that this condition can affect people spanning a wide variety of activities in both men and women. Left untreated for too long a worsening case of lateral epicondylitis can also negatively impact socio-economics regarding work related cases, where Lai et al found a worker’s compensation payout of $6,593 per case. Early intervention should be key for treatment efficacy and return to normal function as quickly as possible but also can help lessen the economic effect on one’s individual finances and on the entire country when health insurance premiums are considered. This study used a multi-modal approach to treatment because we have found out that there is no gold standard singular treatment that alone is consistently highly effective. Treatments must be individualized and can include many of the treatment types Rasel et al included in their study: deep tissue friction massage, ultrasound, electric stim (TENS), stretching and strengthening - together addressing key needs such as controlling inflammation and pain, increasing ROM, and restoring optimal function. One shortcoming here was that there was no control group so we cannot with strong evidence here demonstrate that these findings were significantly better than the natural course of lateral epicondylitis. The anecdotal experience of many clinicians is that a typical natural history of lateral epicondylitis disrupts normal pain free activity and does not spontaneously resolve. Thus, the consideration of early treatment is very appropriate and produces the quickest results toward restoring pain free normal function, minimize risks, and striving to reduce total costs to individuals and the healthcare system as a whole, all while enabling the patient to be an active participant in their own recovery through their customized home exercise program. While the modalities included in this study can be helpful, we’ve certainly discovered that the addition of Class IV laser therapy can be an important treatment tool for reducing inflammation and pain. The exercise portion of this study was far more basic and limited in nature than we typically find necessary. For example, customizing stretches into some ulnar deviation movement stretching the common extensor origin is often utilized. Strengthening procedures were not well explained but did include Theraband ® based concentric and eccentric loaded drills for the wrist extensors. We also often find that supinator work needs to be done and dysfunction of this muscle can mimic a more classic lateral epicondylitis. Their exercise parameters of 3x10 QD for the strength exercises are limited in scope and fail to address the tissue’s varying tolerances to loading and primary focus during different phases of healing. - We find that beginning in the more acute/reactive phase it is helpful to use very low load and high volume work (i.e. 10- - - >30 reps done 2-3/day), progressing later into 2x15 QD with light - - > low moderate type loading. The eventual goal is 3x10-12 reps at a challenging load done TIW, more so like a typical strength training workout at the fitness center. The other “stretch” not addressed in the article is the contribution of nerve mobility, specifically the radial nerve Oftentimes manual techniques and home nerve mobility programs are needed to restore normal mobility without pain. Certainly, one critique was that they are only treating the injury via local elbow/forearm related strengthening without any regard for the proximal joints or body as the whole (trunk + lower extremity etc.) which could have predisposed them to their lateral epicondylitis. A prior study of lateral epicondylitis showed that scapular weakness could be a contributing factor. Strengthening around the shoulder may be necessary along with ROM of the thoracic spine. Another option for strengthening would be use of a dumbbell for consistent load vs variable/amplified resistance band loading and more functional gravity based loading. Another issue with the study was the small group size, however, since they did reach statistical significance the level of impact may be even more noteworthy based on the small and somewhat heterogeneous group. This study chose two tests, the NPRS and the Patient Rated Tennis Elbow Evaluation (PRTEE). We believe that physicians should expect high quality PT to include not only self-report style questionnaires that can be helpful with test-retest reliability and trustworthiness but also must include physical testing of function and kinetic chain performance. This helps identify any other triplanar deficits that may be forcing the hand/arm into less than ideal positions to function and therefore be contributing to the eventual epicondylitis being treated. Standard therapies will often address the local symptom well enough but patients who are not treated with more intensive biomechanical assessment and exercise risk recurrences. Commonly, lateral epicondylitis is thought of as a local tissue overuse…which it is, technically, however in practice requires further assessment to ensure any underlying factors have been addressed, minimizing the need to revisit formal care and engage in costly medical system testing and potentially escalated treatments. Usually, a symptom producing activity can be modified via adjusting the plane of motion or body positioning in order to perform it sx-reduced or even sx-free. THE PEAK PERFORMANCE EXPERIENCE Frank said: (3 months later) “I have played 18 holes of golf 1 time, raked leaves & have mowed the lawn without any issues” History: 80 y.o. active male who fell and landed on arm during snowboarding,, three days later sx’s after 9 holes of golf swinging the club. Patient took a couple months off to rest, did Class IV laser, exercise, massage TIW and some physical therapy with slow progress; after 2 wks of interventions trialed tennis and then had sx’s with overhand serve. Subjective: 2/10 intermittent pain 1-2x/wk, pain with heavy carrying, backstroke, heavy pressing, reaching with increased loads no significant impairment with ADL’s most affected by sport; goal is to return to tennis, golf, skiing, snowboarding, and windsurfing DX: R Rotator cuff overuse and R Lateral Epicondylitis Objective: Initial Evaluation Re-Evaluation ~ 6 wks Numeric Pain Rating Scale ( NPRS) 2/10 0/10 DASH/ Quick DASH sport N/T 75% 2% 50% ADL Self rating 70% >= 90% Palpation Point tenderness of lat epi none Wrist extension PROM 60 deg 65 deg Wrist Flexion PROM 67 deg 75 deg FA pronation 60 deg 67 deg Thor Rot ( L/R ) 25 deg /30 deg 40 deg / 43 deg Wrist extension isometric strength 11.8 kg 14.3 kg ( 87%) R Pec minor tightness Moderate minimal Functional Testing 1st grip sx’s 3#--- 25# L >=25# R 30# 8# wrist extension ( L/R ) NT 25x/23x OH reach 8# ( L /R ) 1x/5x 23x/20x Treatment: Ultrasound, E-stim, DTM/ cross - Friction massage to extensor muscle common origin , pec minor, PROM, AROM, resistance training to shoulder, forearm and wrist Re-Evaluation: improved palpation, AROM, PROM, overall function, and strength.

Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE (July 2022) Clinical Decision Making on Reducing Dynamic Knee Valgus-rotation …It’s not always the hip! by William Slapar, PT, DPT, OCS, CMTPT, CAFS Clinical Scenario...What would you do? A 16 year old female comes in for follow-up four weeks after evaluation for persistent left medial patellar pain that developed during running and lacrosse without any specific trauma. She’d already been seeing a personal trainer and has continued working on hip Abd’s and ER’s strengthening drills related to asymmetric dynamic valgus noted on your initial exam. Rest from running/sports x 2 weeks and gradual return to activity was prescribed. She was able to continue strength training with her hip stabilizers but symptoms returned as she resumed interval runs and 50% effort and volume lacrosse practice. Single leg squat observation shows no change of dynamic knee valgus/rotation vs eval findings. Ober’s (-) . Merchant view plain films showed mild but symmetric lateral patellar tilt and glide and Insall-Salvati ratio was (-) for patella alta. Patient is a junior who is eager to get back to lacrosse participation especially for upcoming exposure tournaments and scouting camps to attend this summer. My clinical thinking is: Course of prescription NSAID’s, painfree cross training and no practice, and order MRI to further assess and R/O chondral pathology - FU in 2 wks. Order patellofemoral buttress stabilizer brace and do gradual return to lacrosse. FU 2-3 wks. Refer to sports-ortho Physical therapy including biomechanical eval including distal factors (since hip work thus far not effective controlling dynamic valgus/rotation) - BIW x 4 wks allowing gradual activity return per symptom status. FU 4 wks. Refer for instrument assisted soft tissue mobilization of especially ITB/ lateral structures along with dry needling. CURRENT EVIDENCE Ban R., Yang F. “ Preliminary study on acute effects of an intervention to increase dorsiflexion range of motion in reducing medial knee displacement.” Clinical Biomechanics, 95, 2022; 2-6. SUMMARY: Dynamic Knee Valgus (DKV) is a commonly seen biomechanical failure that can lead to various different knee injuries, from as minor as an MCL sprain or patellar subluxation event to as severe as an ACL tear. Physicians ordering Physical Therapy must consider if they trust a thorough biomechanical screening and care plan will be performed. Key concerns may need to be emphasized on prescription orders for initial care episodes, in post-op cases, and especially changes in therapy providers following failed early rehab attempts when surgery is not yet indicated. There are many different biomechanical factors that may contribute to DKV. Most often physicians/physical therapists/trainers focus on the proximal influence, the hip. This article by Ban and Yang shows that there is an oftentimes missed distal influence as well, limited dorsiflexion, that is amenable to treatment that mutually reduces DKV. This pilot study tested 8 healthy participants (18-32 yo, 6 female, 2 males) presenting with DKV, or medial knee displacement(MKD) (measured as an outcome for DKV), during an overhead squat, where the MKD was reduced by a heel lift. Dorsiflexion ROM was measured in 3 different static forms (passive straight knee, passive bent knee, and lunge). Their intervention (foam roll, static stretching, PF/inversion strength exercise and single leg squats) increased DF ROM and resulted in a reduction in MKD, thus decreasing DKV. Dorsiflexion loss, while a distal sagittal plane restriction, causes a proximal compensatory transverse and frontal plane effect at the knee resulting in DKV. Limited DF can result in a compensatory strategy of talus Internal rotation that unlocks the MTJ to produce needed “DF” but at the midfoot. Kinetic chain biomechanics dictate that talar motion will induce tibial Internal rotation and abduction, leading to femoral internal rotation and adduction - all resulting in DKV. The body often seeks the path of least resistance, here, with the midfoot’s available DF becoming the resource when the ankle proper (TCJ) DF is limited. While that mechanism may produce DKV, likewise, the frontal/transverse plane knee may become it’s own “path” for shock absorption and adaptation to ground changes through DKV when the foot-ankle are not compliant with adequate eversion. This study did not examine all factors contributing to DKV, therefore DF loss alone cannot be assumed the cause of DKV/MKD. Therapists must test all possible contributing factors to DKV to optimize patient outcomes. High quality care goes beyond the simple treatments used in this study to include manual therapy and more biomechanically authentic exercise options to optimize neuromuscular integration for ADL and athletic use. Nevertheless, there was a measurable benefit from a single care episode in reducing MKD/DKV. Depending on the severity of the restriction this may normally take weeks for a difference on DKV. Because traditional therapy often assumes a proximal cause when DKV is present physicians may need to specify “assess and treat knee valgus prox/distal factors” for initial PT scripts. For “failed” cases, it may be beneficial to review with patients specifically what exercises were done to determine if therapists/trainers had discovered and addressed distal factors or not. Background: Dynamic Valgus, medial knee displacement, which has been an important biomechanical failure we see in athletes, especially females, has been associated as a risk factor in lower extremity injury, especially ACL tears. Loss of dorsiflexion (DF) has recently been shown to contribute to medial knee displacement (MKD). Purpose: (1) to explore an intervention to increase ankle dorsiflexion range of motion during the three static measurements (2) to test if increasing dorsiflexion ROM could reduce MKD in individuals who demonstrated MKD corrected by a heel lift in squatting. Methods: Eight healthy participants (18-32 yo, 6 female, 2 males) who displayed dynamic valgus in an overhead squat that was alleviated by a 2 inch heel lift were included Treatment included foam rolling, knee flexed and extended slant board stretch, tubing inversion and WB PF raises in IR, plus single squats for integration - all done in single session. The dorsiflexion was assessed in 3 different ways statically: passive straight-knee, passive bent-knee, and weight-bearing lunge. Findings: A single session of interventions targeting dorsiflexion ROM increased dorsiflexion in all three static positions (all P < 0.01 with moderate effect sizes) and a significant reduction in medial knee displacement (P =0.02) during an overhead squat. Author's Conclusion: The intervention protocol used was beneficial in improving dorsiflexion limitations for those showing MKD on squat testing related to apparent DF restriction and that addressing DF ROM may be helpful in reducing MKD as a a risk factor for ACL injuries. THE PEAK PERFORMANCE PERSPECTIVE Physicians treating knee injuries commonly see Anterior Cruciate Ligament (ACL) tears but also other conditions and injuries that often may experience common overload positioning, whether as microtrauma or as a sudden event, that involve dynamic valgus/rotation. Patellar dislocations and instability, MCL injuries, and meniscal injuries are among these. Early decision making on treatment choices and ensuring risk factors have been properly identified and are being addressed is critical. Physicians making initial treatment orders or especially in cases of “failed care” are tasked with identifying key factors that may require specific emphasis on prescriptions they write to ensure Physical Therapists/Athletic Trainers address biomechanical issues properly in rehab. Anterior cruciate injuries are one of the most common injuries in sports. The fact that this injury is most often a non-contact injury and occurs with between 600-2300 N of force shows that there are numerous factors that we must consider before treating a patient to prevent/reduce the risk of this injury. One well studied and accepted concept related to risk is dynamic valgus/rotation, the biomechanical failure that leads to the increased stress/tensile load on the ACL along with other structures. Ban and Yang provide an important piece of work in connecting the loss of DF with abnormal MKD-DKV during squatting and the ability for even a single session of therapy exercises to significantly influence DKV. We define dynamic knee valgus as being a combination of excessive femoral adduction along with internal rotation in combination with tibial abduction and internal rotation. It is commonly measured via the resultant “medial knee displacement” for objective testing in research or clinical observation. Most often physicians and therapists/trainers alike risk assuming the source is commonly referenced proximal factors at the hip. This results in exercises to strengthen and neuromuscularly train the hip abductors and external rotators. While these are critical considerations and often effective methods careful evaluation is needed in the rehab setting to ensure the primary and ALL key influences potentially contributing to DKV have been identified. Too often a “protocol-like” approach is taken that automates a series of hip based exercises without specific objective evaluation to determine underlying factors. Ban and Yang do a great service to orthopedic and rehab professionals in identifying that a lack of dorsiflexion could be causing a distal or “bottom-up” mechanical compensation into knee dynamic valgus/rotation. However, while this can definitely be true we must then evaluate the other parts of the lower kinetic chain. Each of the reasons listed below requires its own unique treatment path toward the goal of reducing the severity and frequency of DKV, with the end goal of reducing abnormal loading on the at-risk tissues surrounding or in the knee. Strength and motion of the hips are certainly critical, but sometimes it is a bony anomaly, such as anteversion that is pre-loading the system. The foot, not only regarding DF, but also other foot mechanics as the first body part dealing with ground reaction forces that induce kinetic chain loads is critical. Sometimes orthotic intervention is necessary to reduce abnormal forces and to optimize the ability of the neuromuscular system to then improve dynamic stability control actively through exercises. High quality knee rehabilitation must include a substantial checklist to determine the most significant and likely issues for a patient presenting with DKV/MKD. Common deficits we see with patients who have DKV are: Lack of dorsiflexion: this often results in either early heel rise, which reduces the contact area and thus stability within the lower extremity or very often we see this sagittal plane TCJ restriction causing overpronation at the STJ which unlocks the MTJ to obtain the necessary sagittal dorsiflexion for force absorption eccentrically…resulting in the tibial IR distally that contributes to DKV or MKD along with reduced distal stability in general Foot alignment/structure: abnormal foot mechanics issues, including rearfoot and forefoot varus “deformities” can result in compensatory overpronation; this results in tibial IR forces that contribute to DKV tendencies Limited calcaneal eversion: the STJ needs to be able to evert for proper adaptation to the uneven ground and force absorption as a part of our body’s deceleration process; Limited calcaneal eversion can cause excessive compensatory MTJ collapse into general foot pronation and/or kinetic chain demands on the knee to adapt to the frontal/transverse plane absorption normally dealt with by the STJ Hip anteversion: this is a huge disadvantage to DKV, and other joints, due to the anatomy having an increased tendency to femoral internal rotation, displacing the knee medially Weak hip ABD and ER: strength deficits of these are commonly accepted contributors proximal causes of DK, allowing for excessive femoral frontal and transverse plane collapse medially due to ground reaction forces and superincumbent body weight loading Quadriceps weakness: since force dampening/absorption involves the pronation kinetic chain pattern including tibial and femoral IR especially, quad weakness may result in poorer control of knee flexion and a tendency for the knee to collapse medially (far more often than excessive lateral movement) The case below illustrates an example of an athlete who had DF limitations that contributed to abnormal knee dynamic valgus who was helped by specific functional manual therapy and customized therapeutic exercise progressions where proximal factor approaches alone would have missed key contributing factors she needed addressed. THE PEAK PERFORMANCE EXPERIENCE Allison said: “I was able to play my tournaments all weekend long (4 games) and did not have any knee pain on either knee” History: Allison is a Junior in high school who has been playing lacrosse all season and now getting scouted during the summer. She has to run/sprint, cut, play defense,using all three planes of movement at all times during her play. Her knee pain came about as a repetitive overuse nature. She had R sided knee pain that with rest ordered from an Orthopedist resolved but then her opposite L side started to bother her two weeks later. Objective: (*=pain) Eval 4 week Re-Eval STJN WB DF R=250 L=150 R=280 L=250 6” Anterior step down L= * 1st rep, w/ mod. DKV, R= 15x, min-mod DKV increases with reps L=15x (fatigue with 1/10 pain) min. DKV R=x20(fatigue), min. DKV SLB rotations L=stays in pronation, lacking resupination R=5th digit WB with resupination L= min. resupination, LOB R=mod resupination ability Single legged hop 10 sec L= 1x *, mod DKV, with immediate RLE touch down R= mod DKV, LOB L=min DKV, min frontal trunk sway to regain balance R=min DKV, SLB mini-squats L = Mod DKV and * R=mod DKV L=min DKV R=mod DKV Prone Hip PROM (IR/ER) R=55/300 L=53/300 NT Key Findings: LE Posture: squinting patella B with overpronation B; anteversion of B hips, anterior step down shows anterior pelvic tilting of the hips with shaking of the tested leg due to quad inability to descend body weight eccentrically with proper control in sagittal and frontal plane. Hamstring imbalance, ABD and ER strength was near symmetrical based on handheld dynamometer. Treatment: Manual FMR DF mobilization in wb/function followed by STJ neutral stretching of the soleus and calf, supination drills to improve overall foot mechanics in the rearfoot for supination efforts and forefoot for pronation control. Anterior step downs 4-6” with toes off box to isolate the quads better, Hamstring strengthening in functional weight bearing 3D movements. Lunges for all planes with different foot positions during landings to mimic natural lifting patterns. Deceleration exercises through multiple planes at foot positions to mimic on-field play for cutting/agility, multiplanar landings for single legged hips and multiple hops with turns, Blaze Pod reactivity lacrosse drills, and progression of multiplanar speed drills to achieve working in two or more planes at once. Outcome: Pt was able to achieve a personal goal of competing in summer tournaments and scouting camps while being in PT for just 3 sessions and starting speed days within 2 weeks of PT evaluation.Pt is a continuing PT to complete her 3D functional exercise progressions to further optimize the ability to control abnormal DKV in order to improve performance and reduce risk. Pt has difficulties in the frontal plane with more than just sagittal movements. Also increasing proximal kinetic chain work to further improve physical performance.

Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE June 2022 Using 2D Video Testing with Runners - Analyzing Biomechanics to Treat and Prevent Injury CLINICAL SCENARIO…What do you think? A 35 year old runner comes in with L lateral knee pain gradually developing and worsening over time as running mileage has increased and hilly terrains have been added to workouts of 4-5d/wk running. She has (B) mild squinting patella in resting standing, worsened slightly in single leg stance, over pronation L > R in single leg balance, painful single squat from ~ 150 - 400, (-) Ober’s and McMurray’s, unremarkable plain films, and local tenderness over the ITB at the lateral femoral condyle. You refer her for ITBS with orders to evaluate and treat. She’s returning for a 4 week FU and here’s what she tells you about her PT experience so far … A. Did a 10min evaluation and provided her with the clinic’s ITB Syndrome exercise sheet including 3 different ITB stretches, 4” step ups, clam shells. No major changes yet. Sore after step ups but PT said it may hurt for a few weeks and then should begin reducing pain. B. Did a 45 minute evaluation and found less L knee valgus/femoral IR/pronation with medial posting an OTC insert, noted L STJ neutral squat DF loss (prior ankle sprain hx) - doing ankle mob’s and soleus stretching, customized depth of step downs to 1” box to avoid pain during quads training, doing Class IV laser now, working hip ER’s in wb. Sx 40-50% reduced now. Treadmill assessment planned once sx reduced to allow jogging. C. Did 20min evaluation and began with instrument assisted “scraping” technique tissue mobilization to ITB, ultrasound, resistance band walks, NWB inversion tubing to strengthen foot along with towel toe scrunches for intrinsics. Sx 10-20% better. PT requesting script for iontophoresis. What would you decide for each case? 1. Determine the therapy is not specific/customized enough, the eval was too cursory and treatments are not biomechanically focused. Consider allowing 2 -3 more weeks of care before changing (or change now) to a PT/clinic doing more in-depth biomechanical testing and customized exercise. 2. The treatments are appropriate and on track. Happy with present status. Advise to continue PT. 3. Concerned about the lack of more thorough evaluation and use of generic and assumed local ITB approaches (stretches, soft tissue work) despite no (+) ITB tightness findings. Contact the PT to discuss the case and to question if underlying causes/factors identified and what further testing is planned. 4. Order an MRI to R/O a degenerative lateral meniscus tear or small chondral lesion that may be causing the lateral knee pain. Summary: Physicians and physical therapists frequently see runners for their most common issue, lower extremity injuries. If “overuse” is really to blame, knowing running is a bilateral reciprocating activity, then why are these injuries so often unilateral? Physicians routinely send runners for physical therapy. The real key is what happens next. As a physician, do you really know? Is a patient who comes back “feeling better” truly better? How do we get beyond simply treating the pain/inflammation and actually identifying biomechanical causes or technique based issues that may be contributing to the diagnosis made? Is the naked eye adequate in identifying these issues with treadmill or on-ground running analysis? The use of 2D video testing can help identify areas needing further biomechanical and orthopedic assessment for tightness or weakness or poor neuromuscular control. They also provide excellent feedback for possible technique cues runners can implement to alter the abnormal forces being produced. The gold standard in visual recordings to understand the biomechanics during running can be done utilizing expensive 3D (sagittal, frontal/coronal, and transverse plane views) cameras/software but this must include the right operational setting, which is unobtainable by most therapists and their patients. More recently, 2D (sagittal and frontal plane) analysis has been increasing in availability as a practical way to help providers and runners observe individualized mechanics and form during running. This can aid to help better understand the faulty biomechanics potentially leading to the “overuse” injuries we hear patients report in the clinic. Martinez et al. compared sagittal plane 2D and 3D analysis of running kinematics and determined that the 2D measurements 2-50 from the gold standard 3D counterparts and can serve as an effective way to record qualitative and quantitative information that could not be seen easily by the naked eye alone. Maykut et al. in similar fashion looked at 2D vs. 3D in the frontal plane focusing on pelvis-hip-knee relationships and also found good validity and reliability vs 3D. In the mode of “practice what I preach”, I used 2D analysis on myself with the SPARK MOTION ™ app available at Peak Performance to analyze my running mechanics, helping to better understand what I may be doing well, and more obviously not well and perhaps identify reasons for the knee pain I get with increasing training and mileage. (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) CURRENT EVIDENCE Martinez, Caitlyn, et al. "Comparison of 2-D and 3-D Analysis of Running Kinematics and Actual Versus Predicted Running Kinetics." International Journal of Sports Physical Therapy 17.4 (2022): 566-573. Background: It is crucial to have a tool such as 2D kinematic motion analysis to predict kinematic measurements in distance runners and is needed to compare accuracy vs 3D gold standard as well as measured and estimated kinetic variables. Method: 30 runners averaging at least 20 miles/wk ran on an instrumented treadmill at their preferred training pace for 6 minutes before having kinematic data measured by markers placed on anatomical landmarks on left LE then data collected on both 2D and 3D camera systems. Ground reaction forces (GRF) were also recorded as kinetic data to compare against published kinetic prediction formulas vs 2D and 3D measurements. Results: Significant difference did exist between 2D and 3D kinematic measurements however average difference for all 2D kinematic data was within 2-50. Previously published kinetic prediction equations were supported by both 2D and 3D measurements for GRF and loading rate. Author’s Conclusion: Accurate predictions of kinetic variables can be made using spatiotemporal and 2D kinematic variables. Maykut, Jennifer N et al. “Concurrent validity and reliability of 2d kinematic analysis of frontal plane motion during running.” International journal of sports physical therapy vol. 10,2 (2015): 136-46. Background: Due to temporal and financial constraints, concurrent reliability and validity need to be assessed for 2D analysis of runners in the frontal plane. Method: 24 collegiate cross country runners completed a protocol on a treadmill at a self selected speed with frontal plane (FP) data collected using 3D and 2D motion analysis systems. Variables of interest were contra-lateral pelvic drop (CPD) peak hip adduction angle (HADD), and peak knee abduction angle (KABD). Results: 2D analysis demonstrated excellent intra-rater reliability for peak HADD and CPD. Moderate correlations between HADD were noted between 2D and 3D of bilateral LEs and KABD on the left. No statistical significance between CPD between analysis however a strong correlation was present between HADD and CPD. Author’s Conclusion: The ease of 2D running analysis in capturing FP variables can be effective when assessing HADD and with close relations to CPD. THE PEAK PERFORMANCE PERSPECTIVE Andrew Neumeister, DPT, FAFS, CAFS, Certified Running Gait Analyst Physicians must scrutinize what the best options are for the treatment of runners with lower extremity pain. Simply addressing local symptoms with modalities along with rest and gradual return to activity may provide short term relief but not address underlying causes or reduce likelihood of recurrence. Biomechanical based testing, both from a local and global on-ground movement performance basis but also from a functional task analysis (i.e. treadmill or ground) of running itself can be a necessary tool in directing treatment needs. Runners are often considered a different “breed” l because from the external perspective…who enjoys running for the sake of running? But talking to and working with these individuals gives you an appreciation for the dedication they have towards their sport and the oftentimes stress that is willingly put on their bodies. Many runners end up with short or long term recurring injuries that are not easily improved with rest or general stretching. I have been fortunate enough to have had a fairly injury free running career transitioning from sprinting and 400m hurdles to the marathon and ultra-marathon distance post collegiate. As the evidence base for 2D running analysis has grown, it was time to practice what I preach and see what biomechanical flaws I may have with my running form and shed light on a fortunate brief battle with R knee IT band syndrome. Utilization of 2D analysis can provide a skilled practitioner with more specific biomechanical data to assist in both evaluating and treating the patient to more quickly hit the ground running… Martinez et al. accomplished some of the hypotheses they set out to test in the sagittal plane in regards to comparing 2D analysis against the gold standard of 3D. Despite statistical differences noted between leg angles, strong correlations were found between the variables. Variables of interest assessed for the left LE included shoe angle at initial contact, tibia to vertical at initial contact, knee flexion angle at initial contact and mid-stance and vertical position of center of mass at mid-stance and double float. The average difference between 2D and 3D variables were 1.4-4.90 depending on which kinematic angle measured which can provide benefit when assessed by a seasoned biomechanical clinician by assessing for kinetic flaws or potential pitfalls in the injured runner. With an acceptable mean of <50 difference between an affordable 2D analytic system and an impractical 3D motion capture setup for the clinic environment, abnormalities can be discovered that are not otherwise observed with the naked eye in real time. It thus becomes a powerful tool for evaluating and making treatment choices in order to counter biomechanical and/or technique shortcomings. Maykut et al. conducted a similar study to the one above, however looked at the frontal plane positions of the pelvis, femur, and tibia relative to each other and vertical. Again, the authors concluded that no statistical correlation was found between 2D and 3D analysis for pelvic drop and knee abduction, however, peak hip ADD had a strong correlation found and that HADD correlated with CPD. Intra-rater reliability was also found using 2D software and this knowledge allows a clinician to be confident in their observations to make sound decisions to better expedite recovery and return to activity. Peak Performance and Spark Motion™ Technology It is easy to glance over the results or discussion pieces in current literature and see that the authors failed to find statistical significance between certain variables and dismiss the data. Although 2D and 3D analysis is statistically different for many kinetic variables, moderate correlation was found for HADD in the frontal plane which is commonly associated with increased triplanar dynamic valgus (knee abduction, femoral IR, knee flexion). Almost all clinicians will agree that reducing dynamic valgus stress at the knee throughout impact and loading is pivotal for reducing risk of injury. The use of 2D motion capture technology gives clinicians the capability to slow down or even freeze frame and draw vectors to compare asymmetrical loading during a reciprocating activity. Being able to show someone who is having pain while running their own biomechanics and comparing left to right and/or versus normal mechanics is an extremely powerful tool to guide treatment of pathologies. This can be especially true for those with “overuse” injury because the asymmetries or abnormalities in their inherent biomechanics of running technique can be so small they are not otherwise evident. The images of me below are depicting commonly measured variables during 2D analysis in the frontal and sagittal planes performed in our office. One of these pictures may stand out more than the others when assessing running form and body positioning during initial contact, mid stance, and heel off. It may seem trivial when noticing the extent of abnormality/asymmetry when asked to pick it out of this collection below; however would this clear visual have been found without 2D running analysis??? How fast can you spot my mechanical pitfall that contributes to IT syndrome? Being able to “connect the dots” biomechanically is critical in not only helping patients overcome their present issue but also in providing confidence to patients and providers alike that the risk of recurrence has been greatly reduced! R Hip ADD Mid-stance L Hip ADD Mid-stance L Hip Extension Toe Off Tibial Inclination IC Knee Flexion IC 9 Deg DF Mid-stance 9 Deg Knee Flexion Mid-stance 35 Deg

Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE May 2022 Hip Osteoarthritis Clinical Decision Making: New Evidence Affecting Treatment Recommendations by Allison Pulvino, PT, MSPT, CMP, FAFS Clinical Scenario…What would you do? A 62 yr old male with 6+ months of progressive hip pain seen for ortho consult referred by PCP. Pt had been taking NSAID’s for 6 weeks and attending physical therapy for 4 wks with limited improvements in pain, ROM, and overall function. Plain films show Gr III-IV degenerative changes in the R painful hip joint and Gr II-III changes on the pain free L side. He enjoys fitness classes including low to moderate impact drills, playing golf and tennis, and hiking with his wife, including mild-moderate elevations. Clinical exam shows NWB A/PROM asymmetric R hip limited in flexion, IR, extension more so than other directions. I would... Recommend 3 series gel injection and reassess in 3-4 months. Advise to continue HEP given by PT and limit activity to non and low-impact only. Recommend patient stop impact activity and switch to pool exercise and cycling for exercise for 2 months and then FU to consider other options such as injection. Update PT prescription or change providers to include BIW manual therapy (+ advancing exercise for ROM and functional strengthening) for at least 4-6 wks before considering HA gel injections. Perform single cortisone injection. Potentially controversial but presently acceptable since only one recent study showed (-) effects on potential rapid degeneration. Change NSAID’s and advise the patient to continue the present PT program for 4 more weeks. CURRENT EVIDENCE Shepherd, et al. “The Influence Of Manual Therapy Dosing On Outcomes In Patients With Hip Osteoarthritis: A Systematic Review”. Journal of Manual & Manipulative Therapy. (2022) 10. 1080/10669817.2022.2037193 Summary: Hip OA is a common ailment causing symptoms and limiting function. While joint mobilization techniques have been shown to be helpful and clinical practice guidelines have formally recommended them, there is a lack of clear dosing parameters known to produce best outcomes. This systematic review initially found 4,675 potential studies on the topic but only 33 were eligible for further review, with only 10 meeting all criteria - this included being an RCT, measuring outcomes, and having specific dosing parameters reported. Of the 768 total participants, it was noted that sessions were most frequently 2-3x/wk, patients had a mean of 6-12 sessions over 1-12 wks, with manual therapy performed in 7 sessions. Effect sizes ranged from small to large depending on the variable measured (pain, ROM, function). While no clear dosing parameter could be recommended based on findings, there were ranges noted that can serve as evidence based starting point. Hip arthritis care, for patients as well as for providers, risks being viewed as an accepted “routine” and “keep it simple” care model mentality. Many experienced physicians may be relying on evidence based “best practices” from studies published many years or even a decade or more ago. Physicians seeing patients themselves and who are training upcoming physicians in residency or fellowship may be unaware of newer evidence published in recent years around the use of joint mobilization efficacy with hip OA. This is a key factor when considering treatment recommendations and prescription content for physical therapy, along with specific recommendations vs a “wherever is most convenient” thinking that is intended to ease the burden on patients but may unintentionally lack discernment regarding extent of manual therapy performed. Often patients have been told prior to PT that “they’ll show you some stretches to do at home” - setting patients up for expectations about PT that may not be consistent with best practices. This study did not find a specific set of parameters supported by the evidence that can be applied “across the board” for joint mobilization in hip OA cases. The heterogeneity of the mobilization parameters does, however, support the idea that there is no single parameter that needs to be followed to achieve results. It suggests that knowledgeable, skilled PTs have the ability to make clinical judgments regarding the customization of techniques used, application of force, directions, and volume/frequency of treatment that result in (+) outcomes. Physicians should know, when ordering PT, that manual therapy techniques lasting 10-30minutes, 2-3x/week, for 6-12 sessions are an evidence based part of appropriate hip OA care. (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: Hip OA is a common cause of pain and limitation with functional activities for many older adults. There currently is good evidence that joint mobilization is effective in improving pain, ROM, and function however there is not documented well studied specific dosing recommendations for hip OA manual therapy treatment parameters. This review study attempts to establish more specific treatment guidelines for this diagnosis based on RCT level evidence. Methods: This is a systematic review that included randomized controlled trials (RCTs) and utilized joint-focused manual therapy. Inclusion criteria were detailed dosing parameters of manual therapy type, direction of force, session duration, frequency of interventions, and numbers of sessions, were published between January 2000 and December of 2021, and met the criteria for hip OA according to the American College of Rheumatology. Findings: Within 4,675 studies, 33 were eligible and 10 were included meeting all the criteria. There were 768 participants