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

Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE March 2023 Improving Clinical Decision Making on Scapular Dyskinesis with Subacromial Shoulder Pain by Mike Napierala, PT, SCS, CSCS, FAFS Clinical Scenario...What would you do? A 50 yr old female with chronic shoulder pain and stiffness comes to the office for a consult after failing two prior bouts with physical therapy and numerous injections. Recent MRI shows RC tendinopathy and small labral tearing. She is not in acute distress but limited significantly with ADL and fitness/recreational activities. AROM into elevation and abd’d rotations is most restricted along with neutral ER. She has painful weakness with RC testing but no signs of frank tearing. Scapular dyskinesis noted during descent from flexion and with resisted flexion at 1300. She did have prior dx of Adhesive Capsulitis and did not recover fully but did not feel PT was helping. She demonstrated a typical PT HEP routine of GH stretches and scapular retraction, serratus protraction/plus, and RC PRE. My clinical thinking is: Consider arthroscopy since PT and injections failed. Consider MUA to recover ROM unable to be attained through standard PT care and compliant HEP. Refer to PT for more thorough manual therapy and customized exercise including specifically serratus work to reduce scapular dyskinesis contributing to ongoing RC overload/irritation. Refer for deep tissue work with LMT to attempt ROM recovery and then send back to PT. CURRENT EVIDENCE Tangrood ZJ, Sole G, Riberio DC. Is there an association between changes in pain or function with changes in scapular dyskinesis: A prospective cohort study. Musculoskeletal Science and Practice. (48) 2020. 1-7. https://doi.org/10.1016/j.msksp.2020.102172 (We’d love to hear your professional insights on this topic. Let me know your thoughts after reading this summary at PT@PeakPTRochester.com or if you have a patient case you'd like to discuss) SUMMARY: Shoulder pain is a common diagnosis seen by physicians/orthopedists. Oftentimes scapular dyskinesis (SD) may be present. Testing for SD using reliable methods and determining potential meaningfulness contribute to clinical decision making regarding treatment recommendations, especially in the case of “failed” conservative care where more invasive procedures are not called for or necessary yet. Current data has both variable and contradictory findings surrounding SD and the related serratus anterior and/or lower trapezius involvement, along with a lack of clear causal level relationships to pain and/or injury. Tangrood et al demonstrated an association over 8 weeks in a group of 44 participants with shoulder pain that improvements in scapular dyskinesis testing was associated with improved PSFS self-report function scores. One confounding variable included that 65% of those completing all testing were receiving physical therapy and 35% were not. These groups were not separately analyzed which may have shed more light on causes for improvement. Common SD approaches in physical therapy often involve activation of the serratus anterior (SA) that utilizes a “plus” movement (i.e. protraction). While the SA certainly does and can protract the shoulder this risks activation of the pec minor as well with the ongoing risk of facilitating a protraction posturing that otherwise has been identified as a potential risk factor for shoulder pain. In overhead activities the scapula must tilt posteriorly while upward rotating. Many traditional methods of testing and training for SD also utilize long lever positions that painful shoulders struggle in. Authentic biomechanics approaches are necessary to promote scapular integrity via medial border stabilization (superior through inferior angles) along with upward rotation without compromising biceps or rotator cuff tendons or labral structures. A physician’s ability to identify SD in clinical exams in order to prescribe and monitor appropriate PT is often key in achieving optimal outcomes. Background: Scapular dyskinesis (SC) is a debated topic and it is unclear whether it is causative of shoulder dysfunction and subacromial pain or a consequence of symptoms, and, whether the presence of and changing of SD affects function or pain. Purpose: To assess the association of changes in subacromial shoulder pain or function with SD changes over time. Methods: Observational, prospective, cohort study of 44 participants (37 who completed baseline and 8 wk follow up testing), with 24 receiving physical therapy and 13 no treatment, using Numeric Pain Rating Scale (NPRS) 0-10 scale for “at rest” and “during movement” , self-report Patient Specific Functional Scale (PSFS), and the scapular dyskinesis test (0=normal scapular movement and 6= highest scapular dyskinesis, summing using Kibler et al system scoring). Findings: Improvement in function showed a fair association with improved SD (correlation coefficient = -0.4) while no associations found for pain at rest or pain with movement to changes in SD. 89% of patients showed subtle to obvious SD at baseline. Participants showed no changes in “pain at rest”, medium improvements of “pain during movement”, and large function improvements (28.0 mean PSFS score difference w p=0.000) but no significant SD changes. Author's Conclusion: Improved function in patients with subacromial pain was associated with improvements in scapular dyskinesis. Future studies needed to determine causal effects. THE PEAK PERFORMANCE PERSPECTIVE Shoulder pain is one of the most common orthopedic complaints seen by orthopedists and PCP’s alike. One of the most frequent diagnoses includes some form of RC syndrome (tendinitis, tendinosis, tears, impingement, etc.) which contributes to subacromial shoulder pain. Physicians discerning best practices for non-operative care recommendations are often tasked with determining obvious contributing factors they expect to be addressed in physical therapy. Understanding and testing for scapular dyskinesis underlies prescribing practices for these patients and especially for cases of “failed care” where more simple protocol based therapy approaches have not worked. It is also potentially a great example of the concept “because a muscle can doesn’t mean that it does” - in regard to how we classically test and exercise in comparison to how it actually functions. Directing care for shoulder pain of various sorts, whether it be tendon related, bursal, labral, or instability related can be difficult when considering there are few or even no clear truly “BEST practices” approaches that have been proven clearly superior to others. Many studied are more so “only practices” or “doing this happens to work” versus actually finding “bests” in treatment. That makes prescribing care and designing rehab difficult. Certainly there is a blending of science with “art”/experience etc. Secondarily, other kinetic chain contributing factors, whether local to the scapulothoracic articulation, the thoracic spine, or even related to more distal/distant joints (especially when considering complex body movements such as overhead athlete mechanics or total body lifting/reaching ADL demands) have construct validity but often lack clear “evidence” in the literature. Scapular dyskinesis (SD) is one of those entities that has been identified but suffers from conflicting evidence as to its contribution and meaningfulness. Nevertheless, it may be one of those important factors for physicians to consider when prescribing physical therapy. Physicians must therefore consider how SD should be assessed in the office and how are therapists/athletic trainers addressing this through exercises. Kibler et al (2013) and others have identified abnormal scapular mechanics, or scapular dyskinesis, as a potential contributing factor. Kibler proposed a four pattern grading system with Pattern I being inferior angle prominence (tipping), Pattern II being medial border prominence (winging), Pattern III being early scapular elevation or excessive upward rotation (elevation), and Pattern IV being normal rhythm. In-office measurement of scapular dyskinesis can be done utilizing the scapular dyskinesis test (SDT) by Kibler. Arms are raised into flexion to maximum elevation and lowered 3-5x (adding 3-5# to each hand for up to 10 repetitions may be used to accentuate abnormal findings). Most often altered motion occurs during the eccentric descent. Ramiscal et al (Clin Shoulder & Elb 2022) showed grouping Patterns I-III as a “yes” and Pattern IV as a “no” resulted in intra-rater reliability kappa of 0.92 and inter-rater values of 0.85 for expert PT’s with asymptomatic individuals. This sort of chunking certainly reduces potential for reliability errors related to the challenge of ensuring consistency with limited/poor objective measurable means of determining when exactly a “winging” event at the respective scapular reference points has occurred. Break tests of flexion at 1300, abduction at 130-1500, and extension with arms at the side - looking for significant scapular movement should also be done. Kibler wisely has reminded (Int J Sports PT 2022) that lack of research agreement is, in part, related to multiple muscles attaching to the scapula allow for simultaneous and synchronous activation and stabilization during arm movement” causing variability in how individuals perform the same task, thoracic anatomy and varied muscle fiber orientation does not allow for single plane scapular movement - scapular motion involves complex translations/rotations w coupled muscle activation. He differentiates “neurologic” winging that remains disconnected through ascent and descent phases while “altered scapular positioning” is more so evident in descent phases. This differentiation on the surface would seem plausible, however, length-tension relationships, impacts of tissue tightness at different arm positions, and nuances of force couples may otherwise explain why the dyskinesis of abnormal scapular movement often occurs with eccentric phases only or more so than during concentric phases. Causal effects of scapular dyskinesis to pain and/or injury has not been clearly established Finally, Kibler also cautions that scapular dyskinesis is not a “diagnosis” in medical terms but an impairment therefore clinical utility, measuring diagnostic accuracy, is difficult and even inappropriate when no gold standard exists for comparison. Tangrood et al provide some evidence of an association of scapular dyskinesis reduction with improved shoulder function on self-report PSFS questionnaire responses. Repeated measures correlation coefficient showed 16% of the variability in PSFS score changes is explained by scapular dyskinesis changes. Strength of findings are weakened because confounding factors (symptom duration, physical demands, etc.) were not controlled for, especially the fact that 65% of those completing all testing participated in physical therapy (without known parameters) while 35% did not, creating a heterogeneous sample. Data was not analyzed for differences between these groups. Since blinding was not done the risk of examiner bias cannot be ruled out. Subtle dyskinesis made up 57% of the baseline group test findings. Measurement properties make determining change for these subjects more difficult to ascertain. Clinically speaking we find not only for a high percentage of shoulder pain patients that SD is present in some manner but that especially for many of the “failed PT” cases we see that this has not been addressed in rehab or maybe more importantly was only addressed with simple protraction exercises. One consideration is determining the authentic function of a muscle in ADL or sport. Again, we would caution that “because a muscle can doesn’t mean that it does” in regard to certain tests traditionally done or exercises utilized. During elevation function so often related to shoulder overloads and pain the scapula does need to upward rotate but that is coupled with posterior tipping/adduction especially for cocking positions of overhead athletics. The majority of SD exercises, owing to the classically viewed Serratus Anterior role in its capacity to protract the scapula, are most often pre-engaged or emphasized by intentional or forceful protraction. We would contend that in many typical ADL and athletic arm movements the authentic biomechanics necessary contradict coupling upward rotation with anterior tipping/abduction (ie protraction). Yes, that “works” and “fatigues” the Serratus Anterior, leading to a self-fulfilling prophecy of sorts that the exercise is effective. Functional biomechanics would seem to differ with that conclusion. In unique demands of pushing and throwing/propelling the arm and related objects forward certainly serratus function protracting the scapula is an absolute necessity. Relegating the majority of serratus anterior training for the sake of reducing SD though may be oversimplifying muscle function. Because it can doesn’t mean that it is…in this movement or case. Most testing and exercises related to SD factors (i.e. serratus and lower traps) tend to place the arm in longer lever positions. While this creates loads that may quickly increase lever arm effects and identify inadequacies it also risks eliciting pain in inflamed or damaged tissues that causes inhibition of otherwise potentially normal muscles. This is especially true for the “T” and “Y” tests and exercises so often done to address SD. We attempt to approach SD with a functional biomechanics mindset that we are seeking scapular integrity on the thoracic cage wall, with whatever posterior or anterior tipping required, and with adequate and not excessive upward rotational mechanics. While this is not easy to measure objectively or to isolate to singular muscles, due in part to the related pain generating tissue implications noted above, it leads to what we believe is a more authentic approach to scapular dyskinesis through “de-winger” thinking versus promotion of protraction dominated successful activation of serratus anterior that risks over stimulus of pec minor and what would otherwise be abnormal posturing. Kinetic chain biomechanics involving facilitation of thoracolumbar coupling, for example, into same sided rotation and side bending along with extension during cocking phases for overhead athletes, must be addressed if scapular positioning is to be optimized. This involves testing for and addressing Type I and Type II spinal mechanics along with other core and hip function. Too often we see patients having failed traditional PT approaches because classic exercises essentially rely on long lever arm loading into at-risk positions that cause pain of the irritated rotator cuff tendons or labral injury. Care must be taken in many cases of shoulder pain to customize loading of the Serratus Anterior and/or Lower Trapezius to achieve scapular integrity while avoiding symptom exacerbation. The case below involves a patient who had scapular dyskinesis as a contributing factor that required careful attention in testing and exercise. THE PEAK PERFORMANCE EXPERIENCE Holli said: “I had tried a couple of rounds of physical therapy elsewhere with not a lot of improvement in my shoulder after two years of pain. I’m so happy I was finally able to get my range of motion back and not be in pain all day!” History: 50 yr old female nurse fell in 2020 injuring her wrist and then developing L non-dominant shoulder pain. She had PT at a local hospital based outpatient clinic and transitioned to HEP but developed adhesive capsulitis and was then seen for PT several more months. Pt had a total of 4 corticosteroid injections. Now presenting two years after the original fall to address ongoing issues. Subjective: 6/10 max pain with reported function at 80%. Symptoms aggravated by elevation ADL, unable to sleep L sidelying, unable to do pushups and other fitness exercises, cannot kayak. Objective: (*=pain) Eval 5 mo DC ReEval Flexion AROM 1330 / 1660 1670 900 Abd IR AROM 130 / 300 350 900 Abd ER AROM 950 / 1200 NT Wall Serratus Anterior test L @ 4 / 5 with < moderate winging 5- / 5 Pec minor Scapular Retraction (hand @ head) Mod L tight < Min Flexion isometric 1.8 kg * (24%) 5.5 kg (74%) OH reaching (pressing) 5# 33x ( < 66%) 12# 12x (71%) 800 Abd w 900 ER test NT 8# 76% painfree Key Findings: At evaluation Pt had limited elevation AROM along with posterior RC/capsule restriction in Horz Abd and Abd IR. Isometric testing revealed weak/painful elevation and Abd ER along w weak Serratus Anterior during wall scapular integrity resistive test - showing scapular winging medial border. Thoracic L rotation was asymmetrically limited. Impingement / RC tendonitis special tests were (+). Treatment: Manual therapy emphasis to pec minor release, thoracic rotation mobilizations, and especially GH jt mob’s for all motions and capsular restrictions using holding style techniques vs std oscillation approach. Sustained stretching HEP initiated including for pec minor and thoracic L rotation combined with AROM integration drills immediately following. Scapular dyskinesis addressed with Serratus drills in both NWB and WB environments, focusing on “de-winging” emphasis of maintaining scapular integrity during related modified lever arm loaded LUE movements to optimize successful maintenance of scapular positioning…first accomplished in scapular plane and increasingly loaded in sagittal plane. These were eventually moved to upright 900 and then overhead demand positions to mimic authentic biomechanics necessary for ADL and fitness needs. Progressive shoulder/scapular PRE were done moving from BID high reps/low load toward eventual TIW 3x10-12 reps work and including functional considerations for fitness goal movements. Outcome: Pt happy with her progress and wanted to continue remaining work on her own with (I) HEP only. She had had challenges with regular attendance due to other life and work schedule demands. Holli rated function at 90% with Quick DASH 7% and Sport rating 24%. You can trust the Physical Therapists at PEAK PERFORMANCE to do a thorough evaluation, to search for related but underlying contributing factors to kinetic chain dysfunction, and to design exercise progressions that both respect tissue healing and creatively use biomechanics principles to prevent symptoms and optimize carryover to your patients' functional goals. Call us at 218-0240 to discuss your patient's specific needs. Peak Performance is just minutes away from your patients in Penfield, Fairport, Pittsford, Brighton, Rochester, and, of course, East Rochester. We promise Individualized, hands-on and biomechanically appropriate Physical Therapy for your patients. No "one-size-fits-all" approaches. We WILL go the extra mile and "dig deeper" to discover underlying causes for injury risk and delayed recovery using the most advanced Evidence Based methods available and, we’re able to make unique adjustments to exercise prescriptions to speed the return to function and to minimize or prevent symptoms from interfering. No surprises. No hassles. Confident your patient is in the right place. COME VISIT US AT 161 E Commercial St Just 1 mile off 490 exit (585) 218-0240 www.PeakPTRochester.com

Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE February 2023 A “new” Low Cost Treatment for Knee/Hip OA Without NSAID and Tylenol Side Effect Risks and Downstream Medical Costs… by Karen Napierala MS, AT, PT, CAFS What would you do? A 67 yo female enters your office with pain in her L anterior thigh traveling up into her anterior hip/groin. She has pain on heel strike and late stance phase of gait, which is visibly shortened. She can stand 30 minutes maximum while leaning forward to prepare meals at the counter, but can only stand upright < 10 minutes socializing at a family gathering. Hip flexion for tying her shoe is painful and limited. Hip scouring is (+) for pain and limited motion. All hip AROM and PROM are limited, especially with loss of IR, Faber’s, and hip ext. Plain films confirm moderately severe L hip DJD. The Pt’s goals are to resume WNL ADL, watching grandchildren BIW for 5 hr each, fitness class BIW 45min and occasional doubles pickleball. I would prescribe… A. A normal course of NSAID’s along with continued usual activity until 6 wk FU B. A normal course of paracetamol along with continued usual activity until 6 wk FU C. Surgical consult for THR consideration D. Customized PT to include Class IV laser, manual therapy, biomechanical exercise with FU 6 wks E. Provide handout of simple HEP drills for ROM and light strengthening with FU 6-8 wks F. Intra-articular corticosteroid injection with FU 4 wks CURRENT EVIDENCE Weng Q, Goh SL et al. Comparative efficacy of exercise therapy and oral nonsteroidal antiinflammatory drugs and paracetamol for knee or hip osteoarthritis: a network meta-analysis of randomized controlled trials. BJSM, Jan 2, 2023(online). https://bjsm.bmj.com/content/early/2023/01/02/bjsports-2022-105898 SUMMARY: Osteoarthritis is one of the most common orthopedic conditions seen by physicians. Clinical decision making often initially includes pharmaceutical management for control of pain and inflammation along with other potential treatment options. NSAID’s and paracetamol are commonly prescribed medicines but their cost-benefit analysis regarding potential adverse effects and comorbidity profiles (Tuhina Neogi , Amer College of Rheumatology) may make these drugs inappropriate. Exercise is a recommended treatment for restoring ROM, strength, balance, and overall function but pain reduction is more so considered a secondary benefit. Weng et al performed a network meta-analysis that included 152 RCT studies with a total of 17,431 participants with hip or knee OA comparing the efficacy, directly or indirectly, of exercise vs oral NSAID’s and paracetamol for pain and function. The results showed that exercise was comparably effective vs NSAID’s and paracetamol in reducing pain and improving physical function at 4 weeks, 8 weeks, and 24 weeks comparisons. It was also superior to “usual care” (ie. continued daily activities). Exercise may present some challenges regarding the delayed benefit of symptom reduction, requiring compliance by patients, the challenge in slowing down “over-exercisers”, and that oftentimes we find (especially for “failed PT” cases we see) specific biomechanical adjustments and considerations are necessary beyond traditional PT approaches in order to produce successful outcomes. The use of medications, however, does not produce the same expected gains in needed ROM, strength/endurance, and balance these patients require to optimize function and quality of life. Patients relying mainly on continued dosing of NSAID’s and Tylenol also are habituating into a mindset reinforcing quick fixes to symptom control and return to activity that will not serve them long-term regarding their need to modify activity and actively participate in restorative/preventative exercise. Downstream costs for patients relying on these medications also have been shown to increase significantly over time, including due to adverse effects on numerous body systems. The other risk is that patients will contribute unknowingly to accelerated degenerative changes as they medicate their way “successfully” through impact activities that are deleterious to their joint health long term. Expert physical therapy should include specific customizing intended to off-load the compartment mainly effected via specific reaching/shifting maneuvers to allow pain-free/minimized functional strengthening work. Prescriptions should also order kinetic chain evaluation and exercise/manual therapy to address contributing factors (ie., lack of hip IR and ITB length both contributing to varus knee tendency and subsequent medial joint loading). Simple traditional therapy exercises for knee and hip OA do not take these biomechanical considerations into account. (We’d love to hear your professional insights on this topic. Let me know your thoughts after reading this summary at PT@PeakPTRochester.com or if you have a patient case you'd like to discuss) Purpose: Comparing analgesic benefits of exercise vs NSAID’s and paracetamol in hip and knee OA patients. Study Design: Network meta-analysis Methods: Studies included were: 1. RCT’s, 2. Participants with knee or hip OA, 3. Comparisons of exercise with oral NSAIDs , 4. Studies comparing exercise therapy with any common comparator that may be shared with NSAID’s (i.e. usual care/no treatment/waiting list control, glucosamine sulfate/chondroitin/intra-articular hyaluronic acid, topical NSAID’s, acupuncture), and 5. Studies reporting pain or function. Any study with less than 1 week follow up, use of a cross-over design, or postoperative pain were excluded. The full texts of 2738 potentially eligible articles were reviewed. There were 152 studies (17,431 participants) meeting the inclusion criteria. There were 49 studies with data available at or nearest to four weeks, two studies had data available at eight weeks and nine studies at 24 weeks. Most trials recruited participants with knee OA, while 12 studies investigated hip OA and 13 studies were both. Results: For pain relief there was no difference between oral NSAID’s and Tylenol at or nearest to 4, 8, and 24 weeks. Similar findings were noted for function as well. Authors Conclusion: Exercise has similar positive benefits to oral NSAID’s and Tylenol for pain relief and function. Since exercise has an excellent safety profile it should be given more prominence in clinical care, especially for older patients with comorbidity or higher adverse event risks related to NSAID or Tylenol use. THE PEAK PERFORMANCE PERSPECTIVE: Osteoarthritis is one of the most common orthopedic conditions seen by physicians. Clinical decision making often initially includes pharmaceutical management for control of pain and inflammation along with other potential treatment options. With pain relief ultimately comes the expectation that function will be improved significantly as well, optimizing quality of life. NSAID’s and paracetamol are among the most commonly prescribed medicines used for OA, however, the cost-benefit analysis for these medicines presents some challenges for physicians due to both potential adverse effects and comorbidity profiles (ie. Tuhina Neogi , Amer College of Rheumatology) that may make these drugs inappropriate long term or at all. Exercise is often considered a valuable treatment for restoring ROM, strength, balance, and overall function. Pain reduction is often more so thought of as a secondary benefit. Prescribed physical therapy to include formal supervised exercise is frequently delayed until more significant losses of function (i.e., ROM and strength deficits evident on clinical exam) are noted. Boston rheumatologist Jean Liew, MD noted that over 50% of patients receive NSAID’s and the same percent were given an opioid prescription when diagnosed with OA (American College of Rheumatology Convention 2021). Liew, updating their group’s findings looking at patterns of NSAID, opioid, and physical therapy (PT) use among more than 30,000 newly diagnosed patients with knee or hip OA found 9% had NSAID contraindications and 22% had NSAID precautions. This begs the question: Are NSAID’s and paracetamol being prescribed too frequently for hip and knee OA? Weng et al performed a network meta-analysis that included 152 RCT studies with a total of 17,431 participants comparing the efficacy, directly or indirectly, of exercise vs oral NSAID’s and paracetamol for pain and function knee or hip OA. The results not only showed that exercise was a clinically effective treatment (better than usual care) for reducing pain and improving physical function in people with knee or hip OA, but it was comparable in efficacy to NSAID’s and paracetamol at 4 weeks, 8 weeks, and 24 weeks comparisons. NSAID’s, for example, while effective for control of that knee/hip OA pain and inflammation, have been associated with gastrointestinal, renal, and cardiovascular complications, especially in older adults with comorbidities, There are also patients whose comorbidities deem NSAID’s as strictly contraindicated. Together these facts leave physicians and patients in a difficult position regarding ideal options if left to typical medications alone. Exercise, on the other hand, has the multi-faceted benefits of decreasing pain, increasing range of motion, increasing balance and strength - thus improving function, without the ongoing cost or risks associated with medications. Does exercise have some limitations also? There remains no absolute agreed protocols or best practices based on the evidence, however, this also should be viewed in the light that even heterogeneous “exercise” has been shown not only in this study but in numerous others to nevertheless be effective. Numerous orthopedic and rheumatology organizations have included exercise as strongly recommended based on review findings.. Three particular difficulties must be considered and addressed with prescribing exercise, especially if chosen over NSAID’s and paracetamol alone. One, the patient's desire to do the least and get the most results. We live in a society where people often “want results yesterday, not four weeks from now!” If I am told that I can take a pill today and do nothing, or I can go to PT and exercise, but it will probably take four to six weeks to work, what would I do? If I knew that I would get stronger, get off the ground easier, climb stairs better after exercise, and not just relieve the pain, patients would be more likely to follow those orders. Educating patients about these “long term” expectations and benefits fosters the compliance needed for good outcomes. Secondly, patients unaccustomed to exercise may struggle with commitment to an exercise program. There are patients who will flat out refuse to put the effort in. Third, is slowing down those who are avid exercisers. We have to be careful not to overdose, or allow exercise that will overload the joints. Many patients become their own “worst enemy” as they swing the exercise pendulum in the direction of excess, be it volume, frequency, or oftentimes intensity (especially for impact related activities). One study corroborated