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Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE January 2024 Biomechanical Pitfalls Promoting Achilles Tendonitis in Recreational Runners by Andrew Neumeister, PT, DPT, FAFS, Certified Running Gait Analyst Clinical Scenario…What would you do? A 41 yr old male recreational runner with R achilles area pain developing gradually over the past 6 wks comes in for evaluation. Plain films are (-) and clinical exam shows tenderness on the R achilles tendon (AT) several cm above and down to the calcaneal insertion, painful vertical hopping and standing plantarflexion raising. Bilateral squat testing reveals limited ankle wb dorsiflexion while single leg squat shows asymmetric dynamic valgus and overpronation compared to the L side. He reports recently increasing weekly mileage from 20- - - >30 miles over his 4 days/week running frequency. I would … Order an MRI to confirm suspected achilles tendinopathy and R/O other possible causes. FU in 2 wks after starting a course of OTC NSAID’s to check progress and decide a plan of care. Advise rest from running for 4-6 weeks with a change to non-impact cross training options and FU in 4 wks. Prescribe a customized, biomechanical PT evaluation along with a running analysis to establish a customized functional exercise program geared to address any running pathomechanics. To include manual therapy, therapeutic taping trial, and Class IV laser therapy as indicated. Provide handout of standard calf stretching and ankle tubing resisted PF strengthening PRE with orders to reduce running mileage by 50% and frequency to BIW-TIW. Refer for custom orthotics evaluation and management along with non-impact cross training. FU in 4 wks. CURRENT EVIDENCE Skypala J, Hamill J et al. Running-Related Achilles Tendon Injury: A Prospective Biomechanical Study in Recreational Runners. J Appl Biomech. 2023 (online Jul 7), 39(4):237-245. https://journals.humankinetics.com/view/journals/jab/39/4/article-p237.xml 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 in further detail if you wish. The abstract can be found after the case study. PEAK PERFORMANCE PERSPECTIVE Orthopedists and PCP’s often evaluate runners presenting with achilles tendon symptoms, easily discernible through palpation and painful resisted plantar flexion in weight bearing. Achilles tendonitis/tendinopathy (AT) is among one of the most common running related injuries (RRI), occurring up to 22% in recreational runners and has been shown to decrease running performance in up to 66% of runners during the first year after injury. Recommending treatment involves more than simply “routine” physical therapy as studies show that a running analysis can be helpful/necessary and contributing factors can easily be missed when simple “stretching and strengthening exercises'' PT concepts are ordered and employed. The study’s regression analysis showed that knee flexion angle increases at initial contact(IC) and midstance (MS) resulted in greater risk of AT - for every 1° of knee flexion angle increase; there was a 15% rise in AT risk. The authors hypothesized this may be related to alterations in the effective mechanical advantage of the gastroc complex. Dorsiflexion was also significantly greater at midstance. Foot strike patterns were not found to contribute. Clinically speaking we find that AT must involve a thorough biomechanical evaluation as there are numerous potential contributing factors, most of which were not analyzed or data not shown in this study. There are also many possible underlying reasons why a runner might exhibit this increased knee flexion angle at IC and MS. Merely being aware this finding is present does not indicate the actual cause that must be addressed with physical therapy. While coaching/cueing generic running form or cadence changes may temporarily alter symptoms and performance it is paramount that causative factors be identified so that tightness and/or weakness etc. are properly addressed so the compensatory abnormal knee flexion no longer is necessary in the first place. Further Details… Skypala 2023 et al. conducted a prospective biomechanical study in recreational runners to assess which mechanics during phases of running have influence on the RRI of AT. The authors reported that many previous cross sectional and retrospective studies conclude runners with AT have greater ankle dorsiflexion and eversion during the loading phase of running, and also noting conflicting reports showing either increased and decreased knee flexion during stance phase. These studies, however, were performed on runners already having AT, therefore do not confirm causal relationships but may reveal compensatory