with treatments performed by physical therapists and two chiropractors. A variety of manual therapy interventions were performed, including the Mulligan concept (MWM), long-axis high-velocity low-amplitude thrust (LA-HVLAT) mobilization, and non-thrust mobilizations. Parameters used ranged widely. Risk of bias assessment was also done along with outcome-level certainty using the GRADE approach. The most common MT type used was LA-HVLAT. The most common directions of non-thrust mobilizations were lateral and caudal glides with some form of hip IR. Long-axis distraction was used in 7/10 studies. All forms of MT when compared to a control group, improved hip ROM in the short term. Quality of life improvements were documented as medium and large between-group effects after 6 weeks of treatment but small after one year, with regards to the HOOS QoL subscale. Five studies assessed functional performance including walk speed, step-count or a walk test, and large between-group effects were found with walk-test improvements. The largest between-group effect sizes were seen for pain and ROM using MWM into hip flexion and IR when compared to a sham, no-force intervention. Author’s Conclusion: There were some trends that clinicians can consider from this study. The largest within-group effects for pain and ROM and self-reported functional gains were from LA-HVLAT, specifically performing thrust techniques (up to 9 times) and for longer durations of three to six sets (30-45 seconds). When considering non-thrust mobilizations LADM for 10 minutes with 30 second bouts. If hip flexion and IR ROM are limited, then MWM into these motions was shown to have the greatest improvements. There was a lack of specific dosing parameters for many studies so further research is recommended to allow for MT frequency and techniques to be more concisely recommended. Clinical trials should also include baseline sensory and pain neurophysiology assessments, as well as psychosocial assessments as they can influence clinical outcomes. THE PEAK PERFORMANCE PERSPECTIVE Hip OA is a common diagnosis that both primary care and orthopedic physicians see in the office routinely. The pain, progressive loss of motion, and weakness that negatively impact function require consideration of what the best options for treatment recommendations are. Physical therapy has been shown effective in the care of hip OA but physicians considering best practices are oftentimes uncertain regarding the specific recommendations to make on therapy prescriptions and in educating patients about what to expect. Shepherd et al, in this systematic review, analyzed RCT’s to discern if there were specific treatment parameters with manual therapy treatments for hip OA that could be identified for purposes of understanding best practices related to optimizing outcomes. This is critical for both referring physicians writing prescriptions and educating patients regarding therapy expectations. Physicians are also discerning next steps when a patient is apparently “failing” an episode of therapy and the adequacy of care provided must be assessed before deciding if different therapy or escalating care to injections or surgery is called for. And of course these dosing parameters would be critical for practicing therapy providers to understand. While the question on dosing parameters is a good one, this study, like many others, may suffer from the challenge we all see as clinicians. The attempt at a homogeneous answer for the sake of minimizing variability in treatments of the “same condition/diagnosis” is admirable and logical but often ignores the heterogeneity of the patients themselves. Also, many diagnoses have multifactorial considerations. Sometimes evidence exists demonstrating a common approach or parameter that can be consistently used. But, there also exists significant variability within our patients’ lives and bodies that impacts treatment decision making, often leaving linear, singular treatment decisions inappropriate or non-specific to this case. External validity factors in applying research recommendations are often forgotten or neglected too often. Clinical judgment based on both evidence and experience, leaving a “range” of options vs a singular algorithm-like, mathematical equation-like answer that every single provider could and should arrive at equally, is a key portion of our day to day practice as providers. Manual therapy is an effective and necessary component of hip OA care but the evidence does not support a strict and specific dosing parameter that is “one-size-fits-all” in nature. That is not a “bad” finding but speaks to the “art and science” of clinical practice. Our patients are unique - they come with a variety of preconceptions. Oftentimes they verbalize their own expectations of what therapy will entail and will do for them. We have heard requests of massaging the tightness away or to provide them with three or four “easy exercises” to help get them back to where they were years ago or just a quick morning “stretch routine” that can be done daily. Some, of course, say they’ll do whatever it takes to perform their favorite activity again. Many are under the impression or have been expressly told by their physician that physical therapy will be a few short weeks only to learn a home routine. While evidence from the past has certainly demonstrated the efficacy of simple ROM and strengthening exercises with hip OA cases there can sometimes be an unawareness of what the newest research and clinical practice experiences show regarding the efficacy of other treatments in optimizing hip OA outcomes. That can contribute to physicians having mistaken paradigms and providing patients with inaccurate expectations of what physical therapy will include and the length of time likely for formal care. For patients, the disconnect that happens when the PT’s treatment recommendations differ sometimes significantly from their own preconceptions or physician’s advice can sabotage their confidence and trust in therapy, their “buy-in” to the treatment process, and their compliance. It’s helpful, therefore, for physical therapists to share important evidence and experience based updates with referring physicians to update current thinking on best practices in hip OA care. What we as therapists typically do is often different from what physicians and patients expect, both in terms of the extent of biomechanical considerations within the evaluation as well as the variety of treatment options available within therapy. Many patients may have already looked up information from Google that there are the “3 best movements” for everyone’s arthritic hip or have a sheet of six exercise pictures from a friend or other PT or even a physician. Most of the time patients become pleasantly surprised when therapists educate them on all the ways therapy will help them achieve their goals, and it’s much more than exercise. Good evidence exists and clinical practice guidelines now formally recommend the use of manual therapy, especially joint mobilization and/or thrust techniques, for the benefit of pain reduction, ROM gains, and eventual function improvements. While stretching and strength are very important components to be able to move comfortably, it is specifically manual therapy (MT) techniques that decrease pain the fastest and assist in movements with more fluidity and ease, as well as decreasing someone’s compensatory strategies causing pain onset in other joints or even the opposite extremity. Shepherd et al found trends in MT techniques that show the most gains in ROM and pain control, mentioning mobilization with movement techniques (MWM) and long axis high velocity low amplitude thrust (LA-HVLAT) techniques among others, consisting of 10-30 minutes of treatment, 2-3 times per week, for a duration of care from 2-6 weeks as the ranges noted in the RCT’s examined where (+) outcomes were noted using manual therapy to reduce pain, increase ROM, and or function was examined. That is a general suggestion but also needs to be based on individual presentations, level of current and past functional abilities, motivation, fear avoidance, and psychosocial status. All patients are individuals and we as providers need to treat them as they are. Very often a “simple” approach is considered a starting point for all patients. For many this can be appropriate. For many others the case is more complex or goals are loftier. That is where customization of treatment planning comes in…starting with a thorough biomechanical/orthopedic evaluation. We often find that the “regional interdependence” considerations of the kinetic chain result in the need to address other body parts affecting or being affected by the arthritic hip. If one’s goal is to walk 3 miles per day and there is a significant hip flexion contracture, there is a high likelihood of compensations into the spine or opposite knee or hip as that person’s ipsilateral stride is shortened from lack of hip extension. The lumbar spine often hyperextends to take up the lack of extension, potentially contributing to low back pain but also forcing the opposite extremity to be overloaded on impact over time. Carefully assessing the functional mechanics of gait and other ADL, work, or sport movements is key. Many hip OA cases likely require manual joint mobilizations to assist increasing ROM and reducing pain where there hasn’t been correct mobility and mechanics in months or even years. Multi-plane functional hip mobility exercises in all three planes in standing, as well as ankle and knee mobility will all be incorporated into a patient’s treatment plan. Once patients start to feel more comfortable, functional strength and dynamic stability has to be applied through patient specific therapeutic exercises to control their newly achieved hip ROM, thus allowing for functional gains in ADLs and recreational activities. THE PEAK PERFORMANCE EXPERIENCE Diane said: “I feel so great walking, it’s not catching anymore like it used to!” History: Diane was coming into PT for c/o L buttock pain, anterior L hip pain and knee stiffness and pain. She is a nurse and stated she required assistance to help her even walk without limping. She couldn’t quite figure out why she was limping so significantly, but has a history of back, pelvic/SI joint and hip/knee issues on that L leg. Objective: Diane fell off of a step onto her L knee in 2015 initially injuring L knee. She also had been in a MVA in 2000 with c/o L posterior hip pain ever since as well as posterior pelvic pain. She was unable to sit > 20 min, standing > 20 was painful, and any walking was painful at the time of PT exam. Bending forward and squatting was painful as well. Pain could get up to 4/10 and at times was constant. Initial Exam Re-evaluation Hip extension -10deg (flexion contracture) 10deg Prone hip ER 25deg 30deg Prone hip IR 45deg 45deg FABER test Pos Neg O’ber’s test Pos Neg Thomas test Pos Neg Hip Scour Pos Neg Pivoting for directional change L fear of instability No fear/no issue Anterior step down L unable/fear of buckling 2” step down w 8# DB Sit-stand UE assist/stiffness 10x w/o UE assist Key Findings: Diane had a L knee flexion contracture and almost no L hip ER and extension and also was observed to have her L leg longer than her R. She was limping and almost falling into her R leg during gait and her tolerance to any walking was limited (facial grimacing). Treatment: Diane received manual therapy treatment for at least 15 min at the start of every treatment consisting of L hip lateral and caudal (long axis) distraction with a mobilization belt, with 10-20 oscillations followed by 20 sec holds, as well as MWM hip extension and ER mobs 2x10 each direction, each visit. She was also advised to get fitted for a custom external shoe lift as her LLD was of much significance. She performed self SI joint correction, hip ER stretching, elevated hip flexor stretching followed then by resistance band ER pivot step outs and hip flexor loading in/out of extension with sliding discs in WB for ease of increased stride in gait. Other exercises performed including hip adductor stretching and lateral weighted lunges loading adductors instead of abductors, and SLB with transverse plane top-down loading, eccentric step downs for quad loading, incline side planks in/out of hip adduction for ease of WS in gait. Outcome: Diane can walk, squat and negotiate stairs as well as complete all transfers without pain limiting her. She is very happy with her progress and soon to be discharged from PT to live an active lifestyle. 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 April 2022 Key Mistakes in ACLR Return to Sports Decision Making: Can We Trust Hop Testing Data? by Mike Napierala, PT, SCS, CSCS, FAFS Clinical Scenario...What would you do? A 27 yr old male semi-pro developmental league football wide receiver sustained a non-contact deceleration injury during a cutting move and has an MRI confirmed isolated ACL tear. He underwent autologous patellar tendon ACL reconstruction and has been participating in BIW - - > weekly post-operative physical therapy. He has progressed very well and is presently at the 12+ month mark. Subjectively he is painfree. On clinical exam he has (-) Lachmans and Pivot Shift test findings. Your quick MMT of quads and hamstrings sitting on table are very good and painfree. He is eager and confident in his readiness to resume football practices. He reports performing progressive agility and plyometric drills at PT. His PT Re-Evaluation report did not yet make it through for review. He wants your approval to resume non-contact practices including route running and change of direction drills w defender, blocking drills…progressing to full contact scrimmaging and play over the next 4 weeks. My clinical thinking is: He needs to wait until at least the 9 month mark to reduce risks of contralateral knee ACL injury. He is doing well. He may return gradually now and progress his participation based on his comfort level and coaching feedback on movement quality. Perform in-office single leg squats, vertical and rotary hop testing observation and then decide. Call PT to discuss Re-Eval findings while Pt is in office or wait to obtain test findings before final decision. Counsel patient on risk management and call back with orders once testing reviewed. CURRENT EVIDENCE Kotsifaki A, et al. Symmetry in Triple Hop Distance Hides Asymmetries in Knee Function After ACL Reconstruction in Athletes at Return to Sports. Am J Sports Med, 50:2, 2022, 441-450. https://journals.sagepub.com/doi/pdf/10.1177/03635465211063192 SUMMARY: ACLR recovery risks becoming a “routine” for both surgeons, therapists, and patients alike. As a surgeon/physician how do you really know an athlete is ready and safe to return to sports (RTS)? Are you certain they’ve prepared properly and thoroughly in their rehab? Key decision making centers around the quality of rehabilitation especially in the intermediate phase leading up to return to function progressions and eventual testing used to determine return to play. Recent data on recovery from ACLR regarding return to prior sports participation is disappointing. Some evidence suggests that only 65% return to prior levels of sports participation and risks of a second ACL injury have been reported up to 29% (Australian football/rugby showing rates of even 40%). . Limb symmetry index (LSI) is often used for RTS testing of strength and hop performance among others. Consensus is, however, lacking regarding the “best practices” on specific tests and scoring to optimize successful return and reduce future injury risk to the ipsilateral or contralateral knee. Some data suggests that LSI values alone do not accurately reflect the function and biomechanical performance properties of the ACLR knee and limb. Kosifaki et al performed 3D motion analysis during a triple anterior hop test comparing 23 healthy male controls with 24 post-op ACLR male athletes who were cleared for RTS(ages 18-35, Tegner > 7). Among inclusion criteria were quads LSI > 90% and hop battery tests LSI > 90%. They used 42 reflective markers with a 14-camera system and force plate, requiring hands remain on hips and a 2 second hold upon final landing. The ACLR group had 97.1% LSI . The ACLR group showed the involved limb landed with greater hip flexion, trunk flexion, anterior tilt and peak knee flexion angle was less as well as less knee flexion moments. ACLR involved limbs also showed knee work absorption LSI of 80% with second rebound and final landing but only 51% and 66% for work generation LSI during first and second rebound take offs. Hip work was higher and ankle work lower for the involved ACLR group. In controls and uninvolved limbs alike the knee plays a greater role during the abslorption or typical “injury” phase than in the propulsion phase thought to create the distance of the hop test findings. It is imperative that surgeons and therapists be critical about not only the RTS phase of recovery but the intermediate phase preceding that. This phase oftentimes is considered “routine” and merely a “putting in the work” mindset by both clinicians and patients. But it is this foundational strength and power development phase that can set up the knee-quads and lower extremity for success or for compensation based “false success” noted in mere LSI based testing. Traditional PT rehab exercises involving triple extension, while being functional, also risk setting up the ACLR athlete for compensatory patterning with the hip extensors from early on. The ability to “isolate” the quads during integrated functional patterning is critical. Unfortunately it’s all too often a missed or lost art in rehab clinics across the world. That may be the reason that despite such extensive therapy so many ACLR studies show persistent quad weakness, and, that quad weakness remains one of the key limiting factors to successful RTS. This study also did not examine frontal and transverse plane issues with landing mechanics regarding “dynamic valgus” risk factors. These also must be appreciated and addressed during testing performance, beyond simple LSI numerics. Surgeons and physicians during the post-operative phase remain in a critical role because they must discern if the rehab being done is appropriate and thorough enough to confidently trust that desired outcomes will be achieved. Routine care and mere protocol adherence is likely to fail. The literature certainly demonstrates that as a total collective the health care system is not presently producing high outcomes for our ACLR patients. Below are further details regarding key approaches that distinguish biomechanically authentic methods of approaching Quad rehab and hop testing beyond traditional approaches for the sake of optimizing function and reducing re-injury risk. Background: ACLR return to sport (RTS) and