that the exercise for 8 weeks was very effective, but the effect of exercise gradually decreased when reassessed a year from the original study. We must approach such facts with caution, however, as the same would be true for medications taken for 6 weeks and not expecting patients to remain substantially better one year later. Exercise is a treatment that must be continued to have maximum results. Siew-LiGoh et al (Sports Medicine, 2019) compared a variety of exercises with “usual care” (i.e. continuing normal daily activity without other treatment). They found that aerobic, flow and pattern exercise, strength and coordination exercises all reduced the pain in knee and hip OA subjects. The question for physicians remains - if exercise, as shown in this and other studies, can be as effective at pain control as NSAID’s and paracetamol, have positive effects on increased function, strength, movement, coordination, and potential decrease risk in falls, and, lack the adverse effects and downstream medical costs associated with those side effects, then why would exercise not be used with every patient that presents with knee or hip OA in the office? The final but not least important points about exercise prescribing and treatment is that the RIGHT exercise will bring the BEST results. Careful attention to detail is necessary for many OA patients to succeed with exercise. Many patients will appear to succeed early on using simple NWB exercises. Unfortunately that often leaves a large “gap to bridge” to more authentic functional demands. For many of these cases, sometimes becoming “failed PT” cases, although finding effective pain-free/minimized PWB and WB functional strength methods can be a much more daunting task, it provides a more effective impact on day to day life. Expert Physical Therapy applies understanding of key biomechanics in order to both intentionally load healthier portions of articular surfaces and also in order to address key kinetic chain shortcomings that are contributing to joint overload. For example, in a common knee medial joint OA case, where the knee is in a varus presentation, PT exercise should focus on unloading the medial knee joint especially via the frontal plane but also the transverse plane. Specific reaching and shifting during otherwise typically painful exercises like split squats or step ups/downs etc can significantly reduce or abolish symptoms, allowing patients to more effectively strengthen. Key biomechanical shortcomings related to having caused the genu varum or that will perpetuate those forces such is poor hip IR, poor ITB length, poor STJ eversion all should be assessed and custom exercises done to treat. These are not approaches common to traditional physical therapy for knee/hip OA. The following case illustrates an example of simple/traditional exercises not working for his case of knee OA. THE PEAK PERFORMANCE EXPERIENCE: Mark said: “ I came to Peak after other physical therapy didn’t work for me. I was on the verge of needing surgery that I didn't want. I came to a Peak PT knee arthritis workshop. After starting PT I I know what to do, and I’m doing it. I can get through work and vacations now pain free!” History: Mark is a 64 year old male who had prior physical therapy and tried to exercise on his own, but was finding the things that he usually did created medial knee pain. He tried NSAIDs for a few months with some relief, but decided that he didn't see that as a long term solution. His job requires climbing ladders and stairs, squatting and carrying. By the end of the day his R > L medial knee is painful. He knows there is some OA on films, but he is not ready to think about a knee replacement yet. Subjective: He complained of knee pain and stiffness that limited walking, climbing ladders for work, and by the start of PT that his knees “hurt all the time.” Objective: (*=pain) Initial Eval Re-Eval Knee extension R knee 50 10 Single leg squat knee angle L 400/ R Unable ** L 650/R 500 Hip IR standing L 150/R 120 L 300 / R 250 2” quad dom step down (eccentric ) painful * 10 # front racked with ant lateral op toe reach ( inc valg at knee) L 24x / R 15x Step up 6” w 10# wts doing P-L opp foot reach ($ knee valgus for med jt unload) L 5x / R painful** L 16x / R 12x Sit stand to seat 15 sec 7x 12x Single leg balance rotation 15 sec painful ER L 15x R 13x WOMAC 41 % 16 % Key Findings: Poor knee ext and flex ROM, lacking hip IR (B) - slightly worse on R, poor tol of WB rotation, limited/painful squat function Treatment: Mark needed to regain as much knee extension as possible initially before moving into flexion exercises. This immediately decreased his pain with walking. He also worked on his limited hip IR NWB and then he progressed to functional WB methods to improve ADL and work applications. He began strengthening with PWB squats (using 0-300 and 60-950 pain-free depths) that were hip and ankle dominant to offload the knee. He used hands holding onto a stationary pole to unweight using arms also. A small yoga ball between his knees allowed Mark to maintain valgus alignment at the knees, thereby unloading his painful medial joint. All sagittal knee motions such as squats, split squats, step ups, and step downs were modified to decrease forces on the medial compartment of the knee. Frontal plane motion into valgus, and increased pronation or tibial IR were allowed as this relieved symptoms. When Mark was able to progress to impacting he began with crossover lunges focusing on valgus force from the foot up. Even once he progressed to lateral lunges, medial joint unloading was maintained by landing laterally on a wedge. Mark also received 6 sessions of Class IV Laser treatments on his R knee. The pain relief for him was immediate and lasting. This allowed faster progressions and improved his functional status quicker. After 6 weeks: Mark was ambulating at 3.0 mph pain free for 30 min, and could sit stand easily and was pain- free up and down ladders at work. He knows he has a limit for the total amount of weight bearing and work during each day, but has kept himself well under that. Outcome: Pt was DC’d to an (I) HEP, pain-free, able to remain at work full duty performing all tasks w/o troubles, walking and sitting were WNL, and he was able to go on vacation as well. You can trust the Physical Therapists at PEAK PERFORMANCE to do a thorough evaluation, to search for related but underlying contributing factors to kinetic chain dysfunction, and to design exercise progressions that both respect tissue healing and creatively use biomechanics principles to prevent symptoms and optimize carryover to your patients' functional goals. Call us at 218-0240 to discuss your patient's specific needs. Peak Performance is just minutes away from your patients in Penfield, Fairport, Pittsford, Brighton, Rochester and, of course, East Rochester. We promise Individualized, hands-on and biomechanically appropriate Physical Therapy for your patients. No "one-size-fits-all" approaches. We WILL go the extra mile and "dig deeper" to discover underlying causes for injury risk and delayed recovery using the most advanced Evidence Based methods available and, we’re able to make unique adjustments to exercise prescriptions to speed the return to function and to minimize or prevent symptoms from interfering. No surprises. No hassles. Confident your patient is in the right place. COME VISIT US AT 161 E Commercial St Just 1 mile off 490 exit (585) 218-0240 www.PeakPTRochester.com

Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE (October 2022) New Findings for Degenerative Meniscal Tears: A’scopy vs Non-op…1st year joint space narrowing outcomes! by Mike Napierala, PT, SCS, CSCS, FAFS Clinical Scenario...What would you do? A 54 yr old male comes in for a 2nd opinion consult for his L knee. He’s had a h/o various knee injuries in the past with some periodic bouts of stiffness and swelling especially with impact activities if not careful of volume and intensity. Five weeks ago he was getting off the floor while playing with his grandchild and felt a small snap/click in his knee and suddenly had sharp pain with weight-bearing and difficulty extending his knee. His PCP referred him for an orthopedic consult. Mild DJD noted on plain films in the medial > lateral compartment. MRI was done on suspicion of a degenerative medial meniscus tear and found (+). Recommendations were to have Arthroscopic partial meniscectomy. He was assured it would have no bearing on arthritic progression since the torn meniscus was not functioning properly now. His lack of full extension was explained as part of the reason he needed A’scopy. He prefers non-op if possible but does not want to make his knee worse by avoiding surgery. He’s presently doing OTC NSAIDs and prn Tylenol. Findings showed AROM 5-1250 (vs 1350 on R) and extension PROM stiff/painful at 30, with the patient commenting that it had been 100 short just 2 wks ago. Medial joint line is very tender and there is a > 1+ effusion present. McMurrays is (+) with varus/ER especially, reproducing an asymmetric snap in the knee. Single leg squat is painful at 300 vs R 550 and Thessaly WB test is (+) for pain/snap also. My clinical thinking is: A’scopy will more quickly resolve his pain and restore extension for WB with generally very low risks. Recommend A’scopy. ROM has been steadily improving. He already has a mild DJD present on plain films. Leave the meniscus in if he can progress back to asymptomatic with near normal or normal function. Continue non-operative care - prescribe Physical Therapy including Class IV laser and customized biomechanical exercises for 4-6 wks and then reassess. Recommend a steroid injection to reduce inflammation first and reassess in 2-3 wks regarding continuing non-op care with PT vs doing A’scopy. Aspirate the fluid, begin prescription NSAIDs, advising general rest from activity and FU in 2 wks to reassess for surgery vs formal PT. CURRENT EVIDENCE Santana DC, Oak SR et al. Increased Joint Space Narrowing After Arthroscopic Partial Meniscectomy: Data From the Osteoarthritis Initiative. AJSM 50(8): 2075-2082. 2022 03635465221096790 SUMMARY: The question of how to appropriately treat degenerative meniscus tears of the knee remains a clinical challenge. On one hand, experience has shown many physicians and surgeons that immediately remove the damaged meniscus seems to provide earlier pain relief and restore normal motion and function more quickly. Leaving damaged tissue in a joint to potentially impact chondral stresses and even contribute to loose body development may be another rationale for some in addressing these surgically sooner than later. On the other hand numerous orthopedic organizations have recommended against routine degenerative meniscus arthroscopy based on outcome findings in comparison to non-operative rehab at 6 and 12 months. Karen last month shared a JAMA Network Open study from July 2022 showing a 5 year follow up in the ESCAPE RCT showing exercise based physical therapy non-inferior to Arthroscopic Partial Meniscectomy (APM). But another consideration not studied well is the joint space width (JSW) narrowing status comparing APM with non-operative treatment of meniscus tears vs normal knee. Santana et al, using the Osteoarthritis Initiative cohort (4796 adults 45-79 yr old from 4 centers in US who had or were high risk for tibiofemoral OA), looked at 144 patients undergoing APM and having > 12 months of follow ups vs 144 with meniscal tears not undergoing APM and also 144 knees without a meniscus tear - matched by age, sex, Kellgren-Lawrence (KL) arthritis grade and FU time. Minimum medial joint space width was calculated from radiographs taken annually or semiannually following all knees having an MRI at baseline. The authors found the rate of JSW decline over the first 12 months to be 27x greater than the non-operative group and 5x greater than the no tear group. From 12-72 months showed no differences between groups. JSW at baseline vs 72 months was significantly different for the APM group compared to others (P < 0.001) but not between the non-surgical and no-tear groups. Clinically speaking this is a challenging topic, in part because many times patients want a quicker answer for their pain and limitations than non-operative care can bring. A consideration is certainly, however, to do no harm. While further evidence would be needed to confirm these findings, there is some other published evidence that APM leads to an increased rate of TKA. We find non-operative care most often, though not always, effective at resolving symptoms and restoring function in these cases. Two factors that should be considered and require further study but we see regularly on an anecdotal basis is the efficacy of our Class IV 25W laser and customizing especially squat based strengthening exercises to unload the specific meniscus tear side. That is not part of traditional physical therapy approaches. This greater attention to utilizing biomechanics to alter medial and lateral joint forces can literally allow an otherwise painful knee to perform valuable step down or split squat etc. strengthening through effective ranges when traditional technique causes pain that prevents continuing. We find that simply using otherwise deemed “functional” strengthening methods with simple step ups or downs (...etc.) contributes to the appearance for patients and physicians of “failed conservative care” and may lead prematurely to APM and the accelerated degenerative changes noted by Santana et al. Careful consideration by referring physicians of how customized and detailed rehab is for even just a “routine degenerative meniscus tear” case can significantly influence patient outcomes. Background: APM is a widely performed treatment option for patients with degenerative meniscus tears. Recent evidence has produced debate whether APM accelerates progression of OA. Purpose: To compare tibiofemoral joint space width (JSW) across three groups - patients undergoing APM, those with meniscus tears treated non-operatively, and those without a tear. The hypothesis was JSW would be least in those undergoing APM and greatest in those without a tear. Methods: Cohort design using the Osteoarthritis Initiative cohort, inclusion and exclusion criteria identified 144 patients having undergone APM having at least 12 months follow up and no prior knee surgery along with matched (by age, sex, Kellgren-Lawrence grade and follow-up time) 144 each in the meniscus tear without APM and the no meniscus tear groups. Baseline MRI used and then annual or biannual radiographs used to calculate the minimum medial compartment JSW. Linear regressions done. Findings: All groups had comparable 4.33 - 4.38mm JSW at baseline. The rate of JSW decline for the APM group was 27x greater during the first 12 months than the non-surgical tear group and 5x greater than the no tear group. No differences present in the rate of JSW decline between 12 and 72 month follow ups between groups. There was a significant difference in JSW from baseline to 72 months for the APM group vs the other groups (P < 0.001). Author's Conclusion: APM results in a faster rate of joint space narrowing during the first 12 months postoperatively than nonsurgical management of meniscal tears. Comparable rates of OA progression occur between 12 and 72 months regardless of treatment approach. Untreated meniscus tears do not hasten radiographic progression of OA as measured by JSW narrowing. THE PEAK PERFORMANCE PERSPECTIVE Orthopedists, whether non-operative specialists or surgeons, and family practice physicians alike often see patients in the 40+ age range with complaints of sudden onset knee pain and swelling. This is oftentimes accompanied by a lack of motion, catching/snapping symptoms and sometimes frank or pseudo-locking symptoms. With no frank trauma implicating ligament injury, along with joint line tenderness and a (+) McMurray’s, Appley’s or Thessaly sign this is typically considered a degenerative meniscus tear until proven otherwise. MRI is most often utilized to confirm the diagnosis if needed. The question then becomes “what is the next right step for care?” Oftentimes it’s patients themselves who are looking for the “quick fix” of arthroscopy also. Historically, a decade or more ago, these cases were moved to arthroscopic partial meniscectomy (APM). Typically patients have a fairly short recovery and their pain/mechanical symptoms are effectively treated - a seemingly good outcome. The costs and albeit infrequent adverse events related to even a “minor” arthroscopic procedure, among other considerations, led the responsible orthopedic community to study efficacy and alternatives further. I was a lead on the PT care side while at University Sports Medicine in the 90’s of a study done by the Sports Medicine Dept by several surgeons on non-operative care for MRI diagnosed degenerative meniscus tears that began as a 6 wk treatment program. The majority of participants did so well the study was extended. During that time and following, numerous other studies started being published lauding the merits of non-surgical care for degenerative meniscus tears. Various orthopedic societies and organizations have published position statements suggesting routine APM is no longer recommended. Other authors have cited that despite all these recommendations the rate of APM has not significantly dropped (Rongen 2018). There are certainly some percentage of patients with meniscus tears who are good candidates for APM for numerous reasons that may be unique to their situation and life demands, timing needs etc. Clearly this is true for frank locking of the knee due to the tear. Less clear is the “slow to recover non-operatively” knee case. We don’t know how long is “too long” before the benefits outweigh the risks and costs of APM versus waiting longer for the hoped benefits of non-operative care to manifest. One consideration some have indicated is whether leaving the torn, and less effective, meniscus in the joint would impact OA progression or produce risk of further injury. The ESCAPE Trial that Karen’s last newsletter reported on from JAMA Open Network reviewed 5 year follow up results vs APM and noted non-operative care to be non-inferior to APM long term. Obviously these non-op approaches inherently cost less and carry less risk of adverse event than APM. In this study, by Santana et al, joint space narrowing (JSN) was specifically assessed. APM having produced a 27x greater rate of decline in joint space vs non-operative meniscus tear approach weighs significantly into the basis for deciding on APM as an option. While not the standard, and yet to be well studied or an algorithm determined for identifying at-risk patients, we have personally seen numerous times patients with reported “mild to moderate, but not bone-on-bone” plain film radiographic findings who undergo APM for meniscus tear having a very negative post-op course of recovery and eventually have a much earlier than expected TKA done. The question remains, how much pre-existing OA can be tolerated by a joint undergoing APM and not have degradation accelerated to a point more further procedures are needed compared to having left the degenerative meniscus alone? While non-operative physical therapy care will, of course, not “heal” the tear or smooth over rough edges of torn meniscus this study by Santana et al supports the findings of many studies before it that physical therapy care for these cases produces good results very often, allowing patients to forego otherwise anticipated necessity for APM and the associated costs and risks of having a procedure. It also established that leaving a torn degenerative meniscus tear in the joint did not contribute to significant further abnormal narrowing in the first 12 months, and that comparable progression of OA still does occur over ensuing years comparable to that of an intact meniscus knee with OA. The JAMA Open paper did, of course, as expected, reveal that some percentage of non-operative care cases will eventually move on to surgery. Certainly not all meniscus tear cases begun in physical therapy alone will be fully successful in resolving symptoms and restoring full function. The key to recovery from a degenerative meniscus appears though not to be dependent on removal of the tear or rough margins. It often means reduction of pain and inflammation, and recovery of ROM and strength - common pursuits of typical physical therapy care. And now there is mounting evidence suggesting that “fixing” the torn meniscus may bring with it unwanted accelerated adverse effects. What is not typical in non-op care of these cases, however, is the unique demand for biomechanical “respect” for the painful tear side of the joint. Traditional PT does not teach or espouse a keen focus on “unloading techniques” for the painful tear side during typical WB strength or balance exercises. Yes…squats and leg presses, lunges and step downs or step ups, these all can be part of a functional strengthening regime of PT exercises. But done in standard “PT fashion” they oftentimes will requires unnecessary reductions in training ROM and/or loading due to pain issues (without advanced biomechanical approaches being used). The problem is that most degenerative meniscus patients have pain, sometimes very sharp debilitating pain, during these exercises. If one were to employ only NWB quad bench strengthening, even if it were pain-free (which it often is not in these cases), I’d submit we wouldn’t remotely see the effectiveness that studies show for non-op care. We see even better results utilizing biomechanical considerations to unload the painful knee side via frontal and/or transverse plane pre-positioning or reaching techniques that allow needed stimulus of the Quads, for example, but reduce the compressive pain over the meniscus tear. Consider this example - a posterior horn medial meniscus tear on the R knee may be especially loaded in WB by varus (knee adduction) and tibial ER (compression of posterior horn). While not exclusive we often find that patients unable to squat at all for effective strengthening exercise can suddenly perform (happily) through pre-positioning with the R hand reaching down or out to the R (tipping R, creating gapping on the medial knee) or by IR the foot slightly. The use of customized frontal and transverse plane adjustments allows us to identify unique positions for effective strengthening. Another key consideration is the kinetic chain biomechanics. For example, a varus knee with a MM tear must have the ability to internally rotate the hip, pronate the subtalar joint, and adduct the hip (limited by ITB tightness) addressed if there is any chance to reduce the magnified loading of the medial joint biomechanically. These are parts of our Applied Functional Science (AFS ©) training that are not part of traditional PT approaches. Our Class IV 25W laser has also been a key tool in reducing pain and inflammation. Last year I had a typical degenerative meniscus event…simply picking up my leg to dry off in the shower, felt a click. Within an hour the knee was swollen, I was unable to fully extend, ambulation was limited and painful, and flexion was reduced probably 15-200 also. These episodes typically would take me 2-4 wks to recover from. With only 3 laser treatments I was feeling 75% better in just three days! In less than a week I was fully recovered as if nothing had happened, able to do stairs, workout w wts, and golf. The case below illustrates a patient who had plain film confirmed DJD but sharp pain with clunking on McMurrays suggestive of also having a degenerative LM tear. MRI was never done to confirm findings but clinically speaking he presented with findings beyond typical knee OA alone or an ITB syndrome. THE PEAK PERFORMANCE EXPERIENCE Ken said: “Now my knee feels like it’s 95% of normal! I walked 18 holes of golf 3x in one week without trouble.” HX: 68 yr old male retired engineer and recreational golfer developed R knee pain laterally over the prior month especially with descending stairs, sit-stand ADL, and getting out of the car. He was referred by his PCP with plain films apparently showing DJD changes. He had just finished a 5 day steroid dose pack which helped. Subjective: Max sx 3/10 and self-rating function at 70%. WOMAC 28%. CC is pain w stairs (desc > asc), getting out of car, twisting activities, had to change to taking a golf cart to avoid walking hills with reduced golf. Objective: 1+ joint effusion, tender lateral joint line + ITB @ LFC, (+) McMurrays all four combinations w sharp pain and clunk noted @ lateral knee. (*=pain) Eval 6wk DC ReEval Knee ext AROM (L/R) 0/2.00 0/2-30 Knee ext PROM R 20 1-20 hyperext Knee flex AROM (L/R) 135/1320 NT/1430 Isometric Quads @ 300 89% w * 98% Isometric Hams @ 200 87% w * > 100% Single squat 74/650 * NT/750 SLB rotations <5sec/>10sec 7sec/NT FWB hip flexion (glutes/hams fxn) 30/300 45/540 WB hip IR 26/300 40/400 Quads Anterior (toes off) Stepdown 4” w 12# wts NT 35x/35x (100%) Key Findings: (+) McMurrays w lateral sharp pain and clunk consistent w R/O degenerative LM tear. Pt had weakness in Quads/Hams NWB w pain at lat/posterolateral knee, limitation and sx w squat function. WB hip IR restricted (B) - an issue for golf demands (ie, if hip unable to adequately rotate then forces at knee increased) , and poor function of hip extensors as assist w squat function. Treatment: Manual therapy joint mob’s for knee extension + sustained stretch after. Flexibility/ROM work to improve R TFL/ITB and hip IR WB (B) along w knee flex PROM. US utilized at lateral knee/ITB. Class IV laser demo done but pt chose to not purchase package for treatment (was already improving significantly). SLB work done to improve rotational control and tolerance - especially due to being a CC, despite actually better performance at RLE on IE testing than LLE. Functional squat based strengthening for quads/thigh utilized frontal plane unloading during Ant stepdowns initially (tipping trunk L to unload lateral joint - ie, reducing compression forces at LM…attempt to unload potential ITB as primary source via tipping to R worsened sx), tipping L via LUE reach table also utilized during split squats to allow deeper and heavier training. Outcome: Pt progressively reported increasing stairs/squat function and ability to tolerate rotation. Eventually he resumed walking golf, playing even 3x in one week w/o sx prior to his ReEval. WOMAC reduced to 5% and self-report score 95% at DC. You can trust the Physical Therapists at PEAK PERFORMANCE to do a thorough evaluation, to search for related but underlying contributing factors to kinetic chain dysfunction, and to design exercise progressions that both respect tissue healing and creatively use biomechanics principles to prevent symptoms and optimize carryover to your patients' functional goals. Call us at 218-0240 to discuss your patient's specific needs. Peak Performance is just minutes away from your patients in Penfield, Fairport, Pittsford, Brighton, Rochester and, of course, East Rochester. We promise Individualized, hands-on and biomechanically appropriate Physical Therapy for your patients. No "one-size-fits-all" approaches. We WILL go the extra mile and "dig deeper" to discover underlying causes for injury risk and delayed recovery using the most advanced Evidence Based methods available and, we’re able to make unique adjustments to exercise prescriptions to speed the return to function and to minimize or prevent symptoms from interfering. No surprises. No hassles. Confident your patient is in the right place. COME VISIT US AT 161 E Commercial St Just 1 mile off 490 ext (585) 218-0240 www.PeakPTRochester.com

