We’re proud to be the annual sponsors of the The Core Studio soccer team. Here’s an exciting update from team cap’n Travis Dye.
The season got off to a great start with wins in our first six games. Week 7 was a showdown between two 6-0 teams for sole possession of first place. Unfortunately, we had several players who were unable to make it for the game. We were able to field a full team, but were short on subs on a warm day while the other team had close to a full set of replacements on the sideline. We battled to a 1-1 tie at the half, but fatigue and their superior numbers ultimately got the best of us in a 4-1 loss.
Work schedules and vacations made July a bit of a rough stretch for numbers, but we managed to close out the season with one win, one loss, and one tie. Our last game, a 4-4 tie, included a second-half comeback from a 4-1 deficit and gave us momentum that we were able to carry into the post-season tournament. We finished the regular season 7-2-1, which was good for the second seed into the tournament and was our best record in several years, if not the best ever.
We scored the most goals out of the eight teams in the league and gave up the second fewest. Most importantly, everyone had fun and no one was seriously injured.
Our tournament started this past Monday and we were able to get back to our winning ways with a 6-2 victory. We play again on Monday, August 4 with a berth in the August 11 championship game on the line. Except for our goalie who sustained a bruised heel in the final regular season game and another player who is off to Indonesia, we should be at full strength for this week’s match-up. I’ll keep you posted on the outcome.
Thank you again for helping sponsor the team. All of the players have expressed their gratitude that you were willing to help pick up the cost of fielding the team.
Special thanks to star physical therapist Antara Quiñones for providing this write up on a recent article from the Journal of American Academy of Orthopedic Surgery.
Cadaver Cartilage Grafts Prove Promising for Large Cartilage Tears of the Knee
A recent review of the most up-to-date research found that large cartilage tears at the knee joint are best repaired with donations from cadavers. The review found that a technique called “Osteochondral Allograft Transplantation,” or OCA, is versatile in terms of what kinds of repairs it can help and has the best long-term effects when compared to alternative surgical options.
Chondral is a fancy word for cartilage. Cartilage is a protective layer of rubbery tissue that covers the ends of bones to prevent rubbing. There are two important layers of cartilage in the knee- one layer of articular cartilage that covers the end of each leg bone and your knee meniscus, which resemble rubbery washers that sit on top of the articular cartilage. Both of these can be damaged from trauma (like a side blow to the knee or excessive twisting forces) or they can degrade over time from normal wear and tear. Sometimes, due to abnormal forces across the knee joint or excessive use with improper form these pieces of tissue rub and tear earlier in life. This often happens to athletes who perform the same repetitive movements again and again or in athletes with high impact activities. In addition, if there are any muscle imbalances the knee joint moves at the less than optimal angle speeding up the wear and tear on the cartilage. This breakdown in the cartilage causes swelling at the knee, pain, and interferes with a person’s ability to perform their sport or typical functional tasks of life.
Cartilage does not have a good blood supply which means that it does not heal well. What’s more, it has no nerve endings so you do not really realize there is a problem until damage is done. Chondral degradation is graded on a scale from one to five, with five being the worst. Repair options hinge on the size and location of the tear as well as the goals of the patient.
Smaller lesions (<2 cm^2) are often repaired by clipping out the frayed pieces of cartilage (debridement), taking a piece of cartilage from another part of the knee and placing over the tear (osteochondral autograft transplantation), or by poking tiny holes in the bone below the cartilage so the blood clots formed will provide some healing and regrowth of fibrocartilage (microfracture). These techniques, however, are less effective for larger tears (>2cm^2 to <10 cm^2) or deep tears. Bigger tears are treated by either OCA or by an autologous chondrocyte implantation (ACI). An ACI procedure involves harvesting the cartilage cells and growing them outside the body and then planting them in the effected area. It is worth noting, however, that an OCA is the only back up procedure for a failed ACI. Authors of this review found that an OCA is less invasive (only one procedure), is more versatile, and has better long-term outcomes than an ACI.
