FRANCISCO QUINONES, DPT
What is tendinopathy?
Good question and the truth we don’t know exactly what happens to the tendon that makes it painful. We used to think there was an accumulation of microtears in the tendon (from overuse) but we know now this is not the case. For some reason the cells that lay down tendon material seem to go a bit haywire and just start laying down proteins in a haphazard way which changes the tendon stiffness and structure in a part of the tendon.
What causes tendinopathy?
This one we do know, loading a tendon in a way that exceeds it’s normal capacity. Every tissue in our body has a certain capacity both from it’s inherent properties and from the ways we use it (i.e. the ways we have asked it to adapt in the past through exercise or work).
What is a tendon?
Right, let me back up. The tendon is what anchors our muscles to our bones. It is designed mainly to transmit tension (or pulling) loads to the bone and gives the muscle an anchor from which it can contract to perform work.
How do I know if the pain I have is a tendinopathy?
Well you can’t really. There is a reason why we (Physical Therapists) go to school for 7-9 yrs, but, in general if you have a tendinopathy, the pattern should be that your pain occurs when you use the aggravated tendon and is not painful when you don’t. So your pain shouldn’t be showing up when you're resting (although it may ache after exercise) and the more you use it the more it hurts.
So I should rest it right?
No. There is no benefit from long term rest because the tendon will adapt to this too. You can think of all the tissues in our body as constantly adapting, both up and down based on what we do with them. With a tendinopathy the capacity of the tendon has already taken a big hit and the last thing we want to do is have the tendon adapt (down) further toward having a lower capacity. In some (more painful cases) it may help to rest it up to 72 hrs after injury but after this it is time to start the hard work of changing the tendon back to it’s prior capacity.
So how do I get it to change back?
Right. First we need to identify just how much (load) the tendon currently tolerates and we can do this by using your pain as a guide. During exercise we think that pain between 0-3/10 is perfectly safe. pain between 3-5/10 as being on the upper end of ok and anything more than this as being too much. I know everyone hates the pain rating scale but people are actually pretty good at getting these numbers right. If this doesn’t work at all for you than just think of it as it’s ok if the pain is there with exercise whispering at you but you don’t want it yelling at you and you shouldn’t have to reach for Alieve when you are done. Think of that light pain as your tendon telling you this is my capacity right now. Every exercise session then is just a matter of meeting it there every time and doing this consistently (every other day or every third day). This means you may need to go slightly up or down with weight or reps with each exercise on a given day but overall, you should be gradually going up to meet it where it’s at. If this is happening, then you are on your way as it is already adapting to doing more. Pain overall will improve gradually too but it tends to trail behind how much the tendon tolerates.
So It should take a couple of weeks then?
No. Unfortunately the research is clear here to that the road to fixing a tendinopathy is a long one. 12-16 weeks is the current timeline we think it takes to make a permanent change in the tendon. The road to getting it pain-free may be up to six month or more. This doesn’t mean that the pain will still be the same six month later, it will be quite a bit better but may still occasionally show up (with exercise or work).
Can I speed this up if I do exercise every day instead of every other day?
No. There is some research that shows we need to give the tendon at least 24hrs between loading sessions to give it time to adapt for the better. But, you can certainly do other exercises that don’t overload & provoke the tendon like low impact cardio or exercises targeting the non-affected parts of your body.
How do I know if I need the help of a Physical Therapist?
Well if you are able to exercise and keep the pain below a 3/10 and it is gradually getting better than you are probably on your way. But, if you are struggling to figure out what to do and how to load it and getting mixed results or it is getting worse than it would probably be worth your time to have someone with training help you figure out how to navigate this injury. I like to use the analogy of bowling where I just act as the bumper guards for my patients so that they can be successful. Ultimately the work has to be done by you either way but the road back from a tendinopathy can be confusing and anxiety ridden so it may help to have a guide.