second injury rates are both unacceptable. Limb symmetry index (LSI) with hop testing is commonly used as a means of assessing readiness for sport but some data suggests kinetics/kinematics may not be normal despite symmetry of distance measures. Purpose: To determine if restoration of lower limb biomechanics during triple hop for distance testing is ensured by passing discharge criteria post-ACLR. Methods: Controlled clinical lab study using 3D motion analysis of 24 male athletes after ACLR who were cleared to RTS (LSI > 90% for quad strength and hop battery testing) compared to 23 healthy male athletes (participants 18-35 yr ). A 14-camera + force plate, using 42 body markers, was used to collect data. Findings: Despite reaching 97% LSI for ACLR involved side distances, the absorption work LSI was 80% and work generation were only 51% and 66% for first and second rebounds respectively. The relative knee work was less for involved limbs and hip work larger (P < 0.001) for all phases vs uninvolved and control limbs. Hip, pelvis, trunk compensations were noted with ACLR involved side limb testing. Author's Conclusion: Triple hop limb symmetry masked important knee deficits in knee joint work which were more prominent during work generation (concentric push off) than absorption (eccentric landing). THE PEAK PERFORMANCE PERSPECTIVE Surgeons and physicians caring for post-op ACLR patients are most often comfortable with familiar rehabilitation protocols they have often used for years. These oftentimes have been introduced during fellowship training or possibly through interaction with “experts in the field” via publications or conferences. ACLR recovery risks becoming a “routine” task for both clinicians and patients alike, especially for surgeons who perform numerous ACLR’s monthly even upwards to 150+ per year. For patients, physical therapists, and athletic trainers the multiple visits weekly process also risks a “routine” feeling that can undermine the appreciation for subtle biomechanical factors that must be addressed if the RTS phase is to go well. The real question at hand is are we all being scrutinizing enough? Are we discerning the subtle details as best possible in order to optimize recovery and reduce reinjury risks? The literature would suggest we are not! As a surgeon/physician how do you know your patient is ready to RTS? Do you carefully scrutinize the test reports sent by PT’s and ATC’s? How often do you recommend delaying RTS or has it become routine to approve progression based more so on time than supportive data? While there is no consensus or clear answers as to the “right” thing to do the successful return to sport data and second injury data are both disappointing to say the least. While individual experiences may be different the collective data suggest that surgeons and therapists/trainers are too often failing to ensure optimal recovery, including for those allowed to RTS. Over 30% of those undergoing the long recovery process of ACLR never make it back to their prior and expected level of sports participation. One in five sustain a second ACL injury. Surgeons sit at the healm of decision making in terms of protocols used and in discernment over where rehabilitation is done. Therapists and trainers are daily making treatment decisions that impact the training effect achieved…whether that be potentially reinforcing compensation patterns or optimizing more authentic normal neuromuscular function. We all have a hand in these mediocre outcomes. We all want excellence though. Kotsifaki et al demonstrated that despite 97% limb symmetry with triple anterior hop testing that important biomechanical performances were significantly still abnormal/asymmetric compared to the uninvolved limb and control limbs. Knee work was less, especially for concentric push off following an absorption (ie, plyometric type “rebound” effect”) though still only 80% for the typical injury phase eccentric absorptions. Proximal segment compensation from hip/trunk extensors was evident on involved limbs as well. Symmetry on triple hop distances was clearly NOT achieved because the “knee” itself was normal and symmetric! Underlying this subpar performance at the knee, even in just these sagittal plane indicators, is quad strength deficits. Traditional post operative protocols and real-life rehabilitation programming often attempt to utlize what are thought to be “functional” approaches to exercise advancements, with the intention of stimulating the neuromuscular system and mimicking real-life demands for activities like stair climbing that will eventually evolve into decelerating a cut or landing a jump. That means “triple extension” based exercises that intend to stimulate the hip-knee-ankle activation used for successful squating maneuvers. Typically that involves squats, leg presses, split squats, lunges, step downs, step ups, sled pulls and pushes and eventually impact based drills for jumping and hopping…etc. Unfortunately post operative pain and effusion disproportionately effects quadriceps performance more so than other related muscle groups in squat function. That open door for compensation, especially from the hip extensor hamstrings and glutes, more often than the short plantarflexors means that PT’s and ATC’s doing ACLR rehab must be keenly aware of how to recruit quads preferentially. Otherwise the risk is that too early or too casual or careless an “advancement” to functional ADL prep training exercises like stepdowns or step ups etc will produce significant compensation patterns that become harder to undo later down the road. Avoiding these mistakes requires attention to detail and personalized/customized exercise programming and cueing. The use of surface EMG biofeedback can be helpful but the real key is understanding biomechanics and carefully observing exercise techniques during squatting drills. While in one hand we appreciate and desire the “protective” effect of hamstring co-activation regarding it’s potential to reduce anterior shear forces we also need care in habituating quad inhibition and inadequacy during strength training drills. We don’t believe the answer is merely a focus on seated NWB quad extensions to isolate the quad but generic “functional” exercises like lunges and stepdowns done incorrectly can facilitate quad avoidance that will lead to poor declaration mechanics down the road. While this study did not examine frontal and transverse plane mechanics risk factors (ie. Dynamic valgus/IR) which is well known and accepted, these are key areas of focus during ACLR rehab. Since this is a multifactorial issue there is not a singular protocol-based approach or exercise that can simply be done to address dynamic valgus control or deceleration. Focused testing for anteversion, abnormal foot mechanics leading to overpronation issues, hip weakness issues of the abductors and/or external rotators, and dorsiflexion loss are some of the key underlying causes that we find related to dynamic valgus/IR that can be addressed with proper physical therapy care. We do perform hop testing and find it valuable. Normative data tells us that significant asymmetry is not normal. Yet, we also know from Kotsifaki et al’s data and others that mere LSI symmetry is also not enough information to prove normal function. Without expensive research level testing equipment clinical testing relies on keen observation skills and qualitative assessment beyond simple number crunching. But the well studied sagittal plane dominated tests used over the past decades in ACLR research we believe are lacking in their authenticity to real-world mechanism of injury biomechanics where frontal and transverse plane forces also occur. We utilize side-side hopping tests along with rotational hopping tests to force the knee to prove it can handle/decelerate and stabilize dynamic valgus/rotational type loading. Many PT exercise programs post ACLR also maintain a prolonged focus on “knee over the foot” directional intention for landing drills. While this is necessary and safe early on during healing concern time frames it is deleterious to neuromuscular training of authentic biomechanics loading forces the athletes will incur when they do return to the court or field and must contend with multiplanar knee and lower extremity loading. A key consideration is whether rehab has taught that knee and LE to successfully decelerate and reverse dynamic valgus/rotational inertial loading. The reality is that these forces WILL happen to athletes knees during sport. Excellent rehab does not pretend that conscious control of intended ideal paths will always be the norm. It must progress to contending with the original MOI and prove that safe dynamic stabilization and progression of the intended sports movement can happen. Below is a case study of my son’s ACLR experience at Peak Performance. Unfortunately the demands of work and parenthood altered his ideal rehab consistency further into his recovery but his excellent progress in the early formative months post op set him up for his return to football practices and soon to be game play. THE PEAK PERFORMANCE EXPERIENCE Jordan said: “I feel faster than I was before I got hurt. I'm making cuts in practice, getting open and catching the ball. I’m not 100% yet but I’m feeling good!" HX: 29 yr old male sustained a change of direction R knee giving way injury doing a wide receiver route in practice on turf in March 2021. He underwent autologous patellar tendon ACLR 3.29.21 and initiated rehab 2 days later. Subjective: At 7 month ReEval patient reported 1/10 max sx, 70% subjective function. By his 9 month ReEval he reported less frequency of symptoms but not yet painfree, likely due to his progression of activity and reducing HEP and PT compliance (new baby). Subjective function 80% , able to do sprinting, light route running and catching, IKDC 90%. Objective: (*=pain) 7 mo ReEval 9 mo ReEval Isometric 600 Quad 56% 78% 6” cone 900 pron - 600 sup rotational no touches 20sec Prior testing 114%...NT NT Vertical Hop 70% 550/470 3x Crossover Ant Hops 18’3” w reduced knee ant excursion and min excess trunk/hip flexion 19’0’ (97%) w improved knee and trunk mechanics + no abn Dyn Valg 900 Rotational Hops 10sec (40 unit radius) 9x (100%) (60 unit radius) 10x (111%) WB Quads Anterior (toes off) Stepdown 6” 40# DB’s 20x (71%) 50# DB’s 24x (86%) Key Findings: During intermediate phase mild increased hip flexion (ant tilting pelvis) often occurred during intended quad dominant squat PRE type drills and excessive trunk incline (hip extensor compensation) along with limited anterior knee excursion would occur during lunges and split squats. Frontal and transverse plane control had become excellent by 3 months post op and was advanced accordingly but did not require the typical extra attention often noted. Compliance became an increasing issue with PT visits falling off and HEP reducing significantly with birth of first child during at the 8 month post op mark. Treatment: During intermediate phase rehab dynamic frontal and transverse plane proprioceptive/stability drills were advanced via single leg balance drills including use of VibePlate plus reduced visual feedback (eye/eyes closed) work and distraction/perturbation techniques with ball passing and manual perturbations, eventually leading into “on-impact” mini squats with perturbations producing dynamic valgus type loading forces for deceleration/stabilization. Early on reliance on hip extensors and plantarflexors to assist squat function triple extension drills were gradually transitioned into Quad dominant stimuli using “front rack” (upright trunk) DB’s positioning, toes off Ant stepdowns with posterior trunk lean and posterior pelvic tilt cueing and lunging drills with toes off ¾” plywood landings to optimize knee flexion moments for quad recruitment. Impact drills were progressed into single leg push offs for power, single leg landings in place - - - > with distance excursion …and then multiplanar landings. Eventually proximal kinetic chain demands with inertial loading into diagonal patterns producing dynamic valgus replications of sport-like demands were included and then finally with reactive catching medicine balls into “at-risk” positions of the trunk-BUE. Plyometrics and agility drills proceeded as well with intention transition into combined frontal-transverse plane demands. Outcome: Pt has continued HEP inconsistently and returned to weekly (9+ mo mark) - - - >biweekly football practices and now at one year post op has done full contact scrimmaging and preparing for first official team scrimmage out of town. 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 March 2022 Optimizing Outcomes & Reducing Costs for Ankle Sprains: New Evidence on the Impact of Delayed Care by Karen Napierala MS, AT, PT, CAFS CURRENT EVIDENCE Rhon DI, Fraser JJ. et al.“Delayed Rehabilitation Is Associated With Recurrence and Higher Medical Care use After Ankle Sprain Injuries in the United States Military Health System. JOSPT, 51(12), 2021 2021;619-627. (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) Clinical Scenario...What would you do? A 24 year old male comes into your office after a 2nd time ankle inversion MOI with local swelling and pain. Non weight bearing AROM inversion and plantarflexion are limited/painful and dorsiflexion is significantly limited. His gait is antalgic with considerable favoring. Plain radiographs are (-) for fracture. Anterior Drawer test is mild Grade iI laxity. The patient is eager to return to activity as soon as possible, including work on the 2nd floor office building with a mix of sitting/walking/stairs, resuming fitness running and singles tennis league, and has three children aged 3 months to 5 years . I would prescribe… RICE and gradual activity return as able - call if problems. Rest in boot x 1-2 weeks + RICE and then go back to activity gradually - call if problems. PT with Class IV laser, early motion/proprioception work and wb progression activity. FU 4 wks if needed. Crutches PWB until gait normalized, simple HEP exercise sheet of generic ankle exercises, return to activity as symptoms allow. FU in office 6 weeks. SUMMARY: A retrospective cohort study of US MIlitary Health System beneficiaries (active duty/retired, family, etc) seeking care for an ankle sprain between 2010-2012 using only data available with both 12mo look-back and 12mo follow up data, resulting in 24,502 cases. Cases were grouped into receiving rehabilitation and no rehabilitation. Using medical and financial billing records, the effects of timing of rehabilitation on injury recurrence and injury-related medical care costs and visits were measured up to one year after injury. Approximately 1 in 4 people received rehabilitation. The probability of a recurrent ankle sprain increased for each day that rehabilitation wasn’t provided during the first week and plateaued for the next 2 months, becoming 2x (OR = 1.97) greater for those receiving PT at 8-12 weeks vs those starting rehab within 4 weeks. The total cost were also greater (OR = 1.13) for those delaying rehab vs early rehab, up to $1400 per episode. Overall recurrence and costs were less for those not obtaining rehabilitation, however, likely contributing factors such as severity and activity goals were not studied, among others. Data did include stratification considering other military duty related and medical comorbidity effects on recurrence and costs. The conclusion was that the earlier the musculoskeletal rehabilitation care started directly after the ankle sprain occurs the lower the chance of recurrence, as well as the downstream ankle-related medical costs. Early care is also important based on the other studies showing over 33% of ankle sprains go on to become chronically unstable. We believe not only early care is necessary but high quality care that includes discerning biomechanical assessment and customized manual therapy/exercise. There are many potential contributing factors for ankle sprain recurrence that are also related to optimizing recovery from a current episode that are not necessarily part of traditional therapy approaches. Our anecdotal experience supports research showing progression to CAI in what seems to be a significant number of patients who themselves and/or their providers viewed an early ankle sprain in a “routine” or sometimes dismissive way. Many factors related to faster/better recovery and prevention of recurrence are controllable. Background: In the US military, 329,702 enlisted members and 30,554 family members received care for ankle sprains over a 9 year time frame from 2006-2015. Many studies show that after two weeks the pain has retracted. Studies have shown 5-33% of ankle sprains have some pain after one year and that 15-54 % didn't recover after 3 years. Recurrence may happen up to 8 years after the initial injury. Over 33% of these sprains have been shown to become chronic ankle Instabilities (CAI) cases. College students with CAI averaged 2100 less steps per day. Total financial burden (adjusted for inflation) of ankle sprains can range from $11.7M to $90.0M per year. Early treatment for other musculoskeletal disorders has been proven effective. The authors studied time to begin rehabilitation on ankle sprain recurrence or future use of medical care for that ankle. Methods: This retrospective cohort study includes all beneficiaries (all active and retired military members, their families and other affiliated beneficiaries) of the US military Health System seeking care for an ankle sprain over a two year period from 2010-2012(with 12mo look-back 2009 to look-forward 2012 range limits). The 39,340 total cases resulted in 24,502 individuals diagnosed with an ankle sprain injury having a full 12-month look-back and follow up. Groups were divided into those with and without rehabilitation following an ankle injury which they sought formal care. Rehabilitation was identified by cases with medical encounters that included medical billing codes for therapeutic exercise, therapeutic activities, manual therapy, and modalities. Not all rehabilitation was from a physical therapist. There was a sub group for direct military clinic care, or civilian network clinic setting since the costs would be different. Considerations were given for comorbidities including: cardiometabolic factors, chronic pain dx, insomnia, depression, anxiety, concussion/ traumatic brain injury and PTSD. Findings: There were 6150 individuals who sought care for ankle sprains and received rehabilitation and 16,325 who did not have rehabilitation (27.4% who sought care received rehab and 72.6% who sought care did not)! Delayed rehabilitation was linearly associated with increasing probability of recurrence (after adjusting for comorbidities.) The probability of recurrence in the rehab groups increased each day during the first