patterns due to pain. Skypala et al. set out to determine whether biomechanical variables were related to the incidence of RRI AT for one year in low-volume runners. The authors defined an AT RRI as pain in the AT region requiring medical evaluation or resulting in limited/cease of running for at least 7 days or 3 consecutive running sessions. Of the 318 original participants who met the inclusion criteria were 108 recreational runners aged 18 - 65 yr old with a weekly mileage under 51 km/wk and were free of musculoskeletal lower extremity injuries 6 months prior to the study. A 10 camera motion analysis biomechanical assessment using 24 markers while using a self-selected speed (for 45 min run pace) over a 17m force plate runway while wearing provided “neutral” running shoes was done, analyzing R side mechanics for this study. The authors reported that 26 (15 males and 11 females) or 25% of the final 103 participants completing the study had R sided AT within one year after biomechanical analysis, with 18 runners (17%) developing (B) AT. Biomechanical predictors that were associated with development of RRI AT were an increased knee flexion angle at initial contact (OR=1.146, P = .034) and midstance phase (OR=1.143, P=.037). Therefore, a 1° increase of knee flexion at initial contact (IC) and midstance (MS) was associated with a 15% increase in risk of developing RRI of AT. Runners with AT also showed significantly increased dorsiflexion (P=.010, ES=0.630) during stance phase and at baseline had lower body fat % (P=.041, ES=0.491) and reported more mod-vigorous activity (P=.048, ES=0.630). Foot strike pattern was not a risk factor (OR=0.997, P=.807). Effective mechanical advantage (EMA) of the medial and lateral gastroc reduce as the increase in both the knee and ankle flexion angles causes larger external flexion moments which then require greater muscle force to decelerate and then propel the body. The authors proposed this as a potential mechanism for the achilles overloading. Skypala et al’s study does have some important limitations that must be considered. As an endurance runner myself, it can often take time to establish your preferred speed in a study like this where runners were crossing a 17m over 6 minutes and stop/starting at each end. Simply cueing someone to run at a “45 min running pace” cannot simply be established in 6 minutes of inconsistent running. Runners used a “neutral” running shoe which does not account for each individual's preferred footwear during testing, thus potentially causing modifications from their otherwise typical running mechanics but also is then not the same footwear used during the subsequent year of running for the study. Foot dynamics were not assessed during the study thus no data regarding pronation and supination mechanics, with any over-the-counter orthotics, “pronation control”, or minimalist footwear used during training were analyzed. DF angles during IC and MS may be altered depending on different heel drop heights between shoes. The amount of calcaneal eversion can also be variable in control depending on orthotic design or the footwear itself. All of those factors above can influence the stress on the AT during running that was not accounted for during motion analysis in the lab. Regarding foot strike patterns it would require further analysis as to whether an adequate variability and number of participants having differing foot strike tendencies to power finding significant differences were present in the study. Why does any of this matter when recommending an appropriate treatment plan? It is not as simple to tell your patient to reduce their DF and knee flexion angle while on a run to reduce mechanical stress. The data suggests that reducing peak knee flexion and dorsiflexion angle reduces tension on the achilles tendon through improvement in their biomechanics, however does not address how to take this knowledge and then apply it to appropriate treatment methods. It is not inherent for patients and many therapists to know how to provide proper functional treatment while rehabilitating AT taking account of the dynamic activity which caused them to seek medical attention. A specific biomechanical evaluation assessing running form and technique using 2D motion analysis allows for the therapist and patient to visualize where external joint angles can increase stress on the entire lower extremity system contributing to AT pain and other common running injuries at each of the ankle, knee, and hip complexes. Ankle/foot mechanics need to also be assessed to determine where limitations in mobility or pronation control could exist as biomechanical pitfalls. Correction utilizing an appropriate orthotic can aid in