The OCA procedure has become refined with time. The cartilage donation must be collected within 24 hours of the person passing away and is taken from people with healthy knees. The tissue is screened for a host of diseases. This process takes anywhere from 14 to 28 days, during which the cartilage is kept at body temperature, its ideal environment. The cartilage is then selected based on a size and location match, as there is a very minimal risk of tissue rejection since there is little to no immune response in cartilage. If the tear is deep and a bone graft is also required then the risk of rejection is only slightly higher.
An OCA procedure includes several different techniques depending on the type of tear. The most common technique is called a plug, where the chunk of torn cartilage, and perhaps bone, is removed and the new piece of cartilage is fitted perfectly in its place with as tight of a fit as possible. If the fit is not completely snug the surgeon can fasten it in using dissolvable materials or tiny hardware that will not disturb the knee function.
Rehabilitation after the surgery is broken into three phases. The first phase is a period of rest to allow the tissue to heal, with the amount of use of the leg depending on the type of repair. Typically phase one lasts 6 weeks. Phase two is from week six to twelve and involves return to daily activities, strengthening, and full motion of the knee. Phase three is from three months on and involves full return to sport with the guidance of a physical therapist. From six months up to one year after surgery repetitive high impact activities should be avoided.
Long-term outcomes for OCA procedures are promising with the greatest percentage of success in a younger, active population with traumatic onset of cartilage damage less than one year prior to surgery. That being said, however, the numbers are also promising for the non-traumatic middle-aged population with tears greater than 2cm. The authors suggest that an OCA become the standard practice for larger tears of these populations.
Seth L. Sherman, MD, et al. Fresh Osteochondral Allograft Transplantation for the Knee: Current Concepts. In Journal of American Academy of Orthopedic Surgery. February, 2014. Vol 22. No. 2. Pp. 121-133.
For more information on this topic, click here for an informative article that is on our website.
Running is different from walking because you are on only one leg at a time with each stride. With walking you gradually transfer weight from one leg to the other, not so with running. When you break down running to the most basic motion, it is jumping from one leg to the other over and over again.
Everyone has slight differences in strength or flexibility between our legs, but significant differences are amplified with running. To help you decrease the subtle differences between sides it is important to do single leg exercises and stretch the muscles that are tight.
For balance: The first place to start is just balance on one leg. Check to see if you can stand the same amount of time on each leg and how difficult it is. If this is easy start to add arm or opposite leg movements.
For strengthening: do single leg squats or single leg press, single leg calf raises, and single leg bridges (make sure to keep you pelvis level).
For dynamic strength/drills: do bounding (long strides hopping from one leg to the other), side shuffle with quick feet (almost a slight hop from one foot to the other going sideways – both directions), and high knee skipping. These are just a few ideas of ways to start working on individual leg strength.
For flexibility: It is a good idea to stretch the major leg muscles (hamstrings, quads, hip flexors, calf, and gluts).
AFTER a run, if you find that one side is significantly tighter than the other make sure to stretch that muscle group. Get balanced and keep running!
Kristi Moore, MSPT
Alpine Physical Therapy, North
2965 Stockyard Rd.
Missoula, MT 59808
Special thanks to star physical therapist Leah Versteegen for providing this write up on a recent article from The Journal of Bone and Joint Surgery.
Shoulder rotator cuff repair aims to suture torn rotator cuff tendons and provide them with the optimal environment to heal and minimize chance of retear. Overall retear rates have decreased over the years, but are still a major concern. Better suture techniques have been thoroughly investigated but there is less attention paid to the rehabilitation protocol. Currently the gold standard for rehabilitation after surgery is to wear an abduction brace and begin physical therapy for passive range of motion within the first few weeks.
As surgical techniques have evolved from open surgery to arthroscopic surgery, there are questions as to whether this rehabilitation protocol is ideal. Animal studies have shown that longer periods of immobilization are beneficial to healing after rotator cuff repair.
A recent study published in The Journal of Bone and Joint Surgery investigated the effectiveness of immobilization after surgery in human subjects. The goal was to determine if longer periods of immobilization resulted in any clinical differences in outcomes, including shoulder range of motion, retear rates and clinical outcome scores. One hundred participants who met specific criteria and underwent arthroscopic repair of the rotator cuff were randomly sorted into two groups. One group was immobilized after surgery for 4 weeks, the other was immobilized for 8 weeks. After the allotted time of immobilization each participant underwent rehabilitation with a physical therapist that included passive range of motion then progressed to active range of motion and strengthening.
