Ana Soulia, DPT, has joined Alpine Physical Therapy. Soulia earned her doctorate in physical therapy from Pacific University in 2005. Her clinical interests include general orthopedics, Pilates-based rehabilitation, movement impairment evaluation and treatment, hip and pelvic girdle dysfunction, and working with ballet and modern dancers.
When asked: “How did you find your way to Alpine Physical Therapy?” Here’s Ana’s reply:
With the decision to move back to my hometown, I set about researching orthopedic clinics in Missoula, and Alpine immediately stood out with its philosophy of care, promotion of continuing education, and integration of Pilates-based exercises into the rehabilitation process. After meeting with Sam and Angela, I knew that Alpine was a perfect fit for me and am grateful for the opportunity to join this team of skilled and passionate therapists.
Ana, welcome back to Missoula, and welcome to Alpine Physical Therapy. We’re delighted you’re here and know that many people will benefit with your excellent care as a physical therapist.\
Click here for Ana’s full bio.
Special thanks to star physical therapist Leah Versteegen, DPT, of Alpine Physical Therapy for providing this write up on a recent article from the Journal of Bone and Joint Surgery.
ACL rupture affects an estimated 35 people per 100,000 and can increase based on gender and activity. Female athletes face a two to eight times increase in risk of ACL rupture compared to their male counterparts. With numbers like this, it is not wonder that the annual estimated health care cost for ACL repair is three billion dollars just in the United States. The most common treatment for ACL rupture is surgical reconstruction, though nonsurgical rehabilitation is also an option. The decision to reconstruct a ruptured ACL depends on many factors, including age, desired level of activity, episodes of instability and general health.
Before reviewing the surgical options for ACL reconstruction, it is important to understand the basic anatomy of the ACL, or anterior cruciate ligament. It is composed of two functional bundles of ligaments, the anteromedial and posterolateral bundle, which are so named due to their insertion sites on the tibia. Both bundles work together to stabilize the knee into flexion. The anteromedial bundle length remains constant throughout flexion and extension of the knee but is most taut at 45-60 degrees flexion. The posterolateral bundle is tight with extension but loosens with flexion in order to allow some rotation to take place at the knee joint.
Once the the decision to have surgery has been made, there are several factors to consider including timing of the surgery, technique used by the surgeon, and the graft site from which to build the new ACL. When making these decisions one must look at preoperative range of motion, swelling and strength as well as individual anatomy, post-operative activities and goals.
Timing of the knee surgery is one of the first factors to consider. There is evidence supporting early surgery, as it may lead to improved functional outcomes and decreased rate of future meniscal damage. However, delayed surgery can allow for potential avoidance of surgery all together if the individual is satisfied with their knee function. Allowing more time before surgery can definitely help an individual improve preoperative strength and range of motion.
Preoperative strength of at least 90per cent of the quadriceps, is correlated with improved long term functional outcomes. Preoperative swelling and limitations in range of motion are correlated with increased arthrofibrosis after surgery. Thus, a preoperative rehabilitation program focusing on decreased swelling, improved range of motion and quadriceps strength is beneficial.
There are two main surgical techniques utilized in ACL reconstruction, single or double bundle. Though the single bundle technique is far more common, with the double bundle technique being used primarily in Europe and Asia, the rupture pattern of the ACL in that individual and their unique anatomy should be considered by the surgeon when making the ultimate decision on which technique to use. Variations in the tibial notch, arthritic changes, multiligament injuries and bone bruising are all taken into consideration by the surgeon with the aid of a detailed flow chart. Outcomes measures detect no difference in long term functional outcomes between the two techniques, with the exception of fewer reported meniscal injuries with double bundle repair. Regarless, it is important that the surgery match anatomical placement of the ligament in order to help restore optimal biomechanics.
After the technique has been selected, the graft site is the next major decision. Typical graft options include bone-patellar-bone autograft, hamstring tendon autograft, quadriceps tendon autograft, and allograft. If a double bundle repair has been selected the bone-patellar-bone graft cannot be utilized. MRI scans can be helpful in allowing the surgeon to determine which tendon may be most useful based on graft size. The long term goals of the patient are also important in selecting the graft site. For example, an athlete that relies heavily on hamstring strength will not want to use the hamstring autograft. Similarly an individual who has to do a lot of kneeling will not want to choose the bone-patellar-bone autograft.