reducing stress to the system caused by ground up tibial internal rotation and subsequent dynamic valgus. A functionally trained physical therapist with knowledge of running biomechanics can establish a return to running program with necessary cues to reduce impact stress during the stance phase from start to finish. Anderson et al. reported that increasing cadence has been shown to have a large effect on reducing peak ankle DF and knee flexion angles. Through an appropriate biomechanical evaluation and treatment geared specifically to the runner’s goals, results can be obtained quicker by addressing specific biomechanical results. While Skypala et al. used a large group prospectively to better understand commonalities among runners developing AT, it must also be remembered that each individual runner brings unique physical abilities and limitations that potentially affect risk of developing AT. More in-depth biomechanical kinetic chain assessments must be included for effective physical therapy care beyond merely utilizing group findings such as from this study, especially considering the variety of kinetic and kinematic information not analyzed here. A variety of limitations such as limited ankle DF, abnormal foot mechanics leading to prolonged overpronation during propulsion phase, poor contralateral propulsion or swing phase function, proximal hip Abductor and/or ER’s weakness, and weak quadriceps among others have all been findings we’ve noted that potentially have contributed to AT cases in runners. THE PEAK PERFORMANCE EXPERIENCE A 1° increase of knee flexion at initial contact (IC) and midstance (MS) was associated with a 15% increase in risk of developing RRI of AT. At a cadence of 150-160, the peak knee flexion ankle at midstance is 50°. Below are images of the author running at 7.5 mph speed at 8 different cadences ranging from: 150 steps/min to 220 steps/min increasing by 10’s respectively. A reduction of knee peak knee flexion reduces as cadence increases, down to 32° at 220 steps/min. 1. 2. 3. 4. 5. 6. 7. 8. (angles are calculated by (180° - X deg. below) Skypala J, Hamill J et al. Running-Related Achilles Tendon Injury: A Prospective Biomechanical Study in Recreational Runners. J Appl Biomech. 2023 (online Jul 7), 39(4):237-245. Abstract Background: Few running studies have attempted to prospectively identify biomechanical risk factors associated with Achilles tendonitis injuries. Many studies have been done retrospectively on individuals with AT and have not identified if the results are mere correlation and not causation. Purpose: The authors set out to determine what potential factors there may be associated with developing AT in healthy recreational runners. Type: Prospective Study Methods: 103 healthy recreational runners had their kinematics and kinetics assessed with a motion analysis system at a self selected running speed. They then completed weekly questionnaires at home for the following year to determine if they had developed AT per the authors definition of the running related injury. Findings: A more flexed knee at initial contact and at the midstance phase were significant predictors for developing the Running Related Injury of AT. Runners who had a significantly greater maximal ankle dorsiflexion during the stance phase also were found to be a risk factor for developing AT. Author's Conclusion: The incidence of running related AT over a 1-year prospective evaluation was 30%. Participants with AT RRI ran with greater angles of knee flexion and dorsiflexion during stance phase. This potential risk factor could be attributed to a mechanical disadvantage of the gastrocnemius complex with a flexed knee. The effective mechanical advantage is reduced as external moment arms increase at the knee angle ankle with individuals exhibiting greater knee flexion and ankle DF. (Citation for evidence regarding the effect of cadence on running kinematics) 2. Anderson LM, Martin JF, Barton CJ, Bonanno DR. What is the Effect of Changing Running Step Rate on Injury, Performance and Biomechanics? A Systematic Review and Meta-analysis. Sports Med Open. 2022 Sep 4;8(1):112. doi: 10.1186/s40798-022-00504-0. PMID: 36057913; PMCID: PMC9441414. You can trust the Physical Therapists at PEAK PERFORMANCE to do a thorough evaluation, to search for related but underlying contributing factors to kinetic chain dysfunction, and to design exercise progressions that both respect tissue healing and creatively use biomechanics principles to prevent symptoms and optimize carryover to your patients' functional goals. Call us at 218-0240 to discuss your patient's specific needs. Peak Performance is just minutes away from your patients in Penfield, Fairport, Pittsford, Brighton, Rochester and, of course, East Rochester. We promise Individualized, hands-on and biomechanically appropriate Physical Therapy for your patients. No "one-size-fits-all" approaches. We WILL go the extra mile and "dig deeper" to discover underlying causes for injury risk and delayed recovery using the most advanced Evidence Based methods available and, we’re able to make unique adjustments to exercise prescriptions to speed the return to function and to minimize or prevent symptoms from interfering. No surprises. No hassles. Confident your patient is in the right place. COME VISIT US AT 161 E Commercial St Just 1 mile off 490 exit (585) 218-0240 www.PeakPTRochester.com

