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

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

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

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