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 May 2022 Hip Osteoarthritis Clinical Decision Making: New Evidence Affecting Treatment Recommendations by Allison Pulvino, PT, MSPT, CMP, FAFS Clinical Scenario…What would you do? A 62 yr old male with 6+ months of progressive hip pain seen for ortho consult referred by PCP. Pt had been taking NSAID’s for 6 weeks and attending physical therapy for 4 wks with limited improvements in pain, ROM, and overall function. Plain films show Gr III-IV degenerative changes in the R painful hip joint and Gr II-III changes on the pain free L side. He enjoys fitness classes including low to moderate impact drills, playing golf and tennis, and hiking with his wife, including mild-moderate elevations. Clinical exam shows NWB A/PROM asymmetric R hip limited in flexion, IR, extension more so than other directions. I would... Recommend 3 series gel injection and reassess in 3-4 months. Advise to continue HEP given by PT and limit activity to non and low-impact only. Recommend patient stop impact activity and switch to pool exercise and cycling for exercise for 2 months and then FU to consider other options such as injection. Update PT prescription or change providers to include BIW manual therapy (+ advancing exercise for ROM and functional strengthening) for at least 4-6 wks before considering HA gel injections. Perform single cortisone injection. Potentially controversial but presently acceptable since only one recent study showed (-) effects on potential rapid degeneration. Change NSAID’s and advise the patient to continue the present PT program for 4 more weeks. CURRENT EVIDENCE Shepherd, et al. “The Influence Of Manual Therapy Dosing On Outcomes In Patients With Hip Osteoarthritis: A Systematic Review”. Journal of Manual & Manipulative Therapy. (2022) 10. 1080/10669817.2022.2037193 Summary: Hip OA is a common ailment causing symptoms and limiting function. While joint mobilization techniques have been shown to be helpful and clinical practice guidelines have formally recommended them, there is a lack of clear dosing parameters known to produce best outcomes. This systematic review initially found 4,675 potential studies on the topic but only 33 were eligible for further review, with only 10 meeting all criteria - this included being an RCT, measuring outcomes, and having specific dosing parameters reported. Of the 768 total participants, it was noted that sessions were most frequently 2-3x/wk, patients had a mean of 6-12 sessions over 1-12 wks, with manual therapy performed in 7 sessions. Effect sizes ranged from small to large depending on the variable measured (pain, ROM, function). While no clear dosing parameter could be recommended based on findings, there were ranges noted that can serve as evidence based starting point. Hip arthritis care, for patients as well as for providers, risks being viewed as an accepted “routine” and “keep it simple” care model mentality. Many experienced physicians may be relying on evidence based “best practices” from studies published many years or even a decade or more ago. Physicians seeing patients themselves and who are training upcoming physicians in residency or fellowship may be unaware of newer evidence published in recent years around the use of joint mobilization efficacy with hip OA. This is a key factor when considering treatment recommendations and prescription content for physical therapy, along with specific recommendations vs a “wherever is most convenient” thinking that is intended to ease the burden on patients but may unintentionally lack discernment regarding extent of manual therapy performed. Often patients have been told prior to PT that “they’ll show you some stretches to do at home” - setting patients up for expectations about PT that may not be consistent with best practices. This study did not find a specific set of parameters supported by the evidence that can be applied “across the board” for joint mobilization in hip OA cases. The heterogeneity of the mobilization parameters does, however, support the idea that there is no single parameter that needs to be followed to achieve results. It suggests that knowledgeable, skilled PTs have the ability to make clinical judgments regarding the customization of techniques used, application of force, directions, and volume/frequency of treatment that result in (+) outcomes. Physicians should know, when ordering PT, that manual therapy techniques lasting 10-30minutes, 2-3x/week, for 6-12 sessions are an evidence based part of appropriate hip OA care. (We’d love to hear your professional insights on this topic. Let me know your thoughts after reading this summary at PT@PeakPTRochester.com or if you have a patient case you'd like to discuss) Background: Hip OA is a common cause of pain and limitation with functional activities for many older adults. There currently is good evidence that joint mobilization is effective in improving pain, ROM, and function however there is not documented well studied specific dosing recommendations for hip OA manual therapy treatment parameters. This review study attempts to establish more specific treatment guidelines for this diagnosis based on RCT level evidence. Methods: This is a systematic review that included randomized controlled trials (RCTs) and utilized joint-focused manual therapy. Inclusion criteria were detailed dosing parameters of manual therapy type, direction of force, session duration, frequency of interventions, and numbers of sessions, were published between January 2000 and December of 2021, and met the criteria for hip OA according to the American College of Rheumatology. Findings: Within 4,675 studies, 33 were eligible and 10 were included meeting all the criteria. There were 768 participants with treatments performed by physical therapists and two chiropractors. A variety of manual therapy interventions were performed, including the Mulligan concept (MWM), long-axis high-velocity low-amplitude thrust (LA-HVLAT) mobilization, and non-thrust mobilizations. Parameters used ranged widely. Risk of bias assessment was also done along with outcome-level certainty using the GRADE approach. The most common MT type used was LA-HVLAT. The most common directions of non-thrust mobilizations were lateral and caudal glides with some form of hip IR. Long-axis distraction was used in 7/10 studies. All forms of MT when compared to a control group, improved hip ROM in the short term. Quality of life improvements were documented as medium and large between-group effects after 6 weeks of treatment but small after one year, with regards to the HOOS QoL subscale. Five studies assessed functional performance including walk speed, step-count or a walk test, and large between-group effects were found with walk-test improvements. The largest between-group effect sizes were seen for pain and ROM using MWM into hip flexion and IR when compared to a sham, no-force intervention. Author’s Conclusion: There were some trends that clinicians can consider from this study. The largest within-group effects for pain and ROM and self-reported functional gains were from LA-HVLAT, specifically performing thrust techniques (up to 9 times) and for longer durations of three to six sets (30-45 seconds). When considering non-thrust mobilizations LADM for 10 minutes with 30 second bouts. If hip flexion and IR ROM are limited, then MWM into these motions was shown to have the greatest improvements. There was a lack of specific dosing parameters for many studies so further research is recommended to allow for MT frequency and techniques to be more concisely recommended. Clinical trials should also include baseline sensory and pain neurophysiology assessments, as well as psychosocial assessments as they can influence clinical outcomes. THE PEAK PERFORMANCE PERSPECTIVE Hip OA is a common diagnosis that both primary care and orthopedic physicians see in the office routinely. The pain, progressive loss of motion, and weakness that negatively impact function require consideration of what the best options for treatment recommendations are. Physical therapy has been shown effective in the care of hip OA but physicians considering best practices are oftentimes uncertain regarding the specific recommendations to make on therapy prescriptions and in educating patients about what to expect. Shepherd et al, in this systematic review, analyzed RCT’s to discern if there were specific treatment parameters with manual therapy treatments for hip OA that could be identified for purposes of understanding best practices related to optimizing outcomes. This is critical for both referring physicians writing prescriptions and educating patients regarding therapy expectations. Physicians are also discerning next steps when a patient is apparently “failing” an episode of therapy and the adequacy of care provided must be assessed before deciding if different therapy or escalating care to injections or surgery is called for. And of course these dosing parameters would be critical for practicing therapy providers to understand. While the question on dosing parameters is a good one, this study, like many others, may suffer from the challenge we all see as clinicians. The attempt at a homogeneous answer for the sake of minimizing variability in treatments of the “same condition/diagnosis” is admirable and logical but often ignores the heterogeneity of the patients themselves. Also, many diagnoses have multifactorial considerations. Sometimes evidence exists demonstrating a common approach or parameter that can be consistently used. But, there also exists significant variability within our patients’ lives and bodies that impacts treatment decision making, often leaving linear, singular treatment decisions inappropriate or non-specific to this case. External validity factors in applying research recommendations are often forgotten or neglected too often. Clinical judgment based on both evidence and experience, leaving a “range” of options vs a singular algorithm-like, mathematical equation-like answer that every single provider could and should arrive at equally, is a key portion of our day to day practice as providers. Manual therapy is an effective and necessary component of hip OA care but the evidence does not support a strict and specific dosing parameter that is “one-size-fits-all” in nature. That is not a “bad” finding but speaks to the “art and science” of clinical practice. Our patients are unique - they come with a variety of preconceptions. Oftentimes they verbalize their own expectations of what therapy will entail and will do for them. We have heard requests of massaging the tightness away or to provide them with three or four “easy exercises” to help get them back to where they were years ago or just a quick morning “stretch routine” that can be done daily. Some, of course, say they’ll do whatever it takes to perform their favorite activity again. Many are under the impression or have been expressly told by their physician that physical therapy will be a few short weeks only to learn a home routine. While evidence from the past has certainly demonstrated the efficacy of simple ROM and strengthening exercises with hip OA cases there can sometimes be an unawareness of what the newest research and clinical practice experiences show regarding the efficacy of other treatments in optimizing hip OA outcomes. That can contribute to physicians having mistaken paradigms and providing patients with inaccurate expectations of what physical therapy will include and the length of time likely for formal care. For patients, the disconnect that happens when the PT’s treatment recommendations differ sometimes significantly from their own preconceptions or physician’s advice can sabotage their confidence and trust in therapy, their “buy-in” to the treatment process, and their compliance. It’s helpful, therefore, for physical therapists to share important evidence and experience based updates with referring physicians to update current thinking on best practices in hip OA care. What we as therapists typically do is often different from what physicians and patients expect, both in terms of the extent of biomechanical considerations within the evaluation as well as the variety of treatment options available within therapy. Many patients may have already looked up information from Google that there are the “3 best movements” for everyone’s arthritic hip or have a sheet of six exercise pictures from a friend or other PT or even a physician. Most of the time patients become pleasantly surprised when therapists educate them on all the ways therapy will help them achieve their goals, and it’s much more than exercise. Good evidence exists and clinical practice guidelines now formally recommend the use of manual therapy, especially joint mobilization and/or thrust techniques, for the benefit of pain reduction, ROM gains, and eventual function improvements. While stretching and strength are very important components to be able to move comfortably, it is specifically manual therapy (MT) techniques that decrease pain the fastest and assist in movements with more fluidity and ease, as well as decreasing someone’s compensatory strategies causing pain onset in other joints or even the opposite extremity. Shepherd et al found trends in MT techniques that show the most gains in ROM and pain control, mentioning mobilization with movement techniques (MWM) and long axis high velocity low amplitude thrust (LA-HVLAT) techniques among others, consisting of 10-30 minutes of treatment, 2-3 times per week, for a duration of care from 2-6 weeks as the ranges noted in the RCT’s examined where (+) outcomes were noted using manual therapy to reduce pain, increase ROM, and or function was examined. That is a general suggestion but also needs to be based on individual presentations, level of current and past functional abilities, motivation, fear avoidance, and psychosocial status. All patients are individuals and we as providers need to treat them as they are. Very often a “simple” approach is considered a starting point for all patients. For many this can be appropriate. For many others the case is more complex or goals are loftier. That is where customization of treatment planning comes in…starting with a thorough biomechanical/orthopedic evaluation. We often find that the “regional interdependence” considerations of the kinetic chain result in the need to address other body parts affecting or being affected by the arthritic hip. If one’s goal is to walk 3 miles per day and there is a significant hip flexion contracture, there is a high likelihood of compensations into the spine or opposite knee or hip as that person’s ipsilateral stride is shortened from lack of hip extension. The lumbar spine often hyperextends to take up the lack of extension, potentially contributing to low back pain but also forcing the opposite extremity to be overloaded on impact over time. Carefully assessing the functional mechanics of gait and other ADL, work, or sport movements is key. Many hip OA cases likely require manual joint mobilizations to assist increasing ROM and reducing pain where there hasn’t been correct mobility and mechanics in months or even years. Multi-plane functional hip mobility exercises in all three planes in standing, as well as ankle and knee mobility will all be incorporated into a patient’s treatment plan. Once patients start to feel more comfortable, functional strength and dynamic stability has to be applied through patient specific therapeutic exercises to control their newly achieved hip ROM, thus allowing for functional gains in ADLs and recreational activities. THE PEAK PERFORMANCE EXPERIENCE Diane said: “I feel so great walking, it’s not catching anymore like it used to!” History: Diane was coming into PT for c/o L buttock pain, anterior L hip pain and knee stiffness and pain. She is a nurse and stated she required assistance to help her even walk without limping. She couldn’t quite figure out why she was limping so significantly, but has a history of back, pelvic/SI joint and hip/knee issues on that L leg. Objective: Diane fell off of a step onto her L knee in 2015 initially injuring L knee. She also had been in a MVA in 2000 with c/o L posterior hip pain ever since as well as posterior pelvic pain. She was unable to sit > 20 min, standing > 20 was painful, and any walking was painful at the time of PT exam. Bending forward and squatting was painful as well. Pain could get up to 4/10 and at times was constant. Initial Exam Re-evaluation Hip extension -10deg (flexion contracture) 10deg Prone hip ER 25deg 30deg Prone hip IR 45deg 45deg FABER test Pos Neg O’ber’s test Pos Neg Thomas test Pos Neg Hip Scour Pos Neg Pivoting for directional change L fear of instability No fear/no issue Anterior step down L unable/fear of buckling 2” step down w 8# DB Sit-stand UE assist/stiffness 10x w/o UE assist Key Findings: Diane had a L knee flexion contracture and almost no L hip ER and extension and also was observed to have her L leg longer than her R. She was limping and almost falling into her R leg during gait and her tolerance to any walking was limited (facial grimacing). Treatment: Diane received manual therapy treatment for at least 15 min at the start of every treatment consisting of L hip lateral and caudal (long axis) distraction with a mobilization belt, with 10-20 oscillations followed by 20 sec holds, as well as MWM hip extension and ER mobs 2x10 each direction, each visit. She was also advised to get fitted for a custom external shoe lift as her LLD was of much significance. She performed self SI joint correction, hip ER stretching, elevated hip flexor stretching followed then by resistance band ER pivot step outs and hip flexor loading in/out of extension with sliding discs in WB for ease of increased stride in gait. Other exercises performed including hip adductor stretching and lateral weighted lunges loading adductors instead of abductors, and SLB with transverse plane top-down loading, eccentric step downs for quad loading, incline side planks in/out of hip adduction for ease of WS in gait. Outcome: Diane can walk, squat and negotiate stairs as well as complete all transfers without pain limiting her. She is very happy with her progress and soon to be discharged from PT to live an active lifestyle. You can trust the Physical Therapists at PEAK PERFORMANCE to do a thorough evaluation, to search for related but underlying contributing factors to kinetic chain dysfunction, and to design exercise progressions that both respect tissue healing and creatively use biomechanics principles to prevent symptoms and optimize carryover to your patients' functional goals. Call us at 218-0240 to discuss your patient's specific needs. Peak Performance is just minutes away from your patients in Penfield, Fairport, Pittsford, Brighton, Rochester and, of course, East Rochester. We promise Individualized, hands-on and biomechanically appropriate Physical Therapy for your patients. No "one-size-fits-all" approaches. We WILL go the extra mile and "dig deeper" to discover underlying causes for injury risk and delayed recovery using the most advanced Evidence Based methods available and, we’re able to make unique adjustments to exercise prescriptions to speed the return to function and to minimize or prevent symptoms from interfering. No surprises. No hassles. Confident your patient is in the right place. COME VISIT US AT 161 E Commercial St Just 1 mile off 490 exit (585) 218-0240 www.PeakPTRochester.com

Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE April 2022 Key Mistakes in ACLR Return to Sports Decision Making: Can We Trust Hop Testing Data? by Mike Napierala, PT, SCS, CSCS, FAFS Clinical Scenario...What would you do? A 27 yr old male semi-pro developmental league football wide receiver sustained a non-contact deceleration injury during a cutting move and has an MRI confirmed isolated ACL tear. He underwent autologous patellar tendon ACL reconstruction and has been participating in BIW - - > weekly post-operative physical therapy. He has progressed very well and is presently at the 12+ month mark. Subjectively he is painfree. On clinical exam he has (-) Lachmans and Pivot Shift test findings. Your quick MMT of quads and hamstrings sitting on table are very good and painfree. He is eager and confident in his readiness to resume football practices. He reports performing progressive agility and plyometric drills at PT. His PT Re-Evaluation report did not yet make it through for review. He wants your approval to resume non-contact practices including route running and change of direction drills w defender, blocking drills…progressing to full contact scrimmaging and play over the next 4 weeks. My clinical thinking is: He needs to wait until at least the 9 month mark to reduce risks of contralateral knee ACL injury. He is doing well. He may return gradually now and progress his participation based on his comfort level and coaching feedback on movement quality. Perform in-office single leg squats, vertical and rotary hop testing observation and then decide. Call PT to discuss Re-Eval findings while Pt is in office or wait to obtain test findings before final decision. Counsel patient on risk management and call back with orders once testing reviewed. CURRENT EVIDENCE Kotsifaki A, et al. Symmetry in Triple Hop Distance Hides Asymmetries in Knee Function After ACL Reconstruction in Athletes at Return to Sports. Am J Sports Med, 50:2, 2022, 441-450. https://journals.sagepub.com/doi/pdf/10.1177/03635465211063192 SUMMARY: ACLR recovery risks becoming a “routine” for both surgeons, therapists, and patients alike. As a surgeon/physician how do you really know an athlete is ready and safe to return to sports (RTS)? Are you certain they’ve prepared properly and thoroughly in their rehab? Key decision making centers around the quality of rehabilitation especially in the intermediate phase leading up to return to function progressions and eventual testing used to determine return to play. Recent data on recovery from ACLR regarding return to prior sports participation is disappointing. Some evidence suggests that only 65% return to prior levels of sports participation and risks of a second ACL injury have been reported up to 29% (Australian football/rugby showing rates of even 40%). . Limb symmetry index (LSI) is often used for RTS testing of strength and hop performance among others. Consensus is, however, lacking regarding the “best practices” on specific tests and scoring to optimize successful return and reduce future injury risk to the ipsilateral or contralateral knee. Some data suggests that LSI values alone do not accurately reflect the function and biomechanical performance properties of the ACLR knee and limb. Kosifaki et al performed 3D motion analysis during a triple anterior hop test comparing 23 healthy male controls with 24 post-op ACLR male athletes who were cleared for RTS(ages 18-35, Tegner > 7). Among inclusion criteria were quads LSI > 90% and hop battery tests LSI > 90%. They used 42 reflective markers with a 14-camera system and force plate, requiring hands remain on hips and a 2 second hold upon final landing. The ACLR group had 97.1% LSI . The ACLR group showed the involved limb landed with greater hip flexion, trunk flexion, anterior tilt and peak knee flexion angle was less as well as less knee flexion moments. ACLR involved limbs also showed knee work absorption LSI of 80% with second rebound and final landing but only 51% and 66% for work generation LSI during first and second rebound take offs. Hip work was higher and ankle work lower for the involved ACLR group. In controls and uninvolved limbs alike the knee plays a greater role during the abslorption or typical “injury” phase than in the propulsion phase thought to create the distance of the hop test findings. It is imperative that surgeons and therapists be critical about not only the RTS phase of recovery but the intermediate phase preceding that. This phase oftentimes is considered “routine” and merely a “putting in the work” mindset by both clinicians and patients. But it is this foundational strength and power development phase that can set up the knee-quads and lower extremity for success or for compensation based “false success” noted in mere LSI based testing. Traditional PT rehab exercises involving triple extension, while being functional, also risk setting up the ACLR athlete for compensatory patterning with the hip extensors from early on. The ability to “isolate” the quads during integrated functional patterning is critical. Unfortunately it’s all too often a missed or lost art in rehab clinics across the world. That may be the reason that despite such extensive therapy so many ACLR studies show persistent quad weakness, and, that quad weakness remains one of the key limiting factors to successful RTS. This study also did not examine frontal and transverse plane issues with landing mechanics regarding “dynamic valgus” risk factors. These also must be appreciated and addressed during testing performance, beyond simple LSI numerics. Surgeons and physicians during the post-operative phase remain in a critical role because they must discern if the rehab being done is appropriate and thorough enough to confidently trust that desired outcomes will be achieved. Routine care and mere protocol adherence is likely to fail. The literature certainly demonstrates that as a total collective the health care system is not presently producing high outcomes for our ACLR patients. Below are further details regarding key approaches that distinguish biomechanically authentic methods of approaching Quad rehab and hop testing beyond traditional approaches for the sake of optimizing function and reducing re-injury risk. Background: ACLR return to sport (RTS) and second injury rates are both unacceptable. Limb symmetry index (LSI) with hop testing is commonly used as a means of assessing readiness for sport but some data suggests kinetics/kinematics may not be normal despite symmetry of distance measures. Purpose: To determine if restoration of lower limb biomechanics during triple hop for distance testing is ensured by passing discharge criteria post-ACLR. Methods: Controlled clinical lab study using 3D motion analysis of 24 male athletes after ACLR who were cleared to RTS (LSI > 90% for quad strength and hop battery testing) compared to 23 healthy male athletes (participants 18-35 yr ). A 14-camera + force plate, using 42 body markers, was used to collect data. Findings: Despite reaching 97% LSI for ACLR involved side distances, the absorption work LSI was 80% and work generation were only 51% and 66% for first and second rebounds respectively. The relative knee work was less for involved limbs and hip work larger (P < 0.001) for all phases vs uninvolved and control limbs. Hip, pelvis, trunk compensations were noted with ACLR involved side limb testing. Author's Conclusion: Triple hop limb symmetry masked important knee deficits in knee joint work which were more prominent during work generation (concentric push off) than absorption (eccentric landing). THE PEAK PERFORMANCE PERSPECTIVE Surgeons and physicians caring for post-op ACLR patients are most often comfortable with familiar rehabilitation protocols they have often used for years. These oftentimes have been introduced during fellowship training or possibly through interaction with “experts in the field” via publications or conferences. ACLR recovery risks becoming a “routine” task for both clinicians and patients alike, especially for surgeons who perform numerous ACLR’s monthly even upwards to 150+ per year. For patients, physical therapists, and athletic trainers the multiple visits weekly process also risks a “routine” feeling that can undermine the appreciation for subtle biomechanical factors that must be addressed if the RTS phase is to go well. The real question at hand is are we all being scrutinizing enough? Are we discerning the subtle details as best possible in order to optimize recovery and reduce reinjury risks? The literature would suggest we are not! As a surgeon/physician how do you know your patient is ready to RTS? Do you carefully scrutinize the test reports sent by PT’s and ATC’s? How often do you recommend delaying RTS or has it become routine to approve progression based more so on time than supportive data? While there is no consensus or clear answers as to the “right” thing to do the successful return to sport data and second injury data are both disappointing to say the least. While individual experiences may be different the collective data suggest that surgeons and therapists/trainers are too often failing to ensure optimal recovery, including for those allowed to RTS. Over 30% of those undergoing the long recovery process of ACLR never make it back to their prior and expected level of sports participation. One in five sustain a second ACL injury. Surgeons sit at the healm of decision making in terms of protocols used and in discernment over where rehabilitation is done. Therapists and trainers are daily making treatment decisions that impact the training effect achieved…whether that be potentially reinforcing compensation patterns or optimizing more authentic normal neuromuscular function. We all have a hand in these mediocre outcomes. We all want excellence though. Kotsifaki et al demonstrated that despite 97% limb symmetry with triple anterior hop testing that important biomechanical performances were significantly still abnormal/asymmetric compared to the uninvolved limb and control limbs. Knee work was less, especially for concentric push off following an absorption (ie, plyometric type “rebound” effect”) though still only 80% for the typical injury phase eccentric absorptions. Proximal segment compensation from hip/trunk extensors was evident on involved limbs as well. Symmetry on triple hop distances was clearly NOT achieved because the “knee” itself was normal and symmetric! Underlying this subpar performance at the knee, even in just these sagittal plane indicators, is quad strength deficits. Traditional post operative protocols and real-life rehabilitation programming often attempt to utlize what are thought to be “functional” approaches to exercise advancements, with the intention of stimulating the neuromuscular system and mimicking real-life demands for activities like stair climbing that will eventually evolve into decelerating a cut or landing a jump. That means “triple extension” based exercises that intend to stimulate the hip-knee-ankle activation used for successful squating maneuvers. Typically that involves squats, leg presses, split squats, lunges, step downs, step ups, sled pulls and pushes and eventually impact based drills for jumping and hopping…etc. Unfortunately post operative pain and effusion disproportionately effects quadriceps performance more so than other related muscle groups in squat function. That open door for compensation, especially from the hip extensor hamstrings and glutes, more often than the short plantarflexors means that PT’s and ATC’s doing ACLR rehab must be keenly aware of how to recruit quads preferentially. Otherwise the risk is that too early or too casual or careless an “advancement” to functional ADL prep training exercises like stepdowns or step ups etc will produce significant compensation patterns that become harder to undo later down the road. Avoiding these mistakes requires attention to detail and personalized/customized exercise programming and cueing. The use of surface EMG biofeedback can be helpful but the real key is understanding biomechanics and carefully observing exercise techniques during squatting drills. While in one hand we appreciate and desire the “protective” effect of hamstring co-activation regarding it’s potential to reduce anterior shear forces we also need care in habituating quad inhibition and inadequacy during strength training drills. We don’t believe the answer is merely a focus on seated NWB quad extensions to isolate the quad but generic “functional” exercises like lunges and stepdowns done incorrectly can facilitate quad avoidance that will lead to poor declaration mechanics down the road. While this study did not examine frontal and transverse plane mechanics risk factors (ie. Dynamic valgus/IR) which is well known and accepted, these are key areas of focus during ACLR rehab. Since this is a multifactorial issue there is not a singular protocol-based approach or exercise that can simply be done to address dynamic valgus control or deceleration. Focused testing for anteversion, abnormal foot mechanics leading to overpronation issues, hip weakness issues of the abductors and/or external rotators, and dorsiflexion loss are some of the key underlying causes that we find related to dynamic valgus/IR that can be