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

Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE 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 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 July 2021 Clinical Decision Making for Cervical Radiculopathy - Generic vs IVF Opening Technique Efficacy...Exploring Best Practices by Rachele Jones, PTA, ATC, CAFS Mike Napierala, PT, SCS, CSCS, FAFS CLINICAL SCENARIO...What would you do? A 57 year old female fitness/golf/pickleball enthusiast comes to you for evaluation of gradually worsening L cervico-thoracic and scapular pain with progressively worsening LUE pain into the lateral/posterior upper arm and tingling into digit V that has become constant but worsens with LUE activity and with her favorite social/recreation activity of golf. On exam she has sx reproduction and loss of ROM into extension, L sidebending, and L rotation individually and a (+) Spurling’s maneuver to the L for digit V tingling. Plain films show diffuse degenerative findings in the mid-lower facet joints and intervertebral spaces. The patient presents after 6 weeks of conservative care that included Direct Access physical therapy including generic mobilization and exercise for 3 wks after several chiropractic and massage therapy sessions, reporting only temporary relief but no lasting improvements from any of these. How do you determine if the conservative care was appropriate/adequate before making updated treatment recommendations? Is this case suggestive of failed conservative care? ▢ Yes ▢ No My next step(s) would include (check all boxes that apply): ▢ Order an MRI ▢ Order epidural steroid injection ▢ Prescribe Physical Therapy specifying Intervertebral Foramen opening mobilization and exercise ▢ Increase dose of Gabapentin ▢ Advise to obtain surgical consult CURRENT EVIDENCE Langevin P et al, Comparison of 2 Manual Therapy and Exercise Protocols for Cervical Radiculopathy: A Randomized Clinical Trial Evaluating Short Term Effects. Journal of Orthopaedic & Sports Physical Therapy 45:1, 2015, 4-15. SUMMARY: Annual occurrence of Cervical Radiculopathy is 83.2 per 100,000 individuals with peak occurrence in males between their fifth and sixth decades, noting that pain and disability are typically greater than mechanical neck pain. Discernment by physicians in prescribing care for CR ideally hinges to a significant extent on current evidence. This study, like many others, demonstrates that cursory review of author conclusions may not tell the entire story. Langevin et al used the highly respected model, RCT, to compare (very limited) customized manual therapy and exercise “foraminal opening” techniques vs more generic mobilization and exercise over the course of BIW Physical Therapy care over 4 weeks for patients with Cervical Radiculopathy (CR). They did find significant improvement in self-report measures and ROM in both groups at both 4 and 8 weeks but no differences between groups. Although this study supports conservative care with manual therapy and exercise for CR in general it, nevertheless, is misleading in terms of suggesting customized approaches are no better than generic techniques. The study was underpowered for most of the dependent variables measured and the “customized” portion was only two of the four mobilization techniques and one of the three home exercises given. This does not pass the test of being clinically relevant/consistent with normal decision making and treatment planning where a more substantial portion of care is often directed at known tissue unloading methods. At Peak Performance care for patients with CR typically includes specific foraminal opening mobilization and symptom relief position/exercises, manual therapy and exercise focused on adjacent kinetic chain areas contributing to abnormal or excessive demands for cervical extension and ipsilateral sidebending + rotation (ie that close the foramen) - including the thoracic spine and pectoralis minor length, postural strengthening, cervical traction, and