By Kristina Pattison, DPT, OCS, CSCS
Photo by Seth Orme: Jenna Lyons and Kristina Pattison at the 2020 Runners Edge Run Up For Air fundraiser for Climate Smart Missoula
With upcoming races on the calendar, it can be tempting to increase miles quickly this time of year. But gradually building a solid base of running volume is the best way to prevent the dreaded overuse injuries that often plague runners later in the year. When Planning a Race Season and developing Phases of a Running Program it is important to consider both the principles of overload and rest for a safe build up for the year.
It’s important to understand the physiological implications of increased volume over the course of a training season. Increased miles equates to increased forces absorbed by the body as you’re pounding around on the pavement or trails. With each step the body absorbs 2-3 times your body weight while running. These forces are attenuated mostly by soft tissues of the body--muscles, tendons, ligaments. But also cartilage and bone can take a beating as well as the body fatigues, so the goal is to keep your active shock absorbers--muscles--doing the work to offload less compliant tissues like cartilage that is susceptible to irreversible degeneration. This takes time and gradual adaptation. Remember that as you progress miles, it’s been found that increases of less than 10% per week is associated with decreased incidence of injury in runners.
Also, consider that the day you rest is the day your body heals and responds to overload by becoming stronger and more adept at absorbing shock. The soreness you feel when starting a program is considered to be due to healing associated with micro-tears in weaker muscle fibers. As these fibers heal they become stronger and better adapted to withstand that higher amount of stress during future bouts of exercise. When designing training a training program, most coaches will incorporate at least one full day of rest into the week, and vary the intensity of days so there is at least one easy run between each of your harder, longer, or more intense efforts.
Strategically incorporating increases in volume paired with appropriate rest days allows your body to naturally adapt to increased miles and speed so you can reach you race goals without setbacks associated with injuries.
By Kristina Pattison, DPT, OCS, CSCS
Keeping things interesting on a treadmill can be a feat in itself. The boredom of miles spent in one spot can derail the most well-intentioned training program. Here are several ideas to improve your chance of success for the runner who uses the belt:
One of the key measurements of work while running is cadence, or steps per minute. Historically, the rule of thumb for ideal cadence was identified by averaging the cadence of a handful elite Olympians at the 1980 Olympics in Los Angeles. What did they find? Across all distances most of these runners were running at approximately 180 steps per minute. Since then, research has determined that increased cadence results in decreased ground reaction forces through the lower extremity during impact, which can be useful for minimizing pain while running. But also, increased cadence has shown to improve the activation of stabilizer musculature just prior to impact which helps with force attenuation during landing. These improvements can occur at just a 5-15% increase in a runner’s natural cadence.
TREADMILL PLAN: Count your steps for 6 seconds while running at a normal speed, multiply by 10 and this is your steps per minute. Even better, have someone else do it or film you and count for a longer period. Your cadence will change at different speeds and inclines and all of us have a sweet spot where our form is the most efficient. It’s important then to practice keeping a higher cadence while running at the less natural speeds and grades. Try these ideas: shallow hill repeats at 6-8% grade for 3-5 minutes keeping your natural cadence. Or: short intervals at increased speed (1-3 minutes) when cadence naturally speeds up slightly, with the intention of trying to keep an increased cadence during your rest or slow period.
Power is defined as the rate of work performed, with work being the force transmitted multiplied by the displacement of an object. Power is traditionally a metric used in cycling due to ease of measurement of force applied with a meter attached to the bike. Running meters that attach to the shoe (e.g. Stryde) can calculate force development by the foot hitting the ground, multiplied by the distance traveled per unit of time. Ideally, power would provide a more precise interpretation of effort input to gauge the intensity of workouts, instead of using heart rate that has somewhat of a lag to catch up to effort. However, these running power devices can be relatively unreliable and the information they provide is sometimes confusing or easy to misinterpret. If you aren’t a tech connoisseur, you could consider using proprioceptive cues instead for improved force development during your training bouts.
TREADMILL PLAN: During an easy paced run, think of “running through the wall” a proprioceptive cue used by coach and author, Matt Fitzgerald to encourage the runner to exert increased force through the ground propelling the runner horizontally forward. The idea is to visualize a wall in front of you that you must break through to the other side. Importantly, this can result in you running into the front of the treadmill, so be prepared.
