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Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE (December 2023) Clinical Decision Making with PFPS: RCT Evidence for Utility of High-Intensity Laser Therapy by William Slapar, PT, DPT, OCS, FAFS, CMTPT, CAFS Clinical Scenario...What would you do? A 20 yr old competitive female college soccer player with L PFPS for 6 weeks duration has not improved significantly after working with her athletic trainers comes for evaluation and treatment recommendations. She has mild symmetric lateral tracking with plain film Merchant view. There is peripatellar tenderness along medial > lateral border, without inferior pole tenderness. Squatting is limited/painful with slightly asymmetric dynamic valgus/rotation noted. Single hopping is moderately reduced and painful. WB ankle DF is asymmetrically reduced ipsilaterally and prone rotation PROM (IR >> ER) suggests asymm larger L anteversion. The patient has 5 wks remaining before soccer season begins and prefers to avoid repeating traditional rehab (typical simple LE stretches, step ups, leg press, clamshell and abd-add machine hip work, TKE quad bench strengthening) due to the lack of prior efficacy. My clinical thinking is: Obtain an MRI since the patient is not improving and little time left before the season. FU 2 wks for treatment plan. Provide with PF stabilization brace, order continued rehab work with ATC’s but doing more advanced exercise progressions for returning to soccer, allowing < 3/10 sx max Order custom orthotics and Physical Therapy to include nwb hip Abd and ER PRE. Prescribe customized biomechanical PT including specific functional exercise per evaluation findings, Class IV laser photobiomodulation therapy, trial w/elastic therapeutic taping, and joint mobilization for ankle DF. CURRENT EVIDENCE Qayyum HA, Arsalan SA, Tanveer F, Ahmad A, Javaria, Gilani SA. Role of High Power Laser Therapy on Pain Reduction in Patients with Patellofemoral Pain Syndrome. Pakistan Journal of Medical and Health Sciences. 2022;16(6):9-12. doi:https://doi.org/10.53350/pjmhs221669 *** We are modifying the Newsletter format to better match our physicians’ time constraints. The previously more in-depth “Peak Perspective” will now be contained below in more “summary” form. We invite you to reach out to us at PT@peakptrochester.com or call our office at 585-218-0240 to further discuss this article in further detail if you wish. The abstract can be found after the case study. PEAK PERSPECTIVE & SUMMARY: PCP’s and orthopedists often evaluate patients presenting with anterior knee pain that is suspicious for Patellofemoral Pain Syndrome (PFPS) and must determine the optimal treatment regimen to prescribe. Over the past years Class IV therapeutic laser has become more popularized as a treatment option for musculoskeletal conditions. Numerous journals are dedicated to investigating the efficacy of laser (Lasers in Medical Science, Lasers in Surgery and Medicine, Laser Therapy…etc.). Class IV laser becomes a key consideration for physicians considering current evidence and best practices for PFPS cases. Qayyum 2022 et al. performed a randomized control trial (RCT) to determine the effects of High Intensity Laser Therapy (HILT) on pain reduction in patients with PFPS. They compared HILT + “standard” therapy exercises to a control group using the same physical therapy exercises alone over 4 weeks. They found a significant VAS reduction in both groups but by the 4th week there was a statistically significant greater reduction in VAS pain scores in the experimental group compared to the control group. This was maintained through the 8 weeks of the study. While often mistakenly overgeneralized or referred to as chondromalacia, PFPS remains a very common diagnosis in orthopedics and sports medicine. Common treatments including various stretching and strengthening have been proposed. It is now understood to be a multifactorial condition and thus less appropriate for “protocol” based approaches but more so deserving of customized care dependent on the contributing factors discovered on testing. High-Intensity Laser Therapy (HILT) is an important option shown to produce analgesic, anti-inflammatory, and tissue healing effects for musculoskeletal disorders (MSD). This works through a process deemed photobiomodulation. This is where photons are absorbed by proteins in the mitochondria, which then increase ATP production, reactive oxygen species, and nitric oxide to help with tissue healing, cell energy, and improving inflammatory effects. Newer models of Class IV laser therapy, specifically using 25W and even more recently 40W power have greater capacity for more immediate analgesic effects. Especially for those who may have exhausted safe NSAIDs use or who have comorbidities precluding medications assistance with pain/inflammation reduction, this study adds to the body of evidence showing Class IV laser can be not only an effective component to PFPS rehab but, importantly, it can produce superior pain reduction more quickly. It must be noted this study used only a 10W HILT laser while now more powerful Class IV lasers utilizing up to 25W are used in the clinic and have the capacity for deeper penetration and quicker, more significant analgesic effects. The “routine” physical therapy that included standardized LE stretches, patella mobilizations along with strengthening of quads (DB squats and wall squats, SLR), hamstring strengthening (not specified), hip abduction and