postural education regarding work and ADL. We find a common cause for failure is a protocol driven approaches or generic “neck exercise and mob’s” - customization is key. (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: Clinical approaches for cervical radiculopathy ( CR) commonly involve exercises and manual therapy targeting the segment to increase the size of the intervertebral foramen (IVF) but evidence for utilizing specific manual therapy and exercise techniques is sparse/lacking. Methods: Randomized & blinded trial was designed using 36 participants between the ages of 18- 65 yrs with pain, paresthesia, or numbness in one upper limb and also cervical or periscapular pain of less than three months in duration. There also had to be one or more lower motor neuron signs and at least 3 of 4 clinical tests for CR (+). Participants were subdivided into a control group that received general joint mobilization and exercise(not allowed to directly increase IVF space) and an experimental group that included mobilizations and exercise aimed at increasing IVF size. Primary measures were Neck Disability Index (NDI) and secondary shortened Disabilities of the Arm, Shoulder, and Hand (QuickDASH) and numeric pain rating scale (NPRS) along with cervical AROM (all planes) - evaluated at baseline, 4 weeks , and 8 weeks. Patients were seen for 8 visits over 4 weeks of care. Findings: No significant group by time interaction or group effect was observed for NDI,Quick Dash, and NPRS or for AROM following the intervention ( P>- .14 ). However, both groups showed statistically and clinically significant improvements from baseline to 4wks and 4wks to 8wks in the NDI, QuickDash, and NPRS and AROM (ext and sidebending) (P <.05). Author's Conclusion: Results suggest that manual therapy and exercises are effective in reducing pain and functional limitations related to cervical radiculopathy. The addition of techniques thought to increase the size of IVF of the affected nerve root yielded no significant additional benefits. Given the absence of a no-treatment group, spontaneous resolution of symptoms cannot be excluded, although the magnitude of improvement makes spontaneous resolution unlikely. Rachele & Mike's Conclusion: The authors here appear to be risking a Type II error and/or external validity issue. They have overgeneralized their use of 50% (two) customized IVF opening mobilizations and 30% (one) exercises directed at IVF opening as indicative of CR care in the real world PT clinics and by providers. Skilled providers often utilize a substantially higher percent of customized manual therapy and/or exercise techniques when treating CR patients. Their conclusion should more carefully indicate that “limited use” of customized IVF opening techniques was no better than generic approaches. This is key because both Physical Therapists making treatment plans/decisions and Physicians prescribing treatment should be aware that generic techniques, while shown effective in this study, were not, in fact, proven to be generally comparable based on actual clinical practice standards. Patients failing generic approaches may be better served by a more focused and customized approach. Further study would need to be done to test this assertion. THE PEAK PERFORMANCE PERSPECTIVE When reflecting on the study by Langevin et al a key thought to keep in mind is not all CR cases are the same and Physical Therapy care is not characterized well by their use of limited specific techniques in combination with generic/non-specific exercise and manual therapy techniques...so customization is key. Prior studies have shown that manual therapy and exercise care for CR is better than no treatment. This study adds to the evidence that manual therapy and exercise for CR does result in improvements in self-reported symptoms and function along with objectively measured ROM. But the question remains - is there any value in using directed/specific techniques over a general cervical mobilization and exercise program? The study started out well and with good intention exploring a multimodal approach for CR yet they missed the mark with having the control and treatment groups too similar in treatment. Sixty-five percent of the program was the same. The treatment group only had 50% of the mobilizations customized and 30% of the exercises customized to increase the IVF size. This makes it much more difficult to accept the authors’ conclusion overgeneralizing their “no significant differences” finding between groups versus more real-world physical therapy approaches that typically involve a greater extent of direct/specific techniques - which is not what they studied. This risks a false negative finding. As