Historically, effort has been measured in terms of heart rate. Runners can use heart rate as an indicator of effort to ensure easy efforts are truly in an easy range, or to ensure they are staying in the correct intensity ranges during anaerobic efforts. However, clinical trials have found that rate of perceived effort is generally just as applicable for determining your effort zone. The Borg rating of perceived exertion is a scale of 6-20 and roughly correlates to heart rates. For example, 6 is sitting on the couch having a beer at halftime, and 20 is all out sprint to the end zone.
TREADMILL PLAN: Start your warm up at an easy pace where you can easily breathe through your nose and/or if you’re with a partner, carry on a conversation. Note your effort rating on the Borg scale. Then start to increase your speed until you feel you are running about as fast as you can for 10 minutes. Note your effort and speed. Return to easy for a couple minutes and complete the above at a shorter time frame until you’ve tried 10-8-6-4-2 minute reps with a 2 minute rest between. On subsequent reps you should be running faster and may note your effort rating change. With future trials of this workout you may notice your effort decrease at the same speed. Running at an increased step per minute and increasing your force per step will increase your running speed. As your body adapts, you will gradually feel these efforts become easier and easier until it's time to try some runs outside again!
By Kristina Pattison, DPT, OCS, CSCS
Picture: Kristina Pattison in La Palma, Canary Islands off the east coast of Africa, prior to the infamous Transvulcania 75km, May.
After Planning a Race Season for the year, you may be working toward developing a training program that will put you within shooting distance of a PR or podium, or will help you complete a new distance or epic destination race. Whatever your goals, building volume and intensity appropriately over the season is imperative to avoid injury and early burnout. Setting up seasonal phases or blocks of training during your year-long program can help you focus on specific goals. Five common phases of a yearly training program include the base build, the pre-competition period, the early-competition period, the race season, and finally the recovery period.
During the first months of the year, you can take advantage of the winter season to begin base volume. Focusing on running at an easy aerobic pace will help the body physiologically adapt to the energy utilization and cardiorespiratory needs of an endurance athlete, while building tensile strength and durability of musculoskeletal structures. Volume can be measured in various ways--miles, time, gain--so it is important to consider whether you will be incorporating more than just running into this time period. If you train with a variety of methods--skiing, swimming, indoor bike or elliptical--to maintain your aerobic fitness in the winter months, it may be worthwhile to track your volume in terms of time during this phase. Generally, the rule of thumb is to increase the general volume no more than 10% per week to avoid risk for developing overuse injuries during this time. *Quick reference: for every 1 hour of volume, 10% is 6 additional minutes.
As the race season draws near, you may consider changing the composition of your volume of training rather than continuing to increase your volume. For example, if you are sustaining a comfortable amount of training at mostly easy pace, it may be worthwhile to schedule several runs with specific goals. Early in the season, these may include activities such as developing neuromuscular coordination for increased cadence with 4-6 strides at the end of a workout. Or a day where you play with gradual increases in speed over various distances--fartlek runs and progression runs may be good ways to increase speed judiciously. *Quick tip: fartlek, swedish for “speed play” is just that--play. Going by feel is a good way to introduce speed while listening to how the body responds. A great coach of mine once told me during this phase: “Don’t force it. Focus on your love of the sport and the rest will come naturally.”
As spring starts to melt into summer, early season competitions are a great way to start to test the legs. These runs can take the place of a workout or a long run, and are common in the pre-race build up. During this time, your routine workouts and long run may become slightly more intense. Often, as your body adapts to these workouts you will develop speed naturally and be able to progress these improvements with further anaerobic efforts that help with race day performance. Intervals, repeats, hill repetitions--you name it, this is the time to push a little harder per tolerance. One general recommendation is using the 80/20 rule for intensity, where about 20% of training is of higher intensity and the rest is back in the easy, aerobic range. *Quick tip: easy means easy! If you can carry on a conversation or inhale through your nose, you may be in the right zone. Going too hard on easy days is a common mistake during this phase and detracts from your intentionally harder efforts.
