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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 February 2024 Clinical Decision Making: Diagnostic Accuracy of an Updated 2-test Cluster for Greater Trochanteric Hip Pain…reducing time, patient discomfort, and costs for lateral hip pain by Allison Pulvino, PT, MSPT, CMP, FAFS What would you do? A 57 yr old female pickleball player comes for evaluation of lateral L hip pain of gradual onset over the past 2+ months after the start of her doubles pickleball season. She is R handed and moved up a level to more competitive play and from one to two days/wk. She already has been on a therapeutic dose of NSAIDs with only slight symptom reduction and rested for 3+ weeks earlier in the season but symptoms recurred after gradually returning to play again. She denies any frank trauma and has never had ecchymosis at the hip nor been substantially debilitated w ADL. Stairs are painful with mild compensation the day after playing. Early evaluation shows ambulation is WNL without any Trendelenberg sign. Hip AROM is WNL. Plain films show very mild symmetric early degenerative changes at both hips. Hip scour was only subtly uncomfortable at inguinal region symmetrically. Suspicion is for Greater Trochanteric Pain Syndrome with gluteal tendinopathy and/or bursitis. Lumbar screening was unremarkable for potential radicular/referred pain to the hip. I would do the following hip tests to assess for GTPS….. Palpate gluteal tendons/bursa and perform FABER, resisted Abd, resisted ER, resisted external de-rotation, Ober, Trendelenberg standing tests Order an MRI to more clearly assess gluteal/bursa tissues Perform standing single leg squat test, 30sec single stance test, palpate gluteal tendons/bursa, resisted IR Palpate gluteal tendons/bursa and perform resisted Abd Do diagnostic US and consider doing bursa injection if indicated CURRENT EVIDENCE Kinsella R et al. Diagnostic Accuracy of Clinical Tests for Assessing Greater Trochanteric Pain Syndrome: A Systematic Review With Meta-Analysis. Journal of Ortho & Sports PT. January 2024. Volume 54. Number 1. 26-49. PEAK PERSPECTIVE SUMMARY Lateral hip pain due to greater trochanteric pain syndrome (GTPS) is a common complaint seen by physicians, affecting up to 25% of the population, with greater risk from increased age, female sex, low back pain, and greater adiposity. It is highly beneficial to be able to determine the diagnosis in a timely manner and with the least number of painful provocative testing needed for diagnosing the condition and deciding on best treatment options, especially when a patient is in the more painful/reactive acute or subacute stage of symptoms. While imaging can be helpful, plain films are of limited value outside of grading OA changes, which often show varying correlation to actual symptoms or function. MRI and US tests, while being expensive in addition to clinical exams, also have a higher than desired rate of false positive findings regarding abnormalities found in asymptomatic people. The ability to be able to quickly and accurately rule in or rule out certain diagnoses, in this case GTPS, using clinical testing while minimizing the cumulative discomfort we put the patient through is highly valuable and also can improve physician and therapist efficiency in managing busy caseloads. Kinsella et al. did a systematic review looking at diagnostic accuracy studies for GTPS that had 6 of 858 studies meet the criteria for inclusion. There were 272 total subjects (252 with symptoms and 20 without) with 314 hips assessed. Across all studies there were 15 different tests used. These were compared against reference MRI findings. Statistical analysis showed the best combination of positive likelihood ratio (LR) and negative LR for shifting the probability of a positive test confirming GTPS or a negative test ruling out GTPS showed the 2-test cluster of greater trochanteric palpation pain and pain with resisted hip abduction to be best. It was the only combination of tests whose + LR and -LR both shifted the probability of an accurate diagnosis significantly. Others had sensitivity and specificity values that were high on one and moderate or low on the other, same with LR’s. Some of these tests included the 30-second single leg stance, Trendelenburg sign, FABER, and resisted hip external de-rotation testing. The (+) LR for many tests include higher scores such as 30-second single leg stance and Trendelenburg sign, but not necessarily an acceptable (-)LR. Kinsella et al concluded both greater trochanter palpation testing (+ LR 2.62 and -LR 0.25) as well as resisted hip abduction tests (+LR 6.09 and -LR 0.45) as best for patients with GTPS lateral hip pain. Utilizing this 2-test cluster limits the manual manipulation and provocative testing required in a clinical exam of a patient’s hip through painful movements and stresses. One limitation of the study is the use of MRI as the “gold standard” since results can be positive for abnormal findings in asymptomatic patients. This study’s conclusions can assist with saving patients both time and money and also improve clinician efficiency. When the diagnosis is confirmed, the severely symptomatic patient may seek immediate relief with treatments such as cortisone or oral medications, however, in the majority of cases addressing the root underlying cause of the symptoms remains key. In the clinic we often see patients who have had good symptomatic control of their pain and temporarily improved function through various means, whether that be injection, NSAIDs, rest, activity modification etc. but without any specific evaluation of biomechanical/orthopedic issues contributing to the abnormal loading of lateral hip structures. In these cases patients too often exacerbate again upon return to activity because the very same loading patterns and inadequacies exist despite temporarily reduced pain and inflammation. Thorough detailed kinetic chain functional movements and manual assessments done as part of a physical therapy evaluation are necessary to identify limitation patterns in patients with lateral hip pain or a diagnosis from a physician confirming GTPS. The most common findings in PT exams can be hip flexion contractures, lack of functional hip capsular adduction with a common varus deformity (not just typical IT band tension) and/or a lack of functional hip IR mobility - both causing increased lateral tissues tensile loading…but also can be related to excessive hip adduction and/or IR, such as with anteversion or proximal effects of overpronation and dynamic knee valgus that may happen due to foot deformities or even as a compensation due to limited talocrural dorsiflexion (with squatting or lunging) . Others include especially the long leg side of a leg length discrepancy via repetitive tensile loading from always being “on stretch” to the shortened side having abnormal ITB tightness that causes tensile loading (or bursal compression) stresses with various wb activity positions. Hip abductor and external rotator weakness is another area of more obvious causative factors. Scoliosis compensations can also impact demands on the pelvis/hip region and must be assessed. Addressing both these local hip factors and also importantly the other adjacent or even contralateral kinetic chain issues is critical in optimizing long term success for GTPS patients. A focus on Applied Functional Science © approaches using authentic wb proprioceptive input and forces helps ensure the body can effectively transfer those exercise induced training effects into real-life ADL, sport, work, and recreational use. Too often traditional therapy hip exercises involving various NWB stimuli can be highly performed but the disconnect to authentic WB function leaves the hip still overloaded. Oftentimes even a simple correction of foot alignment with OTC, and less often custom, orthotics is helpful/necessary. A thorough functional biomechanics based approach is a key step in optimizing chances the patient can return to activity successfully long term and prevent the need for more invasive procedures down the road. THE PEAK PERFORMANCE EXPERIENCE Mary said: “I’ve had up to 8/10 pain and now I can walk a ton and use the