a referring physician one question you must ask is whether adequate and appropriate treatments were being done when assessing if outcomes warrant escalating medical intervention or simply modifying conservative care orders. In the Clinical Scenario above this might mean digging deeper with the patient regarding what sort of mobilizations and exercises were done, or possibly directly with clinicians when outcomes appear to be inferior. Likewise, in this study only two exceptions were made between both groups: one, the therapists were able to choose only two of the four allowed mobilization techniques to increase IVF size at the same level of the radiculopathy and second, they gave the patient a replacement for the third (of three allowed exercises for HEP) exercise which was specifically targeted to increase IVF. Because this was a new rehabilitation approach Langevin et al chose to dichotomize the patient’s perceived change as either a success or failure. A success was reported if there was an improvement of > 50% or higher in the NDI score and it was a failure if < 50% improvement. Although the study was adequately powered for the primary NDI outcome it was under-powered for several secondary outcomes. While self-report questionnaires are often considered “gold standards” of measuring outcome, there remains room for bias and inaccuracy based on a number of contributing factors, including inconsistent understanding of the measure’s reference end ranges (ie. for NPRS regarding misperceptions of the word “pain” or what a “10” would be). Varying activity levels of participants may also impact the applicability of certain questionnaires depending on ceiling effects. The use of impairment based AROM data in this study, or the use of other functional disability based testing such as pulling or pushing/pressing or reaching capacity and symptom threshold testing would add more objectivity to outcome assessment. Because this was a new rehabilitation approach Langevin et al chose to dichotomize the patient’s perceived change as either a success or failure. A success was reported if there was an improvement of > 50% or higher in the NDI score and it was a failure if < 50% improvement. Although the study was adequately powered for the primary NDI outcome it was under-powered for several secondary outcomes. While self-report questionnaires are often considered “gold standards” of measuring outcome, there remains room for bias and inaccuracy based on a number of contributing factors, including inconsistent understanding of the measure’s reference end ranges (ie. for NPRS regarding misperceptions of the word “pain” or what a “10” would be). Varying activity levels of participants may also impact the applicability of certain questionnaires depending on ceiling effects. The use of impairment based AROM data in this study, or the use of other functional disability based testing such as pulling or pushing/pressing or reaching capacity and symptom threshold testing would add more objectivity to outcome assessment. This was the first study that examined the comparison of targeted IVF opening manual therapy and exercise with more generic techniques. Future studies using more specific/directed IVF opening techniques versus generic only techniques would shed better light on truly understanding if both generic and specific techniques are equally effective. From an anecdotal perspective we certainly find that to be true. Our patient experiences, in hearing the lack of hands-on techniques used or the positions they were in, which helps identify if more targeted opening techniques were being done, along with their description of HEP drills reinforces that very often success can be reached using specific/directed techniques either as the first choice in care or after generic approaches have failed. When evaluating any body part, including the cervical spine, it is crucial to take the kinetic chain into account due to the substantial impact adjacent and even distant body part dysfunction can have on the neck. If the thoracic spine is lacking ROM then that puts more stress on the cervical spine. Limitation of thoracic extension can result in increasing lower cervical extension demands during ADL reaching and gazing head movements, stressing a C-spine having CR. This same concept is true for sidebending and rotations as well. Appreciating biomechanics and ADL/activity demands helps identify key movement patterns that may be underlying stress on the CR segments. Another common source of postural stress (ie. increasing demand for cervical extension) is pectoralis minor tightness. Protracted scapula contribute to thoracic flexion tendency, which in turn, via distal on proximal mechanics will