addressed with proper physical therapy care. We do perform hop testing and find it valuable. Normative data tells us that significant asymmetry is not normal. Yet, we also know from Kotsifaki et al’s data and others that mere LSI symmetry is also not enough information to prove normal function. Without expensive research level testing equipment clinical testing relies on keen observation skills and qualitative assessment beyond simple number crunching. But the well studied sagittal plane dominated tests used over the past decades in ACLR research we believe are lacking in their authenticity to real-world mechanism of injury biomechanics where frontal and transverse plane forces also occur. We utilize side-side hopping tests along with rotational hopping tests to force the knee to prove it can handle/decelerate and stabilize dynamic valgus/rotational type loading. Many PT exercise programs post ACLR also maintain a prolonged focus on “knee over the foot” directional intention for landing drills. While this is necessary and safe early on during healing concern time frames it is deleterious to neuromuscular training of authentic biomechanics loading forces the athletes will incur when they do return to the court or field and must contend with multiplanar knee and lower extremity loading. A key consideration is whether rehab has taught that knee and LE to successfully decelerate and reverse dynamic valgus/rotational inertial loading. The reality is that these forces WILL happen to athletes knees during sport. Excellent rehab does not pretend that conscious control of intended ideal paths will always be the norm. It must progress to contending with the original MOI and prove that safe dynamic stabilization and progression of the intended sports movement can happen. Below is a case study of my son’s ACLR experience at Peak Performance. Unfortunately the demands of work and parenthood altered his ideal rehab consistency further into his recovery but his excellent progress in the early formative months post op set him up for his return to football practices and soon to be game play. THE PEAK PERFORMANCE EXPERIENCE Jordan said: “I feel faster than I was before I got hurt. I'm making cuts in practice, getting open and catching the ball. I’m not 100% yet but I’m feeling good!" HX: 29 yr old male sustained a change of direction R knee giving way injury doing a wide receiver route in practice on turf in March 2021. He underwent autologous patellar tendon ACLR 3.29.21 and initiated rehab 2 days later. Subjective: At 7 month ReEval patient reported 1/10 max sx, 70% subjective function. By his 9 month ReEval he reported less frequency of symptoms but not yet painfree, likely due to his progression of activity and reducing HEP and PT compliance (new baby). Subjective function 80% , able to do sprinting, light route running and catching, IKDC 90%. Objective: (*=pain) 7 mo ReEval 9 mo ReEval Isometric 600 Quad 56% 78% 6” cone 900 pron - 600 sup rotational no touches 20sec Prior testing 114%...NT NT Vertical Hop 70% 550/470 3x Crossover Ant Hops 18’3” w reduced knee ant excursion and min excess trunk/hip flexion 19’0’ (97%) w improved knee and trunk mechanics + no abn Dyn Valg 900 Rotational Hops 10sec (40 unit radius) 9x (100%) (60 unit radius) 10x (111%) WB Quads Anterior (toes off) Stepdown 6” 40# DB’s 20x (71%) 50# DB’s 24x (86%) Key Findings: During intermediate phase mild increased hip flexion (ant tilting pelvis) often occurred during intended quad dominant squat PRE type drills and excessive trunk incline (hip extensor compensation) along with limited anterior knee excursion would occur during lunges and split squats. Frontal and transverse plane control had become excellent by 3 months post op and was advanced accordingly but did not require the typical extra attention often noted. Compliance became an increasing issue with PT visits falling off and HEP reducing significantly with birth of first child during at the 8 month post op mark. Treatment: During intermediate phase rehab dynamic frontal and transverse plane proprioceptive/stability drills were advanced via single leg balance drills including use of VibePlate plus reduced visual feedback (eye/eyes closed) work and distraction/perturbation techniques with ball passing and manual perturbations, eventually leading into “on-impact” mini squats with perturbations producing dynamic valgus type loading forces for deceleration/stabilization. Early on reliance on hip extensors and plantarflexors to assist squat function triple extension drills were gradually transitioned into Quad dominant stimuli using “front rack” (upright trunk) DB’s positioning, toes off Ant stepdowns with posterior trunk lean and posterior pelvic tilt cueing and lunging drills with toes off ¾” plywood landings to optimize knee flexion moments for quad recruitment. Impact drills were progressed into single leg push offs for power, single leg landings in place - - - > with distance excursion …and then multiplanar landings. Eventually proximal kinetic chain demands with inertial loading into diagonal patterns producing dynamic valgus replications of sport-like demands were included and then finally with reactive catching medicine balls into “at-risk” positions of the trunk-BUE. Plyometrics and agility drills proceeded as well with intention transition into combined frontal-transverse plane demands. Outcome: Pt has continued HEP inconsistently and returned to weekly (9+ mo mark) - - - >biweekly football practices and now at one year post op has done full contact scrimmaging and preparing for first official team scrimmage out of town. You can trust the Physical Therapists at PEAK PERFORMANCE to do a thorough evaluation, to search for related but underlying contributing factors to kinetic chain dysfunction, and to design exercise progressions that both respect tissue healing and creatively use biomechanics principles to prevent symptoms and optimize carryover to your patients' functional goals. Call us at 218-0240 to discuss your patient's specific needs. Peak Performance is just minutes away from your patients in Penfield, Fairport, Pittsford, Brighton, Rochester and, of course, East Rochester. We promise Individualized, hands-on and biomechanically appropriate Physical Therapy for your patients. No "one-size-fits-all" approaches. We WILL go the extra mile and "dig deeper" to discover underlying causes for injury risk and delayed recovery using the most advanced Evidence Based methods available and, we’re able to make unique adjustments to exercise prescriptions to speed the return to function and to minimize or prevent symptoms from interfering. No surprises. No hassles. Confident your patient is in the right place. COME VISIT US AT 161 E Commercial St Just 1 mile off 490 exit (585) 218-0240 www.PeakPTRochester.com

Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE March 2022 Optimizing Outcomes & Reducing Costs for Ankle Sprains: New Evidence on the Impact of Delayed Care by Karen Napierala MS, AT, PT, CAFS CURRENT EVIDENCE Rhon DI, Fraser JJ. et al.“Delayed Rehabilitation Is Associated With Recurrence and Higher Medical Care use After Ankle Sprain Injuries in the United States Military Health System. JOSPT, 51(12), 2021 2021;619-627. (We’d love to hear your professional insights on this topic. Let me know your thoughts after reading this summary at PT@PeakPTRochester.com or if you have a patient case you'd like to discuss) Clinical Scenario...What would you do? A 24 year old male comes into your office after a 2nd time ankle inversion MOI with local swelling and pain. Non weight bearing AROM inversion and plantarflexion are limited/painful and dorsiflexion is significantly limited. His gait is antalgic with considerable favoring. Plain radiographs are (-) for fracture. Anterior Drawer test is mild Grade iI laxity. The patient is eager to return to activity as soon as possible, including work on the 2nd floor office building with a mix of sitting/walking/stairs, resuming fitness running and singles tennis league, and has three children aged 3 months to 5 years . I would prescribe… RICE and gradual activity return as able - call if problems. Rest in boot x 1-2 weeks + RICE and then go back to activity gradually - call if problems. PT with Class IV laser, early motion/proprioception work and wb progression activity. FU 4 wks if needed. Crutches PWB until gait normalized, simple HEP exercise sheet of generic ankle exercises, return to activity as symptoms allow. FU in office 6 weeks. SUMMARY: A retrospective cohort study of US MIlitary Health System beneficiaries (active duty/retired, family, etc) seeking care for an ankle sprain between 2010-2012 using only data available with both 12mo look-back and 12mo follow up data, resulting in 24,502 cases. Cases were grouped into receiving rehabilitation and no rehabilitation. Using medical and financial billing records, the effects of timing of rehabilitation on injury recurrence and injury-related medical care costs and visits were measured up to one year after injury. Approximately 1 in 4 people received rehabilitation. The probability of a recurrent ankle sprain increased for each day that rehabilitation wasn’t provided during the first week and plateaued for the next 2 months, becoming 2x (OR = 1.97) greater for those receiving PT at 8-12 weeks vs those starting rehab within 4 weeks. The total cost were also greater (OR = 1.13) for those delaying rehab vs early rehab, up to $1400 per episode. Overall recurrence and costs were less for those not obtaining rehabilitation, however, likely contributing factors such as severity and activity goals were not studied, among others. Data did include stratification considering other military duty related and medical comorbidity effects on recurrence and costs. The conclusion was that the earlier the musculoskeletal rehabilitation care started directly after the ankle sprain occurs the lower the chance of recurrence, as well as the downstream ankle-related medical costs. Early care is also important based on the other studies showing over 33% of ankle sprains go on to become chronically unstable. We believe not only early care is necessary but high quality care that includes discerning biomechanical assessment and customized manual therapy/exercise. There are many potential contributing factors for ankle sprain recurrence that are also related to optimizing recovery from a current episode that are not necessarily part of traditional therapy approaches. Our anecdotal experience supports research showing progression to CAI in what seems to be a significant number of patients who themselves and/or their providers viewed an early ankle sprain in a “routine” or sometimes dismissive way. Many factors related to faster/better recovery and prevention of recurrence are controllable. Background: In the US military, 329,702 enlisted members and 30,554 family members received care for ankle sprains over a 9 year time frame from 2006-2015. Many studies show that after two weeks the pain has retracted. Studies have shown 5-33% of ankle sprains have some pain after one year and that 15-54 % didn't recover after 3 years. Recurrence may happen up to 8 years after the initial injury. Over 33% of these sprains have been shown to become chronic ankle Instabilities (CAI) cases. College students with CAI averaged 2100 less steps per day. Total financial burden (adjusted for inflation) of ankle sprains can range from $11.7M to $90.0M per year. Early treatment for other musculoskeletal disorders has been proven effective. The authors studied time to begin rehabilitation on ankle sprain recurrence or future use of medical care for that ankle. Methods: This retrospective cohort study includes all beneficiaries (all active and retired military members, their families and other affiliated beneficiaries) of the US military Health System seeking care for an ankle sprain over a two year period from 2010-2012(with 12mo look-back 2009 to look-forward 2012 range limits). The 39,340 total cases resulted in 24,502 individuals diagnosed with an ankle sprain injury having a full 12-month look-back and follow up. Groups were divided into those with and without rehabilitation following an ankle injury which they sought formal care. Rehabilitation was identified by cases with medical encounters that included medical billing codes for therapeutic exercise, therapeutic activities, manual therapy, and modalities. Not all rehabilitation was from a physical therapist. There was a sub group for direct military clinic care, or civilian network clinic setting since the costs would be different. Considerations were given for comorbidities including: cardiometabolic factors, chronic pain dx, insomnia, depression, anxiety, concussion/ traumatic brain injury and PTSD. Findings: There were 6150 individuals who sought care for ankle sprains and received rehabilitation and 16,325 who did not have rehabilitation (27.4% who sought care received rehab and 72.6% who sought care did not)! Delayed rehabilitation was linearly associated with increasing probability of recurrence (after adjusting for comorbidities.) The probability of recurrence in the rehab groups increased each day during the first week post injury that treatment was not sought. It then plateaued until the first month, then increased again the second/ third months. Individuals who received physical rehab between 8 and 12 weeks had 1.97 greater odds of recurrence compared to those who received immediate physical rehab within 4 weeks. Delayed rehabilitation was linearly associated with a greater number of ankle-related medical visits.Of all the comorbidities, a chronic pain related diagnosis amplified the amount of visits they were seen in a medical office (by at least 10 visits). This translated to $292 to $2268 per cse for ankle sprains with delayed rehabilitation. Individuals in the non rehab group were 32% less likely to resprain. They hypothesized that these people chose far less risky activities and were much less active following the first sprain. (especially when they had chronic pain, or PTSD). Author's Conclusion: There is a greater chance of ankle sprain recurrence, chronic ankle issues, and increased cost to the system and individuals when rehabilitation for the sprain is delayed. THE PEAK PERFORMANCE PERSPECTIVE: Ankle sprains are one of the most common musculoskeletal injuries that occur. These injuries are seen in primary care, orthopedic, and podiatric physician office regularly. Not only patients but also providers all run the risk of thinking, “It's only an ankle sprain - rest it and go back in a week” …but is that the best option now and in the long run for our patients? For perspective, there are a few key facts to be aware of. Ankle sprains were the primary reason for lost (military) duty days in 2017 - 2018. Recurrence may happen for up to 8 years after the initial injury. Chronic ankle instability occurs in up to 40% of individuals with that first time lateral ankle sprain. The financial burden to the military is 11.7M to 90.9M per year! Military ankle sprain numbers have been shown to be similar to the active civilian population in their response to this injury. This study shows that what we do with them not only affects the patient's lifestyle in the future, but both their own financial costs and the total cost on the insurance system. So how do we as physicians and therapists make our decisions on how to treat? I am seeing a 50 year old male now who has had low back and L knee pain for years. During the initial history he reported the L ankle was sprained repeatedly in high school - with only a “walk it off “ rehabilitation that was popular then. He never regained his normal ankle dorsiflexion, and was left with a host of issues including inability to squat appropriately on his L leg due to that lack of dorsiflexion. His compensation happened to be extreme pronation during squatting. This led to decreased balance, subsequent increases of tibial and femoral internal rotation during WB activity that produced a “dynamic valgus” collapsing of his knee,( resultant patello-femoral pain, and quad weakness) his hip(glut medius weakness and poor pelvic control), and eventually affected his back. If the ankle was treated appropriately initially, 30 years of knee and hip abnormal mechanics may have been prevented. There are internal and external contributors to the ankle sprains. You can get yourself faster, more nimble and able to avoid these, External factors such as a tree root , rocks, uneven surfaces, or another player's ankle all can cause excess motion and sometimes means, no matter how perfect your anatomy is or how well trained your balance and agility and strength may be, you're probably going to sprain that ankle. Internal factors (biomechanics) are really the key place that changes can be made to reduce risk and optimize recovery. Good therapy should include looking at the biomechanics and functional patterns of the entire lower extremity. What is the cause for the injury? Have they returned to full ROM without aberrant planes of motion compensating for the lack of normal motion? Is there poor mobility that can cause the ankle to more frequently “live” near that injury risk position? Here are some key things we’d screen for (outside the typical ankle ROM, strength, etc) : Lack of dorsiflexion in subtalar neutral (needed for late gait phase mechanics). Without proper ankle sagittal plane motion, the ankle will choose to compensate into other planes (such as transverse, or frontal in abnormal amounts) or in the sagittal plane via early heel rise, reducing the area of contact for inherent stability. The ability for the ankle to help dissipate forces with jumping, running, and and cutting relies on all three levels (hip, knee, and ankle) to adjust the speed of deceleration when gravity is accelerating you towards the ground. Foot alignment/structure. An uncompensated rearfoot varus(stiffly inverted NWB and WB) or a compensated forefoot valgus (supinated foot with higher arch - including inversion tendency) - both especially concerning since 94% were lateral or inversion sprains. Limited Calcaneal eversion. The subtalar joint’s ability to “load” into eversion/pronation upon hitting the ground in walking or other movements/athletics allows you adaptation to uneven surfaces. Frequently we see ankle sprain patients unable to evert in general, meaning they are living that much closer to inversion (ie risk). Hip retroversion and/or cocca valga will also set an individual up for the foot to be an inverted position and can predispose an individual to ankle sprains A pronated foot oddly enough may also predispose someone to ankle sprains. A prolonged everted position may negatively impact the proprioceptive awareness of excessive inversion and also be less reactive at the peroneals due to the delayed stretch reflex. We’ve seen numbers of these in the clinic where patients or providers first expected the patient to describe a deltoid or eversion MOI sprain but instead they did experience an uncontrolled inversion episode. Prior concussions or balance issues lead individuals to be less apt to adapt to quick changes of direction, or the surface you are moving on. Proprioception - generic and inversion control specific. Oftentimes balance testing identifies a more general lacking of neurologic sensorimotor mechanoreceptor system function such as with eyes closed or dominant eye closed with head up mini squats, but the ability also to specifically control for frontal and transverse plane loading into inversion/supination must be determined. Left untreated these sprains can bring on secondary issues. The example of the 50 year old with a 30 year old ankle sprain is far from out of the ordinary. Studies show that many ankle sprains “feel “ better in 2 weeks. Once they feel better there is a tendency and risk as a clinician and certainly as the patient to think that they “are” better. But we look at the “being better” as an objective, measurable thing rather than simply a feeling the patient has. We want them to have enough motion to be able to handle the unexpected, or live out their dreams, not just be able to walk on a flat surface for 20 minutes. College students left untreated with subsequent ankle issues were found to walk 2100 steps fewer than their intact ankle cohorts. It’s key that good therapy help take them from “feeling better” to “being better”. That requires simply starting with physical therapy early, as Rhon et al found. The next key is that quality care will include actually looking for the biomechanical issues that predispose them to “living in a box” of safety and limitation. Especially for athletes and for active lifestylers the goal must be instead be to help them be capable of performing “outside the box” of safety and of constrained motions and loading where risks are always kept low, so they can return confidently to the activities they love but do so with less risk of recurrence. The following case exemplifies the benefits of early rehab following an ankle sprain. THE PEAK PERFORMANCE EXPERIENCE: Terry said: “ I am playing volleyball on a high level with minimal to no issues. I can jump and land indoors. The stiffness I had in my ankles is gone!” History: Terry was a high school volleyball middle hitter. She had to jump high, and land hard. If the set and/or her approach was off then she’d have to tolerate landing off balance on one leg, risking inversion forces. She injured her ankle during volleyball when she landed on an opponent’s foot, causing a rapid inversion - she heard a “pop” and immediately had difficulty walking and could not play. Plain films were (-). She used crutches for a week. PT began three days after the incident. Objective: Pain limited R squat to 50 plantarflexed (ie no dorsiflexion on the R). Symptoms were localized to the anterior talofibular ligament and the peroneal tendon below the lateral malleolus. (*=pain) Initial Eval Re-Eval STJn WB Dorsiflexion -5 R/ 21 L 19 R / 21 L Single leg squat knee angle Unable to do / L 55 R 65 / L 70 Calf raise 2 R/ 24 L 28 R/ 30 L 3” quad dom step down (eccentric ) Unable * 10 # front racked R/ 22 L / 24 Single leg hop 10 sec R/unable L/ 14 B 15 16 reps Lateral lunge Unable * 15# low reach R 19x L 21x Single leg balance rotation 15 sec Unable R 6x L 8x Med/lat 3 step directional change 15 sec 8 feet distance unable* 10 reps Key Findings: Treatment: Terry began ROM in PT 3 days post injury. She received manual grade 1-2 mobilization in pain free ROM. She began AROM and dorsiflexion with strap assist. She followed with 3 dimensional WB soleus/ gastroc stretches in available pain free ROM. She was able to do Partial WB calf raise that week, as well as proprioceptive balance training static, and dynamically progressed to full WB Eyes closed within a week. She started regaining strength within a week and began uneven surface/ BAPS, and stepping soon after that. We used Rock tape to ease the swelling and provide stability as she progressed. After 2 weeks: She was able to join in practice limited to serve receive and serving. She practiced swing skills standing at the net. Outcome: By 4 weeks she had been doing enough agility/ strength and proprioception that she went back to playing with an ankle brace on and no limitations You can trust the Physical Therapists at PEAK PERFORMANCE to do a thorough evaluation, to search for related but underlying contributing factors to kinetic chain dysfunction, and to design exercise progressions that both respect tissue healing and creatively use biomechanics principles to prevent symptoms and optimize carryover to your patients' functional goals. Call us at 218-0240 to discuss your patient's specific needs. Peak Performance is just minutes away from your patients in Penfield, Fairport, Pittsford, Brighton, Rochester and, of course, East Rochester. We promise Individualized, hands-on and biomechanically appropriate Physical Therapy for your patients. No "one-size-fits-all" approaches. We WILL go the extra mile and "dig deeper" to discover underlying causes for injury risk and delayed recovery using the most advanced Evidence Based methods available and, we’re able to make unique adjustments to exercise prescriptions to speed the return to function and to minimize or prevent symptoms from interfering. No surprises. No hassles. Confident your patient is in the right place. COME VISIT US AT 161 E Commercial St Just 1 mile off 490 exit (585) 218-0240 www.PeakPTRochester.com

Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE January 2022 Examining the Necessity of Prescribing Joint Mobilization for Plantar Fasciitis by Rachele Jones, PTA, ATC, CAFS Clinical Scenario...What would you do? A 58 yr old male developed gradual onset of R plantar foot and heel pain over the course of 2+ months while continuing to participate in 3mi distance running BIW-TIW, which he’s done for the last six years. He also has mild+ R knee OA that is painful but not preventing him from running. He’s tried OTC arch supports without relief. Plain films are WNL. Tenderness locally at the calcaneal tuberosity plantar fascia insertion and along the medial band of fibers into the longitudinal arch. MTP extension is WNL. NWB ankle DF is WNL both knee flexed and extended. He does have R early heel rise with (B) squat testing. A quick balance assessment shows asymmetric overpronation on his L foot. His morning sx upon 1st wb and local tenderness suggest plantar fasciitis/fasciosis. My clinical thinking is: A. Recommend two visits of Physical Therapy for HEP instruction in simple traditional protocol of stretching the plantar fascia/calf muscles. B. Prescribe a course of NSAID’s and then if not better in 4 wks consider steroid injection. C. Order a night splint to stretch out the plantar fascia. Follow up in 3-4 wks to reassess. D. Prescribe PT Eval/Treat (including Laser, manual therapy as needed, functional strengthening and dynamic balance work) . E. Obtain further diagnostic studies (either diagnostic US or an MRI). CURRENT EVIDENCE Anat Shashua et al, The Effect of Additional Ankle and Midfoot Mobilizations on Plantar Fasciitis: A Randomized Controlled Trial. Journal of Orthopedic & Sports Physical Therapy 45:4, 2015 265- 272. https://www.jospt.org/doi/full/10.2519/jospt.2015.5155?rfr_dat=cr_pub%3Dpubmed&url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org (We’d love to hear your professional insights on this topic. Let me know your thoughts after reading this summary at PT@PeakPTRochester.com or if you have a patient case you'd like to discuss) SUMMARY: Plantar fasciitis, or fasciosis as it is more accurately often referred, is a common condition causing heel/arch-foot pain seen by physicians and physical therapists. Determining appropriate referral practices is dependent on evidence based findings. Plantar fascitis(PF) is commonly treated with stretching based approaches, including joint mobilization techniques, however, clinically we more commonly find overpronation issues as a contributing factor, resulting in “overstretch” of the tissue rather than abnormal local fascial tightness in the foot. Dorsiflexion loss is thought to be one of the kinetic chain issues that might underlie PF. This single blinded RCT examined the addition of a standard set of ankle-foot mobilizations to a routine stretching + ultrasound treatment to determine efficacy of joint mobilizations. While subjects in either group who had limited dorsiflexion showed (+) gains from joint mobilizations, the intervention group did not show improved outcomes on self-report foot scales or algometry or overall group improvements in WB DF ROM. We feel this study cannot be used as a basis to disclude foot-ankle mobilizations from high quality care of PF cases due to heterogeneity of the groups regarding tissue healing phase and limited number of cases with noted DF (or other) ankle ROM and a lack of clarity in maintaining STJ neutral positioning that is authentic to late stance biomechanics demands during testing, stretches, and mobilizations in order to control for compensatory overpronation. Mobilizations should not be assessed in isolation because clinically any gains in ROM should be immediately followed by proprioceptive/strengthening exercises to integrate new mobility into function. Also, the limited BIW x 4 wks treatment time was potentially inadequate for the wide range of chronicity in the sample, ranging from 1 month to 24 months. Physicians should expect high quality physical therapy include specific matching of applied mobilization techniques to joints tested to have limited ROM. This study’s conclusion more accurately should indicate that limited simple joint mobilization techniques applied to cases of PF both with and without proven joint restrictions do not demonstrate group benefits over simple stretching and ultrasound alone. Background: Plantar fasciitis (PF) is a chronic degenerative process to the plantar fascia, better referred to as fasciosis, which affects approximately 10% of people in their lifetime. Ankle dorsiflexion limitations is thought to be a common contributing factor to the development of plantar fascia. Methods: Randomized controlled trial using 50 participants (23-73 yr) who had heel pain generated by pressure, increased pain of 3+ on the NPRS scale in the morning with first few steps or after prolonged non-weight bearing, diagnosed with PF. All participants received 8 treatments at BIW frequency including a stretching program and ultrasound. The intervention group also received manual therapy mobilizations of the ankle and midfoot joints. Primary measures were from three outcomes: numeric pain rating scale (NPRS), Lower Extremity Functional Scale ( LEFS) and algometry. Dorsiflexion was measured twice at the beginning and the end of treatment. Participants were evaluated at baseline, after 4 sessions, end of treatment ( 4 weeks) and a 6 week follow-up via telephone for NPRS and LEFS but only twice for algometry and dorsiflexion ROM were measured at baseline and at end of treatments. Findings: No significant differences in finding between groups and outcomes. Both groups showed significant differences in NPRS and LEFS and improved dorsiflexion ROM. All data analysis was conducted using the intention-to-treat