At the follow up conducted at 6 months and 24 months after surgery, there were no statistical differences between the groups with retear rates, passive range of motion or clinical scores. There were more reports of stiffness by participants who were immobilized for 8 weeks compared to those immobilized for 4 weeks. Patients were also less likely to adhere to the immobilization guidelines for a full 8 weeks compared to those immobilized for 4 weeks.
With no benefit in healing or diminished retear rate gained by immobilization for 8 weeks, it is deemed most beneficial to promote immobilization for 4 weeks after rotator cuff repair. The retear rate in this study was 10%, compared to previously reported rates of 20%-40% in studies that involved early passive range of motion before 4 weeks Thus a 4 week immobilization period may give the rotator cuff ample time to heal without increased stiffness and decrease retear rates.
Kyoung Hwan Koh, MD et al. Effect of Immobilization without Passive Exercise After Rotator Cuff Repair. In The Journal of Bone and Joint Surgery. March 2014. Vol. 96A. No. 6. PpE44 1-9.
Special thanks to star physical therapist Leah Versteegen for providing this write up on a recent article from Sports Health.
The shoulder is one of the most mobile joints and most complex joints in the human body. It moves in no less than seven planes if you consider only movement at the glenohumeral joint. If you then take into consideration that the shoulder also involves the acromioclavicular and sternoclavicular joints as well as the scapula, the movement becomes even more complex. It is essential that the shoulder joint be controlled by well balanced muscles that control each of the aforementioned joints and the scapula, particularly in athletes that rely on shoulder strength and mobility for their sport. As the shoulder ages, well balanced movement becomes harder to achieve, presenting a challenge in injury prevention and treatment. The three most common shoulder diagnosis in the aging shoulder are rotator cuff pathology, osteoarthritis, and adhesive capsulitis.
Rotator cuff pathology is probably the best known shoulder joint injury, particularly in athletes involved in throwing sports, swimming or racquet sports, and can vary from tendinitis to a full thickness tear. Aging is associated with an increase in rotator cuff tears, both partial and full thickness. Smaller tears are often successfully treated with arthroscopic debridement, but this procedure is not as successful for full thickness tears thus leading to surgical repair of the tear. One study showed rates as high as 98 percent patient satisfaction after rotator cuff repair. The next logical question is what the most effective method of repair may be and as expected it depends on the type of tear and the patient (age, post-operative goals, health status, etc). The options are arthroscopic or open repair, single row or double row.
WIth a partial tear the tear can be completed to a full tear then repair or it can be repaired in situ, not completing the tear before repair. The former technique is most common, but in situ repairs are showing a lot of promise with research reports of 94 to 98 per cent patient satisfaction. From a biomechanical perspective, double row repairs are stronger but not necessarily leading to an advantage with clinical outcomes. Augmentation, another major mechanical emphasis in rotator cuff repair, involves using an extracellular matrix to help stimulate tendon healing. The tissue used for augmentation can be an autograft, allograft, xenograft, or synthetic material. Most recently, human dermal allograft shows the most promise with proven clinical results though new techniques for augmentation are being tested with platelet rich plasma and stem cells. Overall, it is important to differentiate age, desired level of sport, and type of sport before deciding on the treatment for rotator cuff pathology.
Osteoarthritis of the shoulder is not as common as the knee or hip, but it is not uncommon and can be quite debilitating for older athletes. Treatment options include debridement, capsular release, microfracture, glenoid resurfacing, or total shoulder arthroplasty. Again it is important to differentiate the athlete and desired goals in order to determine the best treatment. For the older recreational athlete (65 and older), total shoulder arthroplasty results in excellent long term survival rates and high level of return to sport. For younger patients (under 50) almost 50 per cent reported unsatisfactory results in on research study after total shoulder arthroplasty and survival rates were much lower than in their older counterparts. For the younger but still mature athlete, the less invasive treatments are thus more common. Though the research is inconclusive as to which option is best for this population, biological glenoid resurfacing is the most recent promising treatment added to the list of less invasive options. The resurfacing can be achieved with an Achilles tendon allograft, lateral meniscus allograft, or dermal allograft.