stairs as many times as I want!” History: Chronic L lateral hip pain with hx of multiple cortisone injections in trochanteric bursa, and even recent tenex procedure 2 weeks before starting PT. Subjective: Pain gets up to 8/10. Unable to sit > 15min, pain with any stairs with ascending stairs more painful, unable to cross legs or sidelie in bed, and pain wakes her up at night. Objective: (*=pain) Initial Eval Re-Eval 8 wks Ober’s test Positive Negative Thomas test Positive Negative Squatting Not tested d/t pain Full depth and painfree S/L hip abduction test Unable* L 20x, R 16 (No pain/fatigued) SLB endurance Unable* 12 sec Sit-stand Pain* Pain-free Key Findings: Lack of hip extension, adduction and ER mobility, decreased hip abd strength with pain, lack of hamstring flexibility, midfoot pronation collapse in WB B, lack of spinal extension with only 20% and reversal of lordosis, significant gastroc tension affecting foot alignment, L > R hip flexor weakness, femoral IR alignment in WB. Treatment: Manual therapy: Anterior hip glide mobs in NWB and WB, hip ER jt mobs with passive stretching, WB hip mobs into adduction to assist WS in stance phase. Exercise: hip abductor strength progression from gravity eliminated AROM to standing hip OKC abduction to against gravity OKC hip abd to SL balance loading in static and then dynamic phases. Squat progression from bridging with hip abd strap to WB modified range squats to full depth. Lateral stepping progression starting with assist from SG and TR plane stepping drills. Hip flexor stretching and eccentric loading in WB with opp LE fwd stepping/reaching drills. Outcome: Pt able to sit > 30 min, transfers all pain free, walking as long as she would like w/o limitation, stairs pain free multiple times a day. Pain only up to 3/10 with extended periods of WB and advanced tasks such as lifting and carrying. (All progress documented after only 8 weeks of PT). ABSTRACT Background: There are numerous clinical tests that exist that can be performed during hip exams, but determining which are the most accurate can save the clinician time and help arrive at an appropriate diagnosis in less time with more certainty. Purpose: This study aimed to evaluate the accuracy of hip clinical tests that are used to diagnose greater trochanteric pain syndrome. Type: Systematic review with meta-analysis Methods: Literature search using key words mapped to diagnostic test accuracy for GTPS. Risk of bias was assessed using QUADAS-2 tool. And certainty of evidence GRADE framework. MetaDTA “R” random-effects models were used to summarize both individual and pooled data, including sensitivity, specificity, likelihood ratios and pretest-posttest probabilities. Findings: Of 858 studies, 23 full tests were assessed. 6 studies were included for review that involved 15 tests and 272 participants. In participants reporting lateral hip pain, a negative gluteal tendon (GT) palpation test followed by a negative resisted hip abduction test significantly reduced the posttest probability of GTPS from 59% to 14%. In those with a positive GT palpation test followed by a positive resisted hip abduction test, the posttest probability of GTPS significantly shifted from 59% to 96%. Author's Conclusion: Prior use of MRI for diagnosing GTPS is debated due to positive findings in asymptomatic individuals. This study finds a clinical test cluster that can accurately help confirm or refute the presence of GTPS in individuals reporting lateral hip 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 the 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 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 (May 2023) Improving Clinical Outcomes: Diagnostic Accuracy of Chronic Mid-body Achilles Tendinopathy Tests by William Slapar, PT, DPT, OCS, CMTPT, CAFS Clinical Scenario...What would you do? A 36 yr old recreational athlete who does Tae Kwan Do and running presents with L posterior ankle/heel and distal leg pain pointing to the achilles tendon area. She had overused the L wb leg two weeks ago while demonstrating R sided kicks through two consecutive classes and later that week had tried hill runs to break up the monotony of her distance running. She did have similar symptoms three years ago after progressing her first marathon training too fast but has been sx-free since then other than occasional stiffness. The achilles is tender to touch and slightly swollen but without frank crepitus during AROM PF-DF. Pain is reproduced with squatting and < 5x heel raises. Plain films are WNL. She does exhibit some asymmetric L overpronation in SLB standing/mini squats testing and has limited STJ neutral squat DF at approximately 15° L vs 25° R. She has an antalgic gait with poor push off of L foot and shortened R step length. She has iced and used ibuprofen OTC per bottle instructions with some relief. My clinical thinking is: She has achilles tendonitis. Advise to DC ibuprofen and continue with Tylenol for symptom control if needed. Temporary heel lifts x 2 weeks and FU to determine next course of action. Findings suspicious for achilles tendonitis but in-office US testing is indicated to confirm diagnosis before treatment can begin. She has achilles tendonitis. Delay US testing unless 3-4 week FU shows insignificant progress. Advise formal PT including biomechanical evaluation and Laser trial. Findings suspicious of achilles tendonitis but MRI indicated (due to prior hx to R/O more significant tendinopathy/degenerative tearing) including to assist in determining possible PRP recommendation. Initiate physical therapy. She has achilles tendonitis. Advise to continue ibuprofen. No other tests needed. Temporary walking boot x 2 weeks and FU to determine next course of action. CURRENT EVIDENCE Hutchison AM, Evans R, Bodger O, et al. What is the best clinical test for Achilles tendinopathy? Foot and Ankle Surgery. 2013;19(2):112-117. https://doi.org/10.1016/j.fas.2012.12.006 SUMMARY: Achilles tendinopathy can be a common complaint especially for active lifestyle and athletically active people. In the office it can present at different portions of the calf/ankle: insertional, mid body, or at the musculotendinous junction. This three joint muscle (knee, talocrural, subtalar joints) is key to normal function with roles at the knee and foot/ankle in both NWB and WB uses. There are numerous other differential diagnoses that can contribute to retro ankle pain, including retrocalcaneal bursitis, osteophytes and/or bony anomalies, complete or partial achilles tearing, tarsal tunnel syndrome, sural neuritis or neuroma, posterior tibial tendon dysfunction/rupture, arthritic conditions, plantar fasciitis, tenosynovitis of flexor hallucis longus, stress fracture, and/ or osteochondral lesions. Accurate diagnosis is a key starting point for clinical decision making. Many different tests are available to help improve our diagnostic accuracy of mid body achilles tendinopathy and numerous imaging options for more definitive tissue level assessment, however, these are variably expensive and must be weighed in each case regarding necessity. Hutchinson et al. reviewed and used 10 different common clinical diagnostic tests for chronic mid body achilles tendinopathy while using Ultrasound as a reference standard. The most valid tests are pain on palpation of the tendon, self-reported pain at 2-6 cm above insertion, and morning stiffness. The achilles transmits forces to and from the foot and leg/superincumbent body. While often considered a “heel raise” or “push off” muscle one of often neglected roles is to decelerate the advancing body/leg segment over the foot in mid- - - >late stance phase prior to push off. Following clinical testing PCP’s and orthopedists must then consider any further diagnostic testing needed. Utilizing valid existing clinical tests allows physicians to avoid or at least delay more costly tests that may not alter treatment recommendations. With a confident diagnosis of achilles tendinopathy treatment considerations typically include physical therapy. Excellent PT care will include in-depth biomechanical evaluation to assist in problem solving any modifiable contributing factors rather than simply addressing symptom reduction and gradual return to