approach. Author's Conclusion: Results suggest that the addition of manual joint mobilizations of the ankle and foot to improve dorsiflexion ROM is not any more effective than stretching and ultrasound alone. The association between limited DF and plantar fascia is most probably due to soft tissue limitations vs joint restriction. THE PEAK PERFORMANCE PERSPECTIVE Physicians deciding on best practices for the care of their patients with Plantar Fascitis (PF) often must discern both whether Physical Therapy will be ordered but also more specifically appreciate what appropriate treatments will be included in what they might expect to be “excellent” care. Joint mobilizations are commonly incorporated in physical therapy treatments. The question at hand is whether patients with plantar fascitis will benefit from and if appropriate physical therapy care “should” include joint mobilizations. This study by Shashau et al had good intentions and measuring properties but in the long run does not completely support the authors’ conclusion that ankle/midfoot mobilization therapy is not effective for plantar fascitis. First, some key foundational questions physicians and therapists alike must ask are… “Does everyone who has heel pain/ plantar fasciitis have DF restrictions and need ankle and foot mobilizations?” and “Is there a ‘protocol’ - like treatment plan that works well for all plantar fasciitis cases regardless of being acute or chronic or regardless of underlying patient-specific causes?” Let’s begin with the general question/concept of PF that we see first clinically - plantar fasciitis cases generally fall into two groups: excessive PF tightness (supinated or high arched foot) related and excessive lengthening (ie often overpronation) related. In our experience we tend to see more cases involving overstretch mechanism related, oftentimes due to overpronation. Interestingly, most PF “protocols” tend toward treating this as a “PF tightness” problem and focus on further stretching the connective tissue and related muscles. Many “failed PT” cases we see with PF diagnosis have overpronated feet (and overstretched plantar fascia) that were treated with stretching exercises for the plantar fascia. If, as we often see in the clinic, a patient demonstrates considerable or asymmetric overpronation on dynamic testing (ie mini squats balancing, rotational balancing, lunge testing, impact hop testing) that is associated with the plantar fascia being overly lengthened. If the overload is stretch or length that traumatized and irritated the tissue in the first place then why would more stretching be the treatment? On the other hand, if a patient has a high arched foot or compensatory supination (often due to a forefoot valgus or plantarflexed first ray) then that plantar fascia is typically short/tight and the rigors of ADL, or especially athletics, can place more lengthening demand on that foot to comply with change of direction or pronation force dampening (ie shock absorption) than the tissue can accommodate to…leading to stress and eventual pain. Those feet certainly need stretching exercises to improve that foot’s adaptability to shock absorption needs. So, right from the start we find this study’s premise a bit to overgeneralized. This is common in many studies, connecting a diagnosis with a singular potential causative factor. This, of course, leads to underwhelming statistical findings because the group is too heterogeneous if actually there are multiple contributing factors. That seems to be the case here as well. This study provided joint mobilizations to everyone in the intervention/experimental group whether they needed it or not. The groups were not matched regarding DF ROM status nor split based on DF loss. Manual therapy joint mobilization techniques in the real-world clinic setting are used (or should only be used) when a significant limitation of normal motion exists that is determined to be both contributing to the condition/symptoms and is likely joint based rather than merely soft tissue based. This is a key shortcoming to Shashua et al’s study, in that it was not powered based on finding enough participants with defined DF ROM loss where the use of mobilization vs no mobilization could be examined specifically. Certainly, performing mobilizations on a patient with plantar fascitis who has no DF loss would not be expected to produce superior outcomes. Clinically speaking, it is necessary to examine each person’s foot-ankle ROM and biomechanics individually to see where the limitations are and address those limitations specifically. In this study they generically applied joint mobilizations unrelated to any particular deficit or need. In terms of joint functional biomechanics and musculoskeletal conditions, while limited dorsiflexion has been identified as being an intrinsic factor potentially contributing to plantar fasciitis this cannot be viewed as a direct “causal” relationship. All people with plantar fasciitis do not have dorsiflexion limitations. As is true with most orthopedic conditions, we see the literature evidence base pointing to “multifactorial” underlying causes rather than singular “if then, therefore” type relationships. The compensations that a lack of DF may cause could include early heel rise or overpronation, both of which would lead to abnormal loading of the plantar fascia. We believe this study design leads to the results not truly reflecting the efficacy of adding joint mobilizations with PF conditions because both the control and intervention groups both contained some patients who “lacked” normal dorsiflexion - they were too heterogeneous. And, their definition of less than 350 being a deficit does not jive clinically with what we see. That seems to be a high threshold for normal dorsiflexion. Typically we see normal WB dorsiflexion in the 25-300 ranges. The patients in this study had inclinometer values of 39.68 to 41.80 with standard deviations in the control group of + 5.99 - 6.140 and intervention group of 8.96 -9.630 - hardly substantial deficits compared to our real-world experiences. So, there were fewer patients with significant DF loss available for comparison of the mobilization treatment efficacy. There is a chance also that by performing the mobilizations to everyone in the intervention group that it could have made them hypermobile, potentially leading to greater stresses. Remember that dorsiflexion mob’s were not the only type - treatment also included subtalar joint (STJ) inversion and eversion mobilizations along with midtarsal joint (MTJ) inversion and eversion. Forefoot inversion is associated with a WB overpronated foot and forefoot eversion is associated with a supinated or high arched foot in WB at the MTJ. No measurement or assessment of each patient’s MTJ function was mentioned. The generic application of all possible mobilizations to the entire group again waters down the ability to truly discern whether the mobilizations, properly applied ONLY to the sites and directions where both limitations exist AND biomechanical kinetic chain understandings can “connect the dots” to PF overload was effective or not. Yet in this study they did mobilizations in both directions to the STJ and MTJ without regard for specific needs. The study did utilize several different hands-on techniques,some of which we use here in the clinic. But, both their WB testing (another issue that lowers the strength of their findings and conclusion) and mobilizations do not specify any attempt to control for STJ positioning. The STJ has returned to neutral or actually slightly inverted just prior to heel rise when maximum dorsiflexion is needed. During testing, stretches, and mobilizations if the STJ is allowed to be everted (foot pronating) then the “path of least resistance” for functional dorsiflexion in walking and running can be habituated into overpronation and therefore overstretch the plantar fascia in late stance phase. Though they did include mobilizations in WB position for dorsiflexion as well there wasn’t any specific attention given to the STJ positioning in the addendum notes. This potential lack of control of and variability of the foot position certainly impacts the expected reliability of measurements between three PT’s but also disregards the functional gait mechanics the dorsiflexion specifically relates to. We find many patients “know” the typical soleus and gastroc stretches associated with improving dorsiflexion mobility but too often were not instructed in that specific STJ positioning desired for normal gait mechanics and forces. One treatment aspect that cannot be forgotten is that anytime mobilization or stretching is done it is necessary to supplement with appropriate strengthening exercises. Their focus was only on ROM (which may not have been warranted since most were measuring at >300) - the risk then is that ROM is gained without concurrent muscular control, leading to essential functional instability that increases local tissue strain and even downstream injury/inflammation. All gained motion must simultaneously be controlled. To discuss or make conclusions regarding the efficacy of joint mobilizations in isolation, not accompanied by functional strengthening, is a bit misleading because clinically we would never produce improved ROM without stimulating the proprioceptive system to control that new range for optimal ADL or work demand or athletic uses. We would submit that producing increased ROM without strength actually can be deleterious. High quality Physical Therapy for PF should include examining the kinetic chain with an appreciation for authentic function and biomechanics, at minimum testing the nearest proximal and distal joints surrounding the injured tissue for ROM limitations and strength deficiencies. Only then can a therapist develop a program to safely and effectively address those issues. Another important variable in researching the treatment of any dysfunction/ailment is the stage of the tissue irritability and healing phases - whether it is acute or chronic. The subjects in this study had symptoms ranging from 1 month to 2 years, a very large range and diverse group. While there is no clear clinical threshold for defining a PF case as being and “-itis” vs and “-osis” condition the treatment approach for a 1-2 month old recent onset versus a certainly 12-24 month old case may be different. This adds to the heterogeneity of the group. While that may form a more “real-world” sample it also waters down the ability to discern specific treatment approaches if they might not typically applied to that tissue irritability stage. This study used a global and generalized approach without regard to tissue healing phase/stage. That leads to the question also as to whether four weeks was an adequate time to expect substantial change. Especially cases that were 12-24 months old may require greater treatment time to see results compared to someone in the acute phase where tissues are more likely to “bounce back faster” and the recurring scarring from microtears and habitual compensations due to pain have had less time to occur. The following is a case of an older runner who developed problematic heel and plantar foot pain that prevented running and normal painfree ADL. THE PEAK PERFORMANCE EXPERIENCE Dennis says, “I’m walking 2-3 miles now with essentially no or only very min symptoms -- - feeling encouraged!” Hx: 68 yo active male developed left heel pain in mid July after running 3.5 miles 4x/wk, increasing over time to 6/10 NPRS and so the patient had to discontinue running. Other activities impacted include: walking, hiking, jogging, and some ladder climbing with work. Subjective: Pt reports immediate pain 5/10 with jogging, walking longer than five minutes, and stair/ ladder negotiation. Objective: Medial heel and plantar fascia attachment on calcaneal tuberosity tender along with fifth metatarsal, increased NWB L foot forefoot valgus, symptoms worse in the morning. Pt self reports 50% function with a Foot and ankle disability index score (FADI) of 61% function and FADI Sport Module at 28% function. * indicates pain Initial Eval Re- Eval (6wks Dec ) Foot and ankle disability index score (FADI) 61% 63% FADI Sport Module 28 % 31% WB Dorsiflexion (squat , STJ neutral) ROM (L/R) 200/300 260/300 NWB Dorsiflexion DF ( knee flexed) ROM ( L /R) 50/120 200/200 NWB DF knee ext ( L/R) 180/200 200/NT Calcaneal Eversion (L/R) 40/ 80 40/80 Opp Ant toe reach 60units x 15sec 10# wts NT 6.5x / 8x WB Hip extension ROM Moderate limitation (B) WB Hip flex ROM (L /R) 530/ 700 530/ NT Hip Internal Rotation ( prone L/R ) 360/450 450/450 SLB Rot Pronation control ( L /R ) < 5 sec (Poor, avoids pron) / 8 sec (Fair) NT PF reps FWB (L/R) L * 10# 31*x/ 30x Key Findings: L poor pronation control with single leg balance, decreased ROM in calcaneal eversion & DF w/ knee flex and ext, and limited hip mobility. Treatment: Manual mobilizations to (NWB and WB) ankle and (NWB) forefoot for increased DF ROM and forefootinversion. PROM/stretches to increase left soleus/gastrocnemius, and triplanar hip mobility ( psoas, hamstring, IR ). PRE’s for gastrocnemius, supinators of the foot and dynamic balance work for pronation control. Use of modalities for symptoms control and inflammation reduction - use of ultrasound and CLASS IV LASER. Twelve weeks into the program… progressed from a strength based program to a more functional impact and speed day for better preparation for patients goals of returning to running. Formal ReEval upcoming. Outcome: Pt continues to improve with reduction of pain sx’s, increased function, increased strength and ROM and has progressed to impact training and a “speed day” 1 out of 3 d/wk which includes specific deceleration/acceleration based exercises. The pt started the progression of a walk/jog program BIW - - - -> TIW. Peak Performance is just minutes away from your patients in Penfield, Fairport, Pittsford, Brighton, Rochester and, of course, East Rochester. We promise Individualized, hands-on and biomechanically appropriate Physical Therapy for your patients. No "one-size-fits-all" approaches. We WILL go the extra mile and "dig deeper" to discover underlying causes for injury risk and delayed recovery using the most advanced Evidence Based methods available and, we’re able to make unique adjustments to exercise prescriptions to speed the return to function and to minimize or prevent symptoms from interfering. No surprises. No hassles. Confident your patient is in the right place. COME VISIT US AT 161 E Commercial St Just 1 mile off 490 exit (585) 218-0240 www.PeakPTRochester.com

Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE December 2021 New Evidence of Essential Thoracic Mobility for Normal Upper Limb Function by Allison Pulvino, PT, MSPT, CMP, FAFS Clinical Scenario...What would you do? A 35 yr old male firefighter who enjoys playing volleyball on an intermediate level 6's team at the local indoor courts gradually developed complaints of R dominant hitting arm shoulder pain superior/anteriorly during volleyball hitting > blocking and with overhead work and ADL demands. Plain films are unremarkable. Clinical exam shows tenderness at the supraspinatus and LHB tendons, (+) impingement - Rotator cuff syndrome tests, weakness/pain especially with elevation and ER resistive tests. He has a typical "poor posture" both statically and also during AROM testing. You're ordering Physical Therapy and seeing him back in 4 weeks to consider if he is progressing adequately and to decide if further diagnostic testing is necessary. Your expectations of his PT evaluation/report......subsequent treatment would be...? Palpation, special testing, resistive testing.....modalities + simple shoulder stretching & strengthening program AROM shoulder/trunk, palpation, special testing, resistive testing....modalities, manual therapy to trunk/scap and shoulder prn, stretches prn, strengthening scapulothoracic and shoulder muscles/function per findings AROM, resistive testing...simple shoulder protocol (Jobe's exercises or Thrower's Ten) AROM shoulder + kinetic chain trunk/scapula, special testing, palpation, resistive testing... Class IV laser, stretching sleeper/pec major/Hor Add posterior RC, strengthening RC....address thoracic spine if not improving CURRENT EVIDENCE Heneghan et al. Thoracic Spine Mobility, An Essential Link In Upper Limb Kinetic Chains in Athletes: A Systematic Review. Translational Sports Medicine. 2019, 2(6). 301-305. https://doi.org/10.1002/tsm2.109 SUMMARY: Upper limb injury and pain is a commonplace issue, especially of the shoulder, for many athletes and non-athletes alike. Determining and prescribing what "standard care" is for shoulder and upper limb injuries/pain often focused solely on the local tissues but new evidence presented by Heneghan et al supports the concepts of kinetic chain "regional interdependence" that must understood by all musculoskeletal providers in order to optimally care for our patients. These biomechanics relationships, in this case with the thoracic spine, provide a potential source for contributing factors causing tissue overload and kinetic chain issues that also may delay recovery. Understanding these are critical for prescribing treatment and especially performing successful physical therapy in these cases. Heneghan et al provide some important insights into the relationship between normal shoulder ROM and associated thoracic spine mobility, especially noted during end ranges of shoulder flexion more so than other elevation directions and mutually more so than during other motions. Achieving unilateral or bilateral elevation ranges produced the greatest thoracic spine mobility demand, that being extension during shoulder flexion. Clinically we often see kinetic chain factors either addressed generically or not at all. Prescriptions rarely specify expectations of thoracic/scapular assessment and care. Patients seen due to "failed PT" elsewhere often report being handed a generic exercise sheet to learn and perform at home...the same sheet other shoulder patients were using. Assessing and restoring WNL thoracic/scapular kinetic chain function is necessary for the shoulder/upper limb to perform normally. (We’d love to hear your professional insights on this topic. Let me know your thoughts after reading this summary at PT@PeakPTRochester.com or if you have a patient case you'd like to discuss) You can read the full version below Background: Traditional exercising and rehabilitation for shoulder limitations and injuries continue to be heavily focused on GH joint function and strength/mobility, and active and athletic populations can at times have recovery programs falling short to achieve full function. This study looks at thoracic mobility in unilateral and bilateral UE overhead ROM to assess kinetic chain connections in regards to necessities with functional movement. Methods: A systematic review through June 2018 of 554 initially retrieved studies resulted in seven meeting eligibility criteria that included a population of healthy 18-40 year old men and women (Males= 33%) with a sample size of 168 individuals, including 20 athletes. Thoracic spine extension, rotation, and lateral flexion were assessed during upper limb abduction, right scapular elevation, flexion, extension and scapular elevation, flexion and abduction, external rotation, functional flexion and (B) elevation using various data acquisition/measurement systems. Results: Unilateral and bilateral UE full flexion elevation resulted in 6.7-8.0 deg and 12.0 – 15.0 deg of thoracic extension, respectively. Unilateral and bilateral UE abduction elevation resulted in 3-4 degrees 9.0 – 12.8deg of thoracic extension. Lateral flexion ranged from 2.7 – 9.0 deg between various studies during different planes of unilateral end ranges of elevation, most often in contralateral direction and at lower thoracic segments especially. Thoracic rotation ranged from 2.1 – 11 deg for the various planes of elevation, greatest being scaption and abduction. Lateral flexion and rotation were negligible during (B) maximal elevation. Thoracic movement in early/mid ranges of movement have poor evidence/agreement with singular studies reporting 11 deg extension at mid range flexion and 8.9 deg during ER AROM. Author's Conclusion: There was significant thoracic extension occurring in flexion, abduction and scapular elevation in unilateral and bilateral UE elevation. Although the evidence quality is low, sample size small, and more research would be beneficial in an athletic population, a more thorough thoracic spine focus is warranted for practitioners working with athletes on functional UE movements involving the kinetic chain. THE PEAK PERFORMANCE PERSPECTIVE: As a referring physician you’re often challenged by making determinations of what treatments to recommend or what “good” therapy entails when prescribing physical therapy for various upper limb conditions. Common expectations for traditional physical therapy would certainly include possibly local modalities to reduce pain and inflammation, manual therapy, and local stretching and strengthening. Evidence has been lacking regarding the kinetic chain importance of the thoracic spine’s mobility and shoulder/upper limb function. Heneghan et al provide some valuable data that helps identify the relationship of thoracic motion during arm movements, providing a basis for prescribing and expecting that shoulder/upper limb care will assess and treat related thoracic spine limitations that may be contributing factors or could be a source of slow recovery or “failed” conservative care. Individuals coming into a physical therapy clinic with pain and limitations with their shoulder or elbow do not expect that their pain is caused from joints or muscle limitations from a region not directly at the site of their pain. But what we find as movement specialists during kinetic chain assessments, supported by Heneghan et al's findings, is that thoracic spine limitations in any one of the three planes, can play a role in limiting arm mobility (especially thoracic extension related to overhead function) resulting in negative effects during work, ADL, and/or athletic activities performed. These limitations more proximally at the thoracic spine certainly happen for a variety of reasons, most commonly sedentary work duties (especially with prolonged neck flexion or computer screen use) , poor posturing in general, or activities involving prolonged/repetitive spinal flexion such as masonry and lifting from lower levels. Another key component can be attributed to classic forms of fitness training that many have become accustomed to involving isolated single plane movements such as weight machines or group fitness classe. These are commonly performed with bilateral upper extremities simultaneously which can be safe and effective for some, but if there are other mobility restrictions such as with the spine, then not just the shoulder but the more distal joints can be stressed more and in abnormal locations. Those forms of exercises also do not necessarily train one's body for the stresses of athletic events including spiking a volleyball, swimming freestyle or backstroke for example, or throwing/serving overhand in baseball, volleyball or tennis. The repeated stresses on those more mobile joints such as the shoulder, in the presence of thoracic mobility limitations, can then lead to instability and possible more serious tissue damage and even the need for surgery when not addressed in time. Heneghan et al reminds that there exists very little literature on how more proximal segments in the kinetic chain, including the thoracic spine and pelvis, affect more distal segments in athletic events. They do, however, cite that other researchers have discovered approximately 55% of total force and kinetic energy during a throw is derived from the thoracic spine and approximately 80% of total axial rotation is utilized. They also noted prior research demonstrating a 3x higher elbow/shoulder injury prevalence for softball players with limited trunk rotation mobiity. This leads to the question - “Why do so many shoulder rehab programs only focus the involved shoulder, elbow, or wrist?” It has been our experience that many traditional UE strength exercise movements are not tolerated well by patients in a rehabilitation program for "shoulder pain", including unilateral isolated, typically long lever type movements with either weights or resistance bands, as they can excessively stress GH jt structures, and sometimes even bring on more impingement symptoms or joint crepitus, and pain in general - especially because they are oftentimes taught in very strict postures that prevent thoracic mobility contribution to total motion. Some examples include traditional long lever exercises like flexion and abduction raises, empty cans, full can scaption, T-Y-I (mid/lower trap stimulus), wall walking, door sliders (abd press in ER) among others. While these aren't "bad" exercises, they can easily be inappropriately applied at the wrong time during recovery, through ROM that is irritating, and often are done intentionally preventing scapulothoracic motion under the auspices of "strict technique" and "isolation" concepts. These patients or fitness enthusiasts often have increased thoracic kyphosis and anteriorly tipped scapulae, which then prevents fluid and necessary humeral head mobility and control. So if proximal structures that are limited are not addressed, oftentimes recovery is slow or absent leading the patient to report back to their physician complaining that nothing has changed, or the pain has not decreased, or they still cannot play their favorite sport. The appearance of a potential “failed case” of PT then may trigger more expensive testing or injections etc when, in fact, it was simply more thorough kinetic chain care that was needed. Once addressing thoracic and lumbar spine limitations, the scapular and GH joint mechanics and ultimately functional use tends to improve. A great example would be the financial planner sitting 40 to 50 hours per week and then reporting he/she is feeling frustrated when one shoulder hurts when they play in their once weekly volleyball league. Working on transverse and frontal plane thoracic mobility, as well as thoracic extension, will allow for kinetic chain scapular posterior tipping/adduction/upward rotation. This will allow for full overhead GH jt mobility with successful humeral inferior gliding to prevent impingement when serving/hitting overhead, and ipsilateral lateral spinal flexion for loading into overhand serving. Without the thoracic mobility, the scapula will be blocked and rotator cuff impingement will likely happen. With all UE overhead movements, Heneghan et al’s systematic review noted a constant, that all UE movements initiated some level of thoracic ROM, but only at mid to end range of UE elevation. The greatest thoracic ROM needs were found to be thoracic extension with full UE overhead flexion elevation (6.7-8deg uniliateral and 12-15 degrees for B UE), followed closely by scapular elevation (4-8.9 deg unilateral ) and UE abduction (9-12.8 deg bilateral). The limitations for this systematic review do state only one study looked at an athletic population, and some sports with a greater proximal restriction including wheelchair basketball may require more focus and more thorough assessment. The meta analysis does have some limitations. The quality of studies was generally low, the study population was mostly females, and these were not athletes per say but “of athletic age” rather. Therefore the generalizability to other populations must be considered, however, there was a consistency among studies demonstrating thoracic motion relationship to shoulder elevation end ranges especially. Physicians prescribing PT for shoulder and UE conditions have an evidence basis for appreciating the importance of and expecting a full kinetic chain assessment, especially including the thoracic spine, for their patients being prescribed PT for UE pain or limitation, regardless of age, sex or activity. We may also want to consider including more spine focus in post-operative protocols, along with respect to healing the injured and repaired tissue. By considering the authentic biomechanics effecting and contributing to stresses and healing potential of involved tissues. We will be doing a more positive service to our patients and they may even have improved function and mobility than they have ever had prior. THE PEAK PERFORMANCE EXPERIENCE Greg stated: "I don't have any pain with activities!" HX: Greg was performing push-ups during a workout and felt a pop and grinding in his R shoulder and pain continued with even light exercises and movements from that point on for approximately one year. Using his R arm during his job tasks started to become uncomfortable. Pain levels could reach 8/10 at times. Any lifting and reaching with his R arm became an issue. Objective Data: MEASURE ( *=pain) Evaluation DC Thoracic Posture Kyphotic Scapular Posture Protracted Thoracic Rotation 59 / 50 Shoulder Abd IR 50 56 IR up back T10 T8 Overhead Press Reach Unable * 5# done 10x Speed's (+) (-) O'Brien's (+) (-) Jobe's (+) (-) Sulcus sign (+) (+) Treatment: Manual: Post/inferior humeral mobs, pec minor release, horizontal abd with IR stretching Exercises: Posterior capsule stretching, T-spine extension/SB/rotation stretching, T-spine frontal plane/transverse plane strength with dumbbells, T-spine extension drills with shoulder OH pressing with biases towards rotation, resistance tubing RC strength with in-sync T-spine rotation and SB, dumbbell push-pull drills for scap stability, serratus strength with tubing and DBs progressing in scaption and SG plane OH. Outcomes: Painfree ADLs, Painfree incline push-ups ~3ft elevation table, painfree plyo shoulder drills and no limitations with work tasks. You can trust the Physical Therapists at PEAK PERFORMANCE to do a thorough evaluation, to search for related but underlying contributing factors to kinetic chain dysfunction, and to design exercise progressions that both respect tissue healing and creatively use biomechanics principles to prevent symptoms and optimize carryover to your patient's functional goals.

Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE November 2021 Finding Alternative Therapies for Arthritic Patients: Effective Natural Anti-infammatory Option RCT by Mike Napierala, PT, SCS, CSCS, FAFS CURRENT EVIDENCE Deutsch L. Evaluation of the Effect of Neptune Krill Oil on Chronic Inflammation and Arthritic Symptoms. J of Amer College of Nutrition. 26(1). 2007. 39-48. (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) What would you do? Clinical Scenario..... A 65 yr old female c/o 7 yrs of L knee pain w/o obvious trauma, worsening over the past 6 mo with mild swelling, crepitus, and sometimes painful giving way during her favorite activity of doubles pickle ball and also descending stairs. She has used OTC NSAID's regularly over the past 2-3 yrs with limited success. She does have a h/o GI disorders and varying adverse reactions to attempted doubling of OTC ibuprofen or naproxen. She presently uses Tylenol for pain control. Plain radiographs show moderately advanced medial compartment knee degenerative changes. Clinical exam shows asymmetric mild varus deformity L knee and AROM reduced to 7-125deg (R 2-135deg). Single squat is limited/painful with audible crepitation. Patient's goal is avoiding surgery and continuing with fitness and pickle ball with her friends. She inquires if there are any dietary or supplement changes that could help. I would... Start with prescription NSAID's course, allow her to continue playing and reassess in 4 wks. Start with prescription NSAID's course but advise to DC playing for 3-4 wks and then reassess. Encourage anti-inflammatory diet and trial with supplement options such as krill oil or turmeric before considering NSAID's, plus order Physical Therapy. Begin viscosupplementation injection therapy. Order an MRI to R/O symptomatic degenerative meniscal tear. SUMMARY: Deutsch examined the use of a proprietary blend of krill oil (Neptune Krill OilTM ) vs a placebo in an RCT comparing 44 and 43 patients, the majority of whom had osteoarthritis or rheumatoid arthritis (40 of 44 Group A and 38 of 43 Group B placebo). The 30 day trial showed significant reductions in CRP within 7 days and continued decreases over the 30 days compared to the placebo group. “Rescue” acetaminophen use was reduced significantly by the krill oil group and WOMAC scores were more significantly improved for the NKOTM group. Many patients with arthritic symptoms looking for immediate symptom control either prefer non-pharmacologic options, have had GI issues in the past already from prolonged NSAID use, or have comorbidities making them at risk for adverse events with continued NSAID use. This study provides both inflammatory marker and functional WOMAC scale evidence for the (+) impacts related to NKOTM supplementation. While NSAID prescription and OTC use recommendations are commonplace in medicine/orthopedics this provides encouraging alternatives for consideration by physicians looking for effective alternatives to help reduce symptoms and improve function short term, at least, for arthritis sufferers wanting reduced GI and cardiac risks. The case study presents a patient who was preparing for TKA who, through manual therapy and functional exercise, was able to improve adequately to resume goal activities and delay/avoid surgery. Background: C-reactive protein (CRP) has been a strong predictor of future cardiovascular events per the Framingham risk score and it’s production in arthritic joints reflective of proinflammatory cytokines essential to cartilage degradation. A strong association has been shown between CRP and clinical severity of patients with knee or hip OA. Dietary intake of Omega-3 vs Omega-6 fatty acids is critical to inflammatory processes. Neptune Krill Oil is extracted from zooplankton in the Antarctic Ocean and has high EPA and DHA fatty acids and potent antioxidants, especially astaxanthin. Numerous studies have demonstrated the anti-inflammatory properties of these compounds. With increasing evidence of adverse events related to NSAID’s use, the otherwise gold standard for chronic inflammation care, safe alternatives need to be found. Methods: Prospective double blinded RCT with 90 patients from PCP offices in Ontario, Canada randomly assigned to Group A (300mg qd morning NKOTM) or Group B (neutral placebo). NKO contained 17% EPA, 10% DHA and Omega-3:6 ratio of 15 to 1. Fasted blood testing done at baseline (after 1 wk washout) and then at 7, 14, and 30 days. Patients kept a diary of any “rescue” acetaminophen use to maximum of 1-2 capsules q8hr. Forty four patients completed Group A and 43 patients Group B care. Mean age was 54.6 and 55.3 yrs respectively with 55.6% males in Group A and 48.9% in Group B. To avoid acute inflammation cases CRP measured weekly - those > 1mg/dl (no fluctuations > 0.5mg) blindly randomized for treatment and testing. WOMAC completed for those with arthritic disease along with Likert 5-point scale (0 best and 4 worst) for outcome. Findings: No differences between groups at baseline for concomitant medications, CRP levels or three WOMAC scores (pain, stiffness, functional impairment). Patients in Group A taking NKO reduce rescue med’s by 31.6% by 30 days vs Group B placebo only 5.6% reduction (p=0.012). After 7 days of treatment Group A reduced CRP by 19.3% vs 15.7% increase in Group B(p=0.049). CRP further reduced by 29.7% and 30.9% in Group A by 14 and 30 days respectively while Group B increased by 32.1% by 14 days and then reduced by 25.1% at 30days. NKOTM group WOMAC pain scores significantly reduced more than Group A at all three visits as did stiffness and functional impairment. Author's Conclusion: NKOTM at 300mg daily may inhibit inflammation with 7—14 days by reducing CRP and significantly alleviate symptoms caused by OA and RA. THE PEAK PERFORMANCE PERSPECTIVE Arthritis is one of the most common musculoskeletal diagnoses seen in physician’s offices. The routine care of these patients includes consideration of pharmacologics that can be used to quickly control symptoms to improve quality of life. The CDC reports in 2013-2015 22.7% of US adults had some form of arthritis (OA, RA, gout, lupus , fibromyalgia) with 44% reporting some related activity limitation. By 2025 it is projected that 67 million US adults will have an arthritis related diagnosis. In 2013 arthritis attributable wage losses were $164 billion in the US. (https://www.cdc.gov/arthritis/data_statistics/arthritis-related-stats.htm) Physicians are faced with the challenge oftentimes of patients with risk factors for GI adverse events ( > 65 yrs , h/o peptic ulcer, concomitant aspirin or anticoagulant use, alcohol or tobacco use, and others) as well as risks for cardiovascular, renal, or other reported side effects concerns. NSAID users have been shown to have 4-5x relative risk of peptic ulcer vs nonusers (Sostres et al, Arthritis Res Ther 2013)(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3890944/). A 2016 article in British Journal of General Practice cited NSAID’s were responsible for 30% of hospital admissions for adverse drug reactions. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4809680/) These facts along with increasing interest by patients for non-pharmacologic alternatives and/or supportive nutritional supplements that reduce inflammation, makes these findings by Deutsch very pertinent in musculoskeletal care. While as a standalone study it would be inappropriate to fully alter clinical practices regarding NSAID use these findings do add to the body of evidence that options do exist for those needing or wanting to avoid/minimize NSAID use for various reasons. In this study the Neptune Krill Oil (NKOTM) use allowed Group A participants to reduce “rescue” acetaminophen use by 30% from baseline vs only 6% in the placebo group over the 30 days. CRP levels were significantly reduced within 7 days and throughout the 30day testing period and also vs the placebo group mean CRP levels. WOMAC scores for pain were significantly reduced vs placebo Group B scores, as were the change scores for stiffness and functional limitation as well. These positive indicators all clearly support consideration of NKOTM for arthritic symptoms. Although no adverse events were reported in the short 30 day treatment/testing period further research into safety and dosing is certainly necessary. Also, these findings cannot be generalized to all krill oil supplements and require additional testing to determine what minimal and optimal levels of EHA and DPA, anti-oxidant, and/or omega-3 to omega-6 ratios are necessary for therapeutic benefits. As Physical Therapists we are able to give generic nutritional advice but cannot prescribe or recommend specific dietary or supplement intakes to patients. However, many patients also are disinterested or unwilling to formally see a registered dietician or clinical nutritionist for guidance. Nevertheless, patients do often inquire about any diet based or nutritional supplements they might take for anti-inflammatory purposes. The access to information on the internet obviously leaves the public with an endless resource of material ranging from completely unfounded conjecture all the way to excellent expert opinion to peer reviewed studies. For those lacking formal background and training to discern fact from fiction there remains a need for guidance. Physicians remain in an excellent position to share these supplement options with their patients. Conservative care remains the first and most necessary step in the treating of osteoarthritis. Physical Therapy is a most often effective means of both providing an intervention/treatment but also equipping the patient with proper self-help techniques and exercises to reduce symptoms and increase function. While traditional and simple regimens often have significant benefit we find for many patients that more substantial improvements or additional gains after “failed PT” occur when more in-depth biomechanical assessment and exercise/manual therapy approaches are employed. Due to the “regional interdependence” concept of the kinetic chain the appreciation for the impact limitations at adjacent and even distant body segments can have on a symptomatic arthritic joint cannot be overstated. The “failed PT” patients with OA that we see typically were given generic programs doing a rote series of common lower extremity stretches for large muscle group (hamstrings, quads, ITB etc) along with WB/NWB strengthening that is not customized to their ROM and/or symptom issues. There is commonly a lack of attention to less visible planes of motion (transverse plane) such as restoring hip IR for a hip or knee OA case developing progressive varus alignment, or with utilizing unique paths of movement to optimize loading through healthier portions of the articular surfaces (ie. promoting slight dyn valgus for medial knee OA to optimize lateral knee articular cartilage load dispersion). The case below illustrates a patient with knee OA who was able to avoid an anticipated TKA due to the extent of symptom relief and functional improvements he attained through Physical Therapy. THE PEAK PERFORMANCE EXPERIENCE Bud said: "My arthritic left knee was limiting my activities. Now I can mow my yard and walk my dog, and do the stairs better! I'm no longer thinking about a knee replacement." HX: 67 yr old male with 20+ yr h/o knee sx, underwent TKA 2013 R knee and presently c/o worsening L knee sx past 3-4 yrs. Plain films (+) for significant DJD. Pt indicated TKA being considered. Subjective: L knee 6/10 max sx w 75% self-report function. CC with walking dog on uneven surfaces/hills, walking 4-5mi, stairs, standing > 5min. WOMAC 40%. Key Findings: MEASURE ( *=pain) Evaluation Final ReEval @ 3mo AROM L knee ext (deg.) 50 20 AROM L knee flexion (deg.) 1230 1430 PROM hip IR L/R (deg.) 18/60 28 / 120 AROM STJ eversion (deg.) 4 / 80 NT Single leg balance L/R 5 / >15sec 15*/20 (75%) FWB knee ext (deg) 1680* /1830 1720 L knee(no sx) Squat L/R (deg) 400* / 580 65 / 580 WB DF (deg) 24 / 210 NT WB hip ext (deg) 80 flex / 00 10.1/9.6 (105%) Quad isometric 19.2 kg(83%) 30.6kg (94%) WB Ant Stepdown Quads 6” 15# NT >36x / 25x (>100%) Treatment: Pt began with BIW treatments focusing on manual therapy to improve L knee flexion and extension along with (B) hip IR and extension, as well as DF and eversion. Stretching/PROM HEP instructed to compliment mobilization work utilizing long duration 20-30sec sets. Neuromuscular re-integration movements were also used to optimize transfer into ADL use. Once simple single plane movements were successful then stretches were advanced toward multiplanar techniques to improve adaptability to patient’s frequent navigation of uneven surfaces in his large yard/property. Painfree strengthening especially for quads to enhance squat function were done using subtle path deviations to determine and optimize sx-free status throughout for stepdowns, stepups and “hangback” pole squats, attempting to increase loading preferentially to the lateral compartment to avoid medial joint overloading and symptoms. This was done using combinations of proximal and distal pre-positioning along with weight shifting to customize for patient response. Rotational balance work to promote use and control of femoral IR (unloading varus knee tendency) was done. Hip extension and combined ankle DF work of eccentric hip flexors and plantarflexors to normalize gait also included. Outcome: Pt reported sx overall reduced to max of L 3/10 and R 2/10 occurring ~ TIW frequency with walking his lawnmower through rough ground, carrying 40# for distances, sitting > 1 hr. He indicated stairs and getting off floor were much easier. WOMAC reduced to 18% and self-report function 90%. Peak Performance is just minutes away from your patients in Penfield, Fairport, Pittsford, Brighton, Rochester and, of course, East Rochester. We promise Individualized, hands-on and biomechanically appropriate Physical Therapy for your patients. No "one-size-fits-all" approaches. We WILL go the extra mile and "dig deeper" to discover underlying causes for injury risk and delayed recovery using the most advanced Evidence Based methods available and, we’re able to make unique adjustments to exercise prescriptions to speed the return to function and to minimize or prevent symptoms from interfering. No surprises. No hassles. Confident your patient is in the right place. COME VISIT US AT 161 E Commercial St Just 1 mile off 490 exit (585) 218-0240 www.PeakPTRochester.com

Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE October 2021 Subacromial Impingement RCT: Are We Being Fooled by the Literature…. Conservative Care Prescribing for SA Impingement Re-examined by Mike Napierala, PT, SCS, CSCS, FAFS Clinical Scenario...What would you do? A 50 yr old male c/o gradual onset R dominant side shoulder pain possibly related to a new fitness routine started 3 months ago with increasingly heavier loads and new exercises along with a weekend of trimming trees and other yardwork. He has (+) impingement test findings, tender at SS and LHB tendons, limited/painful elevation and Horiz Add AROM, and weakness/pain with resisted Abd, Jobe, and Abd’d rotations isometric screening. Plain radiographs show mild Type II acromion, no frank osteophytic or DJD changes. Patient has used NSAIDs, seen massage therapist several times, and tried 4 weeks of BIW Physical Therapy without significant improvement. My clinical thinking is: PT/ treatment failed: Do a dexamethasone subacromial injection and FU in 2-4 weeks to consider Physical Therapy again. PT /treatment failed: Order an MRI to better ascertain involved structures and ensure no labral pathology or cuff tearing that might explain lack of improvement, then determine best care. Keep things simple: Provide the patient your customized shoulder/RC HEP sheet and encourage specific adherence to that progression, place on prescription level NSAIDs and FU in 4-6 weeks. Prior care may be inadequate/limited: Briefly review what was done in PT. If excellent/thorough then consider A, B, or C, otherwise refer to more expert PT/group for more thorough assessment and individualized program involving manual therapy, customized exercise, and modalities if necessary then FU in 4-6 weeks. PT / treatment failed: Schedule MRI and prepare patient for likelihood of Arthroscopy to get a better look at the joint/tissues and address findings since prior care has failed. CURRENT EVIDENCE Clausen MK et al, Effectiveness of Adding a Large Dose of Shoulder Strengthening to Current Nonoperative Care for Subacromial Impingement. Am J Sports Med, 49:11, 2021, 3040 - 3049. https://journals.sagepub.com/doi/full/10.1177/03635465211016008 (We’d love to hear your professional insights on this topic. Let me know your thoughts after reading this summary at PT@PeakPTRochester.com or if you have a patient case you'd like to discuss) SUMMARY: Shoulder impingement is a highly prevalent shoulder condition that is seen frequently in office by both primary care and orthopedic specialist physicians. Discerning best practices for prescribing conservative care is key, especially as more recent studies have recommended against subacromial decompression surgery ( BMJ 2019), at least as an early treatment option. But clinicians must be wary of quick scanning the literature to avoid misguided thinking based on inappropriate conclusions offered by study authors. As is said…”The devil is in the details” holds true! Clausen et al examined the addition of (an intended) 12 hrs of rotator cuff strengthening exercises over 16 weeks to increase the time under tension stimulus in an Intervention Group(IG) along with “usual care” compared to the control group receiving only “usual care” that reportedly could include modalities, education, exercise, and manual therapy (but were not standardized). There were no between group differences in SPADI score improvements noted from baseline to 4 months. The Intention to Treat analysis also showed no differences for change in Abd or ER strength, Abd AROM scores nor for Patient Acceptable Scale Score(PASS) or global rating of change. Also, only 48% control and 54% intervention groups reached the PASS. The authors concluded that larger strength doses during Subacromial impingement care do not result in superior results. The initial reaction to their conclusion for some may be that four months of therapy was only effective at a mediocre level and some might even characterize as “chance” since only approximately 50% reached the PASS. Others risk deeming this RCT a bit of a “nail in the coffin” of more extensive or lengthy therapy exercise routines, particularly strengthening. One might even be led to ponder “Maybe simple HEP sheets are adequate vs doing formal PT.” It risks serving as evidence that conservative care is inadequate and possibly become reason to entertain surgical intervention earlier. The authors’ conclusion seems premature and inappropriate once you “look under the hood” of this study though. This study’s failure to show superior results with “more strengthening” exercises alone is not disappointing but rather somewhat predictable, especially considering the design allowed in the “usual care” portion. Their findings would, if true, nevertheless, support our position that each patient’s care must be customized to determine not only which exercises are appropriate and when, but also the loading parameters and progressions, as well as pain or inflammation reducing modality/procedure use (ie Class IV laser, iontophoresis, etc) and manual therapy needs for hastening recovery of kinetic chain function. The patient case study demonstrates a comprehensive functional biomechanics and manual therapy based program using customized exercise progressions to achieve recovery in a patient with impingement/RC pain syndrome that is commonly seen in the clinic. Background: With recent recommendations against subacromial decompression non-operative care options become primary treatment, but some studies suggest current care approaches may lack adequate strengthening effect. Purpose: To determine effectiveness of adding a large dose of “time under tension” inducing strength exercises to “usual care” conservative care alone. Methods: RCT design double blind study allocating 200 consecutive patients diagnosed with subacromial impingement syndrome (SIS) aged 18-65 yrs into a Control Group of “usual care” ranging from BIW to 1/mo Physical Therapy over 16 weeks or an Intervention Group (IG) that had four sessions for added training and follow up with a time under tension optimizing strength exercise HEP added that involved eventually three exercises and progressed from 3x20 QD for the first and eventually became QOD for 2x10 for all three during Phase III portion. Measures included SPADI and secondary strength, ROM, quality of life rating, and Patient Acceptable Symptom State (PASS) score. Findings: Both per-protocol and intention-to-treat analysis showed no between group significant differences for any of the outcome measures. SPADI improved for both groups. At 4 months only 54% of IG and 48% of CG patients reached PASS. Author's Conclusion: The addition of larger doses of strengthening exercises to usual nonoperative care for shoulder impingement treatment did not result in superior outcomes. Only half of patients having conservative care achieved PASS by four months, leaving many with unacceptable symptoms. THE PEAK PERFORMANCE PERSPECTIVE It is subtly clear in the background presentation by these authors that the 2019 BMJ recommendation against subacromial decompression surgery was less than appreciated. They state “Such drastic changes to care pathways may leave patients without further treatment options if nonoperative care fails.” Their conclusion added “...leaving many of these patients with unacceptable symptoms. This study showed that adding more exercise is not a viable solution to this problem.” As orthopedic specialists and primary care physicians seeing patients diagnosed with subacromial impingement syndrome making correct decisions about conservative care options is a daily requirement, if not at least weekly. The search for evidence to base those decisions upon could easily land one on articles such as this month’s by Clausen et al in AJSM, considered a highly regarded resource for clinical judgement and introspection. While the data has increasingly supported non-operative measures as a first line of defense for shoulder impingement we do not believe that surgery is unnecessary, unwarranted, or inappropriate depending on the case. Again, the challenge may more so be in how studies are done and data presented. We go back to the concept that each patient is an individual and the patient’s history plus findings along with the professional scientific data can both inform that decision process. Both are necessary. This study does demonstrate, however, that “The devil is in the details” still holds true with scientific studies. In school we’ve all been warned to not simply read the abstract and move on, assuming an author’s conclusions are sincere and thoughtful and reasonable. The risks in Clausen et al’s conclusions here are several fold. One might be led to conclude that conservative care (ie, physical therapy) is generally inadequate and ineffective and thus that surgery may be a necessity earlier in the process of treatment, especially when apparent “failure of care” seems evident. Also, some may believe this data demonstrates that more extensive exercise regimens are unnecessary and ineffective compared to “keeping things simple” with a basic series of HEP from a prepared sheet that could be given out in the office or expected to be the level of “simple care” offered at a PT clinic. Their premise for adding strength exercises is based on evidence of inadequate strength gains from “standard” physical therapy, however, a careful look reveals this came from a design where patients only did strengthening during in-clinic visits and did not have any Home Exercise Program (HEP) responsibilities. That is hardly evidence the “usual” physical therapy is, as a proven standard outcome, falling short in restoring strength. Nevertheless, their contention that therapists oftentimes do underdose strengthening exercises is likely a very valid criticism/concern. Still, before simply throwing more volume of strengthening exercises at patients we must remember that other factors contribute significantly to exercise tolerance and design. ● How inflamed and pain sensitive (and reactive) are the tissues involved? ● Are we seeing true “weakness” having developed or is this potentially pain-induced inhibition that does not necessarily require substantial strengthening dosages/stimuli? ● Are there comorbidities to consider that impact common exercises choices? ● How will pain/discomfort during or after exercises be handled? ○ Attempting generally symptom free strengthening? ○ Allowing limited symptoms during and/or after that must resolve within 2-24 hrs (depending on rationale/philosophy)? ○ Encouraging intensity adequate to produce mild (or greater) symptoms lasting only 2-24 hrs? They also make the mistake of overgeneralizing the concept of “larger doses of strengthening” in the title and article. It more accurately should read “time under tension (including isometric phase) optimized HEP RC strengthening” instead. Clausen et al ignore external validity rules when stating that more “strengthening” exercises are no more effective than usual care. Actually, what is no more effective is utilizing a limited amount of isometric based time-under-tension emphasized home exercise reliance with limited 1/mo average provider training and feedback. A major factor also is the lack of clarity on what sort of strengthening the “usual care” group had already performed. Clausen et al utilized a thoughtful progression regarding QD exercise moving