Adhesive capsulitis is most commonly known as frozen shoulder and is characterized by a loss of both active and passive range of motion at the glenohumeral joint. It is classified as primary idiopathic or secondary to another pathologic process, and can often be associated with diabetes or thyroid disease. Treatment with nonoperative management is highly successful and should be the first option. Conservative treatment may include a steroid injection, physical therapy, or both. Operative treatment is considered with recalcitrant adhesive capsulitis or when conservative treatment fails as can be the case more often with younger patients or those with diabetes.
When considering treatment options for shoulder pathology it is essential to consider the patients demographics, particularly age, and desired level of activity or sport participation. While older athletes may have a more progressive or advanced injury process, often they have lower performance goals.
John M. Tokish. The Mature Athlete’s Shoulder. In Sports Health. January/February 2014. Vol 6. No 1. Pp 31-35.
Doing untold numbers of post-race massages for our esteemed marathon participants today was hard work. But being together with a fantastic group of coworkers made it great. I believe we did more than the 120 massages we did the past two years. At least it seemed that way. I know it got a little tight at times with so many people nearly dying (running can do that to you) to receive one of our quality post-race sessions.
Special thanks to Angela and to Kristi for taking this event and running with it. Uh . . . pun intended! Organizing this entire event for us is a huge undertaking, and we know you put a ton of effort into making it come together so well. Great job! Missoula Marathon number 8 is in the bag.
To everyone involved, all the way from being at hugely the successful Expo, to the folks on the front lines, to massage coordinators, to bottle washers, to the Alpine runners (including Dennis for running the full marathon, along with four others who ran the half), and to our tired-handed PTs, thank you, thank you, THANK YOU! Thanks for giving your time to be there in Alpine array and with your gorgeous smiles . . . and for steading the load for the team. We appreciate all your involvement!
Here’s to our 8th consecutive annual marathon sponsorship. Hooray!
Brent . . . the dude who’s spent . . . from doing a boat load of post-race massages at our favorite marathon event! (Wow. It even rhymed!)
For the 8th consecutive year, Alpine Physical Therapy will be the exclusive physical therapy sponsor of the Missoula Marathon. This prestigious sponsorship puts us face-to-face with runners of all skill levels, giving us opportunities to provide consultation to all participants and to present numerous training seminars for area marathoners.
Our team of 14 therapists provides both pre- and post-race massages for all Missoula Marathoners. In addition, we offer free injury consultations both before and after the race.
We offer a unique service for all runners called The Runner’s Clinic, which is overseen by expert physical therapist, Kristi Moore, MSPT. Kristi is our sport biomechanics expert associated with high-mileage running.
Participants entering The Runner’s Clinic undergo 2-D video analysis of their stride, along with a comprehensive body and movement examination. Integrating the 2-D video analysis with the clinical exam provides an exacting assessment for identifying running faults that can contribute to injury and impact performance. The results of the examination form the basis of specific corrective exercises that you’ll begin learning and doing on day one! For more information on The Runner’s Clinic, be sure to visit our website by clicking here.
Gaining knowledge about your injury and what you can do to resolve it puts you ahead of the pack. We invite you to peruse The Runner’s Clinic section of our website for information on various injuries common to runners. Gather additional information by clicking on the Patient Resources section of our website for news and information on these and other conditions runners face.
We have three locations in Missoula.
- Alpine Physical Therapy, North
We are located at 2965 Stockyard Road in the North Reserve Business Center, just behind Carino’s. 406-541-2606.
- Alpine Physical Therapy, South
We are located in the Peak Health & Wellness Center South on the corner of Highway 93 South and Blue Mountain Road. 406-251-2323.
- Alpine Physical Therapy, Downtown
We are also located in the Peak Health & Wellness Center Downtown at 150 E. Spruce, Ste A. 406-549-0064.
All participants of the Missoula Marathon are provided free injury consultations with one of our physical therapists. Call to schedule a free injury consultation or to schedule for The Runner’s Clinic.
Special thanks for this article to Alpine super star, Antara Quinones, DPT.
IASTM is short for Instrument Assisted Soft Tissue Mobilization and just might be the answer if you have been dealing with nagging, recurrent muscle or “soft tissue restrictions”. Ideally layers of muscle and fascia glide over one another as move through a range or contract muscle tissue.