prior activity. Achilles symptoms may develop due to ipsilateral biomechanical factors but may also result from compensation due to contralateral limb deficiencies also. (We’d love to hear your professional insights on this topic. Let me know your thoughts after reading this summary at PT@PeakPTRochester.com or if you have a patient case you'd like to discuss) Background: Diagnosing chronic mid-body achilles tendinopathy is not straightforward due to amount of tissues in the surrounding area that can be inflamed or have pain associated with stressing them. But the diagnosis aspect is very important to providing the appropriate treatment. So having accurate clinical test that can improve such diagnosis is very helpful. Purpose: To evaluate the accuracy of clinical test in identifying chronic mid-body achilles tendinopathy. Using ultrasound as a reference standard Methods: Twenty-one subjects from three groups, with and without achilles tendinopathy, had an Ultrasound scan followed by ten clinical test performed by two orthopedic surgeons and one senior physiotherapist. Each test accuracy and reproducibility were determined as well. Findings: For chronic mid-body achilles tendinopathy pain with palpation (sensitivity 84%, specificity 73%, Kappa .74-.96) and self-reported pain location from 2-6 cm above insertion (sensitivity 78%, specificity 77%, Kappa .75-.81) are the most accurate test in determining it as a diagnosis from others. Author's Conclusion: Only pain location and pain upon palpation were noted to be accurate and reliable in the diagnosis of chronic mid portion achilles tendinopathy. Further studies need to be conducted due to limitations of the study. THE PEAK PERFORMANCE PERSPECTIVE PCP’s and orthopedists alike deal with patients presenting with posterior distal leg and foot/ankle pain that is suspicious for achilles tendonitis or tendinopathy. Posterior ankle pain can be difficult to differential diagnose because of the many tissues potentially involved, including Achilles tendinopathy, retrocalcenal bursitis, os trigonum, neuritis of sural nerve, tenosynovitis of flexor hallucis longus, osteochondral lesions, etc.) which are stressed in particular ways more than others. Available clinical tests can vary significantly in their diagnostic value. Oftentimes, various imaging(i.e. US, MRI) is utilized by MDs to assess specific tissue quality and for higher sensitivity/specificity for diagnosing, however, these are more expensive and while providing more detailed information about tissue changes/quality may not alter non-operative treatment recommendations. Especially in these times of rising healthcare costs providers are expected by patients and insurers alike to control costs where possible without compromising quality of care. A common procedure is to plain films done to clear any osseus issues or other red flags that could affect treatment recommendations. Diagnostic ultrasound has become a more popular and less costly alternative to the MRI for assessing achilles tendonitis/tendinopathy. Hutchison 2012 et al clearly showed that providers can make an accurate diagnosis of chronic mid body Achilles Tendinopathy through palpation and the patient's subjective symptoms. Palpable tenderness locally showed 84% sensitivity and 73% specificity. “Active listening”for the patient’s local pain site description (being 2-6 cm above the Achilles insertion), is 78% sensitive and 77% specific to such a diagnosis. While these sensitivity or specificity values are adequate and not high, they are the highest of the 10 tested. London Royal test, the arc sign, single leg heel raise, and the hop test all have very poor sensitivity, all individually < 50%. Using “clusters” has been effective for other body parts to improve diagnostic accuracy but Hutchinson states that it is not justified since there were only very small gains in accuracy when using two of the top three most accurate tests: pain with palpation, morning stiffness, and self-reported pain. Hutchinson reminds also about test reproducibility/reliability as well. Consistency of test outcomes is a key component especially when different providers are examining patients. The three tests that were the most reproducible are once again, pain with palpation, self-reported pain, and morning stiffness. Limitations of this study was there was a low sample size with it only being 21 participants, no details on age range ( just 18+ y/o), or of gender. One of the patients from the Achilles tendinopathy group also had retrocalcaneal bursitis. Another potential limitation is the use of ultrasound as a reference standard (however, US has shown good accuracy compared to the gold standard, operative findings). Achilles tendinopathy is a very common diagnosis seen by physicians and PT’s/ATC’s alike. The mid portion/body type is the most common (vs insertional) and correlates to poorer vascularization and thus difficulty for the tendon to repair microtrauma. A key concern then is determining the reason for achilles microtrauma…especially in cases where a bilateral or reciprocating activity produced only a unilateral symptom. Most often a biomechanical deficiency is contributing to this asymmetric overloading - making identifying and addressing it properly crucial. Physicians making referrals for treatment should expect both local tissue recovery (reducing pain and inflammation and/or myofascial/scar issues) and addressing biomechanical faults related to the mechanism of injury (MOI) are being addressed in therapy. Specifying treatment orders can be difficult because there are a vast number of possible contributing factors to achilles overload. While the achilles/calf are certainly dominant sagittal plane loaded tissues there remain triplanar loading effects that must be considered. Common factors we note clinically include overpronation due to rearfoot and/or especially forefoot varus compensations, asymmetric anteversion causing dynamic valgus proximally and triplanar achilles strain distally, reduced dorsiflexion, and weak quads or hip extensors causing overload demands on the plantar flexors for deceleration. Traditional therapies usually implemented are eccentrics to help with the deceleration aspect but usually performed using a vertical force only instead of an angular force that respects horizontal forces of locomotion. Changing up different angles to provide stimulus towards the nature of function can help train more specific to the goals. Although eccentrics are helpful there is some data suggesting heavier loads strength training is key and less focus on isolated/emphasized eccentrics may be required. Of course a well-rounded approach involving manual therapy for joint and soft tissue mobilization is often necessary. Class IV laser therapy has also been a helpful modality to speed healing and reduce inflammation/pain. THE PEAK PERFORMANCE EXPERIENCE Sally said: ”The foot is feeling a lot better and and I’m able to walk farther, stand longer, and go to my grandson’s lacrosse games. I can go up and down stairs better also!” HX: 69 y/o female having progressive pain in the L posterior ankle with any weight bearing activities. Plain films are unremarkable. She was put in a walking boot for 6 weeks. Subjective: 8/10 pain with weight bearing activities, especially walking and going down stairs. Stairs is a one step at a time and walking stride is asymm. Objective: (*=pain) Initial Eval 1 mo ReEval Amb. Sx onset, asymm stride w/ antalgic type gait >15min, incr. *, near symm stride SLB , rotations Sx onset w/ rearfoot varus , no supination control 21 sec, vertical calcaneus, with min pro control and mod supination SL calf raise unable * 15x* (* at the 15th rep) Royal London Test (+) (-) NWB calc. Ev (AROM/ PROM) (0 deg /1deg) (2 deg / 3 deg) WB DF ( knee flexed) 5 degrees * 18 deg NWB DF ( knee ext) 8deg PF’d * 1 degree (100%+) Step down test unable , * 2”, 30x Palpation (TTP) Achilles ( 3cm above insertion), medial Gastroc( mod. to serve) minor TTP of med gastroc, Achilles Key Findings: At evaluation in standing, the patient shows a L foot rear foot varus, with deficits in side to side comparison of dec. calc everison. In ambulation, initial pain during all WB phases of gait of the L LE., due to