Once the surgery has been performed, several questions arise, including when one can return to sport, what is the chance of reinjury and/or developing osteoarthritis in the future. Return to sport is dependent on many factors including the healing of the graft, the individuals anatomy and the desired sporting level. For those who do not return to high level of sport, fear of reinjury is a common reason. Graft failure rate is about 11 percent and does not seem to be dependent of the choice of graft site. Several authors have actually reported a higher rate of ACL injury in the opposite leg compared to a reinjury of the repaired ACL. In general, those who do reinjury a repaired ACL are younger and returning to a higher level of activity. Arthritic changes and the development of osteoarthritis after ACL rupture is more common in those who have sustained some meniscal damage or lose range of motion in the knee joint.
Christopher D. Morawski, et al. Operative Treatment of Primary Anterior Cruciate Ligament Rupture in Adults. In the Journal of Bone and Joint Surgery. April 2014. Vol 96A. No. 8. pp 685-694.
For more information, visit our topic module on ACL injuries by clicking here.
The ‘C-Leaguered’ Alpine PT team has finished their final game for the season with mixed emotions. We had a strong season, then capitulated early in the tournament with a few unlucky kicks in the final moments of our last game. We ended the season with a balanced tally of 4 wins, 3 ties and 4 losses… and many awesome evenings of grass-kickin’ good times on the field.
This year we had many returning players from years past that nicely balanced out our new handful of Alpine staff and friends to the Missoula Parks and Recreation C League. Their were no injuries, no yellow or red cards, no field brawls, but a lot of semi-competitive/fully-recreational soccer games. We thank Alpine Physical Therapy for another fantastic year of sponsoring our soccer team and commend this business for supporting after-work, team-building, as well as health and fitness endeavors.
We have a lot to work on for the years to come and look forward to a cooler fall season of upcoming soccer.
Here’s this year’s team picture!
Special thanks to star physical therapist Leah Versteegen, DPT, of Alpine Physical Therapy for providing this write up on a recent article from the Journal of Bone and Joint Surgery.
Anterior cruciate ligament injuries are one of the more common injuries impacting young athletes. The impacts are not only physical in nature but have psychological components and add financial stress as well. As the prevalence of youth participating in sports has increased, ACL injuries have also increased. Some research estimates that return to sport after ACL rupture and repair is as low as fifty percent in young athletes, while epidemiological studies estimate that females are four to six times more likely to suffer an ACL injury compared to their male counterparts. For these reasons, a considerable amount of attention has been given to programs aimed to decrease ACL injury rate, particularly in the female athlete.
Research supports the effectiveness of many ACL injury prevention programs that have been developed in the past decade. These programs typically involve an altered warm up and inclusion of certain fitness drills in practice that include core work, stretches, plyometrics, strengthening and sport-specific agility drills. The end goal is to optimize muscle balance and improve the athletes biomechanics, particularly with jumping and cutting type movements that typically stress the ACL.
Aside from these ACL injury prevention programs, more recently certain researchers have recommended screening programs to identify the young athletes that may be at higher risk for ACL injury. Medical screening tools ideally are desigend to be sensitive enough to identify only the high risk individuals so that interventions can target this population rather than those who do not need the intervention, thus saving money. With an effective ACL injury screening tool, the athletes that are at highest risk can then participate in an injury prevention program, rather than having all of the athletes in the program, again with a goal of saving time and money.
As finances for youth and college sports can be limited and injury rates continue to rise with increased sport participation, it is important to find the most cost-effective program to implement that also provides the best results. It necessary to take into consideration the cost and accuracy of a screening tool, as the purpose of the screen is to identify those at risk. Similarly it is important to make sure that the intervention is targeting the correct population and is effective in making the modifications desired. Though research supports the sensitivity of screening tools as being effective in predicting ACL injury risk, these screening tests require extensive set-up, expensive motion analysis video equipment, and a skilled tester. Typically the athlete will run through a battery of jump and landing tests to determine the knee abduction moment. Even if a coach is educated on what to look for with a screening test and is able to use a simple camera, the time and cost required to conduct the testing exceeds the benefit.
The incidence of ACL injuries in youth is high enough that a screening tool is just not warranted. The high incidence rate equates to the fact that most athletes will benefit from an ACL injury prevention program, which are very inexpensive and highly effective as supported by research. On average, such programs decrease the incidence of ACL injury from three per cent to one pecent in a single season, saving on average $100 pre player per season in expenses related to such injuries. Universal ACL injury prevention programs for young athletes, male and female, are a cost effective strategy for reducing the physical, psychological and financial burden of ACL pathology.
Eric Swart MD, et al. Prevention and Screening Programs for Anterior Cruciate Ligament Injuries in Young Athletes. In the Journal of Bone and Joint Surgery. May 7, 2014. Volume 96A. Number 9. Pp 705 -711.
For more information on ACL injuries, visit our clinic resource page by clicking here.