Runner’s often end up with injuries that restrict that normal tissue mobility. This lack of mobility often causes pain and inability to run with proper form. Common examples include iliotibial band syndrome (ITB), plantar fasciitis, achilles tendinitis, chronic tight calf muscles. and hamstring strains.
IASTM is a technique physical therapists use to break up the adhesions between the tissue layers and bring blood flow to the area. The treatment is often intense at the time but is quick and highly effective if followed with good stretching and correction of faulty movement patterns.
Want to try it out? Alpine’s Physical Therapists will be performing post-race massages after the Missoula Marathon and we will have our IASTM tools available if you want to try this technique out.
Look for the MASSAGE signs at Caras Park from 8:00 am to 1:00 pm. All massages are 15 minutes for $20. Sign up when you register for the race or at our booth upon completing your run.
For more information, visit our clinic web page on this topic by clicking here.
As we get closer to the Missoula Marathon it’s time to start thinking about the things besides just the running. These are a collection of tips that we’ve collected over the years from our own experience and from others who have shared their wisdom.
In the few days or week leading up to a race, avoid doing new things for your body because you just don’t know how your body will respond. Make the day before a long race a lazy day with minimal prolonged standing and walking. Be extra nice to your knees and feet. If you’re thinking about using tape on race day, make sure you have already tested running with it on.
Morning of the race – eat what your body knows. Warm-up! Run in the shoes you trained in. Run in the clothes you trained in. You don’t want any surprises on race day! BODY GLIDE (nipples, bra line, waist band, inner thighs, under heart rate monitor if you wear one) Don’t overdress – to help get it right you should be a bit cool before you start your warm-up. A few pieces of toilet paper in your pocket might come in handy. Water and Electrolytes are equally important.
Schedule a massage for after, NOT before the race. Believe in yourself and your training. Visualize yourself crossing the finish line. You’ve finished! Jump in the River!
Pre-race injuries: Here’s a guide to help you determine whether to run or not to run.
Quality of Pain
PAUSE: Mostly ache
GO FOR IT: Dull ache, tight, sometimes sharp
JUST SAY NO: Sharp, stabbing, sometimes sharp searing
Intensity of the Pain
GO FOR IT: Mild
JUST SAY NO: Severe
Tolerance to Running
PAUSE: Worsens with mileage
GO FOR IT: Stays the same or improves with mileage
JUST SAY NO: Worsens and increased mileage causes swelling
Effect on Stride or Form
PAUSE: Mild change
GO FOR IT: No change
JUST SAY NO: Altered stride or form
Stage of Injury
GO FOR IT: Chronic
JUST SAY NO: Acute
If you have other questions, need an injury consultation (free to Missoula Marathon runners), or need more information, call our clinics at 406-251-2323.
Persistent pain is a newer term being used in place of “chronic pain.” Nearly all of the physical therapists at Alpine Physical Therapy took part in the 6th annual Montana Pain Initiative Conference, a two-day conference held at the University of Montana on May 30th and 31st. This year’s conference was titled “Treating Pain: Neuroplasticity and Team Care in an Evolving Healthcare System.” Resultantly, we thought it would be appropriate to include a recent literature review on the topic. It’s a bit lengthier than most of our blog posts, but it’s well worth the read.
Chronic pain is constant pain that lasts long after the expected time frame of healing. For instance, if you roll your ankle you would expect that ankle to be painful for the length of time that it takes for the ligaments and tendons to heal—say a week or so depending on the extent of the sprain. If there was an underlying chronic, or persistent pain, component then your ankle might still hurt six months after the injury, long after the actual tissue damage has corrected itself.
To understand why the pain that people feel is very real we need to look at how we actually feel pain. For 400 years the medical model for understanding pain was simple: when you step in a flame the sensors in your feet feel the pain and a pain signal is sent via nerves to your brain which shouts Tissue is being damaged! Move your foot! Then in the 1960s this model was proven to be much more complicated. Instead of one continuous pathway (foot to brain), there is a pathway going up with three junctions (at your limb, at your spine, and in your brain) and a pathway going down with the same junctions. Each of these junctions interprets pain and can do so in multiple ways via pain sensors.