lack of calc eversion. Unable to test strength due to increase in pain with all WB strength/functional testing. Lack of dorsiflexion in WB and NWB for the gastroc and soleus. Treatment: Pt treatment started with Class IV laser, with manual to address hypomobilities in the rear foot and ankle, soft tissue mobilization to address TrPs in the gastroc/ soleus structures. Using a wedge to improve tolerance of load on the achilles in a more Plantar Flexed position to reduce strain during load of the achilles. Then to reduce incline and plantar flexed ankle to a neutral or foot on floor during exercises. She worked on balance and gait training in the frontal plane first then transitioned into the Sagittal plane to reduce the amount strain in the beginning of the treatment. Balance exercises to improve pronation and calcaneal eversion control during weight acceptance of ambulation. Outcome: The patient is now able to walk without an onset of sx until 15 min of continuous walking, able to enjoy going to grandson lacrosse games, and starting back into a walking routine. Pt is able to go down the stairs in the morning with </=2/10 pain in the morning with reciprocal steps. Pt is still in Pt to continue strengthening for deceleration from elevated surfaces, increasing the endurance and strength of the plantar flexors for ambulation. Key Findings: At evaluation in standing the patient shows a L foot rear foot varus, with deficits in side to side comparison of dec. calc everison. In ambulation, initial pain during all WB phases of gait of the L LE., due to lack of calc eversion. Unable to test strength due to increase in pain with all WB strength/functional testing. Lack of dorsiflexion in WB and NWB for the gastroc and soleus. Treatment: Pt treatment started with Class IV laser, with manual to address hypomobilities in the rear foot and ankle, soft tissue mobilization to address TrPs in the gastroc/ soleus structures. Using a wedge to improve tolerance of load on the achilles in a more Plantar Flexed position to reduce strain during load of the achilles. Then to reduce incline and plantar flexed ankle to a neutral or foot on floor during exercises. She worked on balance and gait training in the frontal plane first then transitioned into the Sagittal plane to reduce the amount strain in the beginning of the treatment. Balance exercises to improve pronation and calcaneal eversion control during weight acceptance of ambulation. Outcome: The patient is now able to walk without an onset of sx until 15 min of continuous walking, able to enjoy going to grandson lacrosse games, and starting back into a walking routine. Pt is able to go down the stairs in the morning with </=2/10 pain in the morning with reciprocal steps. Pt is still in Pt to continue strengthening for deceleration from elevated surfaces, increasing the endurance and strength of the plantar flexors for ambulation. You can trust the Physical Therapists at PEAK PERFORMANCE to do a thorough evaluation, to search for related but underlying contributing factors to kinetic chain dysfunction, and to design exercise progressions that both respect tissue healing and creatively use biomechanics principles to prevent symptoms and optimize carryover to your patients' functional goals. Call us at 218-0240 to discuss your patient's specific needs. Peak Performance is just minutes away from your patients in Penfield, Fairport, Pittsford, Brighton, Rochester and, of course, East Rochester. We promise Individualized, hands-on and biomechanically appropriate Physical Therapy for your patients. No "one-size-fits-all" approaches. We WILL go the extra mile and "dig deeper" to discover underlying causes for injury risk and delayed recovery using the most advanced Evidence Based methods available and, we’re able to make unique adjustments to exercise prescriptions to speed the return to function and to minimize or prevent symptoms from interfering. No surprises. No hassles. Confident your patient is in the right place. COME VISIT US AT 161 E Commercial St Just 1 mile off 490 exit (585) 218-0240 www.PeakPTRochester.com

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 (December, 2022) What Constitutes “Passing” When ACLR Return to Play Tests Disagree? by William Slapar, PT, DPT, OCS, CMTPT, CAFS Clinical Scenario...What would you do? A 21 yr old female competitive college soccer player underwent ACLR 7.5 mo ago and has progressed through jog-walk - - - > running- - - >sprinting work and agility progressions. She is presently at an estimated 90% intensity with her functional training. The patient was performing rehab at a facility near her home over the summer and has returned late August to college locally to continue rehab and resume soccer. Updated ReEvaluation testing locally showed the following: Isometric Quads at 600 angle 90% and at 300 was 65% Anterior Stepdown (toes off + posterior lean) @ 6” with front racked 20# DB’s was 65% with mild asymmetric dynamic valgus tendency SLB 6” cones rotational no touches test 70% with asymmetric overpronation tendency > dynamic valgus and delayed resupination action 900 rotational timed hop testing was 75% with mild asymmetric overpronation and dynamic valgus tendency but no frank instability sx reported 3x Ant crossover hop 85% with visible asymm opp leg swing and poorer 3rd hop landing (~ 300 stiff legged vs healthy limb ~ 500 knee flexion dampening) Her PT from home indicated she’d be starting practices at 50% effort and volume and expect to transition to full 100% intensity within 2-3 weeks. At your FU visit the Lachmans’ and Pivot Shift are (-), she has very mild inferior pole tenderness and only a trace effusion. She is eager to resume and confirms a subjective 90% function rating. After reviewing the above local PT ReEval findings you recommend: The knee is doing great and she should proceed with her home PT’s recommendations for a progressive 50% - - - >100% intensity college soccer practices return. Ortho FU 4 wks. The knee is steadily advancing - - keep doing intensive rehab focusing on Quad and Hamstring strength and retest in 3 wks just prior to next ortho FU to reassess RTP potential The knee is improving nicely - - - more strength/power and dynamic control needed before safe to resume soccer play beyond (I) ball drills. Continue functional rehab progression including dynamic valgus control PRE and reactive stability training, retest and FU ortho visit in 3-4 wks. The knee is doing great and she should continue PT work and then proceed with her home PT’s recommendations in 2 wks for a progressive 50% - - - >100% intensity college soccer practices return. Ortho FU in 6 wks. CURRENT EVIDENCE Thompson X.D, Bruce A.S, et al. Disagreement in Pass Rates Between Strength and Performance Tests in Patients Recovering From Anterior Cruciate Ligament Reconstruction, The Journal of Sports Medicine, 2022;50(8):2111-2118 SUMMARY: Many physicians, surgeons, physical therapists, athletic trainers and even personal trainers deal with patients with an ACL injury. A critical discussion between all has been passing rates on tests related to return to play (RTP) criteria for athletes after ACLR. In this article, Thompson et al did a cross sectional study on ACLR subjects that are 5-12 months post-surgical. They utilized a commonly suggested/referenced limb symmetric index (LSI) of 90% for the battery of return to play test and isokinetic testing as return to play criteria. They compared outcomes with quadriceps isokinetic testing vs single leg (SL) maximum distance single hop and triple hop. The authors hypothesized pass rates would be non-uniformly distributed comparing gender, activity levels, and that more would pass hop than strength testing. The authors found 36.5% disagreement between non-weightbearing isokinetic 900/sec quad strength (peak torque) and SL hop test LSI pass rates. For those passing hopping but failing isokinetic testing, a greater portion included patients with higher pre-injury activity ratings, approximately 7 months post-op having more difficulty passing strength tests than hop tests, which they had hypothesized correctly. The key issue then becomes determining why we have so many not passing the strength pass rates and how dynamic hop testing