adduction (not specified) - all done 4 days/wk at 5-10 repetitions for strengthening exercises, is grossly inadequate and as common with many studies was not “high level” therapy, also due in nature to failing to customize exercises to evaluation findings. This is critical because it means some patients were doing stretches that were unnecessary while other important limitations (e.g. hamstrings or soleus) were not addressed. The protocol used also focused solely on sagittal and frontal plane work but appears to have neglected transverse/rotational planes of function. Biomechanical based approaches must include consideration of foot-ankle mechanics influences, proximal hip influences, and even contralateral limb issues that can produce abnormal forces on an involved PFPS knee via kinetic chain effects. We often find that manual therapy techniques are necessary in PFPS cases, whether that be soft tissue mobilization (STM) or joint mobilization work (e.g. ankle DF). The study would be stronger had the authors included objective measures of performance (such as rotational balance ability and control, squat depth, hop function, or quadriceps anterior stepdown strength), to provide better objective proof of improved outcomes. Patient centered outcome scales of performance also were not measured. Scales such as a LEFS or KOOS or IKDC would show evidence of actual performance improvement vs. simply symptom reduction without verifying a return to higher level activity demands. An easily missed finding in Qayyum et al study is that it took four weeks of laser therapy to produce the significantly better VAS reductions. Oftentimes patients can be easily discouraged by slow outcomes with conditions such as PFPS, especially when an impending goal timelines or demand is nearing. This serves as a reminder to PTs and physicians to educate patients that laser efficacy may require weeks of consistent treatment to produce superior outcomes rather than using only a few sessions or two weeks as a litmus test of sorts. Finally, the overall exercise portion in this study was lacking. It is important to consider that PFPS can include contributions from multiple joints via kinetic chain biomechanics. With there being multiple factors involved and needing change to occur to produce symptom relief and improved performance there may be a need for time to pass until the pain/cause of the abnormal mechanics is reduced. Having the necessary patience is not easy for many patients. The case below illustrates a patient who benefited from incorporating Class IV Laser into his program with a diagnosis of PFPS to recover from chronic anterior knee pain to strength training with less symptoms. The patient is still in physical therapy for further treatment. THE PEAK PERFORMANCE EXPERIENCE Brian said: “The right knee is so much better after performing laser, squatting is more manageable and I can perform reciprocating steps down stairs.” History: 36 y/o male with chronic right anterior knee pain with L knee most recent MCL sprain from picking up tennis and twisting right with left leg being planted. Pt had right anterior knee pain for years in which has tried PT before but with not too much of a difference and stairs and squatting motions tend to be more painful and unable to reciprocate descending stairs. Subjective: 6/10 pain with jumping, running, squatting, stair negotiation, getting in and out of a chair Objective: (*=pain) Initial Eval (R/L) After laser demo (RLE) 1 mo ReEval AROM knee flexion 120*/130* (deg) 134 deg 140 B step downs ( 2 inch) quad dom. x8*( DKV moderate)/x15* 10* ( no DKV) 4/10*→2/10* 8# 4 inch x10, x14 SL squat ( knee flexion) 55 */ 85* (deg) squat: 95 deg (4/10*) to 100 deg (2/10*) 100*/ 105 (deg) Ant lunge R= ant knee pain with reduced DF no pain and knees over toes WB StJn DF (knee flexed) 23/25 (deg) 26/ 30 (deg) Step up: 8# R= 4 inch L=6 inch x20*/ x20 R=3/10*→2/10* 15# R=4 inch x22 L=6 inch x18 Prone hip IR 20 deg B 28/25 deg Key Findings: At evaluation pt had pain in the bilateral knees with the right being a chronic case and the other being an MCL sprain from a recent tennis injury. Pt showed having more reduction in strength and function on the right side compared to the left, which could have made the right side compensate more for the right LEs faults. Pt shows reduction in hip internal rotation. Treatment: Pt treatment started with Class IV laser, with manual to address hypomobilities in the ankle, soft tissue mobilization to address TrPs in the quadriceps. Stretching for hip Irs and then addressing movement quality with hip rotation exercises in standing to address sport specific motions. Pt worked on strengthening the hip extensors to improve loading for tennis specific motions. Pt also performed quadriceps strengthening, step downs with post OH reach for quad angulation, which shows a moderate dynamic knee valgus. Outcome: The patient after a laser demo was able to perform more squat motion and stair negotiation ability as well with less pain. The step down also improved in mechanics of no longer having dynamic knee valgus (DKV). Pt is now able to split squat and reach near the floor with 2/10 pain, with increasing loads and depths on functional and sport specific movements to help rehab him to sport. Pt still shows deficits in hip and quadriceps strength comparison and depth which is still coming to PT but there are vast improvements in just one month with having a chronic status of a diagnosis. ABSTRACT Background: PFPS is a very common MSD