week post injury that treatment was not sought. It then plateaued until the first month, then increased again the second/ third months. Individuals who received physical rehab between 8 and 12 weeks had 1.97 greater odds of recurrence compared to those who received immediate physical rehab within 4 weeks. Delayed rehabilitation was linearly associated with a greater number of ankle-related medical visits.Of all the comorbidities, a chronic pain related diagnosis amplified the amount of visits they were seen in a medical office (by at least 10 visits). This translated to $292 to $2268 per cse for ankle sprains with delayed rehabilitation. Individuals in the non rehab group were 32% less likely to resprain. They hypothesized that these people chose far less risky activities and were much less active following the first sprain. (especially when they had chronic pain, or PTSD). Author's Conclusion: There is a greater chance of ankle sprain recurrence, chronic ankle issues, and increased cost to the system and individuals when rehabilitation for the sprain is delayed. THE PEAK PERFORMANCE PERSPECTIVE: Ankle sprains are one of the most common musculoskeletal injuries that occur. These injuries are seen in primary care, orthopedic, and podiatric physician office regularly. Not only patients but also providers all run the risk of thinking, “It's only an ankle sprain - rest it and go back in a week” …but is that the best option now and in the long run for our patients? For perspective, there are a few key facts to be aware of. Ankle sprains were the primary reason for lost (military) duty days in 2017 - 2018. Recurrence may happen for up to 8 years after the initial injury. Chronic ankle instability occurs in up to 40% of individuals with that first time lateral ankle sprain. The financial burden to the military is 11.7M to 90.9M per year! Military ankle sprain numbers have been shown to be similar to the active civilian population in their response to this injury. This study shows that what we do with them not only affects the patient's lifestyle in the future, but both their own financial costs and the total cost on the insurance system. So how do we as physicians and therapists make our decisions on how to treat? I am seeing a 50 year old male now who has had low back and L knee pain for years. During the initial history he reported the L ankle was sprained repeatedly in high school - with only a “walk it off “ rehabilitation that was popular then. He never regained his normal ankle dorsiflexion, and was left with a host of issues including inability to squat appropriately on his L leg due to that lack of dorsiflexion. His compensation happened to be extreme pronation during squatting. This led to decreased balance, subsequent increases of tibial and femoral internal rotation during WB activity that produced a “dynamic valgus” collapsing of his knee,( resultant patello-femoral pain, and quad weakness) his hip(glut medius weakness and poor pelvic control), and eventually affected his back. If the ankle was treated appropriately initially, 30 years of knee and hip abnormal mechanics may have been prevented. There are internal and external contributors to the ankle sprains. You can get yourself faster, more nimble and able to avoid these, External factors such as a tree root , rocks, uneven surfaces, or another player's ankle all can cause excess motion and sometimes means, no matter how perfect your anatomy is or how well trained your balance and agility and strength may be, you're probably going to sprain that ankle. Internal factors (biomechanics) are really the key place that changes can be made to reduce risk and optimize recovery. Good therapy should include looking at the biomechanics and functional patterns of the entire lower extremity. What is the cause for the injury? Have they returned to full ROM without aberrant planes of motion compensating for the lack of normal motion? Is there poor mobility that can cause the ankle to more frequently “live” near that injury risk position? Here are some key things we’d screen for (outside the typical ankle ROM, strength, etc) : Lack of dorsiflexion in subtalar neutral (needed for late gait phase mechanics). Without proper ankle sagittal plane motion, the ankle will choose to compensate into other planes (such as transverse, or frontal in abnormal amounts) or in the sagittal plane via early heel rise, reducing the area of contact for inherent stability. The ability for the ankle to help dissipate forces with jumping, running, and and cutting relies on all three levels (hip, knee, and ankle) to adjust the speed of deceleration when gravity is accelerating you towards the ground. Foot alignment/structure. An uncompensated rearfoot varus(stiffly inverted NWB and WB) or a compensated forefoot valgus (supinated foot with higher arch - including inversion tendency) - both especially concerning since 94% were lateral or inversion sprains. Limited Calcaneal eversion. The subtalar joint’s ability to “load” into eversion/pronation upon hitting the ground in walking or other movements/athletics allows you adaptation to uneven surfaces. Frequently we see ankle sprain patients unable to evert in general, meaning they are living that much closer to inversion (ie risk). Hip retroversion and/or cocca valga will also set an individual up for the foot to be an inverted position and can predispose an individual to ankle sprains A pronated foot oddly enough may also predispose someone to ankle sprains. A prolonged everted position may negatively impact the proprioceptive awareness of excessive inversion and also be less reactive at the peroneals due to the delayed stretch reflex. We’ve seen numbers of these in the clinic where patients or providers first expected the patient to describe a deltoid or eversion MOI sprain but instead they did experience an uncontrolled inversion episode. Prior concussions or balance issues lead individuals to be less apt to adapt to quick changes of direction, or the surface you are moving on. Proprioception - generic and inversion control specific. Oftentimes balance testing identifies a more general lacking of neurologic sensorimotor mechanoreceptor system function such as with eyes closed or dominant eye closed with head up mini squats, but the ability also to specifically control for frontal and transverse plane loading into inversion/supination must be determined. Left untreated these sprains can bring on secondary issues. The example of the 50 year old with a 30 year old ankle sprain is far from out of the ordinary. Studies show that many ankle sprains “feel “ better in 2 weeks. Once they feel better there is a tendency and risk as a clinician and certainly as the patient to think that they “are” better. But we look at the “being better” as an objective, measurable thing rather than simply a feeling the patient has. We want them to have enough motion to be able to handle the unexpected, or live out their dreams, not just be able to walk on a flat surface for 20 minutes. College students left untreated with subsequent ankle issues were found to walk 2100 steps fewer than their intact ankle cohorts. It’s key that good therapy help take them from “feeling better” to “being better”. That requires simply starting with physical therapy early, as Rhon et al found. The next key is that quality care will include actually looking for the biomechanical issues that predispose them to “living in a box” of safety and limitation. Especially for athletes and for active lifestylers the goal must be instead be to help them be capable of performing “outside the box” of safety and of constrained motions and loading where risks are always kept low, so they can return confidently to the activities they love but do so with less risk of recurrence. The following case exemplifies the benefits of early rehab following an ankle sprain. THE PEAK PERFORMANCE EXPERIENCE: Terry said: “ I am playing volleyball on a high level with minimal to no issues. I can jump and land indoors. The stiffness I had in my ankles is gone!” History: Terry was a high school volleyball middle hitter. She had to jump high, and land hard. If the set and/or her approach was off then she’d have to tolerate landing off balance on one leg, risking inversion forces. She injured her ankle during volleyball when she landed on an opponent’s foot, causing a rapid inversion - she heard a “pop” and immediately had difficulty walking and could not play. Plain films were (-). She used crutches for a week. PT began three days after the incident. Objective: Pain limited R squat to 50 plantarflexed (ie no dorsiflexion on the R). Symptoms were localized to the anterior talofibular ligament and the peroneal tendon below the lateral malleolus. (*=pain) Initial Eval Re-Eval STJn WB Dorsiflexion -5 R/ 21 L 19 R / 21 L Single leg squat knee angle Unable to do / L 55 R 65 / L 70 Calf raise 2 R/ 24 L 28 R/ 30 L 3” quad dom step down (eccentric ) Unable * 10 # front racked R/ 22 L / 24 Single leg hop 10 sec R/unable L/ 14 B 15 16 reps Lateral lunge Unable * 15# low reach R 19x L 21x Single leg balance rotation 15 sec Unable R 6x L 8x Med/lat 3 step directional change 15 sec 8 feet distance unable* 10 reps Key Findings: Treatment: Terry began ROM in PT 3 days post injury. She received manual grade 1-2 mobilization in pain free ROM. She began AROM and dorsiflexion with strap assist. She followed with 3 dimensional WB soleus/ gastroc stretches in available pain free ROM. She was able to do Partial WB calf raise that week, as well as proprioceptive balance training static, and dynamically progressed to full WB Eyes closed within a week. She started regaining strength within a week and began uneven surface/ BAPS, and stepping soon after that. We used Rock tape to ease the swelling and provide stability as she progressed. After 2 weeks: She was able to join in practice limited to serve receive and serving. She practiced swing skills standing at the net. Outcome: By 4 weeks she had been doing enough agility/ strength and proprioception that she went back to playing with an ankle brace on and no limitations 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 January 2022 Examining the Necessity of Prescribing Joint Mobilization for Plantar Fasciitis by Rachele Jones, PTA, ATC, CAFS Clinical Scenario...What would you do? A 58 yr old male developed gradual onset of R plantar foot and heel pain over the course of 2+ months while continuing to participate in 3mi distance running BIW-TIW, which he’s done for the last six years. He also has mild+ R knee OA that is painful but not preventing him from running. He’s tried OTC arch supports without relief. Plain films are WNL. Tenderness locally at the calcaneal tuberosity plantar fascia insertion and along the medial band of fibers into the longitudinal arch. MTP extension is WNL. NWB ankle DF is WNL both knee flexed and extended. He does have R early heel rise with (B) squat testing. A quick balance assessment shows asymmetric overpronation on his L foot. His morning sx upon 1st wb and local tenderness suggest plantar fasciitis/fasciosis. My clinical thinking is: A. Recommend two visits of Physical Therapy for HEP instruction in simple traditional protocol of stretching the plantar fascia/calf muscles. B. Prescribe a course of NSAID’s and then if not better in 4 wks consider steroid injection. C. Order a night splint to stretch out the plantar fascia. Follow up in 3-4 wks to reassess. D. Prescribe PT Eval/Treat (including Laser, manual therapy as needed, functional strengthening and dynamic balance work) . E. Obtain further diagnostic studies (either diagnostic US or an MRI). CURRENT EVIDENCE Anat Shashua et al, The Effect of Additional Ankle and Midfoot Mobilizations on Plantar Fasciitis: A Randomized Controlled Trial. Journal of Orthopedic & Sports Physical Therapy 45:4, 2015 265- 272. https://www.jospt.org/doi/full/10.2519/jospt.2015.5155?rfr_dat=cr_pub%3Dpubmed&url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org (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: Plantar fasciitis, or fasciosis as it is more accurately often referred, is a common condition causing heel/arch-foot pain seen by physicians and physical therapists. Determining appropriate referral practices is dependent on evidence based findings. Plantar fascitis(PF) is commonly treated with stretching based approaches, including joint mobilization techniques, however, clinically we more commonly find overpronation issues as a contributing factor, resulting in “overstretch” of the tissue rather than abnormal local fascial tightness in the foot. Dorsiflexion loss is thought to be one of the kinetic chain issues that might underlie PF. This single blinded RCT examined the addition of a standard set of ankle-foot mobilizations to a routine stretching + ultrasound treatment to determine efficacy of joint mobilizations. While subjects in either group who had limited dorsiflexion showed (+) gains from joint mobilizations, the intervention group did not show improved outcomes on self-report foot scales or algometry or overall group improvements in WB DF ROM. We feel this study cannot be used as a basis to disclude foot-ankle mobilizations from high quality care of PF cases due to heterogeneity of the groups regarding tissue healing phase and limited number of cases with noted DF (or other) ankle ROM and a lack of clarity in maintaining STJ neutral positioning that is authentic to late stance biomechanics demands during testing, stretches, and mobilizations in order to control for compensatory overpronation. Mobilizations should not be assessed in isolation because clinically any gains in ROM should be immediately followed by proprioceptive/strengthening exercises to integrate new mobility into function. Also, the limited BIW x 4 wks treatment time was potentially inadequate for the wide range of chronicity in the sample, ranging from 1 month to 24 months. Physicians should expect high quality physical therapy include specific matching of applied mobilization techniques to joints tested to have limited ROM. This study’s conclusion more accurately should indicate that limited simple joint mobilization techniques applied to cases of PF both with and without proven joint restrictions do not demonstrate group benefits over simple stretching and ultrasound alone. Background: Plantar fasciitis (PF) is a chronic degenerative process to the plantar fascia, better referred to as fasciosis, which affects approximately 10% of people in their lifetime. Ankle dorsiflexion limitations is thought to be a common contributing factor to the development of plantar fascia. Methods: Randomized controlled trial using 50 participants (23-73 yr) who had heel pain generated by pressure, increased pain of 3+ on the NPRS scale in the morning with first few steps or after prolonged non-weight bearing, diagnosed with PF. All participants received 8 treatments at BIW frequency including a stretching program and ultrasound. The intervention group also received manual therapy mobilizations of the ankle and midfoot joints. Primary measures were from three outcomes: numeric pain rating scale (NPRS), Lower Extremity Functional Scale ( LEFS) and algometry. Dorsiflexion was measured twice at the beginning and the end of treatment. Participants were evaluated at baseline, after 4 sessions, end of treatment ( 4 weeks) and a 6 week follow-up via telephone for NPRS and LEFS but only twice for algometry and dorsiflexion ROM were measured at baseline and at end of treatments. Findings: No significant differences in finding between groups and outcomes. Both groups showed significant differences in NPRS and LEFS and improved dorsiflexion ROM. All data analysis was conducted using the intention-to-treat approach. Author's Conclusion: Results suggest that the addition of manual joint mobilizations of the ankle and foot to improve dorsiflexion ROM is not any more effective than stretching and ultrasound alone. The association between limited DF and plantar fascia is most probably due to soft tissue limitations vs joint restriction. THE PEAK PERFORMANCE PERSPECTIVE Physicians deciding on best practices for the care of their patients with Plantar Fascitis (PF) often must discern both whether Physical Therapy will be ordered but also more specifically appreciate what appropriate treatments will be included in what they might expect to be “excellent” care. Joint mobilizations are commonly incorporated in physical therapy treatments. The question at hand is whether patients with plantar fascitis will benefit from and if appropriate physical therapy care “should” include joint mobilizations. This study by Shashau et al had good intentions and measuring properties but in the long run does not completely support the authors’ conclusion that ankle/midfoot mobilization therapy is not effective for plantar fascitis. First, some key foundational questions physicians and therapists alike must ask are… “Does everyone who has heel pain/ plantar fasciitis have DF restrictions and need ankle and foot mobilizations?” and “Is there a ‘protocol’ - like treatment plan that works well for all plantar fasciitis cases regardless of being acute or chronic or regardless of underlying patient-specific causes?” Let’s begin with the general question/concept of PF that we see first clinically - plantar fasciitis cases generally fall into two groups: excessive PF tightness (supinated or high arched foot) related and excessive lengthening (ie often overpronation) related. In our experience we tend to see more cases involving overstretch mechanism related, oftentimes due to overpronation. Interestingly, most PF “protocols” tend toward treating this as a “PF tightness” problem and focus on further stretching the connective tissue and related muscles. Many “failed PT” cases we see with PF diagnosis have overpronated feet (and overstretched plantar fascia) that were treated with stretching exercises for the plantar fascia. If, as we often see in the clinic, a patient demonstrates considerable or asymmetric overpronation on dynamic testing (ie mini squats balancing, rotational balancing, lunge testing, impact hop testing) that is associated with the plantar fascia being overly lengthened. If the overload is stretch or length that traumatized and irritated the tissue in the first place then why would more stretching be the treatment? On the other hand, if a patient has a high arched foot or compensatory supination (often due to a forefoot valgus or plantarflexed first ray) then that plantar fascia is typically short/tight and the rigors of ADL, or especially athletics, can place more lengthening demand on that foot to comply with change of direction or pronation force dampening (ie shock absorption) than the tissue can accommodate to…leading to stress and eventual pain. Those feet certainly need stretching exercises to improve that