is being passed when the quadriceps, a key power production muscle for the concentric and eccentric demands of hopping, remains significantly weak as defined by isokinetic measures. A potential source of error when using limb symmetry postoperatively as the key indicator of recovery is the integrity of the non-operative limb, which we now know from studies, does underperform most often compared to pre-surgical status. That risks falsely elevating limb symmetry scores for the post-operative side, in this case, the ACLR knee, and giving passing grades prematurely, thereby exposing patients to potentially greater re-injury risk. Making pre-op measurements either (i.e. pre-season test battery) prior to injury or prior to surgery (which would likely exclude a significant portion of patients whose injured knee may not allow safe hop test performance of the uninjured limb) would improve accuracy of subsequent RTP tests use LSI of 90% as the criteria for passing. While isokinetic strength testing is very good at isolating concentric knee extensor muscle force production and is considered very reliable as a measurement property, it does lack great authenticity of the WB demands the knee and quads must deal with performing at-risk activities of hopping, cutting, jumping, agility etc. While a SL hop has the advantages of measuring a much more global and authentic movement demand associated with sport, its weakness is that no single muscle group deficit can be identified with such testing. Multi-joint tests like these must have some constraints in order to minimize obvious or excessive compensatory actions. For example, in this study, while isokinetic testing operationally controlled for excessive UE involvement by crossing arms the hop test description did not contain any clear language indicating control over arm swing or opposite limb swing, leaving substantial potential for the expected poorer ACLR knee/limb to perform acceptably due not to excellent capacity of the quads/knee necessarily but due to asymmetric arm and/or opposite leg swing during testing. It is critical that physical therapists/athletic trainers be hypervigilant during all types of testing, but especially during final rehab stage RTP testing as false (+) passing on LSI scoring can lead to patients resuming higher risk activities. Physicians likewise have a key role in discerning the types and accuracy of RTP testing being utilized as they discern progressive activity allowances. While quad strength and sagittal plane/vertical force based hop testing is a key and valuable measure we believe it is critical that frontal and transverse plane capacities must also be scrutinized as these are known contributors to the mechanism of injury, yet too often are ignored with clinical RTP testing. A crossover triple hop can begin to identify some of this frontal/transverse plane control required however we advocate intentional plane dominant side-side and also rotary timed hop testing as well. (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: ACL re-injury rates at 29.5% (30.4% ipsilateral and 69.6% contralateral knee) after returning to physical activity. Clinicians, whether surgeons or PT’s/ATC’s, have difficulty in determining the correct test criteria to follow on functional performance and strength tests especially when there is disagreement in scoring. Purpose: The purpose of this study is to show a comparison of the pass rates between strength (isokinetic peak torque) and SL hop and triple hop tests comparing results among men and women as well as to compare lower versus higher preinjury activity levels (Tegner). Authors hypothesized that the pass rates would be non-uniformly distributed among gender, and activity levels, and that more subjects would pass hop tests over strength tests. Methods: Testing completed by a total of 299 participants (146 Men; 153 women) at a mean of 6.8 +/-1.4 months on unilateral/uncomplicated ALCR. Isokinetic testing at 900/s and 1800/s was used for quadriceps strength, while single leg (SL) hop and triple hop test was measured in cm for jump distance. The measurements were evaluated and compared via the Limb symmetry index (LSI), passing defined as 90% . Findings: Pass rates were found to be non-uniformly distributed between the SL HOP test and 900/sec isokinetic test (p<.001). Of the 299 subjects, 36.5% (102/299) failed the strength test while passing the SL HOP test, and also reported that there was no difference between men and women with pass rates. A higher portion of those passing hop testing but failing strength testing reported higher preinjury Tegner activity levels. Author's Conclusion: Patients with ACLR who had higher activity levels prior to surgery were more likely to pass hop testing despite failing strength testing, likely through movement compensations to achieve jump symmetry despite the presence of weak quadriceps. THE PEAK PERFORMANCE PERSPECTIVE ACL reconstruction remains a “hot topic” across multiple medical field journals, whether it is through biomechanics, surgery/orthopedics, or sports medicine. Surgeons and rehab professionals are tasked with deciding when a patient recovering from ACLR is ready to begin jogging progressions and agility/jumping work and eventually when return to play (RTP) to actual athletics/recreational activities can safely begin. Since re-injury rates are considered unacceptably high it is imperative that high quality testing be used as a basis for these key decisions. Paterno M. et al 2014, showed re-injury rates near 30% overall, with 30% being to the ipsilateral knee and nearly 70% to the contralateral knee on a 24 month follow-up study of ACLR. It’s initially surprising to many that a 70% contralateral knee injury rate could exist on the knee that did not have disuse atrophy or painful inhibition of the quadriceps muscle. Might this implicate underlying contralateral limb biomechanical risk factors, poor technique tendencies, or post-operative deconditioning effects on the “normal” leg…or might it suggest an abnormal reliance on the “healthy/normal” leg due to incomplete rehab and/or premature return to sports placing excess demands on the post-operative side? Statistics like these are the cause for both surgeons and PT’s/ATC’s to take notice and explore deeper understanding of contributing factors so we each can be more effective in our responsibilities working to optimize outcomes and reduce re-injury. Functional performance and strength tests are used as a guide to both measure progress of rehabilitation and for RTP criteria. Not only which tests to use but what criteria to base the ‘passing score’ on varies highly and is in disagreement between clinicians. Common tests include isolated (typically quads, NWB isokinetic) muscle strength, SL hop or triple hop along with crossover triple hop, vertical jumping, and/or agility tasks. Side-side comparison, typically with a “passing score” as 90% is used for the limb symmetry index (LSI). As a surgeon or orthopedist, when do you know that your patient has met RTP criteria? Do you have specific criteria you adhere to? Are you strict in using those passing grades as requirements or how often do other factors play a role in approving RTP despite the patient not yet passing RTP testing? How confident are we, as both surgeons/orthopedists and rehab professionals, that the tests used are highly likely to be effective tools in reducing re-injury rate? Unfortunately, the current literature suggests we’re not tremendously effective on a consistent basis. For return to sport or work it would be ideal if we had and used specific details about expected demands, chose specific tests based on those functional requirements, and had agreed criteria passing grades rather than a singular “RTP battery” used as a standard for all. Because no one job or sport is the same, they are all unique and require different skills. Thompson et al show there is difficulty in patients reaching this “passing score” on isokinetic strength testing in the knee extensors. Quadriceps strength is necessary for all knee surgeries and for ACLR’s we all can agree is a must. Studies have shown it is one of the top factors relating to satisfaction after surgery and level of activity