in which affects 23% of the general population and high prevalence in elite athletes. There are very many biomechanical factors that can be causing pain at the knee, whether it be weakness, reduction in ROM or abnormal structure of a specific joint in the LE kinetic chain. HILT has shown positive impacts in reducing pain in other MSD. HILT shows having effects on inflammation, tissue healing, and pain reduction. Purpose: To determine if HILT will reduce knee pain in with patients with PFPS Methods: Sixty-six subjects from 2 groups, control group of routine physical therapy (PT), and the experimental group of HILT and routine PT. Pain was interpreted using the VAS scale Findings: The data shows that there was a within group significant difference for each assessment of pain for routine PT and routine PT + HILT. At week 4 and 8 between groups shows a significant difference in the mean showing HILT + PT shows superior results in reduction in pain. Author's Conclusion: There is a reduction in pain when using HILT for patients with PFPS. 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 November 2023 The Effects of Power Training Frequency on Muscle Power and Functional Performance in Older Women: A Randomized Controlled Trial by Karen Napierala MS, AT, PT, CAFS What would you do? A 72 year old woman comes to PT with a history of falling over the past year. Her primary CC is a painful R knee along with lumbar DJD symptoms also. She underwent L THR three years prior and reports good function without hip pain. She wants to play in the yard with her grandchildren, who are under 10 yrs old, but feels unsure of her footing on the grass and at times is apprehensive due to occurrences of a “step in the wrong direction” causing sudden knee pain and associated giving way. Plain films show > moderate DJD of her R knee. R knee AROM is 5-1150, single leg squat is moderately decreased vs L, and SLB control is minimally reduced with static testing. I would prescribe… A. “RICE”, NSAIDs, and gradual activity return as able over 2-4 wks - call if problems persist. B. Obtain a knee MRI and lumbar plain films. Prescribe NSAID’s and recommend Physical Therapy (providing a geographic based list of options). C. Customized biomechanical PT to include Class IV laser, manual therapy, customized exercise/balance training progressing to include “speed/power” training - FU 6 wks. CURRENT EVIDENCE The Effects of Power Training Frequency on Muscle Power and Functional Performance in Older Women: A Randomized Controlled Trial, Katsoulis, Konstantina; Amara, Catherine Et al., Journal of Strength and Conditioning Research 37(11): p 2289-2297, November 2023. *** We are modifying the Newsletter format to better match our physicians’ time constraints. The previously more in-depth “Peak Perspective” will now be contained below in more “summary” form. We invite you to reach out to us at PT@peakptrochester.com or call our office at 585-218-0240 to further discuss this article in further detail if you wish. The abstract can be found after the case study. PEAK PERSPECTIVE & SUMMARY Physicians frequently see older patients with orthopedic conditions causing movement limitations, ranging from difficulty with simple ADL (such as walking and sit-stand or stairs) all the way up to higher demand athletic endeavors. While the worst of these cases involve actual falling and fall risks, a majority of older patients will complain of loss of quicker movement ability, reduced pace of activity, excessive perceived exertion with low demand activity, and also reduced ability to react to losses of balance…etc. Traditional physical therapy, despite its focus on typical ROM/flexibility, balance, and strength training, often neglects purposeful speed of movement focus (i.e., power). Physicians prescribing physical therapy must determine best practices for expectations and prescription habits surrounding these less customary but critical speed of motion components related to the patient’s goals and also determine appropriate DC criteria. Buford et al (2010) showed we lose 3-8% of muscle mass/yr as we age. Postmenopausal women lose more muscle mass per pound of body weight than men during aging, which is proportionally fast > slow twitch fibers (Fontera, et al 2000 Cell Physiology; Purves et al). This is consistent with the fall risk concerns of aging, where a component includes rapid deceleration capacity and acceleration qualities. Strength is important but inadequate itself in securing the capacity for rapid force generation. Muscle power training tends to be underutilized in physical therapy care but must be considered as part of a standard rehab progression if function is to be optimized. Low intensity power training has been used as an effective method to improve power and functional performance in these older adults in the gym, but it is underutilized in Physical Therapy. The RCT by Katsoulis and Amara studied the frequency of power training (1, 2 or 3 days per week) for 12 weeks on various power and strength measures in older women. Their “power” exercises focused solely on the concentric power in sagittal plane dominant exercise movements. Measures included 1 RM leg press, isokinetic knee extension, stair climbing , sit stands in 30 seconds and 400 m walk among several others. Functional tests such as leg press, sit stand, 4 m walk improved in the power training (PT) groups with 1-3 sessions/wk anywhere from 6-12%. Leg press 1 RM increased 23% pre to post. Rate of perceived exertion (RPE) for