induce lower cervical extension loading, which tends to be poorly tolerated and symptom producing in CR cases. Manual therapy techniques should not only address attempts at IVF opening but also these kinetic chain issues, when present. Eventually, techniques to restore the lacking motions of ext, same side SB, and same side Rot are necessary but are best tolerated when pre-positioning the involved C-spine segments in foraminal opened plane positions prior to mobilizing or stretching/moving into IVF closing directions. Certainly other treatments such as cervical traction can be key, along with postural education and work environment and recreation/fitness education to minimize the occurrence of extension or Spurling’s like positioning demands. Therapeutic taping techniques may also be helpful in some cases to cue posturing. THE PEAK PERFORMANCE EXPERIENCE Jane said: “I was able to play 36 holes in 24hrs , and I'm feeling good!” HX: 59 yo female woke up early one month prior with spontaneous symptoms on left side of neck down into left scapula, posterior arm, distal arm, and fifth digit. Pt has seen the chiropractor, massage therapist and no resolve. Patient is a very active individual that fitness trains, plays golf 3+ days a week, and plays pickleball. Subjective: Pt reports intermittent pain 3/10 , approximately TID, worst in the morning and is also driven by 0activity with bending, reaching, and lifting. Pt self reports 90% function with a Neck Disability Index of 20%. Objective: * indicates pain Initial Eval Re- Eval (8wks) Re- Eval (13 wks) Neck Disability Index ( NDI) 20% 12% 4% Numeric Pain Rating Scale (NPRS) 3/10 1.5/10 1/10 Spurlings (+) L scap (-) NT Strength: L/R Wrist extension 6.7 kg/ 9.1 kg L 8.6 kg (95%) NT Elbow extension 8.3 kg/ 16.3 kg L 9.9 kg (88%) NT Cerv ROM ( Active) : Flexion 500 630 600 Extension 600 deg 600 670 Rotation affected ( L) 550 deg 630 630 Rotation non affected ( R ) 730 deg 710 700 Lat Flex affected ( L ) 260 * 280 * mild 320 Lat Flex non affected ( R ) 250 300 400 Key Findings: (+) Spurlings; hypersensitive 5th digit, decreased myotome strength in triceps and wrist extensors. During initial evaluation repeated protraction and retraction increased symptoms into left cervical and 5th digit and forward bending with right sidebending and right rotation abolished symptoms. Treatment: Manual mobilizations to the cervical spine to increase IVF by use of left side glides in a slightly flexed position prepositioned in right rotation and cervical traction starting with hands and progression to cervical traction unit. Manual mobilization to upper thoracic spine into extension (head slightly flexed), 1st rib and pec minor release to help reduce cervical extension demands based on Spurlings sx reproduction and flexion based relief. PROM/stretches to increase left IVF opening at cervical spine and also improve thoracic extension and rotations per limitations found. Utilized pre-positioning IVF opening in FB/RSB to restore LR and FB/RR to restore LSB ability. PRE’s for triceps and wrist extensors and isometrics of cervical spine with several variations of planks for gravity training upper cervical flexors and mid-lower extensors for posturing. Outcome: Pt continued to improve and was awaiting discharge after trial phase of HEP-only, however, experienced exacerbation after playing 18 holes 3x in 48 hours and has temporarily returned for care. You can trust the Physical Therapists at PEAK PERFORMANCE to do a thorough evaluation, to search for related but underlying contributing factors to kinetic chain dysfunction, and to design exercise progressions that both respect tissue healing and creatively use biomechanics principles to prevent symptoms and optimize carryover to your patients' functional goals. Call us at 218-0240 to discuss your patient's specific needs. Peak Performance is just minutes away from your patients in Penfield, Fairport, Pittsford, Brighton, Rochester and, of course, East Rochester. We promise Individualized, hands-on and biomechanically appropriate Physical Therapy for your patients. No "one-size-fits-all" approaches. We WILL go the extra mile and "dig deeper" to discover underlying causes for injury risk and delayed recovery using the most advanced Evidence Based methods available and, we’re able to make unique adjustments to exercise prescriptions to speed the return to function and to minimize or prevent symptoms from interfering. No surprises. No hassles. Confident your patient is in the right place. COME VISIT US AT 161 E Commercial St Just 1 mile off 490 exit (585) 218-0240 www.PeakPTRochester.com

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

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