performed. Returning to running and sport a person must be able control impact on a single leg repetitively in succession and for cutting/agility movements certainly larger sudden, unexpected larger impact loads. These are without a doubt where we can start when looking at RTP. In this study Thompson et al showed that SL HOP and quad strength pass rates do not line up uniformly at an average 7 month mark of rehabilitation. SL HOP metric was passed more than isokinetic quad strength tests using the 90% LSI criteria. Even though that is what they should have done for the past 7 months is work on quad strength. But we have to look at how the quadriceps was tested in strength and how it was actually strengthened. In the study they used an isokinetic machine in which the patient was performing a kicking motion at 180 and 900/s. While this is a very reliable measure it does have some controversy or debate associated with it based on the “authenticity” criteria - real life demands of the quads in work, recreation, and sport most often involve gravity based body weight demands through squat motions and injury most often occurs during deceleration phases. It is critical to remember these often involve combined planes of motion into the frontal and/or transverse plane as well, and not simply just sagittal plane performance. Isokinetics would be most authentic for things like kicking a ball where distal limb loading occurs, however, even then those loads are minimal and rapid contractile forces produce acceleration prior to any external load where force is generated. Isokinetic devices show acceleration (and some also eccentric deceleration measures as well) limited to the sagittal plane only. Great care in how to facilitate the quadriceps must be performed early in rehab to diminish likelihood of compensations by the short toe and ankle flexors or the hip extensors for motions or squatting, lunging, and stair negotiation. This is performed by understanding the biomechanics, carefully watching form, use of surface EMG biofeedback, and knowing how to target the quadriceps through functional movements. Too often what are thought to be “closed chain” or “functional” training methods become facilitators of abnormal neurologic habituation/compensation patterns. Anterior step downs with the distal foot off the box, and other similar quad dominating techniques, are key in stimulating the weak quads during ACLR rehab and testing. This provides the opportunity to more authentically stimulate and measure quad performance in WB environments while minimizing compensatory muscle activation that clouds the validity of test results. We often see patients perform NWB isometric knee extension testing well only to grossly underperform on WB testing. Therefore we never rely mainly on nwb test findings. While this study did not look at frontal and transverse planes, which together contribute to the dynamic valgus mechanism of the injury, this must be a key focus of rehab. Careful considerations of dorsiflexion loss, hip weakness of the abductors and ERs, overpronation foot mechanics, and femoral anteversion make rehab very multifactorial. Specifically testing for and addressing these dynamic valgus factors, rather than oversimplifying strengthening of the quadriceps and hips in general is a key aspect to high level functional rehabilitation. One of the key issues with the Thompson et al study here is the lack of clear control over arm swing and opposite leg swing during hop testing. While arms contribution during isokinetic testing was controlled they do not address arm/leg swing as confounding factors during hop testing. This leaves room for the “apparent” success (i.e. passing) of SL hop and triple hop findings to not have been due to excellent quad/knee performance but potentially due to momentums generated from elsewhere. We believe strongly in hop testing and find it very useful in discerning when the patient is ready for the next step. Using the SL Hop shows the sagittal plane well but there must be more standardization of this test to really show that the LEs are what are providing the power and distance rather than other influencers, upper extremities or the contralateral extremities. We need to avoid allowing a false (+) passing test which could actually put someone on the field with an actual increased risk. Thompson et al. did state that here were compensatory movement patterns used to pass the hop tests but was not clear on what. The fact that higher Tegner activity patients pre-op were most often the ones who passed hop testing but failed isokinetics may speak to proprioceptive/neurologic aptitude and their ability to compensate with high performing remaining “triple extension” hip and ankle power sources. This likely needs more study but we find a “cleaner” testing method of hands remaining on hips simply removes arm swing as a variable, thereby isolating true LE power more clearly. Cueing and observation to ensure hop performance is due to actual hop efforts and not contralateral leg swing is key. Quality assessment of final landing is critical as well - focusing on willingness of the knee to tolerate dampening forces into knee flexion vs weaker patients using a “peg leg” style landing. Of course frontal and transverse plane control must also be visualized and considered. Finally, opposite limb training must be included in formal rehab and home programming in order to avoid false (+) pass rates due to underperformance of the healthy limb occurring over time based on deconditioning effects. This also may have played some role in the Thompson et al results but is not clear how it differently may have affected isokinetic vs hop outcomes. The battery of tests must consider the sport/activity that the individual wants to return to but more importantly any known MOI that occurred, and its biomechanical contributors. While the single hop and triple hop sagittal plane tests are useful some other examples are lateral SL hop, vertical hop, triple cross-over hop, rotational hops, SL squatting ability under load, Anterior step down test with toes off…etc. These tests are biomechanically and proprioceptively more consistent with the functional demands and MOI prevention considerations of most patients. THE PEAK PERFORMANCE EXPERIENCE Justin said: “I never knew how much went into an ACL rehab. I definitely have more confidence in my knee now than I did prior to surgery with squatting and lunging. I never liked lunges because my knee hurt.” History: Justin is a ski instructor and trainer for the youth US ski team. During a ski session he fell and his ski did not come off. He felt a “pop” in his knee during his fall. He came to Peak for pre-hab and then post-op for his ACLR with partial lateral meniscectomy. Objective: (*=pain) 6 mo ReEval 7 mo ReEval Isometric 600 Quad 74% 89% 6” cone 600 pron - 600 sup rotational no touches 20sec 48% 62% SL squats 15sec 78%, fatigue shows consistent DKV @ last 5 sec 89%, inconsistent DKV happening rarely 3x Crossover Ant Hops 9’11” w/ reduced knee flexion and more hip flexion, contr leg swing, min DKV 10’2” w/ improved knee flexion (but still reduced), less contraleg swing, min DKV 900 Rotational Hops 10sec (30 unit radius) 4x (67%) (50 unit radius) 8x (80%) WB Quads Anterior (toes off) Stepdown 6” 10# DB’s 12x (75%) 15# DB’s 15x (75%) Key Findings: ALCR in which there was a lateral meniscectomy. Pt is in the intermediate phase of treatment showing weakness still in the quadriceps functionally and isometrically. Pt has inconsistent anterior pelvic tilting during such as well. The hopping test shows hip flexion compensation during lands of hops with minimal dynamic knee valgus. During rotational hops there was less speed from time of impact to lift but very minimal to no dynamic knee valgus during both trials. Treatment: In this intermediate phase dynamic frontal and transverse planes were worked on to really minimize the dynamic valgus and enhance the stability of the lower extremity. Squatting on incline board was done to mimic transfer of forces at angles with dumbbell hang position for skiing efforts. Unstable surface SL squatting was performed to improve overall stability of force absorption with a noncompliant surface. Toes off anterior step downs were still used with a posterior lean for quadriceps strengthening through function with a cross reach to minimize DKV while overloading the muscles. Speed training to improve fast twitch fiber reaction on unstable and slated surfaces for proper ground reaction to sport. Justin required fast small impact drills to mimic the oscillatory action of skiing downhill. The Vibeplate also helped with Single legged balance training for the nervous system at high levels for return to fast oscillatory motions as well. Outcome: Pt is still working through physical therapy to start skiing soon with small slopes. Pt shows great determination to get back to it with consistent work on HEP and shows changes weekly. 