the 400 M walk was significantly improved over the controls in all groups. The BIW trained women improved in the stair climb test over the 12 week period. Chair sits to stand improved 10-19% in all PT groups. An 11-13 % improvement was seen in the 4 M walk. While significant power changes in 1, 2, and 3 times/week training groups were noted for isokinetic knee extension, the 3/wk power training group had four times more gains. This type of resistance training with quick motion and lower weight is crucial for functional results. Not only does weight training enhance muscle function, but the power or quick motion enhances fast twitch fibers necessary for reactive movements and power movements of getting up from the ground unassisted and climbing stairs, or even chasing grandchildren. While this study was done on otherwise healthy > 65 yr old females and external validity prevents us from directly applying the results in orthopedic patients we can still use this data to help frame important considerations for this population. Our patients are dealing with one or more painful joints that need to be addressed before moving into more progressive balance/strengthening and functional exercise activities intended to truly move the needle toward safer and higher function. We know that true strength takes at least 6 weeks to see results but changes related to the efficiency of the nervous system are occurring in the first weeks of training. Unfortunately, especially in this era of efficiency of care and early independence efforts and cost containment we often see patients following up with their physicians at a six week checkup who “feel better” but who still have significant disparities in strength and function still present, yet are oftentimes discharged from formal care to “keep doing your home program on your own” sort of thinking. Optimizing pace of movement and reactive ability, both for safety and performance/quality of life, are best done using speed based exercise movement drills vs simply traditional load based drills. Nevertheless, adequate strength must be developed first. Patients often are happy with the changes they’ve noticed already without appreciating the limitations their lack of speed capacity for deceleration/acceleration and perceived exertion are going to have. We utilize a “speed day” akin to this study’s intentions, however, importantly include or even focus on eccentric/deceleration based stimuli instead of just concentric power production. This is a known key to injury prevention. This often looks like 50% loads of their typical 8-12 reps training loads on a “strength” day workout but done with faster pacing usually over a short time of 10-20 seconds. Since many limitations and injuries come from the inability to control the forces of gravity while slowing down the body in motion, stopping, or especially reactively catching oneself after a slip or trip the eccentric “power” component is critical. This is often ignored in traditional therapy and as a requirement by physicians prior to discharge. Another key shortcoming in this study was the sagittal plane only training. In real-world function the frontal and transverse planes must be developed both in a dynamic stabilization sense during more frequent sagittal plane activities but also through motion also for activities like tennis, golf, and playing with grandchildren as even a few examples. The case below illustrates a patient who benefited greatly from incorporating this “speed day” training to optimize their recovery toward safer and higher level performance. THE PEAK PERFORMANCE EXPERIENCE Jody said: “I finally feel comfortable on the grass, and in the woods. I’m moving faster and my husband doesn't have to wait for me!” History: Jody is 84 and has (B) THA and a L TKA. She remained sluggish in her movement following her h/o DJD and the replacements but was also concerned about her “good” R knee’s progressive symptoms with stair. She struggled to get down on the ground to clean and needed a chair to help her up. Subjective: “I never felt like I fully got back to my activities. It took me much longer to get my housework done. I really want to take a walk on a path with my husband and keep up with the grandkids!” Objective: (*=pain) Initial Eval Re-Eval 6 wks Re eval 12 wks Sit -Stand 15 seconds 6x 7x 9 x Single leg squat knee angle L 550/ R 50 ** L 650/R 550 L75/R 67 Calf raise in 15 sec L 10/R 8 L 13 / R 10 L/R 16 3” quad dom step down (eccentric ) Unable * L 8x / R 7x L 16/ 14 TUG 20’ 16 sec 14 sec 12 sec Timed SLB rotations 15 sec Unable L 12x R 9x L 13x R 10x IKDC 32% 54% 79% Key Findings: Jody had 50 degrees knee flexion in a squat with pain at her patellofemoral joint. Split squat depth was 8 inches off the floor L forward. She had difficulty controlling ER’s on the R>L hip, and her R.L quad were weak. Calf weakness, especially soleus, was evident on the R side. Her balance was poor B in a single leg stance where she was unable to stand for more than 1-2 seconds at a time. Treatment: Jody has been in PT at Peak PT before and after each of her total hip surgeries. She has always been discharged after 6 -8 weeks of PT because she “felt better” and seemed capable of basic ADL. She is now realizing her “better” was actually not as strong as she needed to be and that she lacked the ability to move more quickly playing with her grandkids, carry loads down stairs, or hike on uneven terrain comfortably. After 3 weeks of lower level modified quads work (to avoid sx noted