“Don’t force it. Focus on your love of the sport and the rest will come naturally.” --Mike Wolfe, Mountain Project
In the months surrounding your main event(s), your intensity will generally be at its peak. During this time frame, volume wanes as race-specific training at a higher intensity is a greater focus. Shorter, more intense bursts of speed during longer race-specific efforts, fast finish long-runs, and tempo runs to practice race-pace are common. At this phase, you may gear your training toward race-specific conditions--what you will eat and wear, how you warm up, and what you have at aid stations are all considerations at this point. For longer efforts, such as ultramarathon, or destination races with particular environmental and travel demands, logistical considerations become increasingly important. Quick tip: *travel to races is a demand in itself, so planning carefully is important. Ensure you have considered your need for recovery from travel days, honoring your taper, and having your race kit close at hand just in case.
At last, once you’ve made it past the finish line, and you are still basking in the afterglow of all your hard work put to the test, it is time to relax! Most athletes will plan a recovery timeframe lasting at least a couple weeks to detach from the training schedule, allow the body to reset, and let the new goals stir. You may consider not tracking workouts and just doing whatever feels good, or not running at all. This period is imperative just as much for the mental break as the physical break. Consider restorative workouts--Pilates, CoreAlign, yoga--and use the time to scan the body for any hitch in your giddy-up. This is a good time to check in with your physical therapist with any specific concerns before next season!
Alpine Physical Therapy | Downtown Clinic
150 E. Spruce Street
Missoula, MT 59802
By Kristina Pattison, DPT, OCS, CSCS
Kristina Pattison running in the north hills, Missoula. Photo by Ben Herndon Photography
January is when runners reassess, rebuild, and refocus on the coming season. This year, with or without resolutions, is an opportunity to grow and improve. When considering which races to select and how to structure the season try these ideas to make the most of your year and reduce the risks of developing an overuse injury: select your key races, identify training blocks for each race, and consider using other races for practice.
SELECT KEY RACES
First, selecting your most important, or key races often will be intuitive. Which races are you the most excited about or drive you to compete or set a PR? I had a coach once tell me “the key race is the one you geek out about the most.” When considering these events are they spaced apart enough to give you time to reassess, rebuild and refocus? Generally, the space between events is relative to the race
duration. For marathons, for example, you may only have time during the season to achieve peak fitness for one or two key events.
PLAN TRAINING BLOCKS
Second, once your events are planned and entry into those races is guaranteed, you may begin by looking at structuring your year training and racing calendar. Running coaches will plan a progressive build up to race season, selecting blocks of time that focus on specific goals e.g. building base miles, improving speed to meet race goals, or race specific training. These may be divided into the base build when you build volume, the pre-competition period when you are working on speed or quality, the early-competition period when you start competing to practice for the big event, the race season when you’re at your peak fitness, and finally the recovery period.
PREPARE FOR THE BIG EVENT
Third, as you consider the goals of the early-competition period, you may consider entering some less important events to practice racing. This can be at an event that is sensible considering the distance of the practice race, and time before your main event. When considering these races, it is important to be very cautious with your goals because you shouldn’t be at peak fitness until you’re fully ready for the main event. Often these races are fun, local, low-key events (or not local if friendly competition will spur you to over-weight the race).
Planning your season ahead is a very important step to ensuring you get the most of your training, you perform as well as you would like, and to decrease chances of being sidelined by injury or overtraining.
Kristina Pattison is a Missoula, Montana based runner focused on mountain, ultra, sky and trail. Locally, she works as a physical therapist for Alpine Physical Therapy at the Peak Health and Wellness Center Downtown. She is board certified in orthopedics and certified as a specialist in strength and conditioning. Alpine provides specific services for runners including gait evaluation and running-specific training.
Alpine Physical Therapy
150 E. Spruce Street
Missoula, Montana 59802
Author: JOCEE LONG, DPT
This blog post is in response to a community question submitted via Instagram.
Should I be rolling out my muscles pre-workout or post-workout?
In a nutshell, I think foam rolling post-workout is more ideal. Some research suggests foam rolling from 10-20 minutes post high intensity exercise can reduce delayed onset muscle soreness (DOMS) and enhance post-exercise muscle recovery.