Special thanks to star physical therapist Brace Hayden, DPT, CSCS of Alpine Physical Therapy for providing this write up on a recent article from Spine.
It is widely accepted that low back pain is one of the most common orthopedic pains we will experience in a given year. It is also a highly scrutinized and researched health condition, as it is a very costly public health problem that affects a third of all adults.
Treatments for low back pain range from medication, to surgery, to therapist-delivered care. Recently, Dipesh Mistry and a team of health scientists from the UK’s Warwick Medical School, performed a systematic review of the research on the quality and effectiveness of low back pain treatments performed by therapists. Acceptable therapies for low back pain included a lot of treatments from psychological interventions to intensive rehabilitation programs, from laser acupuncture in Australia to high velocity thrust manipulation in Sweden.
The targeted types of low back pain were classified as ‘nonspecific’, meaning they do not come from a likely cause such as a fracture, tumor, infection or inflammatory disease. Nonspecific back pain is generally known as the common back ache or strain.
Mistry’s team combed through the research to select only high-quality, randomized controlled trial-based articles on subjects older than 18 with a history of nonspecific low back pain. Their results largely followed the prior literature reviews consensus small, rather than the conventionally-accepted moderate positive effective gains from therapeutic treatments. They were able to use a total of 39 articles from various search engines (ie. Medline and Cochrane Controlled Trial Register) completed between the years of 1948 to 2013.
They divided the articles into two sub-classifications as either a confirmatory finding or an exploratory finding. Confirmatory are more rigorous, follow-up research that strides to confirm or test the hypothesis. Exploratory are more preliminary research that aims to generate future hypotheses or build a base for future research.
Of the accepted, high-quality studies, only 3 studies (8%) tested hypotheses and were classified as confirmatory. Eighteen studies (46%) were classified as exploratory findings. The remaining 18 (46%), fell short of a substantive conclusion and were given the ‘insufficient findings’ status.
The researchers further tweezed each articles’ respective study methods for appropriate statistical testing for each interaction between studied variables. Fortunately, appropriate stats were employed in 27 of the 39 of the articles. The remaining articles had sub-classification reporting deficiencies or other areas deemed too weak to qualify for this paper’s systematic review.
They concluded that the sub-classified (either the confirmatory or exploratory findings) therapies for treating nonspecific low back pain have been ‘severely underpowered’ in their analysis. In other words, over the past 65 years, the 39 acceptable high-quality articles were only able to provide exploratory class research with insufficient evidence to boot. Moreover, they had poor quality data in their reported findings.
Mistry’s team also generalized that if we hope to better identify which form of low back pain treatment will be the most economical and effective, then we need to better classify which subgroup of persons with back pain are appropriate for each treatment.
Future research was suggested here to develop new methods to effectively identify subgroups in back pain research. Furthermore, they recommended that the low back pain research community needs to collectively revise their current approach to subgrouping the back pain studies. Continued perpetuations of exploratory class research won’t help improve the care for our substantial population of persons with back aches looking for effective therapies.
Dipesh Mistry, MSc, et al. Evaluating the Quality of Subgroup Analyses in Randomized Controlled Trials of Therapist-Delivered Interventions for Nonspecific Low Back Pain. A Systematic Review. In Spine. 2014, Volume 39, Number 7, pp 618 – 629.
For more information on the specialties and services provided by Alpine Physical Therapy, please visit our clinic website by clicking here.
When you come to visit us at Alpine Physical Therapy for an evaluation or reevaluation, you might wonder why you have to fill out a form answering questions about what you can and cannot do when your therapist will be asking you about it anyway. There are several reasons that we ask you to fill out these “outcome measures.” (These forms are available on our website. Simply click here.)
First, they offer a nice sounding board for questioning during our evaluation. Physical therapy is about getting back to the things you love or functioning in your daily life with ease. We are better able to get you back to these things if we know what they are, and we can get to the heart of the problem more efficiently with a heads up of your areas of difficulty.
Second, in our changing healthcare industry, insurance companies and Medicare are becoming more focused on objective measurements to track progress. They want a hard fast number that shows improvement. By filling out an outcome measure initially, then again after a month or so of therapy, they have a more concrete idea of how far along you are in your healing process, which in turn legitimizes further therapy appointments.
Finally, outcome measures help the physical therapy profession as a whole better monitor effectiveness and timeliness of treatment techniques. Each outcome measure that Alpine uses is carefully selected based on evidence of its effectiveness at accurately reporting physical deficits and gains. We want to provide you with the best care possible, and outcome measures are another tool available to us to ensure that we are doing so.
Fore more information to help you get started at Alpine Physical Therapy, click here for our new patient web page.
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.