toward QOD, however, it was odd that they added one exercise per month with an eventual program of 2x15- - - > 2x10 QOD for each of the three added strengthening drills, two of which were for ER’s. It was a bit unusual that during the QD phase patients performed 3x20 as their “to failure” target. Normally in strength and conditioning if an athlete were performing a progressive resistive exercise for three sets to fatigue they’d very likely be taking 48 hr recovery between sessions. They utilize very specific slow contractions + isometric “time under tension” model program of only three additional Abd and ER exercises. This hardly qualifies as what many might deem “larger doses” of exercise and, in fact, the eventual compliance finding was that instead of 12 hrs of additional total exercise achieved that the IG only did 2.9 hrs of added exercise (per time under tension) over the course of the study. Despite being a “gold standard” RCT design, the findings here should be taken with caution in leading a clinician to forsake significant strengthening stimuli for impingement cases. It does also call to question the common concept of “protocol” type approaches to care. While the study individualized the loading used based on performance and symptom resolution within 24 hours, it nevertheless used very specific, limited exercises and did not allow for customizing angles, planes, exercise choices and sequencing/progressions or altering exercise parameters. It is not clear that cervicothoracic or scapular issues were adequately addressed as key contributing factors to the condition’s onset or recovery capacity. Decades of experience have shown us that individualized functional biomechanics screening and exercise progressions are very often necessary, instead of more simplistic protocol driven simple progressions. Customizing exercise selection, order, sequencing, and making unique adjustments (such as path of motion plane tweaks to avoid symptoms, hand placement to effect more RC stimulus, the use of or cueing away from allowing kinetic chain synergy among others. Manual therapy to address pec minor restrictions that are facilitating functional impingement along with ensuring thoracic extension and ipsilateral rotation especially ( due to more common same-side reaching with ADL) is crucial. With more advanced demands during goal activity then Type I and II thoracic motion can be considered. Finally, modalities such as the Class IV laser can be very helpful in reducing pain and inflammation to allow earlier intensive exercise. The case below illustrates a comprehensive approach that worked successfully, rather than a mere “extra-volume” of simple RC strengthening drills. A kinetic chain approach helps ensure that the key or at least some of the likely underlying contributing factors for having developed an overuse problem are addressed. THE PEAK PERFORMANCE EXPERIENCE Michael said: “I feel better than I have in years! Now I can lift weights again and golf without pain!" HX: 57 yr old male reports h/o five years with (B) shoulder pain that developed gradually with increasing fitness exercise and weight lifting as well as ADL use. His CC are frequent L and infrequent but more intense dominant side R shoulder pain with fitness/exercise, ADL lifting and reaching, sleep, and recreation (golf, shooting basketball with son). Subjective: Pt reports 80% function and pain L 2/10 and R 4/10. Quick Dash 11% and Sport module 19%. Objective: (Pt had inconsistent attendance due to job demands. Seen 14x over 4 months) (*=pain) Initial Eval DC Re-Eval Flexion AROM 1500/1500 1630/1520 IR AROM T9 * / T11 T6 / T9-10 Abd IR AROM 250/250 550/470 Pec Minor Tightness Mod/Mod Min+/Mod Isometric Flexion 6.6 kg* / 12.8kg 12.8kg / 14.5kg Abd 8.8kg * / 13.7kg 13.4kg / 13.4kg Overhead Press 1st sx L 3# / R> 45# 25# elliptical 16x/19x Abd ER NT 15# 27x / 30x Push ups ½ depth painful 10” box > 10x no sx Key Findings: Thoracic extension and rotation limited, pec minor very tight (B), posterior RC/capsule limited with Hor Add and Abd IR ROM. Elevation strength and Abd Rot’s all weak and painful. Impingement tests (+) in (B) shoulders. Treatment: Manual therapy targeting thoracic spine and pec minor along with GH joint capsule mobilizations for restoring especially inferior capsule length to allow elevation end ranges along with Horiz Add and Abd IR. Self stretching/mobilization/ROM program for same structures-tissues done. Painfree strengthening progression initiated for promoting better scapular retraction and also improving upward rotation ease (based on pec minor induced chronic protraction with reaching/lifting especially) and also 300 abd’d rotations. Strengthening progressed on to sx-free plane elevation with reduced depth starting motion on incline press to reduce gravity demand at 90 and end ranges of lift. Long lever strengthening began lying with tubing to again reduce demands at key impingement ROM zones will still proprioceptively stimulating independent function into full available elevation without pain. Early on parameters were BID 10- - ->30x and then later once a base established PRE were gradually progressed to 2x15 QD and then finally 3x 10-12 TIW for more intensive loading. Outcome: Pt had difficulty attending regularly due to demands of job. He was only infrequently seen BIW and more often 1/wk and still then bouts of 2-3 weeks without visits. Nevertheless he reached self reported > 90% function on each shoulder and had resumed canoeing, kayaking, shooting baskets with his son, playing golf and sleeping comfortably. You can trust the Physical Therapists at PEAK PERFORMANCE to do a thorough evaluation, to search for related but underlying contributing factors to kinetic chain dysfunction, and to design exercise progressions that both respect tissue healing and creatively use biomechanics principles to prevent symptoms and optimize carryover to your patients' functional goals. Call us at 218-0240 to discuss your patient's specific needs. Peak Performance is just minutes away from your patients in Penfield, Fairport, Pittsford, Brighton, Rochester and, of course, East Rochester. We promise Individualized, hands-on and biomechanically appropriate Physical Therapy for your patients. No "one-size-fits-all" approaches. We WILL go the extra mile and "dig deeper" to discover underlying causes for injury risk and delayed recovery using the most advanced Evidence Based methods available and, we’re able to make unique adjustments to exercise prescriptions to speed the return to function and to minimize or prevent symptoms from interfering. No surprises. No hassles. Confident your patient is in the right place. COME VISIT US AT 161 E Commercial St Just 1 mile off 490 exit (585) 218-0240 www.PeakPTRochester.com

Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE September 2021 Patellar Tendinopathy: Eccentrics May Not Be The Way to Go! by Karen Napierala MS, AT, PT, CAFS CURRENT EVIDENCE “Effectiveness of progressive tendon-loading exercise therapy in patients with patellar tendinopathy: a randomized clinical trial. Breda SJ, et al. Br J Sports Med 2021; 55:501–509. “ (We’d love to hear your professional insights on this topic. Let me know your thoughts after reading this summary at PT@PeakPTRochester.com or if you have a patient case you'd like to discuss) SUMMARY: Eccentric exercise has been the key form of exercise prescribed by physicians/surgeons and used by therapists and trainers during rehab for tendinopathy conditions. Breda et al in BJSM present important data that contradicts this reliance and focus on eccentrics. Instead their study demonstrated that a HEP based program of progressive loading/strengthening outperformed an eccentric based program in a RCT of patellar tendinopathy patients, 82% of which had failed prior care, in self report pain/function/sport questionnaire after 24 weeks and also showed a trend toward higher return to sport (43% vs 27%) . Despite concerns about generally low compliance with this HEP based treatment of independent exercise progression (40-49% compliance) and low overall return to sport rates after 6 months the study does still demonstrate that eccentric focused rehab approaches are not superior to progressive loading based approaches. The low compliance also suggests more formal care from a therapist is warranted since reliance on patients following a HEP progression without regular follow ups produced mediocre outcomes, however, this group was a mostly “failed care” group to begin with. Our experiences and successes with tendinopathy also suggest that kinetic chain biomechanics must be well understood and evaluated/addressed, that in-depth appreciation of subtle exercise adjustments for proper loading combined with control of symptoms, and the use of other treatment modalities such as Class IV laser all play an important role in effectively treating patellar tendinopathy. Meticulous appreciation for and attention to optimal ranges for training the extensor mechanism, for optimizing Quad recruitment while avoiding sx typical of traditional rehab exercises, and limiting recruitment of compensatory muscle groups during attempted strengthening are all key factors we see in failed PT/conservative care cases referred for advanced rehab. Background: Studies note that 45% of elite jumping athletes and up to 58% of those with physically demanding work/sports activities at some time experience patellar tendinopathy. The term tendinopathy has replaced the commonly referred “tendinitis” based on numerous studies showing histopathologic tissue changes and only minimal inflammatory cells in these cases. Anti inflammatories alone are thought to be not recommended. Research has demonstrated the effectiveness of eccentric overload to enhance tendon strength and recovery, however, is pain-provoking and especially a concern for in-season athletes. This study compared progressive tendon loading exercises (PTLE) with the eccentric exercise therapy (EET) over 24 wks on clinical outcome measures. Methods: Seventy-six patients (18-35 years old) who participated in sports at least 3/wk with diagnosed patellar tendinopathy based on local tenderness, structural changes on Doppler, and <80 score on the Victorian Institute of Sports Assessment for Patellar Tendons (VISA-P) were randomly assigned into the EET or the PTLE group for 24 weeks of an independent exercise program. Median symptom length prior to the study was 2 years. 82% had failed prior PT. The EET group was instructed to perform pain provoking single leg decline squat (eccentric only) on a 24 0slant board with body weight at 2/day x 12 weeks with a maximum pain level of 5/10 (VAS, visual analog scale). They progressed to loaded single leg squat and then to sports specific exercises over the next 12 weeks as able. The PTLE group started with isometric leg press at 60 0 or a body weight wall squat with 70% max voluntary contraction 45 seconds x 5 reps. They moved to isometrics plus isotonic leg press 4 x 6 reps the following day. Their maximum pain allowed was 3/10 on the VAS scale. Step ups or lunges were added on the isotonic day when able. They progressed to day three jumping, split squat jumps, box jumps with the isometric and isotonic exercise on day one and two, respectively. Finally, sports specific activities such as running, cutting, and their actual sports were slowly resumed. They maintained a < 3/10 pain level using the VAS and progressed as tolerated through this sequence over 24 weeks. Both groups were also assessed for open chain hamstring, gastrocnemius and quadriceps flexibility. They noted their WB squat dorsiflexion soleus length and had isometric hip abductors and quad strength measured. The program and the targeted flexibility / strength exercises were given to each of the participants via a pamphlet. Videos were included and the participants met at baseline, 12 weeks and 24 weeks for retesting. All exercise groups performed their programs independently of each other and of tester feedback. Findings: The primary outcome was the VISA-P questionnaire (100 point maximum as no pain, maximal function and unrestricted return to play). It was self -administered at baseline, 12 and 24 weeks. Secondary outcomes were the return to sports rate, exercise adherence (% of sessions registered) , and patient satisfaction. VISA-P score improved significantly from 56 to 84 at 24 wks in PTLE. And from 57 to 75 in the EET group. After 24 weeks 87% in the PTLE group (32 patients) and 77% in the EET group (23 patients) achieved the 13 point MCID or better. In the PTLE group 21% returned to the desired sports at preinjury level after 12 weeks and 43% after 24 weeks. In the EET group, only 7% after 12 weeks and 27% after 24 weeks returned to pre-injury levels. Percent of patients with an excellent satisfaction rating was 38% in PTLE and10% in EET. After 24 weeks and 23 patients in the EET group achieved the MCID (Visa score increased 13 points minimally. In the PTLE group, 21% (n=7) returned to the desired sports at preinjury level after 12 weeks and 43% (n=16) after 24 weeks. In the EET group, 7% (n=2) returned to the desired sports at preinjury level after 12 weeks and 27% (n=8) after 24 weeks. The VAS for pain related to tendon-specific exercises at 24 weeks was significantly lower in the PTLE group than in the EET group with an estimated mean of 2 vs 4 (adjusted mean between- group difference: 2 (95% CI 1 to 3); p=0.0 Author's Conclusion: In the largest clinical trial in patients with patellar tendinopathy (PT) to date, progressive tendon-loading exercises (PTLE) resulted in a clinically relevant benefit compared with pain-provoking eccentric exercise therapy (EET) after 24 weeks follow-up. THE PEAK PERFORMANCE PERSPECTIVE The use of eccentric based strengthening exercises for tendinopathy has for some time now been accepted “best practices” in prescribing conservative care for these cases. Numerous prior studies had shown the efficacy of eccentrics,which usually includes an intentional pain-provoking aspect, especially with achilles tendinopathy. The challenge does remain, however, that most athletes who develop tendinopathy symptoms do so gradually and with a period of ‘working through symptoms” that eventually did not result in resolution but likely, in part, contributed to their “overuse” stresses. It can be difficult for providers and patients alike to have certainty over those levels of intentionally produced symptoms that are actually therapeutic. This study reminds us how common failed tendinopathy cases can be. Failed cases present a unique task for referring physicians who are charged with determining possibly why prior PT failed or what more thorough or advanced conservative care may be called for since surgical procedures here are the very last resort and rarely necessary. The participant’s limited/poor compliance and the low return to play rates do suggest that “keeping it simple” with easy-to-do home program recommendations is inadequate. ... The question must always be asked “What exactly was the actual cause of their tendinopathy?” While referring physicians generally are and should be less concerned with this question it is incumbent on therapists and athletic trainers to be not only concerned about this but equipped to test and assess in ways that give athletes confidence the right changes have been induced that will prevent recurrence upon return. Athletes often are confused that the entire team is jumping or cutting, yet only they or a few ever developed tendon symptoms. Very frequently both lower extremities are experiencing essentially the same bilateral or reciprocating stresses with a sport, making identification of the “overuse” more challenging and oftentimes uncertain or illogical, since the opposite knee tolerated the very same “overuse” without trouble. In other cases there are clear asymmetric loading patterns that occur such as in soccer kicking (plant leg and kick leg each) or basketball (layups) or high/long jumping. In all cases it is critical to discern any biomechanical factors such as leg length discrepancy that produce asymmetric loading. Other issues such as asymmetric anteversion, overpronation, loss of ankle dorsiflexion, hip extensor weakness all are examples of commonly seen contributing factors consistent with potential overloading of the patellar tendon/extensor mechanism. Oftentimes “protocol” driven mindsets or “one-size fits all” approaches may address gradual tissue loading and training but never end up in having addressed what may be the real underlying mechanism - leaving patients “treated” but never really rehabilitated. This study by Breda et al had 82% of the cases happened to be failed prior PT situations. This itself is cause for concern regarding traditional PT approaches. . The direct correlation according to this author is not known. Whether internal biomechanics, or external overload, the tendon needs to be restored to its full strength to handle the loads of the activity. Breda et al’s randomised controlled clinical trial showed the PTLE approach provided superior clinical outcomes compared with EET after 24 weeks follow-up. Additionally PTLE showed a trend towards a higher return to sports rate compared with EET (43% vs 27%) and that the exercises were significantly less painful to perform (VAS 2/10 vs 4/10). While this study itself is not enough to completely disregard all the prior evidence supporting eccentrics it does present some compelling evidence that even with an unsupervised independent home routine approach that progressive loading approaches do not require “eccentric only/emphasized” design to reduce symptoms and improve function. Since only 27 - 43% of the patients in either group returned to sport over the 6 month period, the overall perspective should not be that the treatment approach used was a success. Based on our experience with similar cases we would suggest that the treatment approach itself was inadequate, the limited compliance contributed to mediocre outcomes, and/or the protocol did not address predisposing factors adequately - although they did attempt to address this with the additional testing and exercises provided. We find regularly that alternative rehab methods that include triplanar strengthening, using emphasized eccentrics at a lower pain scale, and progressive loading similar to Breda et al’s approach and also Class IV laser use are important aspects of effective tendinopathy care. The lack of regular professional supervision in this study left patients in a decision making position regarding technique, general program advancement, and load progression that is normally done by or in conjunction with the rehab professional. Training was designed to be 3/week for PTLE and 2 / week for EET, but the groups left to their own showed a low rate of compliance with 7-8 of the people not completing the testing, and all participants averaging .9 mean sessions of training over the 24 weeks. All exercises were performed without the benefit of skilled and knowledgeable feedback. The exercise program especially for the PTLE group was quite specific and extensive. Clinically, to foster progressions of this nature to be not only within the pain scale limitations and also to be mechanically correct with no substitutions, professional guidance is necessary. A HEP only approach risks a patient choosing to progress too quickly out of impatience and yet for others too slowly out of fear. A limited number of secondary contributing factors were assessed, but more extensive biomechanical examination was lacking. Thus while several stretches and non-functional strengthening exercises were included, they were not given based on individual test findings for need, and were very limited in scope. Another shortcoming was the singular resistance band for exercise loading. It would not likely provide either customized loading for each participant nor proper loading over a span of 24 weeks to be considered proper training stimulus. The participants were pre and post tested on their flexibility and vertical jump height. From baseline to 24 weeks there was literally no change in strength or jumping ability. There was some significant pain with single leg squat test where PTLE went from pain of 4.8/10 to 1.5 after 24 weeks, and EET group reduced from 4.9/10 pain to 2.7. THE PEAK PERFORMANCE EXPERIENCE: John said: “ I am back to skating in practice with no pain the next day. I'm looking forward to really playing hard in games soon!” History: John was a hockey player who had R > L patellar tendinopathy. He had pain for > 6 months that limited play until he finally had to discontinue athletics. Symptoms limited walking, sitting, and stairs. Objective: See below. Objective: (*=pain) Initial Eval Re-Eval STJn WB Dorsiflexion 13 R/ 15 L 17 R / 20 L Single leg squat R 10 * / L 22 * R 55 / L 70 Step ups 8" Unable * 15 # low reach R/25 L 32 3" quad dom step down( eccentric ) Unable * 10 # front racked R/ 22 L / 35 B squat proper form Pronates, heel rise R, lumbar flexion** 25# front racked 16 reps Lateral lunge Unable * 15# low reach R 17 L 21 Single leg bal rotation hands on hips 15 sec Unable R 5 L 7 Forefoot varus R 10deg L 7deg Corrected with superfeet and wedge posting 4-6 deg forefoot 2-3 degrees rearfoot Key Findings: Limited ankle dorsiflexion combined with forefoot varus producing compensatory overpronation and tibial IR producing abnormal loading at knee/patellar tendons with squatting activity. Treatment: John began stretching soleus in STJ neutral for late stance gait mechanics authenticity along w functional strengthening combination using opposite foot anterior foot reaches. Gradually he was able to begin squats at 50 % BW and progress to single leg quad dominant step downs. He also obtained SuperFeet OTC orthotics which were posted in the clinic accordingly to produce improved function on WB testing. Eccentric slow lowering was incorporated here with 2-3/10 max pain during this phase. By dominating the hip and transverse plane to accomplish strengthening he was able to overload his muscles, and also load his patellar tendon in two planes for added strength while avoiding tendon pain. While the tendon is primarily a sagittal plane worker, by loading in transverse and frontal planes, the strengthening could be progressed faster - with increasing tensile loading capacity while remaining still pain-free. At the same time, the hip ER’s were facilitated using tubing in the transverse plane upright. Hip flexion was increased during the ER for more authentic skating stimulus. He then began speed training to stimulate fast twitch fibers and start impact loading needed for running in gym class and life. After 6 weeks: He was able to begin skating 15 minutes at a time painfree. Outcome: He continues to improve his strength and stability. He uses the posted OTC Superfeet in his shoes and skates. He is now practicing 30-45 minutes at near maximum and is ready to progress to game status. You can trust the Physical Therapists at PEAK PERFORMANCE to do a thorough evaluation, to search for related but underlying contributing factors to kinetic chain dysfunction, and to design exercise progressions that both respect tissue healing and creatively use biomechanics principles to prevent symptoms and optimize carryover to your patients' functional goals. Call us at 218-0240 to discuss your patient's specific needs. Peak Performance is just minutes away from your patients in Penfield, Fairport, Pittsford, Brighton, Rochester and, of course, East Rochester. We promise Individualized, hands-on and biomechanically appropriate Physical Therapy for your patients. No "one-size-fits-all" approaches. We WILL go the extra mile and "dig deeper" to discover underlying causes for injury risk and delayed recovery using the most advanced Evidence Based methods available and, we’re able to make unique adjustments to exercise prescriptions to speed the return to function and to minimize or prevent symptoms from interfering. No surprises. No hassles. Confident your patient is in the right place. COME VISIT US AT 161 E Commercial St Just 1 mile off 490 exit (585) 218-0240 www.PeakPTRochester.com

Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE September 2020 Rachele Jones PTA, ATC, CAFS You decide…. Patient Scenario: A high school soccer athlete comes to you for what they think is a strain in their hamstring. While playing they felt a small “twang” or “pop” in their mid-belly at the posterior thigh and are having pain with completing knee extension, especially in sitting, with bending over, taking long strides, and cannot jog. Your clinical exam is consistent with a biceps femoris muscle strain. You’re ordering Physical Therapy. Clinical Decision Making… How do I decide where to send the patient? Will their rehab be essentially the same wherever they go? Are generic HS exercises adequate or will they customize exercise stresses for my patient to target specific injured tissue for functional demands? Will proximal kinetic chain factors be tested and addressed to handle underlying risk factors? Summary: Physicians regularly are charged with making decisions on best practices regarding hamstring strains for overall care, specifying prescription orders vs releasing full trust to the PT to “figure things out and do what’s best”, and how referrals to PT are decided. The authors present data that shows in a group of male soccer athletes over 1.5 seasons there was a 20% reduction in HS strains for those sprinting with 10% greater gluteal activity during early front swing phase and 6% reduction for those with greater trunk/core activity during backswing phase of sprinting during pre-season testing. The general concept is that proximal activation of those muscles/groups appears to be at least somewhat protective against HS strains and therefore must be considered as a potentially important component of rehabilitation. It is surprising they found no significant differences for late swing and early contact phase, where the HS forces would intuitively be higher and at greater risk of strain. It must be remembered that EMG demonstrates neurologic activation but is not proportional necessarily to actual force production. The study does fail to indicate how exactly these findings can be put into practical application during Physical Therapy. This would require specific research to determine any best practices on specific exercises that promote EMG evidenced activation along with experimental cause-effect determination if injuries are, in fact, prevented using specific training practices and if reinjury is avoided using similar concepts during rehab. Current Evidence: Joke Schuermans, et al. Proximal Neuromuscular Control protects against hamstring injuries in male soccer players. The American Journal of Sports Medicine 2017; 45 (6) 1315- 1325. Background: Hamstring injuries remain the highest incidence and the most detrimental functional repercussion in male soccer athletes. Proximal neuromuscular control (“core stability”) is considered to be a key importance to primary and secondary hamstring prevention although scientific evidence is currently nonexistent. Method: Sixty amatuer soccer players participated in pre-season testing using multi-muscle surface electromyography (sEMG), assessing medial/lateral hamstrings, gluteals, and trunk erector spinae and int/ext obliques(later analyzed as a group) during maximal acceleration to full speed sprinting. Time frame of 1.5 seasons was evaluated and athletes would self-report. Follow up of the hamstrings, gluteals, and trunk muscle activity during airborne and stance phases of acceleration were evaluated and statistically explored for possible causal association with self-reported injury occurrence and absence from sport during follow up. Results: Players that did not experience a self-reported injury to the hamstring, showed an increase in gluteal muscle activity during (early) front swing phase and higher trunk muscle activity during backswing of sprinting. The risk of hamstring injury lowered by 20% from A 10% increase in gluteal activity during front swing and decreased by 6% with a 10% increase in trunk muscle activation during backswing. AUTHOR’S Conclusion: Higher amounts of gluteal and trunk activity were shown during airborne phases during sprinting which was associated with lowering the risk of hamstring injuries. This provides a basis for improvement on rehabilitation and prevention focusing on the increasing neuromuscular control of the glut and trunk muscles during sport specific activities ( sprinting drill, and agility drills). Peak Perspective: Looking at the anatomy and physiology of the hip, the hamstrings ( bicep femoris, semimembranosus, semitendinosus), gluteus maximus, and the adductor magnus are all muscles that produce hip extension or decelerate hip flexion. Hip extension force occurs with deceleration of late swing knee extension and hip flexion, early stance phase as a hip extensor to produce forward propelling momentum, and in early backswing as hip extension and knee flexion occur. While not actually defined by Schuermans et al, back swing is the moment from toe off until the leg reaches maximum extension behind the body. Front swing is the moment when the leg begins to swing forward and ends just before heel strike. One would expect the greatest demand on hamstrings to be late swing and early stance phase. This study showed that those who eventually reported hamstring strains showed sprint function tendencies for lesser gluteal and trunk activation during NWB swing phases (back swing and early front swing). This may warrant modifying current rehab practices if these findings were to be confirmed with further research. Until then it is likely premature. Examining pre-injury functional patterns for potential risk factors is valuable. The limited size of this study and number of injuries reported along with the fact injuries were self-reported, and especially that the mechanism was not specified as sprinting related necessarily all contribute to uncertainty whether this really does rise to the level of evidence driving a change in physician treatment expectations of physical therapists and athletic trainers for hamstring injury care. For example, what if the strain was related to a misstep or slide tackle contact or unexpected perturbation during a “50-50 ball”? It would become a bigger leap of faith that sprinting sEMG findings were reflective of greater risk during that injury mechanism. One issue is no reporting as to when the athlete's injury occurred, what was the mechanism of injury, (whether during running or contact with another player), the severity of the injury, and what made them more susceptible to injury. With this information being withheld was can not correlate what areas to concentrate on whether more linear patterns or the unexpected which would be best for prevention or quicker return to play status. As a measure of nerve activation, sEMG, in this study, resulted in findings opposite of what we would have expected, showing that the hamstring was most responsive in the backswing and early swing phases. Even if that were accepted to be true - studies have not been done to demonstrate which exercises are best employed to activate the gluteals and proximal trunk/core during swing phase, preferentially to other muscles, for prevention and return to play training. Then a “causal” relationship would need to be shown between whatever specific activation drills might be done, the effective improvement of gluteal and core activation in sprinting, and a reduction in hamstring strains. The authors seem a bit quick here to accept correlational level findings as likely causal in their conclusion and recommendations. Regardless, the findings suggest physicians and therapists might consider more open chain exercises for stimulating gluteal and trunk/core activation for swing phase (rather than a main focus on WB hamstring work), in order to improve the timing activation of these muscles/groups in running like positions/movements for swing phase. This is an area we need to give further consideration to and develop exercise strategies for. Since these findings, however, remain too early to be prescriptive for “best practices” of hamstring strain recovery, the biomechanically relevant considerations of understanding when the hamstring is under maximal tension (nearing and at heel strike) and when the greatest contractile demands and lever arm loads are occurring can and should remain a key principle to rehab and to treatment expectations from physicians. At Peak Performance we find that using a “hamstring strain” protocol or exercise series consistent across all patients is not effective. Strains may be more medial or lateral. They may involve more proximal fibers vs more mid-belly or even distal muscle-tendon junction. Customizing each exercise to the deficits and symptoms of the patient and to the demands of what activity/sports they want to resume are critical. All three planes of motion must be tested and considered to thoroughly retrain an injured hamstring. Transitioning into specific speed-power exercises is necessary for rapid acceleration and deceleration muscle performance and helps prepare for sport specific drills and eventual return to sports. Since this study found sprinting based swing phase muscle activation to account for some risk factor, open chain loading and neuromuscular type exercises would also be appropriate. The VibePlate, a vibration platform designed to stimulate the neural system, is one tool we use oftentimes during hamstring strain recovery. A popular exercise is the Nordic Hamstring curl. While a very demanding exercise and having some limited evidence basis, aside from being very challenging and therefore stimulating, it functionally trains the hamstring’s ability to decelerate a thigh extending over a fixed lower leg. That is not typically consistent with athletic function nor definitively with injury mechanisms. Functional loading with multidirectional lunges incorporating an anterior reach with weights trains the hip extensors’ ability to effectively decelerate as would occur in planting and changing direction or using implements reaching for a ball (lacrosse, tennis, field hockey, hockey..etc). Tubing resisted terminal swing phase directly trains the hamstrings as an eccentric decelerator of knee extension + hip flexion in prep for heel strike. RDL’s and tubing based horizontal pulling based stepping drills train early stance phase hip extensor ability. All of these are also customized to include multiple planes in consideration of multilateral sport movement demands or also based specifically on injury mechanism. The case below demonstrates a patient where many of these principles were utiilzed, despite not specifically incorporating the backswing and early swing phase gluteal/core activation referenced in Schuermans' study, and this patient did extremely well - the objective tests show gluteal, hamstring and core have all improved to >100% of the uninjured side. Peak Experience: “ I feel a lot better. There’s more flexibility in my leg and I didn’t notice it at all with soccer tryouts!” “ I was able to do half field sprints, all drills and have been able to do short runs now.” HX: 15 yo female soccer player injured 5 months prior, reporting pain in the ischial tuberosity and right hamstring due to increased running mileage of 3 miles a day/ 5 days a week. Subjective: Pt reports intermittent 3/10 pain in R hamstring and ischial tuberosity after increasing mileage in preparation for the upcoming soccer season. Symptoms are increased by seated hamstring stretch , cartwheels, walking up a hill, squatting, ascending stairs, and any duration of running. Patient self reports being at 70% overall function and Lower Extremity Functional Scale 88% function Objective: Patient showed decreased overall hip mobility, ankle mobility, calf tightness, and decreased hamstring strength on contralateral limb. Hamstring range of motion significantly decreased on R. See below re Eval and Re-Eval findings. *pain Initial Evaluation (L/R ) ReEvaluation 8+ wks (L/R) Self Rating 70% overall function 90% Overall function LEFS Scale 88% 90% Pain scale max 3/10 max 3/10 - only deep squat Supine 90/90 HS length 12deg/23deg 8deg/7deg DF ROM knee extend’d 0deg/10deg 11deg/13deg Prone Single Leg FA plank NT L WB 4 sec / R WB 7 sec SL Squat - - - -> hop Squat: R* > L dyn valgus SL hop: Dyn valgus = HS isometric 9.0 kg/11.0 kg 10.7 kg/11.0 kg 6” Step up test 10# DB’s NT 30x/30x Treatment: Exercise - Mobility, strengthening, power, function… Kinetic chain stretching of hip, hamstring (HS), STJ, and calf including mulitplanar. PRE’s including NWB, WB, Impact/speed based drills, and agility - utilizing multiple angles and a proximal- - >distal and distal- - >proximal directed movement loading approaches. (Included: SL bridges, 6” step ups (gluts focus), tube resisted stepback to pull thru hip extensions in 3 paths, SLB with UE reaching for medial and lateral HS stimulus) Core work including: Incline single arm side plank with Ant-Post LE stepping, prone incline plank w LE knee hip cross to opposite hip, SLB on the Vibe Plate w weighted UE running arms for additional strength, and running progressions. Agility progressed to SL hopping in multiple directions, and incline demand during treadmill. Peak Performance is just minutes away from your patients in Penfield, Fairport, Pittsford, Brighton, Rochester and, of course, East Rochester. We promise Individualized, hands-on and biomechanically appropriate Physical Therapy for your patients. No "one-size-fits-all" approaches. We WILL go the extra mile and "dig deeper" to discover underlying causes for injury risk and delayed recovery using the most advanced Evidence Based methods available and, we’re able to make unique adjustments to exercise prescriptions to speed the return to function and to minimize or prevent symptoms from interfering. No surprises. No hassles. Confident your patient is in the right place. COME VISIT US AT 161 E Commercial St Just 1 mile off 490 exit (585) 218-0240 www.PeakPTRochester.com

Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE August 2020 The Impact of LBP Recurrences A Call to Reconsider Clinical Decision Making? T Da Silva, K Mills, et al. What Is The Personal Impact Of Recurrence Of Low Back Pain? Sub analysis Of An Inception Cohort Study. JOSPT, June 2020: 50 (6): 294-300. by Allison Pulvino, PT, MSPT, CMP, FAFS The full text review is available via the Read More link below. We've begun using this summary of our article overview as a quick read version In an effort to honor your time demands. SUMMARY: There was a significant number of participants (68%) that had recurrences of their LBP after 1-2 wk. reduction to <1/10 for 1-2 weeks following formal care. Over 70% of those with exacerbation's had at least moderate level impact or needed formal care again, despite the authors concluding there was generally low impact overall from “non-specific” (this was poorly defined re diagnostic criteria etc.) LBP recurrences. While the authors don’t adequately specify what the treatments were exactly, the recurrence rate and impact on symptoms and function suggest several possible reasons that would affect how “non-specific” LBP presently is treated. The extent and impact of recurrences may indicate that the treatments prescribed and done in this case were potentially incomplete and/or ineffective since 68% experienced episodes again. We propose discharge criteria for LBP should include having done biomechanical scan and treatment of key contributing areas via corrective exercises at least, in order to minimize risk of recurrence vs symptom reduction modalities and exercises only. Also, counselling patients on gradual transition back to prior and goal based activities is key along with compliance with continuing their HEP until fully returned to all prior ADL, work, recreational, fitness, social, and athletic function. Background: Currently, it is known that recurrence of LBP is common but it is unclear what the ongoing pain issues may be or the limitations on physical function are for individuals who experience recurrences of low back pain. This study aimed to examine the impact of LBP over 1 year after recovery of a recent LBP episode, differences in impact between those with and without recurrences, and compare the impact considering three different definitions of a “recurrence”. Method: This is a preplanned sub analysis using data from a cohort study. There were 250 participants in this study that were 18 yrs. or older, and had recently completed care from a physical therapist or chiropractor in the last month from an episode of nonspecific low back pain. A patient-reported impact score outcome measure (pain intensity, pain interference with activity, and functional status) was used to assess the prior 3 months at 3, 6, 9, and 12 months. A recurrence was defined as an episode of LBP > 24 hrs. and >2/10 intensity, a recurrence of activity-limiting low back pain, or third – a recurrence of low back pain resulting in subject/patient seeking health care. Results: Of the 250 participants in this study 68% reported a recurrence of low back pain in the 12 month period, of which 14.0% reported a LBP recurrence of symptoms, 14.4% an episode of moderate activity limitation, and 39.6% needing to seek health care. The authors then conclude that these findings are not significant and patients should be reassured that many occurrences will have little impact on them in the future. This statement is not supported by the findings. Peak Performance Perspective: Assessing and treating low back pain is commonplace for many medical providers. There are various etiologies of low back pain, and most of us can agree it is not a “one size fits all” in the way of treatment. This study addresses the important topic of the “impact” LBP has on patients after recovery and from subsequent recurrences. It speaks to the efficacy of prior care and treatment decision making, patient compliance, and how we counsel patients about their LBP and expectations both surrounding recovery but also when a recurrence does occur. And when recurrences of pain happen, we first have to wonder why. While this study’s abstract states that the average impact due to recurrence of low back pain was low, this is not really what the results are showing. First, the authors used “median” rather than “means” in their analysis but neglected to explain why. They show that at least 68% of participants experienced recurrences of low back pain, with 80% of those (or 50% of the study’s participants) having experienced recurrences reporting moderate or greater activity limitation or needing formal healthcare again. Also, the Impact Score range appears small at first glance - with those with no recurrences having 11.1 points and 15.2 points for those with recurrences. Further review shows that recurrence groups ranged from 12.7 points for LBP recurrence episode, 15.5 points when moderate activity restriction recurrence, and up to 16.9 points for those needing to obtain further healthcare - therefore a majority of those having recurrences actually were showing impact scores in proximity to the 19 point Impact Score participants scored during the original LBP episode. The authors didn’t include the number of individuals that experienced minimal limitations, and there was no specifics provided as to what the affected activities were. This is a significant weakness of the study. One person’s minimal limitation could be another’s severe – this is contextual to their personal level of normal activity. As an example, one person doesn’t feel lifting 25 pounds is a necessary task to return to, but a young parent who has to repeatedly lift a 25 pound child all day has to have that ability. Another weakness of this study was that after the first two recurrences are reported by a participant, no further recurrences would be included or recorded. This could be significantly affect the real number of recurrences, and could affect the conclusion the authors tried to make altogether. Da Silva, et al. mention only nonspecific low back pain was the inclusion criteria, but gave a vague description and examples. There are many other structures and tissues that can cause LBP, including SI joint dysfunction, facet compression/dysfunction, and movement restrictions including flexion or extension sensitivities that tell re not specifically diagnosed by radiographic abnormalities or asymmetries by referring physicians. Since the authors only indicate radiographic based diagnoses as examples of exclusionary (specific) diagnoses, it remains unknown what commonly seen movement based diagnoses were included here or findings be applied to. Without imaging, there can be no medical diagnosis, which is true, but even with movement and tissue sensitivity screening; flexion and extension sensitivities can arise, leading towards obtaining a functional diagnosis. The high number of recurrences should make us wonder why these individuals were discharged from care, and what criteria did they meet. Were they just pain free for a few days or were they actually assessed to be functional and able to return to their favorite activity or sport or full time manual labor job? This detail would likely help give us more understanding into the care they may have or have not received. Feeling great for a few days over the weekend while sedentary doesn’t usually translate into going back to work and lifting 30 pound boxes or carrying 50 pound pieces of machinery over the course of eight or more hours. Many times patients ask us if “this could be the last day” when they walk into the clinic because they haven’t had any back pain in 5 days and they can finally get in and out of their car pain free. Being pain-free with basic ADLs, while excellent and a sign of meaningful progress, doesn’t mean they are ready to lift a heavy box off the ground or run a 5K race the next week. The few movements and activities they did over the weekend weren’t hard enough, and didn’t load their bodies and tissues in the way that is similar to the eventual ADL, work, or recreational task they still haven’t gotten back to. Participants in this DaSilva et al study needed only rate their symptoms at 0-1 out of 10 for 7 consecutive days but there is no functional scale reported here and certainly no mention of the PT or Chiropractor using any standardized means of assessing functionality or kinetic chain factors prior to discharge. The bypassing of key details like this does an injustice to how both PT’s and physicians view what should be high level care of patients with LBP. Care that focuses only local symptom reduction and generic stretching and strengthening may be easy to implement and produces seemingly good short term results in terms of pain relief and low level activity return, however, with many of the “failed prior care” cases we see it becomes evident more thorough vetting of underlying kinetic chain factors are often neglected and later become a mainstay in why we see many patients succeed. Many times individuals will go to a healthcare facility because it’s convenient and close to home or work, and often this is a driving factor in physician referral decisions as well. While for many patients simple, traditional PT care may suffice, this study demonstrates that LBP recurrences are far too high and that substantial limitations do happen with these recurrences. Properly screening the kinetic chain for limitations that would overload tissues in the lower back takes added time and skill. Too often patients come in and tell us they were asked to move their trunk in several directions and then given a canned sheet of “low back” exercises. Missing that patient’s stiff ankle or maybe a hip, especially when their ADL requires twisting into that side to reach 20 times a day could cause a strain as the low back compensates for the hip that has reached its ROM limits (but that wasn’t discovered because it was just a “low back pain” issue). Or maybe walking any distance feels fine, but any standing still sends pain into one side of the back because the leg length discrepancy is causing a unilateral pelvic rotation, and nobody saw that because it was just a “back” ache and the original five or six traditional physical therapy exercises made the pain go away for a couple of days. It takes a whole body system assessment to see what joint, and in what plane of movement and with what stress does that person experience his or her pain. It takes time and it takes individualized focused care and problem solving. And it also takes proper patient education from the PT for the patient to stick with their program long term, as that is the only way they have a greater chance of preventing the dreaded recurrence, which according to this article occurs all too often. That leads into our patient example. When multiple PT attempts did nothing for her pain, Amy looked into other options including spinal injections and a nerve ablation to help get through her day. She was a triathlete and even an Ironman competitor at one of the highest levels, but when her lower back pain became unable to be managed, she finally came into our clinic for what she said was her last hope for a pain free life. Peak Patient Experience Amy Said: "Now I am totally pain free and stiffness free!" Pt reported feeling pain free with all ADLs, work tasks, all transfers, and able to return to pain free running 3-3.5miles up to 3x/week. History: 45 year old female with a 3+ year history of lower back and SI joint pain, with a previous L5-S1 disc herniation a few years prior. Prior PT at one other facility for multiple months without relief of sx’s, as well as multiple L facet injections and a nerve ablation without success. Previous Ironman and elite triathlon competitor with now an inability to perform almost all ADLs without pain limiting her. Subjective: “Peak Performance is my last resort at trying to get better! I have to take a muscle relaxer in order to even sleep, and I can barely move and get in and out of the car.” 8/10 max sx's, with a constant 2/10 even at rest. Sx's exacerbated by any transfers, forward reaching, or squatting, ADL or fitness. She was unable to run or to don/doff shoes and socks without intense pain. Objective: * = pain Initial DC Eval Spinal Flexion 25% * 100% Spinal Extension 25% * 90% Spinal Rotation L 380, R 400 L 450, R 470 Hip Extension L 200, R 150 L 230, R 210 Prone hip ER L 270, R 240 L 350, R 310 Active Knee Extension Hamstring L -600, R -500 L -290, R -280 Slump test (+) B ** (-) B Leg length discrepancy R greater troch higher Neutral w/ lift Max pain 8/10 mild--1-2/10 Treatment: Manual therapy: Functional wb hip extension and ER mobilization, thoracic spine SB and extension mobilization, deep tissue release to hip flexors and hip rotators, SI joint muscle energy corrections for sacrum/ischium/ilia and Modalities: Class IV laser treatment-10 sessions with 25 watt intensity; L heel lift provided to correct leg length discrepancy Exercise: Stretching: 3-plane dynamic hip ext, thoracic spine ROM and self-mobilization, prolonged hip ER/hamstring/hip flexor stretching, McKenzie prone spinal extension stretching Strength: Standing eccentric extension drills of anterior chain with weights-overhead pressing and posterior tipping through hip flexor loading, thoracic spine and scapular strength drills, proper lunge mechanics tubing resistance lunges for proper hip hinge mechanics , dynamic plank drill for frontal and sagittal stability, frontal plane strength drills with opposite and same side load, hip ER resistance tubing stepping drills