When and why would you roll before exercise?
The research suggests that short bouts of foam rolling 1 session for 30 sec - 2 minutes does not enhance or negatively affect muscle performance but may positively change the perception of fatigue. Rolling can have short term effects on increasing joint range of motion, however since there isn’t enough evidence, exact amounts of how much is too much has not been determined. And since we know stretching too much pre-workout can have negative effects on muscle performance, if you choose to roll before your workout try to keep your pre-workout lower extremity rolling session under 2 minutes.
Research really only supports foam rolling for decreasing delayed onset muscle soreness (DOMS) and potentially giving short term benefits with changes in joint range of motion. Are you foam rolling for stiffness in your muscles? My question is, why are your muscles chronically tight in the first place? Healthy muscles are meant to be worked and shouldn’t be getting ‘tight’ after normal or even intense workouts. So if you feel like you have to roll out to feel good after a workout, you might want to chat with a physical therapist about possible movement dysfunctions you have that are likely causing the muscle stiffness in the first place.
10/21/2019 0 Comments
Breathing exercises are powerful tools that are often ignored. Our ability to control our breath and actively alter our breathing patterns can give us a greater control of our stress response, anxiety, and promote our body's natural self-healing abilities. Below are four breathing exercises to help get you started.
Rock and Roll Breathing
Cat and Cow
WHAT AND WHY?
Ergonomics simply means arranging your environment to fit your needs, NOT arranging your body to fit your environment. It's important to prevent injury or promote healing if we've been injured. Too often we don't change our environment until we're already hurting.
Three factors are considered with an ergonomic assessment:
- POSTURE: aiming for neutral.
- FORCE: level of force our body can tolerate is relative to the strength and condition on our tissues (i.e. muscles, joints).
- REPETITION: this can be repeated movement or sustained position, but our tissues need breaks. Breaks can be changing a task so we are putting different stress on our body, it can be taking a quick stroll around the office after sitting for 30 minutes.
WHAT IS NEUTRAL?
Neutral simply means that our joint(s) are in a position where there is the least amount of stress on our tissues on every side of the joint. Examples are:
i. The wrist is in a natural line from the forearm.
ii. The shoulders are not shrugged up to the ears.
iii. The neck isn't turned one direction to look at the keyboard.
iv. The natural curves in our spine are maintained.
BENEFITS OF NEUTRAL POSTURE
i. Provides the greatest strength and stability.
ii. Places the least stress on muscles, tendon, joints, etc.
iii. Results in the lowest risk of repetitive strain injury which are the most common work related injuries.
SETTING UP YOUR OFFICE SPACE
- You want your feet to touch the ground. You can use a footrest if needed.
- Your hips need to be higher than the knees.
- Seat depth is approximately 2-4 fingers from the back of the knee.
- Chair back: Office work is typically forward so chair needs to promote forward work. Position: Neutral or forward, not reclined while working.
- Lumbar Support/Roll only helps if:
1. You sit all the way back in the chair.
2. Pelvis is in neutral position so your spinal curves are maintained. Are you sitting on your 'sit bones' (good) or your tailbone (bad)?
- Armrests: at elbow or slightly higher so you can relax the shoulders.
- Distance: take a piece of paper with print about the sam size as your computer screen and determine at which distance your eyes have to work the least. Measure from the eye to the paper - this is the distance the monitor should sit from your eyes.
- Height: our relaxed line of sight is 10-15 degrees below the horizon (slightly down).
- Elbow angle 90-110 degrees (opened up).
- Same height as your keyboard.
- Limit reaching for frequently used items.
LOOKING FOR ERGONOMIC OFFICE SUPPLIES?
Check out our friends at MT ERGOFIT !
Author: Brace Hayden, DPT
Sleep is something that is vital to the human body. Every system in our body needs sleep to function efficiently. Many people struggle with getting sufficient quality sleep. Getting inadequate or poor-quality sleep is linked to a variety of health-related disorders and reduces your body’s ability to heal. Fortunately, getting more quality sleep is a skill that can be improved with ‘sleep hygiene’ practices. Here are some strategies we have gleaned from the current research (see references below) that can help improve your sleep.