with a more flexed knee) Jody increased to resistive training into squats/ lunges/ and rotational/frontal plane assisted motion ensuring use of knee, ankle and hip muscles. By 6 weeks she was able to begin her light locomotion based agility program and also a “speed day” utilizing 50% of her typical loads for faster reps over 3 x 15 sec sets. The depth or ROM were adjusted as needed to optimize pace, maintain excellent technique and avoid symptoms. Keeping in line with this study's results she incorporated “speed/agility” day no more than 1-2/ week sandwiched in between her strength days. Outcome: Jody was doing well with only strength work but the addition of power and speed took her to the next functional level. She was finally able to move faster, feeling more secure and without falling. This is the best she has performed and felt in the past three years. ABSTRACT Background: It is known that muscle mass and strength decline with age but studies also show that power or dynamic strength capacities also decrease disproportionately for women vs men. Power training, where the load is substantial but significantly lighter than traditional strength training intensities, and the concentric phase is quick, is a form of exercise that is not frequently used in the older population but has been shown effective in improving muscle power and functional performance in older adults. Older adults often also feel more comfortable and willing to exercise with lighter loads. Purpose: To determine the efficacy of a low intensity (i.e. load), high speed exercise program done 1, 2, or 3 d/wk on lower body power and total body functional performance indicators. Type: Noninferiority RCT Methods: Fifty four healthy independent, active women over 70 yr of age were randomized into 1,2, or 3 d/wk of Power Training (PT) or the control group (CON) for 12 weeks. There were three testing sessions - baseline, midpoint, and 12 weeks as the dependent variables. Subjects were given four sessions of sub-max testing to prepare for the maximal effort tests. Measures included: Biodex maximal knee extension isokinetic test, leg press 1 RM, 30 second chair sit-stand , stair climbing power and timed 13 step stair climbing, 400 m walk, and a short physical performance battery (balance, 4m usual pace walk, 5 chair sit-stands). Findings: No differences were found between 1, 2, and 3 d/wk training frequency groups in leg press 1 RM, isokinetic knee extension power, or functional performance after 12 weeks. Leg press 1 RM increased 20-33% across all PT groups. Isokinetic power increased by 10% for 2 d/wk and 12% for 3 d/wk PT groups. All PT groups showed significant improvements in 30sec chair stands and in the Short Physical Performance Battery (6-22%). The 1 d/wk and 3 d/wk groups improved 400m walk times while the 2 d/wk PT group improved over controls in stair climbing power and stair climb time (4-7%). RPE was also significantly improved over controls. Author's Conclusion: In healthy older females incorporating low-intensity power training at 40% 1RM at 1,2,or 3 sessions/ week will improve the muscle strength and functional performance and training 2-3 d/wk may be required to improve both power and functional performance. 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

EVIDENCE BASED PRACTICE UPDATE November 2020 New Evidence on Running Injuries... Thinking beyond simple “overuse” WHAT WOULD YOU DO? A 27 yr old recreational runner complaining of unilateral plantar fascia pain developing with running 2 wks ago after increasing mileage from 20- - >30 mi/wk over the prior 3 weeks is in for evaluation. They have run for 6 years with only short bouts of minor musculoskeletal issues related to running, never requiring formal care, never needing more than one week rest. This time one week rest did not allow a painfree return to running. Their shoes demonstrate substantial lateral aspect of heel wear patterns. You notice an asymmetric medial collapse on that side during a brief hallway jog assessment. PMH includes an ankle sprain one year ago that is no longer symptomatic and patient reports 100% function restored. · Do you recommend complete rest for 2-3 weeks from running? · Do you order Physical Therapy or NSAID’s first or both? · If NSAID’s - do you have any reservations regarding affects on stages of tissue healing? · What is your hypothesis for unilateral symptom development? · What immediate recommendation can you give to alter potential abnormal forces while potentially allowing some running still? · Do you have a generic “plantar fasciitis protocol” that addresses this patient’s contributing factors? · Do you expect the Physical Therapist to implement the generic protocol or to evaluate the patient for unique biomechanical influences and address accordingly? SUMMARY Physicians regularly see runners who are experiencing pain and looking for solutions. The current pandemic may compel even more fitness enthusiasts to take up running as gyms are closed or limited. Beyond making a diagnosis and recommending proper treatment/therapy physicians are in position to immediately impact symptoms for many runners with in-office education. Last month (Click HERE to read) we brought you a running article that showed a common flaw in running (abnormal hip adduction via pelvic drop) that was a significant cause of injury in many runners. This month’s review focuses on impact-related ground reaction forces (GRF) in running. Johnson et al showed that various markers related to GRF were greater