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 2022 Five Year Follow-up on Physical Therapy vs Arthroscopic Partial Meniscectomy for Degenerative Meniscal Tears: ESCAPE RCT Results by Karen Napierala MS, AT, PT, CAFS What would you do? A 52 year old male limps into your office after stepping on an uneven muddy surface, slipping, and feeling pain in his medial knee. He is lacking full knee extension by 50 degrees with a springy empty end feel. End range flexion is painful/limited, as is full weight bearing. He denies any frank locking symptoms. A small effusion is present and tenderness is isolated to the medial joint line, especially posteromedially. Plain films show very mild joint space narrowing. McMurray’s provocative testing reproduces pain with tibial ER + varus compression. The patient is eager to return to hiking, and outdoor activities as soon as possible. I would prescribe… “RICE”, NSAIDs, and gradual activity return as able over 2-4 wks - call if problems persist. Order MRI for suspected medial meniscus tear. NSAID’s and 3x PT visits based on ease of location for HEP training. Intra-articular steroid injection and reassess in 2 weeks. Customized biomechanical PT to include Class IV laser, manual therapy as needed, customized exercise for off-loading medial knee. FU 4-6 weeks. Refer for or schedule knee Arthroscopy for expected partial medial meniscectomy and chondral debridement. CURRENT EVIDENCE Rhon DI, Fraser JJ. et al.“.Effect of Physical Therapy vs Arthroscopic Partial Meniscectomy in People with Degenerative Meniscal Tears: Five-Year Follow-up of the ESCAPE Randomized Clinical Trial, JAMA Network open, 2022:5(7), 2022, 2021; 619-27. SUMMARY: Meniscectomies for degenerative meniscal tears are performed throughout the United States but more recently have been recommended less routinely than in the past due to numerous studies showing no clear clinical benefit over non-operative care in the first two years. Debate is ongoing, however, regarding the implications that arthroscopy vs rehabilitation choices may have on subsequent cartilage degeneration over a longer period of time. Some have suggested that addressing unstable meniscal tissue will reduce the potential for abnormal stresses on the articular cartilage. A multicenter randomized clinical trial (RCT) on arthroscopy vs exercise therapy for degenerative meniscus tears (ESCAPE Trial) was conducted in the orthopedic departments of 9 hospitals in the Netherlands. Recruited subjects had symptomatic, MRI confirmed degenerative meniscus tears - 321 patients aged 45 - 70 years participated between 2013 and 2020. Patients were randomly assigned to arthroscopic surgery + written HEP or 16 sessions of exercise based PT. The study was non-inferiority RCT after 5 years following up on the original ESCAPE Trial group of which 278 of 321 patients completed the study. Neither IKDC nor radiographic knee OA indicators (OARSI and Kellgren-Lawrence scales) showed statistically significant differences at five year follow up. It should be noted also that as-treated analysis also showed no differences, with 32% of the PT group subjects’ crossing over to delayed surgery but still never achieved significant improvements over the PT-only group for function. Comparable rates of progression of radiographic knee osteoarthritis were noted between treatments. Noorduyen et al concluded that exercise-based PT remained non-inferior to arthroscopic partial meniscectomy for patient-reported knee function and radiographic knee OA during the following five years. They concluded that “PT should therefore be the preferred treatment over surgery for degenerative meniscal tears”. While the PT program that included simple ROM and generic squats, step-ups and lunges was as helpful as the surgery. There was a significant amount of patients from the PT groups that were unsuccessful. Our experience has shown that numerous biomechanical factors must be considered to optimize and expedite patient recovery. These focus both on potential underlying contributing factors that accentuate forces through the medial or lateral joint and also include specific techniques used to off-load the medial or lateral joint tissues during otherwise limited and painful squat based WB strengthening exercises. These are not commonly addressed in traditional physical therapy programs. The addition of Class IV laser has also proven helpful for many patients having degenerative meniscal tear diagnoses. (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: Recommendations for care of degenerative meniscus tears has changed toward non-operative PT/exercise based on studies comparing arthroscopic partial meniscectomy (APM) outcomes over two years. A significant reduction in APM, however, has not been seen. Neither surgery nor conservative treatment (exercise) necessarily prevents the development of OA. Conversely, some studies have shown APM in these degenerative knees to accelerate this articular degenerative process. Purpose: This study looked to compare patient-reported knee function at the 5 year follow-up mark after APM and exercise-based PT in patients with a degenerative meniscal tear. Secondarily, it looked to assess the radiographic progression of knee OA. Their hypothesis was that exercise-based PT is non-inferior to arthroscopic partial meniscectomy after 5 years. Type: Non-inferiority RCT Methods: This study followed up on the ESCAPE Trial or “Cost-effectiveness of Early Surgery versus Conservative Treatment” begun in 2013. In this study, 321 patients aged 45-70 were recruited who had MRI confirmed degenerative meniscus tears. They were randomized to APM within four weeks or PT exercise groups within two weeks of injury. APM included a written HEP (after 8 weeks access to PT only for delayed recovery) and PT was BIW x 8 wks + HEP training for 16 sessions of supervised exercise. IKDC self-report instrument was the primary outcome, checked at 3.6.9.12. 18 and 24months and secondary outcomes were radiographic knee OA measures (OARSI and KL scores). At 3 month patients visited the outpatient department for physical examination. At 24 months plain films were obtained. A follow-up questionnaire, exam, and radiograph were also obtained at 60 months. Knee locking or subsequent trauma, or failure to progress in PT were grounds to consider APM surgery. Findings: Of the 321 patients (mean age=58 yr), 278 completed the 5-year follow-up. The mean IKDC improvement was 29.6 points in the APM group and 25.1 in the PT group. The crude between group differences was 3.5 in both which did not exceed the non-inferiority measure of 11 points on the IKDC. Radiographic OA changes were not statistically significantly different between groups at 5-year follow up. In a previous study, those 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. Author's Conclusion: Exercise-based PT remained non-inferior to APM for patient-reported knee function. PT should therefore be the preferred treatment over surgery for degenerative meniscal tears of non-obstructive nature. THE PEAK PERFORMANCE PERSPECTIVE: My last doctor's newsletter also focused on long term health care costs being reduced with PT vs arthroscopy for degenerative meniscal tears. Historically speaking, meniscal surgery is the most performed orthopedic surgical intervention with 30,000 procedures annually (van Arkel ERA, Van Essen, et al) in 2013 the U.S. There was a 49% increase in arthroscopic partial meniscectomies (APM) between 1996 and 2006 (Kim S Bosque, et