Reduce Anxiety and Stress
Anxiety is a massive sleep killer. Do everything you can to banish it from your bed. There are ample methods to reduce anxiety: counseling, making lists, self-calming techniques (relaxation, meditation, deep breathing, coloring).
Make Sleep a Habit
Set a routine and stick to it. Your sleep clock or circadian rhythm can get off balance with variations in your sleep-wake cycle schedule. Set a desired wake-up time and a bedtime routine that you can consistently stick with 7 days a week. On average, most adults need seven to nine hours of sleep. Seniors (over 65 years) require less sleep and tend to wake more often throughout the night. Training your body for optimized sleep requires a set routine. Go to bed early, as studies have shown that people feel more refreshed and awake when they get more hours of deep sleep before midnight.
“Power napping” during the day for 20 minutes or less can be beneficial if you are feeling sleepy. A nap duration for more than 20 minutes can negatively effect on your sleep routine.
Dark, Cool and No Devices
Keep your bedroom dark and cool. Blackout shade or heavy curtains will help keep you asleep during the longer daylight spring and summer months. Avoid electronics in the bedroom (phones, tablets, TVs, and night-lights).
Regular aerobic exercise will improve sleep. Try to get 5-7 days of aerobic exercise for at least 40-60 minutes (walk, jog, bike, swim, etc.). Avoid stimulating activity and vigorous exercise within three hours before sleep.
Liquid Intake and Caffeine
Limit liquid intake (water, alcohol, milk, etc.) in the evening for the 2-3 hours prior to your bedtime to avoid multiple bathroom breaks during the night. Avoid bladder and brain irritants (alcohol. caffeine) in the evening, especially after 7 pm. Limit eating or drinking caffeinated drinks or food (chocolate, tea, coffee, etc.) after 2:00 p.m.
Close Your Eyes
If you wake up in the middle of the night or can’t fall asleep after 30 minutes of winding down. Get out of your bed, go into another room, and reset your pre-bed relaxation routine. Try to do something that is not too interesting or stimulating for 30-45 minutes (listen to relaxing music, meditate, practice taking long slow deep breaths, color, or read something dry). Tossing and turning trains your body and brain have a negative relationship to being relaxed and sleepy in your bed. Beds are for sleeping (and sex).
REFERENCES (available online or at your public library):
The sleep solution: why your sleep is broken and how to fix it
Author: Winter, W. Chris
Quiet your mind & get to sleep: solutions to insomnia for those with depression, anxiety, or chronic pain
Author: Carney, Colleen
Fall is upon us, but there is still time for numerous adventures and sites to explore. For those recovering from injury or suffering from pain, it can be hard to find a hike that fits your fitness capabilities. The last thing you need is to get there and realize that this outing is doing more harm then good. Fortunately for Missoulians, we have access to a wide variety of trails ranging from short trails with minimal inclines to long steep hikes up nearby mountains. Here are a few trails to check out.
Bolle Birdwatching Trail – Greenough Park
This is the prefect trail for those who are recovering from injury and need a hike with very little elevation gain. This trail is located in the Rattlesnake area and is a loop design. Since this trail is only one mile, it takes about 30 min to do.
Blue Mountain Saddle to Blue Mountain Lookout
This trail is a there-and-back hike with a 660 foot elevation gain over the 2.2 miles. Thus, it is an easy hike for those who want to ease into hiking. The full hike takes about 1.5 hours, but due to its design you can turn back at anytime to make the trial fit your time requirement.
Main Rattlesnake Trail
This is another great trail in the Rattlesnake area. This trail has a little elevation change, so it’s a good hike if you are looking for a longer hike. This one is a there-and-back hike of up to 4.8 miles. So you can make it as long as you’d like.
Hiking is a great way to get in your daily exercise while exploring the outdoors. Capitalize on the great weather by exploring some of these easier trails. They are great for beginners and those faced with the challenges of knee and back pain.
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