in injured runners vs healthy controls and also uniquely for those subgroups with patellofemoral pain, plantar fasciitis, and achilles tendinopathy but not for tibial stress injury or ITBS. While the findings demonstrate an association and not necessarily causal relationships, in combination with other existing literature there is good basis for counseling and training runners in methods to reduce GRF. Physicians can simply do so with several different recommendations when they believe impact related forces are playing some role in a runner’s symptoms. CURRENT EVIDENCE Johnson, Adam, Tenforde, Davis. Impact-Related Ground Reaction Forces are More Strongly Associated With Some Running Injuries Than Others. AJSM, 48:12, 2020 pp. 3072-3080 Background: It has been reported that 33-50% of recreational runners sustain injuries, with the causes of which are multifactorial. This includes things like running mechanics, shoe choice, ground stiffness, muscle strength/endurance, flexibility, and daily or weekly mileage. Common injury diagnoses are primarily divided into the achilles tendonitis/tendinopathy, patellofemoral pain, plantar fasciitis, tibial bone stress related and iliotibial band syndrome. Purpose: This controlled lab study retrospectively compared vertical load rates and stiffness between healthy and injured runners and also within injury groups. Methods: Male and female runners age 25 to 52 y.o. with >2/10 pain on a VAS during running who used a rearfoot striking running pattern and utilized conventional running shoes (ie. not minimalist shoes) met the inclusion criteria. One hundered twenty-five injured runners (divided among the five diagnoses: Patellofemoral pain, Iliotibial band syndrome, Tibial bone stress injury, Achilles tendinopathy, and Plantar fasciitis) were compared to 65 matched healthy controls. All participants were analyzed at one treadmill session with 3D video analysis using a self-selected speed. Ground Reaction Force (GRF) variables were measured and compared between groups and also for individual diagnoses. GRF measures included Vertical Stiffness (change in the body’s center of mass [COM] relative to a change in the vertical GRF), VILR or Vertical Instantaneous Load Rate (peak rate of change in vertical GRF between two successive points), VALR or Vertical Avg Load Rate (avg rate of change in vertical GRF across 20% to 80% of the region of interest),and VSIL or Vertical Stiffness at Initial Loading (peak vertical force divided by the vertical change in COM over 20-80% region of interest). (See Figure) Results: Injured runners had a significantly higher VALR compared to healthy controls. VALR and VILR were higher in the patellofemoral pain and the plantar fasciitis groups compared with healthy controls. Significantly higher VSIL were found with patellofemoral and achilles tendinopathy groups in comparison to the healthy control groups. All injured groups showed significantly higher force impact (16-20%) in all 3 areas but only the above reached statistical significance. Authors’ Conclusion: Impact variables for the injured group were higher than healthy controls but are driven by specific injury diagnoses. This highlights the need to take an injury specific approach to biomechanical risk factors with running injury. PEAK PERFORMANCE PERSPECTIVE Karen Napierala, MS, AT, PT, CAFS With the gyms vacillating between closed and open in the past 6 months many people are opting to keep it simple…. to run. This potentially means more people who have not trained to run now will be running to train or stay fit. This will likely lead to more physician office visits due to a spike in injuries. It bears repeating – 33-50% of recreational runners will develop injury. Physicians can easily also go beyond the necessary diagnostic role with early treatment via patient education/counselling (see below). These results certainly suggest that we need to address impact loading for injured runners, especially at least those who are rearfoot strikers and have patellofemoral pain, plantar fasciitis, or achilles tendinopathy. Johnson et al’s findings also support Van Der Work et al’s findings of a positive association between vertical impact rates and general running-related injuries. These longer term studies have also shown the increased loading rate directly related to the progression of injury and further cartilage damage. From a treatment perspective it is encouraging to note that Chan et al did report that training runners to reduce vertical loading rates lowered running injuries by 62% over one year. Physicians are in a unique position even during their first encounter with runners who rearfoot strike to begin education/counselling. Runners should know that studies indicate >40 miles/wk increase injury risk within the next year. And, we must remember - runners WILL often keep running regardless of having pain. Rather than ordering a full stoppage initially it’s possible to help them find the threshold where they remain pain free. Here are two simple, practical methods to reduce the volume and then the severity of GRF based contributing factors: 1. Determine total weekly mileage. The first option, of course, is simply to have them cut their daily mileage (2/3, ½...etc) and reduce frequency by 1 day/wk to begin with. Many runners we see admit to non-compliance when an “all-or-nothing” complete refrain from all running is the first recommendation a physician or PT gives. 