foot’s adaptability to shock absorption needs. So, right from the start we find this study’s premise a bit to overgeneralized. This is common in many studies, connecting a diagnosis with a singular potential causative factor. This, of course, leads to underwhelming statistical findings because the group is too heterogeneous if actually there are multiple contributing factors. That seems to be the case here as well. This study provided joint mobilizations to everyone in the intervention/experimental group whether they needed it or not. The groups were not matched regarding DF ROM status nor split based on DF loss. Manual therapy joint mobilization techniques in the real-world clinic setting are used (or should only be used) when a significant limitation of normal motion exists that is determined to be both contributing to the condition/symptoms and is likely joint based rather than merely soft tissue based. This is a key shortcoming to Shashua et al’s study, in that it was not powered based on finding enough participants with defined DF ROM loss where the use of mobilization vs no mobilization could be examined specifically. Certainly, performing mobilizations on a patient with plantar fascitis who has no DF loss would not be expected to produce superior outcomes. Clinically speaking, it is necessary to examine each person’s foot-ankle ROM and biomechanics individually to see where the limitations are and address those limitations specifically. In this study they generically applied joint mobilizations unrelated to any particular deficit or need. In terms of joint functional biomechanics and musculoskeletal conditions, while limited dorsiflexion has been identified as being an intrinsic factor potentially contributing to plantar fasciitis this cannot be viewed as a direct “causal” relationship. All people with plantar fasciitis do not have dorsiflexion limitations. As is true with most orthopedic conditions, we see the literature evidence base pointing to “multifactorial” underlying causes rather than singular “if then, therefore” type relationships. The compensations that a lack of DF may cause could include early heel rise or overpronation, both of which would lead to abnormal loading of the plantar fascia. We believe this study design leads to the results not truly reflecting the efficacy of adding joint mobilizations with PF conditions because both the control and intervention groups both contained some patients who “lacked” normal dorsiflexion - they were too heterogeneous. And, their definition of less than 350 being a deficit does not jive clinically with what we see. That seems to be a high threshold for normal dorsiflexion. Typically we see normal WB dorsiflexion in the 25-300 ranges. The patients in this study had inclinometer values of 39.68 to 41.80 with standard deviations in the control group of + 5.99 - 6.140 and intervention group of 8.96 -9.630 - hardly substantial deficits compared to our real-world experiences. So, there were fewer patients with significant DF loss available for comparison of the mobilization treatment efficacy. There is a chance also that by performing the mobilizations to everyone in the intervention group that it could have made them hypermobile, potentially leading to greater stresses. Remember that dorsiflexion mob’s were not the only type - treatment also included subtalar joint (STJ) inversion and eversion mobilizations along with midtarsal joint (MTJ) inversion and eversion. Forefoot inversion is associated with a WB overpronated foot and forefoot eversion is associated with a supinated or high arched foot in WB at the MTJ. No measurement or assessment of each patient’s MTJ function was mentioned. The generic application of all possible mobilizations to the entire group again waters down the ability to truly discern whether the mobilizations, properly applied ONLY to the sites and directions where both limitations exist AND biomechanical kinetic chain understandings can “connect the dots” to PF overload was effective or not. Yet in this study they did mobilizations in both directions to the STJ and MTJ without regard for specific needs. The study did utilize several different hands-on techniques,some of which we use here in the clinic. But, both their WB testing (another issue that lowers the strength of their findings and conclusion) and mobilizations do not specify any attempt to control for STJ positioning. The STJ has returned to neutral or actually slightly inverted just prior to heel rise when maximum dorsiflexion is needed. During testing, stretches, and mobilizations if the STJ is allowed to be everted (foot pronating) then the “path of least resistance” for functional dorsiflexion in walking and running can be habituated into overpronation and therefore overstretch the plantar fascia in late stance phase. Though they did include mobilizations in WB position for dorsiflexion as well there wasn’t any specific attention given to the STJ positioning in the addendum notes. This potential lack of control of and variability of the foot position certainly impacts the expected reliability of measurements between three PT’s but also disregards the functional gait mechanics the dorsiflexion specifically relates to. We find many patients “know” the typical soleus and gastroc stretches associated with improving dorsiflexion mobility but too often were not instructed in that specific STJ positioning desired for normal gait mechanics and forces. One treatment aspect that cannot be forgotten is that anytime mobilization or stretching is done it is necessary to supplement with appropriate strengthening exercises. Their focus was only on ROM (which may not have been warranted since most were measuring at >300) - the risk then is that ROM is gained without concurrent muscular control, leading to essential functional instability that increases local tissue strain and even downstream injury/inflammation. All gained motion must simultaneously be controlled. To discuss or make conclusions regarding the efficacy of joint mobilizations in isolation, not accompanied by functional strengthening, is a bit misleading because clinically we would never produce improved ROM without stimulating the proprioceptive system to control that new range for optimal ADL or work demand or athletic uses. We would submit that producing increased ROM without strength actually can be deleterious. High quality Physical Therapy for PF should include examining the kinetic chain with an appreciation for authentic function and biomechanics, at minimum testing the nearest proximal and distal joints surrounding the injured tissue for ROM limitations and strength deficiencies. Only then can a therapist develop a program to safely and effectively address those issues. Another important variable in researching the treatment of any dysfunction/ailment is the stage of the tissue irritability and healing phases - whether it is acute or chronic. The subjects in this study had symptoms ranging from 1 month to 2 years, a very large range and diverse group. While there is no clear clinical threshold for defining a PF case as being and “-itis” vs and “-osis” condition the treatment approach for a 1-2 month old recent onset versus a certainly 12-24 month old case may be different. This adds to the heterogeneity of the group. While that may form a more “real-world” sample it also waters down the ability to discern specific treatment approaches if they might not typically applied to that tissue irritability stage. This study used a global and generalized approach without regard to tissue healing phase/stage. That leads to the question also as to whether four weeks was an adequate time to expect substantial change. Especially cases that were 12-24 months old may require greater treatment time to see results compared to someone in the acute phase where tissues are more likely to “bounce back faster” and the recurring scarring from microtears and habitual compensations due to pain have had less time to occur. The following is a case of an older runner who developed problematic heel and plantar foot pain that prevented running and normal painfree ADL. THE PEAK PERFORMANCE EXPERIENCE Dennis says, “I’m walking 2-3 miles now with essentially no or only very min symptoms -- - feeling encouraged!” Hx: 68 yo active male developed left heel pain in mid July after running 3.5 miles 4x/wk, increasing over time to 6/10 NPRS and so the patient had to discontinue running. Other activities impacted include: walking, hiking, jogging, and some ladder climbing with work. Subjective: Pt reports immediate pain 5/10 with jogging, walking longer than five minutes, and stair/ ladder negotiation. Objective: Medial heel and plantar fascia attachment on calcaneal tuberosity tender along with fifth metatarsal, increased NWB L foot forefoot valgus, symptoms worse in the morning. Pt self reports 50% function with a Foot and ankle disability index score (FADI) of 61% function and FADI Sport Module at 28% function. * indicates pain Initial Eval Re- Eval (6wks Dec ) Foot and ankle disability index score (FADI) 61% 63% FADI Sport Module 28 % 31% WB Dorsiflexion (squat , STJ neutral) ROM (L/R) 200/300 260/300 NWB Dorsiflexion DF ( knee flexed) ROM ( L /R) 50/120 200/200 NWB DF knee ext ( L/R) 180/200 200/NT Calcaneal Eversion (L/R) 40/ 80 40/80 Opp Ant toe reach 60units x 15sec 10# wts NT 6.5x / 8x WB Hip extension ROM Moderate limitation (B) WB Hip flex ROM (L /R) 530/ 700 530/ NT Hip Internal Rotation ( prone L/R ) 360/450 450/450 SLB Rot Pronation control ( L /R ) < 5 sec (Poor, avoids pron) / 8 sec (Fair) NT PF reps FWB (L/R) L * 10# 31*x/ 30x Key Findings: L poor pronation control with single leg balance, decreased ROM in calcaneal eversion & DF w/ knee flex and ext, and limited hip mobility. Treatment: Manual mobilizations to (NWB and WB) ankle and (NWB) forefoot for increased DF ROM and forefootinversion. PROM/stretches to increase left soleus/gastrocnemius, and triplanar hip mobility ( psoas, hamstring, IR ). PRE’s for gastrocnemius, supinators of the foot and dynamic balance work for pronation control. Use of modalities for symptoms control and inflammation reduction - use of ultrasound and CLASS IV LASER. Twelve weeks into the program… progressed from a strength based program to a more functional impact and speed day for better preparation for patients goals of returning to running. Formal ReEval upcoming. Outcome: Pt continues to improve with reduction of pain sx’s, increased function, increased strength and ROM and has progressed to impact training and a “speed day” 1 out of 3 d/wk which includes specific deceleration/acceleration based exercises. The pt started the progression of a walk/jog program BIW - - - -> TIW. 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 December 2021 New Evidence of Essential Thoracic Mobility for Normal Upper Limb Function by Allison Pulvino, PT, MSPT, CMP, FAFS Clinical Scenario...What would you do? A 35 yr old male firefighter who enjoys playing volleyball on an intermediate level 6's team at the local indoor courts gradually developed complaints of R dominant hitting arm shoulder pain superior/anteriorly during volleyball hitting > blocking and with overhead work and ADL demands. Plain films are unremarkable. Clinical exam shows tenderness at the supraspinatus and LHB tendons, (+) impingement - Rotator cuff syndrome tests, weakness/pain especially with elevation and ER resistive tests. He has a typical "poor posture" both statically and also during AROM testing. You're ordering Physical Therapy and seeing him back in 4 weeks to consider if he is progressing adequately and to decide if further diagnostic testing is necessary. Your expectations of his PT evaluation/report......subsequent treatment would be...? Palpation, special testing, resistive testing.....modalities + simple shoulder stretching & strengthening program AROM shoulder/trunk, palpation, special testing, resistive testing....modalities, manual therapy to trunk/scap and shoulder prn, stretches prn, strengthening scapulothoracic and shoulder muscles/function per findings AROM, resistive testing...simple shoulder protocol (Jobe's exercises or Thrower's Ten) AROM shoulder + kinetic chain trunk/scapula, special testing, palpation, resistive testing... Class IV laser, stretching sleeper/pec major/Hor Add posterior RC, strengthening RC....address thoracic spine if not improving CURRENT EVIDENCE Heneghan et al. Thoracic Spine Mobility, An Essential Link In Upper Limb Kinetic Chains in Athletes: A Systematic Review. Translational Sports Medicine. 2019, 2(6). 301-305. https://doi.org/10.1002/tsm2.109 SUMMARY: Upper limb injury and pain is a commonplace issue, especially of the shoulder, for many athletes and non-athletes alike. Determining and prescribing what "standard care" is for shoulder and upper limb injuries/pain often focused solely on the local tissues but new evidence presented by Heneghan et al supports the concepts of kinetic chain "regional interdependence" that must understood by all musculoskeletal providers in order to optimally care for our patients. These biomechanics relationships, in this case with the thoracic spine, provide a potential source for contributing factors causing tissue overload and kinetic chain issues that also may delay recovery. Understanding these are critical for prescribing treatment and especially performing successful physical therapy in these cases. Heneghan et al provide some important insights into the relationship between normal shoulder ROM and associated thoracic spine mobility, especially noted during end ranges of shoulder flexion more so than other elevation directions and mutually more so than during other motions. Achieving unilateral or bilateral elevation ranges produced the greatest thoracic spine mobility demand, that being extension during shoulder flexion. Clinically we often see kinetic chain factors either addressed generically or not at all. Prescriptions rarely specify expectations of thoracic/scapular assessment and care. Patients seen due to "failed PT" elsewhere often report being handed a generic exercise sheet to learn and perform at home...the same sheet other shoulder patients were using. Assessing and restoring WNL thoracic/scapular kinetic chain function is necessary for the shoulder/upper limb to perform normally. (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) You can read the full version below Background: Traditional exercising and rehabilitation for shoulder limitations and injuries continue to be heavily focused on GH joint function and strength/mobility, and active and athletic populations can at times have recovery programs falling short to achieve full function. This study looks at thoracic mobility in unilateral and bilateral UE overhead ROM to assess kinetic chain connections in regards to necessities with functional movement. Methods: A systematic review through June 2018 of 554 initially retrieved studies resulted in seven meeting eligibility criteria that included a population of healthy 18-40 year old men and women (Males= 33%) with a sample size of 168 individuals, including 20 athletes. Thoracic spine extension, rotation, and lateral flexion were assessed during upper limb abduction, right scapular elevation, flexion, extension and scapular elevation, flexion and abduction, external rotation, functional flexion and (B) elevation using various data acquisition/measurement systems. Results: Unilateral and bilateral UE full flexion elevation resulted in 6.7-8.0 deg and 12.0 – 15.0 deg of thoracic extension, respectively. Unilateral and bilateral UE abduction elevation resulted in 3-4 degrees 9.0 – 12.8deg of thoracic extension. Lateral flexion ranged from 2.7 – 9.0 deg between various studies during different planes of unilateral end ranges of elevation, most often in contralateral direction and at lower thoracic segments especially. Thoracic rotation ranged from 2.1 – 11 deg for the various planes of elevation, greatest being scaption and abduction. Lateral flexion and rotation were negligible during (B) maximal elevation. Thoracic movement in early/mid ranges of movement have poor evidence/agreement with singular studies reporting 11 deg extension at mid range flexion and 8.9 deg during ER AROM. Author's Conclusion: There was significant thoracic extension occurring in flexion, abduction and scapular elevation in unilateral and bilateral UE elevation. Although the evidence quality is low, sample size small, and more research would be beneficial in an athletic population, a more thorough thoracic spine focus is warranted for practitioners working with athletes on functional UE movements involving the kinetic chain. THE PEAK PERFORMANCE PERSPECTIVE: As a referring physician you’re often challenged by making determinations of what treatments to recommend or what “good” therapy entails when prescribing physical therapy for various upper limb conditions. Common expectations for traditional physical therapy would certainly include possibly local modalities to reduce pain and inflammation, manual therapy, and local stretching and strengthening. Evidence has been lacking regarding the kinetic chain importance of the thoracic spine’s mobility and shoulder/upper limb function. Heneghan et al provide some valuable data that helps identify the relationship of thoracic motion during arm movements, providing a basis for prescribing and expecting that shoulder/upper limb care will assess and treat related thoracic spine limitations that may be contributing factors or could be a source of slow recovery or “failed” conservative care. Individuals coming into a physical therapy clinic with pain and limitations with their shoulder or elbow do not expect that their pain is caused from joints or muscle limitations from a region not directly at the site of their pain. But what we find as movement specialists during kinetic chain assessments, supported by Heneghan et al's findings, is that thoracic spine limitations in any one of the three planes, can play a role in limiting arm mobility (especially thoracic extension related to overhead function) resulting in negative effects during work, ADL, and/or athletic activities performed. These limitations more proximally at the thoracic spine certainly happen for a variety of reasons, most commonly sedentary work duties (especially with prolonged neck flexion or computer screen use) , poor posturing in general, or activities involving prolonged/repetitive spinal flexion such as masonry and lifting from lower levels. Another key component can be attributed to classic forms of fitness training that many have become accustomed to involving isolated single plane movements such as weight machines or group fitness classe. These are commonly performed with bilateral upper extremities simultaneously which can be safe and effective for some, but if there are other mobility