al). Half of these were performed in patients over 45 years old. These numbers continue to rise since the proportion of the population over 60 years will double from 11% to 22% between 2000 and 2050 (WHO). APM therefore contributes significantly to healthcare costs. Meniscal surgeries range from $5,000 to $30,000 depending on insurance coverage status. Sudden onset knee pain with some swelling and painful/limited knee motion in patients over 35 years without significant associated trauma is a common finding and often considered a potential degenerative meniscus tear until proven otherwise. Physicians and surgeons see these patients frequently for evaluation. Clinical decision making has changed over the years regarding best practices for these cases. First, I really want to stress that although cost can be a large factor driving decisions, quality of healthcare is of primary influence here at Peak. Noorduyn et al showed here that both surgery or exercise yield similar outcomes on the IKDC and regarding radiographic changes in knee osteoarthritis following 5 years after a meniscus injury, based on their non-inferiority RCT with 278 patients following up (87%) at 9 centers over that time. While APM has decreased in popularity (due to research supporting non-operative care - Herrli and, Hallander et al NEJM 2013; Kise and Risberg et al, BMJ 2016) in the past years, there remain some physicians/surgeons and certainly patients who would tend to prefer surgery over formal PT/exercise. In cases when symptoms persist or in cases of mechanical obstruction (locking and limited range of motion) APM has been proven to be an effective treatment to restore knee function. Although arthroscopy for obstructive meniscal tears in patients over 50 are widely accepted, knee derangement symptoms may be triggered by meniscal tears, or by early onset osteoarthritis (OA). A study by Englund (2008) identified meniscal tears on MRI in 61% of nearly 1000 asymptomatic volunteers over 50 years old. If treatment of non-obstructive meniscal tears focuses primarily on reducing symptoms, first the symptom producing tissue needs to be idefined. Are we really sure that knee pain is from the meniscus, or is it generated from the chondral bone below, or other innervated structures? Shvonen et al looked at the long term changes in osteoarthritis of the injured knee joint and showed slightly increased risk of radiographic knee OA following APM compared with exercise therapy. Katz et al found a 5 times higher risk for total knee replacement after surgery vs an exercise-based PT program. While a subset of patients with degenerative meniscus tears initiated with non-operative care do move on to arthroscopy we also have seen cases as described above, where an otherwise routine and “minor” APM and associated chondral debridement led to an exacerbation of DJD symptoms and in a number of cases resulted in far earlier than expected transition to TKA. Faster progression to OA will lead to more patients desiring to stop the pain thru knee replacement (which results in more medical cost). Preventing this acceleration of OA may result in people with increased function, independence, and less chance for early total knee surgeries. This will trigger a substantial reduction of costs of healthcare while maintaining patients' outcomes and independent lifestyles. Traditional physical therapy, while proven effective in many studies for degenerative meniscus tears, often neglects key components that can shorten the time needed to move to an effective independent HEP. This is based on customized PT utilizing Applied Functional Science (AFS ®) biomechanical approaches being able to adjust body/limb segment postures and paths/directions during especially WB exercises to lessen medial or lateral compartment stresses. For a medial meniscus injury, for example, oftentimes traditional PT squat based exercises like common step ups or step downs or various lunges would be limited and painful, delaying recovery. Utilizing biomechanical approaches, however, AFS trained PT’s would likely find foot ER, tipping the ipsilateral hand / shoulders down laterally and drifting the opposite foot 15-200 off midline all serve to decompress the medial joint and typically allow patients to train their quads and squatting like movements much earlier and much more effectively. Let's consider that same patient who has a medial meniscal tear. There are other biomechanical factors that can accentuate medial joint loading that must be addressed. Typical step ups, step downs, lunges often continue to produce discomfort or must be constrained to very shallow depths due to symptoms. Tight ITB/TFL will contribute to knee varus tendencies, as will retroversion or lack of hip IR (tightness of ER’s). At the foot, a lack of calcaneal eversion and general foot pronation, or a short leg can add to varus knee forces that may enhance medial joint forces and thus pain at the degenerative meniscus and related subchondral bone and/or synovial area. If the foot allows, a neutral or 2 degree valgus forefoot/rearfoot wedge may be used to unload the medial knee joint. The opposite idea, yet the same biomechanics can be applied to the lateral joint issues with the focus being on limiting the causation of pronation from the foot to the hip. THE PEAK PERFORMANCE EXPERIENCE: Nicolas said: “After 5 years I am still out in the wilderness leading boy scouts and leaders. Just last month I was out kayaking across Greenland with kayak portages and climbing mountains! I have no pain in my knee joint as of today!” History: Nicolas was a 50 year old Boy Scout leader who spent many weekends roughing it in the wild and training other leaders. He went out with his son training for a marathon when he felt knee pain. He suspected 26 miles was too much but he really wanted to do this with his son. After a few weeks of training his medial knee was painful to stand on. Subjective: It began with a small ache, and after a week more of running, he could barely walk. Objective: (*=pain) Initial Eval Re-Eval Knee extension R knee 50 Full extension Single leg squat knee angle L 650/ Unable ** L 750/R 650 Calf raise L 240/R 20 L 260 / R 240 3” quad dom step down (eccentric ) Unable * 15 # front racked L 24x / R 15x Single leg hop 10 sec L 14x / R unable ** L 16x / R 5x ** Knee Flexion R 700 R 1250 Single leg balance rotation 15 sec Unable L 12x R 9x IKDC 32% 64% Treatment: Nicolas presented with limited ROM due to pain. He had limited calcaneal eversion R >L. R forefoot valgus was 50, while L is 30. His PT began with restoring ROM as able. Once he could fully extend his knee, he was able to do weight bearing activities beginning with B at 50% WB on the leg and progressing to SL weight bearing as able. He received mobilization to his calcaneus to increase available eversion and reduce his varus knee force on each step. To decrease WB forces on the medial meniscus, Nicolas used a 4 degree lateral forefoot and 2 degree lateral rearfoot wedge in his R shoe. He had limited hip IR to 15 degrees B. Hip IR stretching NWB was added in, as well as hip extension. His exercise program progressed to upright hip ext and IR stretches and then small range strengthening of the ER’s and hip extensors. As symptoms allowed he also began quad dominant step downs, ant medial lunges to facilitate a valgus force at the knee, and calf raises. After 3 weeks: Pt ambulating at 2.5 mph with no pain. Outcome: By controlling the knee varus through his shoe posting, and allowing him freer calcaneus, hip, and knee frontal plane motion, Nicolas was able to return slowly to prior activities. It took him 3 months to return to walking on even surfaces, and almost 6 months before uneven surface and small hiking, (specially downhill) felt good. I interviewed him last week, and after five years he is hiking, portaging (carrying) his canoe/kayak, climbing mountains, and getting on and off the ground with no pain. Jumping and landing on the R leg alone will bring on some discomfort (1-2/10), as will planting R and cutting L if he isn’t careful. He has returned to his full activities with no complaints. 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 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