2. Increase cadence by 10%. Efficient runners often have a cadence (step count) of 85-95 steps/minute (ie. 170-190 stride rate). Advise your runner to count their steps (every time R foot lands) in one minute when they are fresh and then again when they are fatigued or at the end of a run (ie., a runner at 77 step count would have to add 8 steps to their cadence and now reset the metronome at 85). There are free metronome apps they can download to their phone, providing an excellent and consistent audible cue for them. Rearfoot strikers particularly have been known for their slight over striding at heel strike which increases GRF. This can happen for two reasons. First, is when the runner reaches forward with their heel to contact the ground. (Could be many reasons including tight ankles, hips or weakness in the calf…ETC) The heel contacts hard, leading to “braking” type forces and the runner “pulls” themselves thru instead of leaning forward more, landing their heel closer to the COG, and “pushing off” to propel themselves forward. The second is when runners “sit their hips back”, causing an anterior pelvic tilt (potentially related to tight hip flexors, weak gluteals...etc). While the heel strike itself distally doesn’t appear visibly as anterior as the “overstrider”, the proximal pelvic segment/COG are relatively more posterior. The outcome is the same – increased GRF at heel strike. This, of course, then has ramifications up the kinetic chain as well. For example, high vertical load rates can result in increasing sagittal plane forces at the patellofemoral joint leading to rising patellofemoral joint (PFJ) compression forces. Increased vertical loading causes greater rates of vertical arch deformation which in turn stresses the plantar fascia, first in the sagittal plane but as the arch collapses it does so concurrently in the traverse/frontal planes also. This contributes to overloading other tissues related to local shock absorption distally as well. In this study Johnson et al found plantar fasciitis group values of 52.4BW /s or higher for VALR associated with 11x increase in injury risk. This study, oddly, did not find increased GRF forces in the tibial bone stress runners subgroup. However, these runners had taken 1-2 months rest off as part of their treatment, prior to the study, and were allowed to run with a max of 2/10 pain, which possibly meant they were using altered/compensating mechanics. Mean vertical loading rates were not significantly higher in the ITB or achilles tendinopathy groups. These injuries have been linked with frontal and transverse plane weakness or excessive motion. Traditional PT often overlooks or misses these issues, like frontal plane stiffness in calcaneal eversion as a cause of distal foot overpronation (MTJ). Vertical stiffness during impact loading measures downward excursion of the COM per unit of force during the early stance. These “stiffer” joints are less able to dissipate external forces resulting in increased rate of injury. Higher knee joint stiffness and injury have been associated previously in other studies. Conversely, a decrease of vertical stiffness (ie. excessive collapse) is also a potential risk factor. Research has yet not pinpointed the exact amounts of stiffness necessary to prevent injury and properly dissipate forces. There is a likely safe range that is dependent on an individual’s biomechanics, strength and flexibility, etc. This study was retrospective. Therefore we’re uncertain whether it was capturing biomechanical factors that were causative of the injury. Studies do show that 86% of all runners will run through pain. This fact compels us as health care providers to carefully address running injury since runners who do, in fact, continue to train may be risking more severe or additional injury - leading to even more eventual disability, time off running, medical intervention and expenses downstream. This study differed in in that the runners here were rested for at least a month before being tested. Many prior studies looked at runners who were running their normal mileage while still in pain. This study had several limitations which the authors astutely noted. First, regarding external validity, because rearfoot strikers only were allowed to participate, the results cannot be extrapolated to fore- or midfoot strikers. It is important we caution against overgeneralizing these findings to runners in general especially as we more and more runners hearing about and attempting to utilize mid and forefoot strike patterns. The authors calculated risk thresholds (ie. VALR > 57.4BW in the patellofemoral pain group was linked to knee pain). These GRF injury risk thresholds (Table 4 in original article) are not intended to be definitive since this was not an experimental design study able to demonstrate causality. While it is accepted that increased force is associated with increased likelihood of injury down the road, it remains unclear what that time duration prior to symptom onset might be or the threshold for tissue overload that triggers inflammation and symptoms, especially regarding the level that alters function. It is impossible to establish whether the observed differences in this study are a cause or result of the recent injury. At what point do runners in pain modify their running mechanics, and to what degree, in order to decrease symptoms and continue to run? Johnson et al looked at runners after they were injured. Future prospective studies examining GRF patterns of asymptomatic runners and then following them over time to determine the relationship between many of these impact related variables and subsequent injury would be even more helpful to physicians and therapists clinically. Injured runners require skilled physical therapy capable of analyzing gait patterns that may contribute to increased GRF variables like Johnson et found in this study. Traditional or generic/protocol based therapy approaches often fail to identify functional biomechanical factors contributing to the “why” a runner is performing the skill or gross motor activity of running in the way they do. We must assume runners, like most athletes, are likely either utilizing the mechanics that inherently/naturally feel most efficient within their own body (based on the capabilities and the limitations they have) and/or are based on their interpretation of what they’ve learned or observed as “proper technique” that they are attempting to emulate. Running is a complex and integrated biomechanical skill. Not every injury has the same cause. There are internal biomechanical issues, training issues, and impact force issues among others. What caused the impact force to be intolerable on one side of the body when each foot took the same number of steps? Determining why one side had an increased force across the injured tissue is a key puzzle to be solved. It is imperative that therapy be capable of analyzing functional mechanics issues that my underlie abnormal running form and/or contribute to inefficiencies that lead to tissue overload. Thorough 3D testing and exercise progressions that resonate with the proprioceptive/neuromuscular system are key. For example, the hip abductors being trained to forcefully abduct the thigh is not “authentic” hip abductor force use. In running the abductors stabilize the pelvis and decelerate mild normal pelvic drop into hip adduction before concentrically contributing to re-leveling of the pelvis for push off. Concepts such as this are often missed with common clamshell or circle tubing abduction walk drills that do, in fact, “work” those muscles but are not authentic in their true preparation for running. Certainly GRF in runners is controllable to a significant degree by altering the forces at impact, in the case of runners, particularly with rearfoot strikers via increasing running cadence or steps/minute. Often in the clinic the injured runner is down around 75-80 steps per minute. They may think running slower is better for them, or easier...not realizing that when many runners lower their cadence they end up overstriding and thus increasing GRF. Recommending an increase in stride rate will actually move COM forward and decrease their impact forces through the heel, which, based on this study, may be helpful especially for runners with PFPS, plantar fasciitis, and achilles tendinopathy. PEAK PERFORMANCE PATIENT: Marley said: “ I didn’t know I would feel so much faster and more efficient when I run at the higher step count. This is the strongest I have ever felt!“ History: Marley was a collegiate runner training at 35-40 miles/week. She developed L hip symptoms that were diagnosed at school as hip bursitis. Rest was ordered but every time she tried to resume running the pain returned. We met Marley at a runners camp where she was assisting in coaching high school runners. Being around other runners only fueled her desire to run. Objective: Standing STJn showed leg length discrepancy. NWB and WB hip Abductor length testing showed tightness. FWB recovery from Hip Adduction was poorer. Asymm foot overpronation noted with esp SLB dynamic testing. Subsequent TM run test once painfree showed an 180 inclination angle at heel contact and a cadence of 78.steps/min on R foot. (See Fig A) Fig A Fig B Discharge Re-Evaluation: Marley’s running was again analyzed in 2D (Figure and her angle of inclination at foot contact was now 12 degrees. She had a cadence of 88-90 steps/min R LE. She was still a heel striker, but the contact point on her heel was slightly anterior to the original contact point. Her body lean was inclined forward, and she felt much stronger and able to push off easier. She self selected a comfortable speed of 6.5 mph on the second analysis. She has been running now for 6 weeks and has zero pain. Treatment: Initial: Shoe lift to address LLD. Functional dynamic stretching for her ITB/TFL along with WB based strengthening of hip Abd’s and ER’s as well. Dynamic balance exercises promoting pronation deceleration and the ability to resupinate were initiated and advanced. Superfeet OTC inserts were obtained and self-adhesive posting was added to semi-customize biomechanical demands. Subsequent – once symptoms gone: Cadence was increased for Marley to 84 and maintain that for 5 minutes in a 30/30 walk/run using a metronome app on her phone to ensure proper pace. She was taken up to 88-90 steps/min with the use of a metronome to ensure keeping the new cadence. Ran 3-4/week while also continuing her strengthening and functional stretching program. She did this for four weeks and gradually increased her run 5 seconds while decreasing her walking 5 seconds until she was running 5 minutes. When was then able to gradually maintain that new cadence she would increase the running by one min every three days. Once she hit ten minutes successfully, she used the metronome sporadically only and continued her gradual increase in time running. 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. Karen Napierala, PT, AT, MS, CAFS 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