restrictions such as with the spine, then not just the shoulder but the more distal joints can be stressed more and in abnormal locations. Those forms of exercises also do not necessarily train one's body for the stresses of athletic events including spiking a volleyball, swimming freestyle or backstroke for example, or throwing/serving overhand in baseball, volleyball or tennis. The repeated stresses on those more mobile joints such as the shoulder, in the presence of thoracic mobility limitations, can then lead to instability and possible more serious tissue damage and even the need for surgery when not addressed in time. Heneghan et al reminds that there exists very little literature on how more proximal segments in the kinetic chain, including the thoracic spine and pelvis, affect more distal segments in athletic events. They do, however, cite that other researchers have discovered approximately 55% of total force and kinetic energy during a throw is derived from the thoracic spine and approximately 80% of total axial rotation is utilized. They also noted prior research demonstrating a 3x higher elbow/shoulder injury prevalence for softball players with limited trunk rotation mobiity. This leads to the question - “Why do so many shoulder rehab programs only focus the involved shoulder, elbow, or wrist?” It has been our experience that many traditional UE strength exercise movements are not tolerated well by patients in a rehabilitation program for "shoulder pain", including unilateral isolated, typically long lever type movements with either weights or resistance bands, as they can excessively stress GH jt structures, and sometimes even bring on more impingement symptoms or joint crepitus, and pain in general - especially because they are oftentimes taught in very strict postures that prevent thoracic mobility contribution to total motion. Some examples include traditional long lever exercises like flexion and abduction raises, empty cans, full can scaption, T-Y-I (mid/lower trap stimulus), wall walking, door sliders (abd press in ER) among others. While these aren't "bad" exercises, they can easily be inappropriately applied at the wrong time during recovery, through ROM that is irritating, and often are done intentionally preventing scapulothoracic motion under the auspices of "strict technique" and "isolation" concepts. These patients or fitness enthusiasts often have increased thoracic kyphosis and anteriorly tipped scapulae, which then prevents fluid and necessary humeral head mobility and control. So if proximal structures that are limited are not addressed, oftentimes recovery is slow or absent leading the patient to report back to their physician complaining that nothing has changed, or the pain has not decreased, or they still cannot play their favorite sport. The appearance of a potential “failed case” of PT then may trigger more expensive testing or injections etc when, in fact, it was simply more thorough kinetic chain care that was needed. Once addressing thoracic and lumbar spine limitations, the scapular and GH joint mechanics and ultimately functional use tends to improve. A great example would be the financial planner sitting 40 to 50 hours per week and then reporting he/she is feeling frustrated when one shoulder hurts when they play in their once weekly volleyball league. Working on transverse and frontal plane thoracic mobility, as well as thoracic extension, will allow for kinetic chain scapular posterior tipping/adduction/upward rotation. This will allow for full overhead GH jt mobility with successful humeral inferior gliding to prevent impingement when serving/hitting overhead, and ipsilateral lateral spinal flexion for loading into overhand serving. Without the thoracic mobility, the scapula will be blocked and rotator cuff impingement will likely happen. With all UE overhead movements, Heneghan et al’s systematic review noted a constant, that all UE movements initiated some level of thoracic ROM, but only at mid to end range of UE elevation. The greatest thoracic ROM needs were found to be thoracic extension with full UE overhead flexion elevation (6.7-8deg uniliateral and 12-15 degrees for B UE), followed closely by scapular elevation (4-8.9 deg unilateral ) and UE abduction (9-12.8 deg bilateral). The limitations for this systematic review do state only one study looked at an athletic population, and some sports with a greater proximal restriction including wheelchair basketball may require more focus and more thorough assessment. The meta analysis does have some limitations. The quality of studies was generally low, the study population was mostly females, and these were not athletes per say but “of athletic age” rather. Therefore the generalizability to other populations must be considered, however, there was a consistency among studies demonstrating thoracic motion relationship to shoulder elevation end ranges especially. Physicians prescribing PT for shoulder and UE conditions have an evidence basis for appreciating the importance of and expecting a full kinetic chain assessment, especially including the thoracic spine, for their patients being prescribed PT for UE pain or limitation, regardless of age, sex or activity. We may also want to consider including more spine focus in post-operative protocols, along with respect to healing the injured and repaired tissue. By considering the authentic biomechanics effecting and contributing to stresses and healing potential of involved tissues. We will be doing a more positive service to our patients and they may even have improved function and mobility than they have ever had prior. THE PEAK PERFORMANCE EXPERIENCE Greg stated: "I don't have any pain with activities!" HX: Greg was performing push-ups during a workout and felt a pop and grinding in his R shoulder and pain continued with even light exercises and movements from that point on for approximately one year. Using his R arm during his job tasks started to become uncomfortable. Pain levels could reach 8/10 at times. Any lifting and reaching with his R arm became an issue. Objective Data: MEASURE ( *=pain) Evaluation DC Thoracic Posture Kyphotic Scapular Posture Protracted Thoracic Rotation 59 / 50 Shoulder Abd IR 50 56 IR up back T10 T8 Overhead Press Reach Unable * 5# done 10x Speed's (+) (-) O'Brien's (+) (-) Jobe's (+) (-) Sulcus sign (+) (+) Treatment: Manual: Post/inferior humeral mobs, pec minor release, horizontal abd with IR stretching Exercises: Posterior capsule stretching, T-spine extension/SB/rotation stretching, T-spine frontal plane/transverse plane strength with dumbbells, T-spine extension drills with shoulder OH pressing with biases towards rotation, resistance tubing RC strength with in-sync T-spine rotation and SB, dumbbell push-pull drills for scap stability, serratus strength with tubing and DBs progressing in scaption and SG plane OH. Outcomes: Painfree ADLs, Painfree incline push-ups ~3ft elevation table, painfree plyo shoulder drills and no limitations with work tasks. 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 patient's functional goals.

Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE October 2021 Subacromial Impingement RCT: Are We Being Fooled by the Literature…. Conservative Care Prescribing for SA Impingement Re-examined by Mike Napierala, PT, SCS, CSCS, FAFS Clinical Scenario...What would you do? A 50 yr old male c/o gradual onset R dominant side shoulder pain possibly related to a new fitness routine started 3 months ago with increasingly heavier loads and new exercises along with a weekend of trimming trees and other yardwork. He has (+) impingement test findings, tender at SS and LHB tendons, limited/painful elevation and Horiz Add AROM, and weakness/pain with resisted Abd, Jobe, and Abd’d rotations isometric screening. Plain radiographs show mild Type II acromion, no frank osteophytic or DJD changes. Patient has used NSAIDs, seen massage therapist several times, and tried 4 weeks of BIW Physical Therapy without significant improvement. My clinical thinking is: PT/ treatment failed: Do a dexamethasone subacromial injection and FU in 2-4 weeks to consider Physical Therapy again. PT /treatment failed: Order an MRI to better ascertain involved structures and ensure no labral pathology or cuff tearing that might explain lack of improvement, then determine best care. Keep things simple: Provide the patient your customized shoulder/RC HEP sheet and encourage specific adherence to that progression, place on prescription level NSAIDs and FU in 4-6 weeks. Prior care may be inadequate/limited: Briefly review what was done in PT. If excellent/thorough then consider A, B, or C, otherwise refer to more expert PT/group for more thorough assessment and individualized program involving manual therapy, customized exercise, and modalities if necessary then FU in 4-6 weeks. PT / treatment failed: Schedule MRI and prepare patient for likelihood of Arthroscopy to get a better look at the joint/tissues and address findings since prior care has failed. CURRENT EVIDENCE Clausen MK et al, Effectiveness of Adding a Large Dose of Shoulder Strengthening to Current Nonoperative Care for Subacromial Impingement. Am J Sports Med, 49:11, 2021, 3040 - 3049. https://journals.sagepub.com/doi/full/10.1177/03635465211016008 (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: Shoulder impingement is a highly prevalent shoulder condition that is seen frequently in office by both primary care and orthopedic specialist physicians. Discerning best practices for prescribing conservative care is key, especially as more recent studies have recommended against subacromial decompression surgery ( BMJ 2019), at least as an early treatment option. But clinicians must be wary of quick scanning the literature to avoid misguided thinking based on inappropriate conclusions offered by study authors. As is said…”The devil is in the details” holds true! Clausen et al examined the addition of (an intended) 12 hrs of rotator cuff strengthening exercises over 16 weeks to increase the time under tension stimulus in an Intervention Group(IG) along with “usual care” compared to the control group receiving only “usual care” that reportedly could include modalities, education, exercise, and manual therapy (but were not standardized). There were no between group differences in SPADI score improvements noted from baseline to 4 months. The Intention to Treat analysis also showed no differences for change in Abd or ER strength, Abd AROM scores nor for Patient Acceptable Scale Score(PASS) or global rating of change. Also, only 48% control and 54% intervention groups reached the PASS. The authors concluded that larger strength doses during Subacromial impingement care do not result in superior results. The initial reaction to their conclusion for some may be that four months of therapy was only effective at a mediocre level and some might even characterize as “chance” since only approximately 50% reached the PASS. Others risk deeming this RCT a bit of a “nail in the coffin” of more extensive or lengthy therapy exercise routines, particularly strengthening. One might even be led to ponder “Maybe simple HEP sheets are adequate vs doing formal PT.” It risks serving as evidence that conservative care is inadequate and possibly become reason to entertain surgical intervention earlier. The authors’ conclusion seems premature and inappropriate once you “look under the hood” of this study though. This study’s failure to show superior results with “more strengthening” exercises alone is not disappointing but rather somewhat predictable, especially considering the design allowed in the “usual care” portion. Their findings would, if true, nevertheless, support our position that each patient’s care must be customized to determine not only which exercises are appropriate and when, but also the loading parameters and progressions, as well as pain or inflammation reducing modality/procedure use (ie Class IV laser, iontophoresis, etc) and manual therapy needs for hastening recovery of kinetic chain function. The patient case study demonstrates a comprehensive functional biomechanics and manual therapy based program using customized exercise progressions to achieve recovery in a patient with impingement/RC pain syndrome that is commonly seen in the clinic. Background: With recent recommendations against subacromial decompression non-operative care options become primary treatment, but some studies suggest current care approaches may lack adequate strengthening effect. Purpose: To determine effectiveness of adding a large dose of “time under tension” inducing strength exercises to “usual care” conservative care alone. Methods: RCT design double blind study allocating 200 consecutive patients diagnosed with subacromial impingement syndrome (SIS) aged 18-65 yrs into a Control Group of “usual care” ranging from BIW to 1/mo Physical Therapy over 16 weeks or an Intervention Group (IG) that had four sessions for added training and follow up with a time under tension optimizing strength exercise HEP added that involved eventually three exercises and progressed from 3x20 QD for the first and eventually became QOD for 2x10 for all three during Phase III portion. Measures included SPADI and secondary strength, ROM, quality of life rating, and Patient Acceptable Symptom State (PASS) score. Findings: Both per-protocol and intention-to-treat analysis showed no between group significant differences for any of the outcome measures. SPADI improved for both groups. At 4 months only 54% of IG and 48% of CG patients reached PASS. Author's Conclusion: The addition of larger doses of strengthening exercises to usual nonoperative care for shoulder impingement treatment did not result in superior outcomes. Only half of patients having conservative care achieved PASS by four months, leaving many with unacceptable symptoms. THE PEAK PERFORMANCE PERSPECTIVE It is subtly clear in the background presentation by these authors that the 2019 BMJ recommendation against subacromial decompression surgery was less than appreciated. They state “Such drastic changes to care pathways may leave patients without further treatment options if nonoperative care fails.” Their conclusion added “...leaving many of these patients with unacceptable symptoms. This study showed that adding more exercise is not a viable solution to this problem.” As orthopedic specialists and primary care physicians seeing patients diagnosed with subacromial impingement syndrome making correct decisions about conservative care options is a daily requirement, if not at least weekly. The search for evidence to base those decisions upon could easily land one on articles such as this month’s by Clausen et al in AJSM, considered a highly regarded resource for clinical judgement and introspection. While the data has increasingly supported non-operative measures as a first line of defense for shoulder impingement we do not believe that surgery is unnecessary, unwarranted, or inappropriate depending on the case. Again, the challenge may more so be in how studies are done and data presented. We go back to the concept that each patient is an individual and the patient’s history plus findings along with the professional scientific data can both inform that decision process. Both are necessary. This study does demonstrate, however, that “The devil is in the details” still holds true with scientific studies. In school we’ve all been warned to not simply read the abstract and move on, assuming an author’s conclusions are sincere and thoughtful and reasonable. The risks in Clausen et al’s conclusions here are several fold. One might be led to conclude that conservative care (ie, physical therapy) is generally inadequate and ineffective and thus that surgery may be a necessity earlier in the process of treatment, especially when apparent “failure of care” seems evident. Also, some may believe this data demonstrates that more extensive exercise regimens are unnecessary and ineffective compared to “keeping things simple” with a basic series of HEP from a prepared sheet that could be given out in the office or expected to be the level of “simple care” offered at a PT clinic. Their premise for adding strength exercises is based on evidence of inadequate strength gains from “standard” physical therapy, however, a careful look reveals this came from a design where patients only did strengthening during in-clinic visits and did not have any Home Exercise Program (HEP) responsibilities. That is hardly evidence the “usual” physical therapy is, as a proven standard outcome, falling short in restoring strength. Nevertheless, their contention that therapists oftentimes do underdose strengthening exercises is likely a very valid criticism/concern. Still, before simply throwing more volume of strengthening exercises at patients we must remember that other factors contribute significantly to exercise tolerance and design. ● How inflamed and pain sensitive (and reactive) are the tissues involved? ● Are we seeing true “weakness” having developed or is this potentially pain-induced inhibition that does not necessarily require substantial strengthening dosages/stimuli? ● Are there comorbidities to consider that impact common exercises choices? ● How will pain/discomfort during or after exercises be handled? ○ Attempting generally symptom free strengthening? ○ Allowing limited symptoms during and/or after that must resolve within 2-24 hrs (depending on rationale/philosophy)? ○ Encouraging intensity adequate to produce mild (or greater) symptoms lasting only 2-24 hrs? They also make the mistake of overgeneralizing the concept of “larger doses of strengthening” in the title and article. It more accurately should read “time under tension (including isometric phase) optimized HEP RC strengthening” instead. Clausen et al ignore external validity rules when stating that more “strengthening” exercises are no more effective than usual care. Actually, what is no more effective is utilizing a limited amount of isometric based time-under-tension emphasized home exercise reliance with limited 1/mo average provider training and feedback. A major factor also is the lack of clarity on what sort of strengthening the “usual care” group had already performed. Clausen et al utilized a thoughtful progression regarding QD exercise moving toward QOD, however, it was odd that they added one exercise per month with an eventual program of 2x15- - - > 2x10 QOD for each of the three added strengthening drills, two of which were for ER’s. It was a bit unusual that during the QD phase patients performed 3x20 as their “to failure” target. Normally in strength and conditioning if an athlete were performing a progressive resistive exercise for three sets to fatigue they’d very likely be taking 48 hr recovery between sessions. They utilize very specific slow contractions + isometric “time under tension” model program of only three additional Abd and ER exercises. This hardly qualifies as what many might deem “larger doses” of exercise and, in fact, the eventual compliance finding was that instead of 12 hrs of additional total exercise achieved that the IG only did 2.9 hrs of added exercise (per time under tension) over the course of the study. Despite being a “gold standard” RCT design, the findings here should be taken with caution in leading a clinician to forsake significant strengthening stimuli for impingement cases. It does also call to question the common concept of “protocol” type approaches to care. While the study individualized the loading used based on performance and symptom resolution within 24 hours, it nevertheless used very specific, limited exercises and did not allow for customizing angles, planes, exercise choices and sequencing/progressions or altering exercise parameters. It is not clear that cervicothoracic or scapular issues were adequately addressed as key contributing factors to the condition’s onset or recovery capacity. Decades of experience have shown us that individualized functional biomechanics screening and exercise progressions are very often necessary, instead of more simplistic protocol driven simple progressions. Customizing exercise selection, order, sequencing, and making unique adjustments (such as path of motion plane tweaks to avoid symptoms, hand placement to effect more RC stimulus, the use of or cueing away from allowing kinetic chain synergy among others. Manual therapy to address pec minor restrictions that are facilitating functional impingement along with ensuring thoracic extension and ipsilateral rotation especially ( due to more common same-side reaching with ADL) is crucial. With more advanced demands during goal activity then Type I and II thoracic motion can be considered. Finally, modalities such as the Class IV laser can be very helpful in reducing pain and inflammation to allow earlier intensive exercise. The case below illustrates a comprehensive approach that worked successfully, rather than a mere “extra-volume” of simple RC strengthening drills. A kinetic chain approach helps ensure that the key or at least some of the likely underlying contributing factors for having developed an overuse problem are addressed. THE PEAK PERFORMANCE EXPERIENCE Michael said: “I feel better than I have in years! Now I can lift weights again and golf without pain!" HX: 57 yr old male reports h/o five years with (B) shoulder pain that developed gradually with increasing fitness exercise and weight lifting as well as ADL use. His CC are frequent L and infrequent but more intense dominant side R shoulder pain with fitness/exercise, ADL lifting and reaching, sleep, and recreation (golf, shooting basketball with son). Subjective: Pt reports 80% function and pain L 2/10 and R 4/10. Quick Dash 11% and Sport module 19%. Objective: (Pt had inconsistent attendance due to job demands. Seen 14x over 4 months) (*=pain) Initial Eval DC Re-Eval Flexion AROM 1500/1500 1630/1520 IR AROM T9 * / T11 T6 / T9-10 Abd IR AROM 250/250 550/470 Pec Minor Tightness Mod/Mod Min+/Mod Isometric Flexion 6.6 kg* / 12.8kg 12.8kg / 14.5kg Abd 8.8kg * / 13.7kg 13.4kg / 13.4kg Overhead Press 1st sx L 3# / R> 45# 25# elliptical 16x/19x Abd ER NT 15# 27x / 30x Push ups ½ depth painful 10” box > 10x no sx Key Findings: Thoracic extension and rotation limited, pec minor very tight (B), posterior RC/capsule limited with Hor Add and Abd IR ROM. Elevation strength and Abd Rot’s all weak and painful. Impingement tests (+) in (B) shoulders. Treatment: Manual therapy targeting thoracic spine and pec minor along with GH joint capsule mobilizations for restoring especially inferior capsule length to allow elevation end ranges along with Horiz Add and Abd IR. Self stretching/mobilization/ROM program for same structures-tissues done. Painfree strengthening progression initiated for promoting better scapular retraction and also improving upward rotation ease (based on pec minor induced chronic protraction with reaching/lifting especially) and also 300 abd’d rotations. Strengthening progressed on to sx-free plane elevation with reduced depth starting motion on incline press to reduce gravity demand at 90 and end ranges of lift. Long lever strengthening began lying with tubing to again reduce demands at key impingement ROM zones will still proprioceptively stimulating independent function into full available elevation without pain. Early on parameters were BID 10- - ->30x and then later once a base established PRE were gradually progressed to 2x15 QD and then finally 3x 10-12 TIW for more intensive loading. Outcome: Pt had difficulty attending regularly due to demands of job. He was only infrequently seen BIW and more often 1/wk and still then bouts of 2-3 weeks without visits. Nevertheless he reached self reported > 90% function on each shoulder and had resumed canoeing, kayaking, shooting baskets with his son, playing golf and sleeping comfortably. 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

Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE June 2021 Is Shoulder Pain and Mobility Loss Really The Shoulder’s Fault? by Allison Pulvino, PT, MSPT, CMP, FAFS CURRENT EVIDENCE Malmstrom et al. A Slouched Body Posture Decreases Arm Mobility And Changes Muscle Recruitment In The Neck And Shoulder Region. Euro J Appl Physiol, 2015. 115: 2491-2503. Background: Shoulder pain is one of the more common areas of the body to develop pain and limitations, and it is thought that having a slouched posture due to congenital reasons, prolonged desk work, or ADLs requiring repeated flexed postures. When the body alignment changes, joints, and muscles have to change how they move through their available range and Malmstrom et al. want to see if there is a correlation between increased thoracic kyphosis and increased work for shoulder muscles as a result, including upper trap, lower trap and serratus anterior. Methods: Twelve male subjects (23.3 +/- 1.5 years) performed maximum arm elevation in both upright and slouched postures with a 3D movement and EMG recording arm movement and spine movement, as well as EMG activity in the upper trap, lower trap, and serratus anterior. Results: Slouched posture resulted in a decreased total arm elevation by 15degrees and a decreased arm velocity by 8% during upward and downward arm movements. The peak muscle activity in a slouched posture also increased in all three muscles: UT +32.3%, LT +48.6%, SA +20.9%. The total muscle work with upward movements in a slouched posture increased significantly as well: UT +36.6%, LT +89.0%, SA +19.4%. Downward movements had increased total muscle work as well: UT +29.8%, LT +122.5%. Limitations: The main limitation in this study is the 12 participants being asked to create an increased thoracic kyphosis. Although the position of the spine will be the same nonetheless, the muscle recruitment could possibly be much different if there is a prolonged positional spinal change for true chronic spinal positions instead of an instantaneous forced conscious change. (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: While there is not a singular “cause” underlying non-traumatic shoulder pain the topic of “poor posture” often is acknowledged but risks becoming so routine in the minds of clinicians and certainly the public that its role too often gets neglected or even dismissed during rehab. This study provides good foundational “mechanisms” of evidence to compel both clinicians and patients to fully appreciate the literal negative impact accentuated kyphosis has on shoulder demands and function. Malmstrom et al examined the association between an increased thoracic kyphosis and changes in shoulder kinematics and muscle recruitment/activity in the upper trap, lower trap, and serratus anterior. Their findings showed a positive correlation with both a decrease in maximal overhead shoulder ROM and an increase in muscle work required to elevate the shoulder overhead during increased thoracic kyphosis as compared to normal posture. This study provides valuable data to motivate patients to take the connection of postural-focused manual therapy and especially exercise to their shoulder recovery seriously. It also provides a valuable reminder to referring physicians as they order Physical Therapy and also are scrutinizing care choices for patients who may appear to be “failing” initial therapy. THE PEAK PERFORMANCE PERSPECTIVE It has been pretty commonplace to assess a patient with shoulder pain and hear the main aggravating movement is reaching overhead. Both doctors and physical therapists alike have heard this many times over, yet each patient may have other limiting factors needing further assessment. As a referring physician, the expectation most often is that the Physical Therapist must “play further detective” to see what body structures are potentially contributing to pain and limitations, determining how to address both the local tissue pain/inflammation along with necessary ROM/strength/neuromuscular retraining work. At Peak Performance PT we’re in full agreement with what Malmstrom et al confirmed in this particular study, that an increased thoracic kyphosis does affect overhead shoulder mobility and muscle efficiency. And while that fact may not seem like “rocket science” (and is generally well known and understood in musculoskeletal care), it all too often ends up being brushed by the wayside by all the various local shoulder exercises available. When hearing a patient’s history of their present shoulder complaint, repetitive overhead reaching activities obviously stand out in our mind as physicians or therapists as being potential causes for why this individual is in our office. For example, gardening for 4 hours in the afternoon which includes leaning over (kyphosis) and reaching out or maybe it’s painting walls...and then pain is felt later that night putting dishes away in the top kitchen cabinets or changing a light bulb. Malmstrom et al’s data help provide a “connecting of the dots” for many cases that help us as clinicians appreciate why the shoulder pain developed but also empowers patients to realize how this talk about posture is more than just your grandmother’s old warnings about sitting up straighter. It helps bridge the gap between a shoulder that is painful and the thoracic spine that “feels fine” to them and therefore seems unimportant and unrelated. For some patients, the thoracic kyphosis was induced by positioning, as in the gardening example with temporary thoracic flexion posturing. For others, they do have generally accentuated thoracic kyphosis, which leads also to the protracted scapula and pec minor shortening, affecting scapulohumeral mechanics. We see shoulder patients who’ve sometimes been given generic HEP sheets or found shoulder rehab programs on the internet that may even include “postural exercises” like simple scapular retractions. We don’t find those adequate at stimulating change in most patients, despite possibly “checking the box” as having addressed posture. Other times we see “failed PT” cases where plenty of appropriate local shoulder exercises were done but too often patients indicate “the therapist never put their hands on me” (ie. manual therapy) - especially for the thoracic spine and scapula. While as clinicians we both know these cases aren’t surgical, but as referring physicians it’s difficult to motivate patients to “try PT again” If they had already been through physical therapy and they only feel slightly better and are still limited at tennis or lifting their toddler into the car seat...etc. Patients are simply looking for answers and solutions that work...but they also often ask “what’s going to be different ‘this time with my PT?” As a referring physician, you also play a key role in prefacing the PT experience too. Providing patients evidence like Malmstrom et al found, noting the significantly increased load on muscles and the loss of ROM with increased kyphosis it helps “connect the dots” for the patient as to why “out of the blue” this developed. When you confidently note that their PT will be addressing their postural issues it also reinforces that their physician and PT are on the same page and to feel confident they actually don’t need shoulder surgery like their sister or neighbor did, and physical therapy can help them recover. Protocol type approaches may work for a limited number of patients long term but at Peak Performance, we find a very high percentage of our shoulder pain patients do have scapulothoracic factors that potentially are contributing. They’re evaluated on Day One as one of our clinical standards. It’s a simple concept associated with our specialization in Applied Functional Science – the kinetic chain components, especially adjacent joints/structures, must be evaluated as integral parts of understanding the stresses on that local injured/painful shoulder tissue. We find that working on the body as a whole system will always find other regions that are secondary factors of pain, but still affect ADL life. For example, if someone sits for work 40 hours per week and has a slightly increased thoracic kyphosis, they may also need to have their psoas and pectoralis minor flexibility in the sagittal (but also frontal and transverse) plane assessed likely potential kinetic chain limiters of full overhead shoulder mobility. Tight hip flexors can lead to a forward pitched spine in standing and therefore disadvantage full elevation similarly to a thoracic kyphosis pre-positioning. A restricted pec minor that prevents adequate posterior tipping, as per the commonly referred Upper Crossed Syndrome, and also popularized by Kibler and others will clearly lead to abnormal forces at the shoulder and impingement. Since flexion reaching while bent over in thoracic flexion or upright in kyphotic postures disadvantages normal shoulder function, then a key focus should be improving thoracic extension, scapular posterior tipping, and upward rotation. Although it’s not always easy to directly focus solely on gaining sagittal plane mobility. Traditional PT exercises work serratus anterior as a scapular protractor, isn’t scapular protraction related to more thoracic flexion? Is a lack of protraction function what the serratus was lacking? Asking a patient how their prior PT was going and what exercises they were doing can shed some light on this topic. They may have been performing typical overhead arm stretching, scapular protraction exercises with weights, and then standing or prone back extensions. But these exercises initiate movement in neutral (their kyphosis) where the maximum spinal range may already be achieved. Focusing away from the end range and tweaking spinal extension while biased in another plane may be more beneficial and help stay away from the pain provocation. Addressing the “other” thoracic planes of motion can also be critical, though not a specific point of the Malmstrom et al study. Seeing frontal plane thoracic limitations with proper mobility assessment can shed some light on why abduction or lateral overhead shoulder reaching is painful, as the scapular upward rotation has to happen to prevent impingement in the subacromial space. In the same way that a sagittal plane thoracic kyphosis affects especially sagittal plane scapular and thereby GH mechanics for elevation, we must remember that frontal and transverse plane thoracic to shoulder mobility connections also exist. It is not common to have pure sagittal shoulder overhead flexion without coupling in some side bending and rotational movement, for example with swimmers and throwers. Every individual has specific limitations when shoulder pain is the primary complaint. Directly assessing someone’s multiplane shoulder ROM but also especially adjacent (and distant) kinetic chain 3D function can shed some light on how many different regions of the upper quadrant or even the hips and pelvis can be affecting their life in a negative and inhibiting manner. Normal and pain-free shoulder elevation with proper scapulohumeral rhythm can be achieved when proper spinal mobility and the correct use of shoulder muscle recruitment is trained, always in a manner that is specific for each patient. The case below demonstrates how important manual therapy and specific functional exercise approaches were helpful in resolving symptoms and restoring function for a very typical shoulder pain case. THE PEAK PERFORMANCE EXPERIENCE Doris states: “Watch how I can lift my arm all the way now! It doesn’t even hurt!” HX: Doris is a 72-year-old female with ℅ L shoulder pain from “reaching too far and too much” she believes. Sx’s started to be referred down to the elbow and she lost the ability to reach her L arm in all directions. She also reported that sleep became almost impossible. No trauma reported in the past. Subjective: Doris reported 8/10 L shoulder pain with any active L shoulder movement. She was unable to use it for any ADLs initially and could not sleep well or lean on L arm. Objective: Unable to tolerate any active ROM so special tests NT. TTP all RC muscle bellies and tendons including proximal bicep. No neural involvement. All UE dermatomes intact. Cspine mobility screening negative for radicular sx’s. Severe Tspine kyphosis with dowager’s hump. MEASURE ( *=pain) Evaluation (limited due to severity of Sx) Discharge Shoulder flexion (deg.) 130* (PROM only) 1520 AROM Abduction (deg.) NT due to pain 1200AROM ERn (deg.) 42* 650 ER 90(deg.) NT due to pain 700 IR 90 (deg.) NT due to pain 800 Tspine rotation L 180, R 300 NT Cspine rotation L 50%, R 75% B 75% Cspine ext 50%* 75% Cspine SB L 50%, R 25% 50% B Tspine ext UNABLE d/t L pain 50% with L shoulder flexion overhead Apley's Scratch test ER L Unable, R T1 T1 B shoulders Apley's Scratch test IR L L5*, R L1 L3 B shoulder (no pain) Treatment: Modalities: High-intensity laser treatment, 2 sessions, entire L GH jt capsule, and periscapular soft tissue. Manual: Tspine rotation and extension mobs with WB lateral flexion mobs. GH mobs for post and inf capsular mobility. Soft tissue mobilization UT, levator, teres major, pec minor, and infraspinatus. Exercises: Spinal extension active self-mobilizations in WB, spinal AROM drills for FR and TR plane spinal mobility, PROM GH flexion/abduction/ER. AROM UE overhead drills with spinal extension and scapular elevation with BW and weights for progression, TR plane spinal rotation with weighted diagonal pattern TR plane loading and spinal extension loading in standing, FR plane spinal load for shoulder and ROM progressing from AAROM to AROM with weight. Outcome: Pt is able to sleep without pain, carry groceries in L arm, reach overhead in flexion and abduction without pain onset, and can grab objects in her kitchen cabinets overhead without pain.