At the level of your limbs there are two types of pain sensors, which are then further divided into sub categories. Each of these categories is responsible for a different type of pain detection such as hot or sharp. They also each transmit signals to the spine at varying speeds. This explains why when you accidentally touch something hot you quickly pull back your hand but when your leg falls asleep from sitting you do not notice for a while. To make things more complicated, one category of these pain sensors (known as C fibers) sends signals very slowly with generalized information in regards to pain location and are extra sensitive to inflammatory chemicals that your body creates to help to heal itself. As an example, C fibers are responsible for that achy pain you might have after rolling your ankle; the pain is in your foot and a little up your calf even though the tissue damage might only be at the outside of your ankle. Luckily, C-fibers respond well to NSAIDs like ibuprofen so you take a few of these and the pain signals being sent from your ankle to your brain are quieted as the inflammation decreases.
Pain sensors at the next level, your spine, are more complicated. The sensors here are the go-between from your limbs to your central nervous system (think brain and spinal cord). The caveat is these pain sensors can be ignored by your brain. For instance, if you are in a house fire you grab your baby and run out of the house before you realize that your arm is burned. Your arm is obviously hurt, but you didn’t feel it at the time because of your brain sending a message down to your spine pain receptors saying, Override, there are more important matters at hand!
The highest levels of pain sensors are in your brain in multiple locations. At each of these locations pain is controlled by complex relationships between emotions, brain chemicals, and the nerve matrix itself. Your brain determines what pain you acknowledge and what pain you ignore.
Remember that there are three levels of pain sensors going in both directions? If our brains responded to all of the pain sensors signals at all three levels imagine how much information that would be. A key piece to a healthy pain response is for our brain to recognize which signals are important to acknowledge and which ones we should ignore. Or, which signals are telling us that there is actual tissue damage occurring, and which ones are simply saying, this surface is lukewarm.
In people with persistent or chronic pain, their pain response system at one of those three levels has lost the ability to send accurate signals or ignore signals all together. In other words, the communication lines are crossed and even though there is no tissue damage occurring that person is feeling very real pain. Psychotherapy, relaxation techniques, and rehabilitation (physical therapy or occupational therapy) to down-train the hypersensitivity of the pain sensors are all ways the muddled pain system can be addressed without drugs at the brain level and are often rather effective since the brain is the control center of the pain itself.
Drug management of chronic pain is complicated and controversial. NSAIDs (i.e. ibuprofen), aspirin and acetaminophen (i.e. Tylenol) have mixed effects for treating chronic pain depending on pain location. Long-term use of NSAIDs can cause issues in your stomach and intestines. Opiates and opioids (most commonly morphine) has been the standard drug prescribed. This drug class acts at all three levels of pain sensors. The catch is three fold: you develop a dependency, require higher and higher doses, and suffer side effects as a result. Long-term use studies (>6 months) show that opiates lose their effectiveness over time so it is not recommended to take them long term.
More promising are drugs that address the pain at the control center itself: your brain. These drugs include:
1. Anticonvulsants (i.e. gabapentin and carbamazepine)
2. Antidepressants (which low doses address both depression as well as diminish the pain signals being sent)
3. Tramadol (acts similarly to anticonvulsants and antidepressants but can cause many of the same side effects as opiates).
4. Muscle relaxants (i.e. cyclobenzaprine, tizanidine, both which do not have evidence to support the effectiveness of long term use)
More location specific treatments include creams or patches placed on your skin at the pain location such as lidocaine or NSAID patches.
Moderate evidence exists for non-invasive treatment strategies, which include transcutaneous electrical nerve stimulation (TENS) (this confuses your pain sensors and decreases pain by wearing sticky pads with mild current flowing to your skin), hot or cold packs, and acupuncture. Spinal injections or nerve blocks are yet another way to help to manage pain but have mixed results as well.
However, no matter what drug options are used, it should be noted that the most effective way to treat persistent pain is in utilizing multiple approaches and calling on a team of health care providers to help to restore a person’s overall function.
Richard L. Uhl, MD, et al. Management of Chronic Musculoskeletal Pain. In Journal of American Academy of Orthopedic Surgery. February 2014. Vol 22, No 2. Pp 101-110.