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

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

I initially injured my knee a few years ago and never sought treatment. After starting to be more active and working out regularly, the pain was intense to the point normal walking was very uncomfortable and I could not work out like I wanted to. I finally sought out treatment and was fairly discouraged after my MRI that there was not a more specific diagnosis. I was referred to Peak Performance and was extremely skeptical that PT would help my situation. My mind was instantly changed after my first visit when Andrew was able to determine that my knee pain was related to my IT band. I finally saw light at the end of the tunnel after receiving his diagnosis! After working the program Andrew gave me, I am now able to perform normal daily activities virtually pain free, and am regularly working out 4 to 5 times a week. I have my occasional flare-up, but now feel I have the tools to know how to alleviate the pain. Thank you, Andrew! Sarah Rosenberg

After decades of running without injury despite my weaknesses and poor mechanics, things finally caught up with me in the form of a hip problem and plantar fasciitis. That is when, providentially, my path crossed with Allison. Even though I live on the West side with many PT locations between there and East Rochester, I felt led to make the trek to Peak Performance and I am so thankful to have landed here! As Allison has shared her knowledge, skill, creativity and encouragement, I have learned so much, am way stronger and have the tools to stay that way. I am back to running and look forward to increasing the time and distance while continuing to implement all that I’ve been taught. A shoutout, also, to Mike, Karen, and Andrew, who were also sources of advice at certain times over the past year. It is a great team that Rochester is blessed to have working to help so many get relief from pain and regain function. Thank you! Lynn Eich Sept. 4, 2019

After years of running, I developed pain in my left ankle. The pain increased to the point where I couldn’t run anymore and had to look for other options for cardiovascular exercise. My doctor recommended Peak Performance Physical Therapy. I was fortunate enough to work with Allison, who provided me with a thorough assessment of what was causing the pain. Allison provided me with a variety of exercises to build strength and increase flexibility/mobility. After a few months of physical therapy I am back running pain free. Thank you, Allison! ~ Ryan Tauriello May 31, 2019

I am a year and a half out from back/disc surgery and thought I would never be able to run or work out again. Andrew and Mark helped to isolate issues that most likely contributed to my long-term back issues, and worked through exercises to specifically help me get back in shape and be able to work out again. They not only helped to alleviate some of the pain, but brought me through workout routines that I can take home and do on my own. I appreciate their dedication and hard work to create a routine tailor made for me. Michael G. September 20, 2018

Before PT I had a hard time jumping; now it is fine. I had a hard time running and now it’s fine. My heel has gotten so much better with my PT! Ryan G. September 20, 2018

When I arrived at Peak Performance, I struggled with standing and walking for more than 5 minutes at a time. I was sleeping only on my back. Now, thanks to Mike and Karen (mostly Karen-but she called for backup when I needed a manipulation), I am walking and beginning to run again. Thank you Lord, Karen and Mike! Carl L. April 18, 2018

I came to Peak Performance after having foot surgery. At the time, I enjoyed running but was not able to run, due to the pain. Throughout my experience I learned stretches and exercises that helped strengthen my foot. Slowly I began to regain my full strength and resume my favorite activities. The environment at Peak is very warm, comforting and welcoming. This was not my first time at Peak…4 years ago I came in for a broken leg, and Mike helped me get off my crutches and back to normal. I was so glad that I came back here. If I ever have another injury, I will come back again. I would 100% recommend anyone with an orthopedic problem to come to Peak Performance. Myles V. April 10, 2018

Last fall my knee made a popping noise while I was running and became sore and unstable, which shut down a number of my most enjoyable workout activities and ultimately led me to Peak Performance and Andrew Neumeister. Over the course of several months, Andrew worked with me to rebuild strength and stability in my knee and helped me understand potential causes of the problem. More importantly, he provided a regimen of exercises that have increased the strength and flexibility in my injured leg. As Andrew introduced each new exercise, he explained its purposes (strength, speed, balance) and which muscles they were designed to work. He has endless imagination for creating new exercises and hitting muscles in ways that work for a particular injury. Andrew’s personality was a big plus. He displayed confidence and expertise while being empathetic and friendly, a rare and effective combination of traits. He encouraged me and kept things light, which helped me to take ownership of my recovery and to develop enduring approaches to fitness. About four times a week I go through variations of the exercises and drills Andrew taught me, and I appreciate the discipline and form he taught me so that the exercises do what they are intended to. This spring I am hitting the trails running again, and I have Andrew to thank for that! Jeffrey C. March 23, 2018

Peak Performance has helped me get back into the game! I live a very active lifestyle and being able to do all the things I love without pain or limitations is important. I came into Peak Performance because the pain I was experiencing was so intense it made even walking difficult at times. Mike was able to identify the source of my pain and gave me the tools to get back to doing the things I love like running, hiking, biking, basketball, volleyball, soccer and weightlifting. Now I feel that I can get back to my usual lifestyle just in time for summer. Peak Performance will get you back to doing the things you love! Christopher P. March 5, 2018

My experience at Peak Performance Physical Therapy has been great! Before coming here, I couldn’t play soccer, run or even walk like I could before. Now I am fully healed and can perform even better than I could prior to coming to Peak. Thanks, Karen! Janelle E. February 8, 2018

When I started with Mike I was limping badly and thinking about meniscus surgery. After a lot of work and patience with Mike, I am now pain free. I am returning to my normal activity day to day as well as working out again, running, biking, and swimming. Soon I will also be back to hockey and skiing. I want to say a very large thank you to Mike for helping me heal a very painful knee. Everyone at Peak has been extremely helpful, making this healing process tolerable and ultimately successful. Christopher W. November 6, 2017

I was born without kneecaps and have developed undersized, misshapen kneecaps over the years. This has prevented me from playing basketball and running, the two things I love. When I came to Peak Performance, I couldn’t even do a squat without weight. I had severe knee pain while jumping and working out. Over time I have majorly increased the flexibility of my knees and improved my overall ability. I am able to perform at a normal level without pain, and I can do what I love without any problems. Peak Performance has made me a better basketball player, and has helped me through my knee issues. Justin H. November 2, 2017

After surgery on my left meniscus, I had very limited range of motion and strength. I started PT with Andrew and he gave me hope that I would regain full function and get back into my weight routine and jogging. In the beginning, I didn’t really believe I would ever jog again. Andrew slowly worked with me on exercises for my knee and also helped me with lower back issues. He challenged me but made sure I didn’t work past pain. Andrew has a pleasant and patient way about him. I really like how clearly he explained each exercise to me. I hope I don’t need additional therapy, but if I do, I will surely be back and request Andrew! Catherine R. June 6, 2017

Before I came to Peak Performance, I was unable to run and had to sit out a whole season of indoor track and part of outdoor. Now I am back running and finally feel fast again. Mike has helped me overcome my injuries and regain my confidence! Ann H.

I’ve been running competitively for 40 years. Last year, I came to Peak Performance with high hamstring tendinopathy. Mike took a methodical approach, with measurements, along the way. He was a willing, interested partner in my diagnosis and pushed me to “be” better, and not just “feel” better. I am now back to full-scale competitive running, including speed work. Peak Performance, and Mike in particular, has allowed me to continue to function at a high level, pursuing lifelong aspirations. I can’t thank Mike enough. He's helped me many times over the years, this one being the longest, most frustrating rehab. I wouldn’t have gotten through it without him. David B.

Before I came to PT, I was having trouble with my Achilles. I was having trouble running and sometimes even standing for long periods of time. After PT, I am back to my normal routine and am running again with no problem! Travis C. January 19, 2017

Before I came to Peak Performance, I was having trouble running at all. I was used to running 6-8 miles a day, and by the time I started coming, just 100 yards was very painful. Right now I am back running and building my endurance back up to be in racing shape. Overall, I feel much better and I am back to doing everything I love doing. Peak Performance has helped me recover, get stronger, and get back on my feet! Sarah Henretta December 28, 2016

Before coming to physical therapy, I had trouble with the activities I enjoy doing most. I couldn’t run as far or as fast as I wanted without pain, and my ability to run slowly started to drop to the point where I couldn’t go on a run. I started at Peak Performance with inflexibility in my Achilles and stress reactions in both my shins. After a couple months at PT, I am back to running better than ever and have more motion/flexibility in places I didn’t before! Claire Powell December 27, 2016

My experience at Peak Performance started with me hobbling in to bring my daughter in for a shoulder injury. At the time, I was in a full calf walking cast due to a sprained ankle. When I got the cast off, I could barely move my foot. I was unable to go up or down stairs, run or even walk for very long. The time in the cast made my ankle very stiff and weak. After working with Andrew, and making sure I stretched every day and did my work at home, I am almost back to where I was before my injury. I am back to yoga, taking stairs and working my way to running a 5k! Jennifer S. Dec. 20, 2016

Before PT, I could not run more than .2 miles without pain. Now I can run at least 20 minutes (2.4 miles) with no pain! Prior to PT, I was experiencing pain when squatting or pivoting with weight (playing with my kids). Now I’m able to do so with no pain. Prior to PT, I was unable to do lunges without pain and swelling. Now I do lunges with 8 pound weights and only some mild feeling if I do too